EXHIBIT 10.8
FAMILY HEALTH PLUS
MODEL CONTRACT
OCTOBER 1, 2001
MISCELLANEOUS/CONSULTANT SERVICES
STATE AGENCY (Name and Address): NYS COMPTROLLER'S NUMBER:
New York State Department of Health
Office of Managed Care
Empire State Plaza
Corning Tower, Room 2074
Albany, NY 12237-0094 ORIGINATING AGENCY CODE:12000
_________________________________ ___________________________________
CONTRACTOR (Name and Address): TYPE OF PROGRAM(S):
WellCare of New York, Inc. Family Health Plus
Hurley Avenue Extension
P.O. Box 4800
Kingston, NY 12402
_________________________________ ___________________________________
CHARITIES REGISTRATION NUMBER: CONTRACT TERM
FROM: October 1, 2001
TO: September 30, 2003
FEDERAL TAX IDENTIFICATION NUMBER:
FUNDING AMOUNT FOR CONTRACT TERM:
Based on approved capitation rates
MUNICIPALITY NO. (if applicable):
_________________________________ ___________________________________
STATUS: THIS CONTRACT IS RENEWABLE FOR
CONTRACTOR IS ( ) IS NOT ( ) A ONE ADDITIONAL TWO-YEAR PERIOD AND
SECTARIAN ENTITY A SUBSEQUENT ONE-YEAR PERIOD
CONTRACTOR IS ( ) IS NOT ( ) A NOT- SUBJECT TO THE APPROVAL OF THE
FOR-PROFIT ORGANIZATION STATE DEPARTMENT OF HEALTH, THE
CONTRACTOR IS ( ) IS NOT ( ) A DEPARTMENT OF HEALTH AND HUMAN
N Y STATE BUSINESS ENTERPRISE SERVICES, AND THE OFFICE OF THE
STATE COMPTROLLER
_________________________________ ___________________________________
BID OPENING DATE:
Proposal Due Dates:
March 16, 2001 (Phase I) and
April 13, 2001 (Phase II)
APPENDICES ATTACHED AND PART OF THIS AGREEMENT
- -X- APPENDIX A Standard Clauses as required by the Attorney General for all State contracts.
- -X- APPENDIX B Certification Regarding Lobbying
- -X- APPENDIX B-1 Standard Contract/Bid Insert Form
- -X- APPENDIX C New York State Department of Health FHPlus Guidelines for the Provision of Family Planning and
Reproductive Health Services
- -X- APPENDIX D New York State Department of Health FHPlus Marketing Guidelines
- -X- APPENDIX E New York State Department of Health FHPlus Member Handbook Guidelines
- -X- APPENDIX F New York State Department of Health FHPlus Complaint and Appeals Program Guidelines
- -X- APPENDIX G New York State Department of Health Guidelines for the Provision of Emergency Care and Services for
the FHPlus Program
- -X- APPENDIX H New York State Department of Health Guidelines for the Processing of Enrollments and Disenrollments
for the FHPlus Program
- -X- APPENDIX I New York State Department of Health-Guidelines for Use of Medical Residents in the FHPlus Program
- -X- APPENDIX J New York State Department of Health Guidelines for FHPlus Compliance with the Americans with
Disabilities Act
- -X- APPENDIX K New York State Department of Health FHPlus Prepaid Benefit Package Definitions of Covered and
Non-Covered Services
- -X- APPENDIX L Approved Capitation Payment Rates for the FHPlus Program
- -X- APPENDIX M Service Area for the FHPlus Program
- -X- APPENDIX N Proof of Worker's Compensation Coverage
- -X- APPENDIX O Proof of Disability Insurance Coverage
- -X- APPENDIX P FHPlus Facilitated Enrollment, if applicable
- -X- APPENDIX X Modification Agreement Form (to accompany modified appendices for changes in term or consideration on
an existing period or for renewal periods)
TABLE OF CONTENTS FOR FAMILY HEALTH PLUS MODEL CONTRACT
Contract Cover Page/Signature Page
Recitals
Section 1 Definitions
Section 2 Agreement Term, Amendments, Extensions, and General Agreement Administration Provisions
2.1 Term
2.2 Amendments
2.3 Approvals
2.4 Entire Agreement
2.5 Renegotiation
2.6 Assignment and Subcontracting
2.7 Termination
a. SDOH initiated Termination of Agreement
b. Contractor and SDOH Initiated Termination
c. Contractor Initiated Termination
d. Termination Due to Loss of Funding
2.8 Close-Out Procedures
2.9 Rights and Remedies
2.10 Notices
2.11 Severability
Section 3 Compensation
3.1 Capitation Payments
3.2 Modification of Rates During Agreement 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 Supplemental Maternity Capitation Payment
3.9 Contractor Financial Liability
3.10 Reinsurance
3.11 Enrollment Limitations
Section 4 Service Area
Section 5 FHPlus Eligibles
5.1 Eligible Persons
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Section 6 Enrollment
6.1 Enrollment Guidelines
6.2 Equality of Access to Enrollment
6.3 Enrollment Decisions
6.4 Prohibition Against Conditions on Enrollment
6.5 Newborn Enrollment
6.6 Effective Date of Enrollment
6.7 Roster
6.8 Automatic Re-Enrollment
Section 7 Initial Enrollment Period
7.1 Initial Enrollment Period
7.2 Disenrollment During Initial Enrollment Period
7.3 Notifications Regarding Initial Enrollment Period and End of Initial
Enrollment Period
Section 8 Disenrollment
8.1 Disenrollment Guidelines
8.2 Disenrollment Prohibitions
8.3 Reasons for Voluntary Disenrollment
8.4 Processing of Disenrollment Requests
8.5 Contractor Notification of Disenrollments
8.6 Contractor's Liability
8.7 Enrollee Initiated Disenrollment
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 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/EPSDT
10.6 Adult Protective Services
10.7 Court-Ordered Services
10.8 Family Planning and Reproductive Health Services
10.9 Prenatal Care
10.10 Direct Access
10.11 Emergency Services
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10.12 Services for Which Enrollees Can Self-Refer
a. Mental Health and Alcohol/Substance Abuse
b. Vision Services
c. Diagnosis and Treatment of Tuberculosis
d. Family Planning/Reproductive Health
10.13 Second Opinions for Medical or Surgical Care
10.14 Coordination with Local Public Health Agencies
10.15 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
10.16 Adults with Chronic Illnesses and Physical or Developmental Disabilities
10.17 Persons Requiring Ongoing Mental Health Services
10.18 Member Needs Relating to HIV
10.19 Persons Requiring Alcohol/Substance Abuse Services
10.20 Native Americans
10.21 Women, Infants, and Children (WIC)
10.22 Coordination of Services
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 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
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
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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
15.1 Service Continuation
a. New Enrollees
b. Enrollees Whose Health Care Provider Leaves the 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 Annual On-Site Review
17.4 Cooperation During Review of Services by External Review Agency
Section 18 Contractor Reporting Requirements
18.1 Time Frames for Report Submissions
18.2 SDOH Instructions for Report Submissions
18.3 Liquidated Damages
18.4 Notification of Changes in Report Due Dates, Requirements or
Formats
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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. No Contact Report
n. Additional Reports
o. 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 FHPlus Enrollees
and Applicants
20.2 Confidentiality of Medical Records
20.3 Length of Confidentiality Requirements
Section 21 Participating Providers
21.1 Network Requirements
21.2 Credentialing
21.3 SDOH Exclusion or Termination of Providers
21.4 Evaluation Information
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21.5 Payment In Full
21.6 Choice/Assignment of PCPs
21.7 PCP Changes
21.8 PCP Status Changes
21.9 PCP Responsibilities
21.10 Member to Provider Ratios
21.11 Minimum Office Hours
21.12 Primary Care Practitioners
21.13 PCP Teams
21.14 Hospitals
21.15 Dental Networks
21.16 Mental Health, Alcohol and Substance Abuse Providers
21.17 Laboratory Procedures
21.18 Federally Qualified Health Centers (FQHCs)
21.19 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
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
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TABLE OF CONTENTS FOR FAMILY HEALTH PLUS MODEL CONTRACT
26.1 Basis for External Appeal
26.2 Eligibility For External Appeal
26.3 External Appeal Determinations
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 SDOH
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 Disclosure Requirements for Subcontractors
Section 34 Non-Discrimination
34.1 Equal Access to Benefit Package
34.2 Non-Discrimination
34.3 Equal Employment Opportunity
34.4 Native Americans Access to Services From Tribal or Urban Indian
Health Facility
Section 35 Compliance with Applicable Laws
35.1 Contractor and SDOH Compliance With Applicable Laws
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void Agreement
Provisions
35.3 Certificate of Authority Requirements
35.4 Contractor's Financial Solvency Requirements
35.5 Compliance With Care For Maternity Patients
35.6 Informed Consent Procedures for Hysterectomy and Sterilization
35.7 Non-Liability of Enrollees For Contractor's Debts
35.8 SDOH Compliance With Conflict of Interest Laws
35.9 Compliance With PHL Regarding External Appeals
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TABLE OF CONTENTS FOR FAMILY HEALTH PLUS MODEL CONTRACT
Section 36 New York State Standard Contract Clauses
Section 37 Miscellaneous
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APPENDICES
A. New York State Standard Clauses and Local Standard Clauses
B. Certification Regarding Lobbying
B-1. Standard Contract/Bid Insert Form
C. New York State Department of Health FHPlus Guidelines for the Provision
of Family Planning and Reproductive Health Services
D. New York State Department of Health FHPlus Marketing Guidelines
E. New York State Department of Health FHPlus Member Handbook Guidelines
F. New York State Department of Health FHPlus Complaint and Appeals Program
Guidelines
G. New York State Department of Health Guidelines for the Provision of
Emergency Care and Services for the FHPlus Program
H. New York State Department of Health Guidelines for the Processing of
Enrollments and Disenrollments for the FHPlus Program
I. New York State Department of Health Guidelines for Use of Medical Residents
in the FHPlus Program
J. New York State Department of Health Guidelines for FHPlus Compliance with
the Americans with Disabilities Act
K. New York State Department of Health FHPlus Prepaid Benefit Package
Definitions of Covered and Non-Covered Services
L. Approved Capitation Payment Rates for the FHPlus Program
M. Service Area for the FHPlus Program
N. Proof of Worker's Compensation Coverage
O. Proof of Disability Insurance Coverage
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TABLE OF CONTENTS FOR FAMILY HEALTH PLUS MODEL CONTRACT
P. FHPlus Facilitated Enrollment, if applicable
X. Modification Agreement Form
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STATE OF NEW YORK
FAMILY HEALTH PLUS
PARTICIPATING MANAGED CARE PLAN AGREEMENT
This AGREEMENT is hereby made by and between the New York State Department of
Health ("SDOH") and WellCare of New York, Inc. ("Contractor").
RECITALS:
WHEREAS, pursuant to Title 11-D of Article 5 of the New York State
Social Services Law ("SSL"), codified as SSL Section 369-ee, a comprehensive
health insurance program known as Family Health Plus (FHPlus) has been created
for eligible persons who do not qualify for Medical Assistance pursuant to Title
11 of Article 5 of the SSL; and
WHEREAS, organizations certified under Article 44 of the New York
State Public Health Law ("PHL") or licensed under Article 43 of the New York
State Insurance Law are eligible to provide comprehensive health care service
programs to Eligible Persons as defined in Title 11-D of the SSL; and
WHEREAS, the Contractor offers a comprehensive health services plan
that is able to make provision for furnishing health care benefits and has
proposed to SDOH to provide those services to Eligible Persons; and
WHEREAS, SDOH issued a Recruitment, dated February 2, 2001
("Recruitment"), for the purpose of soliciting proposals from eligible
organizations seeking to enroll and provide comprehensive health care services
to FHPlus beneficiaries, which is on file in the offices of SDOH, and which is
hereby made a part of this Agreement as if fully set forth herein; and
WHEREAS, the Contractor has submitted a written proposal for the
enrollment and delivery of services to FHPlus beneficiaries, which addresses the
requirements and conditions of participation specified in the Recruitment, and
which is hereby made a part of this Agreement as if set forth fully herein; and
WHEREAS, SDOH has determined that the Contractor meets the criteria
established for selection as a FHPlus provider pursuant to the Recruitment.
NOW THEREFORE, the parties agree as follows:
FHPlus
Recitals
October 1, 2001
Page 1 of 1
1. DEFINITIONS
"ALCOHOL AND SUBSTANCE ABUSE SERVICE" means the treatment of addiction to
alcohol and/or one or more drugs or the treatment of impairments to normal
development or functioning including, but not limited to, social,
emotional, familial, educational, vocational or physical impairments due
to use of alcohol or drugs.
"BEHAVIORAL HEALTH SERVICE" means is the assessment or treatment of mental
and/or alcohol disorders and/or substance abuse disorders.
"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.
"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 and FHPlus
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.
"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 Benefit Package and reimbursable under Title XIX of the
Federal Social Security Act (See SSL 364-j(4)(r)).
"DAYS" means calendar days except as otherwise stated.
"DESIGNATED THIRD PARTY CONTRACTOR" means the provider who contracts with
the SDOH to provide Family Planning Services for enrollees in FHPlus plans
whose benefit package excludes such services.
"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 6.6(b)
and Appendix H of this Agreement.
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"EFFECTIVE DATE OF ENROLLMENT" means the date on which an Enrollee may
receive services from the Contractor pursuant to Section 6.6(b) and
Appendix H of this Agreement.
"ELIGIBLE PERSON" means a person whom the local department of social
services (LDSS), state or federal government determines to be eligible for
FHPlus in accordance with state and federal law.
"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.
"ENROLLEE" means an Eligible Person who, either personally or through an
authorized representative, has enrolled 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 to potential
Medicaid managed care Enrollees; effectuates enrollments and
disenrollments in Medicaid and FHPlus managed care; and provides other
contracted services on behalf of the SDOH and the LDSS.
"ENROLLMENT FACILITATOR" means an entity under contract with SDOH, and
its agents, that assists children and adults in the Medicaid, Family
Health Plus, Child Health Plus and/or WIC application and enrollment
process. This includes assisting potentially eligible family members and
adults in completing the required application form, conducting the
face-to-face interview, assisting in the collection of required
documentation, assisting in the health plan selection process, and
referring individuals to WIC or other appropriate sites.
"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.
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(DEFINITIONS)
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"FACILITATED ENROLLMENT" means the simplified, user friendly enrollment
infrastructure established by SDOH to assist children and adults in
applying for the Medicaid, Family Health Plus or Child Health Plus
programs or the Special Supplemental Food Program for Women, Infants, and
Children (WIC), using a joint application.
"FAMILY HEALTH PLUS OR FHPLUS" means the program established under Title
11-D, Section 369-ee of the Social Services Law.
"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 effective date
of the FHPlus Eligible's initial enrollment in a FHPlus plan 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 FHPlus
eligibility provided that Federal financial participation in the cost of
such coverage is available.
"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/FHPlus complaint and
disenrollment information; collection of Medicaid/FHPlus financial reports
collection and reporting of managed care provider networks systems (PNS);
and the reporting of Medicaid/FHPlus encounter data systems (MEDS).
"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.
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"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.
"INITIAL ENROLLMENT PERIOD" means the one year period of time during
which the Enrollee may not disenroll from the Contractor's plan and enroll
in a different FHPlus plan, except during the initial 90 days or unless
the Enrollee can demonstrate good cause as defined by the State Department
of Health.
"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 18NYCRR 505.20 and 10NYCRR,
Part 85.
"MANAGED CARE ORGANIZATION" or "MCO" means a health maintenance
organization ("HMO"), prepaid health service plan ("PHSP"), or integrated
delivery system ("IDS") certified under Article 44 of the New York State
P.H.L or a corporation licensed pursuant to Article 43 of the State
Insurance Law.
"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 potential Enrollees 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
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(DEFINITIONS)
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suffering, endanger life, result in illness or infirmity, interfere with
such person's capacity for normal activity, or threaten some significant
handicap.
"MEMBER HANDBOOK" means the publication prepared by the Contractor and
issued to new enrollees to inform them how to access health care services
and explain their rights and responsibilities as a FHPlus enrollee. For
purposes of Article 48 and 49 of the New York State Insurance Law, the
Member Handbook shall be deemed a subscriber contract.
"NATIVE AMERICAN" means, for purposes of this Agreement, a person
identified in the Medicaid eligibility system as a Native American.
"NONCONSENSUAL ENROLLMENT" means Enrollment of an Eligible Person in a
FHPlus plan 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.
"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 Family Health Plus Enrollees
enrolled by the Contractor.
"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.
"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/certified
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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.
"SUPPLEMENTAL MATERNITY CAPITATION PAYMENT" means the fixed amount paid to
the Contractor in addition to the monthly Capitation Rate for the
inpatient and outpatient costs of services normally provided as part of
maternity care including antepartum care, delivery and post-partum care.
"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.
"URGENT MEDICAL CONDITION" means a medical or behavioral condition other
than an emergency condition, manifesting itself by acute symptoms of
sufficient severity that, in the assessment of a "prudent lay person",
possessing an average knowledge of medicine and health, could reasonably
be expected to result in serious impairment of bodily functions, serious
dysfunction of a bodily organ, body part, or mental ability, or any other
condition that would place the health or safety of the Enrollee or another
individual in serious jeopardy in the absence of medical or behavioral
treatment within twenty-four (24) hours.
FHPlus - Section 1
(DEFINITIONS)
October 1, 2001
1-6
2. AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL AGREEMENT
ADMINISTRATION PROVISIONS
2.1 Term
a) This Agreement is effective October 1, 2001 and shall remain
in effect until September 30, 2003 or until the execution of
an extension, renewal or successor Agreement approved by the
SDOH, the Department of Health and Human Services (DHHS), the
Office of the State Comptroller (OSC), and any other entities
as required by law or regulation, whichever occurs first.
b) This Agreement shall not be automatically renewed at its
expiration. The parties to this Agreement shall have the
option to renew this Agreement for an additional two (2) year
term and for a subsequent one (1) year term, subject to the
approval of SDOH, DHHS, OSC, and any other entities as
required by law or regulation.
c) The maximum duration of this Agreementis five (5) years. An
extension to this Agreement beyond the five year maximum 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
Agreement; or
II. The Contractor has submitted a termination notice and
transition of Enrollees will not be completed by the
expiration date of the current Agreement.
d) Notwithstanding the foregoing, this Agreement will
automatically terminate upon the expiration of federal financial
participation for the program.
2.2 Amendments
This Agreement may be modified only in writing. Unless otherwise
specified in this Agreement modifications must be approved by the
DHHS, signed by the parties and approved by OSC 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.
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS,
EXTENSIONS, AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-1
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, OSC, and any other entity as required in law and regulation.
SDOH will provide a notice of such approval to the Contractor.
2.4 Entire Agreement
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) The body of this Agreement;
3) The appendices attached to the body of this Agreement; other
than Appendix A, the Recruitment Notice and the Contractor's
Response
4) The Contractor's approved:
i) Marketing Plan on file with SDOH and LDSS
ii) Complaint and Appeals Procedure on file with SDOH
iii) Quality Assurance Plan on file with SDOH
iv) Americans with Disabilities Act Compliance Plan on file
with SDOH
v) Fraud and Abuse Prevention Plan on file with SDOH.
5) New York State Department of Health Recruitment of
Participating Managed Care Plans for the Family Health Plus
Program, dated February 2, 2001, a copy of which is
incorporated by reference herein and is on file with the New
York State Department of Health, Office of Medicaid Management
("Recruitment")
6) Family Health Plus Plan Recruitment Proposal of WellCare of
New York, Inc., dated March 15, 2001, a copy of which is
incorporated by reference herein and is on file with the New
York State Department of Health, Office of Medicaid Management
("Proposal").
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-2
2.5 Renegotiation
The parties to this Agreement shall have the right and obligation 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 to renegotiate or
amend 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 DHHS.
2.6 Assignment and Subcontracting
a) The Contractor shall not, without 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. SDOH
agrees that it will not unreasonably withold consent of the
Contractor's assignment of this Agreement, in whole or in
part, to a parent, affiliate or subsidiary corporation, or to
a transferee of all or substantially all of its assets. Any
assignment, transfer, conveyance, sublease, or other
disposition without SDOH's consent shall be void.
b) Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by a written
agreement, as set forth in Section 22 of this Agreement. The
Contractor may subcontract for provider services and
management services including, but not limited to, marketing,
quality assurance and utilization review activities and such
other services as are acceptable to SDOH. 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 Part 98.11, 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 to the extent such
regulations are or become effective that are appropriate to
the service or activity delegated under such subcontract.
Contractor agrees that it shall remain legally responsible to
SDOH for carrying out all activities under this
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-3
Agreement and that no subcontract shall limit or terminate
Contractor's responsibility.
2.7 Termination
a) SDOH Initiated Termination of Agreement
i) SDOH 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;
B) has engaged in an unacceptable practice under 18
NYCRR, Part 515, that affects the fiscal integrity
of the Medicaid/FHPlus program;
C) has its Certificate of Authority suspended,
limited or revoked by SDOH or has its license
suspended, limited or revoked by the State
Insurance Department;
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 SDOH'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);
G) changes the provider network, such that Enrollees
access to the Contractor's services is no longer
consistent with the standards set forth in
Sections 15, 21 and 22 and Appendix I of this
Agreement; or
H) 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 SDOH 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.
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-4
iii) If SDOH suspends, limits or revokes Contractor's
Certificate of Authority under P.H.L. Section 4404 or if
the State Insurance Department (SID) suspends, limits or
revokes Contractor's license, this Agreement shall
expire on the date the Contractor ceases to have
authority to serve the designated geographic area. The
Contractor will be allowed to continue to serve any
designated geographic areas not affected by such
actions. No hearing will be required if the Agreement
expires due to SDOH suspension, limitation or revocation
of the Contractor's Certificate of Authority or due to
SID suspension, limitation, or revocation of the
Contractor's license.
iv) Prior to the effective date of the termination the SDOH
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 SDOH Initiated Termination
The Contractor and the SDOH 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 written notice specifying the reason for
and the effective date of termination, which shall not be less
time than will permit an orderly disenrollment of Enrollees or
transfer to another MCO, 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 SDOH 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 within such longer period as the parties may
agree, of the Contractor's written request for
compliance. The Contractor shall give SDOH 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 or
transfer to another managed care program, 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. In
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-5
such event, Contractor shall give 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 or transfer to another MCO, 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 SDOH 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
C) the effective date of the termination, which shall
not be less time than will permit an orderly
disenrollment of Enrollees or transfer to another
MCO, 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 SDOH 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.
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-6
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 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 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 SDOH and receives written approval from
SDOH and all other governmental agencies from which approval
is required, for an extension of time for this submission;
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 SDOH for the orderly
disenrollment of Enrollees or transfer to 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) The Contractor shall allow an Enrollee who has entered the
second trimester of pregnancy to continue treatment with a
Participating Provider for a transitional period that includes
the provision of post-
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-7
partum care directly related to the delivery; only if a
participating provider is willing 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;
ii) adhere to the Contractor's quality assurance
requirements and agree 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;
g) SDOH shall promptly pay all claims and amounts owed to the
Contractor;
h) Any termination of this Agreement by either the Contractor or
SDOH shall be done by amendment to this Agreement, unless the
contract is terminated by the SDOH 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 SDOH and the Contractor provided
expressly in this Section shall not be exclusive and are in addition
to all other rights and remedies provided by law or under this
Agreement.
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 and the SDOH at the
following addresses:
For SDOH:
New York State Department of Health
Empire State Plaza
Corning Tower, Rm. 2074
Albany, NY 12237-0065
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-8
For the Contractor:
Wellcare of N.Y.
280 Broadway
New Burg, NY 12550
________________________________________
[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.
FHPlus - Section 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL AGREEMENT ADMINISTRATION PROVISIONS)
October 1, 2001
2-9
3. COMPENSATION
3.1 Capitation Payments
Compensation to the Contractor shall consist of a monthly capitation
payment for each Enrollee and the Supplemental Maternity Capitation
Payment 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 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.
d) Capitation Rates shall be effective for the entire Agreement
period, except as described in Section 3.2.
3.2 Modification of Rates During Agreement 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 to the Benefit Package, shall be
deemed incorporated into this Agreement without further action
by the parties, upon approval and written notice to the
Contractor by SDOH.
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.
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
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 approved modified Capitation Rates are not acceptable.
In such case, the Contractor shall give written notice to
FHPlus - Section 3
(COMPENSATION)
October 1, 2001
3-1
the SDOH 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 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 this 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 6.7 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
FHPlus - Section 3
(COMPENSATION)
October 1, 2001
3-2
processing within thirty (30) business days from date of
receipt of the claim by the Fiscal Agent. Processing of
Contractor claims shall be in compliance with the requirements
of 42 CFR Section 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 Family Health Plus care, services and supplies.
3.5 Denial of Capitation Payments
If the Health Care Financing Administration (HCFA) 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 HCFA, 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 will deny capitation payments to
the Contractor for the same Enrollees for the period of time for
which HCFA 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 FHPlus Enrollees listed on a Roster
if it is determined by the SDOH that the Contractor was not at risk
for provision of Benefit Package services for any portion of the
payment period.
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
FHPlus - Section 3
(COMPENSATION)
October 1, 2001
3-3
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 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 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 under Family Health Plus 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 under Family Health Plus 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.
d) In instances where the Enrollee was enrolled in the
Contractor's plan under Family Health Plus 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 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.
FHPlus - Section 3
(COMPENSATION)
October 1, 2001
3-4
3.9 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.
3.10 Reinsurance
The Contractor shall purchase reinsurance coverage unless it can
demonstrate to SDOH's satisfaction the ability to self-insure. The
cost of purchasing reinsurance shall be allowed in the calculation
of capitation rates, provided that such costs are determined to be
reasonable by the SDOH. Recoveries from reinsurance shall also be
reflected in the Contractor's financial reports as a reduction to
claims experience and shall be considered in the calculation of
capitation rates.
3.11 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) SDOH shall have the right, upon consultation with LDSS as it
deems appropriate, 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, specifying the actions contemplated and the
reason(s) for such action(s). Nothing in this paragraph limits
other remedies available to the SDOH under this Agreement.
FHPlus - Section 3
(COMPENSATION)
October 1, 2001
3-5
4. SERVICE AREA
For purposes of this Agreement, the Contractor's service area shall
consist of the county(ies) described in Appendix M of this Agreement,
which is hereby made a part of this Agreement as if set forth fully
herein. The Contractor must request written SDOH approval to expand its
service area for purposes of providing FHPlus services. In no event,
however, shall the Contractor provide services to the expanded service
area until it has received such approval. Any modifications made to
Appendix M as a result of an approved request to expand the Contractor's
service area shall become effective fifteen (15) days from the date of the
written SDOH approval without the need for further action on the part of
the parties to this Agreement.
FHPlus - Section 4
(SERVICE AREA)
October 1, 2001
4-1
5. FHPLUS ELIGIBLES
5.1 Eligible Persons
An "Eligible Person" is an individual who meets the following criteria:
a) Permanent resident of New York State.
b) Age 19 through 64.
c) Citizen or qualified alien pursuant to the Personal
Responsibility and Work Reconciliation Act of 1996.
d) Not eligible for Medicaid solely due to income and/or
resources, or is eligible only through the application of
excess income toward the costs of medical care and services.
e) Not in receipt of equivalent health care coverage or insurance
as defined by the Health Insurance Portability and
Accountability Act.
f) Gross household income at or below the following federal
poverty levels:
i) Parent(s) living with a child(ren) under the age of 21,
gross family income up to:
- 133% of FPL as of October 1, 2001, and
- 150% of FPL as of October 1, 2002
ii) Individuals without dependent children in their
households will qualify with gross household incomes up
to 100% FPL.
FHPlus - Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2001
5-1
6. ENROLLMENT
6.1 Enrollment Guidelines
a) A variety of methods and programs for enrollment of Eligible
Persons may be employed including, but not limited to,
enrollment assisted by the Contractor or SDOH-approved
Enrollment Facilitators, 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) Enrollment of Eligible Persons will be conducted in accordance
with the guidelines set forth in Appendix H.
c) The SDOH may make modifications to the guidelines set forth in
Appendix H. 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 Contractor.
6.2 Equality of Access to Enrollment
Eligible Persons shall be enrolled in the Contractor's plan, in
accordance with the requirements set forth in Appendix H, Section A.
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.
6.4 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.
FHPlus - Section 6
(ENROLLMENT)
October 1, 2001
6-1
6.5 Newborn Enrollment
a) All newborn children not in a Medicaid managed care excluded
category shall be enrolled in the MCO of the mother, effective
from the first day of the child's month of birth, if that MCO
also participates in Medicaid.
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 of Enrollees are enrolled in the
Contractor's Medicaid managed care plan, if applicable
ii) Issuing a letter informing Enrollees about their newborn
child's enrollment in the Contractor's plan or a member
identification card within 14 days of the date on
which the Contractor becomes aware of the birth, if
applicable
iii) Assuring that enrolled pregnant women select a PCP for
an infant prior to birth and make an appointment with
the PCP immediately after the birth.
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 SDOH and LDSSs shall be responsible for ensuring that
timely Medicaid eligibility determination and enrollment of
the newborn 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.
6.6 Effective Date of Enrollment
a) The Contractor 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 must notify the Enrollee of the
change.
FHPlus - Section 6
(ENROLLMENT)
October 1, 2001
6-2
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 herein after 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 the cost of
hospitalization for an Eligible Person, who is
hospitalized after completing and submitting an
enrollment form to enroll in the Contractor's plan, and
who remains hospitalized on or after the Effective Date
of Enrollment.
iii) 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.
6.7 Roster
a) The combination of the first and second monthly Rosters
generated by SDOH 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, where
applicable, prior to the end of the month in which the Roster
is generated.
b) LDSSs 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 LDSSs or the Enrollment Broker notify the Contractor in
writing or electronically of changes in the first (1st) Roster
and provide 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. If the
Contractor does not receive the Roster before the last
business day of the month prior to the Roster effective date,
the Contractor shall receive the applicable monthly Capitation
Rate for any individual who is no longer on the Roster, was
eligible the prior month,
FHPlus - Section 6
(ENROLLMENT)
October 1, 2001
6-3
and is inadvertently served by the Contractor before receipt
of the Roster.
d) All Contractors must have the ability to receive these Rosters
electronically.
6.8 Automatic Re-Enrollment
a) The Contractor agrees that Eligible Persons who are
disenrolled from the Contractor's plan due to loss of FHPlus
eligibility and who regain eligibility within three (3) months
will automatically be prospectively re-enrolled with the
Contractors plan, subject to availability of enrollment
capacity in the plan.
b) The Contractor agrees that FHPlus Enrollees disenrolled from
the Contractor's plan due to loss of FHPlus eligibility who
gain full Medicaid eligibility will be enrolled by an LDSS in
the Contractor's Medicaid Managed Care Plan, if the Contractor
also participates in the Medicaid managed care program in the
individual's county of fiscal responsibility, and the Enrollee
does not indicate in writing that he/she wishes to enroll in
another Medicaid managed care plan or receive coverage through
Medicaid fee-for-service.
FHPlus - Section 6
(ENROLLMENT)
October 1, 2001
6-4
7. INITIAL ENROLLMENT PERIOD
7.1 Initial Enrollment Period
Enrollees are subject to a twelve (12) month Initial Enrollment
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.
7.2 Disenrollment During Initial Enrollment Period
a) An Enrollee may disenroll from the Contractor's plan during
the Initial Enrollment Period in the first 90 days without
cause and for the duration of the Initial Enrollment Period
for "good cause" as that term is defined by the SDOH. Examples
of good cause include but are not limited to the following:
i) failure of the Contractor to furnish accessible and
appropriate medical care to which the Enrollee is
entitled;
ii) nonconsensual enrollment;
iii) Enrollee, MCO, and LDSS agree that a change of MCO is in
the best interest of the Enrollee.
b) Notwithstanding the above, a pregnant Enrollee may disenroll
from the Contractor's plan during the Initial Enrollment
Period if she chooses to receive health insurance coverage
through Medicaid.
7.3 Notifications Regarding the Initial Enrollment Period
The LDSS, either directly or through the Enrollment Broker where
applicable, shall notify Enrollees of their right to change MCOs in
the Family Health Plus Acceptance Letter sent to individuals after
they have selected a MCO. SDOH or he LDSS/ Enrollment Broker will be
responsible for providing a notice of End of the Initial Enrollment
Period and the right to change MCOs at east sixty (60) days prior to
the first plan enrollment anniversary date.
FHPlus - Section 7
(INITIAL ENROLLMENT PERIOD)
October 1, 2001
7-1
8. DISENROLLMENT
8.1 Disenrollment Guidelines
a) Disenrollment of an Enrollee from the Contractor's Plan may be
initiated by the Enrollee, an 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, Sections D and E of this
Agreement.
b) LDSSs and the Contractor will conduct disenrollments in
accordance with the guidelines set forth in Appendix H,
Sections D and E of this Agreement.
c) The SDOH 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.
d) LDSSs shall make the final determination concerning
disenrollments, except for Contractor-initiated disenrollments
and expedited disenrollments, which may be subject to SDOH
approval as specified elsewhere in this Agreement.
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.
b) any of the factors listed in Section 34 of this Agreement; or
c) on the Capitation Rate payable to the Contractor related to
the Enrollee's participation with the Contractor.
8.3 Reasons for Voluntary Disenrollment
An 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
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-1
Unless otherwise specified in Appendix H, Section E, 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 an LDSS or the SDOH. Substantiation of
the request by the SDOH or the LDSS will result in an
expedited disenrollment in accordance with the
guidelines and timeframes as set forth in Appendix H.
The LDSS will make this decision unless the LDSS
delegates this responsibility to the SDOH.
ii) Enrollees may request an expedited disenrollment by an
LDSS or the SDOH based on a complaint of Non-consensual
Enrollment. Substantiation of such a request by an LDSS
or the SDOH shall result in an expedited disenrollment
which may be effected retroactive to the first day of
the month of enrollment, if deemed by the SDOH or the
LDSS and the Enrollee to be in the best interest of the
Enrollee.
c) Retroactive Disenrollment
Retroactive disenrollments may be warranted in rare instances and
include when an Enrollee is later determined to have entered and
stayed in a residential institution; to have been incarcerated; to
have moved out of the county of fiscal responsibility, subject to
any time remaining in the Enrollee's guaranteed eligibility period;
or to have died 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 an 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 an 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
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-2
disenrollment. Such consultation shall not be required for the
retroactive disenrollment in cases where it is clear that the
Contractor was not at 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,
an 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 Contractor was not at risk for the
provision of Benefit Package services during the month.
8.6 Contractor's Liability
The Contractor is not responsible for providing the Benefit Package
under this Agreement after the Effective Date of Disenrollment
unless the Enrollee is admitted to a hospital prior to the expected
Effective Date of Disenrollment and is not discharged from the
hospital until after the expected Effective Date of Disenrollment,
in which case the Contractor is responsible for the entire hospital
claim. 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 may initiate disenrollment from the
Contractor's plan for "good cause" as that term is
defined by the SDOH at any time during the Initial
Enrollment Period and may disenroll from the FHPlus plan
for any reason at any time after the twelfth (12th)
month following the Effective Date of Enrollment.
ii) An Enrollee 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.
iii) Enrollees granted disenrollment for "good cause" may
join another FHPlus plan, if one is available.
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
Enrollee of his or her right to a fair hearing pursuant
to 18 NYCRR Part 358.
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-3
In the event that the Enrollee's request to disenroll is
approved, the notice must state the Effective Date of
Disenrollment.
v) Once the FHPlus Initial Enrollment Period has expired,
an Enrollee may disenroll from the Contractor's plan at
any time, for any reason.
b) Disenrollment Based on Pregnancy
A pregnant Enrollee may initiate disenrollment from the
Contractor's plan to receive Medicaid coverage.
8.8 Contractor Initiated Disenrollment
a) Contractor initiated disenrollment(s) will be limited to
circumstances in which there is clear and consistent
documentation that the individual's behavior is verbally or
physically abusive and/or causes harm to other Enrollees or to
the plan providers and staff, or is repeatedly non -
compliant. Disenrollment may not be initiated due to an
Enrollee's refusal to accept a specific treatment nor for
behavior resulting from an underlying medical condition,
alcohol or substance abuse, mental illness, mental retardation
or other developmental disability.
b) To request disenrollment to an Enrollee, the Contractor must
do the following if applicable:
i) show evidence of professional evaluation ruling out an
underlying medical condition, alcohol or substance
abuse, mental illness, mental retardation or other
developmental disability as cause for Enrollee behavior.
ii) document difficulty encountered with the Enrollee;
nature, extent and frequency of abusive or harmful
behavior, violence, inability to treat or engage
client.
iii) identify and document unique issues that may be
affecting the Contractor's ability to provide treatment
effectively to certain Enrollees as well as the
appropriateness of providers in network.
iv) document special training offered to providers to
improve their ability to deal with difficult,
non-compliant patients, or those having the above
mentioned conditions.
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. In the event the Contractor is the
sole FHPlus MCO in the county, the notice must explain the
ramifications of losing FHPlus coverage.
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-4
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 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 he 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 SDOH or LDSS will review each Contractor initiated
disenrollment request in accordance with protocols established
by SDOH. Where applicable, as set out in those protocols, an
LDSS or the SDOH, through or with the cooperation of the LDSS,
shall consult with local mental health and substance abuse
authorities in the County when making the determination to
approve or disapprove a Contractor initiated disenrollment
request.
g) An LDSS will render a decision within thirty (30) days of
receipt of the disenrollment request. A 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 the right to a fair hearing. If an
Enrollee requests 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.
i) In New York City, the Metropolitan Regional Office of the SDOH
will assume the LDSS responsibility for reviewing and
approving requests as set forth in Sections 8.8(f) and (g) of
this Agreement.
8.9 LDSS Initiated Disenrollment
a) An LDSS will promptly initiate disenrollment when:
i) an Enrollee is no longer eligible for FHPlus; or
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-5
ii) the Guaranteed Eligibility Period ends (See Section 9)
and an Enrollee is no longer eligible for FHPlus; or
iii) an Enrollee is no longer the financial responsibility of
the LDSS; or
iv) 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.
FHPlus - Section 8
(DISENROLLMENT)
October 1, 2001
8-6
9. GUARANTEED ELIGIBILITY
Except as may otherwise be required by law:
9.1 A new Enrollee who loses eligibility for FHPlus during the first six
(6) months of his or her enrollment, other than an Enrollee
described in Sections 9.2 and 9.7 of this Agreement, is entitled to
receive FHPlus benefits from the Contractor's plan for a period of
six (6) months from his or her Effective Date of Enrollment.
9.2 Guaranteed Eligibility is not available to Enrollees who lose FHPlus
eligibility for one of the following reasons:
i) death,
ii) moving out of State, or
iii) incarceration.
9.3 The services covered during the Guaranteed Eligibility period
shall be those contained in the Benefit Package, as specified in
Appendix K.
9.4 An Enrollee-initiated disenrollment from the Contractor's plan
terminates the Guaranteed Eligibility period.
9.5 An Enrollee who loses and regains FHPlus eligibility within a three
(3) month period will not be entitled to a new period of six (6)
months Guaranteed Eligibility.
9.6 If a FHPlus Enrollee wishes to retain FHPlus eligibility during the
Guaranteed Eligibility Period, an Enrollee may not change health
plans.
9.7 A FHPlus Enrollee who becomes eligible for Medicaid benefits
without an income or resource spenddown and remains in the
Contractor's plan, is not entitled to the six (6) month Guaranteed
Eligibility Period because he or she has not lost benefits as a
result of the change in coverage.
FHPlus - Section 9
(GUARANTEED ELIGIBILITY)
October 1, 2001
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 FHPlus program,
subject to the limitations defined in Appendix K, except for
services specifically excluded by the Agreement, or subsequently
enacted by Federal or State Law.
10.2 Compliance with Applicable Laws
Benefit Package services provided by the Contractor under this
Agreement shall comply with all applicable requirements of the State
Public Health and Social Services Laws.
10.3 Definitions
By signing this Agreement the Contractor agrees to the terms of the
entire Agreement, including the definitions of "Benefit Package" and
"Non-covered Services" contained in Appendix K which is incorporated
by reference as if fully set forth herein.
10.4 Provision of Services Through Participating and Non-Participating
Providers
With the exception of Emergency Services described in Section 10.11
of this Agreement, and services for which Enrollees can self refer
as described in Section 10.12 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 /EPSDT
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, all of which are incorporated by reference into
the Agreement as if fully set forth herein. The Contractor and
its Participating Providers are required to provide C/THP
services to FHPlus Enrollees under 21 years of age when:
FHPlus - Section 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 2001
10-1
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 enrollees who are pregnant women and or parents
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 for 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 that focus on health guidance,
immunizations, and screening for physical, emotional, and
behavioral conditions.
FHPlus - Section 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 2001
10-2
10.6 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 that are covered in the FHPlus benefit
package.
10.7 Court Ordered Services
a) The Contractor shall provide any Benefit Package services to
Enrollees as ordered by a court of competent jurisdiction. The
MCO must use Non-Participating Providers only in the event
that the Court-Ordered Service is a covered service and the
MCO does not have a Participating Provider available to
provide that service. Non-Participating Providers shall be
reimbursed by the Contractor at the Medicaid fee schedule. The
Contractor is responsible for court-ordered services to the
extent that such services are covered by Family Health Plus.
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
treatment for mental health and/or alcohol and/or substance
abuse or dependence), or other FHPlus covered services. The
plan is responsible for payment of those FHPlus services
covered by the Benefit Package.
10.8 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 Participating Provider of such services if
the MCO provides Family Planning and Reproductive Services, or
directly from a provider affiliated with the Designated Third
Party Contractor if such services are not provided directly by
the MCO 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
FHPlus - Section 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 2001
10-3
Agreement as if set forth fully herein, from either the
Contractor, if family planning is a part of the Contractor's
Benefit Package, or from the Designated Third Party
Contractor, where applicable, 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 the Designated Third Party Contractor, where
applicable, 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.
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
and/or the Designated Third Party Contractor, where
applicable, 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, may share patient information
with the Contractor and/or the Designated Third Party
Contractor, where applicable, for purposes of claims payment,
utilization review and quality assurance when the appropriate
patient consent has been obtained. The Contractor and/or
Designated Third Party Contractor, where applicable, 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 and educate its practitioners and
administrative personnel about policies concerning direct
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 this American
College of Obstetricians and
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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 identify
family planning counseling as an integral part of primary and
preventive care.
g) 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
Agreement as if set forth herein.
h) If Contractor does not include family planning and
reproductive health services in its Benefit Package,
Contractor must submit to the SDOH, within ninety (90) days of
signing this Agreement, 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 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
Agreement as if set forth fully herein.
i) 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 Contractor, such modifications is shall be
deemed incorporated into this Agreement without further action
by the parties.
10.9 Prenatal Care
Contractors are responsible for the provision of comprehensive
Prenatal Care Services to all pregnant women enrolled in FHPlus,
including all services enumerated in Subdivision 1, Section 2522 of
the Public Health Law in a manner consistent with the standards set
forth in 10 NYCRR Part 85.40 (Prenatal Care Assistance Program),
both of which are incorporated by reference.
10.10 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
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the Contractor's network providers or the Designated Third Party
Contractor, where applicable, without a referral from the PCP as
set forth in Public Health Law Section 4406-b(1).
10.11 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 services for Urgent Medical
Conditions. 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
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 Agreement
as if set forth fully herein.
e) Emergency transportation is included in the Contractor's
Benefit Package: The Contractor shall reimburse for all
emergency ambulance
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services without regard to final diagnosis or prudent layperson
standards.
10.12 Services for Which Enrollees Can Self-Refer
a) Mental Health and Alcohol/Substance Abuse
The Contractor will allow Enrollees to make self referral or
referral for one mental health and one alcohol/substance abuse
assessment from a Participating Provider in any calendar year
period without requiring pre-authorization or referral from
the Enrollee's Primary Care Provider.
i) The Contractor shall make available to all Enrollees a
complete listing of their participating mental health
and alcohol/substance abuse providers.
ii) The Contractor will also ensure that its Participating
Providers have available and use formal assessment
instruments to identify Enrollees requiring mental
health and alcohol/substance abuse 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 services from
appropriate providers based on the findings of their
assessment.
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 10.15 (a) 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 10.8 and Appendix C of
this Agreement.
10.13 Second Opinions for Medical or Surgical Care
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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.
10.14 Coordination with Local Public Health Agencies
The Contractor will coordinate its public health-related activities
with Local Public Health Agencies. 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 SDOH
may require the Contractor to comply with local district
requirements for coordinating with Local Public Health Agencies.
10.15 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 SDOH 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 TB related
services, unless these services are ordered by a court
of competent jurisdiction. The Local Public Health
Agency will: 1) make reasonable efforts to
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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.
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) cost. The
Contractor agrees to make all reasonable effort to
ensure coordination with DOT providers regarding
clinical care and services. The Contractor also will not
be financially liable for treatments rendered to
Enrollees who have been institutionalized as a result
of local health commissioner's order due to
non-compliance with TB care regimens.
viii) The Contractor remains responsible for communicating,
cooperating, and coordinating clinical management of TB
with the TB/DOT provider.
b) Immunizations
i) Immunizations and administration of immunizations for
Enrollees 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 be used in the absence of a negotiated
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rate. Upon implementation of the immunization registry,
the Local Public Health Agency shall not be required
to contact the PCP.
c) Prevention and Treatment of Sexually Transmitted Diseases
The Contractor will be responsible for requiring that its
Participating Providers educate their Enrollees about the
risk and prevention of sexually transmitted disease (STD). The
Contractor also will be responsible for requiring 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.
d) Lead Poisoning
The Contractor will require its Participating Providers to
coordinate lead poisoning screening and follow-up with Local
Public Health Agencies to assure appropriate follow -up in
terms of environmental investigation, risk management and
reporting requirements.
10.16 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 with 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) 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.
c) Satisfactory methods to assure access to pediatric providers
and subspecialists, and tertiary care centers for the
treatment of individuals with congenital diseases and
malformations (e.g. sickle cell disease, cystic fibrosis).
d) Satisfactory methods to assure access to specialty care
centers for rare disorders both within and outside of New York
State.
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e) Satisfactory methods for case management of individuals with
complex medical needs.
f) Satisfactory systems for coordinating service delivery with
out-of-network providers, including behavioral health
providers, for all Enrollees.
g) Policies and procedures to allow for the continuation of
existing relationships with out-of-network providers,
consistent with P.H.L. Section 4403 and Section 15.5 of this
Agreement.
10.17 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 system.
d) Satisfactory systems for coordinating service delivery among
physical health, alcohol/substance abuse, 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.
10.18 Member Needs Relating to HIV
Persons with HIV infection will be permitted to enroll into FHPlus
health plans.
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 can be obtained from the Contractor
during the period the Enrollee is enrolled in the Contractor's plan.
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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 FHPlus, 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 counselling 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 the 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 CTRNP services 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 Section 98-1.2 and in Subpart 69-I)
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
withproviders funded under the Ryan White CARE Act. The
Contractor 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 HIV community-based
psychosocial case management services.
f) Reporting. The Contractor shall require its Participating
Providers to 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.
10.19 Persons Requiring Alcohol/Substance Abuse Services
The Contractor will have in place all of the following for its
Enrollees requiring alcohol/substance abuse services:
a) Participating Provider networks consisting of licensed
providers, as defined in Section 21.16 of this Agreement.
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b) Satisfactory methods for identifying persons requiring such
services and encouraging self-referral and early entry into
treatment. In the case of 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, alcohol/substance abuse, 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 alcohol and substance addictions,
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 Alcohol/Substance
Abuse Services and related activities.
10.20 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.
10.21 Women, Infants, and Children (WIC)
The Contractor shall develop linkage agreements or other mechanisms
to ensure women Enrollees are referred to WIC services if qualified
to receive such services. The Contractor shall refer pregnant women
to WIC local agencies for nutritional assessments and supplements.
10.22 Coordination of Services
The Contractor shall coordinate care when appropriate for Enrollees
with:
a) the court system (for court ordered evaluations and
treatment);
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b) specialized providers of health care for the homeless, and
other providers of services for victims of domestic violence;
c) family planning clinics, community health centers, migrant
health centers, rural health centers;
d) WIC
e) special needs plans;
f) programs funded through the Ryan White CARE Act;
g) other pertinent entities that provide services out of network;
h) Prenatal Care Assistance Program (PCAP) Providers;
i) local governmental units responsible for public health, mental
health, mental retardation or alcohol and substance abuse
services; and
j) specialized providers of long term care for people with
developmental disabilities.
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.
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11. MARKETING
11.1 Marketing Plan
The Contractor shall have Marketing Plans, that have been
prior-approved by the SDOH and/or LDSSs, that describe the
Marketing activities the Contractor will undertake within designated
geographic areas during the term of this Agreement.
The Marketing Plans 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.
County-specific Marketing Plans shall be kept on file in the offices
of the Contractor, LDSS, and the SDOH. Marketing Plans may be
modified by the Contractor subject to prior written approval by the
SDOH and/or the LDSS. The SDOH and/or LDSS will 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 approved
Marketing Plans.
11.3 Prior Approval of Marketing Materials, Procedures, Subcontractors
The Contractor shall submit all subcontracts, procedures, and
materials related to Marketing to potential Enrollees 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 have not
approved.
11.4 Marketing Infractions
Infractions of the Marketing Guidelines may result in the following
actions being taken by the SDOH in collaboration with LDSSs to
protect the interests of the program and its clients.
a) If an MCO or its representative commits a first time
infraction of marketing guidelines and the SDOH and/or LDSS
deems the infraction to be minor or unintentional in nature,
the SDOH and/or LDSS may issue a warning letter to the MCO.
b) For subsequent or more serious infractions, the SDOH in
collaboration with LDSSs, may impose liquidated damages of
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$2,000 or other appropriate non-monetary sanction for each
infraction.
c) The SDOH in collaboration with LDSSs 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 or
commits an egregious first-time infraction, the SDOH in
collaboration with LDSSs 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 for a period up to the remainder
of the contract; or
iii) terminate the contract pursuant to termination
procedures described therein.
11.5 Additional Marketing Guidelines
The SDOH may require the Contractor to comply with Local District
specific marketing guidelines.
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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
callers 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 FHPlus Enrollees or
FHPlus and Medicaid Managed Care Enrollees if the Contractor also
participates in the Medicaid program. 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.
12.2 Translation and Oral Interpretation
a) 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.
b) In addition, verbal interpretation services must be made
available to Enrollees who speak a language other than English
as a primary
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language. Interpreter services must be offered in person where
practical, but otherwise may be offered by telephone.
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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13. ENROLLEE NOTIFICATION
13.1 Provider Directories/Office Hours for Participating Providers
a) The Contractor will provide to each Enrollee, and upon
request to each prospective Enrollee, a list of
Participating Providers by specialty and a list of
facilities for the county/borough in which the Enrollee
or prospective Enrollee resides. Such list shall include
names, office addresses, telephone numbers, board
certification for physicians, and information on
language capabilities and wheelchair accessibility of
Participating Providers. This information must be
provided in the form of a Provider Directory which must
be updated by the Contractor quarterly. Updates for
three consecutive quarters may be accomplished through
inserts which minimally include additions or deletions
of Participating Providers. An updated provider
directory must be provided in writing to the
Contractor's Enrollees at least annually. Provider
directories, including all relevant inserts, shall be
made available to new Enrollees, and to prospective
Enrollees, upon request.
b) In addition, the Contractor must make available to the
SDOH/LDSS the office hours for Participating Providers.
This requirement may be satisfied by providing a copy of
the list or Provider 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;
and
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.
b) If on 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.
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 or
FHPlus - Section 13
(ENROLLEE NOTIFICATION)
October 1, 2001
13-1
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.
13.3 Member Handbooks
The Contractor shall issue to a new Enrollee within fourteen
(14) days of the Effective Date of Enrollment a FHPlus Member
Handbook, which is consistent with the SDOH guidelines
described in Appendix E, a copy of which is amended hereto
and incorporated by reference into the body of this agreement
as if fully set forth 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 FHPlus 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
Specialty Services and 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.
c) Offer assistance in arranging an initial visit to the
Enrollee's PCP for a baseline physical and other
preventive services,
FHPlus - Section 13
(ENROLLEE NOTIFICATION)
October 1, 2001
13-2
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 the Enrollee has not already chosen a PCP.
13.6 Enrollee's Rights to Advance Directives
The Contractor shall, in compliance with the requirements of 42 CFR
Section 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 for review and prior
approval to the SDOH and/or LDSS. All written notifications must be
written at a fourth (4th) to sixth (6th) grade level and in at least
ten (10) point print.
FHPlus - Section 13
(ENROLLEE NOTIFICATION)
October 1, 2001
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13.8 Contractor's Duty to Report Lack of Contact
The Contractor must inform the LDSS of any Enrollee whom it has been
unable to contact within ninety (90) days of enrollment using
reasonable efforts as defined in Section 13.5 of the Agreement and
who has 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
SDOH will require LDSS to 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 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 Family Health Plus 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/or LDSS, and shall obtain the prior approval
of the notification from SDOH and/or LDSS.
FHPlus - Section 13
(ENROLLEE NOTIFICATION)
October 1, 2001
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 that may be brought by Enrollees,
consistent with Articles 44 and 49 of the New York State
P.H.L. or Articles 48 and 49 of the New York State
Insurance Law ("Insurance Law").
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 Family Health Plus Complaint and Appeals
Program Guidelines described in Appendix F, a copy of
which is annexed hereto and incorporated by reference
into the body of this Agreement as if fully set forth
herein. The SDOH 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.
FHPlus - Section 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 2001
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b) The Contractor's complaint and appeal procedures shall
be approved by the SDOH and kept on file with the
Contractor and SDOH.
c) The Contractor shall not modify its complaint and
appeals procedure without the prior written approval of
SDOH and shall provide SDOH with a copy of the approved
modifications within fifteen (15) days after its
approval.
14.4 Complaint Investigation Determinations
The Contractor must adhere to determinations resulting from
complaint investigations conducted by SDOH.
FHPlus - Section 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 2001
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.
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 on what to
do to obtain services after business hours and on weekends.
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.
- -----------------
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.
FHPlus - Section 15
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October 1, 2001
15-1
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 30
minutes in metropolitan areas or 30 minutes/30 miles in
non-metropolitan areas, In rural areas, transport time and
distance to primary care sites may be greater than 30
minutes/30 miles if consistent with the community standard for
accessing care or if by Enrollee choice.
b) Other Providers
Travel time/distance to specialty care, hospitals, mental
health, lab and x-ray providers shall not exceed 30 minutes/30
miles. In rural areas, transport time and distance to
specialty care, hospitals, mental health, lab and x-ray
providers may be greater than 30 minutes/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-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:
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(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2001
15-2
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 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 the 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
P.H.L. Section 4403(6)(e) or insurance law Section 4804 (a).
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;
ii) adhere to the Contractor's quality assurance
requirements and 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
FHPlus - Section 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2001
15-3
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 participating specialists for Enrollees who
have ongoing needs for care from such specialists, consistent with
P.H.L Section 4403(6)(b) unless the Contractor does not have a
specialist qualified to meet a particular enrollee's needs. In such
case, the Contractor shall make a referral to an appropriate
provider consistent with P.H.L. Section 4403(6)(a) or Insurance Law
Section 4804 (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 participating specialist, who will
then function as the coordinator of primary and specialty care for
that Enrollee, consistent with P.H.L. Section 4403(6)(c) unless the
Contractor does not have a specialist qualified to meet a particular
enrollee's needs. In such case, the Contractor shall make a referral
to an appropriate provider consistent with the P.H.L. Section
4403(6)(a) or Insurance Law Section 4804 (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
participating specialty care center with expertise in treating the
life-threatening or degenerative and disabling disease or condition,
consistent with New York State P.H.L. Section 4403(6)(d) unless the
Contractor does not have a specialty care center qualified to meet a
particular enrollee's needs. In such case, the Contractor shall make
a referral to an appropriate provider consistent with the P.H.L.
Section 4403(6)(a) or Insurance Law Section 4804 (d).
FHPlus - Section 15
(EQUALITY OF ACCESS AND TREATMENT)
October 1, 2001
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 FHPlus services consistent with
P.H.L. Article 49 and 42 CFR Part 456 and Article 48 and 49 of
the Insurance Law. Recipients' records must include
information needed to perform utilization review consistent
with 42 CFR Sections 456.111 and 456.211. The Contractor's
approved quality assurance program must be kept on file by the
Contractor. The Contractor shall not modify the quality
assurance program without the prior written approval of the
SDOH.
b) The Contractor shall incorporate the findings from reports in
Section 18 of this Agreement into its quality assurance
program. When 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 a plan for improving
performance subject to approval by the SDOH. The Contractor
agrees to meet with the SDOH up to twice a year to review
improvement plans and quality performance.
16.2 Standards of Care
The Contractor must adopt practice guidelines consistent with
current standards of care, and in compliance 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 had 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.
FHPlus - Section 16
(QUALITY ASSURANCE)
October 1, 2001
16-1
17. MONITORING AND EVALUATION
17.1 Right to Monitor Contractor Performance
The SDOH and/or LOSS, 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 and/or LDSS, and DHHS in the monitoring and
evaluation of the services provided under this Agreement.
17.3 Cooperation During Annual On-Site Review
The Contractor shall cooperate with SDOH and LDSS in an annual
on-site review of the MCO's operations. SDOH shall give the
Contractor notification of the annual review and survey format at
least forty-five (45) days prior to the annual site visit. This
requirement shall not preclude SDOH and/or LDSS 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
the annual review of the quality of services rendered to its
Enrollees to be performed by an external review agent selected by
the SDOH.
FHPlus - Section 17
(MONITORING AND EVALUATION)
October 1, 2001
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 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 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 upon sixty (60) days' written notice
to the Contractor.
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 SDOH 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 SDOH for each day other reports required by
this Section are late. The SDOH shall not impose liquidated damages
for a first time infraction by the Contractor unless the SDOH 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 SDOH. Liquidated damages may be
waived at the sole discretion of SDOH. Nothing in this Section shall
limit other remedies or rights available to 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 may extend due dates, or modify report requirements or formats
upon a written request by the Contractor to the SDOH 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.
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
18-1
18.5 Reporting Requirements
The Contractor shall submit the following reports to SDOH except in
those instances in which this Agreement specifies the reports shall
be submitted also to the LDSS:
a) Annual Financial Statements:
The 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:
The 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 SDOH reserves the right to require
Contractor to submit such relevant financial reports and
documents related to the financial condition of the plan 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
records 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.
e) Quality of Care Performance Measures:
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
18-2
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 the 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.
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 the following
information to the SDOH 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
committee the fraud or abuse;
D) A description of the fraud or abuse;
E) The approximate range of dollars involved;
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
18-3
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 Provide 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 FHPlus
Enrollees. The report submission must comply with the Managed
Care Provider Network Data Dictionary. Networks must be
reported separately for each designated geographic area in
which the Contractor operates.
i) Appointment Availability/Twenty-four (24) Hour/Access and
Availability Surveys:
The Contractor will conduct county-specific (or service area
if appropriate) reviews 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 SDOH 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 purpose of these studies will be to promote
quality improvement within the
FHPlus - Section 18
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October 1, 2001
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MCO. SDOH will provide guidelines for the studies' structure.
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.
l) New Enrollee Health Screening Completion Report:
The Contractor shall submit a quarterly report to the SDOH and
LDSS 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 the Agreement.
m) No Contact Report:
The Contractor shall submit a monthly report within thirty
(30) days of the close of the reporting period to the LDSS of
any Enrollee it is unable to contact, through reasonable
means, including by mail, and by telephone, using methods
described in Section 13.5 and/or of any Enrollees who have not
utilized any health care services through the Contractor or
its Participating Providers, within ninety (90) days of the
Effective Date of Enrollment.
n) Additional Reports:
Upon request by the SDOH, 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 reserves the right to give thirty (30) days
notice in circumstances where time is of the essence.
o) LDSS Specific Reports:
The SDOH may require the Contractor to comply with LDSS
specific reporting requirements for FHPlus.
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
18-5
18.6 Ownership and Related Information Disclosure
The Contractor shall report ownership and related information to
SDOH 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 Sections 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 SDOH of any
revisions of the Contractor's license under Article 43 of the
Insurance Law.
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 obligations 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 P.H.L. 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 sixty (60) 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.
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
18-6
18.10 Certification Regarding Individuals Who Have Been Debarred Or
Suspended By Federal or State Government
Contractor will certify to the SDOH initially and immediately upon
changed circumstances after 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 FHPlus program, consistent with
requirements of SSA Section 1932 (d)(1).
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) on 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 and Section
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.
FHPlus - Section 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2001
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 SDOH and any
other authorized governmental agency may require including
books, accounts, journals, edgers, 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 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 or a period of six (6)
years thereafter except that the Contractor shall retain Enrollees'
medical records that are in the
FHPlus - Section 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2001
19-1
custody of the Contractor 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. 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 review or audit findings involved in the record
have been resolved and final action taken.
FHPlus - Section 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2001
19-2
20. CONFIDENTIALITY
20.1 Confidentiality of Identifying Information about FHPlus Enrollees
and Applicants
All information relating to services to FHPlus Enrollees and
applicants which is obtained by the Contractor shall be confidential
pursuant to the New York State P.H.L., including P.H.L. 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 FHPlus Enrollees and
applicants 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 FHPlus information.
20.2 Confidentiality of Medical Records
Medical records of FHPlus Enrollees 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.
20.3 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
FHPlus Enrollees and applicants.
FHPlus - Section 20
(CONFIDENTIALITY)
October 1, 2001
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 FHPlus prepaid
Benefit Package as defined in Appendix K, a copy of
which is amended hereto and incorporated by reference
herein as if fully set forth in the body of this
Agreement, 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
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-1
accept assignment of new Enrollees due to capacity
limitations, as determined by the SDOH, 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.
d) Notice of Provider Termination
The Contractor shall immediately notify SDOH of any notice of
termination of a provider agreement to the Contractor's
provider network received from the following providers
i) Hospital
ii) IPA
iii) Medical Group
The Contractor shall also notify 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 SDOH, at
least forty-five (45) days prior to the termination or
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 providers 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 SDOH. SDOH 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 SDOH, and develop a transition plan on an
expedited basis and provide notice to patients subject to the
consent of SDOH.
Upon Contractor notice of failure to re-execute, or
termination of, a provider agreement, the SDOH may waive the
requirement of submission of a contingency plan upon a
determination by the SDOH 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
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-2
of time necessary to provide not less than thirty
(30) days notice to Enrollees.
SDOH reserves 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 I 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
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-3
with appropriately qualified health care professionals. Upon
request, the application procedures and minimum qualification
requirements must be made available to health care
professionals.
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 FHPlus
program, and agrees to no longer utilize the services of the subject
provider, as applicable. The Contractor will receive a listing of
currently excluded Medicaid providers mailed monthly to the
correspondence address, that the Contractor specified to SDOH during
the initial provider enrollment process. Such listing shall be
deemed to constitute constructive notice. This notification should
not be the sole basis for identifying current exclusions or
termination of previously approved providers. Should the Contractor
become aware, through any 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.
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-4
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 will be payment in full for services provided to
Enrollees.
21.6 Choice/Assignment of PCPs
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 who 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 or 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, the 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.
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-5
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 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 a PCP to an Enrollee 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 and as a
result he/she lives beyond the PCP travel time/distance
standard.
iii) The Enrollee's PCP ceases to participate in the
Contractor's network.
iv) The Enrollee's behavior 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) Prior to 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 PCP Status Changes
The Contractor agrees to notify its Enrollees of any of the
following PCP changes:
a) Enrollees will be notified within three (3) business days from
the date on which the Contractor becomes aware of the change
if:
i) Office address/telephone number change.
ii) Office hours change.
b) Enrollees will be notified within fifteen (15) days from the
date on which the Contractor became aware of the following
changes:
i) An Enrollee's PCP ceases participation with the
Contractor (in such cases, the Contractor must ensure
that a new PCP is
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-6
assigned within thirty (30) days of the date of notice
to the Enrollee).
ii) An Enrollee is in an ongoing course of treatment with
another Participating Provider who becomes unavailable
to continue to provide services to such Enrollee. In
such cases, the notice shall also describe the
procedures for continuing care.
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, 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 and FHPlus Enrollees, are
Contractor-specific, and assume the practitioner is a full-time
equivalent (FTE) (defined as a provider practicing at least forty
(40) hours per week for the Contractor):
i) No more than 1,500 Medicaid and FHPlus 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 and FHPlus 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.
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-7
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. The physician must be
available at least eight (8) hours/week, the physician must be
practicing in a Health Provider Shortage Area (HPSA) or other
similarly determined shortage area, 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 Contractor 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
its 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 Assistants as Physician Extenders
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-8
The Contractor is permitted to use registered physician
assistants as physician-extenders, subject to their scope of
practice limitations under New York State Law.
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 I Appendix I which is
incorporated by reference herein as if fully set forth in the
body of this agreement.
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 no
hospitals are located within such a distance. If no hospitals
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.
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-9
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 oral
surgeon. Orthognathic surgery, temporal mandibular disorders (TMD)
and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists
and endodontists must also be available by referral. The network
should include dentists with expertise in serving special needs
populations (e.g., HIV+ and developmentally disabled patients).
Dental surgery performed in an ambulatory clinic or inpatient
setting is the responsibility of the Contractor regardless of
whether the plan has opted to provide dental services.
21.16 Mental Health, Alcohol and Substance Abuse Providers
The Contractor will include a full array of mental health and
substance abuse providers in its networks in sufficient numbers to
assure accessibility to services on the part of Enrollees, 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 substance abuse providers to
include the following: 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 alcoholism/substance
abuse services certified or licensed pursuant to Articles 23 or 31
of Mental Hygiene Law, as appropriate. OASAS programs include
Certified Drug and Alcohol Counselors employed only by OASAS
licensed programs.
21.17 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.
21.18 Federally Qualified Health Centers (FQHCs)
FHPlus - Section 21
(PARTICIPATING PROVIDERS)
October 1, 2001
21-10
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.
21.19 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.
If the Contractor enters into subcontracts for the performance of
work pursuant to this Agreement the Contractor shall take full
responsibility for the acts or omissions of its subcontractors.
Nothing in the subcontract shall impair the rights of the State
under this Agreement. No contractual relationship shall be deemed to
exist between the subcontractor and the State.
The Contractor agrees not to enter into any agreements, with third
party organizations for the performance of its obligations, in whole
or in part, under this Agreement without the State's prior written
approval of such third parties and the scope of the work to be
performed by them. The State's approval of the scope of work and the
subcontractor does not relieve the Contractor of its obligation to
perform fully under this Agreement. The responsibilities of the
Contractor and any subcontractors will be limited to those specified
in the subcontracts.
22.2 Permissible Subcontracts
Contractor may subcontract for provider services as set forth in
Sections 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 only as are
acceptable to the SDOH.
All subcontracts, including provider agreements, entered into by the
Contractor to provide program services for Family Health Plus under
this Agreement shall contain the provisions specifying:
a. That the work performed by the subcontractor must be in
accordance with the terms of this Agreement;
b. That nothing contained in such agreement shall impair
the rights of the State; and
c. That the subcontractor specifically agrees to be bound
by the confidentiality provisions set forth in the
Agreement between the State and the Contractor.
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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 and any material amendments thereto shall
require the approval of SDOH as set forth in P.H.L. 4402 and
10 NYCRR Part 98.
b) If a subcontract is for management services under 10 NYCRR
Section 98.11, it must be approved by SDOH prior to becoming
effective.
c) Any material modifications to existing or new subcontract
arrangements to perform activities relative to service
provided under this Agreement must be submitted in writing and
approved by SDOH before they may be implemented.
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 DHHS, SDOH, or the LDSS.
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 SDOH and the
Contractor shall create any contractual relationship between
any subcontractor of the Contractor, including Participating
Providers, and SDOH.
d) Any subcontract entered into by the Contractor shall fulfill
the requirements of 42 OFR 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
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in accordance with the subcontract or Provider Agreement, the
subcontractor or Participating Provider will not seek payment
from the LDSS, SDOH, the Enrollees, their eligible dependents,
or anyone authorized to act on an Enrollee's behalf.
f) The Contractor shall include in every Provider Agreement a
procedure for the resolution of disputes between the
Contractor and its Participating Providers.
22.6 Timely Payment
Contractor shall make payments to affiliated health care providers
for items and services covered under this Agreement on a timely
basis, consistent with the claims payment procedures described in
Insurance Law Section 3224-a.
22.7 Restrictions on Disclosure
The Contractor shall not by contract or by written policy or
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.
22.8 Transfer of Liability
No contract or agreement between the Contractor and a health care
provider shall contain any cause purporting to transfer to the
health care provider, other than a medical group, by indemnification
or otherwise, any
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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's 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.
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
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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 P.H.L 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.
22.12 Physician Incentive Plan
If Contractor elects to operate a 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.
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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 the agreement between the Contractor and
each subcontractor.
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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.
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
guidelines in Appendix J of this Agreement a copy of which is amended
hereto and incorporated into the body of the Agreement as if fully set
forth herein. Said plan must be approved by the SDOH and be filed with the
Commissioner of Health and be kept on file by the Contractor.
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 for Article 44 plans
or Articles 48 and 49 of the State Insurance Law for Article 43
plans.
25.3 Contractor Notice to Enrollees
a) Contractor must issue a written Notice of Adverse
Determination and Fair Hearing Rights to any Enrollee:
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i) When Contractor or its utilization review agent has
denied a request to approve a Benefit Package service
ordered by an MCO provider; or
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 ten (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) A description of the action Contractor intends to take;
ii) Contractor's reasons for the intended action;
iii) The circumstances under which expedited complaint or
utilization review is available and how to request it;
iv) Notice of Enrollee's right to file a complaint with the
Contractor, a complaint with SDOH, and/or request a
State fair hearing through the Office of Administrative
Hearings (OAH);
v) Instructions to the Enrollee regarding how the Enrollee
may file complaints, utilization appeals and State fair
hearing requests, including use of the Notice of Right
to Request a Fair Hearing which will inform Enrollees of
his or her possible right to aid continuing and that
such aid can be accessed only if the Enrollee requests a
State fair hearing.
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 has been completed and there is a
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October 1, 2001
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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 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) Although an Enrollee may request a State fair hearing in any
given dispute, Contractor is required to maintain and operate
in good faith its own internal 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 disenrollment 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.
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October 1, 2001
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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 fair 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 or requirements imposed by DHHS. 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.
h) The information describing fair hearing rights, aid
continuing, complaint procedures and utilization review
appeals shall be included in all FHPlus 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
benefits. In the event
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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
FHPlus 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 FHPlus 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 and
Article 49 of the Insurance law 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
resultant administrative codes, rules and regulations related to the
Medical Assistance Program or to the delivery of the contracted for
services.
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28. ENVIRONMENTAL COMPLIANCE
The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act 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
("EPA") 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
and SDOH, 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, agents, employees, or
subcontractors, including Participating Providers, in
connection with the performance of this Agreement;
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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 SDOH will provide the Contractor with prompt
written notice of any claim made against the SDOH,
and the Contractor, at its sole option, shall
defend or settle said claim. The SDOH 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 SDOH, its employees,
or agents.
32.2 Indemnification by SDOH
The SDOH agrees to indemnify and hold the Contractor harmless, to
the extent authorized by Article 3, Section 19 of the New York State
Constitution and subject to the availability of lawful
appropriations as required by State Finance Law, Section 41, from
any liability, loss, damage, claim, suit, or judgment, and all
allowable costs and expenses including but not limited to,
reasonable counsel fees and disbursements, of any kind or nature, as
determined by the New York State Court of Claims and arising out of
the actions or the omissions of the SDOH, its officers, agents or
employees in connection with this Agreement. Provisions during the
term of this Agreement are set forth in the New York State Court of
Claims Act, and any damages arising from such liability shall issue
from the New York State Court of Claims Fund or applicable, annual
appropriation of the Legislature of the State of New York.
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
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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.
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 Disclosure Requirements for 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 the Capitation rate that the Contractor will receive for such
Eligible Persons or Enrollees.
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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.
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 covered
benefits from or through a tribal health or urban Indian health
facility or center which is included in the Contractor's network.
35. COMPLIANCE WITH APPLICABLE LAWS
35.1 Contractor and SDOH Compliance With Applicable Laws
Notwithstanding any inconsistent provisions in this Agreement, the
Contractor and SDOH 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; and
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. The parties
agree that this Agreement shall be interpreted according to the laws
of the State of New York.
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void
Agreement 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
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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 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 FHPlus Program. The
Contractor shall continue to be financially responsible as defined
in PHL Section 4403(1 )(c) and shall comply with the contingent
reserve fund and escrow deposit requirements of 10 NYCFR Section
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 MCO 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.
35.5 Compliance With Care for Maternity Patients
Contractor must comply with Section 2803-n of the Public Health Law
and Section 3216 (i) (10) (a) of the State Insurance Law related to
hospital care for maternity patients.
35.6 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.
35.7 Non-Liability of Enrollees for Contractor's Debts
Contractor agrees that in no event shall the Enrollee or any person
authorized to act on the Enrollee's behalf become liable for the
Contractor's debts as set forth in SSA Section 1932(b)(6).
35.8 SDOH Compliance With Conflict of Interest Laws
SDOH and its employees shall comply with General Municipal Law
Article 18 and all other appropriate provisions of New York State
law, local laws
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and ordinances and all resultant codes, rules and regulations
pertaining to conflicts of interest.
35.9 Compliance With PHL Regarding External Appeals
Contractor must comply with Article 49 Title II of the Public Health
Law and Article 49 of the Insurance Law regarding external appeal of
adverse determinations.
36. NEW YORK STATE STANDARD CONTRACT CLAUSES
Appendix A (Standard Clauses as required by the Attorney General for all
State contracts) is attached and incorporated as if set forth fully herein
and any amendment thereto and takes precedence over all other parts of the
agreement.
37. MISCELLANEOUS
The prior review of the State is required before the Contractor or any of
its employees, agents or independent contractors at any time, either
during or after termination of, or cessation of the services required by
this agreement, issue any written statement to the media or issues any
material for publication through any medium of communication bearing on
the work performed relating to financial results, enrollment, outcomes,
utilization patterns, and/or health status under this agreement. Any data
related to the implementation or outcome of the programs funded pursuant
to this agreement used for publication in trade or scientific medium shall
require prior review by the State.
No report, document or other data produced in whole or in part with the
funds provided under this agreement may be copyrighted by the Contractor
without consent by the State, nor shall any notice of copyright be
registered by the Contractor in connection with any report, document or
other data developed pursuant to this agreement. All Information and data
developed under this agreement shall be the property of the State.
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APPENDIX A
NEW YORK STATE STANDARD CLAUSES
AND LOCAL STANDARD CLAUSES
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APPENDIX A
STANDARD CLAUSES FOR ALL NEW YORK STATE 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.
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. In accordance with 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, age,
disability 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 nor 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
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A-2
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 REQUIREMENT. 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 contractors
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.
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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 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
purpose 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
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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 hereof 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 Division 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.
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15. LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article XI-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.
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.
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Information on the availability of New York State subcontractors and
suppliers is available from:
Department of Economic Development
Division for Small Business
30 South Pearl Street
Albany, New York 12245
Tel. 518-292-5220
A directory of certified minority and women-owned business enterprises
is available from:
Department of Economic Development
Minority and Women's Business Development Division
30 South Pearl Street
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.
Contact the Department of Economic Development, Division for Small
Business, 30 South Pearl Street; Albany New York 12245, for a current list
of jurisdictions subject to this provision.
Revised November 2000
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APPENDIX B
CERTIFICATION REGARDING LOBBYING
NEW YORK STATE DEPARTMENT OF HEALTH
PLAN NAME Wellcare of New York
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B-1
APPENDIX B
CERTIFICATION REGARDING LOBBYING
The undersigned certified, 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
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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 placed when this transaction was made or entered into. Submission
of this certification is a prerequisite for making or entering into this
transaction pursuant to U.S.C. Section 1352. The failure to file the required
certification shall subject the violator to a civii penalty of not less than
$10,000 and not more than $100,000 for each such failure.
DATE: 8-7-01
SIGNATURE [ILLEGIBLE]
TITLE V.P. Operations
ORGANIZATION Wellcare of N.Y.
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APPENDIX B-1
FAMILY HEALTH PLUS
STANDARD CONTRACT/BID INSERT FORM
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APPENDIX B-1
Bid Form Request-<Number>
BID FORM
WellCare of New York, Inc. bids a total price of
- -----------------------------------
Name of Firm
$ N/A
------------------ /s/ Darcy Shepard
3/16/2001 Signature
- ------------------- Darcy Shepard
Date Vice President of Network [ILLEGIBLE]
Federal Identification Number
14-1676443
- -------------------
Print Name Title
Name of Company
WellCare of New York, Inc.
Telephone Date
845-334-7140 3/16/2001
Address
P.O.bBox 4800
City Kingston State NY Zip Code 12402
--------------------------------------------------------
Bidders choosing not to bid are requested to complete and return only this
form. Please check one box:
[ ]
1. We do not provide the requested services. Please remove our firm
from your mailing list.
[ ]
2. We are unable to bid at this time because
Please retain our firm on this list.
/s/ Lori E. Masterson
-------------------------------
LORI E. MASTERSON
Notary Public, State of New York
NO. 02MA6002545
APPENDIX Qualified in Ulster County
Commission Expires February 9, 2002
7
APPENDIX B-1
BIDDER'S NAME: WellCare of New York, Inc. REQUEST NUMBER
STANDARD CONTRACT/BID INSERT FORM
This form must be completed and returned with your response to this proposal. If
awarded to you, the contract will incorporate this form as completed by you.
NONDISCRIMINATION IN EMPLOYMENT IN NORTHERN IRELAND:
MacBRIDE FAIR EMPLOYMENT PRINCIPLES
Note: Failure to stipulate to these principles may result in the contract being
awarded to another bidder. Governmental and non-profit organizations are
exempted from this stipulation requirement.
In accordance with Chapter 807 of the Laws of 1992 (State Finance Law Section
174-b), the bidder, by submission of this bid, certifies that it or any
individual or legal entity in which the bidder holds a 10% or greater ownership
interest, or any individual or legal entity hat holds a 10% or greater ownership
interest in the bidder, either
- - has business operations in Northern Ireland Y N xx
-------- --------
- - if yes to above, shall take lawful steps in good faith to conduct any business
operations they have in Northern Ireland in accordance with the MacBride Fair
Employment Principles relating to non-discrimination in employment and freedom
of workplace opportunity regarding such operations in Northern Ireland, and
shall permit independent monitoring of their compliance with such Principles:
Y N
----- -----
OMNIBUS PROCUREMENT ACT OF 1992
Is the Bidder a New York State Business Enterprise? Y X N
--- -----
The State Finance Law defines a "New York State Business Enterprise" as a
business enterprise, including a sole proprietorship, partnership, or
corporation, which offers for sale or lease or other form of exchange, goods
which are sought by the department and which are substantially manufactured,
produced or assembled in New York State, or services which are sought by the
department and which are substantially performed within New York State. The
Department of Health considers "substantially" to mean "over 50%".
- - 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.
APPENDIX
8
- - Information on the availability of New York State subcontractors and
suppliers is available from:
Empire State Development
Division for Small Business
(518)474-7756
- - A directory of minority-and women-owned business enterprises is available
from:
Empire State Development
Minority and Women's Business Development Division
(518)474-1979
FOR ALL CONTRACTS WHERE THE TOTAL BID AMOUNT IS $1 MILLION OR MORE
The Omnibus Procurement Act of 1992 requires that, by signing this bid proposal,
contractors certify that whenever the total bid amount is greater than
$1 million:
1. The contractor has made all reasonable efforts to encourage the
participation of New York State Business Enterprises as suppliers and
subcontractors on this project, and has retained the documentation of
these efforts to be provided upon request to the State;
2. The contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L. 92-261), as amended;
3. The contractor agrees to make all 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;
4. The contractor acknowledges notice that New York 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.
APPENDIX
9
APPENDIX C
NEW YORK STATE DEPARTMENT OF HEALTH
FAMILY HEALTH PLUS
GUIDELINES FOR THE PROVISION OF
FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
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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 the Designated Third
Party Contractor.
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 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 transmissible disease.
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,
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C-2
and 10 NYCRR Section 751.9 and Part 753 relating to informed consent and
confidentiality.
Routine obstetric and/or gynecologic care, including hysterectomies, pre-natal,
delivery and post-partum care are the responsibility of the Contractor if they
are covered contract services.
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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 provider without referral or approval. The
notification must contain the following:
1) notification of the FHPlus 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 a
Contractor's Participating Provider without referral, approval or
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.
The Contractor must notify its Participating Providers that all claims for
family planning services must be billed to the Contractor.
FHPlus
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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 Agreement.
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 included
in the Contractor's Benefit Package.
b. Such services may be obtained through a third party
specifically under contract with SDOH for the provision of
these services.
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 the above 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.
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.
4) The member handbook and marketing materials indicating that the
Contractor has elected not to cover certain reproductive health and
family planning services,
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Appendix C
October 1, 2001
C-5
and explaining the right of all Enrollees to secure such services
through the Designated Third Party Contractor.
5) Mechanisms to provide all new Enrollees with an SDOH approved letter
explaining how to access family planning services through the
Designated Third Party Contractor and the list of participating
providers available through that arrangement. This material will be
furnished by SDOH to the Contractor and must be mailed with the
first new Enrollee communication.
6) If an Enrollee or prospective Enrollee requests information about
these family planning and reproductive health services, the
Contractor will advise the Enrollee or prospective Enrollee as
follows:
a. Certain family planning and reproductive health services such
as abortion, sterilization and birth control are not covered
directly by the Contractor.
b. Enrollees can receive these non-covered services using the
Designated Third Party Contractor.
c. The Contractor will mail to each Enrollee or prospective
Enrollee who calls for information about family planning and
reproductive health services, a copy of the SDOH approved
letter explaining the Enrollee's right to receive these
services through the Designated Third Party Contractor and the
list Participating Providers available through that
arrangement. The Contractor will mail these materials within
48 hours of the contact.
d. Enrollees can call the Contractor's member services number or
the New York State Growing-Up-Healthy Hotline (1-800-522-5006)
to request a list of providers available through the
Designated Third Party Contractor for family planning
services.
7) The procedure for maintaining a manual log of all requests for such
information, including the date of the call, the Enrollee's ID
number, and the date the SDOH approved letter and SDOH approved list
were mailed. The Contractor will review this log monthly and upon
request, submit a copy to SDOH by county.
8) 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 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
provide the Enrollee with a list of providers available through the
Designated Third Party Contractor, or give the Enrollee the member
services number to call to obtain this listing.
9) The Contractor must recognize that the exchange of medical
information, when indicated in accordance with generally accepted
standards of professional
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C-6
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 separate contract with SDOH.
10) 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 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.
Call monitoring 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 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 programs 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.
FHPlus
Appendix C
October 1, 2001
C-7
APPENDIX D
NEW YORK STATE DEPARTMENT OF HEALTH
FAMILY HEALTH PLUS
MARKETING GUIDELINES
FHPlus
Appendix D
October 1, 2001
D-1
MARKETING GUIDELINES
INTRODUCTION
The purpose of these guidelines is to provide an operational framework for
localities and FHPlus 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.
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October 1, 2001
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A. Marketing Plans
1. The MCO shall develop marketing plans that meet SDOH guidelines and any
local requirements as approved by the State Department of Health (SDOH).
2. The SDOH and/or 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 authorized by Section
11.5 of this Agreement must be described in the MCO's county-specific
marketing plans.
4. The MCO must have on file with the SDOH and each LDSS an approved
marketing plan, prior to the contract award date or before marketing and
enrollment begin, whichever is sooner. Subsequent changes to the marketing
plans must be submitted to the LDSS or SDOH for approval at least sixty
(60) days before implementation.
5. The marketing 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.
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October 1, 2001
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 FHPlus and/or a MCO's FHPlus care product. The target
audience for these marketing materials is low-income, uninsured
people who do not qualify for Medicaid, and who are living in a
defined service area.
b) Marketing materials include any information that references the
FHPlus 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 incentives.
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 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.
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Appendix D
October 1, 2001
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 "You get free, unlimited visits." Materials must not use
broad, sweeping statements-- for example, "If you are uninsured, you
are eligible for FHPlus and/or the XYZ Health Plan."
f) The material must accurately reflect general information, which is
applicable to the average customer of FHPlus.
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 take 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, enrollment broker, SDOH-approved
Enrollment Facilitators 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 individual
in making an informed choice of MCO.
j) The Contractor shall advise potential Enrollees, in written
materials related to enrollment, to verify with the medical services
providers they prefer, or have existing relationships with, that
such medical services providers participate in the selected FHPlus
MCO's network and are available to serve the Enrollee.
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 applicable LDSSs.
b) The SDOH will delegate to LDSSs review and approval of the
following marketing material:
i) MCO marketing plans;
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Appendix D
October 1, 2001
D-5
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;
iv) MCO informational brochures to be included in LDSS
enrollment packets or to be used by SDOH-approved Enrollment
Facilitators; and
v) All direct mailing from MCOs targeted to the FHPlus 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 Contractor Outreach Materials
The Contractor shall provide to the LDSS and/or Enrollment Broker or
SDOH-approved Enrollment Facilitators upon request, an approved
marketing/informational brochure or alternative informational document
that describes coverage in the service area.
The Contractor shall, upon request, submit to the LDSS, Enrollment
Broker, or SDOH-approved Enrollment Facilitators a current provider
directory, together with information that describes how to determine
whether a provider is presently available.
FHPlus
Appendix D
October 1, 2001
D-6
C. Marketing Activities
1. Definitions
a) Marketing activities are occasions during which marketing
information and material regarding FHPlus 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 fully capitated for family planning
services, the representative must tell the prospective
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
from the Designated Third Party Contractor;
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 MCOs may engage in marketing activities
that include community-sponsored social gatherings, provider-hosted
informational sessions, or MCC-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 FHPlus eligibles only.
c) Media campaigns are the distribution of information/materials
regarding the FHPlus program and/or a specific MCO for the purpose
of encouraging the uninsured to join a FHPlus 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 affected LDSSs.
2. Marketing Sites
a) With prior LOSS 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
FHPlus
Appendix D
October 1, 2001
D-7
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.
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 MCOs 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 FHPlus program, or the
program or policy requirements of the LDSS or the SDOH.
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Appendix D
October 1, 2001
D-8
b) MCOs are PROHIBITED from purchasing or otherwise acquiring or using
mailing lists of FHPlus eligibles 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.
d) MCOs 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 the Capitation Rate that the Contractor will receive for such
Eligible Person. 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 FHPlus eligibles 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 FHPlus Enrollees. Examples of inappropriate behavior include
interfering with other health plan presentations, talking negatively
about another health plan, and participating with FHPlus Enrollees
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
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Appendix D
October 1, 2001
D-9
completion of immunizations or other health related programs. Such
rewards may not exceed $5000 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 financial or other kinds of incentives to
marketing representatives that use the number of Enrollees as a
factor in compensation. MCOs may reward representatives based on the
achievement of health goals by the Enrollee. For example, an MCO may
offer an incentive to a marketing representative who has enrolled an
individual who subsequently completes a smoking cessation session
and stops smoking.
j) Individuals employed by MCOs as marketing representatives and
employees of marketing subcontractors must have successfully
completed a training program about the basic concepts of managed
care and the FHPlus enrollee's rights and responsibilities relating
to membership in managed care. MCOs must submit a copy of the
training curriculum for their marketing representative 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.
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Appendix D
October 1, 2001
D-10
D. MARKETING INFRACTIONS
1. Infractions of the marketing guidelines may result in the following
actions being taken by the SDOH in collaboration with LDSSs to protect the
interests of the program and its clients.
a) If an MCO or its representative commits a first time infraction of
marketing guidelines and the SDOH and or LDSS deems the infraction
to be minor or unintentional in nature, the SDOH and/or LDSS may
issue a warning letter to the MCO.
b) For subsequent or more serious infractions, the SDOH, in
collaboration with LDSSs, may impose liquidated damages of
$2,000.00, or other appropriate non-monetary sanctions for each
infraction.
c) The SDOH in collaboration with LDSSs 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 SDOH in collaboration with LDSSs may:
i) prohibit the MCO from conducting any marketing activities
for a period up to the end of the Agreement period;
ii) suspend new enrollments, for a period up to the remainder of
the Agreement; or
iii) terminate the Agreement pursuant to termination procedures
described therein.
FHPlus
Appendix D
October 1, 2001
D-11
E. LDSS SPECIFIC MARKETING GUIDELINES
Local districts may adopt, subject to SDOH approval, additional and/or more
restrictive marketing guidelines to the extent appropriate to local conditions
and circumstances. The SDOH may require the Contractor to comply with local
district-specific marketing guidelines.
FHPlus
Appendix D
October 1, 2001
D-12
APPENDIX E
NEW YORK STATE DEPARTMENT OF HEALTH
FAMILY HEALTH PLUS
MEMBER HANDBOOK GUIDELINES
FHPlus
Appendix E
October 1, 2001
E-1
INTRODUCTION
This document contains member handbook guidelines for use by managed care
organizations (MCOs) under contract to serve New York FHPlus 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 in its review of all FHPlus 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
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 listings 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 SDOH Family Health Plus
Program.
GENERAL FORMAT
Member handbooks must be written in a style and reading level that will
accommodate the reading skills of many FHPlus Enrollees. 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 percent (5%) 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
FHPlus
Appendix E
October 1, 2001
E-2
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.
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) Choice of Primary Care Provider (including how to make an appointment)
i) Explanation of the role of POP 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.
d) 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.
e) 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 specialized medical care over a prolonged
period of time, may request
FHPlus
Appendix E
October 1, 2001
E-3
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.
f) 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 contract definition).
iii) Services not covered by the plan or FHPlus.
iv) Prior authorization and other requirements for treatments and
services.
v) Family planning and reproductive health services policy.
vi) HIV counseling and testing policy.
vii) Plan toll-free number for Enrollee to call for more information.
g) Out of Area Coverage
i) Explanation of what to do and who to call if medical care is
required when Enrollee is out of plan's service area.
h) 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.).
i) 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.
v) Right to an appeal, including expedited and standard appeals
processes and the time frames for such appeals.
vi) Right to designate a representative.
FHPlus
Appendix E
October 1, 2001
E-4
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).
j) Enrollment and Disenrollment Procedures
i) Explanation of the Initial Enrollment Period, and initial grace
period when a person may change plans.
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.
k) 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.
l) Language
i) Description of how the Contractor addresses the needs of non-English
speaking Enrollees.
m) 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.
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.
FHPlus
Appendix E
October 1, 2001
E-5
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.
n) Fair Hearing
Explain that:
i) Enrollee has a right to a State Fair Hearing and Aid 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 FHPlus 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).
o) External Appeals
i) Description of circumstances when 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.
p) 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.
q) 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.
FHPlus
Appendix E
October 1, 2001
E-6
r) 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, if
applicable.
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.
FHPlus
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October 1, 2001
E-7
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.
FHPlus
Appendix E
October 1, 2001
E-8
APPENDIX F
NEW YORK STATE DEPARTMENT OF HEALTH
FAMILY HEALTH PLUS
COMPLAINT AND APPEALS PROGRAM GUIDELINES
FHPLUS
APPENDIX F
October 1, 2001
F-1
I. OVERALL OBJECTIVES
The FHPlus 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 defined as a written or verbal contact to the plan
in which the Enrollee or provider describes a concern with any of
the following:
- A determination made by the MCO, other than a determination of
medical necessity or a determination that a service is
considered experimental or investigational;
- Treatment experienced through the MCO, its providers, or
Contractors; or
- Any other concern with the MCO, its benefits, employees or
providers.
b) An "inquiry" is defined as a request for information by an Enrollee.
Inquiries may include instances where a MCO clarifies the Benefit
Packages or procedures for accessing services; or other issues
relative to an Enrollee's question.
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; or determines that a requested benefit is not
covered in the MCO's Benefit Package, the MCO shall provide written
notice of the procedures for the
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APPENDIX F
October 1, 2001
F-2
Enrollee to file a complaint, including the notice containing
information on the right to request a fair hearing.
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) The Enrollee shall be informed of the toll-free number to call in
order to file a complaint and of their right to complain to the SDOH
and LDSS (phone numbers and address) at anytime.
e) 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 hours 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.
f) Determinations of all clinical complaints involving clinical
decisions shall be made by qualified clinical personnel.
g) 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
The MCO shall send a notice to the Enrollee upon receipt of the following types
of complaints anytime the MCO: 1) 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 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.
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APPENDIX F
October 1, 2001
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 the 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.
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APPENDIX F
October 1, 2001
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. The determination shall include:
i) the detailed reasons for the determination;
ii) the clinical rationale for the determination, if applicable;
iii) the procedures for the filing of an appeal of the
determination including required appeal forms;
iv) the Enrollee's option to also contact the State Department of
Health (800-206-8125) with their complaint;
v) the notice containing fair hearing rights.
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 a 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 designed, 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 matters 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 pare 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
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APPENDIX F
October 1, 2001
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;
FHPlus
APPENDIX F
October 1, 2001
F-6
e) date and copy of the Enrollee's appeal;
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.
FHPlus
APPENDIX F
October 1, 2001
F-7
APPENDIX G
NEW YORK STATE DEPARTMENT OF HEALTH -
GUIDELINES FOR THE PROVISION
OF EMERGENCY CARE and SERVICES
FOR THE FAMILY HEALTH PLUS PROGRAM
FHPlus
APPENDIX G
October 1, 2001
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, including psychiatric stabilization and medical detoxification
from drugs or alcohol, that are provided for an emergency medical
condition.
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.
Failure by the participating ED to notify the MCO for visits that do not
meet the definition of an Emergency Medical Condition should not be the
sole basis for denial of triage fee or other payment-unless it can be
shown to be part of a pattern of non-notification by the participating ED.
Non-participating EDs cannot be denied payment on the basis of non-
notification.
PROTOCOL FOR ACCEPTABLE TRANSFER BETWEEN FACILITIES
All relevant COBRA requirements must be met.
FHPlus
Appendix G
October 1, 2001
G-2
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.
Payment of the triage fee is contingent on reasonable notification efforts
by a participating hospital to the health plan and/or patient's primary
care provider, so that appropriate follow-up can occur.
FHPlus
Appendix G
October 1, 2001
G-3
APPENDIX H
NEW YORK STATE DEPARTMENT OF HEALTH GUIDELINES FOR THE
PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
FOR THE FAMILY HEALTH PLUS PROGRAM
FHPlus
APPENDIX H
October 1, 2001
H-1
APPENDIX H
SDOH GUIDELINES
FOR THE PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
FOR THE FHPLUS PROGRAM
This appendix is intended to provide general guidelines to MCOs for the
processing of enrollments and disenrollments. Where an enrollment broker exists,
the enrollment broker may be responsible for some or all of LDSS
responsibilities. To allow LDSSs flexibility in developing processes that will
meet their needs, SDOH may require MCOs to follow local district modifications
to specific timeframes and procedures.
A. ENROLLMENT
SDOH RESPONSIBILITIES:
1. The SDOH is responsible for monitoring enrollment activities, including
facilitated enrollment, and providing technical assistance to LDSSs 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:
LDSSs are responsible for FHPlus eligibility determinations and the enrollment
of eligible persons into FHPlus MCOs.
1. LDSSs are responsible for coordinating the FHPlus application and
enrollment process with SDOH-approved Enrollment Facilitators consistent
with SDOH Administration Directives on Family Health Plus and Facilitated
Enrollment. Such coordination shall include, but not be limited to:
i) working with SDOH-approved Enrollment Facilitators to develop/amend
protocols for the receipt and processing of applications and for the
provision of information on managed care options to potential
Enrollees.
ii) providing information to SDOH-approved Enrollment Facilitators to
assist in determining a health care provider's participation in
Medicaid managed care or FHPlus.
iii) accepting Medicaid managed care/FHPlus enrollment forms from
SDOH-approved Enrollment Facilitators and pending the enrollment
until eligibility has been established and enrollment can be
completed in the PCP Subsystem.
FHPlus
APPENDIX H
October 1, 2001
H-2
iv) providing feedback to SDOH-approved Enrollment Facilitators on
incomplete or incorrect applications so that problems may be
addressed in a timely fashion.
v) delegating the Medicaid/FHPlus face-to-face interview with the
applying individual/families to the Enrollment Facilitators or
establish procedures that allow the facilitator to act as the
authorized representative for the applicant, for the purposes of a
face-to-face interview with local district staff.
2. LDSSs are responsible for ensuring that pre-enrollment information
provided to individuals eligible for FHPlus is consistent with Social
Services Law, Section 369-ee and may train persons providing counseling to
potential Enrollees, including SDOH-approved Enrollment Facilitators.
3. LDSSs must ensure that potential Enrollees are informed of the
availability of FHPlus MCOs and the scope of services covered by each.
4. LDSSs must ensure that potential Enrollees are informed of the right to
confidential face-to-face counseling and will make confidential
face-to-face sessions available upon request.
5. LDSSs shall ensure that potential Enrollees are advised, 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 plan's
provider network and are available to serve the participant.
6. For enrollments made during face-to-face counseling, if the potential
Enrollee has a preference for particular medical services providers, LDSSs
shall ensure that enrollment counselors verify with the medical services
providers that such medical services providers whom the potential Enrollee
prefers participate in the MCO's network and are available to serve the
participant.
7. LDSSs will approve the Contractor's phone enrollment process, if
applicable.
8. LDSSs will determine the status of enrollment applications. Applications
will be enrolled, pended or denied.
9. LDSSs enter individual enrollment form data and transmit 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
FHPlus
APPENDIX H
October 1, 2001
H-3
iii) LDSS electronically transfers data, via a dedicated line or
Electronic Medicaid Eligibility Verification System (EMEVS) to the
PCP Subsystem.
10. LDSSs are required to send SDOH-prescribed notices to applicants or
Enrollees, which may include but are not limited to the following:
i) Notice of Acceptance: This letter informs the applicant of approval
of eligibility for FHPlus and the name of the MCO selected by the
applicant.
ii) Enrollment Confirmation Notice: This letter indicates the Effective
Date of Enrollment, the name of the FHPlus MCO and all individuals
who are being enrolled.
iii) Notice of Denial of Enrollment: This letter is used when an
individual has been determined by LDSS to be ineligible for
enrollment into FHPlus and it includes notice of fair hearing
rights.
MCO RESPONSIBILITIES:
1. In those instances in which the Contractor is directly involved in
assisting in enrolling Eligible Persons, the Contractor will submit to
LDSSs, enrollments along with attestations (if applicable) within a
maximum of five (5) business days from the day the complete enrollment
application 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.
3. The Contractor must report any changes in status for its enrolled members
to LDSSs within five (5) business days of such information becoming known
to the Contractor.
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 network and are available to serve the
participant.
B. NEWBORN ENROLLMENTS:
If the Contractor is also a Medicaid MCO, the Contractor agrees to enroll and
provide coverage for eligible newborn children of FHPlus 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 its of Section 366-g of the
Social Services Law as amended by Chapter 412 of the Laws of 1999.
LDSS Responsibilities:
FHPlus
APPENDIX H
October 1, 2001
H-4
1. Grant Medicaid eligibility for newborns for one (1) year if born to a
woman eligible for and receiving FHPlus on the date of birth. (Social
Services Law Section 366 (4) (1))
2. LDSSs must insure that Medicaid coverage is authorized for the unborn
child as soon as a pregnancy is medically verified.
3. In the event that an LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is to establish Medicaid eligibility and enroll the
unborn in the plan of the pregnant woman if that plan participates in
Medicaid managed care. If the plan does not participate in Medicaid
managed care, the pregnant woman will be asked to select a Medicaid
managed care plan for the unborn. If Medicaid managed care is unavailable
in the district, or is not chosen by the mother, the newborn will be
eligible for Medicaid fee-for-service coverage, and such information will
be entered on the WMS.
4. Upon notification of the birth by the Contractor, Enrollee or hospital,
the LDSS will update WMS with the demographic data for the newborn. If the
MCO participates in Medicaid and enrollment has not already taken place,
LDSSs will enroll the newborn in the mother's plan. The PCP subsystem will
automatically be updated and the newborn will appear as Medicaid eligible
on the next month's Roster after the update to WMS. In districts where
Medicaid managed care is unavailable or is not chosen by the mother, the
newborn will be eligible for Medicaid fee-for-service coverage.
5. When an unborn has not been pre-enrolled with the Contractor, LDSSs, upon
receiving notification of the birth from the Contractor, Enrollee or
hospital, must retroactively enroll the newborn back to the first (1st)
day of the month of birth, if the mother was enrolled at that time,
provided the plan also participates in Medicaid. If not, the newborn will
be covered by fee-for service Medicaid until such time as the mother
selects a plan, if available and appropriate.
6. Where newborns will be enrolled in the mother's MCO, LDSSs must ensure
that the mother is informed that the effective date of enrollment will be
the first day of the month of birth.
7. LDSSs 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
Identification Number (CIN), and the Expected Date of Confinement (EDC).
FHPlus
APPENDIX H
October 1, 2001
H-5
2. Upon the newborn's birth, the Contractor must send verification of
infant's demographic data to the LDSS, within five (5) days after
knowledge of the birth. The demographic data must include: the mother's
name and CIN, the newborn's name and CIN (if newborn has a CIN), sex and
the date of birth.
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, the Contractor may submit an
electronic enrollment of the newborn to the Enrollment Broker.
4. MCOs that participate in Medicaid managed care will follow the Enrollment
Guidelines as outlined in Appendix H of the Medicaid managed care model
contract.
C. 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 LDSSs. SDOH uses data contained in
both these files to generate the Roster.
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 LDSSs can
be accomplished via paper transmission, magnetic media, or via an
electronic bulletin board.
3. The SDOH shall also forward an error report as necessary to each MCO and
LDSS.
4. 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 LDSSs a second Roster which contains any additional Enrollees that an
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) LDSSs must notify the Contractor in writing of changes in the Roster and
error report, no later than the end of the month. (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.
FHPlus
APPENDIX H
October 1, 2001
H-6
2) Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, adjusting 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.
2) The Contractor must submit claims to the State's Fiscal Agent for all
Eligible Persons that are on the 1st and 2nd Rosters, adjusted to add
Eligible Persons enrolled by the LDSS after Roster production 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 Package
services. Mere payment of subcapitation does not constitute "provision of
Benefit Package services."
D. DISENROLLMENT:
SDOH RESPONSIBILITIES:
1. LDSSs may delegate to SDOH the responsibility for the review and
approval of a MCO-initiated request to disenroll an Enrollee. The
SDOH will be responsible for notification of the Enrollee of the
status of the MCO request and if appropriate the right to request a
fair hearing.
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. LDSSs must utilize the State's Disenrollment
form.
2. Enrollees may initiate a request for an expedited disenrollment to
LDSSs or the SDOH. LDSSs will expedite the disenrollment process in
those cases where an Enrollee's request for disenrollment involves
an urgent medical need, or a complaint of non-consensual enrollment.
If approved, the LDSS will manually process the disenrollment
through the PCP Subsystem.
3. LDSSs 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.
FHPlus
APPENDIX H
October 1, 2001
H-7
4. LDSSs will disenroll Enrollees automatically upon death or loss of
FHPlus eligibility (subject to any remaining a applicable "six
months guaranteed eligibility" coverage). All such disenrollments
will be effective at the end of the month in which the death or loss
of eligibility occurs. However, if a FHPlus Enrollee gains full
Medicaid eligibility and FHPlus Plan is also a Medicaid managed care
plan, the LDSS will enroll the individual in the Medicaid Managed
Care product of the FHPlus plan, unless the individual indicates in
writing that he/she wishes to enroll in another Medicaid managed
care plan or receive coverage through Medicaid fee-for-service.
5. LDSSs will promptly disenroll Enrollees who request disenrollment
during their Initial Enrollment Period upon determination that they
meet good cause criteria as defined by SDOH. The LDSS will provide
Enrollees with notice of their right to request a fair hearing if
their disenrollment request is denied. LDSSs will transfer Eligible
persons to another FHPlus plan, if one is available, upon a
determination that good cause criteria for disenrollment during the
Initial Enrollment period are met.
6. Retroactive disenrollments are to be used only when absolutely
necessary. Circumstances warranting a retroactive disenrollment are
rare and include when an Enrollee is later determined to have
entered and stayed in a residential institution; to have been
incarcerated; to have moved out of the County of fiscal
responsibility subject to any time remaining in the Enrollee's
guaranteed eligibility period; or to have died - as long as the
Contractor was not at risk for provision of Benefit Package services
for any portion of the retroactive period. LDSSs must notify the
Contractor of a retroactive disenrollment prior to the action. LDSSs
must find out if the Contractor has made payments to providers on
behalf of the Enrollee prior to disenrollment. After this
information is obtained, LDSSs and the Contractor will agree on a
retroactive disenrollment or prospective disenrollment date.
a) Generally the effective dates of retroactive disenrollment for
specific circumstances are described below:
REASON FOR DISENROLLMENT EFFECTIVE DATE OF DISENROLLMENT
------------------------ -------------------------------
- - Death of Enrollee - First day of the month after death
- - Enrollee entered or stayed - First day of the month following entry or
in a residential institution first day of the month following
classification of the stay as permanent,
subsequent to entry
- - Incarceration - First day of the month following entry
- - Move by Enrollee outside - First day of the month after the update of
of District/County of Fiscal Responsibility the system with the new address
FHPlus
APPENDIX H
October 1, 2001
H-8
b) 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 Contractor's 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.
7. LDSSs are responsible for informing Enrollees of their right to change
MCOs including any applicable Initial Enrollment Period restrictions.
8. LDSSs are responsible for sending SDOH-prescribed notices to Enrollees
regarding their enrollment status. Where practicable, the process will
allow for timely notification to Enrollees unless there is "good cause"
to disenroll more expeditiously. Such notices may include, but are not
limited to:
a) Notice of Disenrollment: This letter will advise the Enrollee of
the status of an Enrollee initiated (voluntary) disenrollment for
"good cause", or of an LDSS or Contractor initiated (involuntary)
disenrollment, including the effective date of disenrollment.
b) When LDSSs deny an Enrollee's request for disenrollment for "good
cause" pursuant to Section 8 of the Agreement; LDSSs 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 Initial Enrollment Period Notice: Enrollees must be
notified sixty (60) days before the end of their Initial
Enrollment Period.
d) End of FHPlus Coverage: These notices will advise the Enrollee
that their FHPlus coverage is ending and contain pertinent
information regarding fair hearing rights.
9. LDSSs or the SDOH will render a decision within thirty (30) days of the
receipt of a fully documented request for disenrollment. A final
written determination will be provided to the Enrollee and the
Contractor by LDSSs or the SDOH. This will include notification to the
Enrollee of their right to request a fair hearing.
10. In those instances where LDSSs and/or the SDOH approve 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
allowed by law.
FHPlus
APPENDIX H
October 1, 2001
H-9
11. LDSSs and/or the SDOH will review each Contractor requested
disenrollment in accordance with protocols established by SDOH in
conjunction with the applicable oversight agency. Where applicable,
LDSSs and/or the SDOH, shall consult with local mental health and
substance abuse authorities in the county when making the determination
to approve or disapprove the request.
12. LDSSs may establish procedures whereby MCOs refer cases which are
appropriate for an LDSS-initiated disenrollment, and submit supporting
documentation to the LDSS. The Contractor shall notify the LDSS when it
learns that its Enrollees have died, moved, been incarcerated, or are
in receipt of equivalent insurance coverage.
13. After LDSSs receive and, if appropriate, approve a request for
disenrollment either from the Enrollee or the Contractor LDSSs will
update the PCP subsystem file with an end date. EMEVS and the Fiscal
Agent are then updated and 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 disenrollment requests to
LDSSs for processing within five (5) business days. During pulldown week
these forms may be faxed to the LDSS, followed by transmission of a hard
copy.
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 Client Identification
number.
3. To initiate an involuntary disenrollment of an Enrollee, the Contractor
must where applicable:
a) Show evidence of professional evaluation ruling out an underlying
medical condition, alcohol or substance abuse, mental illness,
mental retardation or other developmental disability as a cause
for Enrollee behavior.
b) Document difficulty encountered with the Enrollee; nature, extent
and frequency of abusive or harmful behavior, violence, inability
to treat or engage Enrollee and outreach efforts to Enrollee
employed.
c) Identify and document unique cultural issues that may be affecting
the Contractor's ability to provide treatment effectively to
certain Enrollees as well as the appropriateness of providers in
the network.
FHPlus
APPENDIX H
October 1, 2001
H-10
d) Document special training offered to providers to improve their
ability to deal with difficult, non-compliant patients, or those
having the above mentioned conditions.
4. The Contractor, once the actions in # 3 above have been taken, will
provide prior verbal and written notice to the Enrollee, with a copy to
the LDSS or the SDOH of its intent to request disenrollment. The notice
will advise the Enrollee that the request has been forwarded to the LDSS
or the SDOH for review and approval. The notice must include the mailing
address and telephone number of the LDSS or the SDOH.
5. The Contractor will not consider an Enrollee disenrolled without
confirmation from the LDSS or the Roster (as described in Section C of
this Appendix).
E. EXPEDITED DISENROLLMENTS
Enrollees may request an expedited disenrollment if they have an urgent medical
need to disenroll or if they were non-consensually enrolled in FHPlus. Enrollees
may request expedited disenrollment by LDSSs or SDOH as stated in Section 8.4
(b) of this Agreement.
LDSS RESPONSIBILITIES:
1. LDSSs, to the extent possible, will process an expedited
disenrollment within two business days of its determination that an
expedited disenrollment is warranted. 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,
if determined to be in the best interest
of the Enrollee.
FHPlus
APPENDIX H
October 1, 2001
H-11
F. LDSS SPECIFIC PROCEDURES
The SDOH may require the Contractor to comply with local district
specific procedures for enrollment and disenrollment.
FHPlus
APPENDIX H
October 1, 2001
H-12
APPENDIX I
NEW YORK STATE DEPARTMENT OF HEALTH
GUIDELINES FOR THE USE OF MEDICAL RESIDENTS
IN THE FAMILY HEALTH PLUS PROGRAM
FHPlus
APPENDIX H
October 1, 2001
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 certified 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 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
FHPlus
APPENDIX H
October 1, 2001
I-2
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.
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 still 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.
FHPlus
Appendix I
October 1, 2001
I-3
(b) MEDICAL RESIDENTS AS SPECIALTY CARE PROVIDERS
(1) Residents may participate in the specialty care of FHPlus 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
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 the 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 hours. 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.
FHPlus
Appendix I
October 1, 2001
I-4
(7) All training programs participating in FHPlus 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.
(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 payer. Training sites must integrate the care of Medicaid,
FHPlus uninsured and private patients in the same settings.
FHPlus
Appendix I
October 1, 2001
I-5
APPENDIX J
NEW YORK STATE DEPARTMENT OF HEALTH
GUIDELINES FOR
FAMILY HEALTH PLUS
COMPLIANCE WITH THE
AMERICANS WITH DISABILITIES ACT
FHPlus
APPENDIX J
October 1, 2001
J-1
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 FHPlus is a government program, health services provided
through FHPlus Managed Care must be accessible to all that 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 FHPlus program, an MCO 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 MCO Qualification Standards to qualify MCOs for
participation in the FHPlus Program. Pursuant to the State's responsibility to
assure program access to all FHPlus enrollees, 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 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.
FHPlus
APPENDIX J
OCTOBER 1, 2001
J-2
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 MCOs as they develop a plan to assure
compliance with the Americans with Disabilities Act (ADA); and
- To provide standards for the review of the 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, Braille 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.
III. SCOPE OF MCO COMPLIANCE PLAN
The MCO Compliance Plan must address accessibility to services at 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
FHPlus
APPENDIX J
October 1, 2001
J-3
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.
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, and audiotapes) 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
MCO marketing representatives
5. Enrollee health promotion material/activities targeted specifically
to persons with disabilities (e.g. secondary infection prevention,
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
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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 drop-offs
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
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
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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
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 MCOs prior to enrollment. Once a MCO
has been chosen, a health assessment form may be used to assess the
person's health care needs.
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
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COMPLIANCE PLAN SUBMISSION
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
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 MCO. 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
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
MCO 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
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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 the 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
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 MCOs by receiving, processing,
and resolving grievances and complaints in an expeditious manner, with the
goal of ensuring resolution of complaints and access to appropriate
services as rapidly as possible.
All enrollees must be informed about the complaint process within
their MCO and the procedure for filing complaints. This information will
be made available through the member handbook, SDOH toll-free complaint
line [1-(800) 206-8125] and the MCO'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.
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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 the 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 the MCO monitors 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.
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
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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
D. PARTICIPATING PROVIDERS
STANDARD FOR COMPLIANCE
MCO 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
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1. Process for the 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 a 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 TTV (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 the 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 an accessible to persons with disabilities, the
health plan 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 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
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- This may include the implementation of a referral system to
ensure that the health care needs of enrollees with
disabilities are met appropriately
- The 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 the ADA Compliance Summary Report or health plan
statement that data submitted to SDOH on the Health Provider Network (HPN)
files is an accurate reflection of each network's physical accessibility
E. POPULATIONS WITH 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. Linkages with behavioral health agencies, disability and advocacy
organizations, etc.
3. Adequate network of providers and sub-specialists (including
pediatric providers and sub-specialists) and contractual
relationships with tertiary institutions
4. Procedures for assuring that these populations receive appropriate
diagnostic work-ups on a timely basis
5. Procedures for assuring that these populations receive appropriate
access to durable medical equipment on a timely basis
6. Procedures for assuring that these populations receive appropriate
allied health professionals (Physical, Occupational and Speech
Therapists, Audiologists) on a timely basis
7. State designation as a Well Qualified Plan to serve the 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
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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, child protective service
agencies, early intervention officials, behavioral health, and
disability and advocacy organizations.
3. A description of the sub-specialist network, including contractual
relationships with tertiary institutions to meet the health care
needs of people with disabilities
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 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
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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.
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APPENDIX K
NEW YORK STATE DEPARTMENT OF HEALTH
FAMILY HEALTH PLUS
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND NON-COVERED SERVICES
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Appendix K
October 1, 2001
K-1
COVERED SERVICES
The categories of services in the FHPlus 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 services are in summary form; the full description and scope of each of
the FHPlus covered services 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 emergency services and emergency transportation,
including air ambulance.
INPATIENT HOSPITAL SERVICES
Inpatient hospital services, shall include, except as otherwise specified,
medically necessary care, treatment, maintenance and nursing services, on an
inpatient hospital basis, up to 365 days per year (366 in leap years). MCOs will
not be responsible for hospital stays that commence prior to the effective
enrollment date, but will be responsible for stays that commence prior to the
effective disenrollment date. Among other services, inpatient hospital services
encompass a full range of medically necessary diagnostic and therapeutic care
including medical, surgical, nursing, radiological, and rehabilitative services.
Services are provided under the direction of a physician, nurse practitioner, or
dentist, and include inpatient detoxification services provided in Article 28
hospitals for all enrollees. Inpatient dental services are also covered (see
dental definition).
INPATIENT STAY PENDING ALTERNATE LEVEL OF MEDICAL CARE
Continued care in a hospital pending placement in an alternate lower
medical level of care, consistent with the provisions of 18 NYCRR 505.20 and 10
NYCRR, Part 85.
PROFESSIONAL AMBULATORY SERVICES
Outpatient hospital services are provided through ambulatory care
facilities including hospital outpatient Departments (OPDs), diagnostic and
treatment centers (D&Ts or free-standing clinics), and emergency rooms. These
facilities may provide those medically necessary medical, surgical, and
rehabilitative services and items authorized by their operating certificates.
Outpatient services (clinic) also include preventive, primary medical,
specialty, mental health, alcohol, Child/Teen Health Plan (C/THP) services,
ambulatory dental surgery, and family planning services provided by ambulatory
care facilities.
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K-2
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.
PREVENTIVE HEALTH SERVICES
Preventive care means care and services 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 restorative programs.
MCOs must offer the following preventive services essential for promoting
wellness and preventing illness:
- General health education classes.
- Pneumonia and influenza immunizations for at risk populations.
- Smoking cessation classes, with targeted outreach for young adults
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 testing and counseling.
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K-3
LABORATORY SERVICES
Laboratory services include medically necessary tests and procedures
ordered by a qualified medical professional and listed in the Medicaid fee
schedule for laboratory services.
All laboratory testing sites providing services 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 the
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.
RADIOLOGY SERVICES
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.
EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICES THROUGH THE
CHILD TEEN HEALTH PROGRAM (C/THP) AND ADOLESCENT PREVENTIVE SERVICES
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 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 in obtaining services, including outreach, education, appointment
scheduling, administrative case management and transportation assistance.
HOME HEALTH SERVICES
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Appendix K
October 1, 2001
K-4
FHPlus will cover up to 40 home health care visits per year in lieu of a
skilled nursing facility stay or hospitalization. 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 Public Health Law as a Certified Home Health
Agency (CHHA). Home health services mean the following services when prescribed
by a provider and provided to an 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 serves the county, 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 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 plan has no CHHA
available, a registered nurse, or therapist.
Personal care tasks performed by a home health aide incidental to a CHHA
visit, and pursuant to an established care plan, are covered.
Services include care rendered directly to the individual and instructions
to his/her family or caretaker in the procedures necessary for the patient's
treatment or maintenance.
The plan must provide up to two post-partum home visits for 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), and
the first visit must occur within forty-eight (48) hours of discharge.
EMERGENCY ROOM SERVICES
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.
Emergency room services are 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
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October 1, 2001
K-5
average knowledge of medicine and health, could reasonably expect the absence of
medical attention to result in:
- 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;
- Serious impairment of such person's bodily functions;
- Serious dysfunction of any bodily organ or part of such person; or
- Serious disfigurement of such person.
VISION CARE
Emergency, preventive and routine eye care is covered. Eye care includes
the services of 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 MCO does not include upgraded eyeglasses or additional
features such as scratch coating, progressive lenses, or photo-gray 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 are covered only as necessary and as required by the individual's
particular condition. Examinations that include refraction may be limited to
every two years unless otherwise justified as medically necessary.
Eyeglasses do not require changing more frequently than every two 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.
FHPlus
Appendix K
October 1, 2001
K-6
Enrollees may self-refer to any participating provider of vision services
(optometrist or ophthalmologist) for refractive vision services.
DURABLE MEDICAL EQUIPMENT
Durable medical equipment (DME) are devices and equipment ordered for the
treatment of a medical condition which can withstand repeated use for a
protracted period of time; are primarily and customarily used for medical
purposes; are generally not useful in the absence of illness or injury; and are
usually not fitted or designed for a particular person's use unless customized
or custom-made. DME is covered when medically necessary as ordered by an MCO's
participating provider and procured from a participating provider. Coverage
includes equipment servicing, but excludes disposable medical supplies.
AUDIOLOGY, HEARING AID SERVICES AND PRODUCTS
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.
Audiology services include audiometric examinations and testing, hearing
aid evaluations and hearing and prescriptions or recommendations, as medically
indicated.
Hearing aid products include hearing aids, earmolds, special fittings, and
replacement parts. (batteries are covered as part of the prescription benefit)
FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
[x] COVERED [ ] NOT COVERED
Family planning and reproductive health services means the offering,
arranging and furnishing of those health services which enable individuals who
may be sexually active to prevent or reduce the incidence of unwanted pregnancy.
These include diagnosis and all medically necessary treatment, sterilization,
screening and treatment for sexually transmissible diseases, and screening for
disease and pregnancy.
Also included are HIV counseling and testing when provided as part of a
family planning visit. Additionally, reproductive health care includes coverage
of
FHPlus
Appendix K
October 1, 2001
K-7
all medically necessary abortions. Elective induced abortions must be covered
for New York City residents. Fertility services are not covered.
MCOs that do not include family planning services in the capitation are
still required to provide the following services:
- Screening, related diagnosis, ambulatory treatment, and referral to
participating providers as needed for dysmenorrhea, cervical
cancer, or other pelvic abnormality/pathology.
- Screening, related diagnosis, and referral to participating
providers for anemia, cervical cancer, glycosuria, proteinuria,
hypertension, breast disease, or pregnancy.
(See Appendix C, New York State Department of Health FHPlus Guidelines for
the Provision of Family Planning and Reproductive Health Services).
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, and
respiratory, circulatory and obstetrical emergencies.
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. Emergency transportation
via 911 or any other emergency call system is a covered benefit and the
Contractor is responsible for payment. The Contractor shall reimburse for all
emergency ambulance services without regard to final diagnosis or prudent lay
person standard.
DENTAL
[x] COVERED [ ] NOT COVERED
FHPlus
Appendix K
October 1, 2001
K-8
MCOs opting to include dental services in their benefit package will cover
medically necessary preventive, prophylactic and other routine dental care,
services and supplies and dental prosthetics required to alleviate a serious
health condition, including one which affects employability.
Routine dental care, procedures which help prevent oral disease from
occurring, and emergency treatment required to alleviate pain and suffering
caused by dental disease or trauma are covered consistent with the policies
outlined in the MMIS Provider Manual for Dental Services, and include, but are
not limited to:
- Prophylaxis every six (6) months
- Topical fluoride applications at 6 month intervals where the local
water supply is not fluoridated and documented as medically
necessary for adults
- Examinations, visits and consultations every six months
- Full mouth/panoramic x-rays every three (3) years if necessary
- Bitewing x-rays at six-twelve (6-12) month intervals
- Other x-rays as required
- Simple extractions and other routine dental surgery, including pre-
and postoperative care and in-office conscious sedation
- Amalgam or composite restorations and stainless steel or porcelain
fused to metal crowns
- Endodontic procedures for treatment of diseased pulp chamber and
pulp canals, where hospitalization is not required
- Complete or partial dentures including (six) 6 months of follow-up
care
- Insertion of identification slips, repairs, relines and rebases
- Treatment of cleft palate
- Fixed bridges are not covered unless required due to the presence of
a neurologic or physiologic condition that would preclude the
placement of a removable prosthesis.
- Cosmetic dentistry, implants and orthodontia are not covered.
All MCOs must cover ambulatory or inpatient surgical services (subject to
prior authorization by the plan). This coverage excludes the professional
services of the dentist if dental services are not covered by the MCO's benefit
package
PROSTHETICS
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. Prosthetics are covered when medically necessary as ordered by the
FHPlus
Appendix K
October 1, 2001
K-9
MCO's participating provider. Artificial eyes are covered as part of the eye
care benefit.
ORTHOTICS
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. Covered when medically necessary as ordered by the MCO's
participating provider.
MENTAL HEALTH/ALCOHOL AND SUBSTANCE ABUSE SERVICES (OUTPATIENT)
FHPlus will cover up to a total of 60 visits per year for mental health
and for the diagnosis and treatment of alcoholism and substance abuse, when
medically necessary.
Outpatient alcoholism/substance abuse services involve a planned
combination of multiple non-residential services provided to persons suffering
from alcohol abuse or alcoholism or substance abuse or to their significant
others under the supervision of a physician. Services include but are not
limited to assessment; individual, group, or family counseling; education;
treatment planning; preventive counseling; discharge planning; and services to
significant others. Services may be provided in facilities licensed by the
Office of Alcoholism and Substance Abuse or by licensed individual
practitioners. Enrollees must be allowed to self refer for one alcohol/substance
abuse assessment from a plan's participating provider in a calendar year.
Outpatient mental health services include but are not limited to:
assessment, stabilization, treatment planning, discharge planning, verbal
therapies, education, symptom management, case management services, crisis
intervention and outreach services, chlozapine monitoring and collateral
services as certified by the Office of Mental Health. Services may be provided
in-home, in a provider's office or in the community. Services may be provided by
licensed OMH providers or by other providers of mental health services including
clinical psychologists, and physicians.
Enrollees must be allowed to self refer for one mental health assessment
from a plan's participating provider in a calendar year.
MENTAL HEALTH/ALCOHOL AND SUBSTANCE ABUSE SERVICES (INPATIENT)
FHPlus will cover up to a combined total of thirty (30) days per year of
medically necessary inpatient mental health and alcoholism and substance abuse
services.
FHPlus
Appendix K
October 1,2001
K-10
Inpatient mental health services include voluntary or involuntary
admissions for mental health services.
Inpatient alcoholism and substance abuse treatment and rehabilitation
services involve a program of continuous twenty-four (24) hour care and services
under medical direction for the treatment of alcoholism or substance abuse
dependency or withdrawal. Services include, but are not limited to: assessment;
management of detoxification and withdrawal conditions; group, individual or
family counseling; alcohol and substance abuse education; rehabilitation; and
discharge planning.
Inpatient detoxification in a hospital setting is considered an inpatient
hospital benefit covered up to 365 medically necessary days per year (366 days
for leap years).
EXPERIMENTAL AND/OR INVESTIGATIONAL TREATMENT
Services and treatment that may be deemed experimental and/or
investigational treatment may be covered on a case-by-case basis. If a FHPlus
MCO denies coverage on the basis that the service or treatment is experimental
and/or investigational, the Enrollee may appeal that determination in accordance
with Article 49 of the Public Health Law (Utilization Review and External
Appeal).
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.
PHYSICIAN SERVICES
Physician services, whether furnished in the office, the Enrollee's home,
a hospital, or elsewhere, means services furnished by a physician:
- Within the scope of practice of medicine or osteopathy as defined in
law by the New York State Education Department; and
- 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.
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.
FHPlus
Appendix K
October 1,2001
K-ll
The following are 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 and school.
- Health and mental health assessments for the purpose of making
recommendations regarding an enrollee's disability status for
Federal SSI applications.
- Annual preventive health visits for adolescents.
- Health screening, assessment and treatment of refugees, including
the completion of SDOH/LDSS required forms.
- Child/Teen Health Program or EPSDT services which are comprehensive
primary health care services provided to children under twenty-one
(21) years of age.
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 nurse practitioner's licensure and
collaborative practice agreement with a licensed physician in accordance with
the requirements of the Department of Education.
The following services are also included in the nurse practitioner's scope
of services, without limitation:
- C/THP or EPSDT services which are comprehensive primary health care
services provided to children under 21.
- Physical examinations including those that are necessary for
employment and school.
REHABILITATION SERVICES
Short-term rehabilitation services are covered for the maximum reduction
of physical or mental disability and restoration to the individual's best
functional level. Rehabilitation services include care and services rendered by
physical therapists and occupational therapists, up to twenty (20) visits per
year. Covered speech therapy services are those required for a condition
amenable to significant clinical improvement within a two-month period.
Rehabilitation services may be provided in an Article 28 inpatient or outpatient
facility, an enrollee's home, by an approved home health agency, in the office
of a private practicing therapist or speech pathologist, or in a Residential
Health Care Facility (RHCF), as long as the Enrollee's stay is classified as a
rehabilitative stay.
FHPlus
Appendix K
October 1, 2001
K-12
Rehabilitation services are covered as medically necessary when ordered by the
MCO's participating provider, and if applicable, with prior approval by the MCO.
MIDWIFERY
Midwifery services include the management of a normal pregnancy,
childbirth and postpartum care as well as primary preventive reproductive health
care to essentially healthy women as specified in a written practice agreement,
and shall include newborn evaluation, resuscitation, and referral for infants.
The care may be provided on an inpatient or outpatient basis including in a
birthing center or in the enrollee's home as appropriate. The midwife must be
licensed by the State Education Department.
CLINICAL PSYCHOLOGICAL SERVICES
Clinical psychological services include psychological evaluation and
testing and therapeutic treatment for personality or behavior disorders.
Clinical psychology visits are subject to the applicable mental health benefit
limits.
PRESCRIPTION DRUGS
Medically necessary prescription drugs are covered under FHPlus, but may
be limited to generic medications where medically acceptable. All medications
used for preventive and therapeutic purposes are covered, as well as family
planning or contraceptive medications or devices. Coverage includes enteral
formulas for home use for which a physician or other provider authorized to
prescribe has issued a written order. Enteral formulas for the treatment of
specific diseases shall be distinguished from nutritional supplements taken
electively. Coverage for certain inherited diseases of amino acid and organic
acid metabolism shall include modified solid food products that are low-protein
or which contain modified protein. Vitamins are not covered except when
necessary to treat a diagnosed illness or condition.
Experimental investigational drugs are generally excluded, except where
approved in the course of experimental/investigational treatment. Drugs
prescribed for cosmetic purposes are excluded. Over-the-counter items are
excluded with the exception of diabetic supplies, including insulin and smoking
cessation agents.
SECOND MEDICAL/SURGICAL OPINIONS
MCOs will allow enrollees to obtain second opinions for diagnosis of a
condition, treatment or surgical procedure by a qualified physician or
appropriate specialist, including one affiliated with a specialty care center. A
second opinion in the event of a positive or negative diagnosis of cancer, a
recurrence of cancer, or a recommendation of a course of treatment of cancer is
covered also. In the
FHPlus
Appendix K
October 1, 2001
K-13
event that the Contractor determines that it does not have a Participating
Provider in its network with appropriate training and experience rendering the
Participating Provider capable of providing a second opinion, the Contractor
shall make a referral to an appropriate Non-Participating Provider. The
Contractor shall pay for the cost of the services provided by the
Non-Participating Provider.
SMOKING CESSATION PRODUCTS
MCOs must cover at least two courses of smoking cessation therapy per
person per year, as medically necessary. A course of treatment is defined as no
more than a 90-day supply, (an original prescription and two (2) refills, even
if less than a 30-day supply is dispensed in any fill). Duplicative use of one
agent is not allowed (i.e., same drug/same dosage form/same strength). Both
prescription and over-the-counter treatments/agents are covered; this includes
nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
COURT ORDERED SERVICES
Court ordered services are those services ordered by a court of competent
jurisdiction which are performed by or under the supervision of a physician,
dentist, or other provider qualified under State Law to furnish medical, dental,
behavioral health (including treatment for mental health and/or alcohol and/or
substance abuse or dependence), or other FHPlus covered services. The MCO is
responsible for payment of those services as covered by the benefit package.
NON-COVERED SERVICES
FHPlus MCOs are not required to provide the following services.
NON-EMERGENT TRANSPORTATION SERVICES
Since enrollees qualify for FHPlus by virtue of meeting higher income
guidelines, it has been assumed that Enrollees will be able to meet the
occasional transportation expenses associated with accessing medical care and
services (the exception being transportation assistance for 19 and 20 year olds
receiving EPSDT services). Local districts will not be administering a
transportation program for FHPlus enrollees.
(Only emergency transportation by ambulance and air ambulance is covered under
FHPlus.)
FHPlus
Appendix K
October 1, 2001
K-14
PERSONAL CARE AGENCY SERVICES
Personal care services are the provision of some or total assistance with
personal hygiene, dressing and feeding; and nutritional and environmental
support (meal preparation and housekeeping). Individuals eligible to receive
such services are generally expected to be in receipt of such services for an
extended period of time (years). They would generally be expected to qualify for
Medicaid, which administers this program through the LDSS. Local districts will
not be administering a personal care program for FHPlus enrollees.
FHPlus does cover short-term home health care, which may include some personal
care tasks provided by home health aides incidental to a certified home health
agency visit; these services are covered in lieu of hospitalization or as part
of a post-partum home visit only.
PRIVATE DUTY NURSING SERVICES
FHPlus does not cover private duty nursing services provided by a private
practitioner.
(FHPlus only covers up to 40 certified home health agency visits per year in
lieu of hospitalization or as part of a post-partum home visit only.)
LONG TERM CARE SKILLED NURSING FACILITIES
FHPlus does not cover skilled nursing services in a RHCF (see 18 NYCRR Section
360-1.4(k)).
(Short-term (i.e., less than 30 days) rehabilitation in such a setting, is a
covered benefit.)
NON-PRESCRIPTION (OTC) DRUGS AND MEDICAL SUPPLIES
Over-the-counter drugs and medical/surgical supplies are not included in the
benefit package. These items are: consumable, non-reusable, disposable, or serve
a specific rather than incidental purpose, and generally have no salvageable
value (e.g. gauze pads, bandages and diapers).
(Medical supplies routinely furnished on administered as part of a clinic or
office visit are covered. Smoking cessation products, hearing aids and supplies
including batteries, and diabetic supplies and equipment are covered under
FHPlus.)
FHPlus
Appendix K
October 1,2001
K-15
ALCOHOL AND SUBSTANCE ABUSE (ASA) SERVICES ORDERED BY THE LDSS
FHPlus enrollees will not be assessed by the LDSS for employability, and will
not be mandated to receive such alcohol and substance abuse services as a
condition of eligibility for FHPlus.
OFFICE OF MENTAL HEALTH/ OFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL
DISABILITIES SERVICES
FHPlus does not cover residential services (intermediate care facilities or
community residences) or care.
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 months or less. Hospice is not a
covered service under FHPlus.
SCHOOL SUPPORTIVE HEALTH SERVICES
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 through the age of 21. These services are not covered under FHPlus.
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). FHPlus does not cover
Comprehensive Medicaid Case Management.
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.
(Clinical management of tuberculosis is covered in the FHPlus benefit package.
The plan's responsibility is limited to communicating, cooperating and
coordinating clinical management of TB with the TB/DOT provider, if applicable.)
FHPlus
Appendix K
October 1, 2001
K-16
AIDS ADULT DAY HEALTH CARE
Adult Day Health Care Programs (ADHCP) are programs designed to assist
individuals with HIV disease to live more independently in the community or
eliminate the need for residential health care services. Registrants in ADHCP
require a greater range of comprehensive health care services than can be
provided in any single setting, but do not require the level of services
provided in a residential health care setting. This is not a covered service
under FHPlus, however plans should coordinate and refer to these services.
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. This is not a covered service under FHPlus, however
plans should coordinate and refer to these services.
HOME AND COMMUNITY BASED SERVICES WAIVER
Home and Community Based Services Waivers are programs designed as alternatives
to institutionalization or residential placement for special populations under
the Medicaid program. They are not covered under FHPlus.
FHPlus
Appendix K
October 1, 2001
K-17
Appendix L
Family Health Plus
Approved Capitation Payment Rates
for the FHPlus Program
FHPlus
Appendix L
October 1, 2001
WELLCARE OF NEW YORK, INC.
FAMILY HEALTH PLUS RATES
EFFECTIVE OCTOBER 1, 2001
Adults with Adults without Adults without Maternity
County Children 19 - 64 Children 19 - 29 Children 30 - 64 Kick
- ------------- ---------------- ---------------- ---------------- ---------
Albany $229.55 $281.46 $329.15 $5,113.66
Broome $232.68 $283.10 $346.48 $5,192.46
Columbia $252.53 $279.91 $388.32 $5,134.88
Delaware $252.53 $279.91 $388.32 $5,134.88
Dutchess $251.55 $259.48 $327.31 $5,137.95
Greene $252.53 $279.91 $388.32 $5,134.88
New York City $256.04 $247.85 $376.40 $5,934.00
Orange $251.55 $259.48 $327.31 $5,137.95
Otsego $252.53 $279.91 $388.32 $5,134.88
Rensselaer $229.55 $281.46 $329.15 $5,113.66
Rockland $277.29 $331.12 $358.58 $5,528.75
Saratoga $229.55 $281.46 $329.15 $5,113.66
Sullivan $251.55 $259.48 $327.31 $5,137.95
Tioga $232.68 $283.10 $346.48 $5,192.46
Ulster $251.55 $259.48 $327.31 $5,137.95
Appendix M
Service Area for the Family Health Plus Program
FHPlus
Appendix M
October 1, 2001
Appendix M
WellCare of New York, Inc.'s Family Health Plus Service Area includes the
following counties in their entirety:
Albany
Bronx
Columbia
Dutchess
Greene
Kings
New York
Queens
Rensselaer
Rockland
Ulster
FHPlus
Appendix M
October 1, 2001
Appendix N
Family Health Plus
Proof of Worker's Compensation Coverage
FHPlus
Appendix N
October 1, 2001
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
APPLICATION FOR CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
The undersigned Employer [ILLEGIBLE] to obtain a Certificate of
Workers' Compensation insurance from the
Insurance Carrier Transportation Insurance Company as satisfactory proof
required under the provisions of Section 57 of the Workers' Compensation Law, to
be filed with
Name: WellCare of New York Inc.
-------------------------------------------------------------------
(Name of Bureau, [ILLEGIBLE]
Address: 6800 N. Dale Mabry Hwy., Suite 270-299 Tampa, FL 33614
Locations of Operations: 280 Broadway, 3rd Floor Newburgh, NY 12550
Date operations to begin________________________________________________________
Telephone No 813-290-6200 Signature /s/ Carol K. [ILLEGIBLE] 8/14/01
------------------------ -------
(Name of Employer) (Date)
NOTE This application must be signed by the Employer of an individual, or if a
copartnership, by a member of the copartnership, or by an officer of a
corporation.
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
This is to certify that WellCare of New York, Inc. is insured with the
Transportation Insurance Company under Policy No. [ILLEGIBLE] covering the
entire obligation of this employer for workers' compensation under the New York
Workers' Compensation Law with respect to the locations named in the foregoing
application. The policy term covers the period from 01/01/01 to 01/01/02.
If said policy is changed or cancelled during its term in such manner as to
affect this Certificate, thirty (30) days written notice of such change or
cancellation [ten (10) days written notice in the event of cancellation for
non-payment of premiums] will be given to
_______________________________________________________________________________
NYS Dept of Health Bureau of Intergovernmental Affairs Corning Tower, Rm
2074, Albany, NY 12237-0084
- --------------------------------------------------------------------------------
[ILLEGIBLE] [ILLEGIBLE]
In accordance with whose requirements, this Certificate has been issued Notice
by registered or certified mail, return receipt requested, so addressed shall be
[ILLEGIBLE]
Carrier Transportation Insurance Co By [ILLEGIBLE] 8/16/01
------------------------- -------
(Signature) (Date)
Telephone No (707)797-5193 Title Executive Vice President
THE WORKERS' COMPENSATION BOARD EMPLOYS AND [ILLEGIBLE] PEOPLE WITH DISABILITIES
WITHOUT DISCRIMINATION
C-105.2 (10-94)
Appendix O
Family Health Plus
Proof of Disability Insurance Coverage
FHPlus
Appendix O
October 1, 2001
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
EMPLOYER'S APPLICATION FOR CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS
LAW
INSTRUCTIONS TO EMPLOYER: COMPLETE PART I ONLY AND HAVE YOUR DISABILITY BENEFITS
INSURANCE CARRIER COMPLETE PART II.
PART I. TO BE COMPLETED BY EMPLOYER
EMPLOYER'S NAME AND ADDRESS (Home or Main
Office) LOCATION OF OPERATIONS
- ----------------------------------------------- -----------------------------
The WellCare Management Group, Inc. 280 Broadway, 3rd floor,
6800 N. Dale Mabry Newburgh, NY 12550
Tampa, FL 3361/
NAME UNDER WHICH BUSINESS IS CONDUCTED OPERATIONS TO BEGIN ON OR
IF DIFFERENT FROM ABOVE ABOUT:
- ----------------------------------------------- -----------------------------
WellCare of New York, Inc.
DISABILITY BENEFITS CARRIER (If More Than One, NYS UNEMPLOYMENT INSURANCE
List All) EMPLOYERS REGISTRATION NUMBER
- ----------------------------------------------- -----------------------------
Mutual of Omaha 02-12093
Application is hereby made to the CARRIER for a Certificate of Compliance with
the Disability Benefits Law.
Date Signed 8/29/01 By /s/ [ILLEGIBLE]
----------------------------
(Signature of Owner,
Partner, or Authorized Officer)
Telephone No. [ILLEGIBLE] Title CAO
PART II. TO BE COMPLETED BY DISABILITY BENEFITS CARRIER
CERTIFICATE OF COMPLIANCE WITH DISABILITY BENEFITS LAW
This is to certify that the above-named employer is insured with
Mutual of Omaha OMNY6X007A20 and that the policy covers:
- ----------------------------
(Name of Carrier)
*a. [X] ALL of the EMPLOYER'S employees eligible under the New York
Disability Benefits Law.
*b. [ ] ONLY the following class or classes of the EMPLOYER'S employees:
--------------------------------------------------------------------
--------------------------------------------------------------------
--------------------------------------------------------------------
Date Signed 8/29/01 By Hana Rubin /s/ Hana Rubin
-------------------------------------
Signature of Carrier's Authorized
Representative (Currently on File with
D.B. Bureau)
Telephone No. 914-591-7111 Title Disability Administrator
*IMPORTANT: If BOX "a" is CHECKED; this certificate is COMPLETE. Mail it
directly to the employer.
If BOX 'b' is CHECKED, this certificate is NOT COMPLETE for
purposes of Section 220. Subd. 8 of the Disability
Benefits Law. It must be mailed for completion to the Workers'
Compensation Board, Disability Benefits Bureau, 180 Livingston
Street, Brooklyn, New York 11248-0005.
PART III. TO BE COMPLETED BY WORKERS' COMPENSATION BOARD (ONLY IF BOX "b" OF
PART II HAS BEEN CHECKED)
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
There is on file with the Workers' Compensation Board, Certificates of insurance
indicating that the above-named employer has complied with the Disability
Benefits Law with respect to all of his/her employees.
DISABILITY-BENEFITS BUREAU
Date___________________________ By___________________________________
Telephone No___________________ Title________________________________
THE WORKERS' COMPENSATION BOARD EMPLOYS AND [ILLEGIBLE] PEOPLE WITH DISABILITIES
WITHOUT DISCRIMINATION
DB-120.1 (9-92)
Appendix P
Family Health Plus
FHPlus Facilitated Enrollment
FHPlus
Appendix P
October 1, 2001
APPENDIX P
Plan Name: WellCare of N. Y.
1. EFFECTIVE DATE OF AGREEMENT/SERVICE AREA
This Appendix shall become effective on the date specified in the written
notice from SDOH to the Contractor to initiate Facilitated Enrollment
services. The Contractor will perform FHPlus/MA Facilitated Enrollment in
the counties/boroughs identified by the Department by written notice.
2. FACILITATED ENROLLMENT STANDARDS
The Contractor agrees to perform FHPlus/MA Facilitated Enrollment in
accordance with the following standards:
(A) To provide an efficient and cost effective Facilitated Enrollment process
approved by SDOH, including use of the "train-the-trainer" approach.
(B) To assure that all facilitators Participate in the SDOH-sponsored
FHPlus/MA training program to be conducted by a private contractor to be
selected by SDOH or other training approved by SDOH.
(C) To provide a sufficient number of facilitators at sites accessible and
convenient to the population being serve to assure applicants have timely
access to facilitated enrollment. The Contractor will provide SDOH and
local districts with a list of the fixed enrollment facilitation sites
(including any new sites established to attract the new adult population)
and must update the list on a monthly basis. Subject to SDOH and local
district approval, the Contractor may offer Facilitated Enrollment at
additional sites not on the list that has already been submitted to SDOH
and LDSS.
(D) To offer Facilitated Enrollment during hours that accommodate the patterns
of the community being served, which must include early morning, evening,
and/or weekend hours.
(E) To hire staff or designate existing staff who are culturally and
linguistically reflective of the community the Contractor serves,
including facilitators who are able to communicate to vulnerable and
hard-to-reach populations (e.g., non-English speaking).
(F) To have mechanisms in place to communicate effectively with applicants who
are vision or hearing impaired e.g., the services of an interpreter,
including sign language assistance for applicants who require such
assistance, telecommunication devices for the deaf (TTY), etc.
(G) To conduct the face-to-face interview in accordance with Medicaid
requirements, policies and procedures. In any LDSS in which the personal
interview is not delegated to the facilitator, one of the Contractor's
facilitators shall act as the enrollee's authorized representative at the
personal interview, which will be conducted by an LDSS representative with
the facilitator.
(H) To comply with procedures and protocols that have been established by the
LDSS and approved by SDOH and LDSS pursuant to Medicaid Administrative
Directive 00 OMM/ADM-2 ("Facilitated Enrollment of Children into Medicaid,
Child Health Plus and WIC") and any other directives issued by SDOH to
assure that facilitators are authorized to perform the Medicaid
face-to-face interview. To assist applicants to complete the
FHPlus/MA/CHPlus joint application, and screen adults and family
applicants to assess their potential eligibility for various programs
using a documentation checklist and screening tool.
(J) To explain the application and documentation required and to help
applicants obtain required documentation. The Contractor will also
follow-up with applicants to ensure application/enrollment and
documentation completion.
(K) To educate all eligible applicants, including adults and families, about
managed care and how to access benefits in a managed care environment.
This will include the distribution of SDOH approved material in English
and other languages reflective of the community regarding all of New York
State's health insurance coverage. This includes brochures and
information developed by SDOH to explain health insurance coverage
options available through FHPlus, CHPlus, and Medicaid Programs and
various other public programs designed to support self sufficiency.
(L) To counsel all eligible applicants, including adult individuals and
families regarding selection of a participating FHPlus/CHPlus/Medicaid
Managed Care ("MMC") healthcare plan, and describe the important role of a
primary care provider ("PCP") and the benefits of preventive health care.
Facilitators must help applicants to determine the appropriate plan to
select based on their current health care needs and PCP availability. The
Contractor will ensure that facilitators have information available about
the providers who participate in each plan and have established procedures
for inquiring into existing relationships with health care providers in
order that the facilitators are able to provide assistance with PCP
selection and enable applicants to maintain existing relationships with
providers to the fullest extent possible.
(M) To ensure that facilitators perform Facilitated Enrollment counseling in a
neutral manner so that every applicant is able to make an informed
decision in selecting the appropriate health care plan for the applicant's
needs.
(N) To comply with LDSS procedures for transmitting the FHPlus or MA
applicant's managed care plan choice directly to the appropriate LDSS or
enrollment broker, when applicable.
(O) To follow-up on each application after a prescribed period of time with
the appropriate LDSS to ensure that applications are being processed and
that applicants are able to enroll and receive services in a timely
manner.
(P) To monitor the progress of each Facilitated Enrollment application on
which the Contractor's facilitators have provided assistance, using the
Internet-based system developed by SDOH for that purpose, and to report
the following information:
(i) time from initial encounter to completed application;
(ii) date and disposition of each application;
(iii) number of applications completed;
(iv) number of applicants; and
(v) any other data SDOH determines is necessary to monitor contract
performance.
The required information must be continually updated by the Contractor on the
Internet-based system no later than the tenth day following the end of each
month to ensure timely and accurate tracking of the applications.
(Q) To provide all applicants with information about their rights regarding
making a complaint to the LDSS about an eligibility determination and
making a complaint to the managed care plan, LDSS or SDOH about a service
decision.
(R) To submit the completed application and required documentation directly to
the appropriate LDSS responsible for processing the application and making
the eligibility determination.
(S) To assist individuals and families enrolled in FHPlus with renewing their
coverage prior to the expiration of their 12-month enrollment period,
including assisting in the completion of the renewal form and collection
of the required documentation on a timely basis, when an enrollee seeks a
facilitator's assistance with renewal.
(T) To cooperate with SDOH and LDSS monitoring efforts, including
unannounced site visits.
(U) To comply with all applicable Federal or State law, regulation,
and/or administrative guidance, including any authority which
supplements or supersedes the provisions set forth in Attachment B2
of the Recruitment Notice, which is incorporated by reference as if
fully set forth herein.
3. SDOH RESPONSIBILITIES
SDOH will be responsible for ensuring that the facilitator's policies and
procedures related to enrollment and marketing are appropriate to meet the
needs of applicants and comply with State and Federal laws, regulations,
and administrative guidance as outlined in Attachment B2 to the
Recruitment Notice.
Prior to commencement and/or expansion of the Contractor's facilitated
enrollment to FHPlus/MA applicants, SDOH will:
(A) Conduct a review to assure that the Contractor has established
policies and procedures satisfactory to SDOH regarding the
processing of applications, communications, contact persons, and
interactions with other MCOs, if applicable.
(B) Review schedules of sites and times, staffing, and Facilitated
Enrollment locations.
(C) Reimburse the Contractor in accordance with Schedule II to this
Appendix, a copy of which is attached hereto.
(D) Ensure that all facilitators have undergone the required training.
(E) Approve amended written protocols between the LDSS and the
Contractor, which details FHPlus/MA operations and practices to
assure that the unique needs and concerns of the local districts are
addressed.
(F) Assess the facilitator's plan selection process to assure that
applicants are presented with unbiased information regarding MCO
selection.
(G) Approve all subcontracting arrangements and all publicity and
educational materials submitted by plans to assure that enrollment
information is comprehensive.
(H) Monitor Facilitated Enrollment through fixed site monitoring,
complaint monitoring, and surveys of individuals enrolled in
Medicaid managed care or FHPlus as a result of Facilitated
Enrollment.
(I) Approve written internal quality assurance protocols for Facilitated
Enrollment.
4. QUALITY ASSURANCE
The Contractor will establish a quality assurance plan, including
protocols to be reviewed and approved by SDOH, which ensures timely
access to Facilitated Enrollment counseling for applicants. The Contractor
will ensure that all applications completed with the assistance of the
Contractor's facilitators are reviewed for quality and completed prior to
being submitted to the LDSS, and are completed and submitted to the LDSS
within the time frames required by the protocols.
SDOH will monitor and evaluate the Contractor's performance of FHPlus/MA
Facilitated Enrollment in accordance with the terms and conditions
contained in section 3 above. SDOH may, at its discretion, conduct
targeted review to assess the performance of facilitators, including
reviews of incomplete or erroneous applications.
5. CONFIDENTIALITY
The Contractor shall maintain confidentiality of applicant and enrollee
information in accordance with protocols developed by the Contractor and
approved by SDOH.
Information concerning the determination of eligibility for MA, CHPlus,
and FHPlus may be shared by the Contractor (including its employees and/or
subcontractors) and the programs and agencies identified in this
agreement, provided that the applicant has given appropriate written
authorization on the Application and that the release of information is
being provided solely for purposes of determining eligibility or
evaluating the success of the program.
Contractor acknowledges that any other disclosure of Medicaid Confidential
Data ("MCD") without prior, written approval of the SDOH MCD Review
Committee ("MCDRC") is prohibited. Accordingly, the Contractor will
require and ensure that any approved agreement or contract pertaining to
the above programs contains a statement that the subcontractor or other
contracting party may not further disclose the MCD without such approval.
Contractor assures that all persons performing Facilitated Enrollment
activities will receive appropriate training regarding the confidentiality
of MCD and provide SDOH with a copy of the procedures that Contractor has
developed to sanction such persons for any violation of MCD
confidentiality.
Upon termination of this Agreement for any reason, Contractor shall ensure
that program data reporting is complete and shall certify that any
electronic or paper copies of MCD collected or maintained in connection
with this Agreement have been removed and destroyed.
6. OUTREACH AND INFORMATION DISSEMINATION
Contractor agrees to comply with the following restrictions regarding
Facilitated Enrollment:
(i) No Facilitated Enrollment will be permitted in emergency rooms or
treatment areas; Facilitated Enrollment may be permitted in patient
rooms only upon request by the patient or their representative.
(ii) No telephone cold-calling, door-to-door solicitations at the homes
of prospective enrollees;
(iii) No incentives to prospective enrollees to enroll in an MCO are
allowed.
Contractor will be responsible for local publicity regarding locations and
hours of operation of Facilitated Enrollment sites. Only SDOH approved
information can be used in conducting Facilitated Enrollment but the
Contractor can tailor materials to the needs of individual communities,
subject to SDOH approval of any such modifications.
7. SANCTIONS FOR NON-COMPLIANCE
If the Contractor is found to be out of compliance with the terms and
conditions required under FHPlus/MA Facilitated Enrollment, SDOH may
terminate the plan's responsibilities relating to Facilitated Enrollment
and reduce the Comptroller's capitation rate to reflect that the
Contractor is no longer performing these functions. SDOH will give the
Contractor sixty (60) days written notice if it determines that the
Contractor's Facilitated Enrollment responsibilities must be terminated.
8. CONTRACTOR TERMINATION OF FACILITATED ENROLLMENT
The Contractor may terminate its Facilitated Enrollment responsibilities
under this Agreement upon sixty (60) day written notice to the SDOH.
SCHEDULE I OF APPENDIX P
Plan Name: WellCare of New York, Inc.
SDOH shall reimburse the Contractor $10.00 per member per month for
Facilitated Enrollment activities up to a maximum amount of $500,000 during the
first twelve months of this Agreement. Such maximum amount shall be reimbursed
to the Contractor in addition to the Capitation Rates shown in Appendix L of
this Agreement. The Contractor acknowledges and accepts the SDOH's right to
discontinue the per member per month payment for Facilitated Enrollment
activities if, during the first twelve months of the Agreement, the above
maximum dollar amount has been reimbursed to the Contractor. The Contractor
acknowledges and accepts the SDOH's right to recover from the Contractor any
amount reimbursed in excess of the agreed upon maximum amount for Facilitated
Enrollment activities during this twelve-month period.
For the remainder of the agreement term, the maximum amount and/or per
member per month amounts agreed to by SDOH and the Contractor shall be
incorporated by reference into this Agreement without further action by the
parties. The Contractor acknowledges and accepts the SDOH's right to discontinue
the per member per month payment for Facilitated Enrollment activities if the
maximum dollar amount is reimbursed to the Contractor during the applicable time
period. The Contractor also acknowledges and accepts the SDOH's right to recover
from the Contractor any amount reimbursed in excess of the maximum amount
allowed for Facilitated Enrollment activities during any applicable time period
under the Agreement. In the event that the SDOH and the Contractor fail to reach
agreement on modifications to the cap on Facilitated Enrollment reimbursement
for a subsequent time period under the Agreement, the Contractor's
responsibilities and functions under this Appendix shall end sixty (60) days
from the date of SDOH written notice of termination to the Contractor.
Appendix X
Family Health Plus
Modification Agreement Form
APPENDIX X
Agency Code _____________________________ Contract No. ____________________
Period __________________________________ Funding Amount for Period________
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through
_____________, having its principal office at _____________, (hereinafter
referred to as the STATE), and _________________,(hereinafter referred to as the
CONTRACTOR), for modification of Contract Number _________________ as amended in
attached Appendix(ices) ________________.
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates appearing under their signatures.
CONTRACTOR SIGNATURE STATE AGENCY SIGNATURE
By: ___________________________ By: _______________________________
___________________________ _______________________________
Printed Name Printed Name
Title: ________________________ Title: ____________________________
Date: _________________________ Date: _____________________________
State Agency Certification:
"In addition to the acceptance of this
contract, I also certify that original
copies of this signature page will be
attached to all other exact copies of
this contract."
STATE OF NEW YORK )
) SS.:
County of _______________ )
On the ____ day of ____ 19 ___, before me personally appeared_______, to me
known, who being by me duly sworn, did depose and say that he/she resides
at_________, that he/she is the _____________ of the, the corporation described
herein which executed the foregoing instrument; and that he/she signed his/her
name thereto by order of the board of directors of said corporation.
(Notary)
STATE COMPTROLLER'S SIGNATURE Title: ____________________________
__________________________________ Date: _____________________________
APPENDIX X
Agency Code 12000 Contract No C017720
Period 4/1/04-9/30/05 Funding Amount for Period Based on approved capitation
rates
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
New York State Department of Health, having its principal office at Corning
Tower, Room 2001, Empire State Plaza, Albany NY 12237, (hereinafter referred to
as the STATE), and WellCare of New York, Inc. (hereinafter referred to as the
CONTRACTOR), to modify Contract Number C017720 by substituting the attached
Appendix L Approved Capitation Payment Rates for the FHPlus Program. The
effective date of these modifications is April 1, 2004.
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates appearing under their signatures.
CONTRACTOR SIGNATURE STATE AGENCY SIGNATURE
By: /s/ Todd S. Farha By: /s/ DONNA FRESCATORE
--------------------------- ---------------------------------------
Todd S. Farha DONNA FRESCATORE
--------------------------- ---------------------------------------
Printed Name Printed Name
Title: President & Chief Executive Title: DEPUTY DIRECTOR, OMC
Officer
Date: April 27, 2004 Date: 4/28/04
[APPROVED AS TO State Agency Certification:
FORM NYS In addition to the acceptance of this
ATTORNEY GENERAL contract, I also certify that original
MAY 18 2004 copies of this signature page will be
ILLEGIBLE] attached to all other exact copies of
this contract.
STATE OF NEW YORK FLORIDA )
)SS.:
County of Hillsborough )
On the 27th day of April 2004, before me personally appeared Todd S. Farha, to
me known, who being by me duly sworn, did depose and say that he/she resides in
New York, that he/she is the CEO & President of WellCare of New York, Inc., the
corporation described herein which executed the foregoing instrument and that
he/she signed his/her name thereto by order of the board of directors of said
corporation
(Notary) KATHLEEN R. CASEY
Notary Public - State of Florida
My Commission Expires Apr 22, 2008 KATHLEEN R. CASEY
Commission # DD305227
Bonded By National Notary Assn.
APPROVED
STATE COMPTROLLER'S SIGNATURE Title: DEPT. OF AUDIT & CONTROL
Date: MAY 21 2004
________________________________________ [ILLEGIBLE]
FOR THE STATE COMPTROLLER
WELLCARE OF NEW YORK, INC.
FAMILY HEALTH PLUS RATES
EFFECTIVE APRIL 1, 2004 THROUGH MARCH 31, 2005
ADULTS WITH ADULTS WITHOUT ADULTS WITHOUT MATERNITY
COUNTY CHILDREN 19 - 64 CHILDREN 19 - 29 CHILDREN 30 - 64 KICK
- ---------- ---------------- ---------------- ---------------- ---------
Albany $261.83 $321.04 $375.43 $4,526.04
Columbia $288.04 $319.28 $442.93 $4,526.04
Dutchess $235.64 $286.69 $350.88 $4,526.04
Greene $288.04 $319.28 $442.93 $4,526.04
NYC $226.90 $219.64 $333.56 $4,693.40
Rensselaer $261.83 $321.04 $375.43 $4,526.04
Rockland $266.03 $317.67 $344.03 $4,526.04
Ulster $235.64 $286.69 $350.88 $4,526.04
OPTIONAL BENEFITS INCLUDED IN THE ABOVE RATES:
FAMILY PLANNING: YES DENTAL: YES