Document:

Exhibit 10.2

     

      
        

      

    

    Back
      to
      Form 8-K

    Exhibit
      10.2

     

    

      STATE
        OF MISSOURI

      OFFICE
        OF ADMINISTRATION

      DIVISION
        OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

      CONTRACT
        AMENDMENT

      

      
        	AMENDMENT NO.: 003	REQ NO.: NR
                886 25757006929
	CONTRACT NO.: C306118005 	BUYER: Laura
                Ortmeyer
	TITLE: Medicaid
                Managed Care - Eastern Region 	PHONE
                NO.: (573)
                751-4579
	ISSUE DATE: 02/23/07	E-MAIL:
                laura.ortmeyer@oa.mo.gov

      

       

      TO: HARMONY
        HEALTH PLAN INC

      23
        PUBLIC SQUARE STE 400

      BELLEVILLE,
        IL 62220

      

      RETURN
        AMENDMENT NO LATER THAN: March
        7, 2007 AT 5:00 PM CENTRAL TIME

       

      RETURN
        AMENDMENT TO:

      
        	
                (U.S.
                  Mail)

                Div
                  of Purchasing & Matls Mgt (DPMM) OR

                PO
                  BOX 809

                JEFFERSON
                  CITY MO 65102-0809

              	
                (Courier
                  Service)

                Div
                  of Purchasing & Matls Mgt (DPMM)

                301
                  WEST HIGH STREET, ROOM 630

                JEFFERSON
                  CITY MO 65101

              

      

      

      OR
        FAX TO: (573) 526-9817 (either
        mail or fax, not both)

      

      DELIVER
        SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING
        ADDRESS:

      

      Missouri
        Department of Social Service

      Division
        of Medical Services

      P.O.
        Box 6500

      Jefferson
        City, MO 65102-6500

      

        SIGNATURE
          REQUIRED

        

        
          	
                  DOING
                    BUSINESS AS (DBA) NAME

                  Harmony
                    Health Plan of Missouri

                	
                  LEGAL
                    NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID
                    NO.

                  Harmony
                    Health Plan of Illinois, Inc.

                
	
                  MAILING
                    ADDRESS

                  23
                    Public Square, Suite 400

                	
                  IRS
                    FORM 1099 MAILING ADDRESS

                  200
                    West Adams Street, Suite 800

                
	
                  CITY,
                    STATE, ZIP CODE

                   

                  Belleville,
                    Illinois 62220

                	
                  CITY,
                    STATE, ZIP CODE

                  Chicago,
                    Illinois 60606

                

        

        

        
          	
                  CONTACT
                    PERSON

                  Tina
                    Gallagher

                	
                  EMAIL
                    ADDRESS

                  Tina.gallagher@wellcare.com

                
	
                  PHONE
                    NUMBER

                  (800)608-8158
                    Ext. 2405

                	
                  FAX
                    NUMBER

                  1-800-608-8157

                
	
                  TAXPAYER
                    ID NUMBER (TIN)

                  36-4050495

                	
                  TAXPAYER
                    ID (TIN) TYPE (CHECK ONE)

                  _X__ FEIN
                    ___ SSN

                	
                  VENDOR
                    NUMBER (IF KNOWN)

                  3640504950
                    1

                
	
                  VENDOR
                    TAX FILING TYPE WITH IRS (CHECK ONE) (NOTE: LLC IS NOT A VALID
                    TAX FILING
                    TYPE.)

                  _X__
                    Corporation ___ Individual ___ State/Local
                    Government ___ Partnership
                    ___ Sole Proprietor ___Other ________________

                
	
                  AUTHORIZED
                    SIGNATURE

                      
/s/  
Thad
                    Bereday               
                    

                	
                  DATE

                  March
                    22, 2007

                
	
                  PRINTED
                    NAME

                  Thaddeus
                    Bereday

                	
                  TITLE

                  Secretary

                

        

        
 

      

      
        
           

        

        
           

          
            

          

        

        
           

        

      

      

      AMENDMENT
        #003 TO CONTRACT C306118005

      

      

      CONTRACT
        TITLE:  Medicaid
        Managed Care - Eastern Region

      

      CONTRACT
        PERIOD: July
        1,
        2006 through June 30, 2007

      

      The
        State
        of Missouri hereby desires to amend the above-referenced contract in accordance
        with the following:

      

      1. Paragraph
        2.4.8 a. 2) is hereby amended effective January 1, 2007:

      

      2) The
        health plan shall pay out-of-network providers for emergency services at
        the
        current Missouri Medicaid program rates in effect at the time of
        service.

      

      2. Paragraph
        2.28.1 b. is hereby amended effective July 1, 2006:

      

      
        	 	
                b.

              	
                If
                  the health plan is new to a MC+ managed care region, the health
                  plan shall
                  agree that its capitation rate shall reflect the average participant
                  ratio
                  of the MC+ managed care health plans that are not new to the region
                  by
                  rate cell and category of assistance for the applicable measurement
                  period
                  reflected in Attachment 11. Beginning January 2008, the new health
                  plan
                  shall agree that their future capitation rates shall be adjusted
                  by the
                  health plan’s actual 12-month HCY/EPSDT participant
                  ratio.

              

      

      

      All
        other
        terms, conditions and provisions of the contract, including all prices, shall
        remain the same and apply hereto.

      

      The
        contractor shall sign and return this document, on or before the date indicated,
        signifying acceptance of the amendment.Exhibit 10.3

    
      

    

    Back
      to Form 8-K

    Exhibit
      10.3

     

    

      MEDICAID
        ADVANTAGE MODEL CONTRACT

       

      Amendment
        of Agreement Between The City of New York And WellCare of New York,
        Inc.

       

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

       

      WHEREAS
        the parties entered into an Agreement effective April 1, 2006 for the purpose
        of
        providing Medicare and Medicaid Advantage Products to eligible recipients
        residing in New York; and

       

      WHEREAS
        the parties desire to amend said Agreement to modify certain provisions to
        reflect current circumstances and intentions, and, as authorized in Section
        2.1
        of the Agreement, to extend the term of the Agreement until December 31,
        2007;

       

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

       

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

       

      2.
        Amend
        Section 9.3 "Covered Services During Guaranteed Eligibility" to read as
        follows:

       

      9.3
        Covered Services During Guaranteed Eligibility

       

      The
        services covered during the Guaranteed Eligibility period shall be those
        contained in the Medicaid Advantage Benefit Package, as specified in Appendix
        K-2, and free access to family planning and reproductive health services
        as set
        forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
        period, Enrollees are also eligible for Medicaid pharmacy benefits as allowed
        by
        State law (select drug categories excluded from the Medicare Part D benefit
        and
        certain medications included in the Part D benefit when the Enrol lee is
        unable
        to receive them from his/her Medicare Advantage plan) on a Medicaid
        fee-for-service basis.

       

      3.
        Amend
        Section 10.7 "Emergency and Post Stabilization Care Services" to read as
        follows:

       

      10.7
        Emergency and Post Stabilization Care Services

       

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

       

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

      

      Medicaid
        Advantage Contract Amendment 

      January
        1.2007 

      Page
        1

      

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

       

      d)
        The
        Contractor shall advise its Enrollees how to obtain Emergency Services when
        it
        is not feasible for Enrollees to receive Emergency Services from or through
        a
        Participating Provider.

       

      e)
        Coverage and payment for Emergency Services that meet the prudent layperson
        definition shall be covered and paid in accordance with the requirements
        of the
        federal Medicare program.

       

      f)
        In
        addition, the Contractor shall cover and reimburse for general hospital
        emergency department services and physician services provided to an Enrollee
        while the Enrollee is receiving general hospital emergency department services,
        in accordance with the following requirements when such services do not meet
        the
        prudent layperson standard:

       

      i)
        Participating Providers

       

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

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the rate of payment specified in
        the
        contract between the Contractor and the physician.

       

      ii)
        Non-Participating Providers 

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
        fee-for-service rate, inclusive of the capital component, in effect on the
        date
        that the service was rendered.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Non-Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the Medicaid fee-for-service rate
        in
        effect on the date that the service was rendered.

      

      

      Medicaid
        Advantage Contract Amendment

      January
        1, 2007

      Page
        2

      

      4.
        Amend
        Subsection 16.3 "Quality Management and Performance Improvement" to read
        as
        follows:

       

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

       

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

      •
        Consumer Assessment of Health Plans Survey (CAHPS); and

      •
Health
        Outcomes Survey (HOS).

       

      5.
        Amend
        Section 18.3 "SDOH Instructions for Report Submissions" to read as
        follows:

       

      18.3
        SDOH
        Instructions for Report Submissions

       

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

       

      6.
        Delete
        Section 18.4 "Liquidated Damages, " and renumber Sections 18.5 "Notification
        of
        Changes in Report Due Dates, Requirements or Formats:" 18.6 "Reporting
        Requirements;" 18.7 "Ownership and Related Information Disclosure;" 18.8
        "Public
        Access to Reports:" 18.9 "Certification Regarding Individuals Who Have Been
        Debarred Or Suspended By Federal. State, or Local Government:" 18.10 "Conflict
        of Interest Disclosure:" and 18.11 "Physician Incentive Plan Reporting:"
        as
        Sections 18.4. 18.5. 18.6. 18.7. 18.8. 18.9. and 18.10
        respectively.

       

      7.
        Amend
        Section 21.5 "Dental Networks " to read as follows:

       

      21.5
        Dental Networks

       

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

      

      Medicaid
        Advantage Contract Amendment 

      January
        1, 2007 

      Page
        3

      

      8.
        Add
        a
        new Section 22.7 "Recovery of Overpayments to Providers" to read as
        follows:

       

      22.7
        Recovery of Overpayments to Providers

       

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

       

      9.
        Renumber
        Section 22.7 "Physician Incentive Plan" as Section 22.8.

       

      10.
        Amend
        Section 3(b) (in) "LDSS Responsibilities" of Appendix H "New York State
        Department of Health Guidelines for the Processing ofMedicaid Advantage
        Enrollments and Disenrollments" to read as follows:

       

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

       

      11.
        The
        attached Appendix K "Medicare and Medicaid Advantage Products and Non-Covered
        Services"
        will be applicable for the period beginning January 1, 2007.

       

      12.
        The
        attached Appendix L "Approved Capitation Payment Rates" will be applicable
        for
        the period beginning
        January 1, 2007.

       

      13.
        The
        attached Appendix M "Service Area" will be applicable for the period beginning
        January 1, 2007.

       

      14.
        Amend
        Subsections 4 (a) and 4 (b) of Section N.4 "Additional Reporting Requirements"
        of Appendix N "New York City Specific Contracting Requirements" to read as
        follows:

       

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

       

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

       

      15.
        The
        attached Schedule ] "DOHMH Public Health Service Fee Schedule" of Appendix
        N
        "New York City Specific Contracting Requirements" will be applicable for
        the
        period beginning January 1.2007.

      

       

      Medicaid
        Advantage Contract Amendment 

      January
        1,2007 

      Page
        4

       

      

      This
        Amendment is effective January 1, 2007 and the Agreement, including the
        modifications made by this Amendment, shall remain in effect until December
        31,
        2007 or until an extension, renewal or successor Agreement is entered into
        as
        provided for in Section 2.1 of the Agreement.

       

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

       

      
        	
                CONTRACTOR

              	
                CITY
                  OF NEW YORK

              
	
                By:
                  /s/
                  Todd S. Farha

              	
                By:
                  /s/
                  Andrew Rein 

              
	
                Printed
                  Name: Todd S. Farha

              	
                Printed
                  Name: Andrew Rein

              
	
                Title:
                  President and CEO

              	
                Title:
                  COO

              
	
                WellCare
                  of New York, Inc.

              	
                NYC
                  DOHMH

              
	
                Date:
                  11/28/2006

              	
                Date:
                  12/11/2006

              

      

      

       

      Medicaid
        Advantage Contract Amendment 

      January
        1,2007 

      Page
        5

       

      

      STATE
        OF
        FLORIDA

      

      COUNTY
        OF
        HILLSBOROUGH

      

      On
        this
28th
        Day of
November  2006, Todd
        S. Farha came
        before me, to me known and known to be the President
        and CEO,
        of
WellCare
        of New York, Inc. who
        is
        duly authorized to execute the foregoing instrument on behalf of said
        corporation and s/he acknowledged to me that s/he executed the same for the
        purpose therein mentioned.

      

      

      NOTARY
        PUBLIC

      

       

      STATE
        OF
        NEW YORK

      

      COUNTY
        OF
        NEW YORK

      

      On
        this
        11 day of December, 2006, Andrew Rein came before me, to me known and known
        to
        be the 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. 

      

      

      

      NOTARY
        PUBLIC

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      Recitals

       

      Section
        1 Definitions

       

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

      2.1
        Term

      2.2
        Amendments

      2.3
        Approvals

      2.4
        Entire Agreement

      2.5
        Renegotiation

      2.6
        Assignment and Subcontracting

      2.7
        Termination

      a.
        DOHMH
        Initiated Termination

      b.
        Contractor and DOHMH Initiated Termination

      c.
        Contractor Initiated Termination

      d.
        Termination Due to Loss of Funding

      2.8
        Close-Out Procedures

      2.9
        Rights and Remedies

      2.10
        Notices

      2.11
        Severability

       

      Section
        3
        Compensation

      3.1
        Capitation Payments

      3.2
        Modification of Rates During Contract Period

      3.3
        Rate
        Setting Methodology

      3.4
        Payment of Capitation

      3.5
        Denial of Capitation Payments

      3.6
        SDOH
        Right to Recover Premiums

      3.7
        Third
        Party Health Insurance Determination

      3.8
        Contractor Financial Liability

      3.9
        Tracking Services Provided by Indian Health Clinics

       

      Section
        4
        Service Area

       

      Section
        5
        Eligibility For Enrollment in Medicaid Advantage

      5.1
        Eligible to Enroll in the Medicaid Advantage Program

      5.2
        Not
        Eligible to Enroll in the Medicaid Advantage Program

      5.3
        Change in Eligibility Status

       

      Section
        6
        Enrollment

      6.1
        Enrollment Requirements

      6.2
        Equality of Access to Enrollment

      6.3
        Enrollment Decisions

      6.4
        Prohibition Against Conditions on Enrollment

      

      Medicaid
        Advantage Contract 

      TABLE
        OF
        CONTENTS 

      New
        York
        City 

      January
        1, 2007 

      1

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      6.5
        Effective Date of Enrollment

      6.6
        Contractor Liability

      6.7
        Roster

      6.8
        Automatic Re-Enrollment

      6.9
        Failure to Enroll in Contractor's Medicare Advantage Product

      6.10
        Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility

      6.11
        Newborn Enrollment

       

      Section
        7
        RESERVED

       

      Section
        8
        Disenrollment

      8.1
        Disenrollment Requirements

      8.2
        Disenrollment Prohibitions

      8.3
        Disenrollment Requests

      a.
        Routine Disenrollment Requests 

      b.
        Non-routine Disenrollment Requests

      8.4
        Contractor Notification of Disenrollments

      8.5
        Contractor's Liability

      8.6
        Enrollee Initiated Disenrollment

      8.7
        Contractor Initiated Disenrollment

      8.8
        LDSS
        Initiated Disenrollment

       

      Section
        9
        Guaranteed Eligibility

      9.1
        General Requirements

      9.2
        Right
        to Guaranteed Eligibility

      9.3
        Covered Services During Guaranteed Eligibility

      9.4
        Disenrollment During Guaranteed Eligibility

       

      Section
        10 Benefit Package, Covered and Non-Covered Services

      10.1
        Contractor Responsibilities

      10.2
        SDOH
        and LDSS Responsibilities

      10.3
        Benefit Package and Non-Covered Services Descriptions

      10.4
        Adult Protective Services

      10.5
        Court-Ordered Services 

      10.6
        Family Planning and Reproductive Health Services

      10.7
        Emergency and Post Stabilization Care Services

      10.8
        Medicaid Utilization Thresholds (MUTS)

      10.9
        Services for Which Enrollees Can Self-Refer 

      a.
        Diagnosis and Treatment of Tuberculosis 

      b.
        Family
        Planning and Reproductive Health Services 

      c.
        Article 28 Clinics Operated by Academic Dental Centers

      10.10
        Coordination with Local Public Health Agencies

      10.11
        Public Health Services

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

       

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS 

      New
        York
        City January 1, 2007 

      2

      Table
        of Contents for Medicaid Advantage Model Contract

       

      b.
        Immunizations c. Prevention and Treatment of Sexually Transmitted
        Diseases

      10.12
        Adults with Chronic Illnesses and Physical or Developmental
        Disabilities

      10.13
        Persons Requiring Ongoing Mental Health Services

      10.14
        Member Needs Relating to HIV

      10.15
        Persons Requiring Chemical Dependence Services

      10.16
        Native Americans

      10.17
        Urgently Needed Services

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

      10.19
        Coordination of Services

       

      Section
        11 Marketing

      11.1
        Marketing Requirements

       

      Section
        12 Member Services

      12.1
        General Functions

      12.2
        Translation and Oral Interpretation

      12.3
        Communicating with the Visually, Hearing and Cognitively Impaired

       

      Section
        13 Enrollee Notification

      13.1
        General Requirements

      13.2
        Member ID Cards

      13.3
        Member Handbooks

      13.4
        Enrollee Rights

       

      Section
        14 Organization Determinations, Actions, and Grievance System

      14.1
        General Requirements

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

      14.3
        Medicaid Advantage Action and Grievance System Additional
        Provisions

      14.4
        Notification of Medicaid Advantage Action and Grievance System
        Procedures

      14.5
        Complaint, Complaint Appeal and Action Appeal Investigation
        Determinations

       

      Section
        15 Access Requirements 

       

      Section
        16 Quality Management and Performance Improvement

       

      Section
        17 Monitoring and Evaluation

      17.1
        Right To Monitor Contractor Performance

      17.2
        Cooperation During Monitoring And Evaluation

      17.3
        Cooperation During On-Site Reviews

      17.4
        Cooperation During Review of Services by External Review Agency

      

      

      Medicaid
        Advantage Contract 

      TABLE
        OF
        CONTENTS 

      New
        York
        City January 1, 2007 

      3

       

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      Section
        18 Contractor Reporting Requirements

      18.1
        General Requirements

      18.2
        Time
        Frames for Report Submissions

      18.3
        SDOH
        Instructions for Report Submissions

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

      18.5
        Reporting Requirements

      18.6
        Ownership and Related Information Disclosure

      18.7
        Public Access to Reports

      18.8
        Certification Regarding Individuals Who Have Been Debarred or Suspended by
        Federal or State Government

      18.9
        Conflict of Interest Disclosure 

      18.10
        Physician Incentive Plan Reporting

       

      Section
        19 Records Maintenance and Audit Rights

      19.1
        Maintenance of Contractor Performance Records

      19.2
        Maintenance of Financial Records and Statistical Data

      19.3
        Access to Contractor Records

      19.4
        Retention Periods

       

      Section
        20 Confidentiality

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

      20.2
        Confidentiality of Medical Records

      20.3
        Length of Confidentiality Requirements

       

      Section
        21 Participating Providers

      21.1
        General Requirements

      21.2
        Medicaid Advantage Network Requirements

      21.3
        SDOH
        Exclusion or Termination of Providers

      21.4
        Payment in Full

      21.5
        Dental Networks

       

      Section
        22 Subcontracts and Provider Agreements for Medicaid Only Covered
        Services

      22.1
        Written Subcontracts 

      22.2
        Permissible Subcontracts

      22.3
        Provision of Services Through Provider Agreements

      22.4
        Approvals

      22.5
        Required Components

      22.6
        Timely Payment

      22.7
        Recovery of Overpayments to Providers

      22.8
        Physician Incentive Plan

       

      Section
        23 Americans With Disabilities Act Compliance Plan

      

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS

      New
        York
        City

      January
        1, 2007

      4

      

      Table
        of Contents for Medicaid Advantage Model Contract

      Section
        24 Fair Hearings

      24.1
        Enrollee Access to Fair Hearing Process

      24.2
        Enrollee Rights to a Fair Hearing

      24.3
        Contractor Notice to Enrollees

      24.4
        Aid
        Continuing

      24.5
        Responsibilities of SDOH

      24.6
        Contractor's Obligations

       

      Section
        25 External Appeal

      25.1
        Basis for External Appeal

      25.2
        Eligibility for External Appeal

      25.3
        External Appeal Determination

      25.4
        Compliance with External Appeal Laws and Regulations

      25.5
        Member Handbook

       

      Section
        26 Intermediate Sanctions

      26.1
        General Practices

      26.2
        Unacceptable Practices

      26.3
        Intermediate Sanctions

      26.4
        Enrollment Limitations

      26.5
        Due
        Process

       

      Section
        27 Environmental Compliance 

      Section
        28 Energy Conservation Independent 

      Section
        29 Independent Capacity of Contractor 

      Section
        30 No Third Party Beneficiaries

      Section
        31 Indemnification

      31.1
        Indemnification by Contractor

      31.2
        Indemnification by DOHMH

       

      Section
        32 Prohibition on Use of Federal Funds for Lobbying

      32.1
        Prohibition of Use of Federal Funds for Lobbying

      32.2
        Disclosure Form to Report Lobbying

      32.3
        Requirements of Subcontractors

       

      Section
        33 Non-Discrimination

      33.1
        Equal Access to Benefit Package

      33.2
        Non-Discrimination

      33.3
        Equal Employment Opportunity

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

       

      

      Medicaid
        Advantage Contract 1 

      TABLE
        OF
        CON CONTENTS 

      New
        York
        City 

      January
        1, 2007

       

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      Section
        34 Compliance with Applicable Laws and Regulations

      34.1
        Contractor and DOHMH Compliance with Applicable Laws

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

      34.3
        Certificate of Authority Requirements

      34.4
        Notification of Changes in Certificate of Incorporation

      34.5
        Contractor's Financial Solvency Requirements

      34.6
        Non-Liability of Enrollees for Contractor's Debts

      34.7
        DOHMH Compliance with Conflict of Interest Laws

      34.8
        Compliance Plan

       

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

       

      

      

      Signature
        Page

      

      Medicaid
        Advantage Contract 

      TABLE
        OF
        CONTENTS

      New
        York
        City 

      January
        1. 2007

      6

      

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      APPENDICES

      

      A.
        New
        York State Standard Clauses 

      B.
        Certification Regarding Lobbying

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

      D.
        New
        York State Department of Health Medicaid Advantage Marketing
        Guidelines

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

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

      G.
        RESERVED

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

      I.
        RESERVED

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

      K.
        Medicare and Medicaid Advantage Products and Non-Covered Services L. Approved
        Capitation Payment Rates

      M.
        Service Area

      N.
        New
        York City Specific Contracting Requirements

      0.
        RESERVED 

      P.
        RESERVED 

      Q.
        RESERVED 

      R.
        New
        York City Standard Clauses

      

      

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS 

      New
        York
        City

      January
        1.2007 7

       

      

      APPENDIX
        K

       

      Medicare
        and Medicaid Advantage Products And Non-Covered Services

      

      

      

      

      

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K

      New
        York
        City 

      January
        1. 2007

      K-l

       

      

      APPENDIX
        K

       

      Appendix
        K is organized into three parts:

      

      I.
        Appendix K-l

      Medicare
        Advantage Product

      

      II.
        Appendix K-2

      

      Medicaid
        Advantage Product 

      Description
        of Medicaid Only Covered Services

      

      III.
        Appendix K-3

      Non-Covered
        Services

      `

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1. 2007 

      K-2

       

      

      APPENDIX
        K.1

       

      MEDICARE
        ADVANTAGE PRODUCT

       

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles -
                  Upstate Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Inpatient
                  Hospital Care Including Substance Abuse and Rehabilitation
                  Services

              	
                Up
                  to 365 days per year (366 days for leap year). $300 per stay
                  co-payment.

              
	
                Inpatient
                  Mental Health

              	
                Medically
                  necessary care. $300 per stay co-payment. 190-day lifetime limit
                  in a
                  psychiatric hospital.

              
	
                Skilled
                  Nursing Facility

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

              
	
                Home
                  Health

              	
                Medically
                  necessary intermittent skilled nursing care, home health aide services
                  and
                  rehabilitation services. $10 per visit

                co-payment

              
	
                PCP
                  Office Visits

              	
                Primary
                  care doctor office visits. Subject to $10 co-payment per
                  visit.

              
	
                Specialist
                  Office Visits

              	
                Specialist
                  office visits. Subject to $20 co-payment for each specialist office
                  visit.

              
	
                Chiropractic

              	
                Manual
                  manipulation of the spine to correct subluxation provided by chiropractors
                  or other qualified providers.

                Subject
                  to $20 co-payment.

              
	
                Podiatry

              	
                Medically
                  necessary foot care, including care for medical

                conditions
                  affecting lower limbs, subject to $20 co-payment. Visits for routine
                  foot
                  care up to 4 visits per year, not subject to
                  co-payment.

              
	
                Outpatient
                  Mental Health

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

              
	
                Outpatient
                  Substance Abuse

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

              
	
                Outpatient
                  Surgery

              	
                Medically
                  necessary visits to an ambulatory surgery center or outpatient
                  hospital
                  facility. $35 per visit to ambulatory surgery or outpatient
                  hospital.

              
	
                Ambulance

              	
                Transportation
                  provided by an ambulance service, including air ambulance. Emergency
                  transportation if for the purpose of obtaining hospital service
                  for an
                  enrollee who suffers from severe, life-threatening or potentially
                  disabling conditions

              

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1. 2007 

      K-3

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles -
                  Upstate Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	 	
                which
                  require the provision of emergency services while the enrollee
                  is being
                  transported. Includes transportation to a hospital emergency room
                  generated by a "Dial 911". $50 co-payment.

              
	
                Emergency
                  Room

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

              
	
                Urgent
                  Care

              	
                Urgently
                  needed care in most cases outside the plan's service area. Subject
                  to $20
                  co-payment.

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Occupational
                  therapy, physical therapy and speech and language therapy subject
                  to $20
                  co-payment.

              
	
                Durable
                  Medical Equipment (DME)

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

              
	
                Prosthetics

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

              
	
                Diabetes
                  Monitoring

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

              
	
                Diagnostic
                  Testing

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

              
	
                Bone
                  Mass Measurement

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

              
	
                Colorectal
                  Screening

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

              
	
                Immunizations

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

              
	
                Mammograms

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

              
	
                Pap
                  Smear and Pelvic Exams

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

              

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1. 2007 

      K-4

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles -
                  Upstate Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Prostate
                  Cancer Screening

              	
                Prostate
                  Cancer Screening exams for men age 50 and older.

                No
                  co-payment

              
	
                Outpatient
                  Drugs

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

              
	
                Hearing
                  Services

              	
                Medicaid
                  and Medicare hearing services and products when medically necessary
                  to
                  alleviate disability caused by the loss or impairment of hearing.
                  Services
                  include hearing aid selecting, fitting, and dispensing; hearing
                  aid checks
                  following dispensing, conformity evaluations and hearing aid repairs;
                  audiology services including examinations and testing, hearing
                  aid
                  evaluations and hearing aid prescriptions;

                and
                  hearing aid products including hearing aids, earmolds, special
                  fittings
                  and replacement parts. No co-payment or limitations.

              
	
                Vision
                  Care Services

              	
                Services
                  of optometrists, ophthalmologists and ophthalmic dispensers including
                  eyeglasses, medically necessary contact lenses and poly-carbonate
                  lenses,
                  artificial eyes (stock or custom-made), low vision aids and low
                  vision
                  services. Coverage includes the replacement of lost or destroyed
                  glasses
                  and the repair or replacement of parts. Coverage also includes
                  examinations for diagnosis and treatment for visual defects and/or
                  eye
                  disease. Examinations for refraction are limited to every two (2)
                  years
                  unless otherwise justified as medically necessary. Eyeglasses do
                  not
                  require changing more frequently than every two (2) years unless
                  medically
                  necessary or unless the glasses are lost, damaged or destroyed.
                  No
                  prerequisite of cataract surgery. No co-payment

              
	
                Routine
                  Physical Exam 1/year

              	
                Up
                  to one routine physical per year. Subject to $10. co-

                payment
                  per visit.

              
	
                Health/Wellness
                  Education

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

              
	
                Additional
                  Part C Benefits, if any Medicare Part D Prescription Drug Benefit
                  as
                  Approved by CMS

              	 

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1, 2007

      K-5

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles -
                  Upstate Counties

              
	
                Category
                  of Service

              	
                Included
                  in

              	
                Medicare

              	
                Capitation

              

      

       

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1, 2007 

      K-6

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Inpatient
                  Hospital Care Including Substance Abuse and Rehabilitation
                  Services

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

              
	
                Inpatient
                  Mental Health

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

              
	
                Skilled
                  Nursing Facility

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

              
	
                Home
                  Health

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

              
	
                PCP
                  Office Visits

              	
                Primary
                  care doctor office visits. No co-payment.

              
	
                Specialist
                  Office Visits

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

              
	
                Chiropractic

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

              
	
                Podiatry

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

              
	
                Outpatient
                  Mental Health

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

              
	
                Outpatient
                  Substance Abuse

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

              
	
                Outpatient
                  Surgery

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

              
	
                Ambulance

              	
                Transportation
                  provided by an ambulance service, including air ambulance. Emergency
                  transportation if for the purpose of obtaining hospital services
                  for an
                  enrollee who suffers from severe, life-threatening or potentially
                  disabling conditions which require the provision of emergency services
                  while the enrollee is being transported. Includes transportation
                  to a
                  hospital emergency room generated by a "Dial 9 II". No
                  co-payment.

              

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K New York City January 1. 2007 

      K-7

       

      

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Emergency
                  Room

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

              
	
                Urgent
                  Care

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

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

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

              
	
                Durable
                  Medical Equipment (DME)

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

              
	
                Prosthetics

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

              
	
                Diabetes
                  Monitoring

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

              
	
                Diagnostic
                  Testing

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

              
	
                Bone
                  Mass Measurement

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

              
	
                Colorectal
                  Screening

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

              
	
                Immunizations

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

              
	
                Mammograms

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

              
	
                Pap
                  Smear and Pelvic Exams

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

              
	
                Prostate
                  Cancer Screening

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

              
	
                Outpatient
                  Drugs

              	
                Medicare
                  Part B covered prescription drugs and other drugs obtained by a
                  provider
                  and administered in a physician
                  office

              

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1. 2007

      K-8

       

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	 	
                or
                  clinic setting that are covered by Medicaid. (No Part
                  D.)

              
	
                Hearing
                  Services

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

              
	
                Vision
                  Care Services

              	
                Services
                  of optometrists, ophthalmologists and ophthalmic dispensers including
                  eyeglasses, medically necessary contact lenses and poly-carbonate
                  lenses,
                  artificial eyes (stock or custom-made), low vision aids and low
                  vision
                  services. Coverage includes the replacement of lost or destroyed
                  glasses
                  and the repair or replacement of parts. Coverage also includes
                  examinations for diagnosis and treatment for visual defects and/or
                  eye
                  disease. Examinations for refraction are limited to every two (2)
                  years
                  unless otherwise justified as medically necessary. Eyeglasses do
                  not
                  require changing more frequently than every two (2) years unless
                  medically
                  necessary or unless the glasses are lost, damaged or destroyed.
                  No
                  prerequisite of cataract services. No co-payment.

              
	
                Routine
                  Physical Exam I/year

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

              
	
                Health/Wellness
                  Education

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

              
	
                Additional
                  Part C Benefits, if any

              	 
	
                Medicare
                  Part D Prescription Drug Benefit as Approved by CMS

              	 

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1. 2007 

      K-9

      
      

      APPENDIX
        K2

       

      MEDICAID
        ADVANTAGE PRODUCT

       

      
        	
                Medicaid
                  Advantage Benefit Package for Dual Eligibles - Upstate
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicaid Capitation

              
	
                Inpatient
                  Hospital Care Including Substance Abuse and Rehabilitation
                  Services

              	
                Elimination
                  of $300 per stay co-payment.

              
	
                Inpatient
                  Mental Health

              	
                Elimination
                  of $300 per stay co-payment, plus days in excess of the Medicare
                  190-day
                  lifetime maximum.

              
	
                Home
                  Health

              	
                Elimination
                  of $10 co-payment per Medicare covered visit. Non-Medicare covered
                  home
                  health services (e.g. home health aide services with nursing supervision
                  to medically
                  unstable individuals).

              
	
                PCP
                  Office Visits

              	
                Elimination
                  of $10 co-payment

              
	
                Specialist
                  Office Visits

              	
                Elimination
                  of $20 co-payment

              
	
                Podiatry

              	
                Elimination
                  of $20 co-payment for medically necessary foot
                  care

              
	
                Outpatient
                  Mental Health

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Substance Abuse

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Surgery

              	
                Elimination
                  of $35 co-payment

              
	
                Ambulance

              	
                Elimination
                  of $50 co-payment

              
	
                Emergency
                  Room

              	
                Elimination
                  of $50 co-payment

              
	
                Urgent
                  Care

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Elimination
                  of $20 co-payment

              
	
                Dental
                  (Optional
                  benefit)

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

              
	
                Routine
                  Physical Exam I/year

              	
                Elimination
                  of $10 co-payment

              
	
                Transportation
                  - Routine (Optional
                  benefit)

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

              
	
                Private
                  Duty Nursing

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

              

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        ,. 2007 

      K-10

       

      

      
        	
                Medicaid
                  Advantage Benefit Package for Dual Eligibles 

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicaid Capitation

              
	
                Inpatient
                  Mental Health

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

              
	
                Home
                  Health

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

              
	
                Specialist
                  Office Visits

              	
                Elimination
                  of $10 co-payment.

              
	
                Podiatry

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

              
	
                Outpatient
                  Mental Health

              	
                Elimination
                  of $20 co-payment.

              
	
                Outpatient
                  Substance Abuse

              	
                Elimination
                  of $20 co-payment.

              
	
                Emergency
                  Room

              	
                Elimination
                  of $50 co-payment

              
	
                Urgent
                  Care

              	
                Elimination
                  of $10 co-payment.

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Elimination
                  of $10 co-payment.

              
	
                Dental
                  (Optional
                  benefit outside of NYC )

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

              
	
                Transportation
                  - Routine (Optional
                  benefit outside of NYC)

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

              
	
                Private
                  Duty Nursing

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

              

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-ll

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      DESCRIPTION
        OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE BENEFIT
        PACKAGE:

       

      Inpatient
        Mental Health Over 190-Day Lifetime Limit

       

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

       

      Non-Medicare
        Covered Home Health Services

       

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

       

      Private
        Duty Nursing Services

       

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

       

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

       

      Dental
        Services (optional benefit outside of NYC)

       

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

       

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

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        I, 2007 

      K-12

       

      

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

       

      If
        Contractor's Benefit Package excludes dental services:

       

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

       

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

       

      Non-Emergency
        Transportation (optional benefit outside of NYC)

       

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

       

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

       

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

       

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

       

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

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City January 1, 2007 

      K-13

       

      

      APPENDIX
        K3

       

      NON
        COVERED SERVICES

       

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

       

      Services
        Covered by Direct Reimbursement from Original Medicare

       

      •
Hospice
        services provided to Medicare Advantage members

       

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

       

      Services
        Covered by Medicaid Fee for Service

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

       

      •
Skilled
        Nursing Facility (SNF) days not covered by Medicare

      •
        Personal Care Services

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

      •
        Methadone Maintenance Treatment Programs

      •
Certain
        Mental Health Services, including

      o
        Intensive Psychiatric Rehabilitation Treatment Programs

      o
        Day
        Treatment

      o
        Continuing Day Treatment

      o
        Case
        Management for Seriously and Persistently Mentally 111 (sponsored by state
        or
        local mental health units) 

      o
        Partial
        Hospitalizations o Assertive Community Treatment (ACT) o Personalized Receiving
        Oriented Services (PROS)

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

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

      •
        Comprehensive Medicaid Case Management

      •
        Directly Observed Therapy for Tuberculosis Disease

      •
AIDS
        Adult Day Health Care

      •
HIV
        COBRA Case Management

      •
Adult
        Day Health Care

      •
        Personal Emergency Response Services (PERS)

       

      Medicaid
        Advantage Program Optional Benefits

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

       

      •
        Non-Emergency Transportation Services

       

      •
Dental
        Service

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K

      New
        York
        City 

      January
        1, 2007 

      K-14

       

      

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

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007

      K-15

       

      

      DESCRIPTION
        OF NON-COVERED SERVICES

       

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

       

      1.
        Hospice Services Provided to Medicaid Advantage Enrollees

       

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

       

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

       

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

       

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

       

      3.
        Personal Care Agency Services

       

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

       

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

      

      

      Medicaid
        Advantage Contract APPENDIX K 

      New
        York
        City January 1, 2007 

      K-16

       

      

      4.
        Skilled Nursing Facility Days Not Covered by Medicare

       

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

       

      5.
        Prescription Drugs Permitted by State Law, Certain Medical Supplies and Enteral
        Formula Not Covered by Medicare

       

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

       

      6.
        Out of Network Family Planning
        Services

       

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

      diagnosis
        and all medically necessary treatment, sterilization, screening and treatment
        for sexually transmissible diseases and screening for disease and
        pregnancy.

       

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

      7.
        Dental (when not in benefit package) (See
        description in Appendix K-2)

       

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

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-17

       

      

      (See
        description in Appendix K-2)

       

      9.
        Methadone Maintenance Treatment Program (MMTP)

       

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

       

      10.
        Certain Mental Health Services

       

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

       

      a.
        Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

       

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

       

      b.
        Day
        Treatment

       

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

       

      c.
        Continuing Day Treatment

       

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

       

      d.
        Case
        Management for Seriously and Persistently Mentally 111 Sponsored by State
        or
        Local Mental Health Units

       

      The
        target population consists of individuals who are seriously and persistently
        mentally ill (SPMI), require intensive, personal and proactive intervention
        to
        help them obtain those services which will permit functioning in the community
        and either have symptomology which is difficult to treat in the existing
        mental
        health care system or are unwilling or unable to adapt to the existing mental
        health care system. Three case management models are currently
        operated

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-18

       

      

      pursuant
        to an agreement with OMH or a local governmental unit, and receive Medicaid
        reimbursement pursuant to Part 506 of 14 NYCRR.

       

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

       

      e.
        Partial Hospitalization Not Covered by Medicare

       

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

       

      f.
        Assertive Community Treatment (ACT)

       

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

       

      g.
        Personalized Recovery Oriented Services (PROS)

       

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

       

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

       

      a.
        OMH
        Licensed CRs*

       

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

       

      b.
        Family-Based Treatment*

       

      Rehabilitative
        services in family-based treatment programs are intended to provide treatment
        to
        seriously emotionally disturbed children and youth to promote their successful
        functioning and integration into the family, community, school or independent
        living situations. Such services

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-19

       

      

      are
        provided in consideration of a child's developmental stage. Children determined
        eligible for admission are placed in surrogate family homes for care and
        treatment.

      *These
        services are certified by OMH under Section 586.3 and Parts 594 and 595 of
        14
        NYCRR. 

       

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

       

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

       

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

       

      b.
        Day
        Treatment

       

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

       

      c.
        Medicaid Service Coordination (MSC)

       

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

       

      MSC
        is
        provided by authorized vendors who have a contract with OMRDD, and who are
        paid
        monthly pursuant to such contract. Persons who receive MSC must not permanently
        reside in an ICF for persons with developmental disabilities, a developmental
        center, a skilled nursing facility or any other hospital or Medical Assistance
        institutional setting that provides service

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007

      K-20

       

      

      coordination.
        They must also not concurrently be enrolled in any other comprehensive Medicaid
        long term service coordination program/service including the Care at Home
        Waiver.

       

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

       

      d.
        Home
        And Community Based Services Waivers (HCBS)

       

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

       

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

       

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

       

      13.
        Comprehensive Medicaid Case Management (CMCM)

       

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

       

      14.
        Directly Observed Therapy for Tuberculosis Disease

       

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

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-21

       

      

      15.
        AIDS Adult Day Health Care

       

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

       

      16.
        HIV COBRA Case Management

       

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

       

      17.
        Adult Day Health Care

       

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

       

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

       

      18.
        Personal Emergency Response Services (PERS)

       

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

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      New
        York
        City 

      January
        1, 2007 

      K-22

       

      

      APPENDIX
        L

      Approved
        Capitation Payment Rates

      

      

      

      

      

      Medicaid
        Advantage Contract

      APPENDIX
        L

      New
        York
        City

      January
        1,2007

      L-l

       

      

      Wellcare
        of New York, Inc

       

      Dual
        Eligible Medicaid Managed Care Rates

       

      

       

      

      
        	
                MM1S
                  ID#:

              	
                02645710

              	
                Effective
                  Date: 01/01/07

              
	
                Region: 

              	
                NYC

              	 
	
                County:

              	
                NYC

              	 

      

      

      

      
        	
                Rate
                  Code

              	
                Premium
                  Group

              	
                Rate
                  Amount

              
	
                2370

              	
                DUALLY
                  ELIGIBLE SSI 21-64 MALE/FEMALE

              	
                $42.58

              
	
                2371

              	
                DUALLY
                  ELIGIBLE SSI 65+ MALE/FEMALE

              	
                $43.38

              

      

       

       

      Optional
        Benefits Offered:

      R
        Dental E
        Non

      R
        Emergent
        Transportation

      

      

      Box
        will be checked if the optional benefit is covered by the
        plan

       

      

      APPENDIX
        M

      Service
        Area

      Medicaid
        Advantage Contract

      APPENDIX
        M

      New
        York
        City

      January
        1, 2007

      M-l

      

      

      The
        Contractor’s Medicaid Advantage service area is comprised of the following
        Counties in their entirety

      

      New
        York

      

      

      Medicaid
        Advantage Contract

      APPENDIX
        M

      New
        York
        City

      January
        1, 2007

      M-2

      

      

      

      Schedule
        1 of Appendix N 

      DOHMH
        Public Health Services Fee Schedule

      

      
        	
                SERVICE
                  

              	
                FEE

              
	
                TB
                  CLINIC

              	
                $125.00

              
	
                IMMUNIZATION

              	
                $
                  50.00

              
	
                HIV
                  COUNSELING AND TESTING VISIT 

              	
                $96.47

              
	
                HIV
                  COUNSELING AND NO TESTING

              	
                $90.12

              
	
                HIV
                  POST TEST COUNSELING 

                Visit
                  Positive Result

              	
                $90.12

              
	
                LAB
                  TESTS

              	 
	
                HIV
                  1 (ELISA Test)

              	
                $12.27

              
	
                HIV
                  Antibody, Confirmatory (Western Blot)

              	
                $
                  26.75

              
	
                DENTAL
                  SERVICES

              	
                $
                  108.00

              

      

      

       

       

       

      

      APPENDIX
        N 

      New
        York
        City January 1. 2007 

      N-15

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