Document:

exv10w3

 

Exhibit 10.3

STOCK PLEDGE AGREEMENT

     This Stock Pledge Agreement (the “Pledge Agreement”) is made and entered
into this 29th day of December, 2004, by and between VESTIN GROUP, INC., a
Delaware corporation (the “Pledgor”) and SHUSTEK INVESTMENTS, INC., a Nevada
corporation (the “Pledgee”).

WITNESSETH

     This Pledge Agreement is made and entered into with reference to the
following facts:

     A. Pledgor has executed and delivered to Pledgee that certain One Million
Six Hundred Thousand Dollar ($1,600,000.00) Promissory Note dated December 29,
2004 (“Note”); and

     B. The Note is secured by this Pledge Agreement and, as such, Pledgor is
obligated to execute, deliver and perform this Pledge Agreement as collateral
security for said Note.

     NOW, THEREFORE, in consideration of the foregoing recitals and mutual
covenants and promises hereinafter set forth and other valuable consideration,
the Pledgor hereby agrees with the Pledgee as follows:

     1. Defined Terms. The following terms used herein shall have the
following meanings:

         (a) “Code” means the Uniform Commercial Code from time to time in effect
in the State of Nevada.

         (b) “Collateral” means the Pledged Stock and all Proceeds.

         (c) “Company” means Vestin Group, Inc., a Delaware corporation.

         (d) “Obligation” means the obligations of the Pledgor under the terms and
conditions of the Note.

         (e) “Pledge Agreement” means this Stock Pledge Agreement, as amended,
supplemented or otherwise modified from time to time.

         (f) “Pledged Stock” means the four hundred thousand (400,000) shares of .0001 par value common stock held by Pledgor in the Company which stock shall
be delivered to Pledgee upon the closing of the transaction between Planned

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Licensing, Inc., Joe Namath and James Walsh and Pledgor whereby Pledgor
among other things is purchasing the Pledged Stock.

         (g) “Proceeds” means all “proceeds” as such term is defined in Section
9-306(1) of the Uniform Commercial Code in effect in the State of Nevada on the
date hereof with respect to the Pledged Stock and, in any event, shall include,
without limitation, all dividends or other income paid on account of the
Pledged Stock, collections thereon or distributions with respect thereto.

         (h) “Stock Power” means “Irrevocable Stock or Bond Power” form.

     2. Pledge: Grant of Security Interest. The Pledgor hereby grants to the
Pledgee a first security interest in the Collateral, as collateral security for
the prompt and complete payment and performance when due (whether at the stated
maturity, by acceleration or otherwise) of the Obligation.

     3. Representations and Warranties. The Pledgor represents and warrants
that:

         (a) The Pledgor has the authority and the legal right to execute and
deliver, to perform his duties hereunder, and to grant the lien on the
Collateral pursuant to this Pledge Agreement, and have taken all necessary
action to authorize its execution, delivery and performance of, and grant of
the lien on the Collateral pursuant to this Pledge Agreement;

         (b) This Pledge Agreement constitutes a legal, valid and binding
obligation of the Pledgor enforceable in accordance with its terms, except as
enforceability may be limited by bankruptcy, insolvency, reorganization,
moratorium or similar laws affecting the enforcement of creditors’ rights
generally; and

         (c) The execution, delivery and performance of this Pledge Agreement by
the Pledgor will not violate any provision of any applicable law or contractual
obligation of the Pledgor and will not result in the creation or imposition of
any lien on any of the properties or revenues of the Pledgor pursuant to any
applicable law or contractual obligation of the Pledgor, except as contemplated
hereby.

     4. Covenants. The Pledgor covenants and agrees with the Pledgee that,
from and after the date of this Pledge Agreement until the Obligation is paid
in full:

         (a) If the Pledgor shall, as a result of its ownership of the Pledged
Stock, become entitled to receive or shall receive any stock certificate
(including, without limitation, any certificate representing a stock dividend
or a distribution in connection with any reclassification, increase or
reduction of capital or any certificate issued in connection with any
reorganization), option or rights, whether in addition to, in substitution of,
as a conversion of, or in exchange for any shares of the Pledged Stock, or

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otherwise in respect thereof, the Pledgor shall accept the same as the
Pledgee’s agent, and hold for the benefit of Pledgee. Any sums paid upon or in
respect of the Pledged Stock upon the liquidation or dissolution of the Company
shall be paid to Pledgee in satisfaction of the Obligation. If any sums of
money or property so paid or distributed in respect of the Pledged Stock shall
be received by the Pledgor, the Pledgor shall hold same for the Pledgee, as
additional collateral security for the Obligation. The Pledgee shall be
entitled to receive said additional collateral security which was issued as a
dividend if there has been a default in the Obligation.

         (b) Without the prior written consent of the Pledgee, the Pledgor will not
(i) sell, assign, transfer, exchange or otherwise dispose of, or grant any
option with respect to, the Collateral, or (ii) create, incur or permit to
exist any lien or option in favor of, or any claim of any Person with respect
to, any of the Collateral, or any interest therein, except for the lien
provided for by this Pledge Agreement.

     5. Rights of the Pledgee. If an event of default in respect of the Note
and Obligation shall occur (i) the Pledgee shall have the right to receive any
and all cash dividends paid in respect of the Pledged Stock and make
application thereof to the Obligation in such order as it may determine, and
(ii) all shares of the Pledged Stock shall be registered in the name of the
Pledgee or its nominee, and the Pledgee or its nominee may thereafter exercise
(A) all voting, corporate and other rights pertaining to such shares of the
Pledged Stock at any meeting of shareholders of the Company or otherwise, and
(B) any and all rights of conversion, exchange, subscription and any other
rights, privileges or options pertaining to such shares of the Pledged Stock as
if it were the absolute owner thereof (including, without limitation, the right
to exchange at its discretion any and all of the Pledged Stock upon the merger,
consolidation, reorganization, recapitalization or other fundamental change in
the corporate structure of the Company, or upon the exercise by the Pledgor or
the Pledgee of any right, privilege or option pertaining to such shares of the
Pledged Stock, and in connection therewith, the right to deposit and deliver
any and all of the Pledged Stock with any committee, depository, transfer
agent, registrar or other designated agency upon such terms and conditions as
it may determine), all without liability except to account for property
actually received by it, but the Pledgee shall have no duty to exercise any
such right, privilege or option and shall not be responsible for any failure to
do so or delay in so doing.

     6. Remedies. If an event of default in the Note shall occur Pledgee may
exercise, in addition to all other rights and remedies granted in this Pledge
Agreement and in any other instrument or agreement securing, evidencing or
relating to the Obligation, all rights and remedies of a secured party under
the Code.

     7. Severability. Any provision of this Pledge Agreement which is
prohibited or unenforceable in any jurisdiction shall, as to such jurisdiction,
be ineffective to the extent of such prohibition or unenforceability without
invalidating the remaining

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provisions hereof, and any such prohibition or unenforceability in any
jurisdiction shall not invalidate or render unenforceable such provision in any
other jurisdiction.

     8. Paragraph Headings. The paragraph headings used in this Pledge
Agreement are for convenience of reference only and are not to affect the
construction hereof or be taken into consideration in the interpretation
hereof.

     9. Waivers and Amendments; Successors and Assigns; Governing Law. None of
the terms or provisions of this Pledge Agreement may be waived, amended,
supplemented or otherwise modified except by a written instrument executed by
Pledgor and the Pledgee, provided that any right afforded to the Pledgee under
this Pledge Agreement may be waived by the Pledgee in a letter or agreement
executed by the Pledgee or by telex or facsimile transmission from the Pledgee.
This Pledge Agreement shall be binding upon the successors and assigns of the
Pledgor and shall inure to the benefit of the Pledgee and its successors and
assigns. This Pledge Agreement shall be governed by, and construed and
interpreted in accordance with, the laws of the State of Nevada and any action
shall be brought in the courts located in Clark County, Nevada.

     9. Notices. Notices by the Pledgee to the Pledgor may be given by
registered or certified mail, return receipt requested, addressed to: 8379 W.
Sunset Road, Las Vegas, Nevada 89113, by personal delivery or by overnight
courier, and shall be effective as of the date of receipt thereof.

     10. Termination of Agreement. When all of the Obligation has been
satisfied in full this Pledge Agreement shall terminate.

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     IN WITNESS WHEREOF, the undersigned have caused this Stock Pledge
Agreement to be duly executed and delivered as of the date first above written.

	 	 	 
	

	 	“PLEDGOR”
	 
	 	 
	

	 	VESTIN GROUP, INC., a Delaware
	

	 	corporation
	 
	 	 
	

	 	By:                                                                              
	

	 	         Name: John Alderfer
	

	 	         Title: Chief Financial Officer
	 
	 	 
	

	 	“PLEDGEE”
	 
	 	 
	

	 	SHUSTEK INVESTMENTS, INC., a
	

	 	Nevada corporation
	 
	 	 
	

	 	By:                                                                              
	

	 	         Name:
	

	 	         Title:

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Exhibit 10.1

MEDICAID MANAGED CARE MODEL CONTRACT

Amendment of Agreement

Between

Ulster County

And

WellCare of New York, Inc.

This Amendment, effective January 1, 2005, amends the Medicaid Managed Care
Model Contract (hereinafter referred to as the “Agreement”) made by and between
the County of Ulster (hereinafter referred to as “LDSS”) and WellCare of New
York, Inc. (hereinafter referred to as “MCO” or “Contractor”).

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

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

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

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

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

“Permanent Placement Status” means the status of an individual in a Residential
Health Care Facility [RHCF] when the LDSS determines that the individual is not
expected to return home based on medical evidence affirming the individual’s
need for permanent RHCF placement.

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

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

January 1, 2005 Amendment

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

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

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

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

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

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

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

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

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

January 1, 2005 Amendment

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

	c)	 	Other Financial Reports:
	 
	 	 	Contractor shall submit financial reports, including certified annual
financial statements, and make available documents relevant to its
financial condition to SDOH and the State Insurance Department (SID) in a
timely manner as required by State laws and regulations including but not
limited to PHL §§ 4403-a, 4404 and 4409, Title 10 NYCRR §§ 98.11, 98.16
and 98.17 and applicable Insurance Law §§ 304, 305, 306, and 310. The
LDSS reserves the right to require Contractor to submit such relevant
financial reports and documents related to the financial condition of the
MCO to the LDSS, as set forth in Section 18.5(n) of this Agreement.

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

	f)	 	Complaint Reports:
	 
	 	 	The Contractor must provide the SDOH on a quarterly basis, and within
fifteen (15) business days of the close of the quarter, a summary of all
complaints received during the preceding quarter on the Health Provider
Network (“HPN”).
	 
	 	 	The Contractor also agrees to provide on a quarterly basis, via the HPN, the
total number of complaints that have been unresolved for more than
forty-five (45) days. The Contractor shall maintain records on these and
other complaints which shall include all correspondence related to the
complaint, and an explanation of disposition. These records shall be readily
available for review by the SDOH or LDSS upon request.
	 
	 	 	Nothing in this Section is intended to limit the right of the SDOH and the
LDSS to obtain information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider complaint.
	 
	 	 	The LDSS reserves the right to require the Contractor to submit a hardcopy
of complaint reports in Section 18.5(n) of this Agreement.

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

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

January 1, 2005 Amendment

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This Amendment is effective January 1, 2005, and the Agreement, including the
modifications made by this Amendment, shall remain in effect until September
30, 2005 or until the execution of an extension, renewal or successor agreement
as provided for in the Agreement.

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

	 	 	 	 	 	 	 
	For the Contractor:	 	For the LDSS:
	 
	 	 	 	 	 	 
	By

	 	-s- Todd S. Farha
	 	By
	 	-s- Patricia Jelacic
	

	 	

	 	 	 	

	 
	 	 	 	 	 	 
	Todd S. Farha	 	Patricia Jelacic
	
	 	

	(Printed Name)	 	(Printed Name)
	 
	 	 	 	 	 	 
	Title

	 	President & Chief Executive Officer
	 	Title
	 	DEPUTY COMMISSIONER
	 
	 	 	 	 	 	 
	Date

	 	12/22/04
	 	Date
	 	12/28/04

January 1, 2005 Amendment

4

 

 

Table of Contents for
Model Contract

Recitals

	 	 	 	 	 	 	 	 	 	 	 
	Section 1	 	Definitions
	Section 2	 	Agreement Term, Amendments, Extensions, and General Contract Administration Provisions
	 	 	 	2.1	 	 	Term
	 	 	 	2.2	 	 	Amendments and Extensions
	 	 	 	2.3	 	 	Approvals
	 	 	 	2.4	 	 	Entire Agreement
	 	 	 	2.5	 	 	Renegotiation
	 	 	 	2.6	 	 	Assignment and Subcontracting
	 	 	 	2.7	 	 	Termination
	

	 	 	 	 	 	a.	 	 	LDSS Initiated Termination of Contract
	

	 	 	 	 	 	b.	 	 	Contractor and LDSS Initiated Termination
	

	 	 	 	 	 	c.	 	 	Contractor Initiated Termination
	

	 	 	 	 	 	d.	 	 	Termination Due to Loss of Funding
	 	 	 	2.8	 	 	Close-Out Procedures
	 	 	 	2.9	 	 	Rights and Remedies
	 	 	 	2.10	 	 	Notices
	 	 	 	2.11	 	 	Severability
	Section 3	 	Compensation
	 	 	 	3.1	 	 	Capitation Payments
	 	 	 	3.2	 	 	Modification of Rates During Contract Period
	 	 	 	3.3	 	 	Rate Setting Methodology
	 	 	 	3.4	 	 	Payment of Capitation
	 	 	 	3.5	 	 	Denial of Capitation Payments
	 	 	 	3.6	 	 	SDOH Right to Recover Premiums
	 	 	 	3.7	 	 	Third Party Health Insurance Determination
	 	 	 	3.8	 	 	Payment for Newborns
	 	 	 	3.9	 	 	Supplemental Maternity Capitation Payment
	 	 	 	3.10	 	 	Contractor Financial Liability
	 	 	 	3.11	 	 	Inpatient Hospital Stop-Loss Insurance
	 	 	 	3.12	 	 	Mental Health and Chemical Dependence Stop-Loss
	 	 	 	3.13	 	 	Residential Health Care Facility Stop-Loss
	 	 	 	3.14	 	 	Stop-Loss Procedures and Documentation
	 	 	 	3.15	 	 	Enrollment Limitations
	 	 	 	3.16	 	 	Tracking Visits Provided by Indian Health Clinics
	Section 4	 	Service Area
	Section 5	 	Eligible, Exempt and Excluded Populations
	 	 	 	5.1	 	 	Eligible Populations
	 	 	 	5.2	 	 	Exempt Populations
	 	 	 	5.3	 	 	Excluded Populations

TABLE OF CONTENTS

January 1, 2005

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Table of Contents for
Model Contract

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	5.4	 	 	Family Health Plus
	 	 	 	5.5	 	 	Family Enrollment
	Section 6	 	Enrollment
	 	 	 	6.1	 	 	Enrollment Guidelines
	 	 	 	6.2	 	 	Equality of Access to Enrollment
	 	 	 	6.3	 	 	Enrollment Decisions
	 	 	 	6.4	 	 	Auto Assignment
	 	 	 	6.5	 	 	Prohibition Against Conditions on Enrollment
	 	 	 	6.6	 	 	Family Enrollment
	 	 	 	6.7	 	 	Newborn Enrollment
	 	 	 	6.8	 	 	Effective Date of Enrollment
	 	 	 	6.9	 	 	Roster
	 	 	 	6.10	 	 	Automatic Re-Enrollment
	Section 7	 	Lock-In Provisions
	 	 	 	7.1	 	 	Lock-In Provisions in Voluntary Counties
	 	 	 	7.2	 	 	Lock-In Provisions in Mandatory Counties and New York City
	 	 	 	7.3	 	 	Disenrollment During Lock-In Period
	 	 	 	7.4	 	 	Notification Regarding Lock-In and End of Lock-In Period
	Section 8	 	Disenrollment
	 	 	 	8.1	 	 	Disenrollment Guidelines
	 	 	 	8.2	 	 	Disenrollment Prohibitions
	 	 	 	8.3	 	 	Reasons for Voluntary Disenrollment
	 	 	 	8.4	 	 	Processing of Disenrollment Requests
	

	 	 	 	 	 	a.	 	 	Routine Disenrollment
	

	 	 	 	 	 	b.	 	 	Expedited Disenrollment
	

	 	 	 	 	 	c.	 	 	Retroactive Disenrollment
	 	 	 	8.5	 	 	Contractor Notification of Disenrollments
	 	 	 	8.6	 	 	Contractor’s Liability
	 	 	 	8.7	 	 	Enrollee Initiated Disenrollment
	

	 	 	 	 	 	a.	 	 	Disenrollment for Good Cause
	 	 	 	8.8	 	 	Contractor Initiated Disenrollment
	 	 	 	8.9	 	 	LDSS Initiated Disenrollment
	Section 9	 	Guaranteed Eligibility
	Section 10	 	Benefit Package, Covered and Non-Covered Services
	 	 	 	10.1	 	 	Contractor Responsibilities
	 	 	 	10.2	 	 	Compliance with State Medicaid Plan and Applicable Laws
	 	 	 	10.3	 	 	Definitions
	 	 	 	10.4	 	 	Provision of Services Through Participating and Non-Participating Providers
	 	 	 	10.5	 	 	Child Teen Health Program / Adolescent Preventive Services
	 	 	 	10.6	 	 	Foster Care Children

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Table of Contents for
Model Contract

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	10.7	 	 	Child Protective Services
	 	 	 	10.8	 	 	Welfare Reform
	 	 	 	10.9	 	 	Adult Protective Services
	 	 	 	10.10	 	 	Court-Ordered Services
	 	 	 	10.11	 	 	Family Planning and Reproductive Health Services
	 	 	 	10.12	 	 	Prenatal Care
	 	 	 	10.13	 	 	Direct Access
	 	 	 	10.14	 	 	Emergency Services
	 	 	 	10.15	 	 	Medicaid Utilization Thresholds (MUTS)
	 	 	 	10.16	 	 	Services for Which Enrollees Can Self-Refer
	

	 	 	 	 	 	a.	 	 	Mental Health and Chemical Dependence Services
	

	 	 	 	 	 	b.	 	 	Vision Services
	

	 	 	 	 	 	c.	 	 	Diagnosis and Treatment of Tuberculosis
	

	 	 	 	 	 	d.	 	 	Family Planning and Reproductive Health Services
	

	 	 	 	 	 	e.	 	 	Article 28 Clinics Operated by Academic Dental Centers
	 	 	 	10.17	 	 	Second Opinions for Medical or Surgical Care
	 	 	 	10.18	 	 	Coordination with Local Public Health Agencies
	 	 	 	10.19	 	 	Public Health Services
	

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

	 	 	 	 	 	b.	 	 	Immunizations
	

	 	 	 	 	 	c.	 	 	Prevention and Treatment of Sexually Transmitted Diseases
	

	 	 	 	 	 	d.	 	 	Lead Poisoning
	 	 	 	10.20	 	 	Adults with Chronic Illnesses and Physical or Developmental Disabilities
	 	 	 	10.21	 	 	Children with Special Health Care Needs
	 	 	 	10.22	 	 	Persons Requiring Ongoing Mental Health Services
	 	 	 	10.23	 	 	Member Needs Relating to HIV
	 	 	 	10.24	 	 	Persons Requiring Chemical Dependence Services
	 	 	 	10.25	 	 	Native Americans
	 	 	 	10.26	 	 	Women, Infants, and Children (WIC)
	 	 	 	10.27	 	 	Urgently Needed Services
	 	 	 	10.28	 	 	Dental Services Provided by Article 28 Clinics Operated by 
Academic Dental Centers Not Participating in Contractor’s Network
	 	 	 	10.29	 	 	Coordination of Services
	 	 	 	10.30	 	 	Prospective Benefit Package Change for Retroactive SSI Determinations
	Section 11	 	Marketing
	 	 	 	11.1	 	 	Marketing Plan
	 	 	 	11.2	 	 	Marketing Activities
	 	 	 	11.3	 	 	Prior Approval of Marketing Materials, Procedures, Subcontracts
	 	 	 	11.4	 	 	Marketing Infractions
	 	 	 	11.5	 	 	LDSS Option to Adopt Additional Marketing Guidelines
	Section 12	 	Member Services
	 	 	 	12.1	 	 	General Functions
	 	 	 	12.2	 	 	Translation and Oral Interpretation

TABLE OF CONTENTS

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Table of Contents for
Model Contract

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	12.3	 	 	Communicating with the Visually, Hearing and Cognitively Impaired
	Section 13	 	Enrollee Notification
	 	 	 	13.1	 	 	Provider Directories/Office Hours for Participating Providers
	 	 	 	13.2	 	 	Member ID Cards
	 	 	 	13.3	 	 	Member Handbooks
	 	 	 	13.4	 	 	Notification of Effective Date of Enrollment
	 	 	 	13.5	 	 	Notification of Enrollee Rights
	 	 	 	13.6	 	 	Enrollee’s Rights to Advance Directives
	 	 	 	13.7	 	 	Approval of Written Notices
	 	 	 	13.8	 	 	Contractor’s Duty to Report Lack of Contact
	 	 	 	13.9	 	 	Contractor Responsibility to Notify Enrollee of Expected Effective Date of Enrollment
	 	 	 	13.10	 	 	LDSS Notification of Enrollee’s Change in Address
	 	 	 	13.11	 	 	Contractor Responsibility to Notify Enrollee of Effective Date of Benefit Package Change
	 	 	 	13.12	 	 	Contractor Responsibility to Notify Enrollee of Termination, Service Area Changes and Network Changes
	Section 14	 	Complaint and Appeal Procedure
	 	 	 	14.1	 	 	Contractor’s Program to Address Complaints
	 	 	 	14.2	 	 	Notification of Complaint and Appeal Program
	 	 	 	14.3	 	 	Guidelines for Complaint and Appeal Program
	 	 	 	14.4	 	 	Complaint Investigation Determinations
	Section 15	 	Access Requirements
	 	 	 	15.1	 	 	Appointment Availability Standards
	 	 	 	15.2	 	 	Twenty-Four (24) Hour Access
	 	 	 	15.3	 	 	Appointment Waiting Times
	 	 	 	15.4	 	 	Travel Time Standards
	

	 	 	 	 	 	a.	 	 	Primary Care
	

	 	 	 	 	 	b.	 	 	Other Providers
	 	 	 	15.5	 	 	Service Continuation
	

	 	 	 	 	 	a.	 	 	New Enrollees
	

	 	 	 	 	 	b.	 	 	Enrollees Whose Health Care Provider Leaves Network
	 	 	 	15.6	 	 	Standing Referrals
	 	 	 	15.7	 	 	Specialist as a Coordinator of Primary Care
	 	 	 	15.8	 	 	Specialty Care Centers
	Section 16	 	Quality Assurance
	 	 	 	16.1	 	 	Internal Quality Assurance Program
	 	 	 	16.2	 	 	Standards of Care
	Section 17	 	Monitoring and Evaluation
	 	 	 	17.1	 	 	Right To Monitor Contractor Performance
	 	 	 	17.2	 	 	Cooperation During Monitoring And Evaluation

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Table of Contents for
Model Contract

	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	17.3	 	 	Cooperation During On-Site Reviews
	 	 	 	17.4	 	 	Cooperation During Review of Services by External Review Agency
	Section 18	 	Contractor Reporting Requirements
	 	 	 	18.1	 	 	Time Frames for Report Submissions
	 	 	 	18.2	 	 	SDOH Instructions for Report Submissions
	 	 	 	18.3	 	 	Liquidated Damages
	 	 	 	18.4	 	 	Notification of Changes in Report Due Dates, Requirements or Formats
	 	 	 	18.5	 	 	Reporting Requirements
	

	 	 	 	 	 	a.	 	 	Annual Financial Statements
	

	 	 	 	 	 	b.	 	 	Quarterly Financial Statements
	

	 	 	 	 	 	c.	 	 	Other Financial Reports
	

	 	 	 	 	 	d.	 	 	Encounter Data
	

	 	 	 	 	 	e.	 	 	Quality of Care Performance Measures
	

	 	 	 	 	 	f.	 	 	Complaint Reports
	

	 	 	 	 	 	g.	 	 	Fraud and Abuse Reporting Requirements
	

	 	 	 	 	 	h.	 	 	Participating Provider Network Reports
	

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

	 	 	 	 	 	j.	 	 	Clinical Studies
	

	 	 	 	 	 	k.	 	 	Independent Audits
	

	 	 	 	 	 	l.	 	 	New Enrollee Health Screening Completion Report
	

	 	 	 	 	 	m.	 	 	Additional Reports
	

	 	 	 	 	 	n.	 	 	LDSS Specific Reports
	 	 	 	18.6	 	 	Ownership and Related Information Disclosure
	 	 	 	18.7	 	 	Revision of Certificate of Authority
	 	 	 	18.8	 	 	Public Access to Reports
	 	 	 	18.9	 	 	Professional Discipline
	 	 	 	18.10	 	 	Certification Regarding Individuals Who Have Been Debarred or Suspended by 
Federal or State Government
	 	 	 	18.11	 	 	Conflict of Interest Disclosure
	 	 	 	18.12	 	 	Physician Incentive Plan Reporting
	Section 19	 	Records Maintenance and Audit Rights
	 	 	 	19.1	 	 	Maintenance of Contractor Performance Records
	 	 	 	19.2	 	 	Maintenance of Financial Records and Statistical Data
	 	 	 	19.3	 	 	Access to Contractor Records
	 	 	 	19.4	 	 	Retention Periods
	Section 20	 	Confidentiality
	 	 	 	20.1	 	 	Confidentiality of Identifying Information about Medicaid Recipients and Applicants
	 	 	 	20.2	 	 	Medical Records of Foster Children
	 	 	 	20.3	 	 	Confidentiality of Medical Records
	 	 	 	20.4	 	 	Length of Confidentiality Requirements

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Table of Contents for
Model Contract

	 	 	 	 	 	 	 	 	 	 	 
	Section 21	 	Participating Providers
	 	 	 	21.1	 	 	Network Requirements
	

	 	 	 	 	 	a.	 	 	Sufficient Number
	

	 	 	 	 	 	b.	 	 	Absence of Appropriate Network Provider
	

	 	 	 	 	 	c.	 	 	Suspension of Enrollee Assignments to Providers
	

	 	 	 	 	 	d.	 	 	Notice of Provider Termination
	 	 	 	21.2	 	 	Credentialing
	

	 	 	 	 	 	a.	 	 	Licensure
	

	 	 	 	 	 	b.	 	 	Minimum Standards
	

	 	 	 	 	 	c.	 	 	Credentialing/Recredentialing Process
	

	 	 	 	 	 	d.	 	 	Application Procedure
	 	 	 	21.3	 	 	SDOH Exclusion or Termination of Providers
	 	 	 	21.4	 	 	Evaluation Information
	 	 	 	21.5	 	 	Payment In Full
	 	 	 	21.6	 	 	Choice/Assignment of PGPs
	 	 	 	21.7	 	 	PCP Changes
	 	 	 	21.8	 	 	Provider Status Changes
	 	 	 	21.9	 	 	PCP Responsibilities
	 	 	 	21.10	 	 	Member to Provider Ratios
	 	 	 	21.11	 	 	Minimum Office Hours
	

	 	 	 	 	 	a.	 	 	General Requirements
	

	 	 	 	 	 	b.	 	 	Medical Residents
	 	 	 	21.12	 	 	Primary Care Practitioners
	

	 	 	 	 	 	a.	 	 	General Limitations
	

	 	 	 	 	 	b.	 	 	Specialists and
Sub-specialists’ as PCPs
	

	 	 	 	 	 	c.	 	 	OB/GYN Providers as PCPs
	

	 	 	 	 	 	d.	 	 	Certified Nurse Practitioners as PCPs
	

	 	 	 	 	 	e.	 	 	Registered Physician’s Assistants as Physician Extenders
	 	 	 	21.13	 	 	PCP Teams
	

	 	 	 	 	 	a.	 	 	General Requirements
	

	 	 	 	 	 	b.	 	 	Medical Residents
	 	 	 	21.14	 	 	Hospitals
	

	 	 	 	 	 	a.	 	 	Tertiary Services
	

	 	 	 	 	 	b.	 	 	Emergency Services
	 	 	 	21.15	 	 	Dental Networks
	 	 	 	21.16	 	 	Presumptive Eligibility Providers
	 	 	 	21.17	 	 	Mental Health and Chemical Dependence Services Providers
	 	 	 	21.18	 	 	Laboratory Procedures
	 	 	 	21.19	 	 	Federally Qualified Health Centers (FQHCs)
	 	 	 	21.20	 	 	Provider Services Function
	Section 22	 	Subcontracts and Provider Agreements
	 	 	 	22.1	 	 	Written Subcontracts
	 	 	 	22.2	 	 	Permissible Subcontracts
	 	 	 	22.3	 	 	Provision of Services Through Provider Agreements
	 	 	 	22.4	 	 	Approvals

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	 	 	 	22.5	 	 	Required Components
	 	 	 	22.6	 	 	Timely Payment
	 	 	 	22.7	 	 	Restrictions on Disclosure
	 	 	 	22.8	 	 	Transfer of Liability
	 	 	 	22.9	 	 	Termination of Health Care Professional Agreements
	 	 	 	22.10	 	 	Health Care Professional Hearings
	 	 	 	22.11	 	 	Non-Renewal of Provider Agreements
	 	 	 	22.12	 	 	Physician Incentive Plan
	Section 23	 	Fraud and Abuse Prevention Plan
	Section 24	 	Americans With Disabilities Act Compliance Plan
	Section 25	 	Fair Hearings
	 	 	 	25.1	 	 	Enrollee Access to Fair Hearing Process
	 	 	 	25.2	 	 	Enrollee Rights to a Fair Hearing
	 	 	 	25.3	 	 	Contractor Notice to Enrollees
	 	 	 	25.4	 	 	Aid Continuing
	 	 	 	25.5	 	 	Responsibilities of SDOH
	 	 	 	25.6	 	 	Contractor’s Obligations
	Section 26	 	External Appeal
	 	 	 	26.1	 	 	Basis for External Appeal
	 	 	 	26.2	 	 	Eligibility For External Appeal
	 	 	 	26.3	 	 	External Appeal Determination
	 	 	 	26.4	 	 	Compliance With External Appeal Laws and Regulations
	Section 27	 	Intermediate Sanctions
	Section 28	 	Environmental Compliance
	Section 29	 	Energy Conservation
	Section 30	 	Independent Capacity of Contractor
	Section 31	 	No Third Party Beneficiaries
	Section 32	 	Indemnification
	 	 	 	32.1	 	 	Indemnification by Contractor
	 	 	 	32.2	 	 	Indemnification by LDSS
	Section 33	 	Prohibition on Use of Federal Funds for Lobbying
	 	 	 	33.1	 	 	Prohibition of Use of Federal Funds for Lobbying
	 	 	 	33.2	 	 	Disclosure Form to Report Lobbying
	 	 	 	33.3	 	 	Requirements of Subcontractors

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	Section 34	 	Non-Discrimination
	 	 	 	34.1	 	 	Equal Access to Benefit Package
	 	 	 	34.2	 	 	Non-Discrimination
	 	 	 	34.3	 	 	Equal Employment Opportunity
	 	 	 	34.4	 	 	Native Americans Access to Services From Tribal or Urban Indian Health Facility
	Section 35	 	Compliance with Applicable Laws
	 	 	 	35.1	 	 	Contractor and LDSS Compliance With Applicable Laws
	 	 	 	35.2	 	 	Nullification of Illegal, Unenforceable, Ineffective or Void Contract Provisions
	 	 	 	35.3	 	 	Certificate of Authority Requirements
	 	 	 	35.4	 	 	Notification of Changes In Certificate of Incorporation
	 	 	 	35.5	 	 	Contractor’s Financial Solvency Requirements
	 	 	 	35.6	 	 	Compliance With Care For Maternity Patients
	 	 	 	35.7	 	 	Informed Consent Procedures for Hysterectomy and Sterilization
	 	 	 	35.8	 	 	Non-Liability of Enrollees For Contractor’s Debts
	 	 	 	35.9	 	 	LDSS Compliance With Conflict of Interest Laws
	 	 	 	35.10	 	 	Compliance With PHL Regarding External Appeals
	Section 36	 	New York State Standard Contract Clauses
	Section 37	 	Insurance Requirements 
	Signature Page
	 

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APPENDICES

	A.	 	New York State Standard Clauses and Local Standard Clauses, if applicable
	 
	B.	 	Certification Regarding Lobbying
	 
	C.	 	New York State Department of Health Guidelines for the Provision of
Family Planning and Reproductive Health Services
	 
	D.	 	New York State Department of Health Marketing Guidelines
	 
	E.	 	New York State Department of Health Member Handbook Guidelines
	 
	F.	 	New York State Department of Health Medicaid Managed Care Complaint and
Appeals Requirements
	 
	G.	 	New York State Department of Health Guidelines for the Provision of
Emergency Care and Services
	 
	H.	 	New York State Department of Health Guidelines for the Processing
of Enrollments and Disenrollments
	 
	I.	 	New York State Department of Health Guidelines for Use of Medical
Residents
	 
	J.	 	New York State Department of Health Guidelines of Federal
Americans with Disabilities Act
	 
	K.	 	Prepaid Benefit Package Definitions of Covered and Non-Covered Services
	 
	L.	 	Approved Capitation Payment Rates
	 
	M.	 	Service Area
	 
	N.	 	Contractor-County Specific Agreements

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APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND

NON-COVERED SERVICES

APPENDIX K

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K-l

 

 

APPENDIX K

PREPAID BENEFIT PACKAGE

DEFINITIONS OF COVERED AND NON-COVERED SERVICES

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

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

This Appendix contains the following two (2) charts:

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

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

Also included:

	I.	 	Prepaid Benefit Package Definitions of Covered Services

	 	A)	 	Medical Services

	 	1.	 	Inpatient Hospital Services
	 
	 	la.	 	Inpatient Stay Pending Alternate Level of Medical Care
	 
	 	2.	 	Professional Ambulatory Services
	 
	 	3.	 	Physician Services
	 
	 	4.	 	Home Health Services
	 
	 	5.	 	Private Duty Nursing Services
	 
	 	6.	 	Emergency Room Services
	 
	 	7.	 	Services of Other Practitioners
	 
	 	8.	 	Eye Care and Low Vision Services
	 
	 	9.	 	Laboratory Services
	 
	 	10.	 	Radiology Services
	 
	 	11.	 	Early Periodic Screening
Diagnosis and Treatment (EPSDT)
Services Through the Child Teen Health Program
(C/THP) and
Adolescent Preventive Services
	 
	 	12.	 	Durable Medical Equipment (DME)
	 
	 	13.	 	Audiology, Hearing Aid Services and Products
	 
	 	14.	 	Preventive Care
	 
	 	15.	 	Prosthetic/Orthotic Orthopedic Footwear
	 
	 	16.	 	Renal Dialysis

APPENDIX K

January 1, 2005

K-2

 

 

	 	17.	 	Experimental or Investigational Treatment
	 
	 	18.	 	Residential Health Care Facility (RHCF) Services

	 	B)	 	Behavioral Health Services

	 	1.	 	Chemical Dependence Services

	 	a)	 	Detoxification Services

	 	i)	 	Medically Managed Inpatient Detoxification
	 
	 	ii)	 	Medically Supervised Withdrawal

	 	b)	 	Chemical Dependence Inpatient
Rehabilitation and Treatment
Services
	 
	 	c)	 	Chemical Dependence Assessment Self-Referral

	 	2.	 	Mental Health Services

	 	a)	 	Inpatient Services
	 
	 	b)	 	Outpatient Services

	 	C)	 	Other Covered Services

	 	1.	 	Federally Qualified Health Center (FQHC) Services

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

	 	A)	 	Family Planning and Reproductive Health Care
	 
	 	B)	 	Dental Services
	 
	 	C)	 	Transportation Services

	 	1.	 	Non-Emergency Transportation
	 
	 	2.	 	Emergency Transportation

	III.	 	Definitions of Non-Covered Services

	 	A)	 	Medical Non-Covered Services

	 	1.	 	Personal Care Agency Services
	 
	 	2.	 	Residential Health Care Facilities (RHCF)
	 
	 	3.	 	Hospice Program
	 
	 	4.	 	Prescription and Non-Prescription
(OTC) Drugs, Medical Supplies,
and Enteral Formula

	 	B)	 	Non-Covered Behavioral Health Services

	 	1.	 	Chemical Dependence Services

	 	a)	 	Outpatient Rehabilitation and Treatment Services

	 	i)	 	Methadone Maintenance Treatment Program (MMTP)
	 
	 	ii)	 	Medically Supervised Ambulatory
Chemical
Dependence Outpatient Clinic Programs
	 
	 	iii)	 	Medically Supervised Chemical
Dependence
Outpatient Rehabilitation Programs
	 
	 	iv)	 	Outpatient Chemical Dependence for Youth Programs

	 	b)	 	Chemical Dependence Services Ordered by the LDSS

	 	2.	 	Mental Health Services

	 	a)	 	Intensive
Psychiatric Rehabilitation Treatment Programs
(IPRT)

APPENDIX K

January 1, 2005

K-3

 

 

	 	b)	 	Day Treatment
	 
	 	c)	 	Continuing Day Treatment
	 
	 	d)	 	Day Treatment Programs Serving Children
	 
	 	e)	 	Home and Community Based
Services Waiver for Seriously
Emotionally Disturbed Children
	 
	 	f)	 	Case Management
	 
	 	g)	 	Partial Hospitalization
	 
	 	h)	 	Services Provided through OMH Designated Clinics
for
Children With a Diagnosis of Serious Emotional
Disturbance (SED)
	 
	 	i)	 	Assertive Community Treatment (ACT)
	 
	 	j)	 	Personalized Recovery Oriented Services
(PROS)

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

	 	a)	 	OMH Licensed CRs

	 	b)	 	 Family-Based Treatment

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

	 	a)	 	Long Term Therapy Services
Provided by Article 16-Clinic
Treatment Facilities or Article 28 Facilities
	 
	 	b)	 	Day Treatment
	 
	 	c)	 	Medicaid Service Coordination (MSC)

	 
	 	d)	 	 Home and Community Based Services Waivers (HCBS)

	 
	 	e)	 	Medicaid Service Coordination (MSC)
Services Provided
Through the Care at Home Program
(OMRDD)

	 	C)	 	Other Non-Covered Services

	 	1.	 	The Early Intervention Program
(EIP) - Children Birth to Two (2)
Years of Age
	 
	 	2.	 	Preschool Supportive Health
Services - Children Three (3)
Through Four (4) Years of Age
	 
	 	3.	 	School Supportive Health Services
 - Children Five (5) Through
Twenty-One (21) Years of Age
	 
	 	4.	 	Comprehensive Medicaid Case Management (CMCM)
	 
	 	5.	 	Directly Observed Therapy for Tuberculosis Disease
	 
	 	6.	 	AIDS Adult Day Health Care
	 
	 	7.	 	HIV COBRA Case Management
	 
	 	8.	 	Fertility Services
	 
	 	9.	 	Adult Day Health Care
	 
	 	10.	 	Personal Emergency Response Systems (PERS)
	 
	 	11.	 	School-Based Health Centers

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

APPENDIX K

January 1, 2005

K-4

 

 

APPENDIX K-1

MANAGED CARE PLAN PREPAID BENEFIT PACKAGE

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

	Inpatient Hospital Services

	 	Up to 365 medically necessary
days per year (366 for leap year)
in accordance with the stop-loss
provisions of Section 3.10 of
this Agreement. Includes
inpatient detoxification services
provided in Article 28 hospitals
for all Enrollees. Inpatient
dental services are covered. (See
dental definition)	 	 
	 
	 	 	 	 
	Inpatient Stay Pending
Alternate Level of Medical Care

	 	Continued care in a hospital
pending placement in an alternate
lower medical level of care,
consistent with the provisions of
18 NYCRR 505.20 and 10 NYCRR,
Part 85.	 	 
	 
	 	 	 	 
	Professional Ambulatory Services

	 	Provided through ambulatory care
facilities including hospital
outpatient departments, D&T
centers, and emergency rooms.
Services include medical,
surgical, preventive, primary,
rehabilitative, specialty care,
mental health, family planning,
C/THP services and ambulatory
dental surgery. Covered as needed
based on medical necessity.	 	 
	 
	 	 	 	 
	Preventive Health Services

	 	Care or service to avert
disease/illness and/or its
consequences. Preventive care
includes primary care, secondary
care and tertiary care. Coverage
includes general health education
classes, smoking cessation
classes, childbirth education
classes, parenting classes and
nutrition counseling (with
targeted outreach to persons with
diabetes and pregnant women). HIV
counseling and testing is a
covered service for all
Enrollees.	 	 
	 
	 	 	 	 
	Laboratory Services

	 	Covered when medically necessary
as ordered by a qualified medical
professional, and when listed in
the Medicaid fee schedule.
Coverage excludes HIV phenotypic,
HIV virtual phenotypic and HIV
genotypic drug resistance tests.
	 	HIV phenotypic, HIV virtual
phenotypic and HIV genotypic drug
resistance tests with a Provider’s
order.
	 
	 	 	 	 
	Radiology Services

	 	Covered when medically necessary
as ordered by a qualified medical
professional, and when ordered
and provided by a qualified
medical
professional/practitioner.	 	 
	 
	 	 	 	 
	EPSDT Services/Child Teen

Health Program (C/THP)

	 	EPSDT is a package of early and
periodic screening, including
inter-periodic screens and,
diagnostic and treatment services
that are offered to all Medicaid
eligible children under
twenty-one (21) years of age
known in New York State as the
Child Teen Health Program
(C/THP).
	 	Services not included in the
managed care Benefit Package
ordered by the child’s physician
based on the results of a
screening.

APPENDIX K

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K-5

 

 

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

	Home Health Services

	 	Home health care services include medically
necessary nursing, home health aide
services, equipment and appliances, physical
therapy, speech/language pathology,
occupational therapy, social work services
or nutritional services provided by a home
health care agency pursuant to an
established care plan. Personal care tasks
performed by a home health aide in
connection with a home health care agency
visit, and pursuant to an established care
plan, are covered.
	 	Services rendered by a personal care agency
which are approved by the Local Social
Services District when ordered by the
Enrollee’s Primary Care Provider (PCP). The
district will determine the applicant’s need
for personal care agency services and
coordinate a plan of care with the personal
care agency.
	 
	 	 	 	 
	Private Duty Nursing Services

	 	Covered service when medically necessary in
accordance with the ordering physician,
registered physician assistant or certified
nurse practitioner’s written treatment plan.	 	 
	 
	 	 	 	 
	Emergency Room Services

	 	Covered for emergency conditions, medical or
behavioral, the onset of which is sudden,
manifesting itself by symptoms of sufficient
severity, including severe pain, that a
prudent layperson, possessing an average
knowledge of medicine and health, could
reasonably expect the absence of medical
attention to result in (a) placing the
health of the person afflicted with such
condition in serious jeopardy, or in the
case of a behavioral condition placing the
health of such person or others in serious
jeopardy; (b) serious impairment of such
person’s bodily functions; (c) serious
dysfunction of any bodily organ or part of
such person; or (d) serious disfigurement of
such person. Emergency services include
health care procedures, treatments or
services, including psychiatric
stabilization and medical detoxification
from drugs or alcohol that are provided for
an emergency medical condition. A medical
assessment (triage) is covered for
non-emergent conditions.	 	 
	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (any age)
physical condition poses a hazard due to the
presence of localized illness, injury or
symptoms involving the foot, or when
performed as a necessary and integral part
of otherwise covered services such as the
diagnosis and treatment of diabetes, ulcers,
and infections.	 	 
	 
	 	 	 	 
	Eye Care and Low Vision Services

	 	Eye care includes the services of an
ophthalmologist, optometrist and an
ophthalmic dispenser and coverage for
contact lenses, polycarbonate lenses,
artificial eyes and replacement of lost or
destroyed glasses (including repairs) when
medically necessary.

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

APPENDIX K

January 1, 2005

K-6

 

 

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

	Durable Medical Equipment (DME)

	 	DME are devices and equipment other than
medical/surgical supplies, enteral
formula, and prosthetic or orthotic
appliances. Covered when medically
necessary as ordered by a Contractor’s
Participating Provider and procured from
a Participating Provider. Coverage
excludes disposable medical/surgical
supplies and enteral formula.
	 	Excluded services, such as disposable medical/surgical supplies
and enteral formula with a Provider’s order.
	 
	 	 	 	 
	Hearing Aids Services

	 	Provided when medically necessary to
alleviate disability caused by the loss
or impairment of hearing. Hearing aid
products include hearing aids, earmolds,
special fittings, and replacement parts.
Coverage excludes hearing aid batteries.
	 	Excluded services, such as hearing aid batteries
with a Provider’s order.
	 
	 	 	 	 
	Family Planning and Reproductive Health
Services

See Schedule A of Appendix K for Coverage
Status

	 	Family planning means the offering,
arranging, and furnishing of those health
services which enable individuals,
including minors, who may be sexually
active, to prevent or reduce the
incidence of unintended pregnancies and
includes the screening, diagnosis and
treatment, as medically necessary, for
sexually transmissible diseases,
sterilization services and screening for
pregnancy. Reproductive health services
also includes all medically necessary
abortions.
	 	Enrollees may always obtain family planning and HIV testing and
counseling services, when part of a family planning visit,
outside of the plan’s network from any Provider that accepts
Medicaid.

APPENDIX K

January 1, 2005

K-7

 

 

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

	Transportation Services

Non-Emergency Transportation

See Schedule A of Appendix K for Coverage
Status

	 	Non-Emergency Transportation:

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

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

For Enrollees with disabilities, the method of
transportation must reasonably accommodate their
needs, taking into account the severity and
nature of the disability.
	 	For Contractors that do not cover
transportation services, these services are
paid for fee-for-service. Non-emergent
transportation requests should be referred to
the LDSS.

For Contractors that cover non-emergency
transportation in the Benefit Package,
transportation costs to MMTP services may be
reimbursed by Medicaid fee-for-service in
accordance with the LDSS transportation
polices in local districts where there is a
systematic method to discretely identify and
reimburse such transportation costs.
	 
	 	 	 	 
	Emergency Transportation

See Schedule A of Appendix K for Coverage
Status

	 	Emergency Transportation

Emergency transportation can only be provided by
an ambulance service. Emergency transportation
is covered for Enrollees suffering from severe,
life-threatening or potentially disabling
conditions which require the provision of
emergency medical services while the Enrollee is
being transported.
	 	 
	 
	 	 	 	 
	Dental Services

See Schedule A of Appendix K for Coverage
Status

	 	Optional Benefit Package dental services include:

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

As described in Sections 10.16 and 10.28 of this
Agreement, Enrollees may self-refer to Article
28 clinics operated by academic dental centers
to obtain covered dental services.

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

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

Coverage excludes the professional services of
the dentist if dental services are not covered
by the Contractor’s Benefit Package.
	 	Routine exams, orthodontic services and
appliances, dental office surgery, fillings,
prophylaxis, provided to Enrollees of plans
not electing to cover dental services.

Orthodontic services are always covered by
fee-for-service.

APPENDIX K

January 1, 2005

K-8

 

 

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

	Court-Ordered Services

	 	Coverage includes such services
ordered by a court of competent
jurisdiction if the services are
in the Contractor’s Benefit
Package.	 	 
	 
	 	 	 	 
	Prosthetic/Orthotic

Services/Orthopedic

Footwear

	 	Covered when medically necessary
as ordered by the Contractor’s
Participating Provider.	 	 
	 
	 	 	 	 
	Mental Health Services

	 	Covered when medically necessary,
in accordance with the stop-loss
provisions as described in
Section 3.12 of this Agreement.
Enrollees must be allowed to
self-refer for one (1) mental
health assessment from a
Contractor’s Participating
Provider in a twelve (12) month
period. In the case of children,
such self-referrals may originate
at the request of a school
guidance counselor or similar
source.
	 	All services in excess of twenty
(20) outpatient visits and thirty
(30) inpatient days in accordance
with the stop-loss provisions in
Section 3.12 of this Agreement.
Contractor continues to reimburse
mental health service providers
and coordinate care. The
Contractor is reimbursed for
payment through the stop-loss
provisions.
	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary
on either an inpatient or
outpatient basis. Such services
are referred to as “Medically
Managed Detoxification Services”
when provided in facilities
licensed under Title 14 NYCRR
Part 816.6 or Article 28 of the
Public Health Law; and “Medically
Supervised Inpatient and
Outpatient Withdrawal Services”
when provided in facilities
licensed under Title 14 NYCRR
Part 8 16.7.
	 	Medically Supervised Inpatient and
Outpatient Withdrawal Services,
when ordered by the LDSS under
Welfare Reform (as indicated by
“code 83”).
	 
	 	 	 	 
	Chemical Dependence
Inpatient
Rehabilitation and
Treatment Services

	 	Covered when medically necessary
in accordance with the stop-loss
provisions described in Section
3.12 of this Agreement.
	 	Chemical Dependence Inpatient
Rehabilitation and Treatment
Services when ordered by the LDSS
under Welfare Reform (as indicated
by “code 83”)
	 
	 	 	 	 
	Chemical Dependence

Assessment

Self-Referral

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

Investigational

Treatment

	 	Covered on a case by case basis
in accordance with the provisions
of Section 4910 of the New York
State P.H.L.	 	 
	 
	 	 	 	 
	Renal Dialysis

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

Care Facility (RHCF)

Services

	 	Residential Health Care Facility
Services means inpatient nursing
home services provided by
facilities licensed under New
York State Public Health Law,
including AIDS nursing
facilities. Covered services
include the following health care
services: medical supervision,
24-hour per day nursing care,
assistance with the activities of
daily living, physical therapy,
occupational therapy, and
speech/language pathology
services and other services as
specified in the New York State
Public Health Law and Regulations
for residential health care
facilities and AIDS nursing
facilities. RHCF Services are
subject to the stop-loss
provisions specified in Section
3.13 of this Agreement.	 	 

APPENDIX K

January 1, 2005

K-9

 

 

K-2

MANAGED CARE PLAN PREPAID HEALTH ONLY BENEFIT PACKAGE

For SSI and SSI Related Recipients

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

	Inpatient Hospital Services

	 	Up to 365 medically necessary days per year
(366 for leap year) in accordance with the
stop-loss provisions of Section 3.10 of this
Agreement. Includes inpatient detoxification
services provided in Article 28 hospitals for
all Enrollees. Inpatient dental services are
covered.	 	 
	 
	 	 	 	 
	Inpatient Stay Pending Alternate Level of
Medical Care

	 	Continued care in a hospital pending
placement in an alternate lower medical level
of care, consistent with the provisions of 18
NYCRR 505.20 and 10 NYCRR, Part 85.	 	 
	 
	 	 	 	 
	Professional Ambulatory Services

	 	Provided through ambulatory care facilities
including hospital outpatient departments,
D&T centers, and emergency rooms. Services
include medical, surgical, preventive,
primary, rehabilitative, specialty care,
family planning, C/THP services and
ambulatory dental surgery. Covered as needed
based on medical necessity.
	 	Mental Health and Chemical Dependence services.
	 
	 	 	 	 
	EPSDT Services/ Child Teen Health Program
(C/THP)

	 	EPSDT is a package of early and periodic
screening, including inter-periodic screens
and diagnostic and treatment services that
are offered to all Medicaid eligible children
under twenty-one (21) years of age, known in
New York State as the Child Teen Health Plan
(C/THP).
	 	Services not included in the managed care
Benefit Package ordered by the child’s
physician based on the results of a screening.
	 
	 	 	 	 
	Preventive Health Services

	 	Care and services to avert disease/illness
and/or its consequences. Preventive care
includes primary care, secondary care and
tertiary care. Coverage includes general
health education classes, smoking cessation
classes, childbirth education classes,
parenting classes and nutrition counseling
(with targeted outreach to persons with
diabetes and pregnant women). HIV counseling
and testing is a covered service for all
Enrollees.	 	 
	 
	 	 	 	 
	Home Health Services

	 	Home health care services include medically
necessary nursing, home health aide services,
equipment and appliances, physical therapy,
speech/language pathology, occupational
therapy, social work services or nutritional
services provided by a home health care
agency pursuant to an established care plan.
Personal care tasks performed by a home
health aide in connection with a home health
care agency visit, and pursuant to an
established care plan, are covered.
	 	Services rendered by a personal care agency
which are approved by the Local Social
Services District when ordered by the
Enrollee’s Primary Care Provider (PCP). The
district will determine the applicant’s need
for personal care agency services and
coordinate with the personal care agency a
plan of care.

APPENDIX K

January 1, 2005

K-10

 

 

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

	Private Duty Nursing Services

	 	Covered service when medically
necessary in accordance with the
ordering physician, registered
physician assistant or certified
nurse practitioner’s written
treatment plan.	 	 
	 
	 	 	 	 
	Emergency Room Services

	 	Covered for emergency conditions,
medical or behavioral, the onset
of which is sudden, manifesting
itself by symptoms of sufficient
severity, including severe pain,
that a prudent layperson,
possessing an average knowledge
of medicine and health, could
reasonably expect the absence of
medical attention to result in
(a) placing the health of the
person afflicted with such
condition in serious jeopardy, or
in the case of a behavioral
condition placing the health of
such person or others in serious
jeopardy; (b) serious impairment
of such person’s bodily
functions; (c) serious
dysfunction of any bodily organ
or part of such person; or (d)
serious disfigurement of such
person. Emergency services
include health care procedures,
treatments or services, including
psychiatric stabilization and
medical detoxification from drugs
or alcohol that are provided for
an emergency medical condition. A
medical assessment (triage) is
covered for non-emergent
conditions.	 	 
	 
	 	 	 	 
	Foot Care Services

	 	Foot care when the Enrollee’s (of
any age) physical condition poses
a hazard due to the presence of
localized illness, injury or
symptoms involving the foot, or
when performed as a necessary and
integral part of otherwise
covered services such as the
diagnosis and treatment of
diabetes, ulcers, and infections.	 	 
	 
	 	 	 	 
	Eye Care and Low Vision
Services

	 	Eye care includes the services of
an ophthalmologist, optometrist
and an ophthalmic dispenser and
coverage for contact lenses,
polycarbonate lenses, artificial
eyes and replacement of lost or
destroyed glasses (including
repairs) when medically
necessary. 

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

APPENDIX K

January 1, 2005

K-ll

 

 

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

	Dental Services

See Schedule A of Appendix K for Coverage
Status

	 	Optional Benefit Package dental services
include:

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

As described in Sections 10.16 and 10.28 of
this Agreement, Enrollees may self-refer to
Article 28 clinics operated by academic
dental centers to obtain covered dental
services.

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

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

Coverage excludes the professional services
of the dentist if dental services are not
covered by the Contractor’s Benefit Package.
	 	Routine exams, orthodontic services and
appliances, dental office surgery, fillings,
prophylaxis, provided to Enrollees of MCOs
not electing to cover dental services.
	 
	 	 	 	 
	Family Planning and Reproductive Health
Services

See Schedule A of Appendix K for Coverage
Status

	 	Family planning means the offering,
arranging, and furnishing of those health
services which enable individuals, including
minors, who may be sexually active, to
prevent or reduce the incidence of unintended
pregnancies and includes the screening,
diagnosis and treatment, as medically
necessary, for sexually transmissible
diseases, sterilization services and
screening for pregnancy. Reproductive
health services also includes all medically
necessary abortions.
	 	Enrollees may always obtain family planning
and HIV testing and counseling services, when
part of a family planning visit, outside of
the Contractor’s network from any Provider
that accepts Medicaid.

APPENDIX K

January 1, 2005

K-12

 

 

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

	Transportation Services

Non-Emergency
Transportation:

See Schedule A of
Appendix K for Coverage
Status

	 	Non-Emergency Transportation:

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

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

For Enrollees with disabilities,
the method of transportation must
reasonably accommodate their
needs, taking into account the
severity and nature of the
disability.
	 	For Contractors that do not cover
transportation services, these
services are paid for
fee-for-service. Non-emergent
transportation requests should be
referred to the LDSS.

For Contractors that cover
non-emergency transportation in
the Benefit Package,
transportation costs to MMTP
services may be reimbursed by
Medicaid fee-for-service in
accordance with the LDSS
transportation polices in local
districts where there is a
systematic method to discretely
identify and reimburse such
transportation costs.
	 
	 	 	 	 
	Emergency Transportation:

See Schedule A of
Appendix K for Coverage
Status

	 	Emergency Transportation

Emergency transportation can only
be provided by an ambulance
service. Emergency transportation
is covered for Enrollees
suffering from severe,
life-threatening or potentially
disabling conditions which
require the provision of
emergency medical services while
the Enrollee is being
transported.	 	 
	 
	 	 	 	 
	Laboratory Services

	 	Covered when medically necessary
as ordered by a medical
professional, and when listed in
the Medicaid fee schedule.
Coverage excludes HIV phenotypic,
HIV virtual phenotypic and HIV
genotypic drug resistance tests.
	 	HIV phenotypic, HIV virtual
phenotypic and HIV genotypic drug
resistance tests with a Provider’s
order.
	 
	 	 	 	 
	Radiology Services

	 	Covered when medically necessary
as ordered by a medical
professional, and when ordered
and provided by a qualified
medical
professional/practitioner.	 	 
	 
	 	 	 	 
	Durable Medical

Equipment (DME)

	 	DME are devices and equipment
other than medical/surgical
supplies enteral formula, and
prosthetic or orthotic
appliances. Covered when
medically necessary as ordered by
the Contractor’s Participating
Provider and procured from a
Participating Provider. Coverage
excludes disposable
medical/surgical supplies and
enteral formula.
	 	Excluded services, such
as disposable
medical/surgical supplies and
enteral formula with a Provider’s
order.

APPENDIX K

January 1, 2005

K-13

 

 

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

	Hearing Aid Services

	 	Provided when medically necessary
to alleviate disability caused by
the loss or impairment of
hearing. Hearing aid products
include hearing aids, earmolds,
special fittings, and replacement
parts. Coverage excludes hearing
aid batteries.
	 	Excluded services, such as hearing
aid batteries with a Provider’s
order.
	 
	 	 	 	 
	Court-Ordered Services

	 	Coverage includes such services
ordered by a court of competent
jurisdiction if the services are
in the Contractor’s Benefit
Package.	 	 
	 
	 	 	 	 
	Prosthetic/Orthotic

Services/ Orthotic
Footwear

	 	Covered when medically necessary
as ordered by a managed care plan
qualified medical professional.	 	 
	 
	 	 	 	 
	Renal Dialysis

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

Inyestigational
Treatment

	 	Covered on a case by case basis
in accordance with the provisions
of Section 4910 of the New York
State P.H.L.	 	 
	 
	 	 	 	 
	Detoxification Services

	 	Covered when medically necessary
on either an inpatient or
outpatient basis. Such services
are referred to as “Medically
Managed Detoxification Services”
when provided in facilities
licensed under Title 14 NYCRR
Part 816.6 or Article 28 of the
Public Health Law; and “Medically
Supervised Inpatient and
Outpatient Withdrawal Services”
when provided in facilities
licensed under Title 14 NYCRR
Part 816.7.	 	 
	 
	 	 	 	 
	Residential Health

Care Facility (RHCF)
Services

	 	Residential Health Care Facility
Services means inpatient nursing
home services provided by
facilities licensed under New
York State Public Health Law,
including AIDS nursing
facilities. Covered services
include the following health care
services: medical supervision,
24-hour per day nursing care,
assistance with the activities of
daily living, physical therapy,
occupational therapy, and
speech/language pathology
services and other services as
specified in the New York State
Public Health Law and Regulations
for residential health care
facilities and AIDS nursing
facilities. RHCF Services are
subject to the stop-loss
provisions specified in Section
3.13 of this Agreement.	 	 

APPENDIX K

January 1, 2005

K-14

 

 

	I.	 	PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES

A. Medical Services

1. Inpatient Hospital Services

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

1 a. Inpatient Stay Pending Alternate Level of Medical Care

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

2. Professional Ambulatory Services

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

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

3. Physician Services

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

	 	(1)	 	within the scope of practice of medicine or osteopathy as
defined in law by the New
York State Education Department; and
	 
	 	(2)	 	by or under the personal supervision of an individual
licensed and currently registered
by the New York State Education Department to practice medicine or
osteopathy.

APPENDIX K

January 1, 2005

K-15

 

 

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

The following are also included without limitations:

	•	 	pharmaceuticals and medical supplies routinely furnished or
administered as part of a clinic or office visit;
	 
	•	 	physical examinations, including those which are necessary for employment, school, and camp;
	 
	•	 	physical and/or mental health, or chemical dependence examinations of
children and their parents as requested by the LDSS to fulfill its statutory responsibilities for the protection of
children and adults and for children in foster care;
	 
	•	 	health and mental health assessments for the purpose of making recommendations regarding a Enrollee’s disability status for Federal SSI applications;
	 
	•	 	health assessments for the Infant /Child Assessment Program (ICHAP);
	 
	•	 	annual preventive health visits for adolescents;
	 
	•	 	new admission exams for school children if required by the LDSS;
	 
	•	 	health screening, assessment and treatment of refugees, including completing SDOH/LDSS required forms;
	 
	•	 	Child/Teen Health Program (C/THP) services which are comprehensive primary health care services provided to children under twenty-one (21) years of age (see
Section 10 of this Agreement).

	4.	 	Home Health Services

 18 NYCRR 505.23(a)(3)

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

	•	 	nursing services provided on a part-time or intermittent basis by a CHHA or, if
there is no CHHA that services the county/district, by a registered professional
nurse or a licensed practical nurse acting under the direction of the Enrollee’s
PCP;
	 
	•	 	physical therapy, occupational therapy, or speech pathology and audiology services; and
	 
	•	 	home health services provided by a person who meets the training requirements of the SDOH, is assigned by a registered professional nurse to
provide home health aid services in accordance with the Enrollee’s plan of care, and is supervised by a registered professional nurse from a CHHA or if
the Contractor has no CHHA available, a registered nurse, or therapist.

APPENDIX K

January 1, 2005

K-16

 

 

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

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

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

5. Private Duty Nursing Services

Private duty nursing services shall be provided by a person possessing a
license and current registration from the NYS Education Department to practice
as a registered professional nurse or licensed practical nurse. Private duty
nursing services can be provided through an approved certified home health
agency, a licensed home care agency, or a private Practitioner. The location
of nursing services may be in the Enrollee’s home or in the hospital.

Private duty nursing services are covered only when determined by the
attending physician to be medically necessary. Nursing services may be
intermittent, part-time or continuous and provided in accordance with the
ordering physicians, or certified nurse practitioner’s written treatment plan.

6. Emergency Room Services

Emergency conditions, medical or behavioral, the onset of which is sudden,
manifesting itself by symptoms of sufficient severity, including severe pain,
that a prudent layperson, possessing an average knowledge of medicine and
health, could reasonably expect the absence of medical attention to result in
(a) placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition placing the health of such
person or others in serious jeopardy; (b) serious impairment of such person’s
bodily functions; (c) serious dysfunction of any bodily organ or part of such
person; or (d) serious disfigurement of such person are covered. Emergency
services include health care procedures, treatments or services, needed to
evaluate or stabilize an Emergency Medical Condition including psychiatric
stabilization and medical detoxification from drugs or alcohol. A medical
assessment (triage) is covered for non-emergent conditions.

7. Services of Other Practitioners

a) Nurse Practitioner Services

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

APPENDIX K

January 1, 2005

K-17

 

 

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

	•	 	Child/Teen Health Program(C/THP) services which are comprehensive primary
health care services provided to children under twenty-one (21) (see page 20 of this
Appendix and Section 10.5 of this Agreement);
	 
	•	 	Physical examinations including those which are necessary for employment, school and camp.
	 
	b.	 	Rehabilitation Services

18 NYCRR 505.1l

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

	c.	 	Midwifery Services

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

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

	d.	 	Clinical Psychological Services

18 NYCRR 505.18(a)

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

	e.	 	Foot Care Services

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

APPENDIX K

January 1, 2005

K-18

 

 

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

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

	8.	 	Eye Care and Low Vision Services

18 NYCRR §505.6(b)(l-3)

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

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

Examinations for diagnosis and treatment for visual defects and/or eye disease
is provided only as necessary and as required by the Enrollee’s particular
condition. Examinations which include refraction are limited to every two (2)
years unless otherwise justified as medically necessary.

Eyeglasses do not require changing more frequently than every two (2) years
unless medically indicated, such as a change in correction greater
than 1⁄2
diopter, or unless the glasses are lost, damaged, or destroyed.

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

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

	9.	 	Laboratory Services

18 NYCRR §505.7(a)

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

APPENDIX K

January 1, 2005

K-19

 

 

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

	10.	 	Radiology Services
   18
NYCRR §505.17(c)(7)(d)

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

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

  18 NYCRR §508.8

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

	12.	 	Durable Medical Equipment (DME)
18
NYCRR §505.5(a)(l) and Section 4.4 of the MMIS DME, Medical
and Surgical Supplies and Prosthetic and Orthotic Appliances Provider
Manual

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

	 	(i)	 	can withstand repeated use for a protracted period of time;
	 
	 	(ii)	 	are primarily and customarily used for medical purposes;
	 
	 	(iii)	 	are generally not useful to a person in the absence
of illness or injury; and

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

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

	13.	 	Audiology,
Hearing Aid Services and Products

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

	 
	a)	 	Hearing aid services and products are provided in compliance with Article
37-A of the General Business Law when medically necessary to alleviate disability caused by the
loss or impairment of hearing. Hearing aid services include: selecting, fitting and
dispensing of hearing aids, hearing aid checks following dispensing of hearing aids,
conformity evaluation, and hearing aid repairs.
	 
	b)	 	Audiology services include audiometric examinations and testing, hearing
aid evaluations and hearing aid prescriptions or recommendations, as medically indicated.
	 
	c)	 	Hearing aid products include hearing aids, earmolds, special fittings,
and replacement parts (hearing aid batteries are excluded from the Benefit Package, but are covered
by Medicaid fee- for-service as part of the prescription benefit).

	14.	 	Preventive Care

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

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

	•	 	General health education classes.
	 
	•	 	Pneumonia and influenza immunizations for at risk populations.
	 
	•	 	Smoking cessation classes, with targeted outreach for adolescents and pregnant women.
	 
	•	 	Childbirth education classes.
	 
	•	 	Parenting classes covering topics such as bathing, feeding, injury prevention, sleeping,
illness prevention, steps to follow in an emergency, growth and development, discipline,
signs of illness, etc.
	 
	•	 	Nutrition counseling, with targeted outreach for diabetics and pregnant women.
	 
	•	 	Extended care coordination, as needed, for pregnant women.
	 
	•	 	HIV counseling and testing.

APPENDIX K

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15. Prosthetic/Orthotic Orthopedic Footwear

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

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

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

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

16. Renal Dialysis

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

17. Experimental or Investigational Treatment

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

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

	(1)	 	The Enrollee has had coverage of a health care service denied on the
basis that such service is experimental and investigational, and
	 
	(2)	 	The Enrollee’s attending physician has certified that the Enrollee has a
life-threatening or disabling condition or disease:

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

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

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

APPENDIX K

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

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

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

18. Residential Health Care Facility (RHCF) Services

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

	 	(a)	 	Who is diagnosed by a physician as having one or more
clinically determined illnesses or conditions that cause the Enrollee to be so
incapacitated, sick, invalid,infirm, disabled, or convalescent as to require at least medical and
nursing care; and
	 
	 	(b)	 	Whose assessed health care needs, in the professional judgment of the Enrollee’s
physician or a medical team:

	 	i)	 	do not require care or active treatment of the
Enrollee in a general or special hospital;
	 
	 	ii)	 	cannot be met satisfactorily in the Enrollee’s
own home or home substitute through provision of such home
health services, including medical and other health and
health-related services as are available in or near his or
her community; and
	 
	 	iii)	 	cannot be met satisfactorily in the physician’s
office, a hospital clinic, or other ambulatory care setting
because of the unavailability of medical or other health and
health-related services for the Enrollee in such setting in
or near his or her community.

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

APPENDIX K

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

B. Behavioral Health Services

These services include Chemical Dependence and Mental Health Services.

	•	 	Chemical Dependence Services:
	 
	 	 	For all Enrollees not categorized as SSI or SSI related, Chemical
Dependence Services in the Benefit Package include inpatient treatment
services including inpatient rehabilitation and treatment services
programs, Detoxification Services (Medically Managed Inpatient
Detoxification and Medically Supervised Inpatient and Outpatient Withdrawal
Services) and self-referral for assessment as described below.
	 
	 	 	For all Enrollees categorized as SSI or SSI related, the Benefit Package
includes Detoxification Services (Medically Managed Inpatient
Detoxification and Medically Supervised Inpatient and Outpatient Withdrawal
Services). All other Chemical Dependence Services, including Chemical
Dependence Inpatient Rehabilitation and Treatment, are covered on a
Medicaid fee-for-service basis for the SSI population.
	 
	•	 	Mental Health Services:
	 
	 	 	The Mental Health Services listed below are in the Benefit Package for all
Enrollees not categorized as SSI or SSI related. For Enrollees who are
categorized as SSI or SSI related, all Mental Health Services are covered
on a Medicaid fee-for-service basis.

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

	 	(a)	 	Medically Supervised Inpatient Withdrawal

APPENDIX K

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	 	 	These programs offer treatment for moderate withdrawal on an inpatient basis.
Services must include medical supervision and direction under the care of a
physician in the treatment for moderate withdrawal. Specific services must
include, but are not limited to: medical assessment within twenty four hours
of admission; medical supervision of intoxication and withdrawal conditions;
bio-psychosocial assessments; individual and group counseling and linkages to
other services as necessary. Maintenance on methadone while a patient is
being treated for withdrawal from other substances may be provided where the
provider is appropriately authorized. Medically Supervised Inpatient
Withdrawal services are provided by facilities licensed under Title 14 NYCRR
Part 816.7.
	 
	 	 	 (b) Medically Supervised Outpatient Withdrawal
	 
	 	 	These programs offer treatment for moderate withdrawal on an outpatient
basis. Required services include, but are not limited to: medical
supervision of intoxication and withdrawal conditions; bio-psychosocial
assessments; individual and group counseling; level of care determinations;
discharge planning; and referrals to appropriate services. Maintenance on
methadone while a patient is being treated for withdrawal from other
substances may be provided where the provider is appropriately authorized.
Medically Supervised Outpatient Withdrawal services are provided by
facilities licensed by Title 14 NYCRR Part 816.7.
	 
	 	 	All detoxification and withdrawal services are a covered benefit for all
Enrollees, including those categorized as SSI or SSI related.
	 
	 	 	Detoxification Services in Article 28 inpatient hospital facilities are
subject to the stop-loss provisions specified in Section 3.11 of this
Agreement.
	 
	b.	 	Chemical Dependence Inpatient Rehabilitation and Treatment Services
	 
	 	 	Services provided include intensive management of chemical dependence symptoms
and medical management of physical or mental complications from chemical
dependence to clients who cannot be effectively served on an outpatient basis
and who are not in need of medical detoxification or acute care. These
services can be provided in a hospital or freestanding facility. Specific
services can include, but are not limited to: comprehensive admission
evaluation and treatment planning; individual group, and family counseling;
awareness and relapse prevention; education about self-help groups; assessment
and referral services; vocational and educational assessment; medical and
psychiatric consultation; food and housing; and HIV and AIDS education. These
services may be provided by facilities licensed by OASAS to provide: Chemical
Dependence Inpatient Rehabilitation and Treatment Services under Title 14
NYCRR Part 818. Maintenance on methadone while a patient is being treated
for withdrawal from other substances may be provided where the provider is
appropriately authorized.
	 
	 	 	MCOs will be reimbursed for qualifying inpatient days of chemical dependence
inpatient treatment beyond thirty (30) days according to stop-loss provisions
contained in Section 3.12 of this Agreement.

APPENDIX K

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	c.	 	Chemical Dependence Assessment Self-Referral
	 
	 	 	Enrollees must be allowed to self refer for one (1) assessment from
a Contractor’s participating provider in a twelve (12) month period.

2. Mental Health Services

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

a. Inpatient Services

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

b. Outpatient Services

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

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

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

APPENDIX K

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C. Other Covered Services

1. Federally Qualified Health Center (FQHC) Services

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

APPENDIX K

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Prepaid Benefit Package

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

	A.	 	Family Planning and Reproductive Health Care
	 
	 	 	Family Planning and Reproductive Health Care services means the offering,
arranging and furnishing of those health services which enable Enrollees,
including minors, who may be sexually active to prevent or reduce the
incidence of unwanted pregnancy. These include: diagnosis and all medically
necessary treatment, sterilization, screening and treatment for sexually
transmissible diseases and screening for disease and pregnancy.
	 
	 	 	Also included is HIV counseling and testing when provided as part of a
family planning visit. Additionally, reproductive health care includes
coverage of all medically necessary abortions. Elective induced abortions
must be covered for New York City recipients. Fertility services are not
covered.
	 
	 	 	If the Contractor excludes family planning from its Benefit Package, the
Contractor is still required to provide the following services:

	i)	 	screening, related diagnosis, ambulatory treatment, and referral to
Participating Provider as needed for dysmenorrhea, cervical cancer or
other pelvic abnormality/pathology;
	 
	ii)	 	screening, related diagnosis, and referral to Participating Provider
for anemia, cervical cancer, glycosuria, proteinuria, hypertension,
breast disease and pregnancy.

	B.	 	Dental Services
	 
	 	 	Dental care includes preventive, prophylactic and other routine dental care,
services, supplies and dental prosthetics required to alleviate a serious
health condition, including one which affects employability.
	 
	 	 	Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor whether dental services are a covered plan
benefit, or not. Inpatient claims and referred ambulatory claims for dental
services provided in an inpatient or outpatient hospital setting for
surgery, anesthesiology, X-rays, etc. are the responsibility of the
Contractor. In these situations, the professional services of the dentist
are covered by Medicaid fee-for-service. The Contractor should set up
procedures to prior approve dental services provided in inpatient and
ambulatory settings.
	 
	 	 	As described in Sections 10.16 and 10.28 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to
obtain covered dental services.
	 
	 	 	If Contractor’s Benefit Package excludes dental services:

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

APPENDIX K

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

	C.	 	Transportation Services

18 NYCRR §505.10
	 
	 	 	 a. Non-Emergency Transportation
	 
	 	 	Transportation expenses are covered when transportation is essential in
order for an Enrollee to obtain necessary medical care and services which
are covered under the Medicaid program (either as part of the Contractor’s
Benefit Package or by fee-for-service Medicaid). Non-emergent transportation
guidelines may be developed in conjunction with the LDSS, based on the LDSS’
approved transportation plan.
	 
	 	 	Transportation services means transportation by ambulance, ambulette fixed
wing or airplane transport, invalid coach, taxicab, livery, public
transportation, or other means appropriate to the Enrollee’s medical
condition; and a transportation attendant to accompany the Enrollee, if
necessary. Such services may include the transportation attendant’s
transportation, meals, lodging and salary; however, no salary will be paid to
a transportation attendant who is a member of the Enrollee’s family.
	 
	 	 	When the Contractor is capitated for non-emergency transportation, the
Contractor is also responsible for providing transportation to Medicaid
covered services that are not part of the Contractor’s Benefit Package.
	 
	 	 	For Contractors that cover non-emergency transportation in the Benefit
Package, transportation costs to MMTP services may be reimbursed by Medicaid
fee-for-service in accordance with the LDSS transportation polices in local
districts where there is a systematic method to discretely identify and
reimburse such transportation costs.
	 
	 	 	For Enrollees with disabilities, the method of transportation must
reasonably accommodate their needs, taking into account the severity and
nature of the disability.
	 
	 	 	 b. Emergency Transportation
	 
	 	 	Emergency transportation can only be provided by an ambulance service
including air ambulance service. Emergency ambulance transportation means
the provision of ambulance transportation for the purpose of obtaining
hospital services for an Enrollee who suffers from severe, life-threatening
or potentially disabling conditions which require the provision of emergency
medical services while the Enrollee is being transported.
	 
	 	 	Emergency medical services means the provision of initial urgent medical
care including, but not limited to, the treatment of trauma, burns,
respiratory, circulatory and obstetrical emergencies.

APPENDIX K

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

APPENDIX K

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Prepaid Benefit Package

III. Definitions of Non-Covered Services

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

A. MEDICAL NON-COVERED SERVICES

1. Personal Care Agency Services

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

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

2. Residential Health Care Facilities (RHCF)

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

3. Hospice Program

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

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

 

APPENDIX K

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K-31

 

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

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

Coverage for drugs dispensed by community pharmacies, over the counter drugs,
medical/surgical supplies and enteral formula are not included in the Benefit
Package and will be paid for by Medicaid fee-for-service. Medical/surgical
supplies are items other than drugs, prosthetic or orthotic appliances, or DME
which have been ordered by a qualified practitioner in the treatment of a
specific medical condition and which are: consumable, non-reusable,
disposable, or for a specific rather than incidental purpose, and generally
have no salvageable value (e.g. gauze pads, bandages and diapers).
Pharmaceuticals and medical supplies routinely furnished or administered
as part of a clinic or office visit are covered.

 

APPENDIX K

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K-32

 

B. Non-Covered Behavioral Health Services

1. Chemical Dependence Services

a. Outpatient Rehabilitation and Treatment Services

i). Methadone Maintenance Treatment Program (MMTP)

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

ii). Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs

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

iii). Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs

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

iv). Outpatient Chemical Dependence for Youth Programs

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

b. Chemical Dependence Services Ordered by the LDSS

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

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

APPENDIX K

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K-33

 

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

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

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

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

2. Mental Health Services

a. Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

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

b. Day Treatment

A combination of diagnostic, treatment, and rehabilitative procedures which,
through supervised and planned activities and extensive client-staff interaction, provides the
services of the clinic treatment program, as well as social training, task and skill training and
socialization activities. Services are expected to be of six (6) months duration. These services are
certified by OMH under 14 NYCRR, Part 587.

c. Continuing Day Treatment

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

d. Day Treatment Programs Serving Children

Day treatment programs are characterized by a blend of mental health and
special education services provided in a fully integrated program. Typically
these programs include: special

 

APPENDIX K

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K-34

 

education in small classes with an emphasis on individualized instruction,
individual and group counseling, family services such as family counseling, support and education,
crisis intervention, interpersonal skill development, behavior modification, art and music therapy.

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

This waiver is in select counties for children and adolescents who would
otherwise be admitted to an institutional setting if waiver services were not
provided. The services include individualized care coordination, respite,
family support, intensive in-home skill building, and crisis response.

f. Case Management

The target population consists of individuals who are seriously and
persistently mentally ill (SPMI), require intensive, personal and proactive intervention to help them
obtain those services which will permit functioning in the community and either have symptomology
which is difficult to treat in the existing mental health care system or are unwilling or unable
to adapt to the existing mental health care system. Three case management models are currently operated
pursuant to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to l4 NYCRR Part 506.

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

g. Partial Hospitalization

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

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

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

i. Assertive Community Treatment (ACT)

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

 

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j. Personalized Recovery Oriented Services (PROS)

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

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

a. OMH Licensed CRs*

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

b. Family-Based Treatment*

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

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

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

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

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

 

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b. Day Treatment

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

c. Medicaid Service Coordination (MSC)

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

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

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

d. Home And Community Based Services Waivers (HCBS)

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

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

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

 

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C. Other Non-Covered Services

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

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

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

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

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

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

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

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

 

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

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

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

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

	4.	 	Comprehensive Medicaid Case Management (CMCM)

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

	5.	 	Directly Observed Therapy for Tuberculosis Disease

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

	6.	 	AIDS Adult Day Health Care

Adult Day Health Care Programs (ADHCP) are programs designed to assist
individuals with HIV disease to live more independently in the community
or eliminate the need for residential health care services. Registrants
in ADHCP require a greater range of comprehensive health care

 

APPENDIX K

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K-39

 

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.

	7.	 	HIV COBRA Case Management

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

	8.	 	Fertility Services

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

	9.	 	Adult Day Health Care

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

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

	10.	 	Personal Emergency Response Services (PERS)

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

 

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K-40

 

	11.	 	School-Based Health Centers

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

 

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MEDICAID MANAGED CARE MODEL CONTRACT AMENDMENT ATTESTATION

	 	 	 	 	 	 	 
	I Todd S. Farha, being an individual authorized to execute agreements on behalf of
	 WellCare
of New York, Inc.
 (Name of Managed Care Organization)	(hereafter “MCO”), hereby attest that the contract amendment submitted by MCO to
	 Ulster
 (County Name)	County, follows the latest  model contract amendment provided  to us by the above named county.
	 This executed amendment contains no deviations from the aforementioned model amendment language.

	 	 	 
	12/22/04
	 	-s- Todd S. Farha
	

	 	

	(Date)
	 	(Signature)
	 	 	 
	
	 	Todd S. Farha
	 	

	 	(Print Name in Full)
	 	 
	 	President & Chief
	 	

	 	(Title)
	 	Executive Officer
	 	 	 
	-s- Kathleen R. Casey	 	 
	
	 	 
	(Notary Seal and Signature)	 	 

I Glenn L. Decker , attest that the County has reviewed this executed
contract amendment and that it follows the latest model contract amendment provided
to us by the New York State Department of Health.

	 	 	 
	12/28/04
	 	-s- Patricia Jelacic
	

	 	

	(Date)
	 	(Signature)
	
	 	DEPUTY COMMISSIONER
	 	 	 
	
	 	for Glenn L. Decker
	
	 	

	
	 	(Print Name in Full)
	 	 	 
	
	 	Commissioner
	
	 	

	
	 	(Title)
	 	 	 
	-s- Brigitte C. Watson	 	 
	
	 	 
	(Notary Seal and Signature)	 	 

BRIGITTE C. WATSON

Notary Public, State of New York

Reg. # 01WA6101502

Qualified In Ulster County

Commission Expires November 17, 2007

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