EXHIBIT 10.16
MEDICAID MANAGED CARE
MODEL CONTRACT
October 1, 2004
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TABLE OF CONTENTS FOR MODEL CONTRACT
Recitals
Section 1 Definitions
Section 2 Agreement Term, Amendments, Extensions, and General Contract Administration Provisions
2.1 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 Enrollment Limitations
3.14 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
5.4 Family Health Plus
5.5 Family Enrollment
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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
10.7 Child Protective Services
10.8 Welfare Reform
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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
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
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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
17.3 Cooperation During On-Site Reviews
17.4 Cooperation During Review of Services by External Review Agency
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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 PCPs
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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AGREEMENT BETWEEN
DUTCHESS COUNTY
---------------
County Name or City of New York
And
WELLCARE OF NEW YORK, INC.
--------------------------
Contractor Name
This Agreement is made by and between
DUTCHESS COUNTY (COUNTY)
-----------------------
County Name or City of New York ("County" or "City")
Acting through,
DUTCHESS COUNTY DEPARTMENT OF SOCIAL SERVICES (LDSS)
----------------------------------------------------
Department of Social Services ("LDSS") or Health ("CDOH")
Located at
22 MARKET STREET
----------------
POUGHKEEPSIE, NEW YORK 12601
----------------------------
And
WELLCARE OF NEW YORK, INC.
--------------------------
Contractor Name ("the Contractor")
Located At
11 WEST 19TH STREET 2ND FLOOR
-----------------------------
NEW YORK, NY 10011
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RECITALS
October 1, 2004
Page 1 of 2
RECITALS
Pursuant to Title XIX of the Federal Social Security Act, codified as 42
U.S.C. Section 1396 et seq. (the "Social Security Act"), and Title 11 of Article
5 of the New York State Social
Services Law ("SSL"), codified as N.Y.S.S.L. Section 363 et seq., a
comprehensive program of Medical Assistance for needy persons exists in the
State of New York ("Medicaid").
Pursuant to Article 44 of the Public Health Law ("PHL"), the New York
State Department of Health ("SDOH") is authorized to issue Certificates of
Authority to establish Health Maintenance Organizations ("HMOs"), PHL Section
4400 et seq., and Prepaid Health Services Plans ("PHSPs"), PHL Section 4403-a.
The State Social Services Law defines Medicaid to include payment of part
or all of the cost of care and services furnished by an HMO or a PHSP,
identified as Managed Care Organizations ("MCOs") in this Agreement, to Eligible
Persons, as defined in this Agreement, residing in the geographic area specified
in Appendix M (Service Area) when such care and services are furnished in
accordance with an agreement approved by the SDOH that meets the requirements of
federal law and regulations.
The Contractor is a corporation organized under the laws of New York State
and is certified under Article 44 of the State Public Health Law or Article 43
of the NYS Insurance Law.
The Contractor offers a comprehensive health services plan and represents
that it is able to make provision for furnishing medical and health service
benefits and has proposed to LDSS to provide these
--------------------------------
[INSERT LDSS OR CDOH]
services to Eligible Persons; and
The Contractor has applied to participate in the Medicaid Managed Care
Program and the SDOH and LDSS have determined that
--------------------------------
[INSERT LDSS OR CITY OF NEW YORK]
the Contractor meets the qualification criteria established for participation.
NOW THEREFORE, the parties agree as follows:
RECITALS
October 1, 2004
Page 2 of 2
1. DEFINITIONS
"AUTO-ASSIGNMENT" means a process by which an Eligible Person, who is
mandated to enroll in managed care, but who has not chosen to enroll
within sixty (60) days of receipt of the mandatory notice, is assigned to
a MCO contracted with the LDSS as a Medicaid Managed Care Provider in
accordance with the auto-assignment algorithm determined by the SDOH.
"BEHAVIORAL HEALTH SERVICES" means services to address mental health
disorders and/or chemical dependence.
"BENEFIT PACKAGE" means the covered services described in Appendix K of
this Agreement to be provided to the Enrollee, as Enrollee is hereinafter
defined, by or through the Contractor.
"CAPITATION RATE" means the fixed monthly amount that the Contractor
receives for an Enrollee to provide that Enrollee with the Benefit
Package.
"CHEMICAL DEPENDENCE SERVICES" means examination, diagnosis, level of care
determination, treatment, rehabilitation, or habilitation of persons
suffering from chemical abuse or dependence, and includes the provision of
alcohol and/or substance abuse services.
"CHILD/TEEN HEALTH PROGRAM" or "C/THP" means the program of early and
periodic screening, including inter-periodic, diagnostic and treatment
services (EPSDT) that New York State offers all Medicaid eligible children
under twenty-one (21) years of age. Care and services are provided in
accordance with the periodicity schedule and guidelines developed by the
New York State Department of Health. The services include administrative
services designed to help families obtain services for children including
outreach, information, appointment scheduling, administrative case
management and transportation assistance, to the extent that
transportation is included in the Benefit Package.
"COMPREHENSIVE HIV SPECIAL NEEDS PLAN, OR HIV SNP" means a Managed Care
Organization certified pursuant to Section forty-four hundred three-c
(4403-c) of Article 44 of the Public Health Law (Article 44) which, in
addition to providing or arranging for the provision of comprehensive
health services on a capitated basis, including those for which Medical
Assistance payment is authorized pursuant to Section three hundred
sixty-five-a (365-a) of the Social Services Law, also provides or arranges
for the provision of comprehensive and specialized HIV care to HIV
positive persons eligible to receive benefits under Title XIX of the
federal Social Security Act or other public programs.
"COURT-ORDERED SERVICES" means those services that the Contractor is
required to provide to Enrollees pursuant to orders of courts of competent
jurisdiction, provided however, that such ordered services are within the
Contractor's Medicaid managed care
SECTION 1
(DEFINITIONS)
October 1, 2004
1-1
Benefit Package and reimbursable under Title XIX of the Federal Social
Security Act (SSL 364-j(4)(r)).
"DAYS" means calendar days except as otherwise stated.
"DETOXIFICATION SERVICES" means Medically Managed Detoxification Services;
and Medically Supervised Inpatient and Outpatient Withdrawal Services as
defined in Appendix K.
"DISENROLLMENT" means the process by which an Enrollee's membership in the
Contractor's plan terminates.
"EFFECTIVE DATE OF DISENROLLMENT" means the date on which an Enrollee may
no longer receive services from the Contractor, pursuant to Section 8.6
and Appendix H of this Agreement.
"EFFECTIVE DATE OF ENROLLMENT" means the date on which an Enrollee may
receive services from the Contractor, pursuant to Section 6.8(b) and
Appendix H of this Agreement.
"ELIGIBLE PERSON" means a person whom the LDSS, state or federal
government determines to be eligible for Medicaid and who meets all the
other conditions for enrollment in Medicaid managed care as set forth in
this Agreement.
"EMERGENCY MEDICAL CONDITION" means a medical or behavioral condition, the
onset of which is sudden, that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the
absence of immediate medical attention to result in: (i) 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 the person or
others in serious jeopardy; or (ii) serious impairment to such person's
bodily functions; or (iii) serious dysfunction of any bodily organ or part
of such person; or (iv) serious disfigurement of such person.
"EMERGENCY SERVICES" means covered medical services that are required to
treat an Emergency Medical Condition.
"ENROLLEE" means an Eligible Person who, either personally or through an
authorized representative, has enrolled (or who has been auto-assigned) in
the Contractor's plan pursuant to Section 6 of this Agreement.
"ENROLLMENT" means the process by which an Enrollee's membership in a
Contractor's Plan begins.
"ENROLLMENT BROKER" means the state and/or county-contracted entity that
provides enrollment, education, and outreach services; effectuates
enrollments and disenrollments
SECTION 1
(DEFINITIONS)
October 1, 2004
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in Medicaid managed care; and provides other contracted services on behalf
of the SDOH and the LDSS.
"EXPERIENCED HIV PROVIDER" means an entity grant-funded by the SDOH AIDS
Institute to provide clinical and/or supportive services or an entity
licensed or certified by the SDOH to provide HIV/AIDS services.
"FAMILY" means a mother and child(ren), a father and child(ren), a father
and mother and child(ren), or a husband and wife residing in the same
household or persons included in the same case for purposes of family
enrollment in mandatory counties.
"FISCAL AGENT" means the entity that processes or pays vendor claims on
behalf of the Medicaid state agency pursuant to an agreement between the
entity and such agency.
"GUARANTEED ELIGIBILITY" means the period beginning on the Enrollee's
Effective Date of Enrollment with the Contractor and ending six (6) months
thereafter, during which the Enrollee may be entitled to continued
enrollment in the Contractor's plan despite the loss of Medicaid
eligibility as set forth in Section 9 of this Agreement.
"HEALTH PROVIDER NETWORK" or "HPN" means a closed communication network
dedicated to secure data exchange and distribution of health related
information between various health facility providers and the SDOH. HPN
functions include: collection of Medicaid complaint and disenrollment
information; collection of Medicaid financial reports; collection and
reporting of managed care provider networks systems (PNS); and the
reporting of Medicaid encounter data systems (MEDS).
"HIV SPECIALIST PCP" means a Primary Care Provider that meets the
following criteria:
- Direct clinical management of persons with HIV as part of a
postgraduate program, clinic, hospital-based or private
practice during the last two years. Primary ambulatory care of
HIV-infected patients should include the management of
patients receiving antiretroviral therapy over an extended
period of time. This experience should equal twenty
patient-years experience, and
- Ten hours annually of Continuing Medical Education (CME) that
includes information on the use of antiretroviral therapy in
the ambulatory care setting.
"INPATIENT STAY PENDING ALTERNATE LEVEL OF MEDICAL CARE" means 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.
"INSTITUTION FOR MENTAL DISEASE" or "IMD" means a hospital, nursing
facility, or other institution of more than sixteen (16) beds that is
primarily engaged in providing diagnosis, treatment or care of persons
with mental diseases, including medical attention, nursing care and
related services. Whether an institution is an Institution for Mental
Disease is determined by its overall character as that of a facility
established and maintained primarily for the care and treatment of
individuals with mental diseases,
SECTION 1
(DEFINITIONS)
October 1, 2004
1-3
whether or not it is licensed as such. An institution for the mentally
retarded is not an Institution for Mental Diseases.
"LOCAL PUBLIC HEALTH AGENCY" means DUTCHESS COUNTY DEPARTMENT OF HEALTH
------------------------------------
Insert Name of Agency
"LOCK-IN PERIOD" means the period of time during which the Enrollee may
not disenroll from the Contractor's plan, unless the Enrollee becomes
eligible for an exclusion or an exemption or can demonstrate good cause as
established in state law and in 18 NYCRR Section 360-10.13.
"MANAGED CARE ORGANIZATION" or "MCO" means a health maintenance
organization ("HMO") or prepaid health service plan ("PHSP") certified
under Article 44 of the New York State PHL.
"MARKETING" means any activity of the Contractor, subcontractor or
individuals or entities affiliated with the Contractor by which
information about the Contractor is made known to Eligible Persons for the
purpose of persuading such persons to enroll with the Contractor.
"MARKETING REPRESENTATIVE" means any individual or entity engaged by the
Contractor to market on behalf of the Contractor.
"MEDICAID MANAGEMENT INFORMATION SYSTEM" or "MMIS" means the Medical
Assistance Information and Payment System of the SDOH.
"MEDICAL RECORD" means a complete record of care rendered by a provider
documenting the care rendered to the Enrollee, including inpatient,
outpatient, and emergency care, in accordance with all applicable federal,
state and local laws, rules and regulations. Such record shall be signed
by the medical professional rendering the services.
"MEDICALLY NECESSARY" means health care and services that are necessary to
prevent, diagnose, manage or treat conditions in the person that cause
acute suffering, endanger life, result in illness or infirmity, interfere
with such person's capacity for normal activity, or threaten some
significant handicap.
"NATIVE AMERICAN" means, for purposes of this contract, a person
identified in the Medicaid eligibility system as a Native American.
"NON CONSENSUAL ENROLLMENT" means Enrollment of an Eligible Person, other
than through Auto-assignment, newborn enrollment or case addition, in a
Managed Care Organization without the consent of the Eligible Person or
consent of a person with the legal authority to act on behalf of the
Eligible Person at the time of Enrollment.
"NON-PARTICIPATING PROVIDER" means a provider of medical care and/or
services with which the Contractor has no Provider Agreement.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-4
"PARTICIPATING PROVIDER" means a provider of medical care and/or services
that has a Provider Agreement with the Contractor.
"PHYSICIAN INCENTIVE PLAN" or "PIP" means any compensation arrangement
between the Contractor or one of its contracting entities and a physician
or physician group that may directly or indirectly have the effect of
reducing or limiting services furnished to Medicaid recipients enrolled by
the MCO.
"PREPAID CAPITATION PLAN ROSTER" OR "ROSTER" means the enrollment list
generated on a monthly basis by SDOH by which LDSS and Contractor are
informed of specifically which recipients the Contractor will be serving
for the coming month, subject to any revisions communicated in writing or
electronically by SDOH, LDSS, or the Enrollment Broker.
"PRESUMPTIVE ELIGIBILITY PROVIDER" means a provider designated by the SDOH
as qualified to determine the presumptive eligibility for pregnant women
to allow them to receive prenatal services immediately. Such providers
assist recipients with the completion of the full application for Medicaid
and they may be comprehensive Prenatal Care Programs, Local Public Health
Agencies, Certified Home Health Agencies, Public Health Nursing Services,
Article 28 facilities, and individually licensed physicians and certified
nurse practitioners.
"PREVENTIVE CARE" means the care or services rendered to avert
disease/illness and/or its consequences. There are three levels of
preventive care: primary, such as immunizations, aimed at preventing
disease; secondary, such as disease screening programs aimed at early
detection of disease; and 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 treatment programs.
"PRIMARY CARE PROVIDER" or "PCP" means a qualified physician, or certified
nurse practitioner or team of no more than four (4) qualified
physicians/nurse practitioners which provides all required primary care
services contained in the Benefit Package to Enrollees.
"PROVIDER AGREEMENT" means any written contract between the Contractor and
participating Providers to provide medical care and/or services to
Contractor's Enrollees.
"SCHOOL BASED HEALTH CENTERS" or "SBHC" are SDOH approved centers which
provide comprehensive primary and mental health services including health
assessments, diagnosis and treatment of acute illnesses, screenings and
immunizations, routine management of chronic diseases, health education,
mental health counseling and treatment on-site in schools. Services are
offered by multi-disciplinary staff from sponsoring Article 28 licensed
hospitals and community health centers.
"SERIOUSLY EMOTIONALLY DISTURBED" or "SED" means, a child through
seventeen (17) years of age who has utilized the following during the
twelve (12) month period prior to scheduled enrollment:
SECTION 1
(DEFINITIONS)
October 1, 2004
1-5
- ten (10) or more encounters, including visits to a mental health
clinic, psychiatrist or psychologist, and inpatient hospital days
relating to a psychiatric diagnosis; or
- one (1) or more specialty mental health visits (i.e., psychiatric
rehabilitation treatment program; day treatment; continuing day
treatment; comprehensive case management; partial hospitalization;
rehabilitation services provided to residents of Office of Mental
Health (OMH) licensed community residences and family-based
treatment; and mental health clinics for seriously emotionally
disturbed children).
"SERIOUSLY AND PERSISTENTLY MENTALLY ILL" or "SPMI" means an adult
eighteen (18) years or older who has utilized the following during the
twelve (12) month period prior to scheduled enrollment:
- ten (10) or more encounters, including visits to a mental health
clinic, psychiatrist or psychologist, and inpatient hospital days
relating to a psychiatric diagnosis; or
- one (1) or more specialty mental health visits (i.e., psychiatric
rehabilitation treatment program; day treatment; continuing day
treatment; comprehensive case management; partial hospitalization;
rehabilitation services provided to residents of OMH licensed
community residences and family-based treatment; and mental health
clinics for seriously emotionally disturbed children).
"SUPPLEMENTAL MATERNITY CAPITATION PAYMENT" means the fixed amount paid to
the Contractor for the prenatal and postpartum physician care and hospital
or birthing center delivery costs, limited to those cases in which the
plan has paid the hospital or birthing center for the maternity stay, and
can produce evidence of such payment.
"SUPPLEMENTAL NEWBORN CAPITATION PAYMENT" means the fixed amount paid to
the Contractor for the inpatient birthing costs for a newborn enrolled in
the plan, limited to those cases in which the plan has paid the hospital
or birthing center for the newborn stay, and can produce evidence of such
payment.
"TUBERCULOSIS DIRECTLY OBSERVED THERAPY" or "TB/DOT" means the direct
observation of ingestion of oral TB medications to assure patient
compliance with the physician's prescribed medication regimen.
"URGENTLY NEEDED SERVICES" means covered services that are not Emergency
Services as defined in this Section, provided when an Enrollee is
temporarily absent from the Contractor's service area, when the services
are medically necessary and immediately required: (1) as a result of an
unforeseen illness, injury, or condition; and (2) it was not reasonable
given the circumstances to obtain the services through the Contractor's
plan.
SECTION 1
(DEFINITIONS)
October 1, 2004
1-6
2. AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT
ADMINISTRATION PROVISIONS
2.1 Term
a) This Agreement is effective October 1, 2004 and shall remain
in effect until September 30, 2005; or until the execution of
an extension, renewal or successor Agreement approved by the
SDOH and the Department of Health and Human Services (DHHS);
or until the effective date of an executed agreement between
the Contractor and SDOH for Contractor's participation in the
Medicaid managed care program; whichever occurs first.
b) The parties to the Agreement shall have the option to renew
this Agreement for additional two (2) year and or one (1) year
terms, subject to the approval of the LDSS, SDOH, DHHS and any
other entities as required by law or regulation.
c) However, in no event, shall the maximum duration of this
Agreement exceed five (5) years.
2.2 Amendments and Extensions
a) This Agreement may only be modified in writing. Unless
otherwise specified in this Agreement, modifications must be
signed by the parties and approved by the SDOH, DHHS, and any
other entities as required by law or regulation, prior to the
end of the quarter in which the amendment is to be effective.
b) This Agreement shall not be automatically renewed at its
expiration. This Agreement may be extended by written
amendment, in accordance with the procedures set forth in this
Section.
c) An extension to this Agreement may be granted for reasons
including, but not limited, to the following:
i) Negotiations for a successor Agreement will not be
completed by the expiration date of the current
contract; or
ii) The Contractor has submitted a termination notice and
transition of Enrollees will not be completed by the
expiration date of the current contract.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-1
d) The parties will submit, to the extent practicable, the
proposed signed and dated extensions, including all necessary
local government approvals, to SDOH prior to the scheduled
expiration date of this Agreement.
2.3 Approvals
This Agreement and any amendments to this Agreement shall not be
effective or binding unless and until approved, in writing, by the
DHHS, the SDOH and any other entity as required in law and
regulation. SDOH will provide a notice of each such approval to the
Contractor and the LDSS upon such approval.
2.4 Entire Agreement
This Agreement shall supersede all prior Agreements between the
Contractor and the LDSS. This Agreement, including those
attachments, schedules, appendices, exhibits, and addenda that have
been specifically incorporated herein and written plans submitted by
the Contractor and maintained on file by SDOH and/or LDSS pursuant
to this Agreement, contains all the terms and conditions agreed upon
by the parties, and no other Agreement, oral or otherwise, regarding
the subject matter of this Agreement shall be deemed to exist or to
bind any of the parties or vary any of the terms contained in this
Agreement. In the event of any inconsistency or conflict among the
document elements of this Agreement, such inconsistency or conflict
shall be resolved by giving precedence to the document elements in
the following order:
1) Appendix A, Standard Clauses for all New York State
Contracts;
2) Local Standard Clauses, if any;
3) The body of this Agreement;
4) The appendices attached to the body of this Agreement,
other than Appendix A;
5) The Contractor's approved:
i) Marketing Plan on file with SDOH and LDSS
ii) Complaint and Appeals Procedure on file with SDOH
and LDSS
iii) Quality Assurance Plan on file with SDOH and LDSS
iv) Americans with Disabilities Act Compliance Plan on
file with SDOH and LDSS
v) Fraud and Abuse Prevention Plan on file with SDOH
and LDSS.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-2
2.5 Renegotiation
The parties to this Agreement shall have the right to renegotiate
the terms and conditions of this Agreement in the event applicable
local, state or federal law, regulations or policy are altered from
those existing at the time of this Agreement in order to be in
continuous compliance therewith. This Section shall not limit the
right of the parties to this Agreement from renegotiating or
amending other terms and conditions of this agreement. Such changes
shall only be made with the consent of the parties and the prior
approval of the SDOH and the DHHS.
2.6 Assignment and Subcontracting
a) The Contractor shall not, without LDSS and SDOH's prior
written consent, assign, transfer, convey, sublet, or
otherwise dispose of this Agreement; of the Contractor's
right, title, interest, obligations, or duties under the
Agreement; of the Contractor's power to execute the Agreement;
or, by power of attorney or otherwise, of any of the
Contractor's rights to receive monies due or to become due
under this Agreement. Any assignment, transfer, conveyance,
sublease, or other disposition without LDSS and SDOH's consent
shall be void.
b) Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by written
agreement, as set forth in Section 22 of this Agreement. The
Contractor may subcontract for provider services and
management services. If such written agreement would be
between Contractor and a provider of health care or ancillary
health services or between Contractor and an independent
practice association, the agreement must be in a form
previously approved by SDOH. If such subcontract is for
management services under 10 NYCRR Section 98-1.11, it must be
approved by SDOH prior to its becoming effective. Any
subcontract entered into by Contractor shall fulfill the
requirements of 42 CFR Parts 434 and 438 that are appropriate
to the service or activity delegated under such subcontract.
Contractor agrees that it shall remain legally responsible to
LDSS for carrying out all activities under this Agreement and
that no subcontract shall limit or terminate Contractor's
responsibility.
2.7 Termination
a) LDSS Initiated Termination of Contract
i) LDSS shall have the right to terminate this Agreement,
in whole or in part if the Contractor:
A) takes any action that threatens the health,
safety, or welfare of its Enrollees;
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-3
B) has engaged in an unacceptable practice under 18 NYCRR, Part
515, that affects the fiscal integrity of the Medicaid
program;
C) has its Certificate of Authority suspended, limited or revoked
by SDOH;
D) materially breaches the Agreement or fails to comply with any
term or condition of this Agreement that is not cured within
twenty (20) days, or to such longer period as the parties may
agree, of LDSS's written request for compliance;
E) becomes insolvent;
F) brings a proceeding voluntarily, or has a proceeding brought
against it involuntarily, under Title 11 of the U.S. Code (the
Bankruptcy Code); or
G) knowingly has a director, officer, partner or person owning or
controlling more than five percent (5%) of the Contractor's
equity, or has an employment, consulting, or other agreement
with such a person for the provision of items and/or services
that are significant to the Contractor's contractual
obligation who has been debarred or suspended by the federal,
state or local government, or otherwise excluded from
participating in procurement activities.
ii) The LDSS will notify the Contractor of its intent to terminate this
Agreement for the Contractor's failure to meet the requirements of
this Agreement and provide Contractor with a hearing prior to the
termination.
iii) If SDOH suspends, limits or revokes Contractor's Certificate of
Authority under PHL Section 4404, this Agreement shall expire on the
date the Contractor ceases to have authority to serve the geographic
area of the LDSS. No hearing will be required if the contract
expires due to SDOH suspension, limitation or revocation of the
Contractor's Certificate of Authority.
iv) Prior to the effective date of the termination the LDSS shall notify
Enrollees of the termination, or delegate responsibility for such
notification to the Contractor, and such notice shall include a
statement that Enrollees may disenroll immediately without cause.
b) Contractor and LDSS Initiated Termination
The Contractor and the LDSS each shall have the right to terminate this
Agreement in the event that SDOH and the Contractor fail to reach
agreement on the monthly Capitation Rates. In such event, the party
exercising its right shall give the other party, LDSS, and SDOH written
notice specifying the reason for and the effective date of termination,
which
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-4
shall not be less time than will permit an orderly
disenrollment of Enrollees to the Medicaid fee-for-service
payment mechanism or transfer to another MCO, as determined by
LDSS, but no more than ninety (90) days.
c) Contractor Initiated Termination
i) The Contractor shall have the right to terminate this
Agreement in the event that LDSS materially breaches the
Agreement or fails to comply with any term or condition
of this Agreement that is not cured within twenty (20)
days, or to such longer period as the parties may agree,
of the Contractor's written request for compliance. The
Contractor shall give LDSS written notice specifying the
reason for and the effective date of the termination,
which shall not be less time than will permit an orderly
disenrollment of Enrollees to the Medicaid
fee-for-service payment mechanism or transfer to another
managed care program, as determined by LDSS, but no more
than ninety (90) days.
ii) The Contractor shall have the right to terminate this
Agreement in the event that its obligations are
materially changed by modifications to this Agreement
and its Appendices by SDOH or LDSS. In such event,
Contractor shall give LDSS and SDOH written notice
within thirty (30) days of notification of changes to
the Agreement or Appendices specifying the reason and
the effective date of termination, which shall not be
less time than will permit an orderly disenrollment of
Enrollees to the Medicaid fee-for-service program or
transfer to another MCO, as determined by the LDSS, but
no more than ninety (90) days.
iii) The Contractor shall also have the right to terminate
this Agreement if the Contractor is unable to provide
services pursuant to this Agreement because of a natural
disaster and/or an act of God to such a degree that
Enrollees cannot obtain reasonable access to services
within the Contractor's organization, and, after
diligent efforts, the Contractor cannot make other
provisions for the delivery of such services. The
Contractor shall give LDSS written notice of any such
termination that specifies:
A) the reason for the termination, with appropriate
documentation of the circumstances arising from a
natural disaster and/or an act of God that
preclude reasonable access to services;
B) the Contractor's attempts to make other provision
for the delivery of services; and
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-5
C) the effective date of the termination, which shall
not be less time than will permit an orderly
disenrollment of Enrollees to the Medicaid
fee-for-service payment mechanism or transfer to
another MCO, as determined by LDSS, but no more
than ninety (90) days.
d) Termination Due To Loss of Funding
In the event that State and/or Federal funding used to pay for
services under this Agreement is reduced so that payments
cannot be made in full, this Agreement shall automatically
terminate, unless both parties agree to a modification of the
obligations under this Agreement. The effective date of such
termination shall be ninety (90) days after the Contractor
receives written notice of the reduction in payment, unless
available funds are insufficient to continue payments in full
during the ninety (90) day period, in which case LDSS shall
give the Contractor written notice of the earlier date upon
which the Agreement shall terminate. A reduction in State
and/or Federal funding cannot reduce monies due and owing to
the Contractor on or before the effective date of the
termination of the Agreement.
2.8 Close-Out Procedures
Upon termination or expiration of this Agreement and in the event
that it is not scheduled for renewal, the Contractor shall comply
with close-out procedures that the Contractor develops in
conjunction with LDSS and that the LDSS, and the SDOH have approved.
The close-out procedures shall include the following:
a) The Contractor shall promptly account for and repay funds
advanced by SDOH for coverage of Enrollees for periods
subsequent to the effective date of termination;
b) The Contractor shall give LDSS, SDOH, and other authorized
federal, state or local agencies access to all books, records,
and other documents and upon request, portions of such books,
records, or documents that may be required by such agencies
pursuant to the terms of this Agreement;
c) The Contractor shall submit to LDSS, SDOH, and other
authorized federal, state or local agencies, within ninety
(90) days of termination, a final financial statement and
audit report relating to this Agreement, made by a certified
public accountant or a licensed public accountant, unless the
Contractor requests of LDSS and receives written approval from
LDSS, SDOH and all other governmental agencies from which
approval is required, for an extension of time for this
submission;
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-6
d) The Contractor shall furnish to SDOH immediately upon receipt
all information related to any request for reimbursement of
any medical claims that result from services delivered after
the date of termination of this Agreement;
e) The Contractor shall establish an appropriate plan acceptable
to and prior approved by the LDSS and SDOH for the orderly
disenrollment of Enrollees to the Medicaid fee-for-service
program or enrollment into another MCO. This plan shall
include the provision of pertinent information to identified
Enrollees who are: pregnant; currently receiving treatment for
a chronic or life threatening condition; prior approved for
services or surgery; or whose care is being monitored by a
case manager to assist them in making decisions which will
promote continuity of care.
f) SDOH shall promptly pay all claims and amounts owed to the
Contractor;
g) Any termination of this Agreement by either the Contractor or
LDSS shall be done by amendment to this Agreement, unless the
contract is terminated by the LDSS due to conditions in
Section 2.7 a.(i) or Appendix A of this Agreement.
2.9 Rights and Remedies
The rights and remedies of LDSS and the Contractor provided
expressly in this Article shall not be exclusive and are in addition
to all other rights and remedies provided by law or under this
Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-7
2.10 Notices
All notices to be given under this Agreement shall be in writing and
shall be deemed to have been given when mailed to, or, if personally
delivered, when received by the Contractor, LDSS, and the SDOH at
the following addresses:
For LDSS:
DUTCHESS COUNTY DEPARTMENT OF SOCIAL SERVICES
60 MARKET STREET
POUGHKEEPSIE, NY 12601
[Insert Name and Address]
For SDOH:
New York State Department of Health Empire State Plaza
Corning Tower, Rm. 2074
Albany, NY 12237-0065
For the Contractor:
WELLCARE OF NEW YORK, INC.
11 WEST 19th STREET 2nd FLOOR
NEW YORK, NY 10011
[Insert Name and Address]
2.11 Severability
If this Agreement contains any unlawful provision that is not an
essential part of this Agreement and that was not a controlling or
material inducement to enter into this Agreement, the provision
shall have no effect and, upon notice by either party, shall be
deemed stricken from this Agreement without affecting the binding
force of the remainder of this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2004
2-8
3. COMPENSATION
3.1 Capitation Payments
Compensation to the Contractor shall consist of a monthly capitation
payment for each Enrollee and the Supplemental Capitation Payments
as described in Sections 3.1 (c) and 3.1 (d), where applicable.
a) In no event shall monthly capitation payments to the
Contractor for the Benefit Package exceed the cost of
providing the Benefit Package on a fee-for-service basis to an
actuarially equivalent, non-enrolled population group Upper
Payment Limit (UPL) as determined by SDOH.
b) The monthly Capitation Rates are attached hereto as Appendix L
and shall be deemed incorporated into this Agreement without
further action by the parties.
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 and 3.12 of
this Agreement.
d) Capitation Rates shall be effective for the entire contract
period, except as described in Section 3.2.
3.2 Modification of Rates During Contract Period
a) Any technical modification to Capitation Rates during the term
of the Agreement as agreed to by the Contractor, including but
not limited to, changes in reinsurance or the Benefit Package,
shall be deemed incorporated into this Agreement without
further action by the parties, upon approval by SDOH, and upon
written notice by SDOH to the LDSS.
b) Any other modification to Capitation Rates, as agreed to by
SDOH and the Contractor, during the term of the Agreement
shall be deemed incorporated into this Agreement without
further action by the parties upon approval of such
modifications by the SDOH and the State Division of the
Budget, and upon written notice by SDOH to the LDSS.
c) In the event that SDOH and the Contractor fail to reach
agreement on modifications to the monthly Capitation Rates,
the SDOH will provide formal written notice to the Contractor
and LDSS of the amount and effective date of the modified
Capitation Rates approved by the State Division of the Budget.
The Contractor shall have the option of terminating this
Agreement if such
SECTION 3
(COMPENSATION)
October 1, 2004
3-1
approved modified Capitation Rates are not acceptable. In such case,
the Contractor shall give written notice to the SDOH and the LDSS
within thirty (30) days of the date of the formal written notice of
the modified Capitation Rates from SDOH specifying the reasons for
and effective date of termination. The effective date of termination
shall be ninety (90) days from the date of the Contractor's written
notice, unless the SDOH determines that an orderly disenrollment to
Medicaid fee-for-service or transfer to another MCO can be
accomplished in fewer days. During the period commencing with the
effective date of the SDOH modified Capitation Rates through the
effective date of termination of the Agreement, the Contractor shall
have the option of continuing to receive capitation payments at the
expired Capitation Rates or at the modified Capitation Rates
approved by SDOH and State Division of the Budget for the rate
period.
If the Contractor fails to exercise its right to terminate in
accordance with this Section, then the modified Capitation Rates
approved by SDOH and the State Division of the Budget shall be
deemed incorporated into this Agreement without further action by
the parties as of the effective date of the modified Capitation
Rates as established by SDOH and approved by State Division of the
Budget.
3.3 Rate Setting Methodology
Capitation Rates are determined using a prospective methodology
whereby cost, utilization and other rate-setting data available for
the time period prior to the time period covered by the rates are
used to establish premiums. Capitation rates will not be
retroactively adjusted to reflect actual fee-for-service data or
plan experience for the time period covered by the rates.
3.4 Payment of Capitation
a) The monthly capitation payments for each Enrollee are due to
the Contractor from the Effective Date of Enrollment until the
Effective Date of Disenrollment of the Enrollee or termination
of this Agreement, whichever occurs first. The Contractor
shall receive a full month's capitation payment for the month
in which disenrollment occurs. The Roster generated by SDOH
with any modification communicated electronically or in
writing by the LDSS or the Enrollment Broker prior to the end
of the month in which the Roster is generated, shall be the
enrollment list for purposes of MMIS premium billing and
payment, as discussed in Section 6.9 and Appendix H.
b) Upon receipt by the Fiscal Agent of a properly completed claim
for monthly capitation payments submitted by the Contractor
pursuant to this Agreement, the Fiscal Agent will promptly
process such claim for payment through MMIS and use its best
efforts to complete such processing within thirty (30)
business days from date of receipt of the claim by the Fiscal
Agent. Processing of
SECTION 3
(COMPENSATION)
October 1, 2004
3-2
Contractor claims shall be in compliance with the requirements
of 42 CFR 447.45. The Fiscal Agent will also use its best
efforts to resolve any billing problem relating to the
Contractor's claims as soon as possible. In accordance with
Section 41 of the State Finance Law, the State and LDSS shall
have no liability under this Agreement to the Contractor or
anyone else beyond funds appropriated and available for
payment of Medical Assistance care, services and supplies.
3.5 Denial of Capitation Payments
If the Centers for Medicare and Medicaid Services denies payment for
new Enrollees, as authorized by Social Security Act (SSA) Section
1903(m)(5) and 42 CFR Section 434.67, or such other applicable
federal statutes or regulations, based upon a determination that
Contractor failed substantially to provide medically necessary items
and services, imposed premium amounts or charges in excess of
permitted payments, engaged in discriminatory practices as described
in SSA Section 1932(e)(1)(A)(iii), misrepresented or falsified
information submitted to CMS, SDOH, LDSS, the Enrollment Broker, or
an Enrollee, potential Enrollee, or health care provider, or failed
to comply with federal requirements (i.e. 42 CFR Section 417.479 and
42 CFR Section 434.70) relating to the Physician Incentive Plans,
SDOH and LDSS will deny capitation payments to the Contractor for
the same Enrollees for the period of time for which CMS denies such
payment.
3.6 SDOH Right to Recover Premiums
The parties acknowledge and accept that the SDOH has a right to
recover premiums paid to the Contractor for Enrollees listed on the
monthly Roster who are later determined for the entire applicable
payment month, to have been in an institution; to have been
incarcerated; to have moved out of the Contractor's service area
subject to any time remaining in the Enrollee's Guaranteed
Eligibility period; or to have died. In any event, the State may
only recover premiums paid for Medicaid Enrollees listed on a Roster
if it is determined by the SDOH that the Contractor was not at risk
for provision of Benefit Package services for any portion of the
payment period.
3.7 Third Party Health Insurance Determination
The Contractor and the LDSS will make diligent efforts to determine
whether Enrollees have third party health insurance (TPHI). The LDSS
shall use its best efforts to maintain third party information on
the WMS/MMIS Third Party Resource System. The Contractor shall make
good faith efforts to coordinate benefits with and collect TPHI
recoveries from other insurers, and must inform the LDSS of any
known changes in status of TPHI insurance eligibility within thirty
(30) days of learning of a change in TPHI. The Contractor may use
the Roster as one method to determine TPHI information. The
Contractor will be permitted to retain 100 percent of any
reimbursement for Benefit Package services obtained
SECTION 3
(COMPENSATION)
October 1, 2004
3-3
from TPHI. Capitation Rates are net of TPHI recoveries. In no
instances may an Enrollee be held responsible for disputes over
these recoveries.
3.8 Payment For Newborns
a) The Contractor shall be responsible for all costs and services
included in the Benefit Package associated with the Enrollee's
newborn, unless the child is excluded from Medicaid Managed
Care.
b) The Contractor shall receive a capitation payment from the
first day of the newborn's month of birth and, in instances
where the plan pays the hospital or birthing center for the
newborn stay, a Supplemental Newborn Capitation Payment.
c) Capitation Rate and Supplemental Newborn Capitation Payment
for a newborn will begin the month following certification of
the newborn's eligibility and enrollment, retroactive to the
first day of the month in which the child was born.
d) The Contractor cannot bill for a Supplemental Newborn
Capitation Payment unless the newborn hospital or birthing
center payment has been paid by the Contractor. The Contractor
must maintain on file evidence of payment to the hospital or
birthing center of the claim for the newborn stay. Failure to
have supporting records may, upon an audit, result in
recoupment of the Supplemental Newborn Capitation Payment by
SDOH.
3.9 Supplemental Maternity Capitation Payment
a) The Contractor shall be responsible for all costs and services
included in the Benefit Package associated with the maternity
care of an Enrollee.
b) In instances where the Enrollee is enrolled in the
Contractor's plan on the date of the delivery of a child, the
Contractor shall be entitled to receive a Supplemental
Maternity Capitation Payment. The Supplemental Maternity
Capitation Payment reimburses the Contractor for the inpatient
and outpatient costs of services normally provided as part of
maternity care including antepartum care, delivery and
post-partum care. The Supplemental Maternity Capitation
Payment is in addition to the monthly Capitation Rate paid by
the SDOH to the Contractor for the Enrollee.
c) In instances where the Enrollee was enrolled in the
Contractor's plan for only part of the pregnancy, but was
enrolled on the date of the delivery of the child, the plan
shall be entitled to receive the entire Supplemental Maternity
Capitation Payment. The Supplemental Capitation payment shall
not be pro-rated to reflect that the Enrollee was not a member
of the Contractor's plan for the entire duration of the
pregnancy.
SECTION 3
(COMPENSATION)
October 1, 2004
3-4
d) In instances where the Enrollee was enrolled in the
Contractor's plan for part of the pregnancy, but was not
enrolled on the date of the delivery of the child, the
Contractor shall not be entitled to receive the Supplemental
Maternity Capitation Payment, or any portion thereof.
e) Costs of inpatient and outpatient care associated with
maternity cases that end in termination or miscarriage shall
be reimbursed to the Contractor through the monthly Capitation
Rate for the Enrollee and the Contractor shall not receive the
Supplemental Maternity Capitation Payment.
f) The Contractor may not bill a Supplemental Maternity
Capitation Payment until the hospital inpatient or birthing
center delivery is paid by the Contractor, and the Contractor
must maintain on file evidence of payment of the delivery,
plus any other inpatient and outpatient services for the
maternity care of the Enrollee to be eligible to receive a
Supplemental Maternity Capitation Payment. Failure to have
supporting records may, upon audit, result in recoupment of
the Supplemental Maternity Capitation Payment by the SDOH.
3.10 Contractor Financial Liability
Contractor shall not be financially liable for any services
rendered to an Enrollee prior to his or her Effective Date of
Enrollment in the Contractor's plan.
3.11 Inpatient Hospital Stop-Loss Insurance
The Contractor must obtain stop-loss coverage for inpatient
hospital services. A Contractor may elect to purchase
stop-loss coverage from New York State. In such cases, the
Capitation Rates paid to the Contractor shall be adjusted to
reflect the cost of such stop-loss coverage. The cost of such
coverage shall be determined by SDOH.
Under NYS stop-loss coverage, if the hospital inpatient
expenses incurred by the Contractor for an individual Enrollee
during any calendar year reaches $50,000, the Contractor shall
be compensated for 80% of the cost of hospital inpatient
services in excess of this amount up to a maximum of $250,000.
Above that amount, the Contractor will be compensated for 100%
of cost. All compensation shall be based on the lower of the
Contractor's negotiated hospital rate or Medicaid rates of
payment.
[X] The Contractor has elected to have NYS provide stop-loss
reinsurance.
OR
[ ] Contractor has not elected to have NYS provide stop-loss
reinsurance.
SECTION 3
(COMPENSATION)
October 1, 2004
3-5
TABLE OF CONTENTS FOR MODEL CONTRACT
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
TABLE OF CONTENTS
October 1, 2004
3.12 Mental Health and Chemical Dependence Stop-Loss
a) The Contractor will be compensated for medically necessary and
clinically appropriate Medicaid reimbursable mental health
treatment outpatient visits in excess of twenty (20) visits
during any calendar year at rates set forth in contracted fee
schedules. Any Court Ordered Services for mental health
treatment outpatient visits which specify the use of Non-
Participating Providers shall be compensated at the Medicaid
rate of payment.
b) The Contractor will be compensated for medically necessary and
clinically appropriate inpatient mental health services and/or
Chemical Dependence Inpatient Rehabilitation and Treatment
Services as defined in Appendix K in excess of a combined
total of thirty (30) days during a calendar year at the lower
of the Contractor's negotiated inpatient rate or Medicaid rate
of payment.
c) Detoxification Services in Article 28 inpatient hospital
facilities are subject to the stop-loss provisions specified
in Section 3.11 of this Agreement.
3.13 Enrollment Limitations
a) The Contractor may enroll up to the county specific provider
network capacity limits determined by SDOH, provided that the
Contractor's statewide enrollment does not exceed the MCO's
financial capacity as determined annually by SDOH, or more
frequently as deemed necessary by SDOH.
b) LDSS shall have the right, upon consultation with and notice
to the SDOH, to limit, suspend, or terminate enrollment
activities by the Contractor and/or enrollment into the
Contractor's plan upon ten (10) days written notice to the
Contractor. The written notice shall specify the actions
contemplated and the reason(s) for such action(s) and shall
provide the Contractor with an opportunity to submit
additional information that would support the conclusion that
limitation, suspension or termination of enrollment activities
or enrollment in the Contractor's plan is unnecessary. Nothing
in this paragraph limits other remedies available to the LDSS
under this Agreement.
c) The SDOH shall have the right, upon notice to the LDSS, to
limit, suspend or terminate enrollment activities by the
Contractor and/or enrollment into the Contractor's plan upon
ten (10) days written notice to the Contractor. The written
notice shall specify the action(s) contemplated and the
SECTION 3
(COMPENSATION)
October 1, 2004
3-6
reason(s) for such action(s) and shall provide the Contractor
with an opportunity to submit additional information that
would support the conclusion that limitation suspension or
termination of enrollment activities or enrollment in the
Contractor's plan is unnecessary. Nothing in this paragraph
limits other remedies available to the SDOH or the LDSS under
this Agreement.
3.14 Tracking Visits Provided by Indian Health Clinics
The SDOH shall monitor all visits provided by tribal or Indian
health clinics or urban Indian health facilities or centers to
enrolled Native Americans, so that the SDOH can reconcile payment
made for those services, should it be deemed necessary to do so.
SECTION 3
(COMPENSATION)
October 1, 2004
3-7
4. SERVICE AREA
The Service Area described in Appendix M of this Agreement, which is
hereby made a part of this Agreement as if set forth fully herein, is the
specific geographic area within which Eligible Persons must reside to
enroll in the Contractor's plan.
SECTION 3
(COMPENSATION)
October 1, 2004
4-1
5. ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS
5.1 Eligible Populations
a) Except as specified in Section 5.1 (b) and 5.3 below, all persons in
the following Medicaid-eligible beneficiary categories who reside in
the service area shall be eligible for enrollment in the
Contractor's plan:
i) Singles/Childless Couples - Cash and Medicaid only
ii) Low Income Families with Children - Cash and Medicaid only
iii) Aid to Families with Dependent Children - Medicaid only
iv) Pregnant women whose net available income is at or below two
hundred percent (200%) of the federal poverty level for the
applicable household size.
v) Children aged one (1) year or below whose family's net
available income is at or below two hundred percent (200%) of the
federal poverty level for the applicable household size.
vi) Children between ages one (1) and five (5), whose family's net
available income is at or below one hundred and thirty-three percent
(133%) of the federal poverty level for the applicable household
size.
vii) Children age six (6) up to age nineteen (19), whose family's
net available income is at or below one hundred and thirty-three
percent (133%) of the federal poverty level for the applicable
household size.
viii) Transitional Medical Assistance Beneficiaries
ix) Supplemental Security Income (cash) and Supplemental Security
Income Related (Medicaid only).
b) Medicaid eligible individuals in the following categories may be eligible
for enrollment in the Contractor's plan at the LDSS' option, as indicated
by an X below.
i) Foster care children in the direct care of LDSS.
[ ] Mandatory county - children in LDSS direct care are mandatorily
enrolled.
[X] Mandatory OR voluntary county - children in LDSS direct care are
enrolled on a case-by-case basis.
[ ] Mandatory OR voluntary county all foster care children are excluded
from managed care.
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(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-1
ii) Homeless persons living in shelters outside of New York City may be
eligible for enrollment if so determined by the LDSS.
[ ] Mandatory county - homeless persons are mandatorily enrolled.
[ ] Mandatory OR voluntary county - homeless persons are enrolled on
a case-by-case basis.
[X] Mandatory OR voluntary county - all homeless persons are
excluded from managed care.
5.2 Exempt Populations
The following populations are exempt from mandatory enrollment in
Medicaid managed care, but may enroll on a voluntary basis, if
otherwise eligible.
a) Individuals who are HIV+ or have AIDS.
b) Individuals who are Seriously and Persistently Mentally III or
Seriously Emotionally Disturbed.
c) Individuals for whom a Managed Care Provider is not
geographically accessible so as to reasonably provide
services. To qualify for this exemption, an individual must
demonstrate that no participating MCO has a provider located
within thirty (30) minutes travel time/thirty (30) miles
travel distance from the individual's home, who is accepting
new patients, and that there is a fee-for-service Medicaid
provider available within the thirty (30) minutes travel
time/thirty (30) miles travel distance.
d) Pregnant women who are already receiving prenatal care from a
provider authorized to provide such care not participating in
any Medicaid managed care plan. This status will last through
a woman's pregnancy, extend through the sixty (60) day post-
partum period and end at the end of the month in which the
sixtieth (60th) day occurs.
e) Individuals with a chronic medical condition who, for at least
six (6) months, have been under active treatment with a
non-participating sub-specialist physician who is not a
network provider for any MCO participating in the Medicaid
managed care program service area. This status will last as
long as the individual's chronic medical condition exists or
until the physician joins a participating MCO's network. The
SDOH's Office of Managed Care, Medical Director will, upon the
request of an individual or his/her guardian or legally
authorized representative (health care agent authorized
through a health care proxy), review cases of individuals with
unusually severe chronic care needs for a possible exemption
from mandatory enrollment in managed care if such individuals
are not otherwise eligible for an exemption (i.e., meet one of
the seventeen (17) criteria listed here). The SDOH's OMC
Medical Director may also authorize a plan disenrollment for
such individuals. Disenrollment requests.
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-2
should be made in a manner consistent with the overall
disenrollment request process for "good cause" disenrollment.
f) Individuals with End Stage Renal Disease (ESRD).
g) Individuals who are residents of Intermediate Care Facilities
for the Mentally Retarded ("ICF/MR").
h) Individuals with characteristics and needs similar to those
who are residents of ICF/MRs based on criteria cooperatively
established by the State Office of Mental Retardation and
Developmental Disabilities (OMRDD) and the SDOH.
i) Individuals already scheduled for a major surgical procedure
(within thirty (30) days of scheduled enrollment) with a
provider who is not a participant in the network of a Medicaid
MCO under contract with the LDSS. This exemption will only
apply until such time as the individual's course of treatment
is complete.
j) Individuals with a developmental or physical disability who
receive services through a Medicaid Home-and-Community-Based
Services Waiver or Medicaid Model Waiver (care-at-home)
through a Section 1915c waiver, or individuals having
characteristics and needs similar to such individuals
(including individuals on the waiting list), based on criteria
cooperatively established by OMRDD and SDOH.
k) Individuals who are residents of Alcohol and Substance Abuse
or Chemical Dependence Long Term Residential Treatment
Programs.
l) In New York City, all homeless individuals are exempt. In
areas outside of NYC, exemption of homeless individuals
residing in the shelter system is at the discretion of the
local district. - See Section 5.1 (b).
m) Native Americans
n) Individuals who cannot be served by a managed care provider
due to a language barrier which exists when the individual is
not capable of effectively communicating his or her medical
needs in English or in a secondary language for which PCPs are
available within the Medicaid managed care program.
Individuals with a language barrier will be deemed able to be
served if they have a choice, within time and distance
standards, of three (3) PCPs who are able to communicate in
the primary language of the eligible individual or who have a
person on his/her staff capable of translating medical
terminology. Individuals will be eligible for an exemption
when:
i) The individual has a relationship with a Medicaid
fee-for-service Primary Care Provider who:
A) has the language capability to serve the
individual;
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(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-3
B) does not participate in any of the Medicaid
managed care plans contracted for a service area
which includes the individual's residence;
C) is located within a thirty (30) minute/thirty (30)
mile radius of the eligible individual's
residence;
AND
D) there are fewer than three (3) participating PCPs
available within the thirty (30) minute/thirty
(30) mile radius who are able to communicate in
the primary language of the eligible individual or
who have a person on his/her staff capable of
translating medical terminology.
OR
ii) The individual has a relationship with a Medicaid
fee-for-service Primary Care Provider who:
A) has the language capability to service the
individual;
B) does not participate in any of the Medicaid
managed care plans contracted for a service area
which includes the individual's residence;
C) is located outside a thirty (30) minute/thirty
(30) mile radius of the eligible individual's
residence;
AND
D) there are fewer than three (3) participating PCPs
available within or outside the thirty (30)
minute/thirty (30) mile radius who are able to
communicate in the primary language of the
eligible individual or who have a person on
his/her staff capable of translating medical
terminology.
o) Individuals temporarily residing out of district, (e.g.,
college students) will be exempt until the last day of the
month in which the purpose of the absence is accomplished. The
definition of temporary absence is set forth in Social
Services regulations 18 NYCRR Section 360-1.4(p).
p) SSI and SSI-related beneficiaries are considered exempt and
may enroll on a voluntary basis.
q) Individuals with a "County of Fiscal Responsibility" code of
98 (OMRDD in MMIS) are exempt in counties where program
features are approved by the State and operational at the
local district level to permit these individuals to
voluntarily enroll in Medicaid managed care.
[ ] State-approved program features are in place and
operational at the local district level to permit
individuals with a "County of Fiscal Responsibility"
code of 98 to voluntarily enroll in Medicaid managed
care.
OR
[x] State-approved program features are not in place and
operational at the local district level, therefore
individuals with a "County of Fiscal Responsibility"
code of 98 are excluded from enrollment in Medicaid
managed care.
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-4
r) Individuals who are eligible for Medical Assistance pursuant
to the "Medicaid buy-in for the working disabled"
(subparagraphs twelve or thirteen of paragraph (a) of
subdivision one of Section 366 of the Social Services Law),
and who, pursuant to subdivision 12 of Section 367-a of the
Social Services Law, are not required to pay a premium.
5.3 Excluded Populations
The following populations are ineligible for enrollment in Medicaid
managed care.
a) Individuals who are Dually Eligible for Medicare/Medicaid.
b) Individuals who become eligible for Medicaid only after
spending down a portion of their income (Spend-down).
c) Individuals who are residents of State-operated psychiatric
facilities or residents of State-certified or voluntary
treatment facilities for children and youth.
d) Individuals who are residents of Residential Health Care
Facilities ("RHCF") at the time of Enrollment, and Enrollees
whose stay in a RHCF is classified as permanent upon entry
into the RHCF or is classified as permanent at a time
subsequent to entry.
e) Individuals enrolled in managed long term care demonstrations
authorized under Article 4403-f of the New York State PHL.
f) Medicaid-eligible infants living with incarcerated mothers.
g) Infants weighing less than 1200 grams at birth and other
infants under six (6) months of age who meet the criteria for
the SSI or SSI related category (shall not be enrolled or
shall be disenrolled retroactive to date of birth).
h) Individuals with access to comprehensive private health care
coverage including those already enrolled in an MCO. Such
health care coverage, purchased either partially or in full,
by or on behalf of the individual, must be determined to be
cost effective by the local social services district.
i) Foster children in the placement of a voluntary agency.
j) Certified blind or disabled children living or expected to be
living separate and apart from the parent for thirty (30) days
or more.
k) Individuals expected to be eligible for Medicaid for less than
six (6) months, except for pregnant women (e.g., seasonal
agricultural workers).
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-5
l) Foster children in direct care (unless LDSS opts to enroll
them see Section 5.1(b)).
m) Youths in the care and custody of the Commissioner of the NYS
Office of Children and Family Services.
n) Individuals in receipt of long-term care services through Long
Term Home Health Care programs, or Child Care Facilities
(except ICF services for the Developmentally Disabled).
o) Individuals eligible for Medical assistance benefits only with
respect to TB related services.
p) Individuals placed in State Office of Mental Health licensed
family care homes pursuant to NYS Mental Hygiene Law, Section
31.03.
q) Individuals enrolled in the Restricted Recipient Program.
r) Individuals with a "County of Fiscal Responsibility" code of
99.
s) Individuals admitted to a Hospice program prior to time of
enrollment (if an Enrollee enters a Hospice program while
enrolled in the Contractor's plan, he/she may remain enrolled
in the Contractor's plan to maintain continuity of care with
his/her PCP). Hospice services are accessed through the
fee-for-service Medicaid Program.
t) Individuals with a "County of Fiscal Responsibility" code of
97 (OMH in MMIS).
u) Individuals with a "County of Fiscal Responsibility" code of
98 (OMRDD in MMIS) will be excluded until program features are
approved by the State and operational at the local district
level to permit these individuals to voluntarily enroll in
Medicaid managed care.
v) Individuals receiving family planning services pursuant to
Section 366(l)(a)(ll) of the Social Services Law who are not
otherwise eligible for medical assistance and whose net
available income is 200% or less of the federal poverty level.
w) Individuals who are eligible for Medical Assistance pursuant
to the "Medicaid buy-in for the working disabled"
(subparagraphs twelve or thirteen of paragraph (a) of
subdivision one of Section 366 of the Social Services Law),
and who, pursuant to subdivision 12 of Section 367-a of the
Social Services Law, are required to pay a premium.
x) Individuals who are eligible for Medical Assistance pursuant
to paragraph (v) of subdivision four of Section 366 of the
Social Services Law (persons who are under 65 years of age,
have been screened for breast and/or cervical cancer under
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-6
the Centers for Disease Control and Prevention Breast and Cervical
Cancer Early Detection Program and need treatment for breast or
cervical cancer, and are not otherwise covered under creditable
coverage as defined in the Federal Public Health Service Act).
5.4 Family Health Plus
Individuals eligible for Medicaid (Family Health Plus) pursuant to
Title 11-D of the Social Services Law are not eligible for
enrollment in Medicaid managed care under this Agreement.
5.5 Family Enrollment
In local social service districts where enrollment in managed care
is mandatory, the Contractor agrees that members of the same family
(defined as mother and her child(ren), father and his child(ren), a
husband, wife and child(ren) or a husband and wife residing in the
same household, or persons included in the same case) will be
required to enroll in the same health plan, in accordance with
Section 6.6 of this Agreement.
SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-7
6. ENROLLMENT
6.1 Enrollment Guidelines
a) The LDSS may employ a variety of methods and programs for
enrollment of Eligible Persons including but not limited to
enrollment assisted by the Contractor, enrollment assisted by
an Enrollment Broker, enrollment by LDSS, or a combination of
such. The policies and procedural guidelines which will be
used for enrollment are set forth in Appendix H, which is
hereby made a part of this Agreement as if set forth fully
herein.
b) The LDSS and the Contractor agree to conduct enrollment of
eligible individuals in accordance with the guidelines set
forth in Appendix H.
c) The SDOH and LDSS, upon mutual agreement, may make
modifications to the guidelines set forth in Appendix H. The
parties further acknowledge that such modifications shall be
effective and made a part of this Agreement without further
action by the parties upon sixty (60) days written notice to
the LDSS and the Contractor.
6.2 Equality of Access to Enrollment
Eligible Person's shall be enrolled in the Contractor's plan, in
accordance with the requirements set forth in Appendix H, Section A.
In those instances in which the Contractor is directly involved in
enrolling eligible recipients, the Contractor shall accept
enrollments in the order they are received without regard to the
Eligible Person's age, sex, race, creed, physical or mental
handicap/developmental disability, national origin, sexual
orientation, type of illness or condition, need for health services
or to the Capitation Rate that the Contractor will receive for such
Eligible Person.
6.3 Enrollment Decisions
An Eligible Person's decision to enroll in the Contractor's plan
shall be voluntary except as otherwise provided in Section 6.4 of
the Agreement.
6.4 Auto Assignment
An Eligible Person whose enrollment in a MCO is mandatory and who
fails to select a MCO within sixty (60) days of receipt of notice of
mandatory enrollment may be assigned by the LDSS to the Contractor's
plan pursuant to NYS Social Services Law Section 364-j and in
accordance with Appendix H.
SECTION 6
(ENROLLMENT)
October 1, 2004
6-1
6.5 Prohibition Against Conditions on Enrollment
Unless otherwise required by law or this Agreement, neither the
Contractor nor LDSS shall condition any Eligible Person's enrollment
upon the performance of any act or suggest in any way that failure
to enroll may result in a loss of Medicaid benefits.
6.6 Family Enrollment
a) In local social service districts where enrollment in managed
care is mandatory, all eligible members of the Eligible
Person's Family shall be enrolled into the same plan.
b) In local social service districts where enrollment in managed
care is mandatory, the LDSS must inform Enrollees who have
Family members enrolled in other MCOs that if anyone in the
Family wishes to change plans, all members of the Family must
enroll together in the newly-selected plan. The LDSS shall
also notify the Enrollee that all members of the Family will
be required to enroll together in a single MCO at the time of
their next recertification for Medicaid eligibility unless
waiver of this requirement is approved by the LDSS.
c) Notwithstanding the foregoing,
i) the LDSS may, on a case-by-case basis, waive the same
family rule specified in Sections 6.6 (a) and (b) to
preserve continuity of care:
1) if one or more members of the Family are receiving
prenatal care and/or continuing care for a complex
chronic medical condition from Non-Participating
Providers; or
2) if one or more members of the Family transition
from one government-sponsored insurance program to
another.
ii) the LDSS must allow HIV SNP-eligible individuals within
a family to enroll in an HIV SNP, in Service Areas in
which an HIV SNP exists.
6.7 Newborn Enrollment
a) All newborn children not in an excluded category shall be
enrolled in the MCO of the mother, effective from the first
day of the child's month of birth.
SECTION 6
(ENROLLMENT)
October 1, 2004
6-2
b) In addition to the responsibilities set forth in Appendix H,
the Contractor is responsible for doing all of the following
with respect to newborns:
i) Coordinating with the LDSS the efforts to ensure that
all newborns are enrolled in the managed care plan;
ii) Issuing a letter informing parent(s) about newborn
child's enrollment or a member identification card
within 14 days of the date on which the Contractor
becomes aware of the birth;
iii) Assuring that enrolled pregnant women select a PCP for
an infant prior to birth and the mother to make an
appointment with the PCP immediately upon birth; and
iv) Ensuring that the newborn is linked with a PCP prior to
discharge from the hospital, in those instances in which
the Contractor has received appropriate notification of
the birth prior to discharge.
c) The LDSS shall be responsible for ensuring that timely
Medicaid Eligibility determination and enrollment of the
newborns is effected consistent with state laws, regulations,
and policy and with the newborn enrollment guidelines set
forth in Appendix H, Section B of this Agreement.
6.8 Effective Date of Enrollment
a) The Contractor and the LDSS must notify the Enrollee of the
expected Effective Date of Enrollment. This may be
accomplished through a "Welcome Letter". To the extent
practicable, such notification must precede the Effective Date
of Enrollment. In the event that the actual Effective Date of
Enrollment changes, the Contractor and the LDSS must notify
the Enrollee of the change.
b) As of the Effective Date of Enrollment, and until the
Effective Date of Disenrollment from the Contractor's plan,
the Contractor shall be responsible for the provision and cost
of all care and services covered by the Benefit Package and
provided to Enrollees whose names appear on the Prepaid
Capitation Plan Roster, except as hereinafter provided.
i) Contractor shall not be liable for the cost of any
services rendered to an Enrollee prior to his or her
Effective Date of Enrollment.
ii) Contractor shall not be liable for any part of the cost
of a hospital stay for an Enrollee who is admitted to
the hospital prior to the Effective Date of Enrollment
in the Contractor's plan and who remains hospitalized on
the Effective Date of Enrollment; except when the
Enrollee, on or after the Effective Date of Enrollment,
1) is transferred from one hospital to another; or 2) is
discharged from one unit in the hospital to another unit
in the same facility and under Medicaid fee for service
payment rules, the method of payment changes from: a)
DRG
SECTION 6
(ENROLLMENT)
October 1, 2004
6-3
case-based rate of payment per discharge to a per diem
rate of payment exempt from DRG case-based payment
rates, or b) from a per diem payment rate exempt from
DRG case-based payment rates either to another per diem
rate, or a DRG case-based payment rate. In such
instances, the Contractor shall be liable for the cost
of the consecutive stay.
iii) Except for newborns, an Enrollee's Effective Date of
Enrollment shall be the first day of the month on which
the Enrollee's name appears on the PCP roster for that
month.
6.9 Roster
a) The first and second monthly Rosters generated by SDOH in
combination shall serve as the official Contractor enrollment
list for purposes of MMIS premium billing and payment, subject
to ongoing eligibility of the Enrollees as of the first (1st)
day of the enrollment month. Modifications to the first (1st)
Roster may be made electronically or in writing by the LDSS or
the Enrollment Broker prior to the end of the month in which
the Roster is generated.
b) The LDSS shall make data on eligibility determinations
available to the Contractor and SDOH to resolve discrepancies
that may arise between the Roster and the Contractor's
enrollment files in accordance with the provisions in Appendix
H, Section D.
c) If LDSS or Enrollment Broker notifies the Contractor in
writing or electronically of changes in the first (1st) Roster
and provides supporting information as necessary prior to the
effective date of the Roster, the Contractor will accept that
notification in the same manner as the Roster.
d) All Contractors must have the ability to receive these Rosters
electronically.
6.10 Automatic Re-Enrollment
The Contractor agrees that Eligible Persons who are disenrolled from
the Contractor's plan due to loss of Medicaid eligibility and who
regain eligibility within three (3) months will automatically be
prospectively re-enrolled with the Contractor's plan, subject to
availability of enrollment capacity in the plan.
SECTION 6
(ENROLLMENT)
October 1, 2004
6-4
7. LOCK-IN PROVISIONS
7.1 Lock-In Provisions in Voluntary Counties
All Enrollees in local social service districts where enrollment in
managed care is voluntary shall be subject to a Lock-In Period under this
Agreement if so required by the LDSS as indicated by an x below:
[ ] Enrollees are subject to a twelve (12 ) month Lock-In Period following
the Effective Date of Enrollment in the Contractor's plan with an initial
ninety (90) day grace period to disenroll from the Contractor's plan
without cause.
[x] Enrollees are not subject to a Lock-In Period.
7.2 Lock-In Provisions in Mandatory Counties and New York City
All Enrollees in local social service districts where enrollment in
managed care is mandatory and in New York City are subject to a twelve
(12) month Lock-In period following the Effective Date of Enrollment in
the Contractor's plan, with an initial ninety (90) day grace period in
which to disenroll from the Contractor's plan without cause, regardless of
whether the Enrollee selected or was autoassigned to the Contractor's
plan.
7.3 Disenrollment During Lock-In Period
An Enrollee, subject to Lock-In, may disenroll from the Contractor's plan
during the Lock-In period for "good cause" as established in 18 NYCRR
Subpart 360-10 or, if the Enrollee becomes eligible for an exemption or
exclusion from Medicaid managed care as set forth in Sections 5.2 and 5.3
of this Agreement.
7.4 Notification Regarding Lock-In and End of Lock-In Period
LDSS, either directly or through the Enrollment Broker, shall notify
Enrollees of their right to change MCOs in the enrollment confirmation
notice sent to individuals after they have selected a MCO or been
auto-assigned (the latter being applicable to areas where the mandatory
program is in effect). LDSS and the Enrollment Broker will be responsible
for providing a notice of end of Lock-In and the right to change MCOs at
least sixty (60) days prior to the first plan enrollment anniversary date.
SECTION 7
(LOCK-IN PROVISIONS)
October 1, 2004
7-1
8. DISENROLLMENT
8.1 Disenrollment Guidelines
a) Disenrollment of an Enrollee from the Contractor's Plan may be
initiated by the Enrollee, LDSS or the Contractor under the
conditions specified in Sections 8.4, 8.7, 8.8 and 8.9 and as
detailed in Appendix H, Section E and F of this Agreement.
b) The LDSS and the Contractor agree to conduct disenrollment in
accordance with the guidelines set forth in Appendix H,
Section E and F of this Agreement.
c) The SDOH and LDSS, upon mutual agreement, may modify Appendix
H of this Agreement upon sixty (60) days prior written notice
to the Contractor and such modifications shall become binding
and incorporated into this Agreement without further action by
the parties.
d) LDSS shall make the final determination concerning
disenrollment.
8.2 Disenrollment Prohibitions
Disenrollment shall not be based in whole or in part on any of the
following reasons:
a) an existing condition or a change in the Enrollee's health
which would necessitate disenrollment pursuant to the terms of
this Agreement, unless the change
i) results in the Enrollee being reclassified into an
excluded category for Medicaid managed care as listed in
Section 5.3 of this Agreement;
ii) results in the Enrollee being reclassified into an
exempt category as listed in Section 5.2 of this
Agreement and the Enrollee wants to disenroll from
managed care.
b) any of the factors listed in Section 34 - Non-Discrimination
of this Agreement; or
c) on the Capitation Rate payable to the Contractor related to
the Enrollee's participation with the Contractor.
SECTION 8
(DISENROLLMENT)
October 1 2004
8-1
8.3 Reasons for Voluntary Disenrollment
The LDSS or the Contractor, as agreed upon between the LDSS and
Contractor, shall provide Enrollees who disenroll voluntarily with
an opportunity to identify, in writing, their reason(s) for
disenrollment.
8.4 Processing of Disenrollment Requests
a) Routine Disenrollment
Unless otherwise specified in Appendix H, Section F
disenrollment requests will be processed to take effect on the
first (1st) day of the next month if the request is made
before the date specified in Appendix H. In no event shall the
Effective Date of Disenrollment be later than the first (1st)
day of the second (2nd) month after the month in which an
Enrollee requests a disenrollment.
b) Expedited Disenrollment
i) Enrollees with an urgent medical need to disenroll from
the Contractor's plan may request an expedited
disenrollment by the LDSS. Substantiation of the request
by the LDSS will result in an expedited disenrollment in
accordance with the guidelines and timeframes as set
forth in Appendix H. Individuals who are to be
disenrolled from managed care based on their HIV, ESRD
or SPMI/SED status are categorically eligible for an
expedited disenrollment on the basis of urgent medical
need.
ii) Enrollees may request an expedited disenrollment by the
LDSS based on a complaint of Non-consensual Enrollment.
Substantiation of such a request by the LDSS shall
result in an expedited disenrollment retroactive to the
first day of the month of enrollment.
iii) In New York City and other districts where homeless
individuals are exempt, homeless Enrollees residing in
the shelter system may request an expedited
disenrollment by the LDSS. Substantiation of such a
request by the LDSS will result in an expedited
disenrollment in accordance with the guidelines and
timeframes as set forth in Appendix H.
c) Retroactive Disenrollment
i) Retroactive disenrollments may be warranted in rare
instances and include when an individual is enrolled or
autoassigned while meeting exclusion criteria or when an
Enrollee enters or stays in a residential institution
under circumstances which render the
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(DISENROLLMENT)
October 1, 2004
8-2
individual excluded from managed care; is incarcerated;
is an SSI infant less than six months of age; or dies -
as long as the Contractor was not at risk for provision
of Benefit Package services for any portion of the
retroactive period.
8.5 Contractor Notification of Disenrollments
a) Notwithstanding anything herein to the contrary, the Roster,
along with any changes sent by the LDSS to the Contractor in
writing or electronically, shall serve as official notice to
the Contractor of disenrollment of an Enrollee. In cases of
expedited and retroactive disenrollment, the Contractor shall
be notified of the Enrollee's effective date of disenrollment
by the LDSS.
b) In the event that the LDSS intends to retroactively disenroll
an Enrollee on a date prior to the first day of the month of
the disenrollment request, the LDSS shall consult with the
Contractor prior to disenrollment. Such consultation shall not
be required for the retroactive disenrollment of SSI infants
or in cases where it is clear that the Contractor was not a
risk for the provision of Benefit Package services for any
portion of the retroactive period.
c) In all cases of retroactive disenrollment, including
disenrollments effective the first day of the current month,
the LDSS must notice the plan at the time of disenrollment, of
the Contractor's responsibility to submit to the SDOH's Fiscal
Agent voided premium claims for any months of retroactive
disenrollment where the Contract was not at risk for the
provision of Benefit Package services during the month.
8.6 Contractor's Liability
a) The Contractor is not responsible for providing the Benefit
Package under this Agreement after the Effective Date of
Disenrollment except as hereinafter provided:
i) The Contractor shall be liable for any part of the cost of
a hospital stay for an Enrollee who is admitted to the
hospital prior to the Effective Date of Disenrollment in the
Contractor's plan and who remains hospitalized on the
Effective Date of Disenrollment; except when the Enrollee, on
or after the Effective Date of Disenrollment, 1) is
transferred from one hospital to another; or 2) is discharged
from one unit in the hospital to another unit in the same
facility and under Medicaid fee for service payment rules, the
method of payment changes from: a) DRG case-based rate of
payment per discharge to a per diem rate of payment exempt
from DRG case-based payment rates, or b) from a per diem
payment rate exempt from DRG case-based payment rates to
either another per diem rate, or a DRG case-based
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8-3
payment rate. In such instances, the Contractor shall not be
liable for the cost of the consecutive stay. For the purposes
of this Section, "hospital stay" does not include a stay in a
hospital that is a) certified by Medicare as a long-term care
hospital and b) has an average length of stay for all patients
greater than ninety-five (95 days as reported in the Statewide
Planning and Research Cooperative System (SPARCS) Annual
Report 2002; in such instances, Contractor liability will
cease on the Effective Date of Disenrollment.
b) The Contractor shall notify the LDSS that the Enrollee remains
in the hospital and provide the LDSS with information
regarding his or her medical status. The Contractor is
required to cooperate with the Enrollee and the new MCO (if
applicable) on a timely basis to ensure a smooth transition
and continuity of care.
8.7 Enrollee Initiated Disenrollment
a) Disenrollment For Good Cause
i) An Enrollee subject to Lock-In may initiate
disenrollment from the Contractor's plan for "good
cause" as defined in 18 NYCRR Section 360-10 at any time
during the Lock-In period and may disenroll for any
reason at any time after the twelfth (12th) month
following the Effective Date of Enrollment.
ii) An Enrollee subject to Lock-In may initiate
disenrollment for "good cause" by filing a written
request with the LDSS or the Contractor. The Contractor
must notify the LDSS of the request. The LDSS must
respond with a determination within thirty (30) days
after receipt of the request. The Contractor must
respond timely to LDSS inquiries regarding "good cause"
disenrollment requests to enable the LDSS to make a
determination within 30 days of the receipt of the
request from the Enrollee.
iii) Enrollees granted disenrollment for "good cause" in a
voluntary county may join another plan, if one is
available, or participate in Medicaid fee-for-service
program. In mandatory counties, unless the Enrollee
becomes exempt or excluded, he/she may be required to
enroll with another MCO.
iv) In the event that the LDSS denies an Enrollee's request
for disenrollment for "good cause", the LDSS must inform
the Enrollee of the denial of the request with a written
notice which explains the reason for the denial, states
the facts upon which denial is based, cites the
statutory and regulatory authority and advises the
recipient of his or her right to a fair hearing pursuant
to 18 NYCRR Part 358. In the event that the Enrollee's
request to disenroll is approved, the notice must state
the Effective Date of Disenrollment.
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(DISENROLLMENT)
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v) Once the Lock-In Period has expired, an Enrollee may
disenroll from the Contractor's plan at any time, for
any reason.
8.8 Contractor Initiated Disenrollment
a) The Contractor may initiate an involuntary disenrollment if
the Enrollee engages in conduct or behavior that seriously
impairs the Contractor's ability to furnish services to either
the Enrollee or other Enrollees, provided that the Contractor
has made and documented reasonable efforts to resolve the
problems presented by the Enrollee.
b) Consistent with 42 CFR 438.56 (b), the Contractor may not
request disenrollment because of an adverse change in the
Enrollee's health status, or because of the Enrollee's
utilization of medical services, diminished mental capacity,
or uncooperative or disruptive behavior resulting from the
Enrollee's special needs (except where continued enrollment in
the Contractor's plan seriously impairs the Contractor's
ability to furnish services to either the Enrollee or other
Enrollees).
c) The Contractor must make a reasonable effort to identify for
the Enrollee, both verbally and in writing, those actions of
the Enrollee that have interfered with the effective provision
of covered services as well as explain what actions or
procedures are acceptable.
d) The Contractor shall give prior verbal and written notice to
the Enrollee, with a copy to the LDSS, of its intent to
request disenrollment. The written notice shall advise the
Enrollee that the request has been forwarded to the LDSS for
review and approval. The written notice must include the
mailing address and telephone number of the LDSS.
e) The Contractor shall keep the LDSS informed of decisions
related to all complaints filed by an Enrollee as a result of,
or subsequent to, the notice of intent to disenroll.
f) The LDSS will review each Contractor initiated disenrollment
request in accordance with the provisions of this Section.
Where applicable, the LDSS may consult wit local mental health
and substance abuse authorities in the district when making
the determination to approve or disapprove a Contractor
initiated disenrollment request.
g) The LDSS will render a decision within fifteen (15) days of
receipt of the fully documented request for disenrollment.
Final written determination will be provided to the Enrollee
and the Contractor. If the LDSS determination upholds the
Contractor's request to disenroll, the LDSS's written
determination must inform the Enrollee of the Effective Date
of Disenrollment and include a notice of rights to a fair
hearing. Should an
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(DISENROLLMENT)
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8-5
Enrollee request a fair hearing as a result of the LDSS
determination, the LDSS shall inform the Contractor of the
fair hearing request and the Enrollee will remain enrolled in
the Contractor's plan until disposition of the fair hearing.
h) Once an Enrollee has been disenrolled at the Contractor's
request, he/she will not be re-enrolled with the Contractor's
plan unless the Contractor first agrees to such re-enrollment.
8.9 LDSS Initiated Disenrollment
a) LDSS will promptly initiate disenrollment when:
i) an Enrollee is no longer eligible for any Medicaid
benefits; or
ii) the Guaranteed Eligibility period ends (See Section 9)
and an Enrollee is no longer eligible for any Medicaid
benefits; or
iii) an Enrollee is no longer the financial responsibility of
the LDSS; or
iv) an Enrollee becomes ineligible for enrollment pursuant
to Section 5.3 of this Agreement, as appropriate; or
v) an Enrollee resides outside the Service Area covered by
this Agreement, unless Contractor can demonstrate that
the Enrollee has made an informed choice to continue
enrollment with Contractor and that Enrollee will have
sufficient access to Contractor's provider network.
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9. GUARANTEED ELIGIBILITY
Except as may otherwise be required by law:
9.1 New Enrollees, other than those identified in Sections 9.2 who would
otherwise lose Medicaid eligibility during the first six (6) months
of enrollment will retain the right to remain enrolled in the
Contractor's plan under this Agreement for a period of six (6)
months from their Effective Date of Enrollment.
9.2 Guaranteed eligibility is not available to Enrollees who lose
Medicaid eligibility for one of the following reasons:
a) death, moving out of State, or incarceration;
b) being a woman with a net available income in excess of
medically necessary income but at or below 200% of the federal
poverty level who is only eligible for Medicaid while she is
pregnant and then through the end of the month in which the
sixtieth (60th) day following the end of the pregnancy occurs.
9.3 If, during the first six (6) months of enrollment in the
Contractor's plan, an Enrollee becomes eligible for Medicaid only as
a spend-down, the Enrollee will be eligible to remain enrolled in
the Contractor's plan for the remainder of the six (6) month
guarantee period. During the six (6) month guarantee period, an
Enrollee eligible for spend-down and in need of wraparound services
has the option of spending down to gain full Medicaid eligibility
for the wraparound services. In this situation, the LDSS will
monitor the Enrollee's need for wrap around services and manually
set coverage codes as appropriate.
9.4 The services covered during the Guaranteed Eligibility period shall
be those contained in the Benefit Package, as specified in Appendix
K, including free access to family planning services as set forth in
Section 10.12 of this Agreement. During the Guaranteed Eligibility
period Enrollees are also eligible for pharmacy services on a
Medicaid fee-for-service basis.
9.5 An Enrollee-initiated disenrollment from the Contractor's plan
terminates the Guaranteed Eligibility period.
9.6 Enrollees who lose and regain Medicaid eligibility within a three
(3) month period will not be entitled to a new period of six (6)
months Guaranteed Eligibility.
9.7 During the guarantee period, an Enrollee may not change health
plans. An Enrollee may choose to disenroll from the Contractor's
Plan during the guarantee period but is not eligible to enroll in
any other MCO because he/she has lost eligibility for Medicaid.
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(GUARANTEED ELIGIBILITY)
October 1, 2004
9-1
10. BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES
10.1 Contractor Responsibilities
Contractor must provide all services set forth in the Benefit
Package (Appendix K) that are covered under the Medicaid fee for
service program except for services specifically excluded by the
contract, or enacted or affected by Federal or State Law during the
period of this agreement. SDOH and LDSS shall assure the continued
availability and accessibility of Medicaid services not covered in
the Benefit Package.
10.2 Compliance with State Medicaid Plan and Applicable Laws
Benefit Package services provided by the Contractor under this
Agreement shall comply with all standards of the State Medicaid Plan
established pursuant to Section 363-a of the State Social Services
Law and shall satisfy all applicable requirements of the State
Public Health and Social Services Laws.
10.3 Definitions
Benefit Package and Non-Covered Service definitions agreed to by the
Contractor and the LDSS are contained in Appendix K, which is hereby
made a part of this contract as if set forth fully herein.
10.4 Provision of Services Through Participating and Non-Participating
Providers
With the exception of Emergency services described in Section 10.14
of this Agreement, Family Planning Services described in Section
10.11 of this Agreement, and services for which Enrollees can self
refer as described in Section 10.16 of this Agreement, the Benefit
Package must be provided and authorized by the Contractor through
Provider Agreements with Participating Providers, as specified in
Section 22 of this Agreement. A plan may also arrange for specialty
or other services for Enrollees with Non-Participating Providers, in
accordance with Section 21.1(b) of this Agreement.
10.5 Child Teen Health Program/Adolescent Preventive Services
a) The Contractor and its Participating Providers are required to
provide the Child Teen Health Program C/THP services outlined
in Appendix K (Benefit Package) and comply with applicable
EPSDT requirements specified in 42 CFR, Part 441, sub-part B,
18NYCRR, Part 508 and the New York State Department of Health
C/THP manual. The Contractor and its Participating Providers
are required to provide C/THP services to Medicaid Enrollees
under 21 years of age when:
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i) The care or services are essential to prevent, diagnose,
prevent the worsening of, alleviate or ameliorate the
effects of an illness, injury, disability, disorder or
condition,
ii) The care or services are essential to the overall
physical, cognitive and mental growth and developmental
needs of the child,
iii) The care or service will assist the individual to
achieve or maintain maximum functional capacity in
performing daily activities, taking into account both
the functional capacity of the individual and those
functional capacities that are appropriate for
individuals of the same age.
The Contractor shall base its determination on medical and other
relevant information provided by the Enrollee's PCP, other health
care providers, school, local social services, and/or local public
health officials that have evaluated the child.
b) The Contractor and its Participating Providers must comply
with the C/THP program standards and must do at least the
following with respect to all Enrollees under age 21:
i) Educate pregnant women and families with under age 21
Enrollees about the program and its importance to a
child's or adolescent's health,
ii) Educate network providers about the program and their
responsibilities under it.
iii) Conduct outreach, including by mail, telephone, and
through home visits (where appropriate), to ensure
children are kept current with respect to their
periodicity schedules.
iv) Schedule appointments or children and adolescents
pursuant to the periodicity schedule, assist with
referrals, and conduct follow-up with children and
adolescents who miss or cancel appointments.
v) Ensure that all appropriate diagnostic and treatment
services, including specialist referrals, are furnished
pursuant to findings from a C/THP screen.
vi) Achieve and maintain an acceptable compliance rate for
screening schedules during the contract period.
c) In addition to C/THP requirements, the Contractor and its
Participating Providers are required to comply with the
American Medical Association's Guidelines for Adolescent
Preventive Services which require annual well adolescent
preventive visits which focus on health guidance,
immunizations, and screening for physical, emotional, and
behavioral conditions.
10.6 Foster Care Children
The Contractor shall comply with the health requirements for foster
children specified in 18 NYCRR Section 441.22 and Part 507 and any
subsequent amendments thereto. These requirements include thirty
(30) day obligations for
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a comprehensive physical and behavioral health assessment and
assessment of the risk that the child may be HIV+ and should be
tested.
10.7 Child Protective Services
The Contractor shall comply with the requirements specified for
child protective examinations, provision of medical information to
the child protective services investigation and court ordered
services as specified in 18 NYCRR Section 432, and any subsequent
amendments thereto. Medically necessary services, whether provided
in or out of plan, must be provided. Out of plan providers will be
reimbursed at the Medicaid fee schedule by the Contractor.
10.8 Welfare Reform
a) The LDSS must determine whether each public assistance or
combined public assistance/Medicaid applicant is incapacitated
or can participate in work activities. As part of this work
determination process, the LDSS may require medical
documentation and/or an initial mental and/or physical
examination to determine whether an individual has a mental or
physical impairment that limits his/her ability to engage in
work (12 NYCRR Section 1300.2(d)(13)(i)). The LDSS may not
require the Contractor to provide the initial district
mandated or requested medical examination necessary for an
Enrollee to meet welfare reform work participation
requirements.
b) The Contractor shall require that its Participating Providers,
upon Enrollee consent, provide medical documentation and
health, mental health and chemical dependence assessments as
follows:
i) Within ten (10) days of a request of an Enrollee or a
former Enrollee, currently receiving public assistance
or who is applying for public assistance, the Enrollee's
or former Enrollee's PCP or specialist provider, as
appropriate, shall provide medical documentation
concerning the Enrollee or former Enrollee's health or
mental health status to the LDSS or to the LDSS'
designee. Medical documentation includes but is not
limited to drug prescriptions and reports from the
Enrollee's PCP or specialist provider. The Contractor
shall include the foregoing as a responsibility of the
PCP and specialist provider in its provider contracts or
in their provider manuals.
ii) Within ten (10) days of a request of an Enrollee, who
has already undergone, or is scheduled to undergo, an
initial LDSS required mental and/or physical
examination, the Enrollee's PCP shall provide a health,
or mental health and/or chemical dependence assessment,
examination or other services as appropriate to identify
or quantify an Enrollee's level of incapacitation. Such
assessment must contain a specific diagnosis resulting
from any medically appropriate tests and specify any
work
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limitations. The LDSS, may, upon written notice to the
Contractor, specify the format and instructions for such
an assessment.
c) The Contractor shall designate a Welfare Reform liaison who
shall work with the LDSS or its designee to (1) ensure that
Enrollees receive timely access to assessments and services
specified in this Agreement and (2) ensure completion of
reports containing medical documentation required by the LDSS.
d) The Contractor will continue to be responsible for the
provision and payment of Chemical Dependence Services in the
Benefit Package for Enrollees mandated by the LDSS under
Welfare Reform if such services are already underway and the
LDSS is satisfied with the level of care and services.
e) The Contractor is not responsible for the provision and
payment of Chemical Dependence Inpatient Rehabilitation and
Treatment Services for Enrollees mandated by the LDSS as a
condition of eligibility for Public Assistance or Medicaid
under Welfare Reform (as indicated by Code 83) unless such
services are already under way as described in (c) above.
f) The Contractor is not responsible for the provision and
payment of Medically Supervised Inpatient and Outpatient
Withdrawal Services for Enrollees mandated by the LDSS under
Welfare Reform (as indicated by Code 83) unless such services
already under way as described in (c) above.
g) The Contractor is responsible for the provision and payment of
Medically Managed Detoxification Services ordered by the LDSS
under Welfare Reform.
h) The Contractor is responsible for the provisions of Sections
10.10, 10.16 (a) and 10.24 of this Agreement for Enrollees
requiring LDSS mandated Chemical Dependence Services.
10.9 Adult Protective Services
The Contractor shall cooperate with LDSS in the implementation of 18
NYCRR Part 457 and any subsequent amendments thereto with regard to
medically necessary health and mental health services and all Court
Ordered Services for adults. These services are to be provided in or
out of plan. Out of plan providers will be reimbursed at the
Medicaid fee schedule.
10.10 Court-Ordered Services
a) The Contractor shall provide any Benefit Package services to
Enrollees as ordered by a court of competent jurisdiction,
regardless of whether such services are provided by
Participating Providers within the plan or by a
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Non-Participating Provider in compliance with such court
order. The Non-Participating Provider shall be reimbursed by
the Contractor at the Medicaid fee schedule. The Contractor is
responsible for court-ordered services to the extent that such
court-ordered services are covered by and reimbursable by
Medicaid.
b) Court Ordered Services are those services ordered by the court
performed by, or under the supervision of a physician,
dentist, or other provider qualified under State Law to
furnish medical, dental, behavioral health (including mental
health and/or Chemical Dependence), or other Medicaid covered
services. The Contractor is responsible for payment of those
Medicaid services as covered by the Benefit Package, even when
the providers are not in the Contractor's provider network.
10.11 Family Planning and Reproductive Health Services
a) Nothing in this Agreement shall restrict the right of
Enrollees to receive Family Planning and Reproductive Health
Services from any qualified Medicaid provider, regardless of
whether the provider is a participating provider or a
non-participating provider, without referral from the
Enrollee's PCP and without approval from the Contractor.
b) The Contractor agrees to permit Enrollees to exercise their
right to obtain Family Planning and Reproductive Health
Services as defined in Part C-1 of Appendix C, which is hereby
made a part of this contract as if set forth fully herein,
from either the Contractor, if family planning is a part of
the Contractor's Benefit Package, or from any appropriate
Medicaid enrolled Non-Participating Family Planning Provider
without a referral from the Enrollee's PCP and without
approval by the Contractor.
c) The Contractor agrees to permit Enrollees to obtain pre and
post-test HIV counseling and blood testing when performed as
part of a Family Planning encounter from the Contractor, if
Family Planning is a part of the Contractor's Benefit Package,
or from any appropriate Medicaid enrolled Non-Participating
family planning Provider without a referral from the
Enrollee's PCP and without approval by the Contractor.
d) The Contractor will inform Enrollees about the availability of
in-plan HIV counseling and testing services, out-of-plan HIV
counseling and testing services when performed as part of a
Family Planning encounter and anonymous counseling and testing
services available from SDOH, Local Public Health Agency
clinics and other county programs. Counseling and testing
rendered outside of a Family Planning encounter, as well as
services provided as the result of an HIV+ diagnosis, will be
furnished by the Contractor in accordance with standards of
care.
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October 1, 2004
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e) Contractor must comply with federal, state, and local laws,
regulations and policies regarding informed consent and
confidentiality. Providers who are employed by the Contractor
may share patient information with appropriate Contractor
personnel for the purposes of claims payment, utilization
review and quality assurance. Providers who have a contract
with the Contractor, with an appropriate consent, may share
patient information with the Contractor for purposes of claims
payment, utilization review and quality assurance. Contractor
must ensure that an individual's use of family planning
services remains confidential and is not disclosed to family
members or other unauthorized parties.
f) Contractor must inform its practitioners and administrative
personnel about policies concerning free access to family
planning services, HIV counseling and testing, reimbursement,
enrollee education and confidentiality. Contractor must inform
its providers that they must comply with professional medical
standards of practice, the Contractor's practice guidelines,
and all applicable federal, state, and local laws. These
include but are not limited to, standards established by the
American College of Obstetricians and Gynecologists, the
American Academy of Family Physicians, the U.S. Task Force on
Preventive Services and the New York State Child/Teen Health
Program. These standards and laws indicate that family
planning counseling is an integral part of primary and
preventive care.
g) The Contractor agrees that if Family Planning is part of the
Contractor's Benefit Package, the Contractor will be charged
for the services of out of network providers at the applicable
Medicaid rate or fee. In such instances, out of network
providers will bill Medicaid and the SDOH will issue a
confidential change back to the Contractor. Such charge back
mechanism will comply with all applicable patient
confidentiality requirements.
h) If Contractor includes family planning and reproductive health
services in its benefits package, the Contractor shall comply
with the requirements for informing Enrollees about family
planning and reproductive health services set forth in Part
C-2 of Appendix C, which is hereby made a part of this
contract as if set forth herein.
i) If Contractor does not include family planning and
reproductive health services in its Benefit Package, within
ninety (90) days of signing this Agreement, Contractor must
submit to the SDOH and LDSS a statement of the policy and
procedure that the Contractor will use to ensure that its
Enrollees are fully informed of their rights to access a full
range of family planning and reproductive health services.
Refer to Part C-3 of Appendix C for the SDOH Guidelines for
Plans That Do Not Provide Family Planning Services in their
Capitation. Contractor shall ensure that
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prospective Enrollees and Enrollees are advised of the
family planning services which are not provided by the
Contractor and of their right of access to such services
in accordance with the provisions of Part C-3 of
Appendix C, which is hereby made a part of this contract
as if set forth fully herein.
j) SDOH with DHHS approval may issue modifications to
Appendix (C) consistent with relevant provisions of
federal and state statutes and regulations. Once issued
and upon sixty (60) days notice to the LDSS and
Contractor, such modifications shall be deemed
incorporated into this Agreement without further action
by the parties.
10.12 Prenatal Care
The Contractor is responsible for arranging for the provision of
comprehensive Prenatal Care Services to all pregnant Enrollees
including all services enumerated in Subdivision 1, Section 2522 of
the Public Health Law in accordance with 10 NYCRR Part 85.40
(Prenatal Care Assistance Program).
10.13 Direct Access
The Contractor shall offer female Enrollees direct access to primary
and preventive obstetrics and gynecology services, follow-up care as
a result of a primary and preventive visit, and any care related to
pregnancy from the Contractor's network providers without referral
from the PCP as set forth in Public Health Law Section 4406-b(1).
10.14 Emergency Services
a) The Contractor shall maintain coverage utilizing a toll free
telephone number twenty-four (24) hours per day seven (7) days
per week, answered by a live voice, to advise Enrollees of
procedures for accessing services for Emergency Medical
Conditions and for accessing Urgently Needed Services.
Emergency mental health calls must be triaged via telephone by
a trained mental health professional.
b) The Contractor agrees that it will not require prior
authorization for services in a medical or behavioral health
emergency. The Contractor agrees to inform its Enrollees that
access to Emergency Services is not restricted and Emergency
Services may be obtained from a Non-Participating Provider
without penalty. The Contractor may require Enrollees to
notify the plan or their PCP within a specified time frame
after receiving emergency care and to obtain prior
authorization for any follow-up care delivered pursuant to the
emergency, as stated in Appendix G. Nothing herein precludes
the Contractor from entering into contracts with providers or
facilities that require providers or facilities to provide
notification to the Contractor after Enrollees present for
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Emergency Services and are subsequently stabilized. Except as
otherwise provided by contractual agreement between the
Contractor and a Participating Provider, the Contractor must
pay for services for Emergency Medical Conditions whether
provided by a Participating Provider or a Non-Participating
Provider, and may not deny payments if notification is not
timely.
c) Emergency Services rendered by Non-Participating Providers:
The Contractor shall advise its Enrollees how to obtain
Emergency Services when it is not feasible for Enrollees to
receive Emergency Services from or through a Participating
Provider. The Contractor shall bear the cost of providing
Emergency Services through Non-Participating Providers.
d) The Contractor agrees to abide by guidelines for the provision
and payment of Emergency Care and Services which are specified
in Appendix G, which is hereby made a part of this contract as
if set forth fully herein.
e) When emergency transportation is included in the Contractor's
Benefit Package, the Contractor shall reimburse for all
emergency ambulance services without regard to final diagnosis
or prudent layperson standards.
10.15 Medicaid Utilization Thresholds (MUTS)
Enrollees may be subject to MUTS for outpatient pharmacy services
which are billed Medicaid fee-for-service and for dental services
provided without referral at Article 28 clinics operated by academic
dental centers as described in Section 10.28 of this Agreement.
Enrollees are not otherwise subject to MUTS for services included in
the Benefit Package.
10.16 Services for Which Enrollees Can Self-Refer
a) Mental Health and Chemical Dependence Services
The Contractor will allow Enrollees or LDSS officials on the
Enrollee's behalf to make self referral or referral for one
mental health assessment from a Participating Provider and one
chemical dependence assessment from a Detoxification or
Chemical Dependence Inpatient Rehabilitation and Treatment
Participating Provider in any calendar year period without
requiring preauthorization or referral from the Enrollee's
Primary Care Provider. In the case of children, such
self-referrals may originate at the request of a school
guidance counselor (with parental or guardian consent, or
pursuant to procedures set forth in Section 33.21 of the
Mental Hygiene Law), LDSS Official, Judicial Official,
Probation Officer, parent or similar source.
i) The Contractor shall make available to all Enrollees a
complete listing of their participating mental health
and Chemical Dependence Services
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providers. The listing should specify which provider
groups or practitioners specialize in children's mental
health services.
ii) The Contractor will also ensure that its Participating
Providers have available and use formal assessment
instruments to identify Enrollees requiring mental
health and Chemical Dependence Services, and to
determine the types of services that should be
furnished.
iii) The Contractor will implement policies and procedures to
ensure that Enrollees receive follow-up Benefit Package
services from appropriate providers based on the
findings of their mental health and/or Detoxification or
Chemical Dependence Inpatient Rehabilitation and
Treatment assessment(s).
iv) The Contractor will implement policies and procedures to
ensure that Enrollees are referred to appropriate
Chemical Dependence outpatient rehabilitation and
treatment providers based on the findings of the
Chemical Dependence assessment by the Contractor's
Participating Provider.
b) Vision Services
The Contractor will allow its Enrollees to self-refer to any
participating provider of vision services (optometrist or
ophthalmologist) for refractive vision services. (See Appendix
K).
c) Diagnosis and Treatment of Tuberculosis
Enrollees may self-refer to public health agency facilities
for the diagnosis and/or treatment of TB as described in
Section 10.19 (a)(i) of this Agreement.
d) Family Planning and Reproductive Health Services.
Enrollees may self-refer to family planning and reproductive
health services as described in Section 10.11 and Appendix C
of this Agreement.
e) Article 28 Clinics Operated by Academic Dental Centers
Enrollees may self-refer to Article 28 clinics operated by
academic dental centers to obtain covered dental services as
described in Section 10.28 of this Agreement.
10.17 Second Opinions for Medical or Surgical Care
The Contractor will allow Enrollees to obtain a second opinion
within the Contractor's network of providers for diagnosis of a
condition, treatment or surgical procedure.
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10.18 Coordination with Local Public Health Agencies
The Contractor will coordinate is public health-related activities
with the Local Public Health Agency. Coordination mechanisms and
operational protocols for addressing public health issues will be
negotiated with the Local Public Health and Social Services
Departments and be customized to reflect County public health
priorities. Negotiations must result in agreements regarding
required health plan activities related to public health. The
outcome of negotiations may take the form of an informal agreement
among the parties which may include memos; a separate memorandum of
understanding signed by the Local Public Health Agency, LDSS , and
the Contractor; or an appendix to the contract between the LDSS and
the Contractor which shall be included in Appendix N as if set forth
fully herein.
10.19 Public Health Services
a) Tuberculosis Screening, Diagnosis and Treatment; Directly
Observed Therapy(TB\DOT):
i) Consistent with New York State law, public health
clinics are required to provide or arrange for treatment
to individuals presenting with tuberculosis, regardless
of the person's insurance or enrollment status. It is
the State's preference that the Contractor's Enrollees
receive TB diagnosis and treatment through the
Contractor's plan, to the extent that providers
experienced in this type of care are available in the
Contractor's network of Participating Providers,
although Enrollees may self-refer to public health
agency facilities for the diagnosis and/or treatment of
TB. The Contractor agrees to reimburse public health
clinics when physician visit and patient management or
laboratory and radiology services are rendered to their
Enrollees, within the context of TB diagnosis and
treatment.
ii) The Contractor's Participating Providers must report TB
cases to the Local Public Health Agency. The LDSS will
have the Local Public Health Agency review the
tuberculosis treatment protocols and networks of
Participating Providers of the Contractor, to verify
their readiness to treat Tuberculosis patients. The
Contractor's protocols will be evaluated against State
and local guidelines. State and local departments of
health also will be available to offer technical
assistance to the Contractor in establishing TB policies
and procedures.
iii) The Contractor may require the Local Public Health
Agency to give notification before delivering services,
unless these services are ordered by a court of
competent jurisdiction. The Local Public Health Agency
will: 1) make reasonable efforts to verify with the
Enrollee's PCP that he/she has not already provided TB
care and treatment, and 2) provide documentation of
services rendered along with the claim.
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iv) The Contractor may use locally negotiated fees. In
addition, SDOH will establish fee schedules for these
services, which the Contractor may use in the absence of
locally negotiated fees.
v) Contractors may require prior authorization for
non-emergency inpatient hospital admissions, except that
prior authorization will not be required for an
admission pursuant to a court order or an order of
detention issued by the local commissioner or director
of public health.
vi) The Contractor shall provide the Local Public Health
Agency with access to health care practitioners on a
twenty-four (24) hour a day, seven (7) day a week basis
who can authorize inpatient hospital admissions. The
Contractor shall respond to the Local Public Health
Agency's request for authorization within the same day.
vii) The Contractor will not be capitated or financially
liable for Directly Observed Therapy (DOT) costs. The
Contractor agrees to make all reasonable efforts to
ensure coordination with DOT providers regarding
clinical care and services. HIV counseling and testing
during a TB related visit at a public health clinic,
directly operated by a county health department or the
New York City Department of Health and Mental Hygiene,
will be covered by Medicaid fee-for-service (FFS) at
rates established by the State. The Contractor also will
not be financially liable for treatments rendered to
Enrollees who have been institutionalized as a result of
a local health commissioner's order due to
non-compliance with TB care regimens.
viii) While all other clinical management of tuberculosis is
covered by the Contractor, TB/DOT where applicable, can
be billed directly to Medicaid 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. The Enrollee reserves the right to use any
fee-for-service DOT provider because TB/DOT is a
non-covered benefit.
b) Immunizations
i) Immunizations for adults and administration of
immunizations for children will be included in the
Benefit Package and the Contractor will be required to
reimburse the Local Public Health Agency when Enrollees
self-refer.
ii) In order to be eligible for reimbursement, a Local
Public Health Agency must make reasonable efforts to (1)
determine the Enrollee's managed care membership status;
and (2) ascertain the Enrollee's immunization status.
Such efforts shall consist of client interviews and,
when available, access to the Immunization Registry.
When an Enrollee presents a membership card with a PCP's
name, the Local Public Health Agency shall call the PCP.
If the agency is unable to verify the immunization
status from the PCP or learns that immunization is
needed, the agency shall proceed to deliver the service
as appropriate, and the Contractor will reimburse the
Local Public Health Agency at the negotiated rate or at
a fee schedule to
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be used in the absence of a negotiated rate. Upon
implementation of the immunization registry, the Local
Public Health Agency shall not be required to contact
the PCP.
iii) If the immunization is administered by the PCP,
immunization materials for children should be obtained
free of charge from the "Vaccine For Children Program".
The Contractor will be reimbursed only for administering
the vaccine to children.
c) Prevention and Treatment of Sexually Transmitted Diseases
The Contractor will be responsible for ensuring that its
Participating Providers educate their Enrollees about the risk
and prevention of sexually transmitted disease (STD). The
Contractor also will be responsible for ensuring that its
Participating Providers screen and treat Enrollees for STDs
and report cases of STD to the Local Public Health Agency and
cooperate in contact investigation, in accordance with
existing state and local laws and regulations. HIV counseling
and testing provided during a STD related visit at a public
health clinic, directly operated by a county health department
or the New York City Department of Health and Mental Hygiene,
will be covered by Medicaid FFS at rates established by the
State.
d) Lead Poisoning
The Contractor will be responsible for carrying out and
ensuring that its Participating Providers comply with lead
poisoning screening and follow-up as specified in 10 NYCRR,
Sub-part 67.1. The Contractor shall coordinate the care of
such children with Local Public Health Agencies to assure
appropriate follow-up in terms of environmental investigation,
risk management and reporting requirements.
10.20 Adults with Chronic Illnesses and Physical or Developmental
Disabilities
The Contractor will implement all of the following to meet the needs
of their adult Enrollees with chronic illnesses and physical or
developmental disabilities:
a) Satisfactory methods for ensuring that the Contractor is in
compliance with the Americans with Disabilities Act ("ADA")
and Section 504 of the Rehabilitation Act of 1973. Program
accessibility for persons with disabilities shall be in
accordance with Section 24 of this Agreement.
b) Clinical case management which uses satisfactory
methods/guidelines for identifying persons at risk of, or
having, chronic diseases and disabilities and determining
their specific needs in terms of specialist physician
referrals, durable medical equipment, home health services,
self-management education and training, etc. The Contractor
shall:
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i) develop protocols describing the Contractor's case
management services and minimum qualification
requirements for case management staff;
ii) develop and implement protocols for monitoring
effectiveness of case management based on patient
outcomes;
iii) develop and implement protocols for monitoring service
utilization including emergency room visits and
hospitalizations, with adjustment of severity of patient
conditions;
iv) provide regular information to network providers on the
case management services available to the Contractor's
Enrollees and the criteria for referring Enrollees to
the Contractor for case management services.
c) Satisfactory methods/guidelines for determining which patients
are in need of case management services, including
establishment of severity thresholds, and methods for
identification of patients including monitoring of
hospitalizations and ER visits, provider referrals, new
Enrollee health screenings ands self referrals by Enrollees.
d) Guidelines for determining specific needs of Enrollees in case
management, including specialist physician referrals, durable
medical equipment, home health services, self management
education and training, etc.
e) Satisfactory systems for coordinating service delivery with
out-of-network providers, including behavioral health
providers for all Enrollees.
f) Policies and procedures to allow for the continuation of
existing relationships with out-of-network providers,
consistent with PHL 4403 6(e) and Section 15.5 of this
Agreement.
10.21 Children with Special Health Care Needs
Children with special health care needs are those who have or are
suspected of having a serious or chronic physical, developmental,
behavioral, or emotional condition and who also require health and
related services of a type or amount beyond that required by
children generally. The Contractor will be responsible for
performing all of the same activities for this population as for
adults. In addition, the Contractor will implement the following for
these children:
a) Satisfactory methods for interacting with school districts,
preschool services, child protective service agencies, early
intervention officials, behavioral health, and developmental
disabilities service organizations for the purpose of
coordinating and assuring appropriate service delivery.
b) An adequate network of pediatric providers and
sub-specialists, contractual relationships with tertiary
institutions, to meet their medical needs.
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c) Satisfactory methods for assuring that children with serious,
chronic, and rare disorders receive appropriate diagnostic
work-ups on a timely basis.
d) Satisfactory arrangements for assuring access to specialty
centers in and out of New York State for diagnosis and
treatment of rare disorders.
e) A satisfactory approach for assuring access to allied health
professionals (Physical Therapists, Occupational Therapists,
Speech Therapists, and Audiologists) experienced in dealing
with children and families.
10.22 Persons Requiring Ongoing Mental Health Services
The Contractor will implement all of the following for its Enrollees
with chronic or ongoing mental health service needs:
a) Inclusion of all of the required provider types listed in
Section 21 of this Agreement.
b) Satisfactory methods for identifying persons requiring such
services and encouraging self-referral and early entry into
treatment.
c) Satisfactory case management systems or satisfactory case
management.
d) Satisfactory systems for coordinating service delivery between
physical health, chemical dependence, and mental health
providers, and coordinating services with other available
services, including Social Services.
The Contractor agrees to participate in the local planning process
for serving persons with mental health needs to the extent requested
by the LDSS. At the LDSS' discretion, the Contractor will develop
linkages with local governmental units on coordination, procedures
and standards related to mental health services and related
activities.
10.23 Member Needs Relating to HIV
Persons with HIV infection an exempt from mandatory enrollment;
however, they will be permitted to enroll voluntarily into Managed
Care Organizations. The Contractor must inform Enrollees newly
diagnosed with HIV infection or AIDS, known to the Contractor, of
their enrollment options including the ability to return to
fee-for-service or to disenroll from the Contractor's plan and to
enroll into HIV Special Needs Plans (SNPs) as such plans become
available.
The Contractor agrees that anonymous testing may be furnished to the
Enrollee without prior approval by the Contractor and may be
conducted at anonymous testing sites available to clients. Services
provided for HIV treatment may only
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be obtained from the Contractor during the period the Enrollee is
enrolled in the Contractor's plan.
To adequately address the HIV prevention needs of uninfected
Enrollees, as well as the special needs of individuals with HIV
infection who do enroll in managed care, the Contractor shall have
in place all of the following:
a) Methods for promoting HIV prevention to all Plan Enrollees.
HIV prevention information, both primary, as well as secondary
should be tailored to the Enrollee's age, sex, and risk
factor(s), (e.g., injection drug use and sexual risk
activities), and should be culturally and linguistically
appropriate. HIV primary prevention means the reduction or
control of causative factors for HIV, including the reduction
of risk factors. HIV Primary prevention includes strategies to
help prevent uninfected Enrollees from acquiring HIV, i.e.,
behavior counseling for HIV negative Enrollees with risk
behavior. Primary prevention also includes strategies to help
prevent infected Enrollees from transmitting HIV infection,
i.e., behavior counseling with an HIV infected Enrollee to
reduce risky sexual behavior or providing antiviral therapy to
a pregnant, HIV infected female to prevent transmission of HIV
infection to a newborn. HIV Secondary Prevention means
promotion of early detection and treatment of HIV disease in
an asymptomatic Enrollee to prevent the development of
symptomatic disease. This includes: regular medical
assessments; routine immunization for preventable infections;
prophylaxis for opportunistic infections; regular dental,
optical, dermatological and gynecological care; optimal
diet/nutritional supplementation; and partner notification
services which lead to the early detection and treatment of
other infected persons. All plan Enrollees should be informed
of the availability of HIV counseling, testing, referral and
partner notification (CTRPN) services.
b) Policies and procedures promoting the early identification of
HIV infection in Enrollees. Such policies and procedures shall
include at a minimum: assessment methods for recognizing the
early signs and symptoms of HIV disease; initial and routine
screening for HIV risk factors through administration of
sexual behavior and drug and alcohol use assessments; and the
provision of information to all Enrollees regarding the
availability of in-plan HIV CTRPN services, cut of plan CTRPN
services as part of a family planning visit, and anonymous
CTRPN services from New York State, New York City and Local
Public Health Agencies.
c) The Contractor shall comply with the requirements set forth in
Title 10 NYCRR (including Part 98 and in Subpart 69-1) which
mandate that HIV counseling with testing, presented as a
clinical recommendation, be provided to all women in prenatal
care and their newborns. Consistent with these requirements,
the Contractor shall ensure that Participating Providers refer
such Enrollees determined to have HIV infection for clinically
appropriate services.
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d) Network Sufficiency. A network of providers sufficient to meet
the needs of its Enrollees with HIV. Satisfaction of the
network requirement may be accomplished by inclusion of HIV
specialists within the network or the provision of HIV
specialist consultation to non-HIV specialists serving as PCPs
for persons with HIV infection; inclusion of Designated AIDS
Center Hospitals or other hospitals experienced in HIV care in
the Contractor's network; and contracts or linkages with
providers funded under the Ryan White CARE Act. The Contractor
tractor shall inform the providers in its network how to
obtain information about the availability of Experienced HIV
Providers and HIV Specialist PCPs
e) Case Management Assessment for Enrollees with HIV Infection.
The Contractor shall establish policies and procedures to
ensure that Enrollees who have been identified as having HIV
infection are assessed for case management services. The
Contractor shall arrange for any Enrollee identified as having
HIV infection and needing case management services to be
referred to an appropriate case management services provider,
including in-plan case management, and/or, with appropriate
consent of the Enrollee, COBRA Comprehensive Medicaid Case
Management (CMCM) services and/or HIV community-based
psychosocial case management services.
f) Reporting. The Contractor shall require that its Participating
Providers shall report positive HIV test results and diagnoses
and known contacts of such persons to the New York State
Commissioner of Health. In New York City, these shall be
reported to the New York City Commissioner of Health. Access
to partner notification services must be consistent with 10
NYCRR Part 63.
g) Updates and Dissemination of HIV Practice Guidelines. The
Contractor's Medical Director shall review Contractor's HIV
practice guidelines at least annually and update them as
necessary for compliance with recommended SDOH AIDS Institute
and federal government clinical standards. The Contractor will
disseminate the HIV Practice Guidelines or revised guidelines
to Participating Providers at least annually, or more
frequently as appropriate.
10.24 Persons Requiring Chemical Dependence Services
The Contractor will have in place all of the following for its
Enrollees requiring Chemical Dependence Services:
a) Participating Provider networks consisting of licensed
providers, as defined in Section 21.17 of this contract.
b) Satisfactory methods for identifying persons requiring such
services and encouraging self-referral and early entry into
treatment. In the case of
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pregnant women, having methods for referring to OASAS for
appropriate services beyond the Contractor's Benefit Package
(e.g., halfway houses).
c) Satisfactory systems of care (provider networks and referral
processes sufficient to ensure that emergency services can be
provided in a timely manner), including crisis services.
d) Satisfactory case management systems.
e) Satisfactory systems for coordinating service delivery between
physical health, chemical dependence, and mental health
providers, and coordinating in-plan services with other
services, including Social Services.
The Contractor agrees to also participate in the local planning
process for serving persons with chemical dependence, to the extent
requested by the LDSS. At the LDSS's discretion, the Contractor will
develop linkages with local governmental units on coordination
procedures and standards related to Chemical Dependence Services and
related activities.
10.25 Native Americans
If the Contractor's Enrollee is a Native American and the Enrollee
chooses to access primary care services through their tribal health
center, the PCP authorized by the Contractor to refer the Enrollee
for plan benefits must develop a relationship with the Enrollee's
PCP at the tribal health center to coordinate services for said
Native American Enrollee.
10.26 Women, Infants, and Children (WIC)
The Contractor shall develop linkage agreements or other mechanisms
to ensure women and children enrollees are referred to WIC services
if qualified to receive such services. The Contractor shall refer
pregnant women and children, younger than five (5) years of age, to
WIC local agencies for nutritional assessments and supplements.
10.27 Urgently Needed Services
a) The Contractor is responsible for Urgently Needed Services.
b) Urgently Needed Services are covered only in the United
States, the Commonwealth of Puerto Rico, the U.S. Virgin
Islands, Guam, American Samoa, the Northern Mariana Islands
and Canada.
c) The Contractor must disclose to all Enrollees the procedures
to be followed to obtain Urgently Needed Services.
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d) The Contractor may require Enrollees or the Enrollee's
designee to coordinate with the Contractor or the Enrollee's
PCP prior to receiving care, to ensure that the needed care
will be authorized and covered by the plan as Urgently Needed
Services.
10.28 Dental Services Provided by Article 28 Clinics Operated by Academic
Dental Centers Not Participating in Contractor's Network
a) Consistent with Chapter 697 of Laws of 2003 amending Section
364 (j) of the Social Services Law, dental services provided
by Article 28 clinics operated by academic dental centers may
be accessed directly by Medicaid managed care Enrollees
without prior approval and without regard to network
participation.
b) If dental services are part of the Contractor's Benefit
Package, the Contractor will reimburse non-participating
Article 28 clinics operated by academic dental centers for
covered dental services provided to Enrollees on or after
November 19, 2003 at approved Article 28 Medicaid clinic
rates in accordance with the protocols issued by the SDOH.
10.29 Coordination of Services
a) The Contractor shall coordinate care for Enrollees with:
i) the court system (for court ordered evaluations and
treatment);
ii) specialized providers of health care for the homeless,
and other providers of services for victims of domestic
violence;
iii) family planning clinics, community health centers,
migrant health centers, rural health centers;
iv) WIC, Head Start, Early Intervention;
v) special needs plans;
vi) programs funded through the Ryan White CARE Act;
vii) other pertinent entities that provide services out of
network;
viii) Prenatal Care Assistance Program (PCAP) Providers;
ix) local governmental units responsible for public health,
mental health, mental retardation or Chemical Dependence
Services;
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x) specialized providers of long term care for people with
developmental disabilities; and
xi) School-based health centers.
b) Coordination may involve contracts or linkage agreements (if
entities are willing to enter into such agreement), or other
mechanisms to ensure coordinated care for Enrollees, such as
protocols for reciprocal referral and communication of data
and clinical information on MCO Enrollees.
10.30 Prospective Benefit Package Change for Retroactive SSI
Determinations
The managed care Benefit Package and associated Capitation Rate for
Enrollees who become SSI or SSI related retroactively shall be
changed prospectively as of the effective date of the Roster on
which the Enrollee's status change appears.
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11. MARKETING
11.1 Marketing Plan
The Contractor shall have a Marketing Plan, that has been
prior-approved by the SDOH and/or LDSS, that describes the Marketing
activities the Contractor will undertake within the local district
during the term of this Agreement.
The Marketing Plan and all marketing activities must be consistent
with the Marketing Guidelines which are set forth in Appendix D,
which is hereby made a part of this Agreement as if set forth fully
herein.
The Marketing Plan shall be kept on file in the offices of the
Contractor, LDSS, and the SDOH. The Marketing Plan may be modified
by the Contractor subject to prior written approval by the SDOH
and/or the LDSS. The LDSS or SDOH must take action on the changes
submitted within sixty (60) calendar days of submission or the
Contractor may deem the changes approved.
11.2 Marketing Activities
Marketing activities by the Contractor shall conform to the approved
Marketing Plan.
11.3 Prior Approval of Marketing Materials, Procedures, Subcontracts
The Contractor shall submit all subcontracts, procedures, and
materials related to Marketing to Eligible Persons to the SDOH
and/or LDSS for prior written approval. The Contractor shall not
enter into any subcontracts or use any marketing subcontractors,
procedures, or materials that the SDOH and/or LDSS has not approved.
11.4 Marketing Infractions
Infractions of the Marketing Guidelines may result in the following
actions being taken by the LDSS to protect the interests of the
program and its clients. These actions shall be taken at the sole
discretion of the LDSS.
a) If an MCO or its representative commits a first time
infraction of marketing guidelines and the LDSS deems the
infraction to be minor or unintentional in nature, the LDSS
may issue a warning letter to the MCO.
b) For subsequent or more serious infractions, the LDSS may
impose liquidated damages of $2,000 or other appropriate
non-monetary sanction for each infraction.
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c) The LDSS may require the MCO to prepare a corrective action
plan with a specified deadline for implementation.
d) If the MCO commits further infractions, fails to pay
liquidated damages within the specified timeframe, fails to
implement a corrective action plan in a timely manner on
commits an egregious first-time infraction, the LDSS may:
i) prohibit the plan from conducting any marketing
activities for a period up to the end of the contract
period;
ii) suspend new enrollments, other than newborns, for a
period up to the remainder of the contract; or
iii) terminate the contract pursuant to termination
procedures described therein.
11.5 LDSS Option to Adopt Additional Marketing Guidelines
The LDSS may adopt, subject to SDOH approval, additional and/or more
restrictive terms in the Marketing Guidelines to the extent
appropriate to local conditions and circumstances, which shall be
appended to Appendix D, Section E.
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12. MEMBER SERVICES
12.1 General Functions
The Contractor shall operate a Member Services function during
regular business hours, which must be accessible to Enrollees via a
toll-free telephone line. Personnel must also be available via a
toll-free telephone line (which can be the member services toll-free
line or separate toll-free lines) not less than during regular
business hours to address complaints and utilization review
inquiries. In addition, the Contractor must have a telephone system
capable of accepting, recording or providing instruction to incoming
calls regarding complaints and utilization review during other than
normal business hours and measures in place to ensure a response to
those calls the next business day after the call was received: At a
minimum, the Member Services Department must be staffed at a ratio
of at least one (1) full time equivalent Member Service
Representative for every 4,000 or fewer Enrollees. Member Services
staff must be responsible for the following:
a) Explaining the Contractor's rules for obtaining services and
assisting Enrollees in making appointments.
b) Assisting Enrollees to select or change Primary Care
Providers.
c) Fielding and responding to Enrollee questions and complaints,
and advising Enrollees of the prerogative to complain to the
SDOH and LDSS at any time.
d) Clarifying information in the member handbook for Enrollees.
e) Advising Enrollees of the Contractor's complaint and appeals
program, the utilization review process, and Enrollee's rights
to a fair hearing or external review.
f) Clarifying for potential Enrollees current categories of
exemptions and exclusions. The Contractor may refer to the
LDSS or the Enrollment Broker, where one is in place, if
necessary, for more information on exemptions and exclusions.
12.2 Translation and Oral Interpretation
a) The Contractor must make available written marketing and other
informational materials (e.g., member handbooks) in a language
other than English whenever at least five percent (5%) of the
potential Enrollees of the Contractor in any county of the
service area speak that particular language and do not speak
English as a first language.
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b) In addition, verbal interpretation services must be made
available to Enrollees who speak a language other than English
as a primary language. Interpreter services must be offered in
person where practical, but otherwise may be offered by
telephone.
c) The SDOH will determine the need for other than English
translations based on County-specific census data or other
available measures.
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
The Contractor also must have in place appropriate alternative
mechanisms for communicating effectively with persons with visual,
hearing, speech, physical or developmental disabilities. These
alternative mechanisms include Braille or audio tapes for the
visually impaired, TTY access for those with certified speech or
hearing disabilities, and use of American Sign Language and/or
integrative technologies.
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12-2
13. ENROLLEE NOTIFICATION
13.1 Provider Directories/Office Hours for Participating Providers
a) The Contractor shall maintain and update, on a quarterly
basis, a listing by specialty of the names, addresses and
telephone numbers of all Participating Providers, including
facilities. Such a list/directory shall include names, office
addresses, telephone numbers, board certification for
physicians, and information on language capabilities and
wheelchair accessibility of Participating Providers.
b) New Enrollees, and upon request, prospective Enrollees, must
receive the most current complete listing in hardcopy, along
with any updates to such listing.
c) Enrollees must be notified of updates in writing at least
annually in one of the following methods: provide updates in
hardcopy; provide a new complete listing/directory in
hardcopy; or provide written notification that a new complete
listing/directory is available and will be provided upon
request either in hardcopy, or electronically if the
Contractor has the capability of providing such data in an
electronic format and the data is requested in that format by
an Enrollee.
d) In addition, the Contractor must make available to the LDSS
the office hours for Participating Providers. This requirement
may be satisfied by providing a copy of the list or Provide
Directory described in this Section with the addition of
office hours or by providing a separate listing of office
hours for Participating Providers.
13.2 Member ID Cards
a) The Contractor must issue an identification card to the
Enrollee containing the following information:
i) the name of the Enrollee's clinic (if applicable);
ii) the name of the Enrollee's PCP and the PCP's telephone
number;
iii) the member services toll free telephone number;
iv) the twenty-four (24) hour toll free telephone number
that Enrollees may use to access information on
obtaining services when his/her PCP is not available;
and
v) for ID Cards issued after October 1, 2004, the
Enrollee's Client Identification Number (CIN).
b) If an Enrollee is being served by a PCP team, the name of the
individual shown on the card should be the lead provider. PCP
information may be embossed on the card or affixed to the card
by a sticker.
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(ENROLLEE NOTIFICATION)
October 1, 2004
13-1
c) The Contractor shall issue an identification card within
fourteen (14) days of an Enrollee's Effective Date of
Enrollment. If unforeseen circumstances, such as the lack of
identification of a PCP, prevent the MCO from forwarding the
official identification card to new Enrollees within the
fourteen (14) day period, alternative measures by which
Enrollees may identify themselves such as use of a Welcome
Letter on a temporary identification card shall be deemed
acceptable until such time as a PCP is either chosen by the
Enrollee or auto assigned by the Contractor. The Contractor
agrees to implement an alternative method by which individuals
may identify themselves as Enrollees prior to receiving the
card (e.g., using a "welcome letter" from the plan) and to
update PCP information on the identification card. Newborns of
Enrollees need not present ID cards in order to be seen by the
MCO and its Participating Providers.
13.3 Member Handbooks
The Contractor shall issue to a new Enrollee within fourteen (14)
days of the Effective Date of Enrollment a Member Handbook, which is
consistent with the SDOH guidelines described in Appendix E, which
is hereby made a part of this Agreement as if set forth fully
herein.
13.4 Notification of Effective Date of Enrollment
The Contractor shall inform each Enrollee in writing within fourteen
(14) days of the Effective Date of Enrollment of any restriction on
the Enrollee's right to terminate enrollment. The initial enrollment
information and the Member Handbook shall be adequate to convey this
notice.
13.5 Notification of Enrollee Rights
The Contractor agrees to make all reasonable efforts to contact new
Enrollees, in person, by telephone, or by mail, within thirty (30)
days of their Effective Date of Enrollment. "Reasonable efforts" are
defined to mean at least three (3) attempts, with more than one
method of contact being employed. Upon contacting the new
Enrollee(s), the Contractor agrees to do at least the following:
a) Inform the Enrollee about the Contractor's policies with
respect to obtaining medical services, including services for
which the Enrollee may self-refer, and what to do in an
emergency.
b) Conduct a brief health screening to assess the Enrollee's need
for any special health care (e.g., prenatal or behavioral
health services) or language/communication needs. If a special
need is identified, the Contractor shall assist the Enrollee
in arranging for an appointment with his/her PCP or other
appropriate provider.
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(ENROLLEE NOTIFICATION)
October 1, 2004
13-2
c) Offer assistance in arranging an initial visit to the
Enrollee's PCP for a baseline physical and other preventive
services, including an assessment of the Enrollee's potential
risk, if any, for specific diseases or conditions.
d) Inform new Enrollees about their rights for continuation of
certain existing services.
e) Provide the Enrollee with the Contractor's toll free telephone
number that may be called twenty-four (24) hours a day, seven
(7) days a week if the Enrollee has questions about obtaining
services and cannot reach his/her PCP (this telephone number
need not be the Member Services line and need not be staffed
to respond to Member Services-related inquiries). The
Contractor must have appropriate mechanisms in place to
accommodate Enrollees who do not have telephones and therefore
cannot readily receive a call back.
f) Advise Enrollee about opportunities available to learn about
MCO policies and benefits in greater detail (e.g., welcome
meeting, Enrollee orientation and education sessions).
g) Provide the Enrollee with a complete list of network providers
that may be accessed directly, without referral. The list
should group providers by service type and must include
addresses and telephone numbers.
h) Assist the Enrollee in selecting a primary care provider if
one has not already been chosen.
13.6 Enrollee's Rights to Advance Directives
The Contractor shall, in compliance with the requirements of 42 CFR
434.28, maintain written policies and procedures regarding advance
directives and inform each Enrollee in writing at the time of
enrollment of an individual's rights under State law to formulate
advance directives and of the Contractor's policies regarding the
implementation of such rights. The Contractor shall include in such
written notice to the Enrollee materials relating to advance
directives and health care proxies as specified in 10 NYCRR Sections
98.14(f) and 700.5.
13.7 Approval of Written Notices
The Contractor shall submit the format and content of all written
notifications described in this Section to LDSS for review and prior
approval by LDSS or SDOH. All written notifications must be written
at a fourth (4th) to sixth (6th) grade level and in at least ten
(10) point print.
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(ENROLLEE NOTIFICATION)
October 1, 2004
13-3
13.8 Contractor's Duty to Report Lack of Contact
The Contractor must inform the LDSS of any Enrollee they are unable
to contact within ninety (90) days of enrollment using reasonable
efforts as defined in Section 13.5 of the Agreement and who have not
presented for any health care services through the Contractor or its
Participating Providers.
13.9 Contractor Responsibility to Notify Enrollee of Expected Effective
Date of Enrollment
The Contractor must notify the Enrollee of the expected Effective
Date of Enrollment. In the event that the actual Effective Date of
Enrollment is different from that given to the Enrollee the
Contractor must notify the Enrollee of the actual date of
enrollment. This may be accomplished through a Welcome Letter. To
the extent practicable, such notification must precede the Effective
Date of Enrollment.
13.10 LDSS Notification of Enrollee's Change in Address
The LDSS must notify the Contractor of any known change in address
of Enrollees in the Contractor's plan.
13.11 Contractor Responsibility to Notify Enrollee of Effective Date of
Benefit Package Change
The Contractor must provide written notification of the effective
date of any Contractor-initiated, SDOH and LDSS-approved benefit
package change to Enrollees in the Contractor's plan. Notification
to Enrollees must be provided at least 30 days in advance of the
effective date of such change.
13.12 Contractor Responsibility to Notify Enrollee of Termination, Service
Area Changes and Network Changes
With prior notice to and approval of the SDOH and LDSS, the
Contractor shall inform each Enrollee in writing of any withdrawal
by the Contractor from the Medicaid managed care program pursuant to
Section 2.7, withdrawal from the Service Area encompassing the
Enrollee's zip code, and/or significant changes to the Contractor's
provider network pursuant to Section 21.1(d), except that the
Contractor need not notify Enrollees who will not be affected by
such changes.
The Contractor shall provide the notifications within the timeframes
specified by SDOH and LDSS, and shall obtain the prior approval of
the notification from SDOH and LDSS.
SECTION 13
(ENROLLEE NOTIFICATION)
October 1, 2004
13-4
14. COMPLAINT AND APPEAL PROCEDURE
14.1 Contractor's Program to Address Complaints
a) The Contractor shall establish and maintain a comprehensive
program designed to address clinical and other complaints, and
appeals of complaint determinations, which may be brought by
Enrollees, consistent with Articles 44 and 49 of the New York
State PHL.
b) The program must include methods for prompt internal
adjudication of Enrollee complaints and appeals and provide
for the maintenance of a written record of all complaints and
appeals received and reviewed and their disposition.
c) The Contractor shall ensure that persons with authority to
require corrective action participate in the complaint and
appeal process.
14.2 Notification of Complaint and Appeal Program
a) The Contractor's specific complaint and appeal program shall
be described in the Contractor's member handbook and shall be
made available to all Enrollees.
b) The Contractor will advise Enrollees of their right to a fair
hearing as appropriate and comply with the procedures
established by SDOH for the Contractor to participate in the
fair hearing process, as set forth in Section 25 of this
Agreement. The Contractor will also advise Enrollees of their
right to an external appeal, in accordance with Section 26 of
this Agreement.
14.3 Guidelines for Complaint and Appeal Program
a) The Contractor's complaint and appeal program will comply with
the Managed Care Complaint and Appeals Program Guidelines
described in Appendix F, which is hereby made a part of this
Agreement as if set forth fully herein. The SDOH and LDSS may
modify Appendix F of this Agreement upon sixty (60) days prior
written notice to the Contractor and such modifications shall
become binding and incorporated into this Agreement without
further action by the parties.
b) The Contractor's complaint and appeal procedures shall be
approved by the SDOH and LDSS and kept on file with the
Contractor, LDSS and SDOH.
c) The Contractor shall not modify its complaint and appeals
procedure without the prior written approval of SDOH, in
consultation with LDSS, and shall provide LDSS and SDOH with a
copy of the approved modification within fifteen (15) days
after its approval.
SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 2004
14-1
14.4 Complaint Investigation Determinations
The MCO must adhere to determinations resulting from complaint
investigations conducted by SDOH.
SECTION 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 2004
14-2
15. ACCESS REQUIREMENTS
15.1 Appointment Availability Standards
The Contractor shall comply with the following appointment
availability standards(1).
a) For emergency care: immediately upon presentation at a service
delivery site.
b) For urgent care: within twenty-four (24) hours of request.
c) Non-urgent "sick" visit: within forty-eight (48) to
seventy-two (72) hours of request, as clinically indicated.
d) Routine non-urgent, preventive appointments: within four (4)
weeks of request.
e) Specialist referrals (not urgent): within four (4) to six (6)
weeks of request.
f) Initial prenatal visit: within three (3) weeks during first
trimester, within two (2) weeks during the second trimester
and within one (1) week during the third trimester.
g) Adult Baseline and routine physicals: within twelve (12) weeks
from enrollment. (Adults > 21).
h) Well child care: within four (4) weeks of request.
i) Initial family planning visits: within two (2) weeks of
request.
j) In-plan mental health or substance abuse follow-up visits
(pursuant to an emergency or hospital discharge): within five
(5) days of request, or as clinically indicated.
k) In-plan, non-urgent mental health or substance abuse visits:
within two (2) weeks of request.
1) Initial PCP office visit for newborns: within two (2) weeks of
hospital discharge.
m) Provider visits to make health, mental health and substance
abuse assessments for the purpose of making recommendations
regarding a recipient's ability to perform work when requested
by a LDSS: within ten (10) days of request by an Enrollee, in
accordance with Section 10.8 of this Agreement.
15.2 Twenty-Four (24) Hour Access
a) The Contractor must provide access to medical services and
coverage to Enrollees, either directly or through their PCPs
and OB/GYNs, on a twenty-four (24) hour a day, seven (7) day a
week basis. The Contractor must instruct Enrollees or what to
do to obtain services after business hours and on weekends.
- ----------
1 These are general standards and are not intended to supersede sound clinical
judgement as to the necessity for care and services on a more expedient basis,
when judged clinically necessary and appropriate.
SECTION 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2004
15-1
b) The Contractor may satisfy the requirement in Section 15.2(a)
by requiring their PCPs and OB/GYNs to have primary
responsibility for serving as an after hours "on-call"
telephone resource to members with medical problems. Under no
circumstances may the Contractor routinely refer calls to an
emergency room.
15.3 Appointment Waiting Times
Enrollees with appointments shall not routinely be made to wait
longer than one hour.
15.4 Travel Time Standards
The Contractor will maintain a network that is geographically
accessible to the population to be served.
a) Primary Care
Travel time/distance to primary care sites shall not exceed
thirty (30) minutes in metropolitan areas or thirty (30)
minutes/thirty (30) miles in non-metropolitan areas.
Transport time and distance in rural areas to primary care
sites may be greater than thirty (30) minutes/thirty (30)
miles if based on the community standard for accessing care or
if by Enrollee choice.
Enrollees may, at their discretion, select participating PCPs
located farther from their homes as long as they are able to
arrange and pay for transportation to the PCP themselves.
b) Other Providers
Travel time/distance to specialty care, hospitals, mental
health, lab and x-ray providers shall not exceed thirty (30)
minutes/thirty (30) miles. Transport time and distance in
rural areas to specialty care, hospitals, mental health, lab
and x-ray providers may be greater than thirty (30)
minutes/thirty (30) miles if based on the community standard
for accessing care or if by Enrollee choice.
15.5 Service Continuation
a) New Enrollees
If a new Enrollee has an existing relationship with a health
care provider who is not a member of the Contractor's provider
network, the contractor shall permit the Enrollee to continue
an ongoing course of treatment by the Non-Participating
Provider during a transitional period of up to sixty (60) days
from the Effective Date of Enrollment, if, (1) the Enrollee
has a life-
SECTION 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2004
15-2
threatening disease or condition or a degenerative and
disabling disease or condition, or (2) the Enrollee has
entered the second trimester of pregnancy at the Effective
Date of Enrollment, in which case the transitional period
shall include the provision of post-partum care directly
related to the delivery up until sixty (60) days post partum.
If the Enrollee elects to continue to receive care from such
Non-Participating Provider, such care shall be authorized by
the Contractor for the transitional period only if the
Non-Participating Provider agrees to:
i) accept reimbursement from the Contractor at rates
established by the Contractor as payment in full, which
rates shall be no more than the level of reimbursement
applicable to similar providers within the Contractor's
network for such services; and
ii) adhere to the Contractor's quality assurance
requirements and agrees to provide to the Contractor
necessary medical information related to such care; and
iii) otherwise adhere to the Contractor's policies and
procedures including, but not limited to procedures
regarding referrals and obtaining pre-authorization in
a treatment plan approved by the Contractor.
In no event shall this requirement be construed to require the
Contractor to provide coverage for benefits not otherwise covered.
b) Enrollees Whose Health Care Provider Leaves Network
The Contractor shall permit an Enrollee, whose health care
provider has left the Contractor's network of providers, for
reasons other than imminent harm to patient care, a
determination of fraud or a final disciplinary action by a
state licensing board that impairs the health professional's
ability to practice, to continue an ongoing course of
treatment with the Enrollee's current health care provider
during a transitional period, consistent with New York State
PHL Section 4403(6)(e).
The transitional period shall continue up to ninety (90) days
from the date of notice to the Enrollee of the provider's
disaffiliation from the network; or, if the Enrollee has
entered the second trimester of pregnancy, for a transitional
period that includes the provision of post-partum care
directly related to the delivery through sixty (60) days post
partum. If the Enrollee elects to continue to receive care
from such Non-Participating Provider, such care shall be
authorized by the Contractor for the transitional period only
if the Non-Participating Provider agrees to:
i) accept reimbursement from the Contractor at rates
established by the Contractor as payment in full, which
rates shall be no more than the level of reimbursement
applicable to similar providers within the Contractor's
network for such services;
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(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2004
15-3
ii) adhere to the Contractor's quality assurance
requirements and agrees to provide to the Contractor
necessary medical information related to such care; and
iii) otherwise adhere to the Contractor's policies and
procedures including, but not limited to procedures
regarding referrals and obtaining pre-authorization in
a treatment plan approved by the Contractor.
In no event shall this requirement be construed to require the
Contractor to provide coverage for benefits not otherwise covered.
15.6 Standing Referrals
The Contractor will implement policies and procedures to allow for
standing referrals to specialist physicians for Enrollees who have
ongoing needs for care from such specialists, consistent with PHL
Section 4403(6)(b).
15.7 Specialist as a Coordinator of Primary Care
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or degenerative and disabling
disease or condition, which requires prolonged specialized medical
care, to receive a referral to a specialist, who will then function
as the coordinator of primary and specialty care for that Enrollee,
consistent with PHL Section 4403 (6)(c).
15.8 Specialty Care Centers
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or a degenerative and disabling
condition or disease, which requires prolonged specialized medical
care to receive a referral to an accredited or designated specialty
care center with expertise in treating the life-threatening or
degenerative and disabling disease or condition, consistent with New
York State PHL Section 4403(6)(d).
SECTION 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2004
15-4
16. QUALITY ASSURANCE
16.1 Internal Quality Assurance Program
a) Contractor must operate a quality assurance program which is
approved by SDOH and which includes methods and procedures to
control the utilization of Medicaid services consistent with
PHL Article 49 and 42 CFR Part 456. Recipients' records must
include information needed to perform utilization review as
specified in 42 CFR Sections 456.111 and 456.211. The
Contractors approved quality assurance program must be kept on
file by the Contractor and the LDSS. The Contractor shall not
modify the quality assurance program without the prior written
approval of the SDOH, and notice to the LDSS.
b) The Contractor shall incorporate the findings from reports in
Section 18 of this Agreement into its quality assurance
program. Where performance is less than the statewide average
or another standard as defined by the SDOH and developed in
consultation with plans and appropriate clinical experts, the
Contractor will be required to develop and implement a plan
for improving performance that is approved by the SDOH and
LDSS and that specifies the expected level of improvement and
timeframes for actions expected to result in such improvement.
In the event that such approved plan does not result in the
expected level of improvement, the Contractor shall work with
the SDOH and the LDSS to develop and implement alternative
plans to achieve improvement. The Contractor agrees to meet
with the SDOH and LDSS to review improvement plans and quality
performance.
16.2 Standards of Care
The Contractor must adopt practice guidelines consistent with
current standards of care, complying with recommendations of
professional specialty groups or the guidelines of programs such as
the American Academy of Pediatrics, the American Academy of Family
Physicians, the U.S. Task Force on Preventive Care, the New York
State Child Teen Health Program (C/THP) standards for provision of
care to individuals under age 21, the American Medical Association's
Guidelines for Adolescent and Preventive Services, the US Department
of Health and Human Services Center for Substance Abuse Treatment,
the American College of Obstetricians and Gynecologists, the
American Diabetes Association, and the AIDS Institute clinical
standards for adult, adolescent, and pediatric care. The Contractor
must have mechanisms in place to disseminate any changes in practice
guidelines to its network providers at least annually, or more
frequently, as appropriate. The Contractor shall develop and
implement protocols for identifying providers who do not adhere to
practice guidelines and for making reasonable efforts to improve the
performance of these providers. Annually, the Contractor shall
select a minimum of two practice guidelines and monitor
SECTION 16
(QUALITY ASSURANCE)
OCTOBER 1, 2004
16-1
performance of appropriate providers (or a sample of providers)
against such guidelines.
SECTION 16
(QUALITY ASSURANCE)
OCTOBER 1, 2004
16-2
17. MONITORING AND EVALUATION
17.1 Right to Monitor Contractor Performance
The SDOH, LDSS, and DHHS shall each have the right, during the
Contractor's normal operating hours, and at any other time a
Contractor function or activity is being conducted, to monitor and
evaluate, through inspection or other means, the Contractor's
performance, including, but not limited to, the quality,
appropriateness, and timeliness of services provided under this
Agreement.
17.2 Cooperation During Monitoring and Evaluation
The Contractor shall cooperate with and provide reasonable
assistance to the SDOH, LDSS, and DHHS in the monitoring and
evaluation of the services provided under this Agreement.
17.3 Cooperation During On-Site Reviews
The Contractor shall cooperate with SDOH and LDSS in any on-site
review of the MCO's operations. SDOH shall give the Contractor
notification of the date(s) and survey format for any full
operational review at least forty-five (45) days prior to the site
visit. This requirement shall not preclude LDSS or SDOH from site
visits upon shorter notice for other monitoring purposes.
17.4 Cooperation During Review of Services by External Review Agency
The Contractor shall comply with all requirements associated with
any review of the quality of services rendered to its Enrollees to
be performed by an external review agent selected by the SDOH.
SECTION 17
(MONITORING AND EVALUATION)
October 1, 2004
17-1
18. CONTRACTOR REPORTING REQUIREMENTS
18.1 Time Frames for Report Submissions
Except as otherwise specified herein, the Contractor shall prepare
and submit to SDOH and the LDSS the reports required under this
Agreement in an agreed media format within sixty (60) days of the
close of the applicable semi-annual or annual reporting period, and
within fifteen (15) business days of the close of the applicable
quarterly reporting period.
18.2 SDOH Instructions for Report Submissions
SDOH, with prior notice to the LDSS, will provide Contractor with
instructions for submitting the reports required by Section 18.5 (a)
through (n), 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(o) including time frames and
requisite formats.
18.3 Liquidated Damages
The Contractor shall pay liquidated damages of $2,500 if any report
required pursuant to this Section is materially incomplete, contains
material misstatements or inaccurate information, or is not
submitted on time in the requested format. The Contractor shall pay
liquidated damages of $2,500 to the LDSS if its monthly encounter
data submission is not received by the Fiscal Agent by the due date
specified in Section 18.5(d). The Contractor shall pay liquidated
damages of $500 to the LDSS for each day other reports required by
this Section are late. The LDSS shall not impose liquidated damages
for a first time infraction by the Contractor unless the LDSS deems
the infraction to be a material misrepresentation of fact or the
Contractor fails to cure the first infraction within a reasonable
period of time upon notice from the LDSS. Liquidated damages may be
waived at the sole discretion of LDSS. Nothing in this Section shall
limit other remedies or rights available to LDSS and SDOH relating
to the timeliness, completeness and/or accuracy of Contractor's
reporting submission.
18.4 Notification of Changes in Report Due Dates, Requirements or Formats
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
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-1
determination to grant a modification or extension of time shall be
made by the LDSS with respect to No-Contact, PCP auto assignment,
and reports required by Sections 18.5 (n) and (o) of the Agreement.
18.5 Reporting Requirements
The Contractor shall submit the following reports to SDOH and to the
LDSS except in those instances in which this Agreement specifies the
reports shall be submitted solely to SDOH:
a) Annual Financial Statements:
Contractor shall submit Annual Financial Statements to SDOH.
The due date for annual statements shall be April 1 following
the report closing date.
b) Quarterly Financial Statements:
Contractor shall submit Quarterly Financial Statements to
SDOH. The due date for quarterly reports shall be forty-five
(45) days after the end of the calendar quarter.
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
Sections 4403-a, 4404 and 4409, Title 10 NYCRR Sections 98.11,
98.16 and 98.17 and applicable Insurance Law Sections 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(o) of this Agreement.
d) Encounter Data:
The Contractor shall prepare and submit encounter data on a
monthly basis to SDOH through its designated Fiscal Agent.
Each provider is required to have a unique identifier.
Submissions shall be comprised of encounter records, or
adjustments to previously submitted records, which the
Contractor has received and processed from provider encounter
or claim records of any contracted services rendered to the
Enrollee in the current or any preceding months. Monthly
submissions must be received by the Fiscal Agent by the
Tuesday before the last Monday of the month to assure the
submission is included in the Fiscal Agent's monthly
production processing.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-2
e) Quality of Care Performance Measures:
The Contractor shall prepare and submit reports to SDOH, as
specified in the Quality Assurance Reporting Requirements
(QARR). The Contractor must arrange for an NCQA-certified
entity to audit the QARR data prior to its submission to the
SDOH, unless this requirement is specifically waived by the
SDOH. The SDOH will select the measures which will be audited
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(o) of
this Agreement.
g) Fraud and Abuse Reporting Requirements:
i) The Contractor must submit quarterly, via the HPN
complaint reporting format, the number of complaints of
fraud or abuse made to the Contractor that warrant
preliminary investigation by the Contractor.
ii) The Contractor must also submit to the SDOH the
following on an ongoing basis for each confirmed case of
fraud and abuse it identifies through complaints,
organizational monitoring, contractors, subcontractors,
providers, beneficiaries, Enrollees, etc:
A) The name of the individual or entity that
committed the fraud or abuse;
B) The source that identified the fraud or abuse;
C) The type of provider, entity or organization that
committed the fraud or abuse;
D) A description of the fraud or abuse;
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-3
E) The approximate range of dollars involved;
F) The legal and administrative disposition of the
case including actions taken by law enforcement
officials to whom the case has been referred; and
G) Other data/information as prescribed by SDOH.
iii) Such report shall be submitted when cases of fraud and
abuse are confirmed, and shall be reviewed and signed by
an executive officer of the Contractor.
h) Participating Provider Network Reports:
The Contractor shall submit electronically, to the HPN, an
updated provider network report on a quarterly basis. The
Contractor shall submit an annual notarized attestation that
the providers listed in each submission have executed an
agreement with the Contractor to serve Contractor's Medicaid
Enrollees. The report submission must comply with the Managed
Care Provider Network Data Dictionary. Networks must be
reported separately for each county in which the Contractor
operates.
i) Appointment Availability/ Twenty-four (24) Hour Access and
Availability Surveys:
The Contractor will conduct a county specific (or service area
if appropriate) review of appointment availability and
twenty-four (24) hour access and availability surveys
annually. Results of such surveys must be kept on file and be
readily available for review by the SDOH or LDSS, upon
request. Guidelines for such studies may be obtained by
contacting the SDOH, Office of Managed Care, Bureau of
Certification and Surveillance.
The LDSS reserves the right to require the Contractor to
conduct appointment availability and twenty-four (24) hour
access studies twice a year, and to submit these reports to
the LDSS, as stated in Section 18.5(o) of this Agreement.
j) Clinical Studies:
The Contractor will participate in up to four (4) SDOH
sponsored focused clinical studies annually. The purpose of
these studies will be to promote quality improvement within
the MCO.
The Contractor will be required to conduct at least one (1)
internal focused clinical study each year in a priority topic
area of its choosing, from a list to be generated through the
mutual agreement of the SDOH and the Contractor's Medical
Director. The Contractor may conduct its internal focused
clinical study in conjunction with one or more MCOs. The
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-4
purpose of these studies will be to promote quality
improvement within the MCO. SDOH will provide guidelines which
address study structure and plan collaboration. Results of
these studies will be provided to the SDOH and the LDSS.
k) Independent Audits:
The Contractor must submit copies of all certified financial
statements and a QARR validation audit by independent auditors
of their plan to the SDOH and the LDSS within thirty (30) days
of receipt by the Contractor.
1) New Enrollee Health Screening Completion Report:
The Contractor shall submit a quarterly report within thirty
(30) days of the close of the quarter showing the percentage
of new Enrollees for which the Contractor was able to complete
a health screening consistent with Section 13.5(b) of this
Contract.
m) Additional Reports:
Upon request by the SDOH and/or the LDSS, the Contractor shall
prepare and submit other operational data reports. Such
requests will be limited to situations in which the desired
data is considered essential and cannot be obtained through
existing Contractor reports. Whenever possible, the Contractor
will be provided with ninety (90) days notice and the
opportunity to discuss and comment on the proposed
requirements before work is begun. However, the SDOH and the
LDSS reserve the right to give thirty (30) days notice in
circumstances where time is of the essence.
n) LDSS Specific Reports:
{INSERT LDSS SPECIFIC REPORTS AS APPLICABLE} NONE REQUIRED.
18.6 Ownership and Related Information Disclosure
The Contractor shall report ownership and related information to
SDOH and the LDSS, and upon request to the Secretary of Department
of Health and Human Services and the Inspector General of Health and
Human Services, in accordance with 42 U.S.C. Section 1320a-3 and
1396b(m)(4) (Sections 1124 and 1903(m)(4) of the Federal Social
Security Act).
18.7 Revision of Certificate of Authority
The Contractor shall give prompt written notice to LDSS of any
revisions of its Certificate of Authority issued pursuant to Article
44 of the State Public Health Law.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-5
18.8 Public Access to Reports
Any data, information, or reports collected and prepared by the
Contractor and submitted to NYS authorities in the course of
performing their duties and obligation under this program will be
deemed to be owned by the State of New York subject to and
consistent with the requirements of Freedom of Information Law. This
provision is made in consideration of the Contractor's use of public
funds in collecting and preparing such data, information, and
reports.
18.9 Professional Discipline
a) Pursuant to PHL Section 4405-b, the Contractor shall have in
place policies and procedures to report to the appropriate
professional disciplinary agency within thirty (30) days of
occurrence, any of the following:
i) the termination of a health care provider contract
pursuant to Section 4406-d of the Public Health Law for
reasons relating to alleged mental and physical
impairment, misconduct or impairment of patient safety
or welfare;
ii) the voluntary or involuntary termination of a contract
or employment or other affiliation with such Contractor
to avoid the imposition of disciplinary measures; or
iii) the termination of a health care provider contract in
the case of a determination of fraud or in a case of
imminent harm to patient health.
b) The Contractor shall make a report to the appropriate
professional disciplinary agency within thirty (30) days of
obtaining knowledge of any information that reasonably appears
to show that a health professional is guilty of professional
misconduct as defined in Articles 130 and 131(a) of the State
Education Law.
18.10 Certification Regarding Individuals Who Have Been Debarred Or
Suspended By Federal or State Government
Contractor will certify to the SDOH and LDSS initially and
immediately upon changed circumstances from the last such
certification that it does not knowingly have an individual who has
been debarred or suspended by the federal or state government, or
otherwise excluded from participating in procurement activities:
a) as a director, officer, partner or person with beneficial
ownership of more than 5% of the Contractor's equity; or
b) as a party to an employment, consulting or other agreement
with the Contractor for the provision of items and services
that are significant and material to the Contractor's
obligations in the Medicaid managed care program, consistent
with requirements of SSA Section 1932 (d)(1).
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(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-6
18.11 Conflict of Interest Disclosure
Contractor shall report to SDOH, in a format specified by SDOH,
documentation, including but not limited to the identity of and
financial statements of, person(s) or corporation(s) with an
ownership or contract interest in the managed care plan, or with any
subcontract(s) in which the managed care plan has a 5% or more
ownership interest, consistent with requirements of SSA Section 1903
(m)(2)(a)(viii) and 42 CFR Sections 455.100-455.104.
18.12 Physician Incentive Plan Reporting
The Contractor shall submit to SDOH annual reports containing the
information on all of its Physician Incentive Plan arrangements in
accordance with 42 CFR Section 434.70 or, if no such arrangements
are in place, attest to that. The contents and time frame of such
reports shall comply with the requirements of 42 CFR Section 417.479
and be in a format provided by SDOH.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2004
18-7
19. RECORDS MAINTENANCE AND AUDIT RIGHTS
19.1 Maintenance of Contractor Performance Records
The Contractor shall maintain and shall require its subcontractors,
including its Participating Providers, to maintain appropriate
records relating to Contractor performance under this Agreement,
including:
a) records related to services provided to Enrollees, including a
separate Medical Record for each Enrollee;
b) all financial records and statistical data that LDSS, SDOH and
any other authorized governmental agency may require including
books, accounts, journals, ledgers, and all financial records
relating to capitation payments, third party health insurance
recovery, and other revenue received and expenses incurred
under this Agreement;
c) appropriate financial records to document fiscal activities
and expenditures, including records relating to the sources
and application of funds and to the capacity of the Contractor
or its subcontractors, including its Participating Providers,
if relevant, to bear the risk of potential financial losses.
19.2 Maintenance of Financial Records and Statistical Data
The Contractor shall maintain all financial records and statistical
data according to generally accepted accounting principles.
19.3 Access to Contractor Records
The Contractor shall provide LDSS, SDOH, the Comptroller of the
State of New York, DHHS, the Comptroller General of the United
States, and their authorized representatives with access to all
records relating to Contractor performance under this Agreement for
the purposes of examination, audit, and copying (at reasonable cost
to the requesting party) of such records. The Contractor shall give
access to such records on two (2) business days prior written
notice, during normal business hours, unless otherwise provided or
permitted by applicable laws, rules, or regulations.
19.4 Retention Periods
The Contractor shall preserve and retain all records relating to
Contractor performance under this Agreement in readily accessible
form during the term of this Agreement and for a period of six (6)
years thereafter except that the Contractor shall retain Enrollees'
medical records that are in the custody of the Contractor for six
(6) years after the date of service rendered to the Enrollee or
SECTION 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2004
19-1
cessation of Contractor operation, and in the case of a minor, for
six (6) years after majority. The Contractor shall require and make
reasonable efforts to assure that Enrollees' medical records are
retained by providers for six (6) years after the date of service
rendered to the Enrollee or cessation of Contractor operation, and
in the case of a minor, for six(6) years after majority. All
provisions of this Agreement relating to record maintenance and
audit access shall survive the termination of this Agreement and
shall bind the Contractor until the expiration of a period of six
(6) years commencing with termination of this Agreement or if an
audit is commenced, until the completion of the audit, whichever
occurs later. If the Contractor becomes aware of any litigation,
claim, financial management review or audit that is started before
the expiration of the six (6) year period, the records shall be
retained until all litigation, claims, financial management reviews
or audit findings involved in the record have been resolved and
final action taken.
SECTION 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2004
19-2
20. CONFIDENTIALITY
20.1 Confidentiality of Identifying Information about Medicaid Recipients
and Applicants
All information relating to services to Medicaid recipients and
applicants which is obtained by the Contractor shall be confidential
pursuant to the New York State Public Health Law including PHL
Article 27 F, the provisions of Section 369(4) of the NYS Social
Services Law, 42 U.S.C. Section 1396a(a)(7) (Section 1902(a)(7) of
the Federal Social Security Act), Section 33.13 of the Mental
Hygiene Law, and regulations promulgated under such laws including
42 CFR Part 2 pertaining to Alcohol and Substance Abuse Services.
Such information including information relating to services to
Medicaid recipients and applicants as these relate to the provision
of services to the recipient or applicant under this Agreement shall
be used or disclosed by the Contractor only for a purpose directly
connected with performance of the Contractor's obligations. It shall
be the responsibility of the Contractor to inform its employees and
contractors of the confidential nature of Medicaid information.
20.2 Medical Records of Foster Children
Medical records of enrolled Medicaid recipients enrolled in foster
care programs shall be disclosed to local social service officials
in accordance with State Social Services Law including Sections
358-a, 384-a and 392 and 18 NYCRR Section 507.1.
20.3 Confidentiality of Medical Records
Medical records of Medicaid recipients enrolled pursuant to this
Agreement shall be confidential and shall be disclosed to and by
other persons within the Contractor's organization including
Participating Providers, only as necessary to provide medical care,
to conduct quality assurance functions and peer review functions, or
as necessary to respond to a complaint and appeal under the terms of
this Agreement.
20.4 Length of Confidentiality Requirements
The provisions of this Section shall survive the termination of this
Agreement and shall bind the Contractor so long as the Contractor
maintains any individually identifiable information relating to
Medicaid recipients and applicants.
SECTION 20
(CONFIDENTIALITY)
October 1, 2004
20-1
21. PARTICIPATING PROVIDERS
21.1 Network Requirements
a) Sufficient Number
i) The Contractor will establish and maintain a network of
Participating Providers.
ii) The Contractor's network must contain all of the
provider types necessary to furnish the prepaid Benefit
Package, including but not limited to: hospitals,
physicians (primary care and specialists), mental health
and substance abuse providers, allied health
professionals, ancillary providers, DME providers and
home health providers.
iii) To be considered accessible, the network must contain a
sufficient number and array of providers to meet the
diverse needs of the Enrollee population. This includes
being geographically accessible (meeting time/distance
standards) and being accessible for the disabled.
iv) The Contractor shall not include in its network any
provider who has been sanctioned or prohibited from
serving Medicaid recipients or receiving Medical
Assistance payments.
b) Absence of Appropriate Network Provider
In the event that the Contractor determines that it does not
have a Participating Provider with appropriate training and
experience to meet the particular health care needs of an
Enrollee, the Contractor shall make a referral to an
appropriate Non-Participating Provider, pursuant to a
treatment plan approved by the Contractor in consultation with
the Primary Care Provider, the Non-Participating Provider and
the Enrollee or the Enrollee's designee. The Contractor shall
pay for the cost of the services in the treatment plan
provided by the Non-Participating Provider.
c) Suspension of Enrollee Assignments To Providers
The Contractor shall ensure that there is sufficient capacity,
consistent with SDOH standards, to serve Enrollees under this
Agreement. In the event any of the Contractor's Participating
Providers are no longer able to accept assignment of new
Enrollees due to capacity limitations, as determined by the
SDOH and the LDSS, the Contractor will suspend assignment of
any additional Enrollees to such Participating Provider until
it is capable of further accepting Enrollees. When a
Participating Provider has more than one (1) site, the
suspension will be made by site.
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-1
d) Notice of Provider Termination
The Contractor shall notify LDSS and SDOH of any notice of
termination of
an IPA, hospital or medical group provider agreement which
affects an Enrollee's access to care.
Such notification to the LDSS and the SDOH shall be made
ninety (90) days prior to the effective date of the
termination of the provider agreement or immediately upon
notice from such provider if less than ninety (90) days.
The Contractor shall also notify LDSS and SDOH in the event
that the Contractor and the providers have failed to
re-execute a renewal provider agreement forty-five (45) days
prior to the expiration of the agreement.
The Contractor shall submit a contingency plan to LDSS and
SDOH, at least forty-five (45) days prior to the termination
of expiration of the agreement, identifying the number of
Enrollees affected by the potential withdrawal, if applicable,
and specifying how services previously furnished by the
participating providers will be provided in the event of their
withdrawal. If the provider is a participating hospital, the
Contractor shall identify the number of doctors who would not
have admitting privileges in the absence of such participating
hospital.
The Contractor shall develop a transition plan for patients of
the departing providers subject to approval by LDSS and SDOH.
SDOH and LDSS may direct the Contractor to provide notice to
the patients of PCPs or specialists including available
options for the patients, and availability of continuing care,
consistent with Section 13.7, not less than thirty (30) days
prior to the termination of the provider agreement. In the
event that provider agreements are terminated with less than
the notice period required by this section, the Contractor
shall immediately notify LDSS and SDOH, and develop a
transition plan on an expedited basis and provide notice to
patients subject to the consent of LDSS and SDOH.
Upon Contractor notice of failure to re-execute, or
termination of, a provider agreement, the SDOH and the LDSS,
in their sole discretion, may waive the requirement of
submission of a contingency plan upon a determination by the
SDOH and the LDSS that:
i) the impact upon Enrollees is not significant, and/or
ii) the Contractor and provider are continuing to negotiate
in good faith and consent to extend the provider
agreement for a period of time necessary to provide not
less than thirty (30) days notice to Enrollees.
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-2
SDOH and the LDSS reserve the right to take any other actions
permitted by this Agreement and under regulatory or statutory
authority, including but not limited to contract termination.
21.2 Credentialing
a) Licensure
The Contractor shall ensure in accordance with Article 44 of
the Public Health Law, that persons and entities providing
care and services for the Contractor in the capacity of
physician, dentist, physician's assistant, registered nurse,
other medical professional or paraprofessional, or other such
person or entity satisfy all applicable licensing,
certification, or qualification requirements under New York
law and that the functions and responsibilities of such
persons and entities in providing Benefit Package services
under this Agreement do not exceed those permissible under New
York law.
b) Minimum Standards
The Contractor agrees that all network physicians will meet at
least one (1) of the following standards, except as specified
in Section 21.13(b) and Appendix 1 of this agreement:
i) Be board-certified or -eligible in their area of
specialty;
ii) Have completed an accredited residency program; or
iii) Have admitting privileges at one (1) or more hospitals
participating in the Contractor's network.
c) Credentialing/Recredentialing Process
The Contractor shall have in place a formal process for
credentialing Participating Providers on a periodic basis (not
less than once every three (3) years) and for monitoring
Participating Providers performance.
d) Application Procedure
The Contractor shall establish a written application procedure
to be used by a health care professional interested in serving
as a Participating Provider with the Contractor. The criteria
for selecting providers, including the minimum qualification
requirements that a health care professional must meet to be
considered by the Contractor must be defined in writing and
developed in consultation with appropriately qualified health
care professionals. Upon request, the application procedures
and minimum qualification requirements must be made available
to health care professionals.
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-3
21.3 SDOH Exclusion or Termination of Providers
If SDOH excludes or terminates a provider from its Medicaid Program,
the Contractor shall, upon learning of such exclusion or
termination, immediately terminate the provider agreement with the
Participating Provider as it pertains to the Contractor's Medicaid
program, and agrees to no longer utilize the services of the subject
provider, as applicable. The Contractor shall access information
pertaining to excluded Medicaid providers through the SDOH Health
Provider Network (HPN). Such information available to the Contractor
on the HPN shall be deemed to constitute constructive notice. The
HPN should not be the sole basis for identifying current exclusions
or termination of previously approved providers. Should the
Contractor become aware, through the HPN or any other source, of an
SDOH exclusion or termination, the Contractor shall validate this
information with the Office of Medicaid Management, Bureau of
Enforcement Activities and comply with the provisions of this
Section.
21.4 Evaluation Information
The Contractor shall develop and implement policies and procedures
to ensure that health care professionals are regularly advised of
information maintained by the Contractor to evaluate the performance
or practice of health care professionals. The Contractor shall
consult with health care professionals in developing methodologies
to collect and analyze health care professional profiling data. The
Contractor shall provide any such information and profiling data and
analysis to health care professionals. Such information, data or
analysis shall be provided on a periodic basis appropriate to the
nature and amount of data and the volume and scope of services
provided. Any profiling data used to evaluate the performance or
practice of a health care professional shall be measured against
stated criteria and an appropriate group of health care
professionals using similar treatment modalities serving a
comparable patient population. Upon presentation of such information
or data, each health care professional shall be given the
opportunity to discuss the unique nature of the health care
professional's patient population which may have a bearing on the
health care professional's profile and to work cooperatively with
the Contractor to improve performance.
21.5 Payment In Full
Contractor must limit participation to providers who agree that
payment received from the Contractor for services included in the
Benefit Package is payment in full for services provided to
Enrollees.
SECTION 21
("PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-4
21.6 Choice/Assignment of PCP's
a) The Contractor shall offer each Enrollee the choice of no
fewer than three (3) Primary Care Providers within program
distance/travel time standards. Contractor must assign a PCP
to individuals that fail to select a PCP. The assignment of a
PCP by the Contractor may occur after written notification of
Contractor by LDSS of the enrollment (through Roster or other
method) and after written notification of the Enrollee by the
Contractor but in no event later than thirty (30) days after
notification of enrollment, and only after the Contractor has
made reasonable efforts as set forth in Section 13.5 of this
Agreement to contact the Enrollee and inform him/her of
his/her right to choose a PCP.
b) PCP assignments should be made taking into consideration the
following:
i) Enrollee's geographic location;
ii) any special health care needs, if known by the
Contractor; and
iii) any special language needs, if known by the Contractor.
c) In circumstances where the Contractor operates or contracts
with a multi-provider clinic to deliver primary care
services, the Enrollee must choose or be assigned a specific
provider or provider team within the clinic to serve as
his/her PCP. This "lead" provider will be held accountable for
performing the PCP duties.
21.7 PCP Changes
a) The Contractor must allow Enrollees the freedom to change
PCPs, without cause, within thirty (30) days of the Enrollee's
first appointment with the PCP. After the first thirty (30)
days PCP may be changed once every six (6) months without
cause.
b) The Contractor must process a request to change PCPs and
advise the Enrollee of the effective date of the change within
forty-five (45) days of receipt of the request. The change
must be effective no later than the first (1st) day of the
second (2nd) month following the month in which the request is
made.
c) The Contractor will provide Enrollees with an opportunity to
select a new PCP in the event that the Enrollee's current PCP
leaves the network or otherwise becomes unavailable. Such
changes shall not be considered in the calculation of changes
for cause allowed within a six (6) month period.
d) In the event that an assignment of a new PCP is necessary due
to the unavailability of the Enrollee's former PCP, such
assignment shall be
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-5
made in accordance with the requirements of Section 21.6 of
this Agreement.
e) In addition to those conditions and circumstances under which
the Contractor may assign an Enrollee a PCP when the Enrollee
fails to make an affirmative choice of a PCP, the Contractor
may initiate a PCP change for an Enrollee under the following
circumstances:
i) The Enrollee requires specialized care for an acute or
chronic condition and the Enrollee and Contractor agree
that reassignment to a different PCP is in the
Enrollee's interest.
ii) The Enrollee's place of residence has changed such that
he/she has moved beyond the PCP travel time/distance
standard.
iii) The Enrollee's PCP ceases to participate in the
Contractor's network.
iv) The Enrollee's behaviour toward the PCP is disruptive
and the PCP has made all reasonable efforts to
accommodate the Enrollee.
v) The Enrollee has taken legal action against the PCP.
f) Whenever initiating a change, the Contractor must offer
affected Enrollees the opportunity to select a new PCP in the
manner described in this Section.
21.8 Provider Status Changes
1) PCP Changes
The Contractor agrees to notify its Enrollees of any of the
following PCP changes:
a) Enrollees will be notified within fifteen (15) days from
the date on which the Contractor becomes aware that such
Enrollee's PCP has changed his or her office address or
telephone number.
b) If a PCP ceases participation in the Contractor's
network, the Contractor shall provide written notice
within fifteen (15) days from the date that the
Contractor becomes aware of such change in status to
each Enrollee who has chosen the provider as their PCP.
In such cases, the notice shall describe the procedures
for choosing an alternative PCP and, in the event that
the Enrollee is in an ongoing course of treatment, the
procedures for continuing care consistent with
subdivision 6 (e) of PHL Section 4403.
c) Where an Enrollee's PCP ceases participation with the
Contractor, the Contractor must ensure that a new PCP is
assigned within thirty (30) days of the date of the
notice to the Enrollee.
2) Other Provider Changes
In the event that an Enrollee is in an ongoing course of
treatment with another Participating Provider who becomes
unavailable to continue to provide
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21- 6
services to such Enrollee, the Contractor shall provide written
notice to the Enrollee within fifteen (15) days from the date on
which the Contractor becomes aware of the Participating Provider's
unavailability to the Enrollee. In such cases, the notice shall
describe the procedures for continuing care consistent with
subdivision 6 (e) of PHL Section 4403 and for choosing an
alternative provider.
21.9 PCP Responsibilities
In conformance with the Benefit Package, the PCP shall provide
health counseling and advice; conduct baseline and periodic health
examinations; diagnose and treat conditions not requiring the
services of a specialist; arrange inpatient care, consultation with
specialists, and laboratory and radiological services when medically
necessary; coordinate the findings of consultants and laboratories;
and interpret such findings to the Enrollee and the Enrollee's
family, subject to the confidentiality provisions of Section 20 of
this Agreement, and maintain a current medical record for the
Enrollee. The PCP shall also be responsible for determining the
urgency of a consultation with a specialist and shall arrange for
all consultation appointments within appropriate time frames.
21.10 Member to Provider Ratios
The Contractor agrees to adhere to the member-to-PCP ratios shown
below. These ratios are for Medicaid Enrollees only, are
Contractor-specific, and assume the practitioner is a full time
equivalent (FTE) (defined as a provider practicing forty (40) hours
per week for the Contractor):
i) No more than 1,500 Medicaid Enrollees for each physician, or
2,400 for a physician practicing in combination with a
registered physician assistant or a certified nurse
practitioner.
ii) No more than 1,000 Medicaid Enrollees for each certified nurse
practitioner.
The Contractor agrees that these ratios will be prorated for
Participating Providers who represent less than a FTE to the
Contractor.
21.11 Minimum Office Hours
a) General Requirements
A PCP must practice a minimum of sixteen (16) hours a week at
each primary care site.
b) The minimum office hours requirement may be waived under
certain circumstances. A request for a waiver must be
submitted by the MCO to the Medical Director of the Office of
Managed Care for review and approval; and the physician must
be available at least eight hours/week; and the
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-7
physician must be practicing in a Health Provider Shortage
Area (HPSA) or other similarly determined shortage area; and
the physician must be able to fulfill the other
responsibilities of a PCP (as described in this Section); and
the waiver request must demonstrate there are systems in
place to guarantee continuity of care and to meet all access
and availability standards, (24-hr/7 day week coverage,
appointment availability, etc.). SDOH shall notify the LDSS
when a waiver has been granted.
21.12 Primary Care Practitioners
a) General Limitations
The Contractor agrees to limit its PCPs to the following
primary care specialties: Family Practice, General Practice,
General Pediatrics, General Internal Medicine, except as
specified in (b), (c), (d) and (e) of this Section.
b) Specialist and Sub-specialist as PCPs
The Contractor is permitted to use specialist and
sub-specialist physicians as PCPs when such an action is
considered by the Contractor to be medically appropriate and
cost-effective. As an alternative, the Contractor may
restrict it's PCP network to primary care specialties only,
while relying on standing referrals to specialists and
sub-specialists for Enrollees who require regular visits to
such physicians.
c) OB/GYN Providers as PCPs
The Contractor, at its option, is permitted to use OB/GYN
providers as PCPs, subject to SDOH qualifications.
d) Certified Nurse Practitioners as PCPs
The Contractor is permitted to use certified nurse
practitioners as PCPs, subject to their scope of practice
limitations under New York State Law.
e) Registered Physician's Assistants as Physician Extenders
The Contractor is permitted to use registered physician's
assistants as physician-extenders, subject to their scope of
practice limitations under New York State Law.
SECTION 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 2004
21-8
21.13 PCP Teams
a) General Requirements
The Contractor may designate teams of physicians/certified
nurse practitioners to serve as PCPs for Enrollees. Such teams
may include no more than four (4) physicians/certified nurse
practitioners and, when an Enrollee chooses or is assigned to
a team, one of the practitioners must be designated as "lead
provider" for that Enrollee. In the case of teams comprised of
medical residents under the supervision of an attending
physician, the attending physician must be designated as the
lead physician.
b) Medical Residents
The Contractor shall comply with SDOH Guidelines for use of
Medical Residents as found in Appendix I, which is hereby made
a part of this Agreement as if set forth fully herein.
21.14 Hospitals
a) Tertiary Services
The Contractor will establish hospital networks capable of
furnishing the full range of tertiary services to Enrollees.
Contractors shall ensure that all Enrollees have access to at
least one (1) general acute care hospital within thirty (30)
minutes/thirty (30) miles travel time (by car or public
transportation) from the Enrollee's residence, unless none are
located within such a distance. If none are located within
thirty (30) minutes travel time/thirty (30) miles travel
distance, the Contractor must include the next closest site in
its network.
b) Emergency Services
The Contractor shall ensure and demonstrate that it maintains
relationships with hospital emergency facilities, including
comprehensive psychiatric emergency programs (where available)
within and around its Service Area to provide Emergency
Services.
21.15 Dental Networks
If the Contractor includes dental services in its Benefit Package,
the Contractor's dental network shall include geographically
accessible general dentists sufficient to offer each Enrollee a
choice of two (2) primary care dentists in their Service Area and to
achieve a ratio of at least one (1) primary care dentist for each
2,000 Enrollees. Networks must also include at least one (1)
pediatric dentist and one (1) oral surgeon. Orthognathic surgery,
temporal mandibular disorders (TMD)
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and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists
and endodontists must also be available by referral. The network
should include dentists with expertise in serving special needs
populations (e.g., HIV+ and developmentally disabled patients).
Dental surgery performed in an ambulatory or inpatient setting is
the responsibility of the Contractor whether dental services are a
covered benefit or not, as set forth in Appendix K-II - B-Optional
Service, Dental Services.
21.16 Presumptive Eligibility Providers
Contractors must offer Presumptive Eligibility Providers the
opportunity to contract at terms which are at least as favorable as
the terms offered to other providers performing equivalent services
(prenatal care). Contractors need not contract with every
Presumptive Eligibility Provider in their County, but must include a
sufficient number in their networks of Participating Providers to
meet the distance/travel time standards defined for primary care.
21.17 Mental Health and Chemical Dependence Services Providers
The Contractor will include a full array of mental health and
Chemical Dependence Services providers in its networks, in
sufficient numbers to assure accessibility to Benefit Package
services on the part of both children and adults, using either
individual, appropriately licensed practitioners or New York State
Office of Mental Health (OMH) and Office of Alcohol and Substance
Abuse Services (OASAS) licensed programs and clinics, or both.
The State defines mental health and Chemical Dependence Services
providers to include the following: Individual Practitioners,
Psychiatrists, Psychologists, Psychiatric Nurse Practitioners,
Psychiatric Clinical Nurse Specialists, Licensed Certified Social
Workers, OMH and OASAS Programs and Clinics, and providers of mental
health and/or Chemical Dependence Services certified or licensed
pursuant to Article 31 or 32 of the Mental Hygiene Law, as
appropriate.
21.18 Laboratory Procedures
The Contractor agrees to restrict its laboratory provider network to
entities having either a CLIA certificate of registration or a CLIA
certificate of waiver.
21.19 Federally Qualified Health Centers (FQHCs)
In voluntary counties, the Contractor is not required to contract
with FQHCs.
However, when an FQHC is part of the provider network (voluntary or
mandatory counties) the Provider Agreement must include a provision
whereby the
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Contractor agrees to compensate the FQHC for services provided to
Enrollees at a payment rate that is not less than the level and
amount for a similar set of services which the Contractor would make
to a provider that is not an FQHC.
In mandatory counties, the Contractor shall contract with FQHCs
operating in its Service Area. However, the Contractor has the
option to make a written request to the SDOH for an exemption from
the FQHC contracting requirement, if the Contractor can demonstrate,
with supporting documentation, that it has adequate capacity and
will provide a comparable level of clinical and enabling services
(e.g., outreach, referral services, social support services,
culturally sensitive services such as training for medical and
administrative staff, medical and non-medical and case management
services) to vulnerable populations in lieu of contracting with an
FQHC in its Service Area. Written requests for exemption from this
requirement are subject to approval by HCFA.
When the Contractor is participating in a county where an MCO that
is sponsored, owned and/or operated by one or more FQHCs exists, the
Contractor is not required to include any FQHCs within its network
in that county.
21.20 Provider Services Function
The Contractor will operate a Provider Services function during
regular business hours. At a minimum, the Contractor's Provider
Services staff must be responsible for the following:
a) Assisting providers with prior authorization and referral
protocols.
b) Assisting providers with claims payment procedures.
c) Fielding and responding to provider questions and complaints.
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22. SUBCONTRACTS AND PROVIDER AGREEMENTS
22.1 Written Subcontracts
Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by a written agreement.
22.2 Permissible Subcontracts
Contractor may subcontract for provider services as set forth in
Section 2.6 and 21 of this contract and management services
including, but not limited to, marketing, quality assurance and
utilization review activities and such other services as are
acceptable to the SDOH.
22.3 Provisions of Services through Provider Agreements
All medical care and/or services covered under this Agreement, with
the exception of seldom used subspecialty and Emergency Services,
Family Planning Services, and services for which Enrollees can self
refer, shall be provided through Provider Agreements with
Participating Providers.
22.4 Approvals
a) Provider Agreements shall require the approval of SDOH as set
forth in PHL 4402 and 10 NYCRR Part 98.
b) If a subcontract is for management services under 10 NYCRR
Section 98-1.11, it must be approved by SDOH prior to its
becoming effective.
c) The Contractor shall notify SDOH of any material amendments to
any Provider Agreement as set forth in 10 NYCRR Section
98-1.8.
22.5 Required Components
a) The Contractor shall impose obligations and duties on its
subcontractors, including its Participating Providers, that
are consistent with this Agreement, and that do not impair any
rights accorded to LDSS, SDOH, or DHHS.
b) No subcontract, including any Provider Agreement shall limit
or terminate the Contractor's duties and obligations under
this Agreement.
c) Nothing contained in this Agreement between LDSS and the
Contractor shall create any contractual relationship between
any subcontractor of the Contractor, including Participating
Providers, and the County or LDSS.
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d) Any subcontract entered into by the Contractor shall fulfill
the requirements of 42 CFR Part 434 that are appropriate to
the service or activity delegated under such subcontract.
e) The Contractor shall also ensure that, in the event the
Contractor fails to pay any subcontractor, including any
Participating Provider in accordance with the subcontract or
Provider Agreement, the subcontractor or Participating
Provider will not seek payment from the LDSS, the Enrollees,
or their eligible dependents.
f) The Contractor shall include in every Provider Agreement a
procedure for the resolution of disputes between the
Contractor and its Participating Providers.
g) The Contractor shall ensure that all Provider Agreements
entered into with Providers require acceptance of a woman's
enrollment in the MCO as sufficient to provide services to her
newborn, unless the newborn is excluded from participating in
Medicaid managed care.
22.6 Timely Payment
Contractor shall make payments to health care providers for items
and services covered under this Agreement on a timely basis,
consistent with the claims payment procedures described in NYS
Insurance Law Section 3224-a.
22.7 Restrictions on Disclosure
The Contractor shall not by contract or written policy or written
procedure prohibit or restrict any health care provider from the
following:
a) disclosing to any subscriber, Enrollee, patient, designated
representative or, where appropriate, prospective Enrollee
any information that such provider deems appropriate
regarding:
i) a condition or a course of treatment with such
subscriber, Enrollee, patient, designated representative
or prospective Enrollee, including the availability of
other therapies, consultations, or tests; or
ii) The provisions, terms, or requirements of the
Contractor's products as they relate to the Enrollee,
where applicable.
b) filing a complaint, making a report or comment to an
appropriate governmental body regarding the policies or
practices of the Contractor when they believe that the
policies or practices negatively impact upon the quality of,
or access to, patient care.
c) advocating to the Contractor on behalf of the Enrollee for
approval or coverage of a particular treatment or for the
provision of health care services.
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22.8 Transfer of Liability
No contract or agreement between the Contractor and a health care
provider shall contain any clause purporting to transfer to the
health care provider, other than a medical group, by indemnification
or otherwise, any liability relating to activities, actions or
omissions of the Contractor as opposed to those of the health care
provider.
22.9 Termination of Health Care Professional Agreements
The Contractor shall not terminate a contract with a health care
professional unless the Contractor provides to the health care
professional a written explanation of the reasons for the proposed
termination and an opportunity for a review or hearing as
hereinafter provided. For purposes of this Section a health care
professional is an individual licensed, registered or certified
pursuant to Title 8 of the Education Law.
These requirements shall not apply in cases involving imminent harm
to patient care, a determination of fraud, or a final disciplinary
action by a state licensing board or other governmental agency that
impairs the health care professional's ability to practice.
When the Contractor desires to terminate a contract with a health
care professional, the notification of the proposed termination by
the Contractor to the health care professional shall include:
a) the reasons for the proposed action;
b) notice that the health care professional has the right to
request a hearing or review, at the provider; discretion,
before a panel appointed by the Contractor;
c) a time limit of not less than thirty (30) days within which a
health care professional may request a hearing; and
d) a time limit for a hearing date which must be held within
thirty (30) days after the date of receipt of a request for a
hearing.
No contract or agreement between the Contractor and a health care
professional shall contain any provision which shall supersede or
impair a health care professional's right to notice of reasons for
termination and the opportunity for a hearing or review concerning
such termination.
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22.10 Health Care Professional Hearings
A health care professional that has been notified of his or her
proposed termination must be allowed a hearing. The procedures for
this hearing must meet the following standards:
a) The hearing panel shall be comprised of at least three persons
appointed by the Contractor. At least one person on such panel
shall be a clinical peer in the same discipline and the same
or similar specialty as the health care professional under
review. The hearing panel may consist of more than three
persons, provided however that the number of clinical peers on
such panel shall constitute one-third or more of the total
membership of the panel.
b) The hearing panel shall render a decision on the proposed
action in a timely manner. Such decision shall include
reinstatement of the health care professional by the
Contractor, provisional reinstatement subject to conditions
set forth by the Contractor or termination of the health care
professional. Such decision shall be provided in writing to
the health care professional.
c) A decision by the hearing panel to terminate a health care
professional shall be effective not less than thirty (30) days
after the receipt by the health care professional of the
hearing panel's decision. Notwithstanding the termination of a
health care professional for cause or pursuant to a hearing, a
plan shall permit an Enrollee to continue an on-going course
of treatment for a transition period of up to ninety (90)
days, and post-partum care, subject to provider agreement,
pursuant to PHL Section 4406(6)(e).
d) In no event shall termination be effective earlier than sixty
(60) days from the receipt of the notice of termination.
22.11 Non-Renewal of Provider Agreements
Either party to a contract may exercise a right of non-renewal at
the expiration of the contract period set forth therein or, for a
contract without a specific expiration date, on each January first
occurring after the contract has been in effect for at least one
year, upon sixty (60) days notice to the other party; provided,
however, that any non-renewal shall not constitute a termination for
the purposes of this Section.
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22.12 Physician Incentive Plan
If Contractor elects to operate Physician Incentive Plan, Contractor
agrees that no specific payment will be made directly or indirectly
under the plan to a physician or physician group as an inducement to
reduce or limit medically necessary services furnished to an
Enrollee. Contractor agrees to submit to SDOH annual reports
containing the information on its physician incentive plan in
accordance with 42 CFR Section 434.70. The contents of such reports
shall comply with the requirements of 42 CFR Section 417.479 and be
in a format to be provided by SDOH.
The Contractor must ensure that any agreements for contracted
services covered by this Agreement, such as agreements between the
Contractor and other entities or between the Contractor's
subcontracted entities and their contractors, at all levels
including the physician level, include language requiring that the
physician incentive plan information be provided by the
sub-contractor in an accurate and timely manner to the Contractor in
the format requested by SDOH.
In the event that the incentive arrangements place the physician or
physician group at risk for services beyond those provided directly
by the physician or physician group for an amount beyond the risk
threshold of 25% of potential payments for covered services
(substantial financial risk), the Contractor must comply with all
additional requirements listed in regulation, such as: conduct
enrollee/disenrollee satisfaction surveys; disclose the requirements
for the physician incentive plans to its beneficiaries upon request;
and ensure that all physicians and physician groups at substantial
financial risk have adequate stop-loss protection. Any of these
additional requirements that are passed on to the subcontractors
must be clearly stated in their Agreement.
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23. FRAUD AND ABUSE PREVENTION PLAN
A Fraud and Abuse Prevention Plan for the detection, investigation and
prevention of fraudulent activities must be filed by the Contractor with
the Commissioner of Health to the extent required by SDOH regulations. A
copy of this plan must be submitted to the LDSS, upon request of the LDSS.
24. AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN
Contractor must comply with Title II of the Americans with Disabilities
Act (ADA) and Section 504 of the Rehabilitation Act of 1973 for program
accessibility, and must develop an ADA Compliance Plan consistent with the
SDOH Guidelines for Medicaid MCO Compliance with the ADA which are set
forth in Appendix J, which is hereby made a part of this Agreement as if
set forth fully herein. Said plan must be approved by the SDOH and/or the
LDSS, and filed with the Contractor, SDOH and the LDSS.
25. FAIR HEARINGS
25.1 Enrollee Access To Fair Hearing Process
Enrollees may access the fair hearing process in accordance with
applicable federal and state laws and regulations. Contractors must
abide by and participate in New York State's Fair Hearing Process
and comply with determinations made by a fair hearing officer.
25.2 Enrollee Rights to a Fair Hearing
Enrollees may request a fair hearing regarding adverse LDSS
determinations concerning enrollment, disenrollment and eligibility,
and regarding the denial, termination, suspension or reduction of a
clinical treatment or other Benefit Package services by the
Contractor. For issues related to disputed services, Enrollees must
have received an adverse determination from the Contractor or its
approved utilization review agent either overriding a recommendation
to provide services by a Participating Provider or confirming the
decision of a Participating Provider to deny those services. An
Enrollee may also seek a fair hearing for a failure by the
Contractor to act with reasonable promptness with respect to such
services. Reasonable promptness shall mean compliance with the time
frames established for review of grievances and utilization review
in Sections 44 and 49 of the Public Health Law.
25.3 Contractor Notice to Enrollees
a) Contractor must issue a written Notice of Adverse
Determination and Fair Hearing Rights to any Enrollee
i) When Contractor or its utilization review agent has
denied a request to approve a Benefit Package service
ordered by an MCO provider; or
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ii) When an Enrollee is denied a requested service or
benefit by an MCO provider and has exhausted the
Contractor's approved internal complaint and appeal
procedures or utilization review processes; or
iii) At least 10 days before the effective date of
Contractor's termination, suspension or reduction of a
benefit or treatment already in progress for that
Enrollee.
b) Contractor agrees to serve notice on affected Enrollees by
mail and must maintain documentation of such.
c) Contractor's Notice of Adverse Determination and Notice of a
Right to Request a Fair Hearing shall include the following:
i) the description of the action Contractor intends to
take;
ii) the reasons for the determination including the clinical
rationale, if any;
iii) the process for filing a grievance/complaint with the
organization;
iv) the timeframes within which a grievance/complaint must
be made;
v) the right of an Enrollee to designate a representative
to file a grievance/complaint on behalf of the Enrollee;
vi) the notice of the right of the Enrollee to contact the
New York State Department of Health (800 206-8125) with
their complaint; and
vii) the notice entitled "Managed Care Action Taken"
containing the Enrollee's fair hearing and aid
continuing rights.
d) The Contractor's Notice of Adverse Determination and Notice of
a Right to Request a Fair Hearing for Article 49 Utilization
Review Determinations shall include the following:
(i) a description of the action Contractor intends to take;
(ii) the reasons for the determination including the
clinical rationale, if any;
(iii) instructions on how to initiate standard and expedited
appeals pursuant to section 4904 of the Public Health
Law (PHL);
(iv) instructions on how to initiate an external appeal
pursuant to section 4914 of the PHL;
(v) notice of availability of the clinical review criteria
relied upon to make such determination;
(vi) the additional, if any, necessary information to be
provided to, or obtained by, the UR agent in order to
render a decision on the appeal;
(vii) notice of the right of the Enrollee to contact the New
York State Department of Health (800 206-8125) with
their complaint; and
(viii) the notice entitled "Managed Care Action Taken"
containing the Enrollee's fair hearing and aid
continuing rights.
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25.4 Aid Continuing
Contractor shall be required to continue the provision of the
Benefit Package services that are the subject of the fair hearing to
an Enrollee (hereafter referred to as "aid continuing") if so
ordered by the OAH under the following circumstances:
i) Contractor has or is seeking to reduce, suspend or
terminate a treatment or Benefit Package service
currently being provided;
ii) Enrollee has filed a timely request for a fair hearing
with OAH; and
iii) There is a valid order for the treatment or service from
a participating provider. Contractor shall provide aid
continuing until the matter has been resolved to the
Enrollee's satisfaction or until the administrative
process is completed and there is a determination from
OAH that Enrollee is not entitled to receive the
service, the Enrollee withdraws the request for aid
continuing and/or the fair hearing in writing, or the
treatment or service originally ordered by the provider
has been completed, whichever occurs first.
iv) If the services and/or benefits in dispute have been
terminated, suspended or reduced and the Enrollee timely
requests a fair hearing, Contractor shall, at the
direction of either SDOH or LDSS, restore the disputed
services and/or benefits consistent with the provisions
of Section 25.4(iii) of this Agreement.
25.5 Responsibilities of SDOH
SDOH will make every reasonable effort to ensure that the Contractor
receives timely notice in writing by fax, or e-mail, of all
requests, schedules and directives regarding fair hearings.
25.6 Contractor's Obligations
a) Contractor shall appear at all scheduled fair hearings
concerning its clinical determinations and/or
Contractor-initiated disenrollments to present evidence as
justification for its determination or submit written evidence
as justification for its determination regarding the disputed
benefits and/or services. If Contractor will not be making a
personal appearance at the fair hearing, the written material
must be submitted to OAH and Enrollee or Enrollee's
representative at least three (3) business days prior to the
scheduled hearing. If the hearing is scheduled fewer than
three (3) business days after the request, Contractor must
deliver the evidence to the hearing site no later than one (1)
business day prior to the hearing, otherwise Contractor must
appear in person. Notwithstanding the above provisions,
Contractor may be required to make a personal appearance at
the discretion of the hearing officer and/or SDOH.
b) Despite an Enrollee's request for a State fair hearing in any
given dispute, Contractor is required to maintain and operate
in good faith its own internal
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complaint and appeal process as required under state and
federal laws and by Section 14 and Appendix F of this
Agreement. Enrollees may seek redress of adverse
determinations simultaneously through Contractor's internal
process and the State fair hearing process. If Contractor has
reversed its initial determination and provided the service to
the Enrollee, Contractor may request a waiver from appearing
at the hearing and, in submitted papers, explain that it has
withdrawn its initial determination and is providing the
service or treatment formerly in dispute.
c) Contractor shall comply with all determinations rendered by
OAH at fair hearings. Contractor shall cooperate with SDOH
efforts to ensure that Contractor is in compliance with fair
hearing determinations. Failure by Contractor to maintain such
compliance shall constitute breach of this Agreement. Nothing
in this Section shall limit the remedies available to SDOH,
LDSS or the federal government relating to any non-compliance
by Contractor with a fair hearing determination or
Contractor's refusal to provide disputed services.
d) If SDOH investigates a complaint that has as its basis the
same dispute that is the subject of a pending fail hearing
and, as a result of its investigation, concludes that the
disputed services and/or benefits should be provided to the
Enrollee, Contractor shall comply with SDOH's directive to
provide those services and/or benefits and provide notice to
OAH and Enrollee as required by Section 25.6(b) of this
Agreement.
e) If SDOH, through its complaint investigation process, or OAH,
by a determination after a fair hearing, directs Contractor to
provide a service that was initially denied by Contractor,
Contractor may either directly provide the service, arrange
for the provision of that service or pay for the provision of
that service by a Non-Participating Provider.
f) Contractor agrees to abide by changes made to this Section of
the Agreement with respect to the fair hearing, grievance and
complaint processes by SDOH in order to comply with any
amendments to applicable state or federal statutes or
regulations. Such changes shall become effective without need
for any further action by the parties to this Agreement.
g) Contractor agrees to identify a contact person within its
organization who will serve as a liaison to SDOH for the
purpose of receiving fair hearing requests, scheduled fair
hearing dates and adjourned fair hearing dates and compliance
with State directives. Such individual: shall be accessible to
the State by e-mail; shall monitor e-mail for correspondence
from the State at least once every business day; and shall
agree, on behalf of Contractor, to accept notices to
Contractor transmitted via e-mail as legally valid.
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h) The information describing fair hearing rights, aid
continuing, complaint procedures and utilization review
appeals shall be included in all Medicaid managed care member
handbooks and shall comply with SDOH's member handbook
guidelines.
i) Contractor shall bear the burden of proof at hearings
regarding the reduction, suspension or termination of ongoing
services. In the event that Contractor's initial adverse
determination is upheld as a result of a fair hearing, any aid
continuing provided pursuant to that hearing request, may be
recouped by Contractor.
26. EXTERNAL APPEAL
26.1 Basis for External Appeal
Managed care Enrollees are eligible to request an external appeal
when one or more covered health care services have been denied by
the Contractor on the basis that the service(s) is not medically
necessary or is experimental or investigational.
26.2 Eligibility for External Appeal
An Enrollee is eligible for an external appeal when the Enrollee has
exhausted the Contractor's internal utilization review procedure or
both the Enrollee and the Contractor have agreed to waive internal
appeal procedures in accordance with New York State P.H.L. Section
4914(2)2(a). A provider is also eligible for an external appeal of
retrospective denials.
26.3 External Appeal Determination
The external appeal determination is binding on the Contractor,
however, a fair hearing determination supercedes an external appeal
determination for Medicaid Enrollees.
26.4 Compliance with External Appeal Laws and Regulations
MCOs must comply with the provisions of New York State P.H.L.
Sections 4910-4914 and Title 10 of NYCRR Subpart 98-2 regarding the
external appeal program.
27. INTERMEDIATE SANCTIONS
Contractor is subject to the imposition of sanctions as authorized by
State law including the SDOH's right to impose sanctions for unacceptable
practices as set forth in Title 18 of the Official Compilation of Codes,
Rules and Regulations of the State of New York (NYCRR) Part 515 and civil
and monetary penalties pursuant to 18 NYCRR Part 516 and such other
sanctions and penalties as are authorized by local laws and ordinances and
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resultant administrative codes, rules and regulations related to the
Medical Assistance Program or to the delivery of the contracted for
services.
28. ENVIRONMENTAL COMPLIANCE
The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Ac 42 U.S.C.
Section 1857(h), Section 508 of the Clean Water Act (33 U.S.C. Section
1368), Executive Order 11738, and the Environmental Protection Agency
("EFA") regulations (40 CFR, Part 15) that prohibit the use of the
facilities included on the EPA List of Violating Facilities. The
Contractor shall report violations to SDOH and to the Assistant
Administrator for Enforcement of the EPA.
29. ENERGY CONSERVATION
The Contractor shall comply with any applicable mandatory standards and
policies relating to energy efficiency that are contained in the State
Energy Conservation regulation issued in compliance with the Energy Policy
and Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the
Act.
30. INDEPENDENT CAPACITY OF CONTRACTOR
The parties agree that the Contractor is an independent Contractor, and
that the Contractor, its agents, officers, and employees act in an
independent capacity and not as officers or employees of LDSS, DHHS or the
SDOH.
31. NO THIRD PARTY BENEFICIARIES
Only the parties to this Agreement and their successors in interest and
assigns have any rights or remedies under or by reason of this Agreement.
32. INDEMNIFICATION
32.1 Indemnification by Contractor
The Contractor shall indemnify, defend, and hold harmless the LDSS,
its officers, agents, and employees and the Enrollees and their
eligible dependents from:
a) any and all claims and losses accruing or resulting to any and
all Contractors, subcontractors, materialmen, laborers, and
any other person, firm, or corporation furnishing or supplying
work, services, materials, or supplies in connection with the
performance of this Agreement;
b) any and all claims and losses accruing or resulting to any
person, firm, or corporation that may be injured or damaged by
the Contractor, its officers,
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agents, employees, or subcontractors, including Participating
Providers, in connection with the performance of this
Agreement;
c) any liability, including costs and expenses, for violation of
proprietary rights, copyrights, or rights of privacy, arising
out of the publication, translation, reproduction, delivery,
performance, use, or disposition of any data furnished under
this Agreement, or based on any libelous or otherwise unlawful
matter contained in such data.
i) The LDSS will provide the Contractor with prompt written
notice of any claim made against the LDSS, and the
Contractor, at its sole option, shall defend or settle
said claim. The LDSS shall cooperate with the Contractor
to the extent necessary for the Contractor to discharge
its obligation under Section 32.1.
ii) The Contractor shall have no obligation under this
section with respect to any claim or cause of action for
damages to persons or property solely caused by the
negligence of LDSS, its employees, or agents.
32.2 Indemnification by LDSS
The LDSS shall indemnify and hold harmless the Contractor and its
officers, agents, and employees from any and all claims for damages
resulting from actions by the LDSS or their Contractors in
connection with their performance under this Agreement, except for
such damages, costs, and expenses resulting from the negligence or
culpable act of the Contractor, its officers, agents, employees, or
subcontractors, including Participating Providers.
33. PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
33.1 Prohibition of Use of Federal Funds for Lobbying
The Contractor agrees, pursuant to 31 U.S.C. Section 1352 and 45 CFR
Part 93, that no Federally appropriated funds have been paid or will
be paid to any person by or on behalf of the Contractor for the
purpose of influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection
with the award of any Federal contract, the making of any federal
grant, the making of any Federal loan, the entering into of any
cooperative agreement, or the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement. The Contractor agrees to complete and submit
the "Certification Regarding Lobbying", Appendix B attached hereto
and incorporated herein, if this Agreement exceeds $100,000.
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33.2 Disclosure Form to Report Lobbying
If any funds other than Federally appropriated funds have been paid
or will be paid to any person for the purpose of influencing or
attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with the award of any
Federal contract, the making of any Federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement, and the
Agreement exceeds $100,000, the Contractor shall complete and submit
Standard Form-LLL "Disclosure Form to Report Lobbying," in
accordance with its instructions.
33.3 Requirements of Subcontractors
The Contractor shall include the provisions of this section in its
subcontracts, including its Provider Agreements. For all
subcontracts, including Provider Agreements, that exceed $100,000,
the Contractor shall require the subcontractor, including any
Participating Provider to certify and disclose accordingly to the
Contractor.
34. NON-DISCRIMINATION
34.1 Equal Access to Benefit Package
Except as otherwise provided in applicable sections of this
Agreement the Contractor shall provide the Benefit Package to all
Enrollees in the same manner, in accordance with the same standards,
and with the same priority as Enrollees of the Contractor under any
other contracts.
34.2 Non-Discrimination
The Contractor shall not discriminate against Eligible Persons or
Enrollees on the basis of age, sex, race, creed physical or mental
handicap/developmental disability, national origin, sexual
orientation, type of illness or condition, need for health services,
or Capitation Rate that the Contractor will receive for such
Eligible Persons or Enrollees.
34.3 Equal Employment Opportunity
Contractor must comply with Executive Order 11246, entitled "Equal
Employment Opportunity", as amended by Executive Order 11375, and as
supplemented in Department of Labor regulations.
SECTION 23 - SECTION 37
October 1, 2004
-8-
34.4 Native Americans Access to Services From Tribal or Urban Indian
Health Facility
The Contractor shall not prohibit, restrict or discourage enrolled
Native Americans from receiving care from or accessing Medicaid
reimbursed health services from or through a tribal health or urban
Indian health facility or center.
35. COMPLIANCE WITH APPLICABLE LAWS
35.1 Contractor and LDSS Compliance With Applicable Laws
Notwithstanding any inconsistent provisions in this Agreement, the
Contractor and LDSS shall comply with all applicable requirements of
the State Public Health Law; the State Social Services Law; Title
XIX of the Social Security Act; Title VI of the Civil Rights Act of
1964 and 45 C.F.R. Part 80, as amended; Section 504 of the
Rehabilitation Act of 1973 and 45 C.F.R. Part 84, as amended; Age
Discrimination Act of 1975 and 45 C.F.R. Part 91, as amended; the
Americans with Disabilities Act; Title XIII of the Federal Public
Health Services Act, 42 U.S.C. Section 300e et seq., regulations
promulgated there under; the Health Insurance Portability and
Accountability Act of 1996 (P.L. 104-191) and related regulations;
and all other applicable legal and regulatory requirements in effect
at the time that this Agreement is signed and as adopted or amended
during the term of this Agreement.
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void
Contract Provisions
Should any provision of this Agreement be declared or found to be
illegal or unenforceable, ineffective or void, then each party shall
be relieved of any obligation arising from such provision; the
balance of this Agreement, if capable of performance, shall remain
in full force and effect.
35.3 Certificate of Authority Requirements
The Contractor must satisfy conditions for issuance of a certificate
of authority, including proof of financial solvency, as specified in
10 NYCRR, Section 98.6.
35.4 Notification of Changes in Certificate of Incorporation
The Contractor shall notify LDSS of any amendment to its
Certificate of Incorporation in the same manner as and
simultaneously with the notice given to SDOH pursuant to 10 NYCRR
Section 98.4(a).
35.5 Contractor's Financial Solvency Requirements
The Contractor, for the duration of this Agreement, shall remain in
compliance with all applicable state requirements for financial
solvency for MCOs participating in the Medicaid Program. The
Contractor shall continue to be
SECTION 23 - SECTION 37
October 1, 2004
-9-
financially responsible as defined in PHL Section 4403(1)(c) and
shall comply with the contingent reserve fund and escrow deposit
requirements of 10 NYCRR Sections 98.11(d) and 98.11(e),
respectively, and must meet minimum net worth requirements
established by SDOH and the State Insurance Department. The
Contractor shall make provision, satisfactory to SDOH, for
protections for SDOH, LDSS and the Enrollees in the event of HMO or
subcontractor insolvency, including but not limited to, hold
harmless and continuation of treatment provisions in all provider
agreements which protect SDOH, LDSS and Enrollees from costs of
treatment and assures continued access to care for Enrollees.
35.6 Compliance With Care for Maternity Patients
Contractor must comply with Section 803-n of the Public Health Law
and Section 3216 (i) (10) (a) of the State Insurance Law related to
hospital care for maternity patients.
35.7 Informed Consent Procedures for Hysterectomy and Sterilization
The Contractor is required and shall require Participating Providers
to comply with the informed consent procedures for Hysterectomy and
Sterilization specified in 42 CFR, Part 441, sub-part F, and 18
NYCRR Section 505.13.
35.8 Non-Liability of Enrollees for Contractor's Debts
Contractor agrees that in no event shall the Enrollee become liable
for the Contractor's debts as set forth in SSA Section 1932(b)(6).
35.9 LDSS Compliance With Conflict of Interest Laws
LDSS and its employees shall comply with General Municipal Law
Article 18 and all other appropriate provisons of New York State
law, local laws and ordinances and all resultant codes, rules and
regulations pertaining to conflicts of interest.
35.10 Compliance With PHL Regarding External Appeals
Contractor must comply with Article 49 Title II of the Public Health
Law regarding external appeal of adverse determinations.
36. NEW YORK STATE STANDARD CONTRACT CLAUSES
The parties agree to be bound by the standard clauses for all New York
State contracts and standard clauses, if any, for local government
contracts contained in Appendix A, attached to and incorporated as if set
forth fully herein, and any amendment thereto.
SECTION 23 - SECTION 37
October 1, 2004
-10-
37. INSURANCE REQUIREMENTS
MODEL CONTRACT Note: The LDSS may propose insurance requirements based on
the contract practices of its County. Such requirements must be reasonable
and consistent with the attainment of managed care program objectives.
[X] The LDSS has insurance requirements (attached) as Section 37 of this
Agreement.
[ ] The LDSS does not have insurance requirements.
SECHON 23 - SECTION 37
October 1, 2004
-11-
SECTION 37 - LDSS SPECIFIC INSURANCE REQUIREMENTS
At all times during the term of this Agreement, the Contractor shall maintain,
at its own cost and expense, the following insurance and provide proof thereof
to the County, in the form of a Certificate of Insurance, prior to commencing
work under this Agreement:
(a) Statutory Worker's Compensation coverage in compliance with the Compensation
Law of the State of New York. In the event the statute does not require coverage
of Contractor, Contractor must complete NYS Workers' Compensation Board form
C-105.21 and provide the County with a properly executed copy thereof.
(b) General Liability Insurance coverage in the comprehensive or commercial
general liability form including blanket contractual coverage for the operation
of the program under this Agreement in the amount of $1,000,000. This insurance
shall include coverage for bodily injury and property damage and shall be on an
occurrence form with a waiver of subrogation. The County must be listed as
additional-named insured.
(c) Professional liability. The Contractor shall provide proof of such
insurance with limits of $1,000,000 per occurrence; $3,000,000 in the aggregate.
Prior to cancellation or material change in any policy, a thirty (30) day's
notice shall be given to the County Attorney at the address listed below:
Dutchess County Attorney
County Office Building
22 Market Street
Poughkeepsie, NY 12601
On receipt of such notice, the County shall have the option to cancel this
Agreement without further expense or liability to the County, or to require the
Contractor to replace the cancelled insurance policy, or rectify any material
change in the policy, so that the insurance coverage required by this paragraph
is maintained continuously throughout the term of this Agreement in form and
substance acceptable to the County. Failure of the Contractor to take out or to
maintain, or the taking out or the maintenance of any required insurance, shall
not relieve the Contractor from any liability under this Agreement nor shall the
insurance requirements be construed to conflict with or limit any obligations of
the Contractor concerning indemnification.
All losses of County property shall be adjusted with and made payable directly
to the County.
All Certificates of Insurance shall be approved by the County Director of Risk
Management prior to commencement of any work under this Agreement.
All policies of insurance referred to above shall be underwritten by
companies authorized to do business in the State of New York and acceptable to
the County. In addition, every policy required above shall be primary insurance
and any insurance carried by the County, its officers, or its employees shall be
excess and not contributory insurance to that provided by the Contractor. The
additional insured endorsement for the Comprehensive General Liability insurance
required above shall not contain any exclusion for bodily injury or property
damage arising from completed operations. The Contractor shall be solely
responsible for any deductible losses under each of the policies required above.
Proof of additional insured coverage shall be evidenced through an additional
insured endorsement provided by the insurance carrier.
In the event that claims in excess of these amounts are filed in
connection with this Agreement, the excess amount or any portion thereof may be
withheld from payment due or to become due the Agency until such time as the
Agency furnishes such additional security as is determined necessary by the
County.
SECTION 23 - SECTION 37
October 1, 2004
-12-
This Agreement is effective October 1, 2004 and 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 hereby execute this Agreement.
APPROVED AS TO CONTENT: ACCEPTED: COUNTY OF DUTCHESS
/s/ [ILLEGIBLE] /s/ [ILLEGIBLE]
- ---------------------------------- ------------------------------
Commissioner By: County Executive
Dutchess County Social Services
APPROVED AS TO FORM: ACCEPTED: WELLCARE OF NEW YORK, INC.
/s/ [ILLEGIBLE] /s/ [ILLEGIBLE]
- ---------------------------------- ------------------------------
County Attorney
SIGNATURE PAGE
October 1, 2004
APPENDIX A
NEW YORK STANDARD CLAUSES
AND LOCAL STANDARD CLAUSES
APPENDIX A
October 1, 2004
STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
STANDARD CLAUSES FOR NYS CONTRACTS
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree to
be bound by the following clauses which are hereby made a part of the contract
(the word "Contractor" herein refers to any party other than the State, whether
a contractor, licenser, licensee, lessor lessee or any other party):
1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the
State shall have no liability under this contract to the Contractor or to anyone
else beyond funds appropriated and available for this contract.
2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of the State Finance
Law, this contract may not be assigned by the Contractor or its right, title or
interest therein assigned, transferred conveyed, sublet or otherwise disposed of
without the previous consent in writing, of the State and any attempts to assign
the contract without the State's written consent are null and void. The
Contractor may however, assign its right to receive payment without the State's
prior written consent unless this contract concerns Certificates of
Participation pursuant to Article 5-A of the State Finance Law.
3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State Finance
Law (or, if this contract is with the State University or City University of New
York, Section 355 or Section 6218 of the Education Law), if this contract
exceeds $15,000 (or the minimum thresholds agreed to by the Office of the State
Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if, by this contract, the State agrees to give something
other than money when the value or reasonably estimated value of such
consideration exceeds $10,000, it shall not be valid, effective or binding upon
the State until it has been approved by the State Comptroller and filed in his
office. Comptroller's approval of contracts let by the Office of General
Services is required when such contracts exceed $30,000 (State Finance Law
Section 163.6.a).
4. WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State
Finance Law, this contract shall be void and of no force and effect unless the
Contractor shall provide and maintain coverage during the life of this contract
for the benefit of such employees as are required to be covered by the
provisions of the Workers' Compensation Law.
5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the
Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the
Contractor will not discriminate against any employee or applicant for
employment because of race creed, color, sex, national origin, sexual
orientation, age, disability genetic predisposition or carrier status, or
marital status. Furthermore in accordance with Section 220-e of the Labor Law,
if this is a contract for the construction, alteration or repair of any public
building or public work or for the manufacture, sale or distribution of
materials, equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it not
its subcontractors shall, by reason of race, creed, color, disability, sex, or
national origin: (a) discriminate in hiring against any New York State citizen
who is qualified and available to perform the work; or (b) discriminate against
or intimidate any employee hired for the performance of work under this
contract. If this is a building service contract as defined in Section 230 of
the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees
that neither it nor its subcontractors shall by reason of race, creed, color,
national origin, age, sex or disability: (a) discriminate in hiring against any
New York State citizen who is qualified and available to perform the work; or
(b) discriminate against or intimidate any employee hired for the performance of
work under this contract. Contractor is subject to fines of $50.00 per person
per day for any violation of Section 220-e or Section 239 as well as possible
termination of this contract and forfeiture of all moneys due hereunder for a
second or subsequent violation.
6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor's employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State Labor
Department. Furthermore, Contractor and its subcontractors must pay at least the
prevailing wage rate and pay or provide the prevailing supplements, including
the premium rates for overtime pay, as determined by the State Labor Department
in accordance with the Labor Law.
7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the
State Finance Law, if this contract was awarded based upon the submission of
bids, Contractor warrants, under penalty of perjury, that its bid was arrived at
independently and without collusion aimed at restricting competition. Contractor
further warrants that, at the time Contractor submitted its bid, an authorized
and responsible person executed and delivered to the State a non-collusive
bidding certification on Contractor's behalf.
8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with Section 220-f of the
Labor Law and Section 139-h of the State Finance Law, if this contract exceeds
$5,000, the Contractor agrees, as a material condition of the contract, that
neither the Contractor nor any substantially owned or affiliated person, firm,
partnership or corporation has participated, is participating, or shall
participate in an international boycott in violation of the federal Export
Administration Act of 1979 (50 USC App. Sections 2401 et seq.) or regulations
thereunder. If such Contractor, or any of the aforesaid affiliates of
Contractor, is convicted or is otherwise found to have violated said laws or
regulations upon the final determination of the United States Commerce
Department or any other appropriate agency of the United States subsequent to
the contract's execution, such contract, amendment or modification thereto shall
be rendered forfeit and void. The Contractor shall so notify the State
Comptroller within five (5) business days of such conviction, determination or
disposition of appeal (2NYCRR 105.4).
9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and
statutory rights of set-off. These rights shall include, but not be limited to,
the State's option to withhold for the purposes of set-off any moneys due to
the Contractor under this contract up to any amounts due and owing to the State
with regard to this contract, any other contract with any State department or
agency, including any contract for a term commencing prior to the term of this
contract, plus any amounts due and owing to the State for any other reason
including, without limitation, tax delinquencies, fee delinquencies or monetary
penalties relative thereto. The State shall exercise its set-off rights in
accordance with normal State practices including, in cases of set-off pursuant
to an audit, the finalization of such audit by the State agency, its
representatives, or the State Comptroller.
10. RECORDS. The Contractor shall establish and maintain complete and accurate
books, records, documents, accounts and other evidence directly pertinent to
performance under this contract (hereinafter, collectively, "the Records"). The
Records must be kept for the balance of the calendar year in which they were
made and for six (6) additional years thereafter. The State Comptroller, the
Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this contract, shall
have access to the Records during normal business hours at an office of the
Contractor
Page 1 May, 2003
STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
within the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and (ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.
11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION, (a) FEDERAL EMPLOYER
IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoices or New
York State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State agency
must include the payee's identification number, i.e., the seller's or lessor's
identification number. The number is either the payee's Federal employer
identification number or Federal social security number, or both such numbers
when the payee has both such numbers. Failure to include this number or numbers
may delay payment. Where the payee does not have such number or numbers, the
payee, on its invoice or New York State standard voucher, must give the reason
or reasons why the payee does not have such number or numbers.
(b) PRIVACY NOTIFICATION. (1) The authority to request the above personal
information from a seller of goods or services or a lessor of real or personal
property, and the authority to maintain such information, is found in Section 5
of the State Tax Law. Disclosure of this information by the seller or lessor to
the State is mandatory. The principal purpose for which the information is
collected is to enable the State to identify individuals, businesses and others
who have been delinquent in filing tax returns or may have understated their tax
liabilities and to generally identify persons affected by the taxes administered
by the Commissioner of Taxation and Finance. The information will be used for
tax administration purposes and for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.
12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with
Section 312 of the Executive Law, if this contract is: (i) a written agreement
or purchase order instrument, providing for a total expenditure in excess of
$25,000.00, whereby a contracting agency is committed to expend or does expend
funds in return for labor, services, supplies, equipment, materials or any
combination of the foregoing, to be performed for, or rendered or furnished to
the contracting agency; or (ii) a written agreement in excess of $100,000.00
whereby a contracting agency is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or renovation
of real property and improvements thereon; or (iii) a written agreement in
excess of $100,000.00 whereby the owner of a State assisted housing project is
committed to expend or does expend funds for the acquisition, construction,
demolition, replacement, major repair or renovation of real property and
improvements thereon for such project, then:
(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age, disability
or marital status, and will undertake or continue existing programs of
affirmative action to ensure that minority group members and women are afforded
equal employment opportunities without discrimination. Affirmative action shall
mean recruitment, employment, job assignment, promotion, upgradings, demotion,
transfer, layoff, or termination and rates of pay or other forms of
compensation;
b) at the request of the contracting agency, the Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding, to
furnish a written statement that such employment agency, labor union or
representative will not discriminate on the basis of race, creed, color,
national origin, sex, age, disability or marital status and that such union or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein; and
c) the Contractor shall state, in all solicitations or advertisements for
employees, that, in the performance of the State contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.
Contractor will include the provisions of "a", "b", and "c" above, in every
subcontract over $25,000.00 for the construction, demolition, replacement, major
repair, renovation, planning or design of real property and improvements thereon
(the "Work") except where the Work is for the beneficial use of the Contractor.
Section 312 does not apply to: (i) work, goods or services unrelated to this
contract; or (ii) employment outside New York State; or (iii) banking services,
insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any federal
law concerning equal employment opportunity which effectuates the purpose of
this section. The contracting agency shall determine whether the imposition of
the requirements of the provisions thereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful rules
and regulations of the Governor's Office of Minority and Women's Business
Development pertaining hereto.
13. CONFLICTING TERMS. In the event of a conflict between the terms of the
contract (including any and all attachments thereto and amendments thereof) and
the terms of this Appendix A, the terms of this Appendix A shall control.
14. GOVERNING LAW. This contract shall be governed by the laws of the State of
New York except where the Federal supremacy clause requires otherwise.
15. LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article 11-A of the State
Finance Law to the extent required by law.
16. NO ARBITRATION. Disputes involving this contract, including the breach or
alleged breach thereof, may not be submitted to binding arbitration (except
where statutorily authorized), but must, instead, be heard in a court of
competent jurisdiction of the State of New York.
17. SERVICE OF PROCESS. In addition to the methods of service allowed by the
State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents to service
of process upon it by registered or certified mail, return receipt requested.
Service hereunder shall be complete upon Contractor's actual receipt of process
or upon the State's receipt of the return thereof by the United States Postal
Service as refused or undeliverable. Contractor must promptly notify the State,
in writing, of each and every change of address to which service of process can
be made. Service by the State to the last known address shall be sufficient.
Contractor will have thirty (30) calendar days after service hereunder is
complete in which to respond.
Page 2 May, 2003
STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and
warrants that all wood products to be used under this contract award will be in
accordance with, but not limited to, the specifications and provisions of State
Finance Law Section 165. (Use of Tropical Hardwoods) which prohibits purchase
and use of tropical hardwoods, unless specifically exempted, by the State or any
governmental agency or political subdivision or public benefit corporation.
Qualification for an exemption under this law will be the responsibility of the
contractor to establish to meet with the approval of the State.
In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be performed by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in Section 165 State
Finance Law. Any such use must meet with the approval of the State; otherwise,
the bid may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to meet
with the approval of the State.
19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance with the MacBride Fair
Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby
stipulates that the Contractor either (a) has no business operations in Northern
Ireland, or (b) shall take lawful steps in good faith to conduct any business
operations in Northern Ireland in accordance with the MacBride Fair Employment
Principles (as described in Section 165 of the New York State Finance Law), and
shall permit independent monitoring of compliance with such principles.
20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to
maximize opportunities for the participation of New York State business
enterprises, including minority and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.
Information on the availability of New York State subcontractors and suppliers
is available from:
NYS Department of Economic Development
Division for Small Business
30 South Pearl St - 7th Floor
Albany, New York 12245
Telephone: 518-292-5220
A directory of certified minority and women-owned business enterprises is
available from:
NYS Department of Economic Development
Division of Minority and Women's Business Development
30 South Pearl St - 2nd Floor
Albany, New York 12245
http://www.empire.state.ny.us
The Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or contract, as applicable, Contractors certify that whenever the total bid
amount is greater than $1 million:
(a) The Contractor has made reasonable efforts to encourage the participation of
New York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project, and
has retained the documentation of these efforts to be provided upon request to
the State;
(b) The Contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L. 92-261), as amended;
(c) The Contractor agrees to make reasonable efforts to provide notification to
New York State residents of employment opportunities on this project through
listing any such positions with the Job Service Division of the New York State
Department of Labor, or providing such notification in such manner as is
consistent with existing collective bargaining contracts or agreements. The
Contractor agrees to document these efforts and to provide said documentation to
the State upon request; and
(d) The Contractor acknowledges notice that the State may seek to obtain offset
credits from foreign countries as a result of this contract and agrees to
cooperate with the State in these efforts.
21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province,
state or political subdivision that penalizes New York State vendors, and if the
goods or services they offer will be substantially produced or performed outside
New York State, the Omnibus Procurement Act 1994 and 2000 amendments (Chapter
684 and Chapter 383, respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15, 2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact
NYS Department of Economic Development for a current list of jurisdictions
subject to this provision.
22. PURCHASES OF APPAREL. In accordance with State Finance Law 162 (4-a), the
State shall not purchase any apparel from any vendor unable or unwilling to
certify that: (i) such apparel was manufactured in compliance with all
applicable labor and occupational safety laws, including, but not limited to,
child labor laws, wage and hours laws and workplace safety laws, and (ii) vendor
will supply, with its bid (or, if not a bid situation, prior to or at the time
of signing a contract with the State), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the
bidder.
Page 3 May, 2003
RIDER
1. The Dutchess County fiscal year begins on January 1st and ends on
December 31st of any given year. Notwithstanding anything to the contrary
contained herein, it is understood and agreed that this Agreement shall be
deemed executory only to the extent of the monies available to the Department
for the performance of the terms hereof and that, in the event that the Dutchess
County Legislature fails to appropriate the necessary funds to affect payment in
any calendar year beyond 2004, this Agreement shall automatically cease and
terminate on the last day of the year in which funds have been appropriated for
said Agreement and no liability on account thereof shall be incurred by the
Department beyond the funds available for the performance of the terms of this
Agreement. It is further understood and agreed that neither this Agreement nor
any representation by any public employee or officer creates any legal or moral
obligation to request, appropriate or make available monies for the purpose of
this Agreement.
2. This rider annexed to the Agreement forms a part thereof. In the
event that any term, provision, clause or covenant of the rider contradicts or
creates an ambiguity with any term, provision, clause or covenant of the
Agreement, the terms, provisions, clauses and covenants of this rider shall
govern. All other terms, provisions, clauses and covenants contained in this
Agreement, not expressly altered by the provisions of this rider, shall remain
in full force and effect.
3. Any disagreement arising out of this Agreement, or any rider
thereto, shall be construed pursuant to the laws of the State of New York. The
parties hereby agree to have any dispute arising, directly or indirectly, out of
this contract, determined by the Supreme Court of the State of New York venued
in Dutchess County, New York.
APPENDIX A
October 1, 2004
APPENDIX B
CERTIFICATION REGARDING LOBBYING
APPEND1X B
October 1, 2004
B-1
APPENDIX B
CERTIFICATION REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge, that:
1. No Federal appropriated funds have been paid or will be paid to any
person by or on behalf of the Contractor for the purpose of
influencing or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of a Member of
Congress in connection with the award of any Federal loan, the
entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
2. If any funds other than Federal appropriated funds have been paid or
will be paid to any person for the purpose of influencing or
attempting to influence an officer or employee of any agency, a
Member of Congress in connection with the award of any Federal
contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement, and the
Agreement exceeds $100,000, the Contractor shall complete and submit
Standard Form - LLL "Disclosure Form to Report Lobbying", in
accordance with its instructions.
3. The Contractor shall include the provisions of this section in all
provider Agreements under this Agreement and require all
Participating providers whose Provider Agreements exceed $100,000 to
certify and disclose accordingly to the Contractor.
This certification is a material representation of fact upon which
reliance was place when this transaction was made or entered into. Submission of
this certification is a prerequisite for making or entering into this
transaction pursuant to US.C. Section 1352. The failure to file the required
certification shall subject the violator to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
DATE: 9/24/04
-------
SIGNATURE: [ILLEGIBLE]
-------------
TITLE: President and CEO
-----------------
ORGANIZATION: well care of New York, Inc.
--------------------------
APPENDIX B
October 1, 2004
B-2
Appendix C
New York State Department of Health
Guidelines for the Provision of
Family Planning and Reproductive Health Services
APPENDIX C
October 1, 2004
C-1
C. 1
GUIDELINES FOR THE PROVISION OF
FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
Enrollees may obtain family planning and or reproductive health services and HIV
blood testing and pre-and post-test counseling when performed as part of a
family planning encounter from either the Contractor or from any appropriate
MMIS-enrolled health care provider of the Enrollee's choice. Pharmacy
prescriptions, Medical Supplies, and over the counter drugs are to be billed
fee-for-service by all providers.
Family planning services 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 unwanted pregnancies.
Family planning and reproductive health services include: the following
medically-necessary services, related drugs and supplies which are furnished or
administered under the supervision of a physician or certified nurse
practitioner during the course of a family planning visit for the purpose of:
- - contraception, including insertion/removal of an intrauterine device
(IUD), insertion/removal of Norplant, and injection procedures involving
Pharmaceuticals such as Depo-Provera;
- - sterilization;
- - screening, related diagnosis, and referral to participating provider for
pregnancy;
- - medically-necessary induced abortions and for New York City recipients,
elective induced abortions.
Such services include those education and counseling services to render the
services effective. Medically-necessary induced abortions are procedures, either
medical or surgical, which result in the termination of pregnancy. The
determination of medical necessity shall include positive evidence of pregnancy,
with an estimate of its duration.
When clinically indicated, the following services may be provided as a part of a
family planning and reproductive health visit:
- - screening, related diagnosis, ambulatory treatment and referral as needed
for dysmenorrhea, cervical cancer, or other pelvic abnormality/pathology.
- - screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.
- - screening and treatment for sexually transmissble disease.
APPENDX C
October 1, 2004
C-2
Providers of family planning and reproductive health care shall comply with all
of the requirements set forth in Sections 17 and 18 of the New York State Public
Health Law, and 10 NYCRR Section 751.9 and Part 753 relating to informed consent
and confidentiality.
The above family planning and reproductive health services are the only services
which are covered under the free access policy. Routine obstetric and/or
gynecologic care, including hysterectomies, pre-natal, delivery and post-partum
care are not covered under the free access policy, and are the responsibility of
the Contractor if they are covered contract services.
APPENDIX C
October 1, 2004
C-3
C.2
GUIDELINES FOR PLANS THAT INCLUDE FAMILY PLANNING AND REPRODUCTIVE HEALTH
SERVICES IN THEIR BENEFIT PACKAGE
If the Contractor includes family planning and reproductive health services in
its benefit package, the Contractor must notify all Enrollees of reproductive
age (including minors who may be sexually active) at the time of enrollment
about their right to obtain family planning and reproductive health services and
supplies from any network or non-network provider without referral or approval.
The notification must contain the following:
1) notification of the Medicaid Enrollee's right to obtain the full range of
family planning and reproductive health services (including HIV counseling
and testing when performed as part of a family planning encounter) from
either a Contractor's participating provider or any qualified non-network
provider who accepts Medicaid who undertakes to provide such services to
them, without referral, approval of notification;
2) a current list of qualified network family planning providers, within the
geographic area, including addresses and telephone numbers, who provide
the full range of family planning and reproductive health services.
Contractor may also choose to provide a list of qualified non-network
Medicaid providers who provide the full range of family planning and
reproductive health services;
3) information that the cost of the Enrollee's care will be fully covered by
Medicaid, when services are obtained in accordance with #1 above,
regardless of where the Enrollee obtains services.
The Contractor must notify its participating providers that all claims for
family planning services must be billed to the Contractor and not the Medicaid
fee-for-service program.
APPENDIX C
October 1, 2004
C-4
C.3
GUIDELINES FOR POLICY AND PROCEDURES FOR PLANS THAT DO NOT
INCLUDE FAMILY PLANNING SERVICES IN THEIR CAPITATION
Any Contractor who does not include family planning services in its
Benefit Package must notify all Enrollees and prospective Enrollees that these
services are not covered through the plan and submit a statement of the policy
and procedure they will use to inform Enrollees, prospective Enrollees, and
network providers using the following guidelines. The statement must be sent to
Director, Office of Managed Care, NYS Department of Health, Corning Tower, Room
2001, Albany, NY 12237 before signing the contract.
The policy and procedure statement regarding family planning services must
contain the following:
1) A statement that the Contractor will inform prospective Enrollees, new
Enrollees and current Enrollees that:
a. Certain family planning and reproductive health services (such as
abortion, sterilization and birth control) are not covered by the
Contractor.
b. Such services may be obtained through fee-for-service Medicaid from
any provider who accepts Medicaid.
c. No referral is needed for such services, and that there will be no
cost to the Enrollee for such services.
2) A statement that this information will be provided in the following
manner:
a. Through the Contractor's written marketing materials, including the
member handbook.
b. Orally at the time of enrollment and any time an inquiry is made
regarding family planning and reproductive health services.
c. Included on any web site of the Contractor which includes
information concerning its Medicaid managed care program. Such
information shall be prominently displayed and easily navigated.
3) The procedure for informing the Contractor's primary care providers,
obstetricians, and gynecologists that the Contractor has elected not to
cover certain reproductive and family planning services, but that such
Participating Providers may provide, make referrals, or arrange for these
services in accordance with MA fee-for-service billing policies.
APPENDIX C
October 1, 2004
C-5
4) Mechanisms to inform the Contractor's providers who also participate in
the fee-for-service Medicaid program that, if they render non-covered
reproductive health and family planning services, they do so as a
fee-for-service Medicaid practitioner, independent of the Contractor.
5) The member handbook and marketing materials indicating that the Contractor
has elected not to cover certain reproductive health and family planning
services, and explaining the right of all Enrollees to secure such
services through fee-for-service Medicaid from any Medicaid provider/
clinic which offers these services.
6) With the advent of mandatory enrollment and auto-assignment, mechanisms to
provide all new Enrollees with an SDOH approved letter explaining how to
access family planning services and the SDOH approved or LDSS approved
list of family planning providers. This material will be furnished by SDOH
or LDSS to the plan and mailed with the first new member communication,
prior to the enrollment effective date.
7) If an Enrollee or prospective Enrollee requests information about these
non-covered services, the Contractor's marketing or enrollment staff or
member services department will advise the Enrollee or prospective
Enrollee as follows:
a. Family planning and reproductive health services such as abortion,
sterilization and birth control are not covered through the plan.
b. Enrollees can receive these non-covered services using their
Medicaid card from any doctor or clinic that provides these services
and accepts Medicaid.
c. The Contractor will mail to each Enrollee or prospective Enrollee
who calls, a copy of the SDOH or LDSS approved letter explaining the
Enrollee's right to receive these non-covered services and an SDOH
approved or LDSS approved list of family planning providers, who
participate in Medicaid in the Enrollee's community. The Contractor
will mail these materials within 48 hours of the contact.
d. Enrollees can call the Contractors member services number or the New
York State Growing-Up-Healthy Hotline ( 1-800 522-5006) to request a
copy of the list of Family Planning Providers and for further
information about how to obtain these non-covered services.
8) The procedure for maintaining a manual log of all requests for such
information, including the date of the call, the Enrollees ID number, and
the date the SDOH approved letter and SDOH or LDSS approved list were
mailed. The Contractor will review this log monthly and upon request,
submit a copy to SDOH or the LDSS.
9) Mechanisms to inform participating providers that, if requested by the
Enrollee, or, if in the provider's best professional judgement, certain
reproductive health and family
APPENDIX C
October 1, 2004
C-6
planning services not offered through the Contractor are medically
indicated in accordance with generally accepted standards of professional
practice, an appropriately trained professional should so advise the
Enrollee and either: (1) offer those services on a fee-for-service basis;
or (2) provide the Enrollee with a copy of the SDOH approved or LDSS
approved list of Medicaid family planning providers, or (3) give the
Enrollee the member services number to call to obtain this listing.
10) The Contractor must recognize that the exchange of medical information,
when indicated in accordance with generally accepted standards of
professional practice, is necessary for the overall coordination of
Enrollees' care and will assist primary care providers in providing the
highest quality care to the Contractor's Enrollees. The Contractor must
acknowledge that medical record information maintained by network
providers may include information relating to family planning services
provided under the fee-for-service Medicaid program.
11) Quality assurance initiatives to ensure compliance with this policy. These
should include the following procedures:
a. The Contractor will submit any materials to be furnished to
Enrollees and providers relating to access to non-covered
reproductive health and family planning services to SDOH, Office of
Managed Care for its review and approval before issuance. Such
materials include, but are not limited to, member handbooks,
provider manuals, and marketing materials.
b. Monitoring calls to member services and providers will be conducted
to assess the quality of the information provided. These calls will
be performed weekly by the manager/director or his or her designee.
c. Every month, the plan will prepare a list of Enrollees who have
been sent a copy of the SDOH approved letter and the SDOH approved
or LDSS approved list of family planning providers. This information
will be submitted to the Chief Operating Officer and President/CEO
on a monthly basis.
d. The Contractor will provide all new employees with a copy of this
policy. The Contractor's orientation program will include a thorough
discussion of all aspects of this policy and procedure. Annual
retraining programs for all employees will also be conducted to
ensure continuing compliance with this policy.
APPENDIX C
October 1, 2004
C-7
APPENDIX D
NEW YORK STATE DEPARTMENT OF HEALTH
MARKETING GUIDELINES
APPENDIX D
October 1, 2004
D-1
MARKETING GUIDELINES
INTRODUCTION
The purpose of these guidelines is to provide an operational framework for
localities and Medicaid managed care organizations (MCOs) in the development of
MCO marketing plans, materials, and activities and to describe SDOH's marketing
rules, MCO marketing requirements, and prohibited practices.
The guidelines are consistent with those issued to all states by the Health Care
Financing Administration (HCFA), U.S. Department of Health and Human Services
(DHHS) in August 1994. These guidelines are consistent with the requirements of
New York State.
APPENDIX D
October 1, 2004
D-2
A. MARKETING PLANS
1. The MCO shall develop a marketing plan that meets SDOH guidelines and any
local requirements as approved by the State Department of Health (SDOH).
2. The LDSS is responsible for the review and approval of MCO marketing
plans, using a SDOH approved checklist.
3. Approved marketing plans set forth the allowable terms and conditions and
the proposed activities that the MCO intends to undertake during the
contract period. Locally determined variations, as specified in Section E
of this Appendix, must be described in the MCO's specific marketing plan
for each LDSS the MCO contracts with.
4. The MCO must have on file with the SDOH and each LDSS with which it will
contract, an approved marketing plan, prior to the contract award date or
before marketing and enrollment begin, whichever is sooner. Subsequent
changes to the plan must be submitted to the LDSS or SDOH for approval at
least sixty (60) days before implementation.
5. The plan shall include: a stated marketing goal and strategies; marketing
activities; and staff training, development and responsibilities. The
following must be included in the plan's description of materials to be
used: distribution methods; primary marketing locations, and a listing of
the kinds of community service events the MCO anticipates sponsoring
and/or participating in, during which it will provide information and/or
distribute marketing materials.
6. The MCO must describe how it is able to meet the informational needs,
related to marketing, for the physical and cultural diversity of its
potential membership. This may include, but not be limited to, a
description of the MCO's other-than English language provisions,
interpreter services, alternate communication mechanisms, including sign
language, Braille, audio tapes, and/or use of Telecommunications Device
for the Deaf (TDD)/TTY services.
7. The MCO shall describe measures for monitoring and enforcing compliance
with the guidelines by its marketing representatives and its providers
including: the prohibition of door-to-door solicitation and cold-call
telephoning; a description of the development of pre-enrollee mailing
lists, that maintains client confidentiality and that honors the client's
express request for direct contact by the MCO; the selection and
distribution of pre-enrollment gifts and incentives to consumers; and a
description of the training, compensation and supervision of its marketing
representatives.
APPENDIX D
October 1, 2004
D-3
B. MARKETING MATERIALS
1. Definitions
a) Marketing materials generally include the concepts of advertising,
public service announcements, printed publications, and other
broadcast or electronic messages designed to increase awareness and
interest in Medicaid managed care and/or a MCO's Medicaid managed
care product. The target audience for these marketing materials is
Medicaid-eligible persons who are not enrolled in a Medicaid managed
care plan, and who are living in a defined service area.
b) Marketing materials include any information that references the
Medicaid managed care program, is intended for general distribution,
and is produced in a variety of print, broadcast, and direct
marketing mediums. These generally include: radio, television,
billboards, newspapers, leaflets, informational brochures, videos,
telephone book yellow page ads, letters, and posters. Additional
materials requiring marketing approval include a listing of items to
be provided as nominal gifts or incertives.
2. Marketing Material Requirements
a) Marketing materials must be written in prose that is understood at a
fourth-to sixth-grade reading level and must be printed in at least
ten (10) point type.
b) The Contractor must make available written marketing and other
informational materials (e.g., member handbooks) in a language other
than English whenever at least five percent (5%) of the potential
Enrollees of the Contractor in any county of the service area speak
that particular language and do not speak English as a first
language. SDOH will inform the LDSS and LDSS will inform the
Contractor when the 5% threshold has been reached. Marketing
materials to be translated include those key materials, such as
informational brochures, that are produced for routine distribution,
and which are included within the MCO's marketing plan. SDOH will
determine the need for other than English translations based on
county specific census data or other available measures.
c) Alternate forms of communications must be provided for persons with
visual, hearing, speech, physical, or developmental disabilities.
These alternate forms include Braille or audiotapes for the visually
impaired, TTY access for those with certified speech or hearing
disabilities, and use of American Sign Language and/or integrative
technologies.
d) The plan name, mailing address and location, if different), and toll
free phone number must be prominently displayed on the cover of all
multi-paged marketing materials.
APPENDIX D
October 1, 2004
D-4
e) Marketing materials must not contain false, misleading, or ambiguous
information--such as "You have been pre-approved for the XYZ Health
Plan," or "If you do not choose a plan you will lose your Medicaid
coverage," or "You get free, unlimited visits." Materials must not
use broad, sweeping statements-- for example, "If you are eligible
for Medicaid, you are eligible for Medicaid Managed Care and/or the
XYZ Health Plan."
f) The material must accurately reflect general information, which is
applicable to the average consumer of Medicaid managed care.
g) The Contractor may not use logos or wording used by government
agencies if such use could imply or cause confusion about a
connection between a governmental agency and the Contractor.
h) Marketing materials may not make reference to incentives that may be
available to Enrollees after they join a plan, such as "If you join
the XYZ Plan, you will receive a free baby carriage after you
complete eight prenatal visits."
i) Marketing materials that are prepared for distribution or
presentation by the LDSS or enrollment broker must be provided in a
manner that is easily understood and appropriate to the target
audience. The material covered must include sufficient information
to assist the individal in making an informed choice of MCO.
j) The MCO shall advise potential Enrollees, in written materials
related to enrollment, to verify with the medical services providers
they prefer, or have an existing relationship with, that such
medical services providers participate in the selected managed care
provider's network and are available to serve the participant.
3. Prior Approvals
a) The SDOH will review and approve MCO, marketing videos, materials
for broadcast (radio, television, or electronic), billboards, mass
transit (bus, subway or other livery) and statewide/regional print
advertising materials. These materials must be submitted to the SDOH
for review. A copy must be simultaneously provided to the LDSS.
b) The LDSS will review and approve the following marketing material:
i) MCO marketing plans;
ii) Scripts or outlines of presentations and materials used at
health fairs and other LDSS approved events and locations;
iii) All pre-enrollment written marketing materials - written
marketing materials include brochures and leaflets, and
presentation materials used by marketing representatives;
APPENDIX D
October 1, 2004
D-5
iv) County specific MCO informational brochures to be included in
LDSS enrollment packets; and
v) All direct mailing from MCOs targeted to the Medicaid market.
c) Both SDOH and LDSS will adhere to a sixty (60) day "file and use"
policy, whereby materials submitted by the MCO must be reviewed and
commented on within sixty (60) days of submission or the MCO may
assume the materials have been approved if the reviewer has not
submitted any written comment.
d) The Contractor shall submit all subcontracts, procedures, and
materials related to Marketing to Eligible Persons to the SDOH
and/or LDSS for prior written approval. The Contractor shall not
enter into any subcontracts or use any marketing subcontractors,
procedures, or materials that the SDOH and/or LDSS has not approved.
4. Dissemination of LDSS Outreach Materials
The Contractor shall provide to the LDSS and/or Enrollment Broker upon
request, a marketing/informational brochure or alternative informational
document that describes coverage in the county specific service area.
The Contractor shall, upon request, submit to the LDSS or Enrollment
Broker, a current provider directory, together with infornation that
describes how to determine whether a provider is presently available.
APPENDIX D
October 1, 2004
D-6
C. MARKETING ACTIVITIES
1. Definitions
a) Marketing activities are occasions during which marketing
information and material regarding Medicaid managed care and
information about a particular MCO's affiliated products are
presented. Typically, such information is presented both in verbal
exchanges and through the distribution of written materials,
together with the giving away of nominal gifts. The informal nature
of the marketing activity requires MCOs to be forthright in their
presentations to allow potential Enrollees the exercise of informed
choice, and localities must provide the best assurances that
marketing practices are consistent with established guidelines. Any
exchange of verbal marketing information must include the following:
i) if the plan is not capitated for family planning services, the
representative must tell potential Enrollees that:
a) certain family planning and reproductive health services
(such as abortion, sterilization and birth control) are
not covered by the Contractor;
b) whenever needed, such services may be obtained through
fee-for-service Medicaid from any provider who accepts
Medicaid;
c) no referral is needed for such services;
d) there will be no cost to the enrollee for such services.
b) With prior local approval MCO's may engage in marketing activities
that include community-sponsored social gatherings, provider-hosted
informational sessions, or MCO-sponsored events. Events may include
such activities as health fairs workshops on health promotion,
holiday parties, after school programs, raffles, etc. These events
must not be restricted to Medicaid Recipients only.
c) Media campaigns are the distribution of information/materials
regarding the Medicaid managed care program and/or a specific MCO
for the purpose of encouraging Medicaid recipients to join a managed
care plan. All mediums--including television, radio, billboards,
subway and bus posters, and electronic messages--must be
pre-approved by the SDOH at least thirty (30) days prior to the
campaign. A copy must be simultaneously submitted to the SDOH and
the LDSS.
2. Marketing Sites
a) With prior LDSS approval, MCOs may distribute approved marketing
material in such places as, an income support maintenance center,
community centers (if the center agrees and allows all MCOs to use
the center), markets, pharmacies, hospitals and other provider
sites, schools, health fairs, a resource center established by the
LDSS or the enrollment counseling contractor, and other areas where
potential Enrollees are likely to gather.
APPENDIX D
October 1, 2004
D-7
b) MCOs are PROHIBITED from door-to-door solicitation of potential
Enrollees, or distribution of material, and may not engage in "cold
calling" inquiries or solicitation.
c) MCOs are PROHIBITED from direct marketing or distribution of
material in hospital emergency rooms including emergency room
waiting areas. Marketing may not take place in patient rooms or
treatment areas (except for waiting areas) or other prohibited sites
unless requested by the individual. LDSS may not allow MCO to market
in individual homes without permission of the individual.
d) MCOs may not require its Participating Providers to distribute
plan-prepared communications to their patients.
e) Participating Providers may display the marketing materials of their
contracting MCOs provided that appropriate notice is conspicuously
posted for all other MCOs with whom the Provider has a contract.
f) Participating Providers are encouraged to communicate with their
patients about managed care options and to advise their patients in
determining the MCO that best meets the health needs of the patient
and his/her family. Such advice, whether presented verbally or in
writing, must be individually based and not merely a promotion of
one plan over another. Providers who wish to let their patients know
of their affiliation with one or more MCOs must list each MCO with
whom they hold contracts. In the event marketing material is
included with such communication, the material, together with the
intended communication, must be pre-approved by the LDSS before
distribution.
g) In the event a provider is no longer affiliated with a particular
MCO but remains affiliated with other participant MCOs, the provider
may notify his/her/its patients of the new status and the impact of
such change on the patient.
3 Restricted Marketing Activities
a) MCOs are PROHIBITED from misrepresenting the Medicaid program, the
Medicaid managed care program or the program or policy requirements
of the LDSS or the SDOH.
b) MCOs are PROHIBITED from purchasing or otherwise acquiring or using
mailing lists of Medicaid recipients from third party vendors,
including providers and LDSS offices.
c) MCOs are PROHIBITED from using raffle tickets and event attendance
or sign-in sheets to develop mailing lists of potential Enrollees.
APPENDIX D
October 1, 2004
D-8
d) MCOs may not discriminate against a potential Enrollee based on
his/her current health status or anticipated need for future health
care. The MCO may not discriminate on the basis of disability or
perceived disability of an Enrollee or their family member. Health
assessments may not be performed by MCOs prior to enrollment. MCOs
may inquire about existing primary care relationships of the
applicant and explain whether and how such relationships may be
maintained. Upon request, each potential Enrollee shall be provided
with a listing of all Participating Providers including specialists
and facilities in the MCO's network. The MCO may respond to a
potential Enrollee's question about whether a particular specialist
is in the network. However, MCOs are prohibited from inquiring about
the types of specialists utilized by the potential Enrollee.
e) MCOs may not offer incentives of any kind to Medicaid recipients to
join a health plan. "Incentives" are defined as any type of
inducement whose receipt is contingent upon the recipients joining
the plan.
f) MCOs are responsible for ensuring that their marketing
representatives engage in professional and courteous behavior in
their interactions with LDSS staff, staff from other health plans,
and Medicaid clients. Examples of inappropriate behavior include
interfering with other health plan presentations, talking negatively
about another health plan, and participating with Medicaid clients
during the verification interview with LDSS staff.
g) MCOs may offer nominal gifts of not more than $5.00 in fair-market
value as part of a health fair or other marketing activity to
stimulate interest in managed care and/or the MCO. Such gifts must
be pre-approved by the LDSS, and offered without regard to
enrollment. The MCO must submit a listing of intended items to be
distributed at marketing activities as nominal gifts. The submission
of actual samples or photographs of intended nominal gifts will not
be routinely required, but must be made available upon request by
the state or local reviewer. Listings of item donors or co-sponsors
must be submitted along with the description of items.
h) MCOs may offer its Enrollees rewards for completing a health goal,
such as finishing all prenatal visits, participating in a smoking
cessation session, attending initial orientation sessions upon
enrollment, and timely completion of immunizations or other health
related programs. Such rewards may not exceed $50.00 in fair-market
value per Enrollee over a twelve (12) month period, and must be
related to a health goal. MCOs may not make reference to these
rewards in their pre-enrollment marketing materials or discussions
and all such rewards must be approved by the LDSS.
i) MCOs may not offer compensation to marketing representatives,
including salary increases or bonuses, based solely on the number of
individuals they enroll. However, MCOs may base compensation of
marketing representatives on periodic performance evaluations which
consider enrollment productivity as one
APPENDIX D
October 1, 2004
D-9
of several performance factors during a performance period, subject
to the following requirements:
1) "Compensation" shall mean any remuneration required to be
reported as income or compensation for federal tax purposes;
2) MCOs may not pay a "commission" or fixed amount per
enrollment;
3) Bonuses may not be awarded more frequently than quarterly, and
the annual amount awarded as bonus compensation to a marketing
representative may not exceed 10% of his/her total annual
compensation;
4) Performance evaluations used as a basis for such bonus or
salary increase shall be set forth in writing and available
for inspection by SDOH or the LDSS;
5) Other appropriate factors which may be considered by an MCO in
awarding merit salary increase or bonuses to marketing
representatives include but are not limited to:
- Ratio of "clean" or successful enrollments submitted;
quality of applications;
- Attendance; adherence to marketing schedules; timeliness
- Observed marketing behavior; absence/paucity of
complaints regarding marketing conduct
6) Affiliated providers engaged in marketing on behalf of an MCO
shall be considered "marketing representatives" for purposes
of Section C (3)(i) of Appendix D.
j) Individuals employed by MCO's as marketing representatives, and
employees of marketing subcontractors must have successfully
completed a training program about the basic concepts of managed
care and the Medicaid recipients' rights and responsibilities
relating to membership in managed care. MCOs must submit a copy of
the training curriculum for their marketing representatives to SDOH
and the LDSS as part of the marketing plan. The MCO shall be
responsible for the activities of its marketing representatives and
the activities of any subcontractor or management entity. A
marketing representative means any individual or entity engaged by
the Contractor to market on behalf of the Contractor.
APPENDIX D
October 1, 2004
D-10
D. MARKETING INFRACTIONS
1. Infractions of the marketing guidelines may result in the following
actions being taken by the LDSS to protect the interests of the program
and its clients. These actions shall be taken at the sole discretion of
the LDSS.
a) If an MCO or its representative commits a first time infraction of
marketing guidelines and the LDSS deems the infraction to be minor
or unintentional in nature, the LDSS may issue a warning letter to
the MCO.
b) For subsequent or more serious infractions, the LDSS may impose
liquidated damages of $2,000.00, or other appropriate non-monetary
sanctions for each infraction.
c) The LDSS may require the MCO to prepare a corrective action plan
with a specified deadline for implementation.
d) If the MCO commits further infractions, fails to pay liquidated
damages within the specified timeframe or fails to implement a
corrective action plan in a timely manner or commits an egregious
first-time infraction, the LDSS may:
i) prohibit the plan from conducting any marketing activities for
a period up to the end of the contract period;
ii) suspend new enrollments, other than newborns, for a period up
to the remainder of the contract, or
iii) terminate the contract pursuant to termination procedures
described therein.
APPENDIX D
October 1, 2004
D-11
E. LDSS SPECIFIC MARKETING GUIDELINES
{insert LDSS specific marketing guidelines as applicable}.
LDSS: DUTCHESS COUNTY
MCO: WELLCCARE OF NEW YORK, INC.
APPENDIX D
October 1, 2004
D-12
LDSS SPECIFIC MARKETING GUIDELINES
FOR MANAGED CARE ORGANIZATIONS
(APPENDIX D, SECTION E)
The Contractor (Managed Care Organization - MCO) and the Local Department of
Social Services (LDSS) agree to the marketing guidelines as presented in Section
11 and Appendix D of the Medicaid managed care model contract and to the
following:
The LDSS Commissioner will receive formal notification of any changes to the
marketing plan (function) of the Contractor (MCO).
The Contractor (MCO) will maintain a viable presence within the Local District.
As conditions permit or as otherwise agreed upon by the Contractor (MCO) and the
Local District, the Marketing Representative assigned to the county will be
on-site at the Local District no less than 3 days during recertification weeks
and no less than 2 days during non-recertification weeks. There shall be 1 (one)
marketer per plan per (assigned) day unless otherwise approved.
The Contractor's (MCO's) Regional Marketing Manager and the Local District will
meet no less than quarterly to maintain open communication.
The Contractor (MCO) will submit a copy of the quarterly analysis of
disenrollment reasons for members in the given County to the LDSS.
The Contractor (MCO) marketing and enrollment activities shall take place in the
following sites:
- LDSS offices
- WIC Centers
- Via telephone with proper educational component
All other enrollment initiatives (for example: Provider Offices, Community and
Health Centers) or changes MUST be presented to State DOH and the Local District
for review and approval with at least 30 days notice.
The Contractor (MCO) will supply the Local District with a schedule (2 weeks in
advance) of all prior approved marketing activities including the time and dates
that marketers will be on-site and written notice of all scheduling changes.
The Contractor's (MCO's) marketers will sign in and out on the appropriate
sign-in sheet within the Local District.
The Contractor (MCO) shall conduct or participate in Community Outreach.
The Contractor (MCO) must have an established process with the Local District to
resolve marketing issues and concerns regarding the Marketing Representatives.
The Contractor (MCO) must provide the Local District with a corrective action
plan that includes specific time frames.
APPENDIX D
October 1, 2004
D-l3
The Contractor (MCO) will attempt to resolve all appropriate complaints to the
satisfaction of the Local District.
The Local District has the right to evaluate all marketers. The Local District
may use post enrollment surveys, on-site reviews, follow-up telephone calls and
overall performance in this process. The Local District will share this
information with the appropriate Contractor (MCO) staff.
The Local District designates State DOH as the primary reviewer of all marketing
materials and activities. The Local District, in consultation with State DOH,
will review all marketing materials and activities. The Contractor (MCO) will,
therefore, forward all materials and requests to SDOH and to the county.
APPENDIX D
October 1, 2004
D-14
APPENDIX E
NEW YORK STATE DEPARTMENT OF HEALTH
MEMBER HANDBOOK GUIDELINES
APPENDIX E
October 1, 2004
E-1
INTRODUCTION
This document contains member handbook guidelines for use by managed care
organizations (MCOs) under contract to serve New York Medicaid beneficiaries.
These guidelines may be revised from time to time based on changes in the law
and the changing needs of the program. The guidelines reflect the review
criteria used by the SDOH Office of Managed Care in its review of all Medicaid
managed care member handbooks. Handbooks and addenda must be approved by SDOH
prior to printing and distribution by MCOs. In addition, the SDOH has developed
a model member handbook at the fourth to sixth grade reading level for use by
MCOs. The model member handbook contains language to address required disclosure
regarding free access for family planning; self referral policies; obtaining
OB/GYN services; the definitions of medical necessity and emergency services;
protocols for complaints, utilization review, external appeals, fair hearings
and newborn enrollments; and listing of member entitlements, including benefits,
rights and responsibilities, and information available upon request. MCOs must
use the language provided in these required disclosure areas in their member
handbooks. A copy of the model handbook is available from the Office of Managed
Care, Bureau of Intergovernmental Affairs.
GENERAL FORMAT
Member handbooks must be written in a style and reading level that will
accommodate the reading skills of many Medicaid recipients. In general the
writing should be at no higher than a sixth-grade level, taking into
consideration the need to incorporate and explain certain technical or
unfamiliar terms to assure accuracy. The text must be printed in at least ten
(10) point font. The SDOH reserves the right to require evidence that a handbook
has been tested against the sixth-grade reading-level standard. Member handbooks
must be available in languages other than English whenever at least five (5)
percent of the potential enrollees of the MCO in any county in the MCO's service
area speak a language other than English as a first language.
HANDBOOK REQUIREMENTS
a) General Overview (how the plan works)
i) Explanation of the plan, including what happens when you become a
member.
ii) Explanation of the plan ID card, obtaining routine medical care,
help by telephone, and general information pertaining to the plan,
i.e., location of the plan, providers, etc.
iii) Invitation to attend scheduled orientation sessions and other
educational and outreach activities.
b) Provider Listing, including Site Locations
Note: The information described here can be included in the handbook or as
an insert to the handbook, or can be produced as a separate document and
referenced in the handbook.
APPENDIX E
October 1, 2004
E-2
i) A current listing of providers, including facilities.
ii) For physicians, separate listings of primary care practitioners and
specialty providers; include location, phone number, and board
certification status.
iii) Listing also must include a notice of how to determine whether a
participating provider is accepting new patients.
c) Voluntary or Mandatory Enrollment
i) Must indicate whether enrollment is voluntary or mandatory,
ii) If plan participates in both mandatory and voluntary counties,
explanation of the difference, i.e., disenrollment, family members
in the same plan, etc.
d) Choice of Primary Care Provider (including how to make an appointment)
i) Explanation of the role of PCP as a coordinator of care, giving some
examples, and how to choose one for self and family.
ii) How to make an appointment with the PCP, importance of base line
physical, immunizations and well-child care.
iii) Explanation of different types of PCPs, i.e., family practice,
pediatricians, internists, etc.
iv) Notification that the plan will assign the member to a PCP if one is
not chosen in thirty (30) days.
v) OB/GYN choice rules for women
e) Changing Primary Care Provider
i) Explanation of plan policy, time frames, and process related to
changing PCP.
ii) Explanation of process for changing OB/GYN when applicable.
iii) Explanation of requirements for choosing a specialist as PCP.
f) Referrals to Specialists (in and out-of-plan)
i) Explanation of specialist care and how referrals are accomplished.
ii) Explanation of process for changing specialists.
iii) Explanation of self-referral services, i.e., OB/GYN services, HIV
counseling and testing, eye exams, etc.
iv) Notice that Enrollee may obtain a referral to a Non-Participating
Provider when the plan does not have a Participating Provider with
appropriate training or experience to meet the needs of the
Enrollee; and the procedure for obtaining such referrals.
v) Notice that an Enrollee with a condition that requires ongoing care
from a specialist may request a standing referral to such a
specialist; procedure for obtaining such referrals.
vi) Notice that an Enrollee with a life-threatening condition or
disease, or a degenerative and disabling condition or disease,
either of which require
APPENDIX E
October 1, 2004
E-3
specialized medical care over a prolonged period of time, may
request access to a specialist responsible for providing or
coordinating the Enrollee's medical care; and the procedure for
obtaining such a specialist.
vii) Notice that an Enrollee with a life-threatening condition or
disease, or a degenerative and disabling condition or disease,
either of which require specialized medical care over a prolonged
period of time, may request access to a specialty care center; and
the procedure for obtaining such access.
g) Covered and Non-Covered Services
i) Benefits and services covered by the plan, including benefit
maximums and limits.
ii) Definition of medical necessity used to determine whether benefits
will be covered (same as plan-county contract definition).
iii) Medicaid services not covered by the plan or excluded
from managed care; how to access these services.
iv) Prior authorization and other requirements for treatments and
services.
v) Family planning and reproductive health services free access policy.
vi) HIV counseling and testing free access policy.
vii) Direct access policy for dental services provided at Article 28
clinics operated by academic dental centers when dental is in the
Benefit Package.
viii) Plan policy relating to transportation, including who to call and
what to do if plan does not cover transportation.
ix) Plan toll-free number for Enrollee to call for more information.
h) Out of Area Coverage
i) Explanation of what to do and who to call if medical care is
required when beneficiary is out of plan's service area.
i) Emergency Care Access
i) Definition of emergency services, as defined in law including
examples of situations that constitute an emergency and situations
that do not.
ii) What to do in an emergency, including notice that services in a true
emergency are not subject to prior approval.
iii) A phone number to call if PCP is not available.
iv) Explanation of what to do in non-emergency situations (PCP, urgent
care, etc.).
j) Utilization Review
i) Circumstances under which utilization review will be undertaken.
ii) Toll-free telephone number of the utilization review agent.
iii) Time frames under which UR decisions must be made for prospective,
retrospective, and concurrent decisions.
iv) Right to reconsideration.
APPENDIX E
October 1, 2004
E-4
v) Right to an appeal, including expedited and standard appeals
processes and the time frames for such appeals.
vi) Right to designate a representative.
vii) A notice that all denials of claims will be made by qualified
clinical personnel and that all notices will include information
about the basis of the decision, and further appeal rights (if any).
k) Enrollment and Disenrollment Procedures
i) Where appropriate, explanation of Lock-In requirements, and initial
grace period when person may change plans, or return to
fee-for-service in voluntary areas.
ii) Choice of PCP (each person can have his/her own PCP and can change
thirty (30) days after the initial appointment with their PCP, and
once every six months thereafter).
iii) Procedures for disenrollment.
iv) Opportunities for change
v) LDSS/or enrollment broker phone number for information on enrollment
and disenrollment.
1) Rights and Responsibilities of Enrollees
i) Explanation of what an Enrollee has the right to expect from the
Contractor in the way of medical care and treatment of the Enrollee.
ii) Responsibilities of the Enrollee (general).
iii) Enrollee's financial responsibility for payment when services are
furnished by a provider who is not part of the Contractor's network
or by any provider without required authorization or when a
procedure, treatment, or service is not a covered benefit; also note
exceptions such as family planning and HIV counseling/testing.
iv) Enrollee's rights under State law to formulate advance directives.
v) The manner in which Enrollees may participate in the development of
plan policies.
m) Language
i) Description of how the Contractor addresses the needs of non-English
speaking Enrollees.
n) Grievance Procedures (complaints)
i) Right to file a grievance regarding any dispute between the
Contractor and an Enrollee.
ii) Right to file a grievance orally when the dispute is about referrals
or covered benefits.
iii) Explanation of who in the plan to call, along with the Contractor's
toll-free number.
iv) Time frames and circumstances for expedited and standard grievances.
APPENDIX E
October 1, 2004
E-5
v) Right to appeal a grievance determination and the procedures for
filing such an appeal.
vi) Time frames and circumstances for expedited and standard appeals.
vii) Right to designate a representative.
viii) A notice that all decisions involving clinical disputes will be made
by qualified clinical personnel and that all notices will include
information about the basis of the decision, and further appeal
rights (if any).
ix) NYSDOH number for medically related complaints (1-800-206-8125).
x) New York State Insurance Department number for certain complaints
relating to billing.
o) Fair Hearing
Explain that:
i) Enrollee has a right to a State Fair Hearing and Aid to Continuing
in some situations.
ii) Describe situations when the Enrollee may ask for a fair hearing as
described in Section 25 of this Agreement including State or LDSS
decision about staying in or leaving the plan; decision the
Contractor makes that stops or limits Medicaid benefits; Contractor
decision agreeing with doctor who will not order services (must
complain to the plan first).
iii) Describe how to request a fair hearing (assistance through member
services, LDSS, State fair hearing contact).
p) External Appeals
i) Description of circumstances where a person may request an external
appeal
ii) Time frames for applying for appeal and for decision-making
iii) How and where to apply
iv) Describe expedited appeal time frame
v) Process for Contractor and Enrollee to agree on waiving the UR
appeal process.
q) Payment Methodologies
i) Description prepared annually of the types of methodologies the
plan uses to reimburse providers, specifying the type of
methodology used to reimburse particular types of providers or
for the provision of particular types of services.
r) Physician Incentive Plan Arrangements
i) The Member Handbook must contain a statement indicating the
Enrollees and potential Enrollees are entitled to ask if the MCO has
special financial arrangements with physicians that can affect the
use of referrals and other services that they might need and how to
obtain this information.
APPENDIX E
October 1, 2004
E-6
s) How and Where to Get More Information
i) How to access a member services representative through a toll-free
number.
ii) How and when to contact LDSS for assistance.
OTHER INFORMATION AVAILABLE UPON ENROLLEE'S REQUEST
a) List of the names, business addresses, and official positions of the
membership of the board of directors, officers, controlling persons,
owners or partners of the Contractor.
b) Copy of the most recent annual certified financial statement of the
Contractor, including a balance sheet and summary of receipts and
disbursements prepared by a CPA.
c) Copy of the most recent individual, direct pay subscriber contracts.
d) Information relating to consumer complaints compiled pursuant to Section
210 of the insurance law.
e) Procedures for protecting the confidentiality of medical records and other
Enrollee information.
f) Written description of the organizational arrangements and ongoing
procedures of the Contractor's quality assurance program.
g) Description of the procedures followed by the Contractor in making
decisions about the experimental or investigational nature of medical
devices, or treatments in clinical trials.
h) Individual health practitioner affiliations with participating hospitals.
i) Specific written clinical review criteria relating to a particular
condition or disease and, where appropriate, other clinical information
which the plan might consider in its utilization review process.
j) Written application procedures and minimum qualification requirements for
health care providers to be considered by the plan.
k) Upon request, MCOs are required to provide the following information on
the incentive arrangements affecting the MCO's physicians to current,
previous and prospective Enrollees:
1. Whether the MCO's contract or subcontracts include Physician
Incentive Plans that affect the use of referral services.
2. Information on the type of incentive arrangements used.
3. Whether stop-loss protection is provided for physicians and
physicians groups.
4. If the MCO is at substantial financial risk, as defined in the PIP
regulations, a summary of the required customer satisfaction survey
results.
APPENDIX E
October , 2004
E- 7
APPENDIX F
NEW YORK STATE DEPARTMENT OF HEALTH
MEDICAID MANAGED CARE COMPLAINT AND APPEALS REQUIREMENTS
APPENDIX F
October 1, 2004
F-1
I. OVERALL OBJECTIVES
The Medicaid managed care program complaint process accomplishes four
objectives:
a) Ensures that each MCO resolves its Enrollees' problems promptly and
at the lowest level of formality, wherever possible.
b) Ensures that the MCO reports the full extent of complaint activity
to governmental oversight entities.
c) Ensures that the MCO uses complaint information to assess and
improve program performance.
d) Provides an independent process for complaint resolution when issues
are not resolved by the MCO.
II. DEFINITIONS
a) A complaint is a written or verbal contact to the MCO in which the
Enrollee or designee describes a dissatisfaction with the MCO, its
employees, benefits, providers or contractors, including but not
limited to:
- a determination made by the MCO;
- treatment experienced through the MCO, its providers, or
contractors.
Medical necessity determinations pursuant to Article 49 of the Public
Health Law are not included in the definition of a complaint.
b) An inquiry is a written or verbal question or request for
information posed to the MCO with regard to such issues as benefits,
contracts, and organization rules. Inquiries do not reflect Enrollee
complaints or disagreements with MCO determinations.
c) Summary Complaint Forms are forms developed by the State that
categorize the type of complaints received. These forms should be
submitted via the HPN on a quarterly basis to the SDOH.
III. COMPLAINT PROCEDURES
a) The MCO shall describe its complaint and appeal procedure in the
member handbook, and it must be accessible to non-English speaking,
visually, and hearing impaired Enrollees. The handbook shall comply
with Section 13.3 and The Member Handbook Guidelines (Appendix E) of
this Agreement.
b) Anytime the MCO denies access to a referral; denies or reduces
benefits or services; determines that a requested benefit is not
covered in the MCO's benefit package, or denies payment of a claim
for services the MCO shall provide written notice of the procedures
for the Enrollee to file a complaint, including:
APPENDIX F
October 1, 2004
F-2
i) the description of the action Contractor intends to take;
ii) the reasons for the determination including the clinical rationale,
if any;
iii) the process for filing a grievance/complaint with the organization;
iv) the timeframes within which a grievance/complaint determination must
be made;
v) the right of an Enrollee to designate a representative to file a
grievance/complaint on behalf of the Enrollee;
vi) the notice of the right of the member to contact the New York State
Department of Health (800 206-8125) with their complaint; and
vii) the notice entitled "Managed Care Action Taken" containing the
member's fair hearing and aid continuing rights.
c) If the MCO immediately resolves a verbal complaint to the Enrollee's
satisfaction, that complaint may be considered resolved without any
additional written notification to the Enrollee. Such complaints
must be logged by the MCO and included in the MCO's quarterly HPN
complaint report submitted to SDOH.
d) MCO procedures for accepting complaints shall include:
i) toll-free telephone number;
ii) designated staff to receive calls;
iii) "live" phone coverage at least 40 hours a week during normal
business hours;
iv) a mechanism to receive after hour calls including either:
A) telephone system available to take calls and a plan to
respond to all such calls no later than on the next
business day after the call was recorded.
Or
B) a mechanism to have available on a twenty-four (24)
hour, seven (7) day a week basis designated staff to
accept telephone complaints, whenever a delay would
significantly increase the risk to an Enrollee's health.
e) Determinations of all clinical complaints involving clinical
decisions shall be made by qualified clinical personnel.
f) Upon receipt of a complaint, the MCO shall send a notice to the
Enrollee specifying what information must be provided to the MCO in
order for a determination to be made.
IV. NOTICE TO ENROLLEE PROCEDURES
Upon receipt of the following type of complaints; 1) anytime that the MCO denies
access to a referral; 2) denies or reduces benefits or services; 3) determines
that a requested benefit is not covered by the MCO's benefit package, the MCO
shall send a notice to the Enrollee. The notice shall describe:
a) The Enrollee's right to file a complaint regarding any dispute with
the MCO.
b) The information to be provided to the MCO in order for a
determination to be made.
APPENDIX F
October 1, 2004
F- 3
c) The fact that the MCO will not retaliate or take any discriminatory
action against the Enrollee because he/she filed a complaint or
appeal.
d) The right of the Enrollee to designate a representative to file
complaints and appeals on his/her behalf.
e) The MCO's requirements for accepting written complaints, which can
be either a letter or MCO supplied form.
f) The Enrollee's right to file a verbal complaint when the dispute is
about referrals or covered benefits. The MCO must list a toll-free
number which Enrollee may use to file a verbal complaint.
g) For verbal complaints, whether the Enrollee is required to sign an
acknowledgment and description of the complaint prepared by the MCO.
The acknowledgment must clearly advise the Enrollee that the
Enrollee may amend the description but must sign and return it in
order to initiate the complaint.
V. TIMEFRAMES FOR COMPLAINT RESOLUTION BY THE MCO.
Procedures should indicate the following specific timeframes regarding complaint
resolution:
a) The MCO has to provide written acknowledgment of the complaint
including the name, address and telephone number of the individual
or department handling the complaint within fifteen (15) days of
receipt of the complaint.
b) Complaints shall be resolved whenever a delay would significantly
increase the risk to an Enrollee's health within forty-eight (48)
hours after receipt of all necessary information.
c) Complaints shall be resolved in the case of requests for referrals
or determinations concerning benefits covered by the contractual
benefit package within thirty (30) days after the receipt of all
necessary information.
d) All other complaints shall be resolved within forty-five (45) days
after the receipt of all necessary information. The MCO shall
maintain reports of complaints unresolved after forty-five (45) days
in accordance with Section 18 of this Agreement.
VI. COMPLAINT DETERMINATIONS
Procedures regarding the resolution of Enrollee complaints should include the
following:
a) Complaints shall be reviewed by one or more qualified personnel.
APPENDIX F
October 1, 2004
F-4
b) Complaints pertaining to clinical matters shall be reviewed by one
or more licensed, certified or registered health care professionals
in addition to whichever non-clinical personnel the MCO designates.
c) Determinations by the MCO shall be made in writing to the Enrollee
or his/her designee and include:
i) the detailed reasons for the determination;
ii) in cases where the determination has a clinical basis, the
clinical rationale for the determination;
iii) the procedures for the filing of an appeal of the
determination, including a form for the filing of such an
appeal;
iv) notice of the right of the Enrollee to contact the State
Department of Health (800 206-8125) with their complaint; and
v) if applicable, the notice entitled "Managed Care Action
Taken," containing the Enrollee's fair hearing and aid
continuing rights if not provided with the initial action.
d) Notices of determinations shall be sent to the Enrollee or the
Enrollee's designee within three (3) business days after a
determination is made.
e) In cases where delay would significantly increase the risk to an
Enrollee's health, notice of a determination shall be made by
telephone directly to the Enrollee or to the Enrollee's designee, or
when no phone is available some other method of communication, with
written notice to follow within three (3) business days.
VII. APPEALS
Procedures regarding Enrollee appeals of MCO complaint determinations should
include the following:
a) The Enrollee or designee has no less than sixty (60) business
days after receipt of the notice of the complaint determination to
file a written appeal. Appeals may be submitted by letter or by form
provided by the MCO.
b) Within fifteen (15) business days of receipt of the appeal, the MCO
shall provide written acknowledgment of the appeal including the
name, address and telephone number of the individual designated to
respond to the appeal. The MCO shall indicate what additional
information, if any, must be provided for the MCO to render a
decision.
c) Appeals of clinical matter must be decided by personnel qualified to
review the appeal including licensed, certified or registered health
care professionals who did not make the initial determination, at
least one of whom must be a clinical peer reviewer. Clinical peer
reviewers may be physicians who possess a current and valid
non-restricted license to practice medicine. A clinical peer
reviewer also may be a health care professional, who where
applicable, possesses a current and valid non-restricted license,
certification or registration, or where no provision for a license,
certification, or registration exists, is
APPENDIX F
October 1, 2004
F-5
credentialed by the national accrediting body appropriate to the
profession. The clinical peer reviewer must be a physician or other
health care professional practicing in the same professional
specialty as the healthcare provider who typically manages the
medical condition, procedure or treatment under review.
d) Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original
complaint determination.
e) Appeals shall be decided and notification provided to the
Enrollee no more than:
i) two (2) business days after the receipt of all necessary
information when a delay would significantly increase the risk
to an Enrollee's health;
ii) thirty (30) business days after the receipt of all necessary
information in all other instances.
f) The notice of an appeal determination shall include:
i) the detailed reasons for the determination and the clinical
rationale for the determination;
ii) if applicable, a notice containing fair hearing rights;
iii) the notice shall also inform the Enrollee of his/her option to
also contact the State Department of Health (800-206-8125)
with his/her complaint;
iv) instructions for any further appeal.
VIII. RIGHT TO AN EXTERNAL APPEAL
The MCO shall describe its utilization review policies and procedures including
a notice of the right to an external appeal together with a description of the
external appeal process and the timeframes for external appeal, in the member
handbook. It must be accessible to non-English speaking, visually, and hearing
impaired Enrollees. The handbook shall comply with Section 13 and The Member
Handbook Guidelines (Appendix E) of this Agreement.
IX. RECORDS
The MCO shall maintain a file on each complaint and appeal, if any. The file
shall include:
a) date the complaint was filed;
b) copy of the complaint, if written;
c) date of receipt of and copy of the Enrollee's acknowledgment, if
any;
d) log of complaint determination including the date of the
determination and the titles of the personnel and credentials of
clinical personnel who reviewed the complaint;
e) date and copy of the Enrollee's appeal;
APPENDIX F
October 1, 2004
F-6
f) determination and date of determination of the appeal;
g) the titles, and credentials of clinical staff who reviewed the
appeal.
In addition, the Contractor shall maintain a list of the following:
a) complaints unresolved for greater than 45 days;
b) complaints referred for external appeal.
APPENDIX F
October 1, 2004
F-7
APPENDIX G
NYSDOH GUIDELINES FOR THE PROVISION
OF EMERGENCY CARE AND SERVICES
APPENDIX G
October 1, 2004
G-1
NYSDOH GUIDELINES FOR THE PROVISION OF EMERGENCY CARE AND SERVICES
DEFINITION OF AN "EMERGENCY MEDICAL CONDITION"
The term "Emergency Medical Condition" means a medical or behavioral
condition, the onset of which is sudden, that manifests itself by symptoms
of sufficient severity, including severe pain that a prudent layperson,
possessing an average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result in:
i. 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 the person or others in serious jeopardy; or
ii. serious impairment to such person's bodily functions; or
iii. serious dysfunction of any bodily organ or part of such person; or
iv. serious disfigurement of such person.
Emergency Medical 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.
PROTOCOLS FOR NOTIFICATION/AUTHORIZATION
Preauthorization for treatment of an Emergency Medical Condition is never
required.
In circumstances where notification of arrival in the emergency department
(ED) is requested by the managed care organization following the
assessment and stabilization of the Enrollee, the notification process for
the participating ED should require no more than one (1) phone call (or
fax), and include a limited amount of standard clinical and demographic
information.
APPENDIX G
October 1, 2004
G-2
PROTOCOL FOR ACCEPTABLE TRANSFER BETWEEN FACILITIES
All relevant COBRA requirements must be met.
MCOs must provide for an appropriate (as determined by the ED physician)
transfer method/level with personnel as needed.
MCOs must contact/arrange for an available, accepting physician and
patient bed at the receiving institution.
If a patient is not transferred within eight (8) hours to an appropriate
inpatient setting, after the decision to admit has been made, then
admission at the original facility is deemed authorized.
PROTOCOLS FOR DISPOSITION
If, pursuant to a screening evaluation, ED staff determines that a patient
requires further services (other than emergency medical services), the MCO
will have two (2) hours to respond to a call from the ED with the
appropriate person to discuss the case. If such response is longer than
two (2) hours, that admission or treatment is deemed "authorized" for
purposes of payment.
In the event that the MCO/provider suggests a level of care for a specific
patient deemed inappropriate by the attending physician in the ED, and no
agreement as to disposition can be reached, a physician from the plan must
physically come to the ED and evaluate/take responsibility for this
patient.
TRIAGE FEES
For emergency room services that do not meet the definition of Emergency
Medical Condition, the MCO shall pay the hospital a triage fee of $40.00
in the absence of a negotiated rate.
Non-participating EDs cannot be denied payment on the basis of
non-notification.
APPENDIX G
October 1, 2004
G-3
APPENDIX H
NEW YORK STATE DEPARTMENT OF HEALTH GUIDELINES FOR THE
PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
APPENDIX H
October 1, 2004
H-1
APPENDIX H
SDOH GUIDELINES
FOR THE PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
This appendix is intended to provide general guidelines to LDSS and MCOs for the
processing of enrollments and disenrollments. Where an enrollment broker exists,
the enrollment broker may be responsible for some or all of the LDSS
responsibilities. To allow LDSS and MCOs flexibility in developing processes
that will meet the needs of both parties, SDOH may allow modifications to
timeframes and some procedures. Modifications are to be specified in Section G
of this Appendix and must be agreed to by both parties and receive prior
approval from SDOH.
A. ENROLLMENT
SDOH RESPONSIBILITIES:
1. The SDOH is responsible for monitoring Local District program activities
and providing technical assistance to the LDSS and MCOs to ensure
compliance with the State's policies and procedures.
2. SDOH reviews and approves proposed enrollment materials prior to MCOs
publishing and disseminating or otherwise using the materials.
LDSS RESPONSIBILITIES:
The LDSS has the primary responsibility for the enrollment process.
1. Each local district determines Medicaid eligibility. To the extent
practicable, the LDSS will follow up with Enrollees when the MCO provides
documentation of any change in status which may affect the Enrollee's
Medicaid and/or managed care eligibility.
2. LDSS will provide pre-enrollment information to beneficiaries, consistent
with Social Services Law, Section 364-j(4)(e)(iv) and train persons
providing enrollment counseling to beneficiaries.
3. The LDSS must inform beneficiaries of the availability of MCOs and HIV
SNPs and the scope of services covered by each.
4. LDSS will inform beneficiaries of the right to confidential face-to-face
enrollment counseling and will make confidential face-to-face sessions
available upon request.
5. The LDSS shall advise potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or
have an existing relationship with that such medical services providers
participate in the selected managed care provider's network and are
available to serve the participant.
APPENDIX H
October 1, 2004
H-2
6. For enrollments made during face-to-face counseling, if the participant
has a preference for particular medical services providers, enrollment
counselors shall verify with the medical services providers that such
medical services providers whom the participant prefers participate in the
MCO's network and are available to serve the participant.
7. The LDSS is responsible for the timely processing of managed care
enrollment applications, exemptions, and exclusions and ensuring
attestations are on file for all Enrollees.
8. The LDSS will determine the status of enrollment applications.
Applications will be enrolled, pended or denied.
9. The LDSS will notify the Contractor of plan-assisted enrollment
applications that are denied.
10. The LDSS enters individual enrollment form data and transmits that data to
the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of
enrollment information may be accomplished by any of the following:
i) LDSS directly enters data into PCP Subsystem; or
ii) LDSS or Contractor submits a tape to the State, to be edited and
entered into PCP Subsystem; or
iii) LDSS electronically transfers data, via a dedicated line or Medicaid
Eligibility Verification System (MEVS) to the PCP Subsystem.
11. The LDSS is required to send the following notices to Eligible Persons:
i) Initial Notification Letter: This letter informs the Eligible
Persons about the mandatory program and the timeframes for choosing
a plan. Included with the letter are managed care brochures, an
enrollment form, and information on their rights and
responsibilities under this program, including the option for
HIV/AIDS infected individuals who are categorically exempt from the
mainstream Medicaid Managed Care program to enroll in an HIV SNP on
a voluntary basis in districts where HIV SNPs exist. (MANDATORY
PROGRAM ONLY)
ii) Reminder Letter: A letter to all Eligible Persons in a mandatory
category who have not responded by submitting a completed enrollment
form within thirty (30) days of being sent or given an enrollment
packet. (MANDATORY PROGRAM ONLY)
iii) Enrollment Confirmation Notice: This notice indicates the Effective
Date of Enrollment, the name of the MCO and all individuals who are
being enrolled. This notice should also be used for case additions
and re-enrollments into the same plan.
iv) Notice of Denial of Enrollment: This notice is used when an
individual has been determined by LDSS to be ineligible for
enrollment into a Medicaid managed care plan. This notice must
include fair hearing rights. Note: This notice is not required when
Medicaid eligibility is being denied (or closed).
APPENDIX H
October 1, 2004
H-3
v) Exemption and Exclusion Request Forms: Exemption forms are provided
to Eligible Persons upon request if they wish to apply for an
exemption. Exclusion forms are provided to individuals in New York
City who self-identify as qualifying for an exclusion. Individuals
precoded on the system as meeting exemption or exclusion criteria do
not need to complete an exemption or exclusion request form.
vi) Exemption and Exclusion Request Approval or Denial: This notice is
designed to inform a recipient who applied for an exemption or
exclusion of the LDSS's disposition of the request, including the
right to a fair hearing if the request for exemption or exclusion is
denied.
MCO RESPONSIBILITIES:
1. In those instances in which the Contractor is marketing to persons already
in receipt of Medicaid, the Contractor will submit plan enrollments to
the LDSS, within a maximum of five (5) business days from the day the
enrollment is received by the Contractor (unless otherwise agreed to by
SDOH and LDSS).
2. The Contractor must notify new Enrollees of their Effective Date of
Enrollment. To the extent practicable, such notification must precede the
Effective Date of Enrollment. (Section 13 of the Model Contract).
3. The Contractor must report any changes in status for its enrolled members
to the LDSS within five (5) business days of such information becoming
known to the Contractor. This includes, but is not limited to, factors
that may impact Medicaid eligibility such as address changes, verification
of pregnancy, incarceration, third party insurance, etc.
4. The Contractor shall advise potential Enrollees, in written materials
related to enrollment, to verify with the medical services providers they
prefer, or have an existing relationship with, that such medical services
providers participate in the MCO's selected network and are available to
serve the participant.
5. The Contractor shall accept all enrollments as ordered by the Office of
Temporary and Disability Assistance's Office of Administrative Hearings
due to fair hearing requests or decisions.
B. NEWBORN ENROLLMENTS:
The Contractor agrees to enroll and provide coverage for eligible newborn
children of Enrollees effective from the time of birth.
SDOH Responsibilities:
1. The SDOH will update WMS with information on the newborn received from
hospitals, consistent with the requirements of Section 366-g of the Social
Services Law as amended by Chapter 412 of the, Laws of 1999.
APPENDIX H
October 1, 2004
H-4
2. Upon notification of the birth by the hospital or birthing center, the
SDOH will update WMS with the demographic data for the newborn and enroll
the newborn in the mother's MCO if not already enrolled. The newborn will
be retroactively enrolled back to the first (1st) day of the month of
birth. Based on the transaction date of the enrollment of the newborn on
the PCP subsystem, the newborn will appear on either the next month's
roster or the subsequent month's roster. On plan rosters for upstate and
NYC, the "PCP Effective From Date" will indicate the first day of the
month of birth, as described in 01 OMM/ADM 5 "Automatic Medicaid
Enrollment for Newborns."
LDSS Responsibilities:
1. Grant Medicaid eligibility for newborns for one (1) year if born to a
woman eligible for and receiving MA assistance on the date of birth.
(SOCIAL SERVICES LAW SECTION 366 (4) (1))
2. LDSS must add eligible unborns to all WMS cases that include a pregnant
woman as soon as the pregnancy is medically verified. (NYS DSS
ADMINISTRATIVE DIRECTIVE 85 ADM-33)
3. In the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is to establish MA eligibility and enroll the unborn
in the Contractor's plan.
4. The LDSS is responsible for newborn enrollment should it not be
successfully competed under the "SDOH Responsibilities" process as
outlined in #2 above.
5. When a newborn is enrolled in managed care, the LDSS must send an
Enrollment Confirmation Notice to inform the mother of the Effective Date
of Enrollment, which is the first (1st) day of the month of birth, and the
plan in which the newborn is enrolled.
6. The LDSS may develop a transmittal form to be used for unborn/newborn
notification between the Contractor and the LDSS.
MCO RESPONSIBILITIES:
1. The Contractor must notify the LDSS in writing of any Enrollee that is
pregnant within thirty (30) days of knowledge of the pregnancy.
Notifications should be transmitted to the LDSS at least monthly. The
notifications should contain the pregnant woman's name, Client ID Number
(CIN), and the expected date of confinement (EDC).
2. Upon the newborn's birth, the Contractor must send verifications of
infant's demographic data to the LDSS, within five (5) days after
knowledge of the birth. The
APPENDIX H
October 1, 2004
H-5
demographic data must include: the mother's name and CIN, the newborn's
name and CIN (if newborn has a CIN), sex and the date of birth.
3. In districts that use an Enrollment Broker, the Contractor shall not
submit electronic enrollments of newborns to the Enrollment Broker, as
this will interfere with the retroactive enrollment of the newborn back to
the first (1st) day of the month of birth. For newborns whose mothers are
not enrolled in the Contractor's plan and who were not pre-enrolled into
the plan as an unborn, the Contractor may submit an electronic enrollment
of the newborn to the Enrollment Broker. In such cases, the Effective Date
of Enrollment will be prospective.
4. In voluntary counties, the Contractor will accept applications for unborns
if that is the mother's intent, even if the mother is not and/or will not
be enrolled in the Contractor's plan. In all Counties when a mother is
ineligible for enrollment or chooses not to enroll, the Contractor will
accept applications for pre-enrollment of unborns who are eligible.
5. The Contractor is responsible for provision of services to the newborn and
payment of the hospital or birthing center bill, if the mother is an
Enrollee at the time of the newborn's birth, even if the newborn is not
yet on the Roster.
6. The Contractor will reimburse the hospital or birthing center at the
Medicaid rate (or at another rate if contractually agreed to between the
Contractor and the hospital or birthing center) for this episode of care.
Hospitals and birthing centers have been advised by SDOH to expeditiously
bill MCOs to allow MCOs to arrange for care for the Enrollees. However,
the Contractor may not deny the inpatient hospital or birthing center
costs if billing/notification is not timely except as otherwise provided
by contractual agreement by the Contractor and hospital or birthing
center.
7. Within fourteen (14) days of the date on which the Contractor becomes
aware of the birth, the Contractor will issue a letter informing parent(s)
about the newborn's enrollment and how to access care or a member
identification card.
8. In those cases in which the Contractor it aware of the pregnancy, the
Contractor will ensure that enrolled pregnant women select a PCP for their
infants prior to birth.
9. The Contractor will ensure that the newborn is linked with a PCP prior to
discharge from the hospital or birthing center, in those instances in
which the Contractor has received appropriate notification of birth prior
to discharge.
C. AUTO-ASSIGNMENT PROCESS (MANDATORY PROGRAM ONLY):
This section only applies to a LDSS where CMS has given approval and the LDSS
has begun mandatory enrollment. The details of the auto-assignment process are
contained in Section 12 of the State's Operational Protocol.
APPENDIX H
October 1, 2004
H-6
SDOH RESPONSIBILITIES:
1. SDOH will provide information to LDSS on a daily basis of those
individuals who have been added to the tickler file through the Potential
Auto-Assign List.
2. SDOH, LDSS or Enrollment Broker will assign eligible individuals not
pre-coded in WMS as exempt or excluded, who have not chosen an MCO in the
required time period to an MCO using an algorithm as specified in State
Law SSL Section 364-j(4)(d).
3. SDOH will ensure the auto-assignment process automatically updates the PCP
Subsystem, and will notify the MCO of auto-assigned individuals
electronically.
4. SDOH will notify the LDSS electronically on a daily basis of those
individuals for whom the State has selected a health plan through the
Automated PCP Update Report. Note: This will not apply in Local Districts
that utilize an enrollment broker.
LDSS RESPONSIBILITIES:
1. The LDSS is responsible for tracking an individual's choice period.
2. The LDSS will use the information contained in the Potential Auto-Assign
List for education and outreach purposes.
3. The LDSS will send at least one reminder notice to individuals who fail to
return the enrollment application within thirty (30) days. The LDSS may
employ other methods during the choice period to encourage individuals to
choose an MCO prior to auto-assignment.
4. The LDSS is responsible for providing notification to individuals
regarding their enrollment status as specified in Section A of this
Appendix.
MCO RESPONSIBILITIES:
1) The Contractor is also responsible for providing notification to
individuals regarding their enrollment status as specified in Section A of
this Appendix.
D. ROSTER RECONCILIATION:
All enrollments are effective the first of the month.
SDOH Responsibilities:
1) The SDOH maintains both the PCP subsystem enrollment files and the WMS
eligibility files, using data input by the LDSS. SDOH uses data contained
in both these files to generate the Roster.
APPENDIX H
October 1, 2004
H-7
2) SDOH shall send each MCO and LDSS monthly (according to a schedule
established by SDOH), a complete list of all Enrollees for which the
Contractor is expected to assume medical risk beginning on the 1st of
the following month (First Monthly Roster). Notification to MCOs and LDSS
will be accomplished via paper transmission, magnetic media, or the HPN.
3) SDOH shall send each MCO and LDSS monthly, at the time of the first
monthly roster production, a Disenrollment Report listing those Enrollees
from the previous month's roster who were disenrolled, transferred to
another MCO, or whose enrollments were deleted from the file. Notification
to the MCOs and LDSSs will be accomplished via paper transmission,
magnetic media, or the HPN.
4) The SDOH shall also forward an error report as necessary to each MCO and
LDSS.
5) On the first (1st) weekend after the first (1st) day of the month
following the generation of the first (1st) Roster, SDOH shall send MCOs
and LDSS a second Roster which contains any additional Enrollees that the
LDSS has added for enrollment for the current month. The SDOH will also
include any additions to the error report that have occurred since the
initial error report was generated.
LDSS RESPONSIBILITIES:
1) LDSS must notify the Contractor electronically or in writing of changes in
the First Roster and error report, no later than the end of the month.
(Note: To the extent practicable the date specified must allow for timely
notice to Enrollees regarding their enrollment status. MCOs and the LDSS
may develop protocols for the purpose of resolving Roster discrepancies
that remain unresolved beyond the end of the month. These protocols should
be contained in Section G of this Appendix.)
2) Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, through manual adjustments to the PCP subsystem enrollment and
WMS eligibility files, if appropriate.
MCO RESPONSIBILITIES:
1) The Contractor is at risk for providing Benefit Package services for those
Enrollees listed on the 1st and 2nd rosters for the month in which the 2nd
Roster is generated. Contractor is not at risk for providing services to
Enrollees who appear on the monthly disenrollment report.
2) The Contractor must submit claims to the State's Fiscal Agent for all
Eligible Persons that are on the 1st and 2nd Rosters (see Appendix H, page
7), adjusted to add Eligible Persons enrolled by the LDSS after Roster
production and to remove individuals disenrolled by LDSS after Roster
production (as notified to the Contractor). In the cases of retroactive
disenrollments, the Contractor is responsible for submitting an adjustment
to void any previously paid premiums for the period of retroactive
disenrollment, where the Contractor was not at risk for the provision of
Benefit
APPENDIX H
October 1, 2004
H-8
Package services. Payment of subcapitation does not constitute "provision
of Benefit Package services."
E. DISENROLLMENT:
LDSS RESPONSIBILITIES:
1. The LDSS will accept requests for disenrollment directly from Enrollees
and may not require Enrollees to approach the MCO for a disenrollment
form. Where an LDSS is authorized to mandate enrollment, all requests for
disenrollment must be directed to the LDSS or the enrollment broker. LDSSs
and the enrollment broker must utilize the State-approved Disenrollment
forms.
2. Enrollees may initiate a request for an expedited disenrollment to the
LDSS. The LDSS will expedite the disenrollment process in those cases
where an Enrollee's request for disenrollment involves an urgent medical
need, a complaint of non-consensual enrollment or, in New York City and
other local districts where homeless individuals are exempt, homeless
individuals in the shelter system. If approved, the LDSS will manually
process the disenrollment through the PCP Subsystem.
3. The LDSS will process routine disenrollment requests to take effect on the
first (1st) day of the following month if the request is made BEFORE the
fifteenth (15th) day of the month. In no event shall the Effective Date of
Disenrollment be later than the first (1st) day of the second month after
the month in which an Enrollee requests a disenrollment
4. The LDSS will disenroll Enrollees automatically upon death or loss of
Medicaid eligibility. All such disenrollments will be effective at the end
of the month in which the death or loss of eligibility occurs or at the
end of the last month of guaranteed eligibility, where applicable.
5. In districts where the LDSS has the authority to operate a mandatory
program, and in voluntary counties that enforce lock-in, the LDSS will
disenroll Enrollees who request disenrollment upon determination that they
meet good cause requirements as specified in Section 7.3 and 8.7 of this
Agreement. The LDSS will provide Enrollees with notice of their right to
request a fair hearing if their disenrollment request is denied. This
notice must outline the reason(s) for the denial.
6. The LDSS will promptly disenroll an Enrollee whose managed care
eligibility or health status changes such that he/she is deemed by the
LDSS to meet the exclusion criteria. The LDSS will provide Enrollees with
a notice of their right to request a fair hearing.
APPENDIX H
October 1, 2004
H-9
7. In instances where an Enrollee requests disenrollment due to exclusion,
the LDSS must notify the Enrollee of the approval or denial of
exclusion/disenrollment status, including fair hearing rights if
disenrollment is denied.
8. The LDSS agrees that retroactive disenrollments are to be used only when
absolutely necessary. Circumstances warranting a retroactive disenrollment
are rare and include when an individual is enrolled or autoassigned while
meeting exclusion criteria or when an Enrollee enters or resides in a
residential institution under circumstances which render the individual
excluded from managed care; is incarcerated; is an SSI infant less than
six (6) months of age; or dies - as long as the Contractor was not at risk
for provision of Benefit Package services for any portion of the
retroactive period. Payment of subcapitation does not constitute
"provision of Benefit Package services." The LDSS must notify the
Contractor of the retroactive disenrollment prior to the action. The LDSS
must find out if the Contractor has made payments to providers on behalf
of the Enrollee prior to disenrollment. After this information is
obtained, the LDSS and Contractor will agree on a retroactive
disenrollment or prospective disenrollment date.
In all cases of retroactive disenrollment, including disenrollments
effective the first day of the current month, the local district must
notice the Contractor at the time of disenrollment, of the Contractors
responsibility to submit to the SDOH's Fiscal Agent voided premium claims
for any full months of retroactive disenrollment where the Contractor was
not at risk for the provision of Benefit Package services during the
month. However, failure by the LDSS to so notify the Contractor does not
affect the right of the SDOH to recover the premium payment as authorized
by Section 3.6 of this Agreement.
APPENDIX H
October 1, 2004
H-10
9. Generally the effective dates of disenrollment are prospective. Effective
dates for other than routine disenrollments are described below:
REASON FOR DISENROLLMENT EFFECTIVE DATE OF DISENROLLMENT
- ------------------------ -------------------------------
- - Infants weighing less than 1200 grams - First Day of the month of birth
at birth and other infants under six (6) or the month of onset of disability,
months of age who meet the criteria for whichever is later
the SSI or SSI related category
- - Death of Enrollee - First day of the month after
death
- - Incarceration - First day of the month
after incarceration
- - Enrollee entered or stayed in a residential - First day of the month
institution under circumstances which following entry or first day of
rendered the individual excluded from the month following
managed care, including when an Enrollee is classification of the stay as
admitted to a hospital that 1) is certified permanent, subsequent to
by Medicare as a long-term care hospital and entry(1)
2) has an average length of stay for all
patients greater than ninety-five (95) days
as reported in the Statewide Planning and
Research Cooperative System (SPARCS) Annual
Report 2002.
- - Individual enrolled or autoassigned - Effective Date of Enrollment
while meeting exclusion criteria in the Contractor's Plan.
Move by Enrollee
- (Non-NYC)-Enrollee moved - First day of the month after
outside of the Service Area of the the update of the system with
contract the new address(2)
- (NYC)-Enrollee moved outside of - First day of month after the
New York City update of the system with the
new address(3)
(1)Local districts shall make adjustments as necessary to allow a
residential institution to be reimbursed by SDOH's Fiscal Agent for
services provided by the residential institution if such stay is under
circumstances which render the Enrollee excluded from managed care. However
in such instances, if the Contractor was at risk for providing Benefit
Package services to the Enrollee for a portion of the month, the Contractor
is entitled to keep the capitation payment for the month.
(2) In counties outside of New York City, LDSSs should work together to
ensure continuity of care through the Contractor if the Contractor's
service area includes the county to which the Enrollee has moved and the
Enrollee, with continuous eligibility, wishes to stay enrolled in the
Contractor's plan.
APPENDIX H
October 1, 2004
H-11
(3)In New York City, Enrollees, not in guaranteed status, who move out of
the Contractor's Service Area but not outside, of the City of New York
(e.g., move from one borough to another), will not be involuntarily
disenrolled, but must request a disenrollment or transfer. These
disenrollments will be performed on a routine basis unless there is an
urgent medical need to expedite the disenrollment.
10. The LDSS is responsible for informing Enrollees of their right to change
MCOs including any applicable lock-in restrictions. For those LDSSs that
have implemented a mandatory enrollment program, families or members of a
case wishing to change MCOs will be required to do so as a unit, unless
the LDSS determines a "good cause" reason to waive this requirement as
specified in Section 6.6(c)(i) of this Agreement.
11. The LDSS will render a decision within thirty (30) days of the receipt of
a fully documented request for disenrollment, except for
Contractor-initiated disenrollments where the LDSS decision must be made
within fifteen (15) days as specified in Section 8.8 (g) of this
Agreement.
12. The LDSS is responsible for sending the following notices to Enrollees
regarding their disenrollment status. Where practicable, the process will
allow for timely notification to Enrollees unless there is "good cause" to
disenroll more expeditiously.
a) Notice of Disenrollment: These notices will advise the Enrollee of
the LDSS's determination regarding an Enrollee-initiated,
LDSS-initiated or Contractor-initiated disenrollment and will
include the Effective Date of Disenrollment. In cases where the
Enrollee is being involuntarily disenrolled, the notice must contain
fair hearing rights.
b) When the LDSS denies any Enrollee's request for disenrollment
pursuant to Section 8 of the contract, the LDSS must inform the
Enrollee in writing explaining the reason for the denial, stating
the facts upon which the denial is based, citing the statutory and
regulatory authority and advising the Enrollee of his/her right to a
fair hearing pursuant to 18NYCRR Part 358.
c) End of Lock-In Notice: Where Lock-In provisions are enforced,
Enrollees must be notified sixty (60) days before the end of their
Lock-In Period.
d) Notice of Change to "Guarantee Coverage": This notice will advise
the Enrollee that his or her Medicaid coverage is ending and how
this affects his or her enrollment in Medicaid managed care. This
notice contains pertinent information regarding "guaranteed
eligibility" benefits and dates of coverage. If an Enrollee is not
eligible for guarantee, this notice is not necessary.
APPENDIX H
October 1, 2004
H-12
13. The LDSS may require that an individual that has been disenrolled at the
request of the Contractor be returned to the Medicaid fee-for-service
program.
14. In those instances where the LDSS approves the Contractor's request to
disenroll an Enrollee, and the Enrollee requests a fair hearing, the
Contractor will continue to keep the Enrollee in the plan until the
disposition of the fair hearing, when Aid to Continue is ordered by OAH.
15. The LDSS will review each Contractor requested disenrollment in accordance
with the provisions of Section 8.8 of this Agreement. Where applicable,
the LDSS may consult with local mental health and substance abuse
authorities in the district when making the determination to approve or
disapprove the request.
16. The LDSS shall establish procedures whereby the Contractor refers cases
which are appropriate for an LDSS-initiated disenrollment and submits
supporting documentation to the LDSS.
17. After the LDSS receives and, if appropriate, approves the request for
disenrollment either from the Enrollee or the Contractor, the LDSS will
update the PCP subsystem file with an end date. MEVS and the Fiscal Agent
are then updated to reflect the Enrollee's return to fee-for-service
processing. The Enrollee is removed from the Contractor's Roster.
MCO RESPONSIBILITIES:
1. In those instances where the Contractor directly receives disenrollment
forms, the Contractor will forward these disenrollments to the LDSS for
processing within five (5) business days (or according to Section F of
this Appendix). During pulldown week, these forms may be faxed to the LDSS
with the hard copy to follow.
2. The Contractor must accept and transmit all requests for voluntary
disenrollments from its Enrollees to the LDSS, and shall not impose any
barriers to disenrollment requests. The Contractor may require that a
disenrollment request be in writing, contain the signature of the
Enrollee, and state the Enrollee's correct MCO or Medicaid identification
number.
3. Following LDSS procedures, the Contractor will refer cases which are
appropriate for an LDSS-initiated disenrollment and will submit supporting
documentation to the LDSS. This includes, but is not limited to, changes
in status for its enrolled members that may impact eligibility for
enrollment in an MCO such as address changes, incarceration, death,
exclusion from managed care, etc.
4. With respect to Contractor-initiated disenrollments:
a) The Contractor may initiate an involuntary disenrollment if the
Enrollee engages in conduct or behavior that seriously impairs the
Contractor's ability
APPENDIX H
October 1, 2004
H-13
to furnish services to either the Enrollee or other Enrollee's,
provided that the Contractor has made and documented reasonable
efforts to resolve the problems presented by the Enrollee.
b) The Contractor may not request disenrollment because of an adverse
change in the Enrollee's health status or because of the Enrollee's
utilization of medical services, diminished mental capacity, or
uncooperative or disruptive behavior resulting from the Enrollee's
special needs (except where continued enrollment in the Contractor's
plan seriously impairs the Contractor's ability to furnish services
to either the Enrollee or other Enrollees).
c) The Contractor must make a reasonable effort to identify for the
Enrollee, both verbally and in writing, those actions of the
Enrollee that have interfered with the effective provision of
covered services as well as explain what actions or procedures are
acceptable.
d) The Contractor shall give prior verbal and written notice to the
Enrollee, with a copy to the LDSS, of its intent to request
disenrollment. The written notice shall advise the Enrollee that the
request has been forwarded to the LDSS for review and approval. The
written notice must include the mailing address and telephone number
of the LDSS.
e) The Contractor shall keep the LDSS informed of decisions related to
all complaints filed by an Enrollee is a result of, or subsequent
to, the notice of intent to disenroll.
5. The Contractor will not consider an Enrollee disenrolled without
confirmation from the LDSS or the Roster (as described in Section D of
this Appendix).
F. EXPEDITED DISENROLLMENTS
Enrollees may request an expedited disenrollment if they have an urgent medical
need to disenroll, if they were non-consensually enrolled in a managed care
plan, or, if they are homeless and residing in the shelter system in New York
City or other local districts where homeless individuals are exempt.
Individuals who request to be disenrolled from managed care based on their
documented 1 HIV, ESRD, or SPMI/SED status are categorically eligible for an
expedited disenrollment on the basis of urgent medical need.
LDSS RESPONSIBILITIES:
1. The LDSS, to the extent possible, will process an expedited disenrollment
within two business days of its determination that an expedited
disenrollment is warranted. A disenrollment notice must be sent to the
Enrollee outlining approval of the disenrollment request, including the
Effective Date of Disenrollment.
APPENDIX H
October 1, 2004
H-14
2. The Effective Date of Disenrollments resulting from expedited processing
are as follows:
REASON FOR DISENROLLMENT EFFECTIVE DATE OF DISENROLLMENT
- ------------------------ --------------------------------
Urgent medical need First day of the next month after
determination except where
medical need requires an earlier
disenrollment
Non-consensual enrollment Retroactive to the first day of
the month of enrollment
Homeless individuals residing in the shelter Retroactive to the first day of
system in NYC or in other districts where the month of the request
homeless individuals are exempt
G. LDSS AND PLAN SPECIFIC ADDENDA TO APPENDIX H.
LDSS Name DUTCHESS COUNTY
MCO Name WELLCARE OF NEW YORK,INC.
APPENDIX H
October 1, 2005
H-15
APPENDIX I
NEW YORK STATE DEPARTMENT OF HEALTH
GUIDELINES FOR USE OF MEDICAL RESIDENTS
APPENEDIX I
October 1, 2004
I-1
APPENDIX I
MEDICAL RESIDENTS
(a) Medical Residents as Primary Care Providers. MCOs may utilize medical
residents as participants (but not designated as 'primary care providers')
in the care of Enrollees as long as all of the following conditions are
met:
1) Residents are a part of patient care teams headed by fully licensed
and MCO credentialed attending physicians serving patients in one or
more training sites in an "up weighted" or "designated priority"
residency program. Residents in a training program which was
disapproved, as a designated priority program solely due to the
outcome measurement requirement for graduates may be eligible to
participate in such patient care teams.
2) Only the attending physicians and nurse practitioners on the
training team, not residents, may be credentialed to the MCO and may
be empanelled with Enrollees. Enrollees must be assigned an
attending physician or certified nurse practitioner to act as their
PCP, though residents on the team may perform all or many of the
visits to the Enrollee as long as the majority of these visits are
under the direct supervision of the Enrollee's designated PCP.
Enrollees have the right to request care by their PCP in addition or
instead of being seen by a resident.
3) Residents may work with attending physicians and certified nurse
practitioners to provide continuity of care to patients under the
supervision of the patient's PCP. Patients must be made aware of the
resident/attending relationship and be informed of their rights to
be cared for directly by their PCP.
4) Residents eligible to be involved in a continuity relationship with
patients must be available at least 20% of the total training time
in the continuity of care setting and no less than 10% of training
time in any training year must be in the continuity of care setting
and no fewer than nine (9) months a year must be spent in the
continuity of care setting.
5) Residents meeting these criteria provide increased capacity for
enrollment to their team according to the following formula:
PGY-1 300 per FTE
PGY-2 750 per FTE
PGY-3 1125 per FTE
PGY-4 1500 per FTE
Only hours spent routinely scheduled for patient care in the continuity of
care training site may count as providing capacity and are based on 1.0
FTE=40 hours.
APPENEDIX I
October 1, 2004
I-2
6) In order for a resident to provide continuity of care to an
Enrollee, both the resident and the attending PCP must have regular
hours in the continuity site and must be scheduled to be in the site
together the majority of the time.
7) A preceptor/attending is required to be present a minimum of sixteen
(16) hours of combined precepting and direct patient care in the
primary care setting to be counted as a team supervising PCP and
accept an increased number of Enrollees based upon the residents
working on his/her team. Time spent in patient care activities at
other clinical sites or in other activities off-site is not counted
towards this requirement.
8) A sixteen (16) hour per week attending may have no more than four
(4) residents on their team. Attendings spending twenty-four (24)
hours per week in patient care/supervisory activity at the
continuity site could have six (6) residents per team. Attendings
spending thirty-two (32) hours per week could have eight (8)
residents on their team. Two (2) or more attendings may join
together to form a larger team as long as the ratio of attending to
residents does not exceed 1:4 and all attendings comply with the
sixteen (16) hour minimum.
9) Specialty consults must be performed or directly supervised by a MCO
credentialed specialist. The specialist may be assisted by a
resident or fellow.
10) Responsibility for the care of the Enrollee remains with the
attending physician. All attending/resident teams must provide
adequate continuity of care, twenty-four (24) hour a day, seven (7)
day a week coverage, and appointment and availability access.
11) Residents who do not qualify to act as continuity providers as part
of an attending/resident team may sill participate in the episodic
care of Enrollees as long as that care is under the supervision of
an attending physician credentialed to a MCO. Such residents would
not add to the capacity of that attending to empanel Enrollees,
however.
12) Certified nurse practitioners and registered physician's assistants
may not act as attending preceptors for resident physicians.
(B) MEDICAL RESIDENTS AS SPECIALTY CARE PROVIDERS
(1) Residents may participate in the specialty care of Medicaid managed
care patients in all settings supervised by fully licensed and
MCO/PHSP credentialed specialty attending physicians.
(2) Only the attending physicians, not residents or fellows, may be
credentialed by the MCO. Each attending must be credentialed by each
APPENEDIX I
October 1, 2004
I-3
MCO with which they will participate. Residents may perform all or
many of the clinical services for the Enrollee as long as these
clinical services are under the supervision of an appropriately
credentialed specialty physician. Even when residents are
credentialed by their program in particular procedures, certifying
their competence to perform and teach those procedures, the overall
care of each Enrollee remains the responsibility of the supervising
MCO-credentialed attending.
(3) It is understood that many Enrollees will identify a resident as
their specialty provider but the responsibility for all clinical
decision-making remains with the attending physician of record.
(4) Enrollees must be given the name of the responsible attending
physician in writing and be told how they may contact their
attending physician or covering physician, if needed. This allows
Enrollees to assist in the communication between their primary care
provider and specialty attending and enables them to reach the
specialty attending if an emergency arises in the course of their
care. Enrollees must be made aware of the resident/attending
relationship and must have a right to be cared for directly by the
responsible attending physician, if requested.
(5) Enrollees requiring ongoing specialty care must be cared for in a
continuity of care setting. This requires the ability to make
follow-up appointments with a particular resident/attending
physician, or if that provider team is not available, with a member
of the provider's coverage group in order to insure ongoing
responsibility for the patient by his/her MCO credentialed
specialist. The responsible specialist and his/her specialty
coverage group must be identifiable to the patient as well as to the
referring primary care provider.
(6) Attending specialists must be available for emergency consultation
and care during non-clinic hour's Emergency coverage may be provided
by residents under adequate supervision. The attending or a member
of the attending's coverage group must be available for telephone
and/or in-person consultation when necessary.
(7) All training programs participating in Medicaid managed care must be
accredited by the appropriate academic accrediting agency.
(8) All sites in which residents train must produce legible (preferably
typewritten) consultation reports. Reports must be transmitted such
they are received in a time frame consistent with the clinical
condition of the patient, the urgency of the problem and the need
for follow-up by the primary care physician. At a minimum, reports
should be transmitted so that they are received no later than two
(2) weeks from the date of the specialty visit.
APPENEDIX I
October 1, 2004
I-4
(9) Written reports are required at the time of initial consultation and
again with the receipt of all major significant diagnostic
information or changes in therapy. In addition, specialists must
promptly report to the referring primary care physician any
significant findings or urgent changes in therapy which result from
the specialty consultation.
All training sites must deliver the same standard of care to all patients
irrespective of payor. Training sites must integrate the care of Medicaid,
uninsured and private patients in the same settings.
APPENEDIX I
October 1, 2004
I-5
APPENDIX J
NEW YORK STATE DEPARTMENT OF HEALTH GUIDELINES OF FEDERAL
AMERICANS WITH DISABILITIES ACT
APPENDIX J
October 1, 2004
J-1
GUIDELINES FOR MEDICAID MCO COMPLIANCE
WITH THE AMERICANS WITH DISABILITIES ACT (ADA)
I. OBJECTIVES
Title II of the Americans With Disabilities Act (ADA) and Section 504 of the
Rehabilitation Act of 1973 (Section 504) provides that no qualified individual
with a disability shall, by reason of such disability, be excluded from
participation in or denied access to the benefits of services, programs or
activities of a public entity, or be subject to discrimination by such an
entity. Public entities include State and local government and ADA and Section
504 requirements extend to all programs and services provided by State and local
government. Since Medicaid is a government program, health services provided
through Medicaid Managed Care must be accessible to all who qualify for the
program.
MCO responsibilities for compliance with the ADA are imposed under Title II and
Section 504 when, as a contractor in a Medicaid program, a plan is providing a
government service. If an individual provider under contract with the MCO is not
accessible, it is the responsibility of the MCO to make arrangements to assure
that alternative services are provided. The MCO may determine it is expedient to
make arrangements with other providers, or to describe reasonable alternative
means and methods to make these services accessible through its existing
contractors. The goals of compliance with ADA Title II requirements are to offer
a level of services that allows people with disabilities access to the program
in its entirety, and the ability to achieve the same health care results as any
program participant.
MCO responsibilities for compliance with the ADA are also imposed under Title
III when the MCO functions as a public accommodation providing services to
individuals (e.g. program areas and sites such as marketing, education, member
services, orientation, complaints and appeals). The goals of compliance with ADA
Title III requirements are to offer a level of services that allows people with
disabilities full and equal enjoyment of the goods, services, facilities or
accommodations that the entity provides for its customers or clients. New and
altered areas and facilities must be as accessible as possible. Whenever MCOs
engage in new construction or renovation, compliance is also required with
accessible design and construction standards promulgated pursuant to the ADA as
well as State and local laws. Title III also requires that public accommodations
undertake "readily achievable barrier removal" in existing facilities where
architectural and communications barriers can be removed easily and without much
difficulty or expense.
The state uses Plan Qualification Standards to qualify MCOs for participation in
the Medicaid Managed Care Program. Pursuant to the state's responsibility to
assure program access to all recipients, the Plan Qualification Standards
require each MCO to submit an ADA Compliance Plan that describes in detail how
the MCO will make services, programs and activities readily accessible and
useable by
APPENDIX J
October 1, 2004
J-2
individuals with disabilities. In the event that certain program sites are not
readily accessible, the MCO must describe reasonable alternative methods for
making the services or activities accessible and usable.
The objectives of these guidelines are threefold:
- to ensure that MCOs take appropriate steps to measure access and
assure program accessibility for persons with disabilities;
- to provide a framework for managed care organizations (MCOs) as they
develop a plan to assure compliance with the Americans with
Disabilities Act (ADA); and
- to provide standards for the review of MCO Compliance Plans.
These guidelines include a general standard followed by a discussion of specific
considerations and suggestions of methods for assuring compliance. Please be
advised that, although these guidelines and any subsequent reviews by State and
local governments can give the contractor guidance, it is ultimately the
contractor's obligation to ensure that it complies with its contractual
obligations, as well as with the requirements of the ADA, Section 504, and other
federal, state and local laws. Other federal, state and local statutes and
regulations also prohibit discrimination on the basis of disability and may
impose requirements in addition to those established under ADA. For example,
while the ADA covers those impairments that "substantially" limit one or more of
the major life activities of an individual, New York City Human Rights Law
deletes the modifier "substantially".
II. DEFINITIONS
A. "Auxiliary aids and services" may include qualified interpreters, note
takers, computer-aided transcription services, written materials,
telephone handset amplifiers, assistive listening systems, telephones
compatible with hearing aids, closed caption decoders, open and closed
captioning, telecommunications devices for enrollees who are deaf or hard
of hearing (TTY/TDD), video test displays, and other effective methods of
making aurally delivered materials available to individuals with hearing
impairments; qualified readers, taped texts, audio recordings, Brailled
materials, large print materials, or other effective methods of making
visually delivered materials available to individuals with visual
impairments.
B. "Disability" means a mental or physical impairment that substantially
limits one or more of the major life activities of an individual; a record
of such impairment; or being regarded as having such an impairment.
APPENDIX J
October 1, 2004
J-3
III. SCOPE OF MCO COMPLIANCE PLAN
The MCO Compliance Plan must address accessibility to services at the
MCO's program sites, including both participating provider sites and MCO
facilities intended for use by enrollee.
IV. PROGRAM ACCESSIBILITY
Public programs and services, when viewed in their entirety, must be
readily accessible to and useable by individuals with disabilities. This
standard includes physical access, non-discrimination in policies and
procedures and communication. Communications with individuals with
disabilities are required to be as effective as communications with
others. The MCO Compliance Plan must include a detailed description of how
MCO services, programs and activities are readily accessible and usable by
individuals with disabilities. In the event that full physical
accessibility is not readily available for people with disabilities, the
MCO Compliance Plan will describe the steps or actions the MCO will take
to assure accessibility to services equivalent to those offered at the
inaccessible facilities.
IV PROGRAM ACCESSIBILITY
A. PRE-ENROLLMENT MARKETING AND EDUCATION
STANDARD FOR COMPLIANCE;
Marketing staff, activities and materials will be made available to persons with
disabilities. Marketing materials will be made available in alternative formats
(such as Braille, large print, audio tapes) so that they are readily usable by
people with disabilities.
SUGGESTED METHODS FOR COMPLIANCE
1. Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary
2. Materials available in alternative formats, such as Braille, large print,
audio tapes
3. Staff training which includes training and information regarding
attitudinal barriers related to disability
4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the marketing script used by plan
marketing representatives
5. Enrollee health promotion material/activities targeted specifically to
persons with disabilities (e.g. secondary infection prevention,
APPENDIX J
October 1, 2004
J-4
decubitus prevention, special exercise programs, etc.)
6. Policy statement that marketing representatives will offer to read or
summarize to blind or vision impaired individuals any written material
that is typically distributed to all enrollees
7. Staff/resources available to assist individuals with cognitive impairments
in understanding materials
COMPLIANCE PLAN SUBMISSION
1. A description of methods to ensure that the MCO's marketing presentations
(materials and communications) are accessible to persons with auditory,
visual and cognitive impairments
2. A description of the MCO's policies and procedures, including marketing
training, to ensure that marketing representatives neither screen health
status nor ask questions about health status or prior health care services
IV. PROGRAM ACCESSIBILITY
B. MEMBER SERVICES DEPARTMENT
Member services functions include the provision to enrollees of information
necessary to make informed choices about treatment options, to effectively
utilize the health care resources, to assist enrollees in making appointments,
and to field questions and complaints, to assist enrollees with the complaint
process.
B1. ACCESSIBILITY
STANDARD FOR COMPLIANCE:
Member Services sites and functions will be made accessible to, and usable by,
people with disabilities.
SUGGESTED METHODS FOR COMPLIANCE (include, but are not limited to those
identified below)
1. Exterior routes of travel, at least 36" wide, from parking areas or public
transportation stops into the MCO's facility
2. If parking is provided, spaces reserved for people with disabilities,
pedestrian ramps at sidewalks, and dropoffs
3. Routes of travel into the facility are stable, slip-resistant, with all
steps > 1/2" ramped, doorways with minimum 32" opening
4. Interior halls and passageways providing a clear and unobstructed path or
travel at least 36" wide to bathrooms and other rooms commonly used by
enrollees
5. Waiting rooms, restrooms, and other rooms used by enrollees are accessible
to people with disabilities
6. Sign language interpreters and other auxiliary aids and services provided
in appropriate circumstances
APPENDIX J
October 1, 2004
J-5
7. Materials available in alternative formats, such as Braille, large print,
audio tapes
8. Staff training which includes sensitivity training related to disability
issues [Resources and technical assistance are available through the NYS
Office of Advocate for Persons with Disabilities - V/TTY (800) 522-4369;
and the NYC Mayor's Office for People with Disabilities - (212) 788-2830
or TTY (212)788-2838]
9. Availability of activities and educational materials tailored to specific
conditions/illnesses and secondary conditions that affect these
populations (e.g. secondary infection prevention, decubitus prevention,
special exercise programs, etc.)
10. MCO staff trained in the use of telecommunication devices for enrollees
who are deaf or hard of hearing (TTY/TDD) as well as in the use of NY
Relay for phone communication
11. New enrollee orientation available in audio or by interpreter services
12. Policy that when member services staff receive calls through the NY Relay,
they will offer to return the call utilizing a direct TTY/TDD connection
COMPLIANCE PLAN SUBMISSION
1. A description of accessibility to the member services department or
reasonable alternative means to access member services for enrollees using
wheelchairs (or other mobility aids)
2. A description of the methods the member services department will use to
communicate with enrollees who have visual or hearing impairments
including any necessary auxiliary aid/services for enrollees who are deaf
or hard of hearing, and TTY/TDD technology or NY Relay Service available
through a toll-free telephone number
3. A description of the training provided to member services staff to assure
that staff adequately understands how to implement the requirements of the
program, and of these guidelines, and are sensitive to the needs of
persons with disabilities
IV. PROGRAM ACCESSIBILITY
B2. IDENTIFICATION OF ENROLLEES WITH DISABILITIES
STANDARD FOR COMPLIANCE:
MCOs must have in place satisfactory methods/guidelines for identifying persons
at risk of, or having, chronic diseases and disabilities and determining their
specific needs in terms of specialist physician referrals, durable medical
equipment, medical supplies, home health services etc. MCOs may not discriminate
against a potential enrollee based on his/her current health status or
anticipated need for future health care. MCOs may not discriminate on the basis
of disability, or perceived disability of an enrollee or their family member.
Health assessment forms may not be used by plans prior to enrollment. ( Once a
plan has been chosen, a health assessment form may be used to assess the
person's health care needs.)
APPENDIX J
October 1, 2004
J-6
SUGGESTED METHODS FOR COMPLIANCE
1. Appropriate post enrollment health screening for each enrollee, using an
appropriate health screening tool
2. Patient profiles by condition/disease for comparative analysis to national
norms, with appropriate outreach and education
3. Process for follow-up of needs identified by initial screening; e.g.
referrals, assignment of case manager, assistance with scheduling/keeping
appointments
4. Enrolled population disability assessment survey
5. Process for enrollees who acquire a disability subsequent to enrollment to
access appropriate services
COMPLIANCE PLAN SUBMISSION
1. A description of how the MCO will identify special health care, physical
access or communication needs of enrollees on a timely basis, including
but not limited to the health care needs of enrollees who:
- are blind or have visual impairments, including the type of
auxiliary aids and services required by the enrollee
- are deaf or hard of hearing, including the type of auxiliary aids
and services required by the enrollee
- have mobility impairments, including the extent, if any, to which
they can ambulate
- have other physical or mental impairments or disabilities, including
cognitive impairments
- have conditions which may require more intensive case management
IV. PROGRAM ACCESSIBILITY
B3. NEW ENROLLEE ORIENTATION
STANDARD FOR COMPLIANCE:
Enrollees will be given information sufficient to ensure that they understand
how to access medical care through the plan. This information will be made
accessible to, and usable by, people with disabilities.
SUGGESTED METHODS FOR COMPLIANCE
1. Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as necessary
2. Materials available in alternative formats, such as Braille, large print,
audio tapes
3. Staff training which includes sensitivity training related to disability
issues [Resources and technical assistance are available
APPENDIX J
October 1, 2004
J-7
through the NYS Office of Advocate for Persons with Disabilities - V/TTY
(800) 522-4369; and the NYC Mayor's Office for People with Disabilities -
(212) 788-2830 or TTY (212)788-2838]
4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the marketing script used by plan
marketing representatives
5. Include in written/audio materials available to all enrollees information
regarding how and where people with disabilities can access help in
getting services, for example help with making appointments or for
arranging special transportation, an interpreter or assistive
communication devices
6. Staff/resources available to assist individuals with cognitive impairments
in understanding materials
COMPLIANCE PLAN SUBMISSION
1. A description of how the MCO will advise enrollees with disabilities,
during the new enrollee orientation on how to access care
2. A description of how the MCO will assist new enrollees with disabilities
(as well as current enrollees who acquire a disability) in selecting or
arranging an appointment with a Primary Care Practitioner (PCP)
- This should include a description of how the MCO will assure and
provide notice to enrollees who are deaf or hard of hearing, blind
or who have visual impairments, of their right to obtain necessary
auxiliary aids and services during appointments and in scheduling
appointments and follow-up treatment with participating providers
- In the event that certain provider sites are not physically
accessible to enrollees with mobility impairments, the MCO will
assure that reasonable alternative site and services are available
3. A description of how the MCO will determine the specific needs of an
enrollee with or at risk of having a disability/chronic disease, in terms
of specialist physician referrals, durable medical equipment (including
assistive technology and adaptive equipment), medical supplies and home
health services and will assure that such contractual services are
provided
4. A description of how the MCO will identify if an enrollee with a
disability requires on-going mental health services and how MCO will
encourage early entry into treatment
5. A description of how the MCO will notify enrollees with disabilities as to
how to access transportation, where applicable
IV. PROGRAM ACCESSIBILITY
B4. COMPLAINTS AND APPEALS
STANDARD FOR COMPLIANCE:
The MCO will establish and maintain a procedure to protect the rights and
interests of both enrollees and managed care plans by receiving, processing, and
resolving grievances and complaints in an expeditious manner, with the goal of
ensuring resolution of complaints and
APPENDIX J
October 1, 2004
J-8
access to appropriate services as rapidly as possible.
All enrollees must be informed about the complaint process within their plan and
the procedure for filing complaints. This information will be made available
through the member handbook, the SDOH toll-free complaint line [1-(800)
206-8125] and the plan's complaint process annually, as well as when the MCO
denies a benefit or referral. The MCO will inform enrollees of: the MCO's
complaint procedure; enrollees' right to contact the local district or SDOH with
a complaint, and to file an appeal or request a fair hearing; the right to
appoint a designee to handle a complaint or appeal; the toll free complaint
line. The MCO will maintain designated staff to take and process complaints, and
be responsible for assisting enrollees in complaint resolution.
The MCO will make all information regarding the complaint process available to
and usable by people with disabilities, and will assure that people with
disabilities have access to sites where enrollees typically file complaints and
requests for appeals.
SUGGESTED METHODS FOR COMPLIANCE
1. 800 complaint phone line with TDD/TTY capability
2. Staff trained in complaint process, and able to provide interpretive or
assistive support to enrollee during the complaint process
3. Notification materials and complaint forms in alternative formats for
enrollees with visual or hearing impairments
4. Availability of physically accessible sites, e.g. member services
department sites
5. Assistance for individuals with cognitive impairments
COMPLIANCE PLAN SUBMISSION
1. A description of how MCO's complaint and appeal procedures shall be
accessible for persons with disabilities, including:
- procedures for complaints and appeals to be made in person at sites
accessible to persons with mobility impairments
- procedures accessible to persons with sensory or other impairments
who wish to make verbal complaints, and to communicate with such
persons on an ongoing basis as to the status or their complaints and
rights to further appeals
- description of methods to ensure notification material is available
in alternative formats for enrollees with vision and hearing
impairments
2. A description of how MCOs monitor complaints and grievances related to
people with disabilities. Also, as part of the Compliance Plan, MCOs must
submit a summary report based on the MCO's most recent year's complaint
data.
APPENDIX J
October 1, 2004
J-9
IV. PROGRAM ACCESSIBILITY
C. CASE MANAGEMENT
STANDARD FOR COMPLIANCE:
MCOs must have in place adequate case management systems to identify the service
needs of all enrollees, including enrollees with chronic illness and enrollees
with disabilities, and ensure that medically necessary covered benefits are
delivered on a timely basis. These systems must include procedures for standing
referrals, specialists as PCPs, and referrals to specialty centers for enrollees
who require specialized medical care over a prolonged period of time (as
determined by a treatment plan approved by the MCO in consultation with the
primary care provider, the designated specialist and the enrollee or his/her
designee), out of plan referrals and continuation of existing treatment
relationships with out-of-plan providers (during transitional
period).
SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting specialist physicians to function as PCP
2. Procedures for requesting standing referrals to specialists and/or
specialty centers, out of plan referrals, and continuation of existing
treatment relationships.
3. Procedures to meet enrollee needs for, durable medical equipment, medical
supplies, home visits as appropriate
4. Appropriately trained MCO staff to function as case managers for special
needs populations, or sub-contract arrangements for case management
5. Procedures for informing enrollees about the availability of case
management services
COMPLIANCE PLAN SUBMISSION
1. A description of the MCO case management program for people with
disabilities, including case management functions, procedures for
qualifying for and being assigned a case manager, and description of case
management staff qualifications
2. A description of the MCO's model protocol to enable participating
providers, at their point of service, to identify enrollees who require a
case manager
3. A description of the MCO's protocol for assignment of specialists as PCP,
and for standing referrals to specialists and specialty centers,
out-of-plan referrals and continuing treatment relationships
4. A description of the MCO's notice procedures to enrollees regarding the
availability of case management services, specialists as PCPs, standing
referrals to specialists and specialty centers, out-of-plan referrals and
continuing treatment relationships
APPENDIX J
October 1, 2004
J-10
IV. PROGRAM ACCESSIBILITY
D. PARTICIPATING PROVIDERS
STANDARD FOR COMPLIANCE:
MCOs networks will include all the provider types necessary to furnish the
benefit package, to assure appropriate and timely health care to all enrollees,
including those with chronic illness and/or disabilities. Physical accessibility
is not limited to entry to a provider site, but also includes access to services
within the site, e.g. exam tables and medical equipment.
SUGGESTED METHODS FOR COMPLIANCE
1. Process for MCO to evaluate provider network to ascertain the degree of
provider accessibility to persons with disabilities, to identify barriers
to access and required modifications to policies/procedures
2. Model protocol to assist participating providers, at their point of
service, to identify enrollees who require case manager, audio, visual,
mobility aids, or other accommodations
3. Model protocol for determining needs of enrollees with mental disabilities
4. Use of Wheelchair Accessibility Certification Form (see attached)
5. Submission of map of physically accessible sites
6. Training for providers re: compliance with Title III of ADA, e.g. site
access requirements for door widths, wheelchair ramps, accessible
diagnostic/treatment rooms and equipment; communication issues;
attitudinal barriers related to disability, etc. [Resources and technical
assistance are available through the NYS Office of Advocate for Persons
with Disabilities -V/TTY (800) 522-4369; and the NYC Mayor's Office for
People with Disabilities - (212) 788-2830 or TTY (212)788-2838]
7. Use of ADA Checklist for Existing Facilities and NYC Addendum to OAPD ADA
Accessibility Checklist as guides for evaluating existing facilities and
for new construction and/or alteration.
COMPLIANCE PLAN SUBMISSION
1. A description of how MCO will ensure that its participating provider
network is accessible to persons with disabilities. This includes the
following:
- Policies and procedures to prevent discrimination on the basis of
disability or type of illness or condition
- Identification of participating provider sites which are accessible
by people with mobility impairments, including people using mobility
devices. If certain provider sites are not physically accessible to
persons with disabilities, the MCO shall describe reasonable,
alternative means that result in making the provider services
readily accessible.
- Identification of participating provider sites which do not have
access to sign language interpreters or reasonable alternative
APPENDIX J
October 1, 2004
J-11
means to communicate with enrollees who are deaf or hard of hearing;
and for those sites describe reasonable alternative methods to
ensure that services will be made accessible
- Identification of participating providers which do not have adequate
communication systems for enrollees who are blind or have vision
impairments (e.g. raised symbol and lettering or visual signal
appliances), and for those sites describe reasonable alternative
methods to ensure that services will be made accessible
2. A description of how the MCO's specialty network is sufficient to meet the
needs of enrollees with disabilities
3. A description of methods to ensure the coordination of out-of-network
providers to meet the needs of the enrollees with disabilities
- This may include the implementation of a referral system to ensure
that the health care needs of enrollees with disabilities are met
appropriately
- MCO shall describe policies and procedures to allow for the
continuation of existing relationships with out-of-network
providers, when in the best interest of the enrollee with a
disability
4. Submission of ADA Compliance Summary Report (see attached - county
specific/borough specific for NYC) or MCO statement that data submitted to
SDOH on the Health Provider Network (HPN) files is an accurate reflection
of each network's physical accessibility
IV. PROGRAM ACCESSIBILITY
E. POPULATIONS SPECIAL HEALTH CARE NEEDS
STANDARD FOR COMPLIANCE:
MCOs will have satisfactory methods for identifying persons at risk of, or
having, chronic disabilities and determining their specific needs in terms
of specialist physician referrals, durable medical equipment, medical
supplies, home health services, etc. MCOs will have satisfactory systems
for coordinating service delivery and, if necessary, procedures to allow
continuation of existing relationships with out-of-network provider for
course of treatment.
SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting standing referrals to specialists and/or
specialty centers, specialist physicians to function as PCP, out of plan
referrals, and continuation of existing relationships with out-of-network
providers for course of treatment
2. Contracts with school-based health centers
3. Linkages with preschool services, child protective agencies, early
intervention officials, behavioral health agencies, disability and
advocacy organizations, etc.
4. Adequate network of providers and subspecialists (including pediatric
providers and sub-specialists) and contractual relationships
APPENDIX J
October 1, 2004
J-12
with tertiary institutions
5. Procedures for assuring that these populations receive appropriate
diagnostic workups on a timely basis
6. Procedures for assuring that these populations receive appropriate access
to durable medical equipment on a timely basis
7. Procedures for assuring that these populations receive appropriate allied
health professionals (Physical, Occupational and Speech Therapists,
Audiologists) on a timely basis
8. State designation as a Well Qualified Plan to serve OMRDD population and
look-alikes
COMPLIANCE PLAN SUBMISSION
1. A description of arrangements to ensure access to specialty care providers
and centers in and out of New York State, standing referrals, specialist
physicians to function as PCP, out of plan referrals, and continuation of
existing relationships (out-of-plan) for diagnosis and treatment of rare
disorders.
2. A description of appropriate service delivery for children with
disabilities. This may include a description of methods for interacting
with school districts, preschool services, child protective service
agencies, early intervention officials, behavioral health, and disability
and advocacy organizations and School Based Health Centers.
3. A description of the pediatric provider and sub-specialist network,
including contractual relationships with tertiary institutions to meet the
health care needs of children with disabilities
V. ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS
Please note that Title III of the ADA applies to all non-governmental providers
of health care. Title III of the Americans With Disabilities Act prohibits
discrimination on the basis of disability in the full and equal enjoyment of
goods, services, facilities, privileges, advantages or accommodations of any
place of public accommodation. A public accommodation is a private entity that
owns, leases or leases to, or operates a place of public accommodation. Places
of public accommodation identified by the ADA include, but are not limited to,
stores (including pharmacies) offices (including doctors' offices), hospitals,
health care providers, and social service centers.
New and altered areas and facilities must be as accessible as possible. Barriers
must be removed from existing facilities when it is readily achievable, defined
by the ADA as easily accomplishable without much difficulty or expense. Factors
to be considered when determining if barrier removal is readily achievable
include the cost of the action, the financial resources of the site involved,
and, if applicable, the overall financial resources of any parent corporation or
entity. If barrier removal is not readily achievable, the ADA requires alternate
methods of making goods and services available. New facilities must be
accessible unless structurally impracticable.
Title III also requires places of public accommodation to provide any auxiliary
aids and services that are needed to ensure equal access to the services it
offers, unless a fundamental alteration in the nature of services or an undue
burden would result. Auxiliary aids include but
APPENDIX J
October 1, 2004
J-13
are not limited to qualified sign interpreters, assistive listening systems,
readers, large print materials, etc. Undue burden is defined as "significant
difficulty or expense". The factors to be considered in determining "undue
burden" include, but are not limited to, the nature and cost of the action
required and the overall financial resources of the provider. "Undue burden" is
a higher standard than "readily achievable" in that it requires a greater level
of effort on the part of the public accommodation.
Please note also that the ADA is not the only law applicable for people with
disabilities. In some cases, State or local laws require more than the ADA. For
example, New York City's Human Rights Law, which also prohibits discrimination
against people with disabilities, includes people whose impairments are not as
"substantial" as the narrower ADA and uses the higher "undue burden"
("reasonable") standard where the ADA requires only that which is "readily
achievable". New York City's Building Code does not permit access waivers for
newly constructed facilities and requires incorporation of access features as
existing facilities are renovated. Finally, the State Hospital code sets a
higher standard than the ADA for provision of communication (such as sign
language interpreters) for services provided at most hospitals, even on an
outpatient basis.
APPENDIX J
October 1, 2004
J-14
APPENDIX K
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND
NON-COVERED SERVICES
APPENDIX K
October 1, 2004
K-1
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
October 1, 2004
K-2
17. Experimental or Investigational Treatment
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
October 1, 2004
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) 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
October 1, 2004
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 Continued care in a hospital pending
Alternate Level of placement in an alternate lower medical level
Medical Care of care, consistent with the provisions of 18
NYCRR 505.20 and 10 NYCRR, Part 85.
Professional Ambulatory Provided through ambulatory care facilities
Services 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 HIV phenotypic, HIV virtual phenotypic and HIV
listed in the Medicaid fee schedule. Coverage genotypic drug resistance tests with a
excludes HIV phenotypic, HIV virtual phenotypic Provider's order.
and HIV genotypic drug resistance test.
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 EPSDT is a package of early and periodic
Health Program (C/THP) screening, including inter-periodic screens Services not included in the managed care
and,diagnostic and treatment services Benefit Package ordered by the child's
that are offered to all Medicaid eligible physician based on the results of a
children under twenty-one (21) years screening.
of age known in New York State
as the Child Teen Health Program (C/THP).
APPENDIX K
October 1, 2004
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 Services rendered by a personal care agency
necessary nursing, home health aide services, which are approved by the Local Social
equipment and appliances, physical therapy, Services District when ordered by the Enrollee's
speech/language pathology, occupational Primary Care Provider (PCP). The district will
therapy, social work services or nutritional determine the applicant's need for personal
services provided by a home health care care agency services and coordinate a plan of
agency pursuant to an established care plan. care with the personal care agency.
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.
Private Duty Nursing Covered service when medically necessary in
Services 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 Eye care includes the services of an
Services 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
October 1, 2004
K-6
COVERED SERVICES MANAGED CARE PLAN SCOPE OF BENEFIT COVERED BY MEDICAID FEE-FOR-SERVICE
---------------- ---------------------------------- -----------------------------------
Durable Medical Equipment DME are devices and equipment other
(DME) than medical/surgical supplies, enteral formula, Excluded services, such as disposable
and prosthetic or orthotic appliances. medical/surgical supplies and enteral
Covered when medically necessary as ordered formula with a Provider's order.
by a Contractor's Participating Provider
and procured from a Participating Provider.
Coverage excludes disposable medical/surgical
supplies and enteral formula.
Hearing Aids Services Provided when medically necessary to alleviate Excluded services, such as hearing aid
disability caused by the loss or impairment of batteries with a Provider's order.
hearing. Hearing aid products include hearing
aids, earmolds, special fittings, and
replacement parts. Coverage excludes hearing
aid batteries.
Family Planning and Family planning means the offering, arranging, Enrollees may always obtain family planning
Reproductive Health Services and furnishing of those health services which and HIV testing and counseling services,
enable individuals, including minors, who may be when part of a family planning visit,
sexually active, to prevent or reduce the outside of the plan's network from any
SEE SCHEDULE A OF incidence of unintended pregnancies Provider that accepts Medicaid.
APPENDIX K FOR COVERAGE and includes the screening, diagnosis and
STATUS treatment, as medically necessary, for sexually
transmissible diseases, sterilization services
and screening for pregnancy. Reproductive health
services also includes all medically necessary
abortions.
APPENDIX K
October 1, 2004
K-7
COVERED SERVICES MANAGED CARE PLAN SCOPE OF BENEFIT COVERED BY MEDICAID FEE-FOR-SERVICE
- ---------------- ---------------------------------- -----------------------------------
Transportation Services NON-EMERGENCY TRANSPORTATION: For Contractors that do not cover
Transportation expenses are covered when transportation is transportation services, these
Non-Emergency essential in order for an Enrollee to obtain necessary services are paid for fee-for-service.
Transportation medical care and services which are covered under this Non-emergent transportation requests
Benefit Package (or by fee-for-service Medicaid for should be referred to the LDSS.
SEE SCHEDULE A OF carved-out services). Non-emergent transportation guidelines
APPENDIX K FOR COVERAGE may be developed in conjunction with the LDSS, based on the For Contractors that cover
STATUS LDSS' approved transportation plan. non-emergency transportation in the
Benefit Package, transportation costs
Transportation services means transportation by ambulance, to MMTP services may be reimbursed by
ambulette or invalid coach, taxicab, livery, public Medicaid fee-for-service in accordance
transportation, or other means appropriate to the Enrollee's with the LDSS transportation polices
medical condition; and a transportation attendant to in local districts where there is a
accompany the Enrollee, if necessary. Such services may systematic method to discretely
include the transportation attendant's transportation, meals, identify and reimburse such
lodging and salary; however, no salary will be paid to a transportation costs.
transportation attendant who is a member of the Enrollee's
family.
For Enrollees with disabilities, the method of transportation
must reasonably accommodate their needs, taking into account
the severity and nature of the disability.
Emergency Transportation EMERGENCY TRANSPORTATION
Emergency transportation can only be provided by an ambulance
SEE SCHEDULE A OF service. Emergency transportation is covered for Enrollees
APPENDIX K suffering from severe, life-threatening or potentially
FOR COVERAGE STATUS disabling conditions which require the provision of emergency
medical services while the Enrollee is being transported.
Dental Services Optional Benefit Package dental services include: Routine exams, orthodontic services
- Medically necessary preventive, prophylactic and other and appliances, dental office surgery,
SEE SCHEDULE A OF routine dental care, services and supplies and dental fillings, prophylaxis, provided to
APPENDIX K FOR COVERAGE prosthetics required to alleviate a serious health Enrollees of plans not electing to
STATUS condition, including one which affects employability. cover dental services.
As described in Sections 10.16 and 10.28 of this Agreement, Orthodontic services are always covered
Enrollees may self-refer to Article 28 clinics operated by by fee-for-service.
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.
APPENDIX K
October 1, 2004
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 Covered when medically necessary as ordered by the
Services/Orthopedic Contractor's Participating Provider.
Footwear
Mental Health Services Covered when medically necessary, in accordance with the All services in excess of twenty (20)
stop-loss provisions as described in Section 3.12 of this outpatient visits and thirty (30)
Agreement. Enrollees must be allowed to self-refer for one inpatient days in accordance with the
(1) mental health assessment from a Contractor's stop-loss provisions in Section 3.12
Participating Provider in a twelve (12) month period. In the of this Agreement. Contractor
case of children, such self-referrals may originate at the continues to reimburse mental health
request of a school guidance counselor or similar source. 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 Medically Supervised Inpatient and
outpatient basis. Such services are referred to as Outpatient Withdrawal Services, when
"Medically Managed Detoxification Services" when provided in ordered by the LDSS under Welfare
facilities licensed under Title 14 NYCRR Part 816.6 or Reform (as indicated by "code 83").
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.
Chemical Dependence Covered when medically necessary in accordance with the Chemical Dependence Inpatient
Inpatient stop-loss provisions described in section 3.12 of this Rehabilitation and Treatment Services
Rehabilitation and Agreement when ordered by the LDSS under Welfare
Treatment Reform (as indicated by "code 83")
Services
Chemical Enrollees must be allowed to self refer for one (1)
Dependence assessment from a Contractor's participating provider in a
Assessment twelve (12) month period.
Self-Referral
Experimental and/or Covered on a case by case basis in accordance with the
Investigational provisions of Section 4910 of the New York State P.H.L.
Treatment
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.
APPENDIX K
October 1, 2004
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 Up to 365 medically necessary days per year (366 for leap
Services 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 Continued care in a hospital pending placement in an
Alternate Level of alternate lower medical level of care, consistent with the
Medical Care provisions of 18 NYCRR 505.20 and 10 NYCRR, Part 85.
Professional Ambulatory Provided through ambulatory care facilities including Mental Health and Chemical Dependence
Services hospital outpatient departments, D&T centers, and services.
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.
EPSDT Services/Child EPSDT is a package of early and periodic screening, including Services not included in the managed
Teen Health Program inter-periodic screens and diagnostic and treatment services care Benefit Package ordered by the
(C/THP) that are offered to all Medicaid eligible children under child's physician based on the results of
twenty-one (21) years of age, known in New York State as the a screening.
Child Teen Health Plan (C/THP).
Preventive Health Care and services to avert disease/illness and/or its
Services 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 Services rendered by a personal care
nursing, home health aide services, equipment and appliances, agency which are approved by the Local
physical therapy, speech/language pathology, occupational Social Services District when ordered
therapy, social work services or nutritional services by the Enrollee's Primary Care
provided by a home health care agency pursuant to an Provider (PCP). The district will
established care plan. Personal care tasks performed by a determine the applicant's need for
home health aide in connection with a home health care agency personal care agency services and
visit, and pursuant to an established care plan, are covered. coordinate with the personal care
agency a plan of care.
APPENDIX K
October 1, 2004
K-10
COVERED SERVICES MANAGED CARE PLAN SCOPE OF BENEFIT COVERED BY MEDICAID FEE-FOR-SERVICE
- ---------------- ---------------------------------- -----------------------------------
Private Duty Nursing Covered service when medically necessary in accordance with
Services 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 Eye care includes the services of an ophthalmologist, optometrist
Services 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
October 1, 2004
K-11
COVERED SERVICES MANAGED CARE PLAN SCOPE OF BENEFIT COVERED BY MEDICAID FEE-FOR-SERVICE
- ---------------- ---------------------------------- -----------------------------------
Dental Services Optional Benefit Package dental services include: Routine exams, orthodontic services and
- Medically necessary preventive, prophylactic and other appliances, dental office surgery,
SEE SCHEDULE A OF APPENDIX routine dental care, services and supplies and dental fillings, prophylaxis, provided to
K FOR COVERAGE STATUS prosthetics required to alleviate a serious health Enrollees of MCOs not electing to cover
condition, including one which affects employability. dental services.
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.
Family Planning and Family planning means the offering, arranging, and furnishing Enrollees may always obtain family
Reproductive Health of those health services which enable individuals, including planning and HIV testing and counseling
Services minors, who may be sexually active, to prevent or reduce the services, when part of a family planning
incidence of unintended pregnancies and includes the visit, outside of the Contractor's
SEE SCHEDULE A OF APPENDIX screening, diagnosis and treatment as medically necessary, network from any Provider that accepts
K FOR COVERAGE STATUS for sexually transmissible diseases, sterilization Medicaid.
services and screening for pregnancy. Reproductive health
services also includes all medically necessary abortions.
APPENDIX K
October 1, 2004
K-12
COVERED SERVICES MANAGED CARE PLAN SCOPE OF BENEFIT COVERED BY MEDICAID FEE-FOR-SERVICE
- ---------------- ---------------------------------- -----------------------------------
Transportation Services NON-EMERGENCY TRANSPORTATION:
Transportation expenses are covered when transportation is For Contractors that do not cover
Non-Emergency essential in order for an Enrollee to obtain necessary transportation services, these
Transportation: medical care and services which are covered under this services are paid for fee-for-service.
Benefit Package (or by fee-for-service Medicaid for Non-emergent transportation requests
SEE SCHEDULE A OF APPENDIX carved-out services). Non-emergent transportation guidelines should be referred to the LDSS.
K FOR COVERAGE STATUS may be developed in conjunction with the LDSS, based on the
LDSS' approved transportation plan.
Transportation services means transportation by ambulance, For Contractors that cover non-emergency
ambulette or invalid coach, taxicab, livery, public transportation in the Benefit Package,
transportation, or other means appropriate to the Enrollee's transportation costs to MMTP services
medical condition; and a transportation attendant to may be reimbursed by Medicaid fee-for-
accompany the Enrollee, if necessary. Such services may service in accordance with the LDSS
include the transportation attendant's transportation, meals, transportation policies in local
lodging and salary; however, no salary will be paid to a districts where there is a systematic
transportation attendant who is a member of the Enrollee's method to discretely identify and
family. 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.
Emergency Transportation EMERGENCY TRANSPORTATION
Emergency transportation can only be provided by an ambulance
SEE SCHEDULE A OF APPENDIX service. Emergency transportation is covered for Enrollees
K FOR COVERAGE STATUS 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 HIV phenotypic, HIV virtual phenotypic
professional, and when listed in the Medicaid fee schedule. and HIV genotypic drug resistance
Coverage excludes HIV phenotypic, HIV virtual phenotypic and tests with a Provider's order.
HIV genotypic drug resistance tests.
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 DME are devices and equipment other than medical/surgical Excluded services, such as disposable
Equipment (DME) supplies enteral formula, and prosthetic or orthotic medical/surgical supplies and enteral
appliances. Covered when medically necessary as ordered by formula with a Provider's order.
the Contractor's Participating Provider and procured from a
Participating Provider. Coverage excludes disposable
medical/surgical supplies and enteral formula.
APPENDIX K
October 1, 2004
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 Excluded services, such as hearing aid
caused by the loss or impairment of hearing. Hearing aid batteries with a Provider's order.
products include hearing aids, earmolds, special fittings,
and replacement parts. Coverage excludes hearing aid
batteries.
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 Covered when medically necessary as ordered by a managed care
Services/Orthotic Footwear 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 Covered on a case by case basis in accordance with the
Investigational Treatment 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.
APPENDIX K
October 1, 2004
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.
1a. 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
October 1, 2004
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
October 1, 2004
K-16
Persona] 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
October l, 2004
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 505.11
Rehabilitation services are provided for the maximum reduction of physical or
mental disability and restoration of the Enrollee to his or her best functional
level. Rehabilitation services include care and services rendered by physical
therapists, speech-language pathologists and occupational therapists.
Rehabilitation services may be provided in an Article 28 inpatient or
outpatient facility, an Enrollee's home, in an approved home health agency, in
the office of a qualified private practicing therapist or speech pathologist,
or for a child in a school, pre-school or community setting, or in a
Residential Health Care Facility (RHCF) as long as the Enrollee's stay is
classified as a rehabilitative stay. Rehabilitation services are covered as
medically necessary, when ordered by the Contractor's Participating Provider.
c. Midwifery Services
SSA Section 1905 (a)(17), Education Law Section 6951(i)
Midwifery services include the management of normal pregnancy, childbirth and
postpartum care as well as primary preventive reproductive heath 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 H
October 1, 2004
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 Section 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
ophthalmologist 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 ophthalmologist) for refractive vision services.
9. LABORATORY SERVICES
18 NYCRR Section 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
October 1, 2004
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 Section 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 Section 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 Section 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 Section 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
(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.
APPENDIX H
October 1, 2004
K-20
DME must be ordered by a qualified practitioner and procured from a
Participating Provider.
13. AUDIOLOGY, HEARING AID SERVICES AND PRODUCTS
18 NYCRR Section 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
October 1, 2004
K-21
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 of 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 H
October 1, 2004
K-22
(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.
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
APPENDIX K
October 1, 2004
K-23
counseling, level of care determinations and referral and linkages to other
services as necessary. Medically Managed Detoxification Services are
provided by facilities licensed by OASAS under Title 14 NYCRR Part 816.6 and
the Department of Health as a general hospital pursuant to Article 28 of the
Public Health Law or by the Department of Health as a general hospital
pursuant to Article 28 of the Public Health Law.
ii) Medically Supervised Withdrawal
(a) Medically Supervised Inpatient Withdrawal
These programs offer treatment for moderate withdrawal on an inpatient
basis. Services must include medical supervision and direction under the
care of a physician in the treatment for moderate withdrawal. Specific
services must include, but are not limited to: medical assessment within
twenty four hours of admission; medical supervision of intoxication and
withdrawal conditions; bio-psychosocial assessments; individual and group
counseling and linkages to other services as necessary. Maintenance on
methadone while a patient is being treated for withdrawal from other
substances may be provided where the provider is appropriately authorized.
Medically Supervised Inpatient Withdrawal services are provided by
facilities licensed under Title 14 NYCRR Part 816.7.
(b) Medically Supervised Outpatient Withdrawal
These programs offer treatment for moderate withdrawal on an outpatient
basis. Required services include, but are not limited to: medical
supervision of intoxication and withdrawal conditions; bio-psychosocial
assessments; individual and group counseling; level of care determinations;
discharge planning; and referrals to appropriate services. Maintenance on
methadone while a patient is being treated for withdrawal from other
substances may be provided where the provider is appropriately authorized.
Medically Supervised Outpatient Withdrawal services are provided by
facilities licensed by Title 14 NYCRR Part 816.7.
All detoxification and withdrawal services are a covered benefit for all
Enrollees, including those categorized as SSI or SSI related.
Detoxification Services in Article 28 inpatient hospital facilities are
subject to the stop-loss provisions specified in Section 3.11 of this
Agreement.
b. Chemical Dependence Inpatient Rehabilitation and Treatment Services
Services provided include intensive management of chemical dependence
symptoms and medical management of physical or mental complications from
chemical dependence to clients who cannot be effectively served on an
outpatient basis and who are not in need of medical detoxification or acute
care. These services can be provided in a hospital or free-standing
facility. Specific services can include, but are not limited to:
comprehensive admission evaluation and treatment planning; individual group,
and family counseling; awareness and relapse prevention; education about
self-help groups; assessment and referral services; vocational and
educational assessment; medical and psychiatric consultation; food and
housing; and HIV and AIDS education. These services may be provided by
facilities
APPENDIX K
October 1, 2004
K-24
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 impatient days of chemical dependence
inpatient treatment beyond thirty (30) days according to stop-loss
provisions contained in Section 3.12 of this Agreement.
c. Chemical Dependence Assessment Self-Referral
Enrollees must be allowed to self refer for one (1) assessment from a
Contractor's participating provider in a twelve (12) month period.
2. MENTAL HEALTH SERVICES
Mental Health Services are subject to the stop-loss provisions specified in
Section 3.12 of this Agreement.
a. Inpatient Services
All inpatient mental health services, including voluntary or involuntary
admissions for mental health services. The Contractor may provide the covered
benefit for medically necessary mental health inpatient services through
hospitals licensed pursuant to Article 28 of the New York State P.H.L.
b. Outpatient Services
Outpatient services including but not limited to: assessment, stabilization,
treatment planning, discharge planning, verbal therapies, education, symptom
management, case management services, crisis intervention and outreach services,
chlozapine monitoring and collateral services as certified by OMH. Services may
be provided in-home, office or the community. Services may be provided by
licensed OMH providers or by other providers of mental health services including
clinical psychologists and physicians. For further information regarding
service coverage consult the following MMIS Provider Manuals: Clinic, Ambulatory
Services for Mental Illness (Clinic Treatment Program), Clinical Psychology, and
Physician (Psychiatric Services).
Enrollees must be allowed to self-refer for one (1) mental health assessment
from a Contractor's Participating Provider in a twelve (12) month period. In the
case of children, such self-referrals may originate at the request of a school
guidance counselor or similar source.
Services provided through OMH designated clinics for Enrollees with a clinical
diagnosis of SED are covered by Medicaid fee-for-service.
APPENDIX K
October 1, 2004
K-25
C. OTHER COVERED SERVICES
1. Federally Qualified Health Center (FQHC) Services
FQHC services include physician services, services and supplies covered under
SSA Section 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
Section 254c(a) & (b)).
APPENDIX K
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K-26
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 am 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
October 1, 2004
K-27
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 Section 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
October 1, 2004
K-28
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
October 1, 2004
K-29
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)
Permanent residency in a Residential Health Care Facility (RHCF) is not covered
(see 18 NYCRR Section 360-1.4 (k)). Rehabilitation services in such a setting
are covered as medically necessary when ordered by the Contractor's
Participating Provider.
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
October 1, 2004
K-30
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
October 1, 2004
K-31
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
October 1, 2004
K-32
- 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
October 1, 2004
K-33
education in small classes with an emphasis on individualized instruction,
individual and group counseling, family services such as family counseling,
support and education, crisis intervention, interpersonal skill development,
behavior modification, art and music therapy.
e. Home and Community Based Services Waiver for Seriously Emotionally Disturbed
Children
This waiver is in select counties for children and adolescents who would
otherwise be admitted to an institutional setting if waiver services were not
provided. The services include individualized care coordination, respite, family
support, intensive in-home skill building, and crisis response.
f. Case Management
The target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention to
help them obtain those services which will permit functioning in the community
and either have symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 506.
Please note: See generic definition of Comprehensive Medicaid Case Management
(CMCM) under OTHER NON-COVERED SERVICES.
g. Partial Hospitalization
Provides active treatment designed to stabilize and ameliorate acute systems,
serves as an alternative to inpatient hospitalization, or reduces the length of
a hospital stay within a medically supervised program by providing the
following: assessment and treatment planning; health screening and referral;
symptom management; medication therapy; medication education; verbal therapy;
case management; psychiatric rehabilitative readiness determination and referral
and crisis intervention. These services are certified by OMH under NYCRR Part
587.
h. Services Provided Through OMH Designated Clinics for Children With A
Diagnosis of Serious Emotional Disturbance (SED)
These are services provided by designated OMH clinics to children and
adolescents with a clinical diagnosis of SED.
i. Assertive Community Treatment (ACT)
ACT is a mobile team-based approach to delivering comprehensive and flexible
treatment, rehabilitation, case management and support services to individuals
in their natural living setting. ACT programs deliver integrated services to
recipients and adjust services over time to meet the recipient's goals and
changing needs; are operated pursuant to approval or certification by OMH; and
receive Medicaid reimbursement pursuant to 14 NYCRR Part 508.
j. Personalized Recovery Oriented Services (PROS)
APPENDIX K
October 1, 2004
K-34
PROS, licensed and reimbursed pursuant to 14 NYCCR Part 512, are designed to
assist individuals in recovery from the disabling effects of mental illness
through the coordinated delivery of a customized array of rehabilitation,
treatment, and support services in traditional settings and in off-site
locations. Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and Support and
Clinical Treatment.
3. REHABILITATION SERVICES PROVIDED TO RESIDENTS OF OMH LICENSED COMMUNITY
RESIDENCES (CRS) AND FAMILY BASED TREATMENT PROGRAMS, AS FOLLOWS:
a. OMH Licensed CRs*
Rehabilitative services in community residences are interventions, therapies and
activities which are medically therapeutic and remedial in nature, and are
medically necessary for the maximum reduction of functional and adaptive
behavior defects associated with the person's mental illness.
b. Family-Based Treatment*
Rehabilitative services in family-based treatment programs are intended to
provide treatment to seriously emotionally disturbed children and youth to
promote their successful functioning and integration into the natural family,
community, school or independent living situations. Such services are provided
in consideration of a child's developmental stage. Those children determined
eligible for admission are placed in surrogate family homes for care and
treatment.
*These services are certified by OMH under 14 NYCRR Part 586.3, 594 and 595.
4. OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES (OMRDD) SERVICES
a. Long Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
or Article 28 Facilities
These services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under 14 NYCRR, Part 679 (or they are provided by Article 28
Diagnostic and Treatment Centers that are explicitly designated by the SDOH as
serving primarily persons with developmental disabilities). If care of this
nature is provided in facilities other than Article 28 or Article 16 centers, it
is a covered service.
b. Day Treatment
APPENDIX K
October 1, 2004
K-35
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 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.
APPENDIX K
October 1, 2004
K-36
C. OTHER NON-COVERED SERVICES
1. THE EARLY INTERVENTION PROGRAM (EIP) - CHILDREN BIRTH to Two (2) Years of Age
This program provides early intervention services to certain children, from
birth through two (2) years of age, who have a developmental delay or a
diagnosed physical or mental condition that has a high probability of resulting
in developmental delay. All managed care providers MUST refer infants and
toddlers suspected of having a delay to the local designated Early Intervention
agency in their area. (In most municipalities, the County Health Department is
the designated agency, except: New York City - the Department of Health, Mental
Retardation and Alcoholism Services; Erie County - The Department of Youth
Services; Jefferson County - the Office of Community Services; and Ulster County
- - the Department of Social Services).
Early intervention services provided to this eligible population are categorized
as Non-Covered. These services, which are designed to meet the developmental
needs of the child and the needs of the family related to enhancing the child's
development, will be identified on MMIS by unique rate codes by which only the
designated early intervention agency can claim reimbursement. Contractor covered
and authorized services will continue to be provided by the Contractor.
Consequently, the Contractor will be expected to refer any enrolled child
suspected of having a developmental delay to the locally designated early
intervention agency in their area and participate in the development of the
Child's Individualized Family Services Plan (IFSP). Contractor's participation
in the development of the IFSP is necessary in order to coordinate the provision
of early intervention services and services covered by the Contractor.
Additionally, the locally designated early intervention agencies will be
instructed on how to identify a managed care Enrollee and the need to contact
the Contractor to coordinate service provision.
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.
APPENDIX K
October 1, 2004
K-37
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
October 1, 2004
K-38
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.
APPENDIX K
October 1, 2004
K-39
11. SCHOOL-BASED HEALTH CENTERS
A School-Based Health Center (SBHC) is an Article 28 extension clinic that is
located in a school and provides students with primary and preventive physical
and mental health care services, acute or first contact care, chronic care, and
referral as needed. SBHC services include comprehensive physical and mental
health histories and assessments, diagnosis and treatment of acute and chronic
illnesses, screenings (e.g., vision, hearing, dental, nutrition, TB), routine
management of chronic diseases (e.g., asthma, diabetes), health education,
mental health counseling and/or referral, immunizations and physicals for
working papers and sports.
APPENDIX K
October 1, 2004
K-40
IV. SCHEDULE A OF APPENDIX K
PREPAID BENEFIT PACKAGE
COVERAGE STATUS OF OPTIONAL COVERED SERVICES
COUNTY: DUTCHESS
MCO: WELLCARE OF NEW YORK, INC.
COVERAGE STATUS
SERVICE COVERED BY NOT COVERED BY
CONTRACTOR CONTRACTOR
Family Planning X
Dental Services X
Emergency Transportation X
Non-Emergency Transportation X
APPENDIX K
October 1, 2004
K-41
APPENDIX L
APPROVED CAPITATION PAYMENT RATES
APPENDIX L
October 1, 2004
L-1
WELLCARE OF NEW YORK, INC.
Medicaid Managed Care Rates
MMIS ID#: 01182503 Effective Date: 04/01/04
Approved by DOB: Yes Region: Mid-Hudson
DOH HMO #: 04-008 County: Dutchess
Reinsurance: Private Status: Voluntary
Premium Group Rate Amount
- ------------- -----------
TANF/SN less than 6mo M/F $222.23
TANF/SN 6mo-14 F $77.91
TANF/SN 15-20 F $140.16
TANF/SN 6mo-20 M $90.59
TANF 21+ M/F $187.60
SN 21-29 M/F $200.37
SN 30+ M/F $362.90
SSI 6mo-20 M/F $207.18
SSI 21-64 M/F $389.65
SSI 65+ M/F $269.26
Maternity Kick Payment $4,526.04
Newborn Kick Payment $2,338.57
Optional Benefits Offered:
[X] Emergency Transportation [ ] Dental
[ ] Non-Emergent Transportation [X] Family Planning
Box will be checked if the optional benefit is covered by the plan
Benefit Limitations:
Outpatient Mental Health Cap of 20 visits
Inpatient Mental Health\Substance Abuse Cap of 30 Days
APPENDIX M
SERVICE AREA
APPENDIX M
October 1, 2004
M-1
The Contractor's Medicaid managed care service area is comprised of DUTCHESS
County in its entirety.
APPENDIX M
October 1, 2004
M-2
APPENDIX N
CONTRACTOR-COUNTY SPECIFIC AGREEMENTS
APPENDIX N
October 1, 2004