EXHIBIT 10.9
CHILD HEALTH PLUS
COMMUNITY INSURANCE PLAN
ELIGIBLE CHILDREN IN NEW YORK STATE
TABLE OF CONTENTS
PAGE
----
I. Introduction...................................................................................... 1
II. Expanded Program Design........................................................................... 9
III. General Information for the Bidder................................................................ 40
IV. Application Format................................................................................ 48
V. Evaluation Criteria............................................................................... 53
VI. Review Process.................................................................................... 59
APPENDICES:
Appendix A - Income Guidelines
Appendix B - Advisory Memoranda
Appendix C - University of Rochester
Final Report to Legislature
Appendix D - Quarterly Enrollment Report
Appendix E - Benefit Package
Appendix F - Procedures and Requirements for Filing
of Rates and Rate Filing Guidelines
Appendix G - Reporting Requirements
Appendix H - Model Application
Appendix I - New York State Standard Clauses (Appendix A)
for all New York State Contracts
Appendix J - Electronic Billing Process
Appendix K - Budget Forms
Appendix L - Bidder's Summary of Proposal
Appendix M - Standard Contract/Bid Insert Form
Stock Item Specification Form
I. INTRODUCTION
A. PURPOSE
The New York State Department of Health (DOH) is issuing this
Request for Proposal (RFP) to voluntarily select and contract with
organizations to provide health insurance coverage, through a
managed care product, to eligible New York State children under the
Child Health Plus program. The New York Health Care Reform Act of
1996 (HCRA of 1996) has expanded the eligibility of the current
program to include children under the age 19 and added inpatient
benefits.
All insurers are eligible to participate in the Child Health
Plus Program. All New York State Medicaid managed care providers are
strongly encouraged to respond to this RFP. It is the goal of the
DOH that every child have a medical home, therefore managed care
products need to be available to all eligible children. The benefits
to insurers of creating a natural linkage between the Child Health
Plus program and Medicaid managed care would include not only
seamless coverage for members of that insurer but also increased
enrollment for the plans.
Improving the health status of New York State's children is
one of DOH's highest priorities. An important way to improve child
health is by increasing access to primary and preventive care. New
York State is taking steps to improve access to care by taking
advantage of key opportunities: the reforming of the State's
Medicaid Program to a managed care system; and reforming the State's
hospital reimbursement methodology so that in addition to
reimbursing hospitals directly for uncompensated care, the State is
subsidizing health insurance for children of low income families
which will emphasize preventive care.
New York is committed to improving the health of children. Low
income children are at particular risk for illness and injury that
affect their health status. In New York State, children of low -
income families, including children on Medicaid, continue to be
over-represented in infant mortality and low birthweight statistics.
These children are more likely to receive care in emergency room
settings for primary health care problems, lack a primary care
provider, and become hospitalized for conditions (e.g. asthma) which
are potentially preventable with high quality ambulatory care. Data
show that these children are also more likely to be less than fully
immunized, suffer
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preventable infectious diseases, and be exposed to toxins such as
lead.
The health care system in New York State is designed to be
proactive, providing children with the health care that focuses on
prevention so that they can lead healthier lives. Under the Child
Health Plus Program, children will have a "medical home" with a
primary care provider who will coordinate his or her health care as
part of a "seamless system", including referrals to specialists,
when appropriate.
In order to promote the objective of "seamless coverage" the
DOH is currently working to develop a joint application process for
Medicaid, Child Health Plus, and the Special Supplemental Food
Program for Women, Infants, and Children (WIC). This joint
application will also have an objective of simplifying
administrative processes for both patient and providers.
Children who enroll in Medicaid or Child Health Plus may
experience changes which make them ineligible for a program.
"Seamless coverage" would allow children the ability to move between
insurance programs without changing providers. The children would
have access to the same provider network, regardless of the payer
(Medicaid or Child Health Plus).
Other DOH projects which are currently underway which focus on
a goal of improving children's health include, but are not limited
to, the following:
- Electronic Birth Certificates
Currently underway in DOH is the implementation of a system of
electronic reporting of birth certificate information. This
system has a goal of simplifying while expediting
bi-directional transfer of information between DOH and health
care providers.
Currently, more than 90% of hospitals (excluding New York
City) report births directly to DOH. Nearly that percentage of
New York City hospitals report electronically to the New
York City Department of Health. The NYC DOH then forwards its
data, once it has been validated, to the State DOH.
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- Immunization Registries
The development of a prototype child immunization registry is
currently underway. This registry will build upon the
electronic birth certificate data base to allow providers to
have access to the immunization status of their pediatric
patients.
DOH currently supports six regional consortia engaged in
designing and promoting the electronic recording of
immunization status in their area. Over time, these regions
are expected to interconnect and begin to include the rest of
the State as well. New York City currently mandates provider
participation in an immunization registry.
- Lead Screening
The DOH Lead Poisoning Prevention Program has been successful
in integrating blood lead screening as part of primary health
care for children. More children are being appropriately
screened within physicians' offices.
In summary, in order to improve the health outcomes of New
York State's children, there must also be a corresponding increase
in access to health care for children of the working poor who are
neither eligible for Medicaid nor covered by health insurance
through their employers. The expansion of the Child Health
program, along with other State initiatives both present and future,
demonstrate the State's commitment to creating a seamless system for
children to access health services.
B. BACKGROUND OF THE CHILD HEALTH PLUS PROGRAM
The current Child Health Plus program provides a subsidized,
primary and preventive health insurance program for uninsured and
underinsured eligible children residing in New York State that are
under the age of 17 (after January 1, 1997, children under the age
of 19); not eligible for Medicaid; and who lack equivalent health
care coverage. Children in households with gross incomes equal to or
less than 222 percent of gross federal poverty levels are eligible
for a premium subsidy under Child Health Plus (please refer to the
income guideline chart in Appendix A). Families above these income
guidelines are able to
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purchase Child Health Plus but do not receive a premium subsidy from New
York State. Equivalent coverage is defined in the program's advisory
memoranda which is enclosed as Appendix B.
C. LEGISLATIVE AUTHORITY
1. New York's Health Care Reform Act of 1996
Legislation enacted as part of the New York Health Care
Reform Act (HCRA) of 1996 continues the Child Health Plus
program through December 31, 1999 and expands the program as
follows:
- from July 1, 1996 through December 31, 1996 provides
benefits for eligible children under the age of 17;
- effective January 1, 1997, children under the age of 19
who meet other eligibility requirements are eligible to
participate in the program;
- inpatient care will be added as a covered benefit in
1997; and
- program funding has been significantly increased to
allow for greater participation of the eligible
population and the expanded benefit package.
2. LEGISLATIVE HISTORY - CHILD HEALTH PLUS
In 1990, Chapters 922 and 923 of the Laws of 1990
(Article 25 of the Public Health Law Section 2510 and 2511)
authorized the Commissioner of Health, in consultation with
the Superintendent of Insurance, to establish a statewide
program to provide subsidized outpatient health insurance for
children under age 13 in low income families. Funding for the
program was limited to $20 million per year. The Department
currently contracts with 15 insurers to provide statewide
coverage for the program. Eligible children began receiving
coverage through the Child Health Plus program in August,
1991. The legislation also authorized the Commissioner of
Health to contract with qualified organizations for purposes
of public education, outreach and recruitment of children. Two
marketing and outreach organizations were selected through a
RFP process.
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Chapter 731 of the Laws of 1993 continued the Child Health
Plus program through December 31, 1995 and increased funding for the
program to $120 million for the two year period. Under this
legislation, contracts with existing insurers, and outreach and
marketing contractors for Child Health Plus, were extended through
1995. The legislation required that the Department implement
measures' to perform an annual review of the participating insurer's
enrollment and recertification procedures. In addition, the
Department was required to conduct a comprehensive evaluation of the
implementation and effectiveness of the Child Health Plus program. A
RFP for the evaluation of the program was issued in May, 1994. The
University of Rochester, Child Health Studies Group, was selected as
the contractor. A summary of the final report which was submitted to
the Governor and Legislature in 1996 is enclosed as Appendix C.
Subsequent program legislation was enacted in 1994 and 1995
that expanded Child Health Plus to eligible children under age 16,
continued contracts with existing insurers and required a RFP for
continuing marketing and outreach activities be issued. The
program's two existing marketing and outreach contractors were the
sole bidders and were awarded contracts to continue this activity.
D. ALLOCATION AND FUNDING
Provisions established through HCRA of 1996 provide that the
Child Health Plus program shall be financed through the Health Care
Initiatives Pool.
Statewide allocations are available for the program in the
following amounts:
January 1, 1997 - December 31, 1997 $109M
January 1, 1998 - December 31, 1998 $150M
January 1, 1999 - December 31, 1999 $207M
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It is expected that the contract period will be May 1, 1997
through December 31, 1999. Any extension of the contract period is
dependent upon continuation of the Child Health Plus program by
legislation and allocation of funds.
E. PROGRAM GOAL AND OBJECTIVES
The program goal for Child Health Plus is to provide access to
comprehensive inpatient and outpatient health care services to low
income children by removing financial barriers and providing a
medical home through a managed care product.
Child Health Plus has the following objectives:
- to improve the health status of children participating in the
program by providing a "medical home";
- to provide primary, preventive, outpatient and inpatient
health insurance coverage to low income children by removing
financial barriers to purchasing such coverage through an
individual subsidy program;
- to increase children's access to primary comprehensive and
preventive health care services; and
- to reduce and more effectively target bad debt and charity
care expenditures in New York State.
F. ENROLLMENT TRENDS
The Child Health Plus Program is growing at a rapid rate and
is receiving a great deal of attention as a large-scale statewide
program which offers all children access to affordable health
insurance coverage. It is anticipated that enrollment in the Child
Health Plus program will continue to be strong and constant,
increasing at a steady rate each year. Since March, 1996, enrollment
in the program has been increasing at a steady rate with
approximately 1,500 new enrollees per month. With the addition of
older children, the Department expects this trend to increase.
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[BAR CHART]
[PLOT POINTS TO COME]
Effective January 1, 1997, the age eligibility will be expanded to
include children age 16 through 18, thereby adding a new population to the
current enrollment. During 1997, inpatient care will also be added as
covered benefit.
Figure 1 is a chart depicting enrollment in the program since 1992,
and the projected enrollment of the age 0-14 and age 15-18 year categories
through 1999. Figure 1 depicts that, as of June, 1996, over 106,000
children were enrolled in Child Health Plus. The latest quarterly
enrollment report with enrollment by age and income level is enclosed and
appears as Appendix D.
An evaluation of the Child Health Plus Program recently completed by
the Rochester Child Health Studies Group, found that the Child Health Plus
program has had beneficial effects on improving access to health care,
utilization of primary care services, and on some measures of quality of
care, to a large number of eligible children. It was also found that
Hispanic and African American children, and children in the
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lowest eligible incomes levels were slightly under-represented in the
Child Health Plus population. It is very important in future enrollment
efforts that these populations be effectively reached as part of an
aggressive community outreach effort.
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II. EXPANDED PROGRAM DESIGN
A. ELIGIBLE ORGANIZATIONS
Organizations eligible to submit proposals for participation
in Child Health Plus are the following:
- a commercial insurance company licensed under New York State
Insurance Law; or
- a corporation or health maintenance organization licensed
under Article 43 of the Insurance Laws; or
- a health maintenance organization certified under Article 44
of the New York State Public Health Law; or
- a comprehensive health service plan operating under the
regulations of the Department of Health.
B. ELIGIBILITY CRITERIA
A child is eligible for a subsidy payment if the following
criteria are met:
- the child is a resident of New York State;
- the child is not eligible for medical assistance (Medicaid);
- the child does not have equivalent health insurance coverage;
- the child resides in a household having a gross household
income at or below 222% of the non-farm gross federal income
official poverty level (as defined and annually revised by the
U.S. Office of Management and Budget); and
- the child is a less than 19 years of age.
The RFP has stated all references to the eligibility
thresholds in terms of gross income levels, as enrollment in the
Child Health Plus program will be determined based upon gross income
levels. The 1996 monthly and annual net and gross income thresholds
are presented in Appendix A.
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The approved organization must establish a means test (income)
for assuring that all enrollees meet defined eligibility criteria.
There will be no resource test (asset) required for program
eligibility.
The insurer is responsible for obtaining and maintaining all
documentation necessary to make an eligibility determination.
Detailed eligibility criteria are contained in Appendix B. Some
examples of appropriate documentation are as follows:
- Income
- annual federal and State tax return statements;
- paycheck stubs or other documentation of income;
- written documentation of income by employer; and/or
- attestation of Self-Declaration of Income (Department of
Health Form which can be found in Appendix B).
- Age
- birth certificate of enrolled;
- passport or Visa;
- school record which documents a child's birthdate;
- religious certificate (i.e., baptismal papers); and
- signed affidavit stating witness of birth.
- Equivalent Insurance
- documentation of other insurance coverage.
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- Residency
- current school records, utility bills, or any mail
addressed to the individual which has been postmarked.
A 60 day presumptive period of eligibility is available to
applicant children as a means of providing services under Child
Health Plus when a child appears eligible for the program, but,
pertinent documentation is lacking. The insurer performs an initial
review of the child's age, family's gross income, residency, and
health care coverage, and from the completed application determines
whether the child appears eligible. If one or more pieces of the
documentation to support these variables is not submitted with the
application, the family is allowed up to 60 days to submit the
additional material or the child is disenrolled from the program.
Only one period of presumptive eligibility per child is allowed. DOH
will reimburse the insurer for the subsidy of a presumptively
enrolled child if the child is later found to be ineligible when the
missing documentation is submitted.
The period of eligibility means that period commencing on the
first day of the month in which the child is covered by the insurer
and ending on the last day of the month in which the child's
coverage ceases. All applications must be approved prior to the
effective date of enrollment as there is no retroactive enrollment
in Child Health Plus.
C. BENEFITS
Child Health Plus insurers will be required to provide a
uniform benefit package as part of their managed care product.
Included in the current benefit package, which was mandated
by prior legislation (Chapters 922 and 923 of the Laws of 1990) are:
well-child care; immunizations; x-ray and laboratory tests;
outpatient/ambulatory surgery; diagnosis and treatment of accident,
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illness and injury; emergency care; prescription drugs; outpatient
treatment for alcoholism and substance abuse; short-term
therapeutic services such as chemotherapy, hemodialysis, radiation
therapy, occupational therapy and physical therapy; diabetic
supplies; diabetic education; and nutritional supplements.
The 1997 enhanced benefit package will include inpatient care
(excluding inpatient mental health substance abuse or alcohol
treatment) as a covered benefit as mandated by HCRA of 1996. The
expanded benefit package will also include limited durable medical
equipment (DME) and outpatient mental health visits (up to 20 per
year as part of the 60 visit maximum for outpatient alcohol and
substance abuse) and home visits when in lieu of inpatient
hospitalizations.
A detailed description of the benefit package is included in
Appendix E. Please note, benefits provided under Child Health Plus
are secondary to any other plan of insurance or benefit program
under which an eligible child may have coverage. The insurer must
have any primary coverage pay any applicable portion of a child's
medical cost in the first instance.
Each provider must follow the well-child care guidelines
established by the American Academy of Pediatrics and the
immunization recommendations as delineated by The New York State
Recommended Childhood Vaccination Schedule which are enclosed as
part of Appendix.
D. CO-PAYMENTS
There will be a $2 co-payment required for all physician
visits, except those provided on an inpatient basis, for well child
care, or as otherwise prohibited by insurance law. A $1 to $3
co-payment also can be charged for prescriptions and nutritional
supplements as defined in the benefit package. Insulin has no
co-payment. A $35 co-payment for failure to notify an insurer within
24 hours of emergency room use and/or inappropriate emergency room
visits
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may be charged. No other co-payments are allowed and there are no
deductibles for State subsidized children.
E. PREMIUMS
Insurance premiums that are submitted with this proposal will
be reviewed by the Commissioner of Health along with the New York
State Insurance Department prior to approval. The premium
requests submitted should be valid at least through December 31,
1997. For premium adjustments that may be required January 1, 1998
and beyond, the insurer will be required to submit an application to
DOH and the State Insurance Department for approval at least ninety
(90) days prior to the requested effective date of such coverage.
In developing the premium proposal, an insurer should reflect
adjustments for children under age one and pregnant women who will
be eligible for Medicaid coverage. Because of expanded Medicaid
eligibility rules for children under age one and pregnant women, it
is expected that very few, if any, children under age one and
pregnant women who are otherwise eligible for a State subsidy (99%
of current enrollees) would be covered through the Child Health Plus
program.
Since legislation also requires that the Child Health Plus
benefit package be available to children who do not qualify for a
premium subsidy, insurers will need to make adjustments to the
premium structure that reflect utilization and cost for this
population. The Child Health Plus program experience indicates that
less than 600 children, who do not receive a premium subsidy, art
currently enrolled. This pattern has remained constant throughout
the life of the program and is expected to continue.
The premium rate filing should follow the format as set forth
in 11 NYCRR Section 52.40 and the rate filing guidelines for the
Child Health Plus insurance plan which can be found as Appendix F.
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F. GEOGRAPHIC AND COVERAGE PARAMETERS
At minimum, the plan must meet the following parameters:
- The plan must include coverage for subsidized and
non-subsidized children;
- The plan must propose to provide coverage in at least one
county. (Bidders may propose and are strongly encouraged to
cover more than one county or the entire State but not partial
counties. The Department reserves the right to waive this
requirement for portions of a county based upon unique needs
of that county);
- DOH reserves the right to limit a bidder's requested service
area; and
- DOH reserves the right to limit at it's own discretion, the
amount of available funding to a given insurer taking into
account total approved insurer proposals and funding
available.
G. SCHOOL-BASED HEALTH CENTERS
A number of school districts throughout the State have
established school-based health centers to provide medical and/or
behavioral health services to their students.
For year one of the program, health plans are encouraged to
contract with school-based health centers, if such centers are
operating within their borough/county. Plans should seek to contract
with every center in their borough/county that wishes to participate
as a network provider.
As another example of the State's effort to create a "seamless
system", starting in year two of the program, the State will require
these school-based health centers and health plans to contract with
each other. The State is developing a model contract for this
purpose and will make it available to both parties in the near
future. Plans and schools may use the model contract, which will
include specific language regarding
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prior authorization procedures, payment and reporting requirements.
H. PRESUMPTIVE ELIGIBILITY PROVIDERS
Since 1990, New York's Medicaid program has provided access to
prenatal care for pregnant women by allowing certain qualified
health care providers to perform presumptive eligibility
determinations at the time of first contact with the woman. The
qualified provider assists the woman in completing the appropriate
application forms and submitting these forms to the local Department
of Social Services (LDSS), which then determines the woman's
eligibility for Medicaid. There are currently about 175 presumptive
eligibility providers located in various areas of the State.
Health plans must develop linkages with these providers (if
geographically available) to facilitate referral to prenatal care
for pregnant women. Plans need not develop linkages with every
presumptive eligibility provider in the borough/county, but must
include a sufficient number. In order to assure statewide coverage
by insurers, DOH reserves the right to accept proposals from
insurers who do not meet the above stated criteria for linkages with
presumptive eligibility providers, if that insurer explains in
detail why they do not meet the criteria and why that does not
jeopardize the goals of the Child Health Plus program.
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I. FAMILY CONTRIBUTION TO THE PREMIUM
It is the insurer's responsibility to collect the family's
portion of the premium for partially subsidized children. The
schedule of maximum liability, by family income level, is as
follows:
Child Health Plus Sliding Scale
Family Contribution Schedule for Basic Coverage
GROSS FAMILY
INCOME (% OF FPL) REQUIRED FAMILY CONTRIBUTION
- ----------------- ----------------------------
Less than 120% No Contribution Required
120-159% $ 9/month per child up to a family maximum of $36/month
160-222% $13/month per child up to a family maximum of $52/month
+ 222% Full premium
At least one month of a family's share of the premium for each applicant
must be paid at the time of application. The balance due will be billed on a
monthly basis one month before the period it covers to allow for a 30 day grace
period prior to the first day of the effective month of coverage. Any child for
whom the family share is not paid within the period will be disenrolled.
As indicated in the above chart, families above 222% of the FPL will be
able to purchase Child Health Plus coverage for their children, but New York
State will not make any subsidy payment toward their premium costs. The cost of
premium for non-subsidized children must be the same as for subsidized children.
However, it is important to note that the non-subsidized number of enrollees in
the current program is a very small percentage of the total population of
enrollees (it represents less than 1/2 of 1%).
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J. OTHER PROGRAM ISSUES
I. Standards for Provider Participation and Enrollment
a. Provider Network
(1) General
Health plans must establish and maintain
provider networks with sufficient numbers of
providers and in geographically accessible
locations for the populations they serve. Health
plan networks must contain all of the provider
types necessary to furnish the prepaid benefit
package, including: hospitals, physicians (primary
care and specialist), mental health and substance
abuse providers, allied health professionals,
pharmacies, DME providers, etc. Health plans shall
not include in their networks, for purposes of
serving Child Health Plus enrollees, any medical
provider who has been sanctioned by Medicare or
Medicaid if the provider has, as a result of the
sanctions, been prohibited from serving Medicaid
clients or receiving medical assistance payments.
To assure statewide coverage by insurers,
the Department of Health shall reserve the right
to accept proposals from insurers whose provider
network may differ from the following
requirements. In this instance, however, the
bidder must explain in detail how their proposal
differs and the reasons for such difference as
well as be able to support that such difference
does not jeopardize the goals of the Child Health
Plus program.
(2) Physicians
All network physicians must meet at
least one of the following standards:
- be Board-Certified or -Eligible in their
area of specialty;
- have completed an accredited residency
program; and
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- have admitting privileges at one or more
health plan network hospitals.
(3) Primary Care Providers
(a) Responsibilities
Health plans must allow each enrollee
to select a primary care provider (PCP) and
make an assignment if one is not chosen.
Members must be offered a choice of at least
three primary care providers. Staff or group
practice or center-based models may require
that enrollees first select a site (clinic
or health center) and subsequently select a
PCP from among those available at the site.
Primary care providers will serve as
each child's initial and most important
point of interaction with the provider
network. To qualify as a PCP, a provider
must practice at least two days per week (16
hours) at each of his/her "primary care"
sites. For example, if a provider has three
office locations and practices 16 hours per
week at location #1, 16 hours per week at
location #2, and 8 hours per week at
location #3, he/she could be offered as a
PCP at the first two sites, but not at the
third.
In addition to meeting office hour
standards, PCPs also must:
- deliver medically necessary primary
care services;
- make referrals for specialty care and
other medically necessary services,
whether or not they are included in
the health plan's prepaid benefit
package. However, the Child Health
Plus program will not be responsible
for payment of
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these referrals if outside the covered
benefit package;
- coordinate each child's overall course
of care with out-of-network providers
to the extent possible; and
- maintain a comprehensive medical
record for the member.
(b) Eligible Specialties
Health plans generally must limit
their PCPs to the following primary care
specialties:
- Family Practice
- General Practice
- General Pediatrics
- General Internal Medicine
Exceptions to these limits are
described below.
(c) OB/GYN Providers
Health plans, at their option, may
permit OB/GYN providers to serve as PCPs,
subject to DOH qualifications. Plans must
also permit direct access for female members
to obstetrics and gynecology services
pursuant to public Health Law Section 4406
b(1).
(d) Registered Physician's Assistants and Nurse
Practitioners
Health plans may use nurse
practitioners and physician assistants as
PCPs, subject to their scope of practice
limitations
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under New York State Law (as put forth
in Article 139 of the Education Law and
Sections 94.1 and 94.2 of Title 10 of New
York Codes, Rules and Regulations -
Health.).
(e) Medical Residents
Health plans may use PGY2, PGY3 and
PGY4 physicians who are enrolled in the
Designated Priority Programs (formerly known
as "upweighted" primary programs) in primary
care as part of their PCP delivery system
subject to the following guidelines:
- each resident team shall be
comprised of no more than four
physicians in training and must be
supervised by an attending physician
(please refer to the next section for
additional information on PCP teams);
- PGY2s practice at least 8 continuity
of care hours per week at a primary
site; PGY3s and PGY4s practice at lest
12 continuity of care hours per week
at a primary site;
- the hours that the attending
physician spends in supervision cannot
also be counted as patient care hours
when determining capacity;
- the following resident to enrollee
ratios for calculating capacity shall
apply:
- PGY4 -- 1:1,500
- PGY3 -- 1:1,125
- PGY2 -- 1:750
(FTE=40) hours). For example, a PGY2
who is a licensed physician and is in
a designated priority program in
primary care that practices 10
continuity of care hours per
20
week at a primary site can be a PCP
and would be allowed to impanel 188
enrollees (i.e. 10/40 times 750).
- residents comprising a team must share
the caseload in a manner which assures
care coordination;
- residents must comply with all
health plan requirements for prior
authorization, utilization review, and
quality assurance and medical
management of plan members; and
- members must be granted
access to the attending physician if
they request an appointment with this
individual.
(f) Primary Care Provider Teams
Health plans with clinic provider
sites may designate teams of physician/nurse
practitioners to serve as PCPs for members
receiving primary care at those sites. Such
teams may include no more than four
practitioners (or four medical residents and
an attending physician) and, when a member
chooses or is assigned to a team, one of the
practitioners must be designated as "lead
provider" for that member. 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.
(g) Distance/Travel Time for Primary Care
Health plans must offer every member
the opportunity to select from at least
three PCPs within the following
distance/travel time standards (by car or
public transportation):
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Normal Conditions, 20 miles;
Primary Roads: 30 minutes
Mountainous / 15 miles
Secondary Roads:
Flat Areas / 25 miles
Interstate
Highways:
Metropolitan 30 minutes by
Areas: public
transportation
Enrollees may, at their discretion,
select plan participating PCPs located
farther from their homes. If three PCPs are
not located within such a distance, the plan
must include the next closest PCPs
available.
(h) Primary Care Provider Status Change
Health plans must notify their members
of any of the following PCP changes within
thirty (30) business days of the effective
date of change:
- office address/telephone number
change;
- office hours change; and
- separation from plan (termination
from network).
(4) Hospitals
Health plans must establish hospital
networks capable of furnishing the full range of
tertiary services to members. Plans must ensure
that all members have access to at least one
general acute care hospital within forty-five (45)
minutes travel time (by car or public
transportation) from the member's residence,
unless none are located within such a distance. If
none are located within forty-five (45) minutes
travel time, the plan must include the next
closest site in its network.
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(5) Pharmacies
Health plans must include network pharmacies
in sufficient numbers to meet the following
distance/travel time standards:
- normal conditions/primary roads - 20
miles/30 minutes
- mountainous/secondary roads - 15 miles
- flat areas/interstate highways - 25 miles
- metropolitan areas - 30 minutes by public
transportation
Health plans also must contract with
twenty-four (24) hour pharmacies and must ensure
that all members have access to at least one such
pharmacy within thirty (30) minutes travel time
(by car or public transportation) from the
member's residence, unless none are located within
such a distance. If none are located within thirty
(30) minutes travel time, the plan must include
the next closest site in its network. For certain
conditions, such as PKU, and cystic fibrosis,
plans are further encouraged to make pharmacy
arrangements with specialty centers treating these
conditions, where such centers are able to
demonstrate quality and cost effectiveness.
Finally, plans are encouraged to make use of mail
order prescription deliveries, where clinically
appropriate and desired by the member.
(6) Home Health Providers
Health plans must contract with and use
certified home health agencies (CHHAs) for
provision of home health services to enrollees in
each county. CHHAs may in turn subcontract with
licensed home health care agencies, but plans must
restrict their contracting to the CHHAs
themselves.
23
(7) Laboratory
Health plans must restrict their laboratory
provider network to entities having either a CLIA
certificate of registration or a CLIA certificate
of waiver.
(8) Notification Regarding Network Changes
Health plans must notify the State in a
timely manner of any significant changes in
network composition that negatively affect member
access to services (for example, an inability to
adhere to geographic standards, or a failure to
meet appointment standards). Such changes may be
grounds for contract termination.
(9) Service Accessibility
(a) General
The State considers service
accessibility to be one of the key
determinants of quality of care and overall
member satisfaction. Accordingly, health
plans will be expected to take all necessary
measures to ensure compliance with the
access standards issued below. The State
will actively monitor health plan
performance in this area and will take
prompt corrective action if and where
problems are identified.
(b) Twenty-Four (24) Hour Coverage
Health plans must provide coverage to
members, either directly or through their
PCPs, on a twenty-four (24) hours a day,
seven (7) days a week basis. Health plans
must also instruct their members on what to
do to obtain services after business hours
and on weekends.
(c) Telephone Access
Health plans may require their PCPs to
have primary responsibility for serving as
an after hours "on-call"
24
telephone resource to members with medical
problems. If the PCP performs this function,
he/she cannot be permitted to "sign-out"
(i.e., automatically refer calls) to an
emergency room.
Whether or not the plan assigns
primary responsibility for after hours
telephone access to PCP, it also must have a
twenty-four hour toll free telephone number
for members to call which is answered by a
live voice (answering machines are not
acceptable). This number need not be stafedf
by the Member Services Department and need
not be equipped to respond to non-medical
inquiries.
(d) Emergency Services
Health plans are prohibited from
requiring members to seek prior
authorization for services in a medical or
behavioral health emergency. Plans must
inform their members that access to
emergency services is not restricted that if
the member experiences a medical or a
behavioral health emergency, he/she may
obtain services from a non-plan physician or
other qualified provider, without penalty.
However, health plans may require members to
notify the plan or their PCPs within a
specified time after receiving emergency
care and may require members to obtain prior
authorization for any follow-up care
delivered pursuant to the emergency.
(e) Days to Appointment
Health plans must abide by the
following appointment standards:
- urgent medical or behavioral problems
within 24 hours;
- non-urgent "sick visits" within 48 to
72 hours, as clinically indicated;
25
- routine, non-urgent or preventive care
visits within four weeks; and
- in-plan, non-urgent mental health or
substance abuse visits within two
weeks.
(10) Second Opinions for Surgical Procedures
Health plans must allow members to obtain
second opinions within the plan's network of
providers for surgical procedures.
(11) Member Services Function
Health plans must operate a member services
function during regular business hours. At a
minimum, the Member Services Department should be
staffed at a ratio of at least one member service
representative for every 4,000 members. Member
services staff must be responsible for the
following:
- explaining health plan rules for obtaining
services and assisting members to make
appointments;
- assisting members to select or change PCPs;
and
- fielding and responding to member questions
and complaints, and advising members on the
availability of their right to file a
complaint with the State DOH.
Health plans with both Child Health Plus and
non-Child Health Plus enrollment are encouraged to
identify and train dedicated staff within the unit
to deal with requirements of the Child Health Plus
program.
(12) Provider Services Function
Health plans must operate a provider
services function during regular business hours.
At a minimum, provider services staff must be
responsible for the following:
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- assisting providers with prior authorization
and referral protocols;
- assisting providers with claims processing
procedures; and
- fielding and responding to provider
questions and complaints.
2. Quality Improvement and Medical Management
a. Internal Quality Improvement Program/Quality Assurance
Plan
Health plans must have internal quality assurance
programs and written quality improvement or assurance
plans (Quality Improvement Programs/Quality Assurance
Programs) for monitoring and improving the quality of
care furnished to members. Such plans must address all
of the following:
- description of quality assurance committee
structure;
- identification of departments/individuals
responsible for QAP implementation;
- description of manner in which network providers
may participate in QAP;
- credentialling/recredentialling procedures
(description below);
- standards of care (description below);
- standards of service accessibility;
- medical records standards;
- utilization review procedures (description below);
- quality indicator measures and clinical studies
(description below);
- quality assurance plan documentation methods; and
- description of the manner in which quality
assurance/quality improvement activities are
integrated with other management functions.
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b. Credentialling/Recredentialling
Health plans must institute a credentialling
process for their providers that includes, at a minimum,
obtaining and verifying the following information:
- evidence of valid current license and valid DEA
certificate, as applicable;
- names of hospitals, HMOs, PHPs, and medical groups
which the provider has been associated;
- reasons for discontinuance of such associations;
- level of malpractice coverage;
- pending professional misconduct proceedings or
malpractice actions and the substance of such
allegations;
- substance of any findings from such proceedings;
- sanctions imposed by Medicare or Medicaid;
- names and relevant information of providers who
will serve as on-call designees for the provider
(applies to non-staff, group models only). Plans
must ensure that all on-call providers are in
compliance with plan credentialling standards,
including any non-participating providers serving
in this capacity;
- attestation of provider as to validity of
information provided;
- information from other HMOs or hospitals which
provider has been associated regarding
professional misconduct or medical malpractice,
and associated judgments/settlements, and any
reports of professional misconduct a by a hospital
pursuant to NYS Public Health Law Section 2803-E;
- review of provider's physical site of practice;
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- review of provider's capacity to provide such
services, based on practice size and available
resources; and
- National Practitioner Data Bank profile.
Health plans must also recredential their
providers at least once every two years. During such
recredentialling, plans should re-examine the items
covered during the initial credentialling, as well as:
- complaints lodged against the provider by plan
members; and
- result of chart audits and other quality
reviews.
3. Utilization Review Procedures
Health plans must develop and have in place utilization
review policies and procedures that include protocols for
prior approval and denial of services, hospital discharge
planning, physician profiling, and retrospective review of
both inpatient and ambulatory claims meeting pre-defined
criteria. Plans also must develop procedures for identifying
and correcting patterns of over- and under-utilization on the
part of their enrollees.
4. Medical Director's Office
Health plans must designate a medical director with
responsibility for the development, implementation, and review
of the internal quality assurance plan. The medical director's
position need not be full time but must include sufficient
hours to ensure that all medical director responsibilities are
carried out in an appropriate manner. Health plans also may
use assistant or associate medical directors to help perform
the functions of this office.
The medical director must be licensed to practice
medicine in the State of New York and must be board-certified
in his or her area of specialty. The specific responsibilities
of the medical director must include, but need not be limited
to the following:
- overseeing the health plan's Quality Assurance
Committee;
29
- overseeing the development and revision of clinical
standards and protocols;
- overseeing the plan's prior authorization/referral
process for non-primary care services;
- overseeing the plan's recruiting, credentialling and
recredentialling activities;
- review potential quality of care problems and overseeing
development and implementation of corrective action
plans;
- serve as a liaison between the plan and its providers,
and/or;
- local public health representatives; and
- available to the health plan's medical staff on a daily
basis for consultation on referrals, denials, and
complaints.
5. Electronic Billing
The selected organizations will be required to submit
monthly billing information electronically to the Department
of Health. An electronic mail account (E-Mail) must be
established with DOH in order to submit monthly billing files.
The files consist of individual records for each enrollee in
the program for that month. The individual record includes
such information as: the child's name, address, county, zip
code, date of birth, effective date of coverage, and premium
information. The required file lay-out and their definitions
are in Appendix G. Selected insurers will be provided with
instructions for establishing an E-Mail account with DOH.
In addition to the electronic files, the insurer must
submit an original signed voucher when claiming payment. If a
bidder cannot file electronically and meets the above
criteria, they will be eliminated from bidding. This is a
non-negotiable item. Monthly voucher bills shall be based on
the actual number of children eligible for a subsidy enrolled
in the program during the month for which payment is being
claimed. All adjustments shall include a listing by enrollee
of any change in enrollment occurring in that period.
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All monthly voucher bills shall be submitted to the State no
later than the tenth business day of the month. The State
reserves the right to process vouchers received later than the
tenth business day of the month in a subsequent period. The
State shall notify the health care initiatives pool
administrator by the first day of the following month, or the
first business day following the first day of the following
month, if the first day falls on a weekend or holiday, to
reimburse the contractor for vouchers for which payment is
being claimed. However, vouchers shall not be submitted to the
State later than ninety (90) days after the ending date of the
period for which reimbursement is being claimed unless the
State has granted an extension for late submission of premium
billing and voucher.
6. Department of Health Advisory Memoranda
DOH issues, Advisory Memoranda clarifies policies that
are either legislated or are in response to questions or
issues raised by the insurers. Examples of past Memoranda
include: updating income guidelines, updating equivalent
coverage definition, explaining new legislated mandates, and
outlining new processes for verifying applicant income. When
issued, the insurers must comply with these Advisory
Memoranda. Copies of pertinent existing policy Advisory
Memoranda addressing policy issues are included in Appendix B.
7. Program Monitoring
To comply with legislation requiring the verification of
insurers' enrollment and recertification procedures, DOH
developed an on-site monitoring program. On-site monitoring
consists of at least one annual visit to each insurer to
review a random sample of individual enrollee's application
records. The insurers are notified in advance of the visit and
told which enrollment files are selected for the sample. A
report is generated to notify the insurer of any deficiencies
found or corrections needed. Periodic, focused desk reviews of
selected enrollment files are also performed.
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8. Education
Some enrollees may not have experience participating in
a private, individual health insurance program. To aid these
enrollees, the enrollment process is to include an educational
component where new enrollees are oriented to the use of Child
Health Plus benefits. This educational component must inform
the enrollee how to select a provider, how to make an
appointment, what benefits are covered, how to obtain
emergency care, and how to obtain care when outside the
insurer's service area. Charges and payment procedures must
also be explained.
K. ENROLLMENT
1. Insurer Responsibility
Insurers will be responsible for enrolling children into
the Child Health Plus program. To do this, the insurer must:
- market the Child Health Plus program to eligible
populations of children, in accordance with the
provisions established by DOH and explained under
sub-heading L of this Section;
- distribute an application to the eligible population and
request the required documentation;
- collect and evaluate applicant submitted documentation
of age, income, insurance status, and New York State
residency;
- refer children who appear Medicaid eligible to the
Medicaid program;
- submit names and addresses of household members of
applicants to DOH for comparison with tax records in
cases where the insurer has reasonable cause to believe
fraudulent income documentation has been submitted;
- if the applicant is presumptively enrolled, request the
applicant to submit missing enrollment documentation
necessary to complete within 60 days. If the family
fails to provide documentation, the child's coverage is
terminated at the end of the 60 day; and
32
- annual recertification of enrollee eligibility.
Specific program requirements and acceptable
documentation are given in Advisory Memoranda in Appendix B.
2. Transferring of Enrollees from Non-Continuing Insurers
Some current Child Health Plus insurers may not be
continuing in the program, or they may not be covering the
same service area. In these instances, children will need to
enroll with new insurers.
3. Recertification/Termination of Coverage
The Child Health Plus subsidy and coverage shall
terminate or not be renewed upon annual recertification for
the following reasons:
- child reaches the age of 19;
- family's gross income exceeds the eligibility criteria
(however the child may enroll as a non-subsidized
enrollee);
- child becomes eligible for Medicaid;
- child no longer resides in the service area of the
insurer; and/or
- the child has equivalent coverage.
Children who "age out" of Child Health Plus are
disenrolled from the plan on the last day of the month in
which they reach 19 years. Conversion policies must be made
available to children who upon their 19th birthday are no
longer eligible for participation in Child Health Plus. If the
contractor is unable to offer a conversion policy from their
own organization then they must provide information on the
insurance options available with another organization to such
children. Such policies need not be identical to Child Health
Plus or be of the same premium cost. Recertification of income
eligibility, coverage under equivalent insurance, and New York
State residency must be performed on an annual basis by the
anniversary date of the child's enrollment. Children who are
found to be enrolled in Medicaid will be disenrolled from
Child Health Plus.
33
Children who do not submit required recertification and
appropriate documentation by the last day of the month prior
to the child's anniversary date, must be disenrolled from the
program.
Enrollees are required to notify insurers if their
circumstances change and they are no longer eligible for Child
Health Plus. These changes can include income changes where
they are no longer eligible for subsidy, equivalent coverage,
including Medicaid, or no longer residing in the service area
of the insurer.
The effective date for a child's enrollment shall be the
first day of the month. There will be no retroactive
enrollment of children. Disenrollment will be midnight on the
last day of a month.
4. Coordination with Medicaid Program
In order to encourage potentially Medicaid eligible
applicants to apply to Medicaid, Child Health Plus insurers
must refer applicants who appear to be Medicaid eligible to
their appropriate office for Medicaid eligibility
determination. Insurers will be required to screen all Child
Health Plus applicants for Medicaid eligibility. If other
information and/or documentation submitted by the family
suggests that the family may be eligible for medical
assistance, the insurer must refer the family to the Medicaid
program. The insurer is to provide each applicant referred to
the Medicaid program with a brochure (provided by the State)
describing the Medicaid program and application process.
Documentation of these referrals are required and reviewed at
the time of the site visit. It is anticipated that very few
cases referred to Medicaid, as a result of a screening, will
not be Medicaid eligible since the screening instrument used
is reliable and accurate. If children become eligible for
Medicaid while enrolled in Child Health Plus, they must be
disenrolled from the Child Health Plus program. The insurers
should be aware of the many Medicaid outstations where
families can apply for Medicaid. These "outstations" are found
in many hospitals and clinics and have facilitated the ease of
the application process.
34
To aid insurers in determining which Child Health Plus
applicants should be referred to Medicaid, DOH developed a
Medicaid referral form, which can be found in Appendix B.
The insurers will be responsible for referring the
family/child directly to the local DSS or outstation, who will
assist these families with applications to the Medicaid
program. Likewise, local DSS will refer families with eligible
children, who have been denied Medicaid or disenrolled from
Medicaid, to the Child Health Plus program.
Currently, Child Health Plus enrollees are compared to
the State's Medicaid enrollment files on a monthly basis to
determine dually enrolled children. Those children who are
enrolled in both programs are disenrolled from Child Health
Plus, provided they cannot supply proof they are not enrolled
in Medicaid. It is anticipated that this process will
continue.
The following chart identifies the income level for
Medicaid Coverage:
INDIVIDUAL / AGE NET FAMILY INCOME (FEDERAL POVERTY LEVEL %)
- ---------------- -------------------------------------------
Pregnant women <185% FPL
Children <1 <185% FPL, without an asset test
Children <6 <133% FPL, without an asset test
Children 6 - 12 <100% FPL, without an asset test
Children 13 - 19 At Medicaid income level, with an asset test
5. Model Application
Each insurer will be allowed to use an application form
that is unique to their plan. However, the variables that are
identified in the Model Application (Appendix H) will need to
be collected. The final application is subject to approval by
the State Insurance Department.
Also, the Department is working to develop a joint
application process for Medicaid, Child Health Plus and
Special Supplemental Food Program
35
for Women, Infants and Children (WIC). This application will
be pilot tested and selected insurers will be expected to
participate in the demonstration project. When the joint
application is implemented statewide all insurers will be
required to use the application form. The application pilot
test project is projected to be September 1, 1997.
Implementation of the joint application is planned for January
1, 1998.
6. Subscriber Contract
Each insurer selected for participation in Child Health
Plus will be required to issue a subscriber contract to
program enrollees. The contract must be approved by the State
Insurance Department in conjunction with the Commissioner of
Health.
DOH has developed a model subscriber contract to assist
an insurer in designing its subscriber contract. The model
contract will be sent to all insurers who submit a Letter of
Intent to the Department, by December 23, 1996.
Insurers are not required to use the model. However, if an
insurer does not use the model, care should be taken to ensure that
the provisions adopted from the model accurately reflect that
insurer's mode of operation.
It is not required that a draft subscriber contract be
included in an insurers response to this RFP. The State Insurance
Department and the DOH will contact each insurer selected for
participation to detail how the insurer files the subscriber
contract for approval.
L. COMMUNITY OUTREACH AND MARKETING
1. Previous Efforts
The Department has previously contracted with two
organizations to provide outreach and marketing for Child
Health Plus. Community outreach and marketing for the program
includes a telephone hotline to refer families to Child Health
Plus and/or Medicaid, printing and distributing of brochures
and posters, and conducting training sessions for interested
organizations. Additional activities include health fairs,
immunization drives, and the establishment of linkages with
schools and other community-based organizations.
36
a. Growing Up Healthy Hotline
The Growing Up Healthy Hotline, a New York State
sponsored referral service, is an 800 telephone number
which refers callers to health and social programs.
Child Health Plus is one of the options available to
callers and many are referred to participating insurers
and/or to Medicaid. In 1995, the Growing Up Healthy
Hotline made over 2,500 referrals to Child Health Plus.
2. Requirements for the Future
The insurers are responsible for marketing the Child
Health Plus program in their service areas. To aid in the
outreach and marketing for the program, the Department of
Health will undertake a mass media marketing campaign and
contract with an organization to provide outreach and
marketing for the program.
Requirements for the future include the continuation of
what the marketing and outreach contractors established for
the program in the past (telephone hotlines to refer families
to Child Health Plus and/or Medicaid, distributing of
brochures and posters, and conducting training sessions for
interested organizations). Additional activities required
include health fairs, immunization drives, and the
establishment of linkages with schools and community-based
organizations.
Insurers must submit to the DOH a general plan of a
marketing program outline with their proposal along with a
complete description on how they expect to conduct community
outreach and marketing activities.
Insurers must develop a comprehensive plan of all
marketing and enrollment activities they will engage in during
the contract period. The plan must be submitted to the DOH
Child Health Plus contract manager for approval prior to
implementation. An informational brochure prepared by DOH will
be available for use by plans until plan-specific marketing
materials are approved and printed. Any subsequent change or
additions to an insurer's marketing plan must be submitted to
the DOH at least thirty (30) days prior to implementation and
must be approved by DOH prior to implementation of such plan
or change.
37
DOH will review and approve all marketing plans and
materials submitted by insurance plans.
Insurers may use radio, television, billboards,
newspapers, leaflets, brochures, yellow page advertisements,
Letters, posters and verbal presentations by marketing
representatives as well as health fairs and events to market
their product to eligible children.
All materials for radio, television, billboards, and
bus, subway and statewide/regional print advertisements must
be submitted to DOH for review and approval.
Insurers must use the DOH official Child Health Plus
logo on all marketing material, applications, and
correspondence.
Insurers may distribute marketing material in local
community centers and gathering places, markets, pharmacies,
hospitals, schools, health fairs and other areas where
potential beneficiaries are likely to gather. Door-to-door
distribution of material is not permitted.
Themes and materials for health fairs must be submitted
by the insurer to DOH for approval at least thirty (30) days
prior to the event.
Insurers may not offer incentives of any kind to Child
Health Plus recipients to join a health plan. Incentives are
defined as any type of inducement, either monetary or in-kind
which might reasonably be expected to result in the person
receiving it to join a plan. However, insurers may offer
nominal gifts of not more than five dollars ($5.00) in value
as part of a health fair or other promotional activity to
stimulate interest in the Child Health Plus program. These
nominal gifts must be given to everyone who requests them
regardless of whether or not they intend to enroll in the
plan.
All material to be used in a media campaign (television,
radio, billboards and subway and bus posters) directed at
encouraging enrollment in Child Health Plus in their plan must
be reviewed and approved by DOH at least 30 days prior to the
campaign.
38
The insurer may not offer financial or other kinds of
incentives to marketing representatives based on the number
enrolled in the plan.
The insurer may not discriminate against a potential
enrollee based on his/her current health status or anticipated
need for future health care. The insurer may not discriminate
on the basis of disability, or perceived disability of an
enrollee. Health assessment forms may not be used by plans
prior to enrollment. Once a plan has been chosen and a child
has been enrolled, a health assessment form may be used to
assess the person's health care needs.
The insurers have responsibility for the local marketing
and working with the Department and Community Outreach
Contractor.
39
III. GENERAL INFORMATION FOR THE BIDDER
A. ISSUING OFFICE
This Request for Child Health Plus Insurance Proposal is
issued by the Division of Health Care Financing, Office of
Health Systems Management, New York State Department of Health
which is responsible for the RFP's contents as well as for the
evaluation of all submitted proposals.
B. ROLE OF NEW YORK STATE AGENCIES IN IMPLEMENTING AND MONITORING
CHILD HEALTH PLUS PROGRAM
1. New York State Department of Health (DOH)
The DOH will be responsible for overall
coordination of the program: making subsidy payments to
insurers to cover subsidy costs for children; monitoring
the use of subsidy payments; monitoring overall program
implementation and operation; and data collection,
policy analysis, and contracting with insurers. DOH also
will conduct on-site visits and desk audits to verify
enrollment policies and procedures, produce quarterly
enrollment reports based on insurers' submission of
monthly enrollment reports and produce a legislatively
mandated annual report. In addition, DOH is responsible
for coordinating activities between the insurers and
DSS, the marketing and outreach contractor(s),
subcontractors, and for providing technical assistance
to contractors.
2. New York State Insurance Department (SID)
The following provisions of Child Health Plus are
subject to the approval of the Superintendent of
Insurance in conjunction with the Commissioner of
Health:
- benefit packages and the cost of such benefit
packages and premiums;
- applications and subscriber contracts;
- financial feasibility of the proposed program; and
- provisions for arranging for, or offering,
conversion coverage in event of termination of
coverage under this plan.
40
C. INFORMATION
All inquiries concerning this RFP should be addressed
to:
Suzanne Moore, Ph.D.
Director
Bureau of Health Economics
Child Health Plus Request for Proposal
New York State Department of Health
Corning Tower Building, Room 1110
Empire State Plaza
Albany, New York 12237-0722
(518) 486-7897
D. BIDDERS' CONFERENCE
A bidder's conference will be held on January 10, 1997,
12:30 to 3:30 p.m. in the Museum Theater, West Gallery,
Cultural Education Center, Empire State Plaza, Albany, New
York. Any bidder wishing to pose a question shall lodge such
an inquiry in writing to Dr. Moore no later than close of
business December 30, 1996. All such questions will be
considered official inquiries and documented together with
appropriate answers by publication in the official minutes of
the meeting.
E. SUBMISSION OF PROPOSAL
Bidders are to notify Dr. Moore in writing by close of
business December 23, 1996 if they intend to submit a
proposal. Failure to provide this notice will result in
disqualification from the bidding.
Proposals are to be prepared concisely. Interested
bidders should submit fifteen (15) copies of their plan to Dr.
Moore by close of business February 14, 1997.
Bidders are responsible for ensuring that their plans
are received on time. The content of each plan will be held in
confidence and no details of any plan will be shared with any
other bidder. There will be no public bid opening.
41
F. RELEVANT DATES
The following are dates in the State's health plan procurement
schedule:
Notice Appears in Contract December 9, 1996
Reporter
RFP is Issued December 9, 1996
Notice Appears in State December 11, 1996
Register
Letter of Intent Due to December 23, 1996
Department by Close of
Business
Due Date for the Submission December 30, 1996
of Questions
Bidder's Conference January 10, 1997
Due Date for Written January 23, 1997
Response to Questions
Proposal Due to Department February 14, 1997
by Close of Business (15
copies)
Panel Review of Proposals February 17, 1997
to March 19, 1997
Notification of Contract March 24, 1997
Awards
Program Implementation May 1, 1997
G. LIABILITIES
The State of New York is not responsible for any cost incurred
by bidders prior to issuance of a contract.
The Department of Health reserves the right to:
- reject any or all plans received in response to this RFP;
- select a bidder on a basis other than apparent lowest cost;
- consider modifications to any plans at any time prior to the
awarding to contracts if such action is in the best interest
of the State;
42
- waive or modify minor irregularities found in any plan
received after notification to, and with the concurrence of,
that bidder;
- utilize any and all ideas submitted in any plan received
unless these ideas are covered by legal patent, copyright or
proprietary rights;
- amend the specifications contained herein after their release.
In the event of such amendments, all competing parties will be
notified and any modified schedules will also be published;
- alter any schedules or dates specified in the RFP to
accommodate changes in existing conditions;
- limit the number of participating insurers in any region of
the State; and
- Department reserves the right to change and/or modify as it
deems necessary, all forms or schedules contained within this
RFP before final approval and implementation of the program by
the insurer.
H. BIDDER PRESENTATIONS
Due to the time frame for this RFP process, DOH does not
anticipate that bidders submitting acceptable plans will be
requested to provide oral presentations of their proposal.
I. SOLE SOURCE RESPONSIBILITY
The selected contractors assume responsibility for all
services and benefits covered by this contract. Plans for
subcontracts should be specified in the applicant's proposal. The
contractor will be held accountable as to any decision or actions
made by the subcontractor. A statement to this effect must be
included in the proposal submitted. A final form of the subcontract
must be approved by DOH. Applicants should specify in the plan how a
satisfactory performance of subcontracts will be ensured.
J. DATA MAINTENANCE
All data relating to design, implementation and outcome of
Child Health Plus must be reported to DOH and made available for a
period of six years following the conclusion of the contract. Data
used as basis for the reports are considered to be patient and
provider specific and are held to all confidentiality controls
pursuant to DOH review standards.
43
K. REPORTS
The insurers will be responsible for submitting reports to DOH
regarding the progress of their enrollment. An insurer should have
the capability to submit reports electronically to the Department,
as that may be a future requirement. However, at this time, reports
can be submitted on DOH developed forms via postal service mail.
These reports include: monthly enrollment reports (detailing
new and ongoing enrollment and disenrollment), quarterly
disenrollment reports, semi-annual and annual financial and
utilization reports, annual progress reports (detailing marketing
and enrollment outcomes), demographic characteristics of enrollees
and utilization outcomes (Appendix G). Inability of a bidder to
complete these forms within the required timeframe will mean
disqualification from bidding.
L. QUALITY ASSURANCE/UTILIZATION REVIEW
The insurer will be responsible for ensuring that the services
and providers under Child Health Plus meet the quality of care
standards pursuant to Public Health Law and regulations. If a bidder
is unable to meet the quality assurance standards as required by the
program, as set forth in Section II, they will be disqualified from
bidding.
Additional DOH sponsored quality assurance studies may be
conducted during the contract period. The insurers will have a
contractual responsibility to work with the Department or its agent
to complete the quality assurance study within the specified
timeframes. This will include supplying the medical records of
enrolled children who are selected for the study sample and
responding to inquiries from the contractor.
As set forth in Section II, the bidder must also specify the
process to be used in verifying an enrollee's health utilization and
be able to forward the data to DOH electronically. This process must
include a method for encouraging that well-child care visits are
scheduled and kept in conformance with the standards of the American
Academy of Pediatrics (Appendix E). These efforts and follow-up
efforts must be documented.
44
M. QUALITY IMPROVEMENT AND MEDICAL MANAGEMENT
Plans must specifically provide quality performance data which
is consistent with the New York State Department of Health Quality
Assurance Reporting Requirements (QARR) data specifications, on an
annual basis for the Child Health Plus population. Some of the
required QARR data elements which will be required to be collected
appear in the table below:
Proposed Reporting Requirements for the Child Health Plus
Population.
Category Variable to Be Collected
- -------- ------------------------
Membership - Member Months of Enrollment by age, sex and payer
- Enrollment by County
Utilization - Frequency of Selected Conditions
- Inpatient Care
- Ambulatory Care
- Maternity Care
- Newborn Care
- Disenrollment Rate
Quality - Prenatal Care
Low Birth Weight, Entry in first
trimester, initial prenatal care visit,
number of prenatal care visits, stage of
pregnancy at time of enrollment
- Well Child Care Visits in First Year of Life
- Age 4, 5, and 6 year old well child visits
- Adolescent Well Child Care Visits (age 12-18)
- HIV Education (age 12-18)
- Substance Abuse Counseling (age 12-18)
- Immunizations
- Mental Health Follow-Up
Access & - Utilization of primary care providers by
Member children
Satisfaction - Availability (waiting times for scheduled
appointments)
- Uniform Member Satisfaction
General Plan - Quality and Service Improvement Studies
Management - Case Management
- Utilization Management
- Risk Management
- Provider Compensation
- New Member Orientation/Education
- Language Services
- Arrangements with public health, education
and social services
45
N. NOTIFICATION OF PLAN ACCEPTANCE
The Office of Health Systems Management will notify the
successful bidders through a Letter of Commitment. A standard State
contract will be developed with the conditions and deliverables for
the program. In the event that program changes are subsequently
defined and agreed to during the period the contract is awarded and
the implementation date, payment for costs consequent to these
adjustments will be negotiated separately. The contract will
incorporate this RFP and the bidder's final plan in addition to the
Appendix A Standard Clauses for all New York State Contracts
(Appendix I), the deliverables and the program budget.
If a bidder's plan is rejected, they will be notified by DOH.
News or public announcements pertaining to this program will not be
made without prior DOH approval, and then only in coordination with
the Office of Health Systems Management.
O. CONTRACTUAL CONTENT
Following selection of the successful bidders, DOH and a
bidder will negotiate a contact to include Standard State Clauses
(Appendix A, found in Appendix I of this RFP), this RFP and the
bidder's plan for the development and implementation of the Child
Health Plus program. The contract will include, but not be limited
to, the items listed below:
- terms and conditions of contract;
- State's obligations;
- contractor's liability;
- financial considerations;
- deliverables;
- subcontracting;
- delivery and implementation dates; and
- evaluation plans.
The forms in Appendix M must be completed and returned with
your response to this RFP. The contract will incorporate these forms
as completed by the successful bidders
46
P. NON-CONCLUSIVE BIDDING REQUIREMENT
In accordance with Section 139-d of the State Finance Law, if
this contract was awarded based upon the submission of bids, the
contractor warrants, under penalty of perjury, that its bid was
arrived at independently and without collusion aimed at restricting
competition. The contractor further warrants that, at the time
Contractor submitted its bid, an authorized and responsible person
executed and delivered to the State a non-conclusive bidding
certification on Contractor's behalf.
Q. WORKERS' COMPENSATION LAW
Chapter 213 of the Laws of 1993 amended the Workers'
Compensation Law by imposing two new contract requirements. Agencies
cannot enter into contracts involving contractor employees unless
proof duly subscribed by an insurance carrier is produced showing
that workers' compensation and disability insurance benefits
coverage has been secured for the employees in accordance with
Sections 57.2 and 220.8(b) of the Workers' Compensation Law. Proof
must be provided prior to signing a contract which will involve
contractor employees. The forms which are satisfactory to the chair
of the Workers' Compensation Board are C-105.2 (Application for
Certificate on Workers Compensation Insurance) and DE0120.1
(Employer's Application for Certificate of Compliance with
Disability Benefits Law).
R. TRADEMARK
Each insurer is obligated to use the State designated logo for
Child Health Plus in any activities. These activities include
outreach and marketing, correspondence with the applicant or
enrollee, on the application, and on the benefit card. In no event
is the acronym, CHP, to be used in referring to the Child Health
Plus program.
47
IV. APPLICATION FORMAT
A. GENERAL REQUIREMENTS
A proposal to participate in the Child Health Plus program
must be submitted as outlined below. Pages should be numbered
consecutively starting with number 1 and continuing through the end
of the plan. Do not use separate numbering for any part of the plan.
The bidder should state how the enrollment, marketing and other
operating plans may change during the length of the program.
In addition to your proposal, please submit a proposal summary
using the outline which appears as Appendix L.
B. SPECIFIC REQUIREMENTS
Follow the sequence of the format, including separate sections
and appendices for each area covered and use the letters and numbers
specified in each section.
1. Letter of Intent
All bidders must submit a Letter of Intent by close of
business on December 23, 1996, indicating that a full proposal
will be submitted by the required date.
2. Letter of Transmittal
A Letter of Transmittal must accompany the proposal. The
letter must be signed by an official of the company or
organization authorized to bind the bidder to the requirements
of the RFP. The plan and all provisions of the offer price are
to remain in effect for one-hundred and twenty (120) days. The
plan is due by close of business February 14, 1997.
3. Proposal
a. Background and Statement of Understanding
Briefly discuss the characteristics of the
population to be served by Child Health Plus and the
estimated enrollment in the proposed service area.
48
b. Contractor Qualifications
- full name and address of your organization and
list responsible officers.
- name and position of the person entitled to
negotiate a contract with the Department.
- name and position of the person who will have
ultimate responsibility and accountability for
this contract.
- management team which will oversee the various
tasks of the project, and the level of access this
team has to your corporate management.
- specific qualifications and experience of the
person(s) having ultimate responsibility and
accountability for this contract that would enable
this (these) person(s) to successfully develop and
implement the project design.
- resources that will be committed to implementing
and operating this program.
- submit, as Appendices I and II respectively,
copies of your organization's Articles of
Incorporation and By-Laws. Include a narrative
description of your organization including the
parent and all subsidiary companies.
- describe the role of board members in governance
and policy making.
- include as Appendix III, organization budgets and
audited financial statements which show sources of
funds for the last complete fiscal year of the
organization. A narrative should accompany the
financial statements, indicating the
organization's long term financial projections and
how cost and income from other programs are
separated. It should also show the results or
sources of upcoming fiscal changes.
49
C. PLAN AND PROJECT DESIGN
Provide a timeline of implementation of the program and a
narrative description of your program. The proposal and narrative
are to include strategies to respond to problems that may arise. The
narrative description should:
- Identify the specific county(ies) that you propose to cover in
your program. Indicate whether the bid covers the entire
State. Include the number of individuals you expect to serve,
the capacity of your proposed program, and how you determined
the need that exists in your area. Submit a projection of the
number of enrollees by member months, and an estimated premium
revenue based on your projection.
- Identify the provider network (by type, number, and county)
include a directory of health care providers and their
geographic accessibility to enrollees. For primary care
providers, you must identify the additional number of Child
Health Plus enrollees that the provider is willing to accept.
- Describe the strategies for recruiting the target population
including uninsured members of the various minority
communities in your county(ies). Be specific in identifying
the minority communities and targeted recruitment strategies.
- Identify the enrollment and eligibility determination
procedures. This should include the identification and
documentation of enrollee eligibility including the
designation of other organizations which may perform such
functions under a subcontract. The enrollment process should
address how enrollees will be educated on the use of the
provider system and should include a flowchart of the process.
- Identify the billing process and procedures to be used. This
billing process description should include the insurer's
policy for disenrollment for non-payment of premiums. Also
identify your capability to meet the Department's electronic
premium payments (Appendix J).
- Detail the arrangements for the reimbursement of participating
providers.
50
- Prepare a budget which includes the family's share of the
premium and New York State's premium share. Include a short
narrative on your budget plans and a description of the
estimated expenses, personnel costs, marketing costs and other
administrative costs. The budget should specify the resources
necessary to implement the plan and be submitted on the Budget
Forms in Appendix K.
- Identify and specify the quality assurance, utilization review
and managed care mechanisms that will be used for Child Health
Plus enrollees.
- Discuss your plan and capability to fulfill data analysis and
reporting requirements including the submittal of the
specified data.
- Describe in detail the benefit package and its costs.
- Detail the provisions and/or arrangements for offering
conversion of benefits in the event of termination of coverage
under this plan, or for children who age out of the program.
- Demonstrate the financial feasibility of your organization's
proposed Child Health Plus program including the financial
requirements of the New York State Insurance Law and Public
Health Law.
- Specify the monthly and annual premium of the Child Health
Plus benefit package and the population on which the premium
is based. The premium components must include covered
services, assumed payment rates to providers, co-insurance and
estimated utilization patterns. This should include:
- schedule of rates;
- actuarial memorandum including but not limited to:
- the formulas and assumptions used in calculating
gross premiums;
- expected claim costs;
- identification of morbidity tables, experience
studies or other data sources utilized;
51
- percentage breakdown of the rates to show
expected claim costs, expenses, contributions to
statutory reserves, and surplus;
- comparison with filed rates for similar benefits
and populations (if the bidder is a current Child
Health Plus insurer, comparison with current rates
should be included);
- HMOs and insurers should comment on the
consistency or variance of actuarial and other
pricing assumptions from those underlying approved
community rates for individual products currently
offered with detailed explanation for variances;
- expected number of covered lives; and
- identify the specific counties that you propose to
cover in your program.
- Identify any services to be provided by subcontractors. These
subcontractors would include providers, pharmaceutical and
diagnostic laboratory networks.
- Discuss how Child Health Plus will interact with other
insurance products, including Medicaid.
52
V. EVALUATION CRITERIA
Proposals will be evaluated on a competitive basis using the
criteria listed below. Each section of the proposal will be scored. The
total score of all parts combined will be a maximum of 100 points. A
ranking will then be assigned. Plans will be chosen in order to ensure an
adequate statewide coverage.
A. UNDERSTANDING OF THE GOAL, OBJECTIVES AND INTENDED RESULTS OF CHILD
HEALTH PLUS.............(15 POINTS)
The proposal demonstrates that the insurer understands the
goal and objectives of Child Health Plus with anticipated results
stated both quantitatively and qualitatively.
B. KNOWLEDGE/EXPERIENCE/CAPABILITY IN AREA.....(70 POINTS)
1. Knowledge and Experience (10 points)
The proposal describes the relevant experience
and competence of the project director(s) and other key staff
in the area. The project director(s) and key staff are
qualified and possess experience in this area and the variety
of skills required to successfully implement the Child Health
Plus program. The applicant provides evidence of understanding
and knowledge of prior and ongoing work in the area. Specific
information is also provided concerning how the personnel are
to be organized in the project, to whom they will report, and
how they will be used to accomplish specific objectives or
components of the project.
The present capacity to provide health care services for
the intended target population should be discussed, including
the capability to comply with New York State Insurance Law.
The proposal will be evaluated on the following three
criteria: network composition, fiscal, and general technical.
2. Network Composition (20 points)
a. NYS Medicaid Managed Care Participants
If you are a participant in the New York State's
Medicaid Managed Care Initiative, then submit a copy of
your Certificate of Authority and state whether or not
there have been any additions, subtractions or other
significant
53
changes to the network which would alter your compliance
with Department standards. Please itemize all changes to
your network, if applicable. In addition, NYS Medicaid
Managed Care Participants are required to submit the
information as required under Section IV.
b. Non-Medicaid Managed Care Participants
If not a participant of the State's Managed Care
Initiative, your network will be evaluated on a
competitively scored basis, according to the following
criteria:
(1) General
Health plans must establish and maintain
provider networks with sufficient numbers of
providers and in geographically accessible
locations for the populations they serve. Health
plan networks must contain all of the provider
types necessary to furnish the benefit package as a
managed care product, including: hospitals,
physicians (primary care and specialist), mental
health and substance abuse providers, allied health
professionals, pharmacies, laboratories, DME
providers, etc. Health plans should not include in
their networks, for purposes of service Child
Health Plus enrollees, any medical provider who has
been sanctioned by Medicare or Medicaid if the
provider has, as a result of the sanctions, been
prohibited from serving Medicaid clients or
receiving medical assistance payments.
(2) Completeness
The insurer's network will be evaluated on the
presence of all required specialties to adequately
meet the needs of Child Health Plus enrollees. In
addition, the entire benefit package as described
in Appendix E.
54
(3) Accessibility
The insurer's network will be evaluated on the
total number of providers and their office hours,
the presence of school-based health centers, and
wheelchair accessibility.
(4) Training
The insurer's network will be evaluated on the
"Board" status of the physicians within he network;
hospital admitting privileges; and residency
completion.
(5) Mainstreaming
The insurer's network will be evaluated on the
percent of the total network which will be open to
Child Health Plus enrollees under the age of 19.
(6) Cultural Competency
The network will be evaluated on whether or not
there is an inclusion of providers who speak
languages other than English.
3. Fiscal Evaluation Criteria (20 points)
a. Premium Range
The premium rate proposal for the Child Health
Plus benefit package must be reasonable in relation to
the benefits provided and may not be excessive,
inadequate, or unfairly discriminatory.
b. Budget
The resources that will be needed to conduct the
project must be specified, including personnel, time,
budget and facilities. The project's cost must be
reasonable in view of the anticipated results. Any
subcontracts with other organizations must be clearly
defined. All resources (personnel, travel, consultants,
equipment, etc.) are detailed and budgeted. The budget
forms in Appendix K must be completed with a short
narrative. The proposal should provide evidence of the
financial feasibility of the
55
impact of the proposed program on overall operations of
the bidder.
4. General Technical Evaluation Criteria (20 points)
a. Marketing
Marketing of the Child Health Plus program to
targeted children and families is critical to the
success of the program. Successful enrollment is
dependent upon well-defined marketing plans.
In addition to the Child Health Plus Community
outreach and Marketing subcontractor which will be
responsible for the marketing of the program on a
statewide basis (which is being solicited through a
separate RFP process), the insurer is also responsible
for marketing the Child Health Plus program to the
targeted population in the regions in which the insurer
covers. The statewide campaign should be considered, by
the insurer, as a base upon which to guide the insurer's
critical local campaign. Proposals submitted should
reflect the targeted enrollment and marketing effort
that will be used to attract applicants. The insurer
should develop a plan to ensure a smooth referral system
for applicants.
b. Benefit Package
The insurance benefit package should be described
in detail, along with the costs for each. The benefit
package must offer the benefits as outlined in Appendix
E.
56
Each provider must follow the well-child care
guidelines established by the American Academy of
Pediatrics and the immunization recommendations as
delineated by the The New York State Recommended
Childhood Vaccination Schedule which are enclosed as
part of Appendix E.
Detail the provisions and/or arranging for
offering conversion of benefits in the event of
termination of coverage under this plan.
c. Reasonable Outreach Efforts
The insurer should submit in their proposal, the
outreach strategies that will be used to disseminate
information regarding Child Health Plus to the targeted
population and recruit and enroll from this population.
Specify methods that will be used to evaluate the
effectiveness of these strategies. These strategies must
follow the guidelines as established in Section II of
this RFP.
d. Patient Education
The insurer should submit in their proposal, the
public education strategies that will be used for the
targeted population. Specify methods that will be used
to evaluate the effectiveness of these strategies.
e. Quality Assurance/Utilization Review/Credentialling
The proposal should identify and specify the
quality assurance, utilization review, credentialling,
and managed care mechanism which will be used for Child
Health Plus enrollees.
f. Reporting Requirements
The proposal should discuss the plan and
capability to fulfill data analysis and reporting
requirements including the submission of data outlined
in the Reports section of this RFP and enrolled data.
57
g. Electronic Billing Capacity
The proposal must clearly detail how the insurer
is able to handle the electronic billing requirements of
the program.
h. Provider and Member Services/Medical Director's Office
As detailed in Section II of this RFP, the
proposal should specify the provider and member services
function, and the medical director's function which will
be used for Child Health Plus enrollees.
i. Other Requirements
The proposal submitted should specify how the
insurer will implement enrollment procedures, coordinate
referrals to presumptive eligibility providers and
develop contracts with school-based health centers.
C. Project Design and Time-
Plan for Implementation...................(15 points)
The activities and resources required to ensure implementation
and operation of the Child Health Plus program should be clearly
defined. As previously described in detail, evaluation of the
project design and time plan will be based on the following:
- geographical location of the program and estimated number of
enrollees;
- adequacy and quality of provider network;
- marketing strategies to be employed and enrollment and
eligibility determination procedures to be used, including a
flowchart of the process;
- payment methodologies for providers and their comparison to
similar benefit plans;
- utilization review, quality assurance and case management
mechanisms;
- ability to meet data analysis and reporting requirements;
- availability of conversion provisions;
58
- appropriateness of the timeframe for implementation of the
program; and
- understanding of how Child Health Plus will interact with the
Medicaid program.
The bidder must be prepared to enroll children for coverage
and provide the health services in the plan by May 1, 1997. These
timeframes should be as objective as possible.
Specific information must be provided concerning how personnel
are to be organized in the project, to whom they will report, and
how they will accomplish the specific tasks of the project. The
staffing pattern clearly links responsibility and levels of effort
to the project tasks. Curriculum Vitae of key personnel should be
included.
VI. REVIEW PROCESS
An independent review of submitted plans will be conducted by a
panel of not less than three people selected by DOH. The review will focus
on the evaluation criteria specified above.
59
[X] APPENDIX X Modification Agreement Form (to accompany modified appendices
for changes in term or consideration on an existing period or
for renewal periods)
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT
on the dates below their signatures.
_____________________________________ _____________________________________
Contract No. C___________________
CONTRACTOR STATE AGENCY
_____________________________________ _____________________________________
_____________________________________ _____________________________________
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) __________________________________
ATTORNEY GENERAL'S SIGNATURE STATE COMPTROLLER'S SIGNATURE
_____________________________________ ____________________________________
Title: ______________________________ Title: _____________________________
Date: ______________________________ Date: _____________________________
APPENDIX A
INCOME GUIDELINES
CHILD HEALTH PLUS
1996 FEDERAL POVERTY LEVELS (FPLs)
EFFECTIVE 4/1/96
Net Income
-------------------------------------------------------------------------
100% 133% 185%
Family Size Annual Monthly Annual Monthly Annual Monthly
- ----------- ------ ------- ------ ------- ------ -------
1 7,740 645 10,294 858 14,319 1,193
2 10,360 863 13,779 1,148 19,166 1,597
3 12,980 1,082 17,263 1,439 24,013 2,001
4 15,600 1,300 20,748 1,729 28,860 2,405
5 18,220 1,518 24,233 2,019 33,707 2,809
6 20,840 1,737 27,717 2,310 38,554 3,213
7 23,460 1,955 31,202 2,600 43,401 3,617
8 26,080 2,173 34,686 2,891 48,248 4,021
Extra Person 2,620 218 3,485 290 4,847 404
Note: The above chart represents net poverty levels (FPLs).
The chart below reflects gross poverty levels for use in determining Child
Health Plus eligibility (net x 1.2 = gross)
Gross Income
-------------------------------------------------------------------------
120% 160% 222%
Family Size Annual Monthly Annual Monthly Annual Monthly
- ----------- ------ ------- ------ ------- ------ -------
1 9,288 774 12,353 1,029 17,183 1,432
2 12,432 1,036 16,535 1,378 22,999 1,917
3 15,576 1,298 20,716 1,726 28,816 2,401
4 18,720 1,560 24,898 2,075 34,632 2,886
5 21,864 1,822 29,080 2,423 40,448 3,371
6 25,008 2,084 33,260 2,772 46,265 3,855
7 28,152 2,346 37,442 3,120 52,081 4,340
8 31,296 2,608 41,623 3,469 57,898 4,825
Extra Person 3,144 262 4,182 349 5,816 485
(3/96)
APPENDIX B
ADVISORY MEMORANDA
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-1
DATE 2/1/92
SUBJECT: I. Emergency Room Copayment and Insurer Liability for
Inappropriate Use
II. Eligibility Documentation
III. Medicaid Eligibility
IV. Presumptive Eligibility - Minimum Days
V. Enrollment Fee
VI. Definition of Equivalent Coverage
VII. Enrollment Issues
VIII. Child Health Plus/Child Information Form
IX. Annual Recertification of Child Health Plus Eligibility
for Coverage
X. Conversion
I. EMERGENCY ROOM COPAYMENT AND INSURER LIABILITY FOR INAPPROPRIATE USE
Considerable concerns were raised by insurers with the initial
interpretation of the statute governing emergency room (ER)
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coverage. The law was virtually interpreted to stipulate that families were
liable for a $35 copayment if use of the ER was not reported to the insurer
within 24 hours, but appeared to not permit denial of the claim.
Based on legislative clarification, a copayment of $35 for ER service is
permissible when the beneficiary does not inform the insurer within 24 hours of
use of such service or when use of the ER was not for an emergency condition. In
the latter case, copayment should be waived if, given the options available, the
ER was the most appropriate site of service. If the insurer determines that the
use of ER was inappropriate, the insurer may deny the claim and the hospital may
directly bill the family for the total charge for the ER visit. Insurers are
responsible for monitoring the use of ER by enrollees and providing feedback
where there is a consistent misuse of the service. The Department will be
collecting information on ER usage including cases where payment is denied or a
copay imposed. The forms for collecting this data are currently under
development and will be issued to insurers upon completion.
It should be noted that it was not the intent of the Legislature that insurers
be required to cover emergency room services in a manner inconsistent with
private health insurance underwriting practices for such services. Several Child
Health Plus insurers have proposed to limit the coverage of emergency room
services in a HMO format, comparable to their ordinary HMO plans. This is
consistent with legislative intent.
Page 2
II. ELIGIBILITY DOCUMENTATION
Insurers have requested clarification regarding the types of documentation
they must obtain from enrollees as proof of eligibility. Eligibility
criteria are:
- the child is not enrolled in Medicaid;
- the child does not have equivalent health insurance coverage;
- the child is less than 13 years of age.
Proof of citizenship or residency is not an eligibility requirement under
Child Health Plus.
Insurers are responsible for assuring that all enrollees meet the defined
eligibility criteria and for retaining copies of proof of eligibility,
which may be audited. As part of the application process, families must
have proof of age, income, and if appropriate, other health insurance
documentation. The following information is provided to insurers as a guide
for meeting these requirements.
A. PROOF OF AGE
Documentation of proof of age may include a copy of birth certificate,
religious documents (baptismal papers), school records, and/or a
signed affidavit stating witness of birth.
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B. PROOF OF INCOME
The means test for income shall include any one of the following: Annual
Federal and State tax returns, paycheck stubs or other documentation of
income, written documentation by employer, a WIC "Income Residency
Documentation Form" or an affidavit of self-income declaration (see Section
II.D and E). Income for the purposes of this part means gross income before
deductions for income taxes, employees' social security taxes, insurance
premiums, bonds, etc. Income includes the following:
1. Monetary compensation for services, including wages, salary,
commissions or fees;
2. Net income from farm and non-farm employment;
3. Social Security;
4. Dividends or interest on savings or bonds, income from estates or
trusts, or net rental income;
5. Public Assistance;
6. Unemployment compensation;
7. Government civilian employee or military retirement or pensions or
veterans' payments;
Page 4
8. Private pensions or annuities;
9. Alimony or child support payments;
10. Regular contributions from persons not living in the household;
11. Net royalties; and
12. Other cash income. Other cash income would include but would not be
limited to, cash amounts received or withdrawn from any source
including savings, investments, trust accounts, and other resources
which are readily available to the family.
Copies of income documents should be retained with insurer records.
However, it should be noted that proof of residency, citizenship, or
documents relating denial of Medicaid eligibility are not required as
proof of eligibility for the Child Health Plus Program.
C. INCOME ELIGIBILITY DETERMINATION
Several insurers have inquired as to whether they must use gross or net
income in determining enrollee eligibility. The Department strongly
recommends that the insurer use the family's gross income to determine
eligibility for subsidy
Page 5
payment. The determination of net income is a complex administrative
process and would require the development of detailed screens and
exemptions. However, the State will permit insurers to use net income as a
criteria in assessing a child's application, if consideration of
appropriate deductions would enable a child to be eligible based on net
income.
If a household has two sources of income and one is entitlement income
such as Medicaid, the entitlement income need not be adjusted to make it
equivalent to gross when calculating the total family income.
D. DECLARATION OF INCOME WITHOUT DOCUMENTATION
Insurers have found it difficult to obtain income eligibility
documentation for some potential enrollees. Specifically, insurers have
found it difficult to document income earned by families who are not
documented U.S. citizens, who are homeless, who have recently moved to New
York, or who are self-employed and are not maintaining records or filing
1040-ES. In addition, insurers have encountered many children who have
parents who work for employers who cannot or are unwilling to supply the
appropriate documentation of wages. Applicants/participants who have
income but cannot document it may make a self-declaration of income by
completing an "Affidavit of Self-Income Declaration", (Appendix II, sample
attached). Self-declaration should only be used in cases where
Page 6
there is truly no way to document income requirements. Insurers can expect
the Department to review the use of self-declaration.
E. USE OF WIC APPLICATION AS PROOF OF INCOME
The Department will allow insurers to accept a copy of the WIC program,
"Income and Residency Documentation Form" as proof of income eligibility
for Child Health Plus (see Appendix I). WIC representatives will refer
income eligible children to Child Health Plus insurers. At the time of
referral, WIC providers will furnish a copy of the WIC application to the
approved WIC participant together with a copy of the Child Health Plus
brochure describing the program and containing a list of insurers to
contact for enrollment in the program. Child Health Plus insurers may use
the approved WIC application as documentation for verification of income
eligibility. Insurers should review the WIC program "Income and Residency
Documentation Form" to verify whether it is in effect on the date which the
family applies for Child Health Plus. Only those WIC program, "Income and
Residency Documentation Forms" which have an effective date which is valid
concurrent with the date of enrollment into the Child Health Plus will be
acceptable as income documentation. Annual recertification of Child Health
Plus eligibility for coverage will be administered in accordance with
Section IX of this memorandum.
Page 7
F. EQUIVALENT COVERAGE
As part of the eligibility process, insurers are required to document
whether a potential enrollee has equivalent coverage. Such
documentation may include a subscriber contract as proof of coverage.
Many insurers have had difficulties in accessing this documentation,
particularly in cases where the parent carrying the insurance for the
child does not live in the same household. Insurers are responsible
for assessing the validity of the subscriber contract and for
determining whether a child has equivalent coverage. (Please refer to
Section VI for further detail.) In such instances where a copy of the
applicable insurance documentation is truly not accessible to satisfy
this requirement, a signed affirmation stating that the child has no
equivalent coverage is permissible.
III. MEDICAID ELIGIBILITY
A. SPEND-DOWN TO MEDICAID ELIGIBILITY LEVEL
To ensure continuity of health care coverage, families enrolled in
Child Health Plus who become Medicaid eligible may include the Child
Health Plus premium as part of the family's expenses qualifying them
as Medicaid eligible. When using the Child Health Plus premium cost in
calculating Medicaid spend-down, families have the option of keeping
the child enrolled in Child Health Plus while the family enrolls in
Medicaid and may
Page 8
continue using the Child Health Plus premium to meet the spend-down
calculation requirement to remain Medicaid eligible.
B. MEDICAID REFERRAL/COORDINATION
Insurers have requested clarification regarding their responsibility for
referring potential applicants to local Department of Social Services (DSS)
offices for Medicaid.
To ensure that appropriate referrals to the Medicaid program are made, all
Child Health Plus applicants whose age, income and family size meet
criteria that indicate a strong potential for Medicaid eligibility, must be
referred by the Child Health Plus insurers for application to Medicaid.
These include children who are less than one year of age and reside in a
household whose gross income is less that 222% of the federal poverty
levels, and children who are less than six years of age and reside in a
household whose gross income is less than 160% of the federal poverty
levels.
In addition to referring those applicants to DSS, insurers must provide all
applicants with a brochure prepared by the State describing the Medicaid
program and application process. Application by the family to Medicaid is
not mandatory but should be strongly encouraged. Children deemed eligible
for Child Health Plus shall remain covered until families referred are
actually enrolled in Medicaid. All children should be
Page 9
accepted into Child Health Plus if all Child Health Plus eligibility
criteria are met regardless of whether they appear Medicaid eligible
or are not.
IV. PRESUMPTIVE ELIGIBILITY - MINIMUM DAYS
The presumptive eligibility process must be used by all contractors under
the Child Health Plus program. Presumptive eligibility provides immediate
coverage pending a full eligibility determination. If an applicant appears
to meet all acceptable eligibility requirements, but does not have all
appropriate documentation available at the time of enrollment, the insurer
shall make the determination that the child is presumptively eligible for
a maximum of 60 days after the initial date of enrollment. Only one period
of presumptive eligibility per child is allowed. At the end of the
presumptive eligibility period, all required documentation must have been
provided to maintain the enrollee's coverage.
If a child is determined to be ineligible, DOH will pay the subsidy for up
to 60 days of presumptive eligibility. Upon request by the family, the
enrollment fee must be refunded by the insurer if the family provided
all required documentation and the child did not use any services during
the 60 days presumptive eligible period. Insurers may claim the cost of
premium incurred during the 60 day presumptive eligibility period in their
monthly premium voucher submission.
Page 10
V. ENROLLMENT FEE
According to statute, families whose gross income is between 160-222
percent of the Federal poverty level pay $25 per child per year with an
annual maximum family contribution of $100. Where applicable, insurers are
responsible for collecting a minimum enrollment fee of $25 at the time of
enrollment regardless of the number of children being enrolled. Insurers
have the discretion of working out a payment plan for up to a 12-month
period for any additional fee required but not paid during the time of
enrollment. However, at the time of annual recertification, payment of any
outstanding balance must be satisfied plus the $25 re-enrollment fee in
order to continue in the program. The insurer has the option of imposing
their own payment plan for those families ineligible for subsidy coverage.
As noted in the, "Presumptive Eligibility," Section IV of this memorandum,
the State will reimburse the insurer for enrollment fees refunded to
applicants who were initially deemed presumptively eligible for Child
Health Plus and were subsequently determined ineligible at some point
during the 60 day presumptive eligibility period.
The insurer cannot retain a portion of any enrollment fee being refunded
to defer the administrative cost related to the enrollment process. The
State will reimburse the insurer the cost of the premium for the period in
which the child was considered
Page 11
presumptively eligible and this will cover the costs associated with the
enrollment processing.Any refunded enrollment fees must be reimbursed by
insurers directly to families.
VI. DEFINITION OF EQUIVALENT COVERAGE
Many insurers continue to have questions relating to the definition of
equivalent coverage. The following guidelines should be followed in
determining equivalent coverage.
- Coverage for primary health care services provided in a physician's
office or other outpatient sites which is consistent with the Child
Health Plus benefit package is considered equivalent coverage.
Insurance plans which do not include prescription drugs or do not
provide preventive care services, but meet the above definition will
be deemed to offer 'equivalent coverage'.
Applicants who have the coverage specified above, but whose insurance requires a
copayment and/or deductible will also be considered to have equivalent coverage.
This will apply where copayments and/or payments are consistent with industry
standards. These are:
- Major medical policies underwritten by Article 43 Corporations and
major commercial carriers with a copayment of 20 percent or less per
visit/service.
Page 12
- copayments for office and physicians visits are $10.00 or less.
- Deductibles are equal to or less that $250 per person per year.
Coverage above the cost of the above industry standards, will not be considered
"Equivalent Coverage," and the applicant will be eligible for coverage under
Child Health Plus. "Limited benefit policies" which pay a fixed dollar amount
per episode of care (regardless of the cost of the medical care) are not
considered equivalent health insurance for determining eligibility for
enrollment in the Child Health Plus program.
VII. ENROLLMENT ISSUES
Many insurers have encountered situations where children are not living
with a parent or legal guardian. In order to eliminate barriers for
enrollment of those children not residing with their parents, DOH is
requesting that insurers permit enrollment of eligible children by
"responsible adults" other than a parent or legal guardian. In these
instances, insurers may request "responsible adults" to furnish written
permission (from the parent or legal guardian) which authorizes the
rendering of health care services. However, this is not a mandatory
requirement for enrollment.
Page 13
VIII. CHILD HEALTH PLUS/CHILD INFORMATION FORM
The purpose of the "Child Health Plus/Child Information Form" is to
capture information from applicants on previous health status,
utilization patterns, and demographic data. All insurers are required to
distribute the "Child Health Insurance/Child Information Form" at the time
of the enrollment application encounter. The completion of the form by
applicants is not a mandatory part of the application or a prerequisite
for enrollment. However, the form must be distributed to all applicants,
and to the extent it is completed by the applicant, collected by the
insurer at the time of application or to be forwarded directly to the
Department by the applicant at a later time. The forms should be batched
and returned to the Department in accordance with instructions provided to
insurers. Insurers should strongly encourage all applicants to complete
this form.
IX. ANNUAL RECERTIFICATION OF CHILD HEALTH PLUS ELIGIBILITY FOR COVERAGE
In accordance with statute, recertification on an annual basis is required
for continued enrollment in the program. Insurers have requested
guidelines regarding the timing which should be used for recertification
of eligibility for coverage under Child Health Plus. Insurers may
recertify all enrollees on the same day, e.g. first of the year or
recertify each child on the anniversary date of his/her enrollment.
Page 14
X. CONVERSION
Legislation requires insurers to provide conversion when enrollees age out
of the program and also when the program terminates under statute on
December 31, 1993, unless extended.
The benefits offered under the conversion policies need not be equivalent
to the coverage provided under Child Health Plus. The insurers may offer
conversion through their existing policies. The Departments of Health and
Insurance are continuing to investigate options for Child Health Plus
insurers who need conversion coverage.
Enrollees who relocate to another part of the State should be referred by
their current Child Health Plus insurer to the Child Health Plus insurer
in the new area. Insurers are not responsible for providing conversion
when an enrollee moves out of the State.
Page 15
Appendix II
in effect 12/31/93
------------------
[ILLEGIBLE]
"DRAFT" 1/16/92
CHILD HEALTH PLUS
AFFIDAVIT OF SELF INCOME DECLARATION
NAME: ________________________________________ PHONE: _________________________
ADDRESS: _______________________________________________________________________
FAMILY INCOME
Annual $________________ Monthly $__________________
BiWeekly $________________ Weekly $__________________
Other (specify) $________________
ALL APPLICANTS MUST READ AND SIGN THE FOLLOWING IN ORDER TO BE CONSIDERED
FOR ELIGIBILITY UNDER SELF-DECLARATION OR INCOME FOR THE CHILD HEALTH PLUS
PROGRAM:
I HEREBY CERTIFY that I have no means for documenting the above cash
income and that all of the above information's true and correct. I
understand that this information is being given in connection with
the receipt of Child Health Plus services. I understand that program
officials may verify information on this form. I understand that
deliberate misrepresentation may subject me to repayment of benefits
received and prosecution under applicable State statutes.
_______________________________________ ___________________
SIGNATURE DATE
LOCAL AGENCY USE ONLY:
APPROVED: ______________________________ DISAPPROVED: _______________________
DATE DATE
CHILD HEALTH INSURANCE REPRESENTATIVE:
______________________________________ ________________________
SIGNATURE DATE
[ILLEGIBLE]
[ILLEGIBLE] STATE DEPARTMENT OF HEALTH CHILD HEALTH PLUS
[ILLEGIBLE] community Health Insurance ATTESTATION OF SELF-DECLARATION
and Finance Systems OF INCOME
INSTRUCTIONS Complete this form ONLY if you have no other proof of family
income. Return the completed form to the insurer where you sent
your Child Health Plus application.
Name(s)of Children Applying for Child Health Plus
1 _____________________________________ 4 _____________________________________
2 _____________________________________ 5 _____________________________________
3 _____________________________________ 6 _____________________________________
Name of adult making application
_______________________________________ _____________________________________
street Apt. or PO Box
Address
________________________________________________________________________________
city state zip
________________________________________________________________________________
Relationship Telephone Number
to children (including area code) ( )
_______________________________________ _____________________________________
FAMILY INCOME
Include all income from all members
living in the household. Enter the amount
of money received by the payment source
and the time period in which it is/was
received. Year income received
SOURCE OF INCOME YEARLY MONTHLY EVERY TWO WEEKS WEEKLY
- ---------------- ------ ------- --------------- ------
Program(s) (Example: Cash
assistance, SSI,
unemployment, disability)
[ILLEGIBLE] $_______ $_________ $________________ $______
[ILLEGIBLE] _______ _________ ________________ ______
[ILLEGIBLE] names) ________ __________ _________________ _______
Wages/Salary ________ __________ _________________ _______
Tips/Gratuities ________ __________ _________________ _______
Commissions ________ __________ _________________ _______
Income from self-employment ________ __________ _________________ _______
Contributions/gifts from
relatives or friends ________ __________ _________________ _______
Support payments ________ __________ _________________ _______
Income from rental property ________ __________ _________________ _______
Interest/dividends ________ __________ _________________ _______
Social Security ________ __________ _________________ _______
Pension (public or private) ________ __________ _________________ _______
Anything else for which money
is received without providing
goods or services ________ __________ _________________ _______
TOTAL ________ __________ _________________ _______
ALL APPLICANTS MUST READ AND SIGN THE FOLLOWING STATEMENT IN ORDER TO BE
CONSIDERED FOR ELIGIBILITY UNDER SELF-DECLARATION OF INCOME FOR THE CHILD HEALTH
PLUS PROGRAM:
I hereby certify that I have no means of proving or documenting the above cash
income and that all of the above information is true and correct. I understand
that this information is being given in connection with application to the Child
Health Plus program. I understand that program officials (Insurer or State) may
verify information on this form. I understand that deliberate misrepresentation
may subject me to repayment of any benefits received under the Child Health
Plus program and for prosecution under applicable State statutes.
____________________________________________ ______/______/_______
Signature of Adult Making Application Date Signed
INSURER USE ONLY Child Health Plus Insurer Represenative:
Approved ____/____/_____
Date: _____/_____/______
Total
Annual Income _______________ Disapproved____/____/_____ Insurer: ____________________________
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-2
DATE April 1992
SUBJECT: I. NEW YORK STATE IMMUNIZATION GUIDELINES FOR HEALTH CARE
PROVIDERS
The New York State Immunization Guidelines for Health Care
Providers (Appendix I) have been revised. As you know, the
Child Health Plus benefit package specifies that the schedule
of immunizations for Child Health Plus enrollees follow the
immunization guidelines issued by the Department of Health.
The enclosed guidelines have been distributed by the Office of
Public Health to approximately 12,000 practicing physicians
including pediatricians, family physicians and other primary
care specialists. Thus, physicians within the Child Health
Plus provider network will also have received these materials.
Please direct any questions on the immunization schedules to
the Bureau of Immunization at (518) 473-4437.
II. 1992 FEDERAL POVERTY LEVELS
The enclosed 1992 Federal Poverty Levels (Appendix II) should
be used effective immediately to determine Child Health Plus
eligibility. Although these guidelines are provided at the net
and gross levels, as noted in the first Advisory Memorandum,
Child Health Plus insurers are to determine eligibility from
gross income levels.
III. DEPARTMENT OF SOCIAL SERVICES LOCAL COMMISSIONERS' MEMORANDUM
The Department of Social Services issued a Local Commissioners
Memorandum on Child Health Plus on February 24, 1992
explaining certain points about Child Health Plus and its
relationship with Medicaid. A copy is enclosed. Questions
pertaining to the NYSDSS memorandum should be directed to your
Child Health Plus program liaison.
CHILD HEALTH PLUS
1 / 92 Federal Poverty Levels
100% 133% 135%
Annual Monthly Annual Monthly Annual Monthly
1 $ 6,810 $ 568 $ 9,057 $ 755 $ 12,599 [ILLEGIBLE]
2 9,190 766 $ 12,223 [ILLEGIBLE] [ILLEGIBLE] [ILLEGIBLE]
3 11,570 964 $ 15,388 1,282 $ 21,405 [ILLEGIBLE]
4 13,950 1,163 $ 18,554 1,546 $ 25,808 2,151
5 16,330 1,361 $ 21,719 1,810 $ 30,211 2,518
6 18,710 1,559 $ 24,884 2,074 $ 34,614 2,884
7 21,090 1,758 $ 28,050 2,337 $ 39,017 3,251
8 23,470 1,956 $ 31,215 2,601 $ 43,420 3,618
Extra Person:
2,380 198 $ 3,165 264 $ 4,403 367
Note: If the above chart represents net poverty levels then the chart below
reflects gross poverty levels (net x 1.2=gross).
120% 160% 222%
Annual Monthly Annual Monthly Annual Monthly
1 $ 8,172 $ 681 $ 10,869 $ 906 $ 15,118 $ 1,260
2 11,028 919 14,667 1,222 20,402 1,700
3 13,884 1,157 [ILLEGIBLE] 1,539 25,685 2,140
4 16,740 1,395 [ILLEGIBLE] 1,855 32,969 2,581
5 19.596 1,633 [ILLEGIBLE] 2,172 36,253 3,021
6 22,452 1,871 29,861 2,488 [ILLEGIBLE] 3,461
7 25,308 2,109 33,660 2,805 46,320 3,902
8 28,164 2,347 37,458 3,122 52,103 4,342
Extra Person:
2,856 238 3,798 317 5,284 [ILLEGIBLE]
LOCAL COMMISSIONERS MEMORANDUM
DSS-4037 [ILLEGIBLE] (Rev. 9/89)
Transmittal No: 92 LCM-38
Date: February 24, 1992
Division: Medical Assistance
TO: Local District Commissioners
SUBJECT: CHILD HEALTH PLUS (CHP) Insurance Program
ATTACHMENTS: Suggested letter to CHP providers: Attachment 1 (on-line)
CHILD HEALTH PLUS Poster: Attachment 2 (not available on-
line)
The Department has received questions relating to the Child Health Plus (CHP)
program. Many CHP questions were answered in Informational Letter 91 INF-71.
This letter will respond to additional questions from the local districts.
Question 1: Administrative Directive 91 ADM-18 notes that the CHP subsidy
must stop when the Medical Assistance (MA) case includes a CHP recipient.
In Section IV.A., the letter reads as follows:
The social services district must contact the [ILLEGIBLE] [CHP]
contract agency to inform it that MA eligibility has been
established.
Within this context, how must the district contact the plan?
Response 1: The district should write a letter to the plan so that the
plan has official notification of MA eligibility for that child before the
plan takes action to drop CHP coverage. This written notification should
detail the child's period of MA eligibility. Generally, a plan will not
accept a phone call by the district as being sufficient, and will require
a letter. In turn, the CHP insurer will disenroll the child from CHP.
Attachment 1 is a suggested letter to CHP providers.
Date February 24, 1992
TRANS. No. 92 LCM-38 Page No. 2
Question 2: Administrative Directive 91 ADM-18, Section [ILLEGIBLE]
[ILLEGIBLE] local social services districts to provide notice of CHP
[ILLEGIBLE] [ILLEGIBLE] denial/closing action affects a child under 13
years of age. The suggested letter was Attachment III to that
Administrative [ILLEGIBLE]. Is there a statewide hotline number that could
be added to the suggested letter?
Response 2: Yes. The Public Policy and Education Fund of New York has a
contract with the New York State Department of Health for CHP outreach.
Their statewide hotline number, which should be added to the letter from
local social services districts, follows:
1-800-698-4KIDS
The CHILD HEALTH PLUS poster, Attachment 2, was developed by the Public
Policy and Education Fund. Staff from the Fund will contact local social
services districts to discuss the interface of CHP with the MA program and
to supply outreach material.
It should be noted that a separate contractor has been selected for CHP
outreach in New York City. The Medical and Health Research Association of
New York City will contact the New York City Human Resources
Administration for CHP outreach.
Question 3: The New York State Department of Health pays a monthly subsidy
to the CHP insurance carrier. The annual subsidies were detailed in 91
LCM-136. Additionally, certain clients are required to pay a $25 fee per
child per year, up to a total of $100 per household per year. How should
these payments/bills be handled for spenddown?
Response 3: The monthly subsidy amount paid to the insurance carrier
by the New York State Department of Health (NYSDOH) can be used to reduce
the monthly spenddown.
For any CHP fee billed to the MA household, as with other health
insurance premiums incurred by the individual or family, treat as a
deduction from countable income. Therefore, the client's share of premium
costs, as well as the subsidy, can be used to reduce the monthly
spenddown.
NOTE: Please remember that persons receiving MA are not eligible for CHP.
Since the household can choose who may apply for MA, please remember that
applicants/recipients can include or exclude persons from the MA
household. Therefore, if a CHP recipient is not included in the MA
application, the CHP coverage remains uninterrupted. The amount of the
NYSDOH subsidy and any household premiums would reduce the monthly
spenddown for the rest of the family. See Administrative Directive 91
ADM-18 for details.
Date February 24, 1992
Trans. No. 92 LCM-38 Page No. 3
Question 4: A 5 person household applied for MA and was [ILLEGIBLE]
accepted as a spenddown case. The monthly spenddown [ILLEGIBLE]
[ILLEGIBLE] household has not met the spenddown requirement in any
[ILLEGIBLE] [ILLEGIBLE] Therefore, the Common Benefit Identification Card
will not be valid, since coverage has not been authorized through
[ILLEGIBLE]. The [ILLEGIBLE] appears income-eligible for CHP. Can the
children in the household under age 13 apply for and get CHP?
Response 4: Yes. This household should apply for CHP. The children are
neither eligible for nor in receipt of MA at this time. Therefore, the
household can apply for and receive CHP for appropriate children if
otherwise eligible. Remember that the CHP subsidy and any premium payments
are used to reduce the excess income of other family members.
Question 5: Is the phone number for GHI correct as given in 91 LCM-136?
Response 5: No. The correct phone number for GHI is 212-960-6655.
***
If there are questions on spenddown, please call Mr. Joseph Kudner on 1-800-
342-3715, extension 3-5509. For questions on CHP, call Mr. John Harwick on
extension 3-5878.
_________________________________
Jo-Ann A. Costantino
Deputy Commissioner
Division of Medical Assistance
ATTACHMENT 1
Suggested letter to CHP when child is on Medicaid and CHP
Dear ______________________:
NAME OF CHILD:
ADDRESS:
SOCIAL SEC.#:
PHONE:
DATES OF ELIGIBILITY
FOR MEDICAL ASSISTANCE:
(from-to}
We have been advised that the above-named child is currently receiving
Child Health Plus from your organization. In accord with Chapters 922 and 923 of
the Laws of 1990, we are informing you that this child is enrolled in the
Medical Assistance program for the time period noted above. Please call (staff
name) on (phone number) if there are any questions.
Sincerely,
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-11
DATE February 1994
SUBJECT: Child Health Plus - Supplemental Form Data Analysis
A self-administered, optional reporting tool was developed by the
Department to collect data to learn some descriptive information about the
population of Child Health Plus applicants. The report was used to collect
data from applicants from the inception of the program through January,
1993. The attached report is an analyses of the collected data.
A few notes contained in the report deserve highlighting:
- The majority of the Child Health Plus population are eligible
due to loss of insurance from loss of employment, or Medicaid
eligibility;
- Most report themselves as in good health;
- The average income of applicants is approximately $16,000,
and;
- The population represents a fairly even distribution by age.
The great majority of Child Health Plus members are white and
english speaking.
Attachment
CHILD HEALTH PLUS
SUPPLEMENTAL FORM DATA ANALYSIS
PLAN INCEPTION THROUGH JANUARY, 1993
New York State Department of Health
Bureau of Community Health Insurance
and Finance Systems
November, 1993
OVERVIEW
The Supplemental Form was an optional data collection tool developed by
the Department to collect data in a uniform manner from Child Health Plus
applicants on demographic, marketing, prior utilization, access, and health
status elements. All but one insurer submitted forms. The form went into use at
the inception of the program and was collected until April, 1993. At that time
the insurers were instructed to stop including the form with the enrollment
packet, but to mail in any forms which they received from previous applicants.
To date, approximately 30,000 forms have been received and entered. The data in
the following tables and graphs is based upon 26,000 forms collected from plan
inception through January, 1993.
While some plans submitted one form per family, others submitted a form
for each child applicant. The results include applicants to Child Health Plus,
not just those who were accepted. Therefore, the number of forms received does
not equal the number of children enrolled. In a few instances, more forms were
received than the insurer enrolled. Other insurers submitted forms for just
those that were accepted into the program. In addition, the data is
self-reported and may not reflect actual use. Not all respondents answered every
question on the form. The results were tallied by completed question and not
completed form. The graphs only include those applicants who answered the
questions.
When more than one answer was given in questions five and six regarding
locus of care, the lowest level of care was entered. For question four, how
coverage was lost, if left/lost job was checked with other items, the question
was coded for left/lost job. For question seven, some people checked "has no
problem" and wrote in: don't need an appointment for the emergency room.If more
than one language was checked for question eight and one was English, the
question was coded for English. Also, if more than one race/ethnicity was
checked for question nine, the question was coded, as other. In many instances
the items to be checked by the insurer in the FOR OFFICE ONLY section were left
blank.
SUMMARY OF FINDINGS
- Most of the applicants learned of Child Health Plus through a
friend/relative.
- Two-thirds to 90 percent of applicants did not have health insurance
and most lost their coverage because parent lost/left their job.
- Most of the applicants had a source of care for an injury or illness
(physician office, clinic, health center).
- Three-fourths of the applicants reported no problem getting access
to care.
- Close to 90 percent of the applicants spoke English, with Spanish
and Chinese being spoken in New York City in two plans.
- Almost three-fourths of the applicants report being
white/non-hispanic
- Less than 10 percent of applicants were under the age of 1 year with
the remainder fairly evenly split between the age categories of
1 - 5 and 6 - 12.
- The male and female applicants were evenly split.
- Approximately 30 percent of the applicants report having an ER visit
in the 12 months prior to application with the average number of
visits 1.8 of those report having visits.
- Less than five percent of applicants reported having an overnight
hospital admission in the 12 months prior to application; however
those who did report admissions averaged 1.5 admissions.
- Over 85 percent of applicants reported having visits to a clinic,
doctor or health center in the 12 months prior to application. Of
those who reported visits, the average number was 3.8 visits.
- The majority of applicants reported their health status as good or
better. Less than one-half of one percent reported their health
status as poor.
- The average income for applicants reporting income is $16,189 per
family.
- The average number of adults per family is about 2, the average
number of children less than 13 per family is about 2, the average
number of children older than 13 is about 1.5 with the overall
average family size about 4.
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Health Economics CHILD HEALTH PLUS: CHILD INFORMATION
Name of health plan/insurer to which you are applying
_____________________________________________________
[CHILD HEALTH PLUS LOGO]
Write in the month, day and year you filled out the
application form for Child Health Plus (example,
January 14, 1991).
_____________________________________________________
INSTRUCTIONS
Child Health Plus is a new program sponsored by this health plan and subsidized
by New York Slate. The New York State Department of Health is asking the
following questions to find out about the health needs of children who apply for
Child Health Plus and to serve better the needs of children who enroll. Please
answer these questions as completely as you can. YOUR ANSWERS WILL NOT AFFECT
YOUR CHILD(REN)'S ENROLLMENT IN CHILD HEALTH PLUS. DO NOT PUT YOUR NAME ON THIS
FORM. If you have any questions about this form please call (518) 474-5050. Give
the completed form back to the health plan/insurer to which you are applying.
Please print your answers in ink.
1. Enter the child(ren)'s zip code (home address) [ ]
2. Place an X in front of all the ways that you found out about Child Health
Plus.
[ ] Material received in the mail [ ] Television [ ] Radio
[ ] Community organization [ ] Through the child(ren)'s school [ ] Newspaper
[ ] Friend/relative [ ] Social services/Medicaid [ ] Health care provider (doctor, nurse, clinic)
[ ] Other (specify)________________________________________
3. What kind of health insurance does/do the child(ren) have now?
[ ] No insurance [ ] Other insurance (specify)
[ ] Medicaid ______________________________________________________________________
4. If the child(ren) were covered by health insurance in the past, how did
they lose that coverage?
[ ] Parent left/lost his/her job [ ] Insurance was cancelled [ ] Other (specify)
[ ] Could not afford premium [ ] Lost Medicaid eligibility _______________________________
5. Where does(do) the child(ren) usually go for routine preventive care
(physicals, immunizations)?
[ ] Emergency room [ ] Clinic [ ] Do not receive care
[ ] Doctor's office [ ] Health center [ ] Other (specify)
_______________________________
6. Where does(do) the child(ren) usually go when they need care for an injury
or illness?
[ ] Emergency room [ ] Clinic [ ] Do not receive care
[ ] Doctor's office [ ] Health center [ ] Other (specify)
_______________________________
7. The last time the child(ren) needed to get health care (illness, injury,
physical), the following was true: Place an X in the box in front of the
best answer.
[ ] Had no problem getting an appointment [ ] Was not able to get an appointment
[ ] Had to wait too long to get an appointment [ ] Did not try to get an appointment
8. Place an X in the box in front of the language the child(ren) speaks most
[ILLEGIBLE] [ILLEGIBLE] at home.
[ ] English [ ] French [ ] Chinese [ ] Hebrew
[ ] Spanish [ ] Italian [ ] Korean [ ] Other (specify)
[ ] Japanese _______________________________
DOH-3403(10/91)
p 1 of 2
NUMBER OF RECORDS PER PLAN
CHILD HEALTH PLUS SUPPLEMENTAL FORMS
Through January, 1993
[PIE CHART]
PERCENT OF
JANUARY ENROLLMENT
BY PLAN
TBHP .84
HCP 7.8
CPHSP 2.4
HIP 10.2
GHI 3.3
EBCBS 31.2
BS NENY 2.5
BCBS CNY 8.8
BCBS UW 8.5
BCBS WNY 7.1
BCBSA 8.2
WPHSP 3.6
CHP 5.7
SOURCES OF REFERRAL TO CHILD HEALTH PLUS
AS REPORTED ON THE SUPPLEMENTAL FORM FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
SOURCES OF REFERRAL TO CHILD HEALTH PLUS
AS REPORTED ON THE SUPPLEMENTAL FORM BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
HEALTH INSURANCE COVERAGE HELD AT TIME OF APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
HEALTH INSURANCE COVERAGE HELD AT TIME OF APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
REASONS CHILDREN LOST HEALTH INSURANCE COVERAGE
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
REASON CHILDREN LOST HEALTH INSURANCE COVERAGE
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
SOURCES OF ROUTINE PREVENTIVE CARE PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
SOURCES OF ROUTINE PREVENTIVE CARE PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
SOURCES OF CARE FOR INJURY OR ILLNESS PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
SOURCES OF CARE FOR INJURY OR ILLNESS PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
ACCESS TO HEALTH CARE PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
ACCESS TO HEALTH CARE PRIOR TO APPLICATION
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
LANGUAGE SPOKEN MOST FREQUENTLY IN THE HOME
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
LANGUAGE SPOKEN MOST FREQUENTLY IN THE HOME
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
RACE/ETHNICITY
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
RACE/ETHNICITY
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
AGE AT LAST BIRTHDAY BY AGE CATEGORY
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
AGE AT LAST BIRTHDAY BY AGE CATEGORY
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS BY PLAN
Through, January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
SEX OF CHILD HEALTH PLUS APPLICANTS
As Reported Through January, 1993 For All Plans
[PIE CHART]
[PLOT POINTS TO COME]
SEX OF CHILD HEALTH PLUS APPLICANTS
As Reported Through January, 1993 By Plan
[BAR CHART]
[PLOT POINTS TO COME]
Overall average number of visits per child of those reporting visits-1.8
Overall percent of children reporting emergency room visits-29.02%
NUMBER OF EMERGENCY ROOM VISITS IN THE 12 MONTHS
PRIOR TO CHILD HEALTH PLUS APPLICATION
AS REPORTED ON THE SUPPLEMENTAL FORM BY PLAN
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
- - Percentage of Children Reporting Emergency Room Visits
- - Average Number of Visits of Those Reporting Visits
Overall average number of hospital admissions per child of those reporting
admissions-1.5
Overall percent of children reporting hospital admissions-4.14%
OVERNIGHT HOSPITAL ADMISSIONS IN THE 12 MONTHS
PRIOR TO CHILD HEALTH PLUS APPLICATION
AS REPORTED ON THE SUPPLEMENTAL FORM BY PLAN
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
- - Percent of Children Reporting Over night Admissions
- - Average Number of Admissions for Those Reporting Admissions
Overall average number of visits per child of those reporting visits-3.8
Overall percent of children reporting visits-85.7%
VISITS TO A CLINIC, DOCTOR OR HEALTH CENTER
IN THE 12 MONTHS PRIOR TO CHILD HEALTH PLUS APPLICATION
BY PLAN
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
- - Percentage of Children Reporting Visits to Clinic, Doctor or Health Center
- - Average Number of Visits of Those Reporting Visits
GENERAL HEALTH STATUS OF CHILD HEALTH PLUS APPLICANTS
AS REPORTED ON THE SUPPLEMENTAL FORM FOR ALL PLANS
Through January, 1993
[PIE CHART]
[PLOT POINTS TO COME]
GENERAL HEALTH STATUS OF CHILD HEALTH PLUS APPLICANTS
AS REPORTED ON THE SUPPLEMENTAL FORM BY PLAN
Through January, 1993
[BAR CHART]
[PLOT POINTS TO COME]
Overall average income of those reporting income-$16,189
AVERAGE FAMILY INCOME OF THOSE REPORTING INCOME
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS
Through January, 1993
[LINE GRAPH]
[PLOT POINTS TO COME]
Overall average number of adults per family-1.8
Overall average number of children greater than 13 per family-1.4
Overall average number of children less than 13 per family-2.1
Overall average number of total family members 4.1
AVERAGE FAMILY SIZE BY AGE CATEGORY BY PLAN
AS REPORTED BY CHILD HEALTH PLUS APPLICANTS
Through January, 1993
[LINE GRAPH]
[PLOT POINTS TO COME]
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-12
DATE 5/1/94
SUBJECT: Definition of Equivalent Coverage
AMENDED POLICY - EFFECTIVE 7/1/94
Effective 7/1/94, the following policy will supersede that contained
in "Child Health Plus Advisory Memorandum #A-1, dated February 7, 1992,
Item VI., pages 12 and 13, with respect to the Definition of Equivalent
Coverage:"
"VI. Definition of Equivalent Coverage
When determining whether a child should be deemed as having
"equivalent coverage," the following guidelines should be followed
effective 7/1/94. This policy will be used to determine eligibility for
new and all existing enrollees who recertify for coverage after 7/1/94:
-Coverage for primary and preventive health care services including
diagnostic and treatment of illness and injury provided in a physician's
office or other outpatient site(s) which is consistent with the Child
Health Plus benefit package is considered equivalent coverage, regardless
of whether or not there is a co-payment for such coverage. If however, a
policy has a deductible of greater than $750.00, per person per year, they
will be eligible for enrollment in Child Health Plus.
Insurance plans which do not include prescription drugs or do not
provide benefits consistent with the Child Health Plus Benefit package as
approved by the New York State Insurance Department, but meet the above
definition, will be deemed to offer "equivalent coverage".
"Limited Benefits Policies" which pay a fixed dollar per episode of
care (regardless of the cost of the medical care provided) are not
considered equivalent health insurance for determining eligibility for
enrollment in the Child Health Plus program.
NEW YORK STATE DEPARTMENT OF HEALTH CHILD HEALTH PLUS
CHILD HEALTH PLUS MEDICAID REFERRAL
Complete this form to help get your children into the best program available for
them. Print all answers clearly in ink. Return this form with your Child Health
Plus application. Answer all questions as completely as you can.
I. IDENTIFICATION OF APPLICANTS
a. Name of person completing form ______________________________________________
Street address ______________________________________________________________
City _________________________ State ___________________ Zip _____________
Telephone number Home (_______) _________ Work (__________)_____________
Relationship to child for whom making application _______________ Birthdate
b. Name of Child applicant(s) 1. _____________________________ _______________
2. _____________________________ _______________
3. _____________________________ _______________
_
4. _____________________________ _______________
5. _____________________________ _______________
6. _____________________________ _______________
Child(ren)'s street address _________________________________________________
City _________________________ State _______________________ Zip ____________
Telephone number Home (______) ____________________
c. Name of child's parent/legal guardian _______________________________________
(if different from person completing form)
Street address ______________________________________________________________
City _______________________ State ______________________ Zip ____________
Telephone number Home (_______)________________ Work (_______)____________
II. MEDICAID AND HEALTH INSURANCE
a. Does applicant(s) currently have Medicaid coverage? Yes [ ] No [ ]
b. If Yes, when will Medicaid coverage stop? _________________________________
c. Has applicant ever received or applied for Medicaid or
assistance? Yes [ ] No [ ]
d. If child is covered by other health insurance, how much is paid for
premiums per month? _______________________________________________________
III. INCOME
a. List all the income received by family members living in your household.
Be sure to include all sources of gross income (before taxes) such as
wages, dividends and interest, AFDC, SSI, annuities, pension, disability,
child support, alimony, cash gifts, and other unearned income.
f. Do you have child
b. Name of person(s) d. How often is money care costs?
working or receiving c. Who provides the received? (Weekly, How much? (weekly,
money. (Attach extra money? (Employer, every two weeks, every two weeks,
sheet if necessary) program or person) monthly) e. What amount? monthly)
- -------------------- ------------------- --------------------- --------------- --------------------
1. Father ___________________ _____________________ _______________ ____________________
2. Mother ___________________ _____________________ _______________ ____________________
3. ___________________ _____________________ _______________ ____________________
4. ___________________ _____________________ _______________ ____________________
5. ___________________ _____________________ _______________ ____________________
g. Total (1+2+3+4+5) ============= ==============
___________________ _____________________ _______________ ____________________
IV. HOUSEHOLD DESCRIPTION
a. Family Size
1. Mother ____________
2. Father ____________
3. Number of children under 21 in home ___________
4. Total _________
V. CERTIFICATION
I certify that all information is correct to the best of my knowledge.
Signature of person who completed the form __________________________________
Relationship to applicant(s)_________________ Date____/____/_________
DOH-3743(8/93)
p. 2 of 2
FOR OFFICE USE ONLY
VI. DEDUCTIONS (MONTHLY)
a. Household's monthly gross income _____________________________
Total (from III. column e, line g) (convert to monthly equivalent, if
needed.)
1. $90 from earned income only _______________________________
(per working parent)
2. Child Care expenses from employment (if applicable)______________________
($175.00 maximum per child age 2 or oven $200.00 maximum per child under
age 2) (from III. column f, line g) (convert to monthly equivalent if
needed)
3. $50 from child support only _________________________
(per household)
4. Health insurance premiums paid ______________________
(from II. d.)
b. Total Deductions (1+2+3+4) ______________________________
c. Net Monthly Income (a-b) ________________________________
VII. MONTHLY INCOME LEVELS (EFFECTIVE 7/1/93)
Add for each
Family Size 1 2 3 4 5 6 7 8 additional person
- ----------- ---- ---- ---- ---- ---- ---- ---- ---- -----------------
100% FPL
Children born
after 9-30-83,
but younger
than age 19 580 785 990 1195 1400 1605 1810 2015 205
133% FPL
Children under
age 6 772 1045 1317 1590 1863 2135 2408 2681 272
185% FPL
Children under
age 1 1074 1453 1833 2212 2591 2970 3350 3729 379
VIII. REFERRAL
Referral (Check one 1. Yes [ ] No [ ] Referral Date __/____/_______
for each child 2. Yes [ ] No [ ]
applicant) 3. Yes [ ] No [ ] Review's initials ___________
4. Yes [ ] No [ ]
5. Yes [ ] No [ ]
6. Yes [ ] No [ ]
DOH-3743(8/93)
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-14
DATE 5/16/94
SUBJECT: I. Requirement to maintain list of 13 and 14 year old individuals
who have aged out of the Child Health Plus program.
II. Medicaid referrals.
I. Due to pending legislation concerning the increase in age
eligibility (13 and 14 year olds) for enrollment in the Child Health
Plus program, it is important that an accurate record of children
currently aging out of the program be kept.
The following procedure should be used as a means of tracking all
Child Health Plus enrollees who age out of the program retroactively
from January 1, 1994.
For those plans which do not already have a system to track aged out
individuals, a database should be maintained with (at a minimum) the
following information:
Policy #
Name
Address
City
State
Zip Code
Phone #
Effective date (the enrollee aged out of the program)
Date of Birth
Social Security Number
Name of Responsible Adult (Address and Phone Number if not same as
above)
II. Effective immediately: If your plan is not already doing so, please
begin a process to refer potentially Medicaid eligible Child Health
Plus enrollees, who are going to age out of the Child Health
program, to Medicaid. To help you determine potentially eligible
children, enclosed is a copy of the Child Health Plus Medicaid
Referral form. Medicaid brochures may be obtained by calling John
Harwick of DSS at (518) 432-2505. The Medicaid brochure is available
in English and Spanish. Please request Medicaid brochure number 16
for the English language version. For the Spanish language version,
please request Medicaid brochure form number 1615S.
NEW YORK STATE DEPARTMENT OF HEALTH CHILD HEALTH PLUS
CHILD HEALTH PLUS MEDICAID REFERRAL
Complete this form to help get your children into the best program available
for them. Print all answers clearly in ink. Return this form with your Child
Health Plus application. Answer all questions as completely as you can.
I. IDENTIFICATION OF APPLICANTS
a. Name of person completing form _____________________________________________
Street address _____________________________________________________________
City ____________________ State _________________ Zip ____________________
Telephone number Home (______)_____________ Work (______)________________
Relationship to child for whom making application ________________ Birthdate
b. Name of Child applicant(s) 1. _____________________ ______________________
2. _____________________ ______________________
3. _____________________ ______________________
4. _____________________ ______________________
5. _____________________ ______________________
6. _____________________ ______________________
Child(ren)'s street address _________________________________________________
City ____________________ State __________________ Zip ____________________
Telephone number Home (_______)__________________
c. Name of child's parent/legal guardian _______________________________________
(If different from person completing form)
Street address ______________________________________________________________
City __________________________ State _________________ Zip _______________
Telephone number Home (______)______________ Work (_______)_______________
II. MEDICAID AND HEALTH INSURANCE
a. Does applicant(s) currently have Medicaid coverage? Yes [ ] No [ ]
b. If Yes, when will Medicaid coverage stop?________________________________
c. Has applicant ever received or applied for Medicaid or assistance?
Yes [ ] No [ ]
d. If child is covered by other health insurance, how much is paid for
premiums per month?______________________________________________________
DOH-3743(8/93)
p 1 of 2
III. INCOME
a. List all the income received by family members living in your household.
Be sure to include all sources of gross income (before taxes) such as
wages, dividends and interest, AFDC, SSI, annuities, pension, disability,
child support, alimony, cash gifts, and other unearned income.
f. Do you have child
b. Name of person(s) d. How often is money care costs?
working or receiving c. Who provides the received? (Weekly, How much? (weekly,
money. (Attach extra money? (Employer, every two weeks, every two weeks,
sheet if necessary) program or person) monthly) e. What amount? monthly)
- ------------------- ------------------ -------- --------------- --------
1. Father ___________________ _____________________ _______________ ____________________
2. Mother ___________________ _____________________ _______________ ____________________
3. ___________________ _____________________ _______________ ____________________
4. ___________________ _____________________ _______________ ____________________
5. ___________________ _____________________ _______________ ____________________
g. Total (1+2+3+4+5) ============ =============
___________________ _____________________ _______________ ____________________
IV. HOUSEHOLD DESCRIPTION
a. Family Size
1. Mother _________
2. Father _________
3. Number of children under 21 in home ________________
4. Total _____________
V. CERTIFICATION
I certify that all information is correct to the best of my knowledge.
Signature of person who completed the form _________________________________
Relationship to applicant(s)_____________________ Date ____/_____/_________
DOH-3743(8/93)
p. 2 of 2
FOR OFFICE USE ONLY
VI. DEDUCTIONS (MONTHLY)
a. Household's monthly gross income ________________________
Total (from III. column e, line g) (convert to monthly equivalent, if
needed.)
1. $90 from earned income only _____________________________________________
(per working parent)
2. Child Care expenses from employment (if applicable) _____________________
($175.00 maximum per child age 2 or over $200.00 maximum per child under
age 2) (from III. column f, line g) (convert to monthly equivalent if
needed)
3. $50 from child support only _____________________________________________
(per household)
4. Health insurance premiums paid __________________________________________
(from II. d.)
b. Total Deductions (1+2+3+4) __________________________________________________
c. Net Monthly Income (a-b) ____________________________________________________
VII. MONTHLY INCOME LEVELS (EFFECTIVE 7/1/93)
Add for each
Family Size 1 2 3 4 5 6 7 8 additional person
- ----------- --- ----- ---- ---- ----- ---- ---- ---- -----------------
100% FPL
Children born
after 9-30-83,
but younger
than age 19 580 785 990 1195 1400 1605 1810 2015 205
133% FPL
Children under
age 6 772 1045 1317 1590 1863 2135 2408 2681 272
185% FPL
Children under
age 1 1074 1453 1833 2212 2591 2970 3350 3729 379
VIII. REFERRAL
Referral (Check one 1. Yes [ ] No [ ] Referral date___/____/______
for each child 2. Yes [ ] No [ ]
applicant) 3. Yes [ ] No [ ] Review's initials __________
4. Yes [ ] No [ ]
5. Yes [ ] No [ ]
6. Yes [ ] No [ ]
DOH-3743(8/93)
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
HEALTH PLAN FOR KIDS
ADVISORY MEMORANDUM NUMBER A-15
DATE June, 1994
SUBJECT: Procedure for Child Health Plus Enrollees Enrolled With More Than One
Insurer
As you are aware, "dual enrollment" (ie: Child Health Plus enrollees with more
than one insurer) has been an ongoing coordination and billing issue. In
response, the following procedure has been developed to streamline current
policy related to dual enrollment. This policy should be used by all Child
Health Plus insurers, and shall become effective immediately.
NYS DOH determines dual enrollment by a Child Health Plus enrollee by comparing
monthly billing files between each of the Plans.
The effective dates are compared to determine the first insurer enrolled. In
case of the same effective date, the first billing file received will be
considered first enrolled.
Once the first enrolled plan is determined, the second plan(s) will be notified
by DOH. Notification will be mailed within 5 business days of receipt of all
plans billing files for the month, directing all second plan(s) to disenroll the
child effective the first of the month following notification. The second
enrolled plan(s) should not bill DOH and will not receive payment from DOH for
the child's premium after that time.
The second plan(s) will notify the child's responsible adult that the child is
being disenrolled, the reason for disenrollment, and the effective date of
disenrollment.
In cases where the responsible adult wants to enroll the child with the second
plan instead of remaining with the first plan the child must be disenrolled from
the second plan until the following occurs:
- Responsible adult must notify first plan of decision to disenroll
child from that plan with a future effective date. Family should
indicate that the purpose for disenrollment is in order to enroll in
a different plan.
- The first plan must send written confirmation of disenrollment with
effective date of termination of coverage to the responsible adult.
- The responsible adult must submit a copy of the written [ILLEGIBLE]
of a disenrollment to the second plan before the child can be
re-enrolled in the second plan.
- The second plan can enroll the child upon receipt of confirmation of
disenrollment. The new effective date must not be prior to the
disenrollment date of the first plan and should be the first of the
month following date of disenrollment from the first plan to avoid
any lapse in coverage.
- The second plan must submit a copy of the confirmation of
disenrollment to the Department of Health/Child Health Plus Program
upon re-enrolling the child. This documentation must be received by
the Department prior to billing for premiums for the child.
If the child's name appears on subsequent billing files from the second plan
before the department receives from the second plan, the copy of confirmation of
disenrollment from the first plan, the monthly premium amount will automatically
be posted as a negative adjustment to the second insurer's billing file by the
Department.
If there is disagreement between insurers as to which insurer is first, NYS
DOH's determination is final.
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-16
DATE January 25, 1995
SUBJECT: Changes in Policies and/or Procedures Required by Chapter 731 of the
Laws of 1993, and Chapters 170 and 731 of the Laws of 1994.
I. Eligibility
II. Change in Status
III. Reporting
IV. Request for Income Verification by the Department of Taxation and
Finance
V. Eligibility Verficiations
VI. Pattern and Practice of Enrolling Ineligible Children
Attachments
1. Changes Needed to Current Application Forms
2. Report on Reasons for Denied Applicants and Disenrollments
I. ELIGIBILITY
A. Age - For the period of January 1, 1994 through December 31, 1995, in
order to be eligible for participation in the Child Health Plus program, the
child must be born on or after June 1, 1980 and must be under fifteen years of
age. Documentation supporting age must be maintained by the insurer.
B. Residency - Proof of residency is now a required element for
determining eligibility. Proof of residency shall be demonstrated by adequate
proof of a New York State street address. Adequate proof shall include but not
be limited to school records, utility bills or any mail addressed to the
individual which is postmarked. Documentation must be maintained by the insurer.
C. Equivalent Health Insurance - The responsible adult must attest to the
source and nature of any health care coverage the child is receiving. The
application must contain a section inquiring about any additional health
insurance. The application must contain a question (e.g. Does the child have any
other health insurance or Medicaid?) which must be answered yes or no. If this
question in answered yes, the insurer must maintain documentation of other
insurance.
D. Income Documentation - The most recently filed income tax return should
be submitted if available. Income statements from employers or paycheck stubs
may be used for income documentation if a tax return is not available. If the
family indicates income has changed since a tax return was filed or if
additional income is currently available to the child which is not documented on
an income tax return, additional income information must be submitted in order
to supplement the income tax return. The most recent form of income
documentation available which accurately represents the current financial status
of the family, should be used in order to determine eligibility. The
self-declaration of income form may only be used if no other means of income
documentation is available. Income documentation must be maintained by the
insurer.
E. Social Security Number - State law requires the collection of social
security account numbers for each parent and legally responsible adult who is a
member of the household and whose income is available to and being received by
or on behalf of the child. In accordance with legislation, social security
numbers must be reported on the application to the insurer if available.
Page 2
F. Medicaid Eligibility - In order to be eligible for participation in the
Child Health Plus program, the child must not be enrolled in Medicaid. If an
insurer discovers that a child enrolled in Child Health Plus is also enrolled in
Medicaid, the insurer must immediately disenroll that child from Child Health
Plus. This practice is known as the "transfer" of children who are eligible or
who become eligible for Medicaid. The existing Medicaid referral policy remains
in effect and documentation of such must be maintained by the insurer.
G. Income Eligibility - Consistent with previous Department policy, income
eligibility determinations should continue to be based upon gross household
income that is available to the child. Please note that, as stated above, social
security numbers and income tax returns may only be collected from parents and
legally responsible adults who are members of the household and whose income is
available to the child. Therefore, this information is not required to be
collected on individuals who have no legal or parental relationship with the
child. However, their income may continue to be used when determining
eligibility and the insurer must maintain income documentation. For example, if
a mother and her children are living with a boyfriend who helps financially
support the children but has no legal or parental relationship with the them,
his income may be counted in determining eligibility. However, his social
security number may not be collected by the insurer.
11. CHANGE IN STATUS
A. The responsible adult is obligated to report to the insurer any change
in status, such as residency, income, or other insurance, that may make the
child ineligible for participation in the program, within 60 days of such
change. It is the insurer's responsibility to review this information in order
to redetermine eligibility and to notify the family and the Commissioner or his
representative if the child is no longer eligible for subsidy, within 30 days of
receipt of this information. Documentation must be maintained by the insurer.
Page 3
III. REPORTING
A. Effective July 1, 1994, the insurer must report to the Department, on a
quarterly basis, the number of applicants and enrollees determined ineligible
for participation in the Child Health Plus program and the reasons for such
determination. This should include applicants initially determined ineligible,
those disenrolled at the close of the presumptive eligibility period, those
that are not recertified due to the fact that they are determined ineligible and
any other disenrollment which occurs at any point during the year. This report
must be received by the Department within 30 days after the close of the
quarter. The attached form should be used to report this information.
B. Effective July 1, 1994, enrollment data includes thirteen and fourteen
year olds who were born on or after June 1, 1980. A new category was added on
the monthly enrollment report for these children.
IV. REQUEST FOR INCOME VERIFICATION BY THE DEPARTMENT OF TAXATION AND FINANCE
This process is currently under development with the Department of
Taxation and Finance. Pending resolution of several outstanding issues
concerning what information may be collected for purposes of verifying income, a
policy will be instituted via an advisory memorandum.
V. ELIGIBILITY VERIFICATIONS
The Department will review, on an annual basis, eligibility verification
and recertification procedures by each insurer to insure appropriate enrollment
of children. This may include an annual review of a statistically valid sample
of cases from each insurer through site visits and/or desk audits to determine
adherence to enrollment policies and procedures, the verification would first
check that, based on the age, family size, residence status, insurance status,
and income reported on the application, the child was actually eligible for
subsidized enrollment. For applications with appropriate income levels, evidence
of Medicaid referral would be checked. In addition, the presence of required
documentation in support of the application would be checked.
Page 4
VI. PATTERN AND PRACTICE OF ENROLLING INELIGIBLE CHILDREN
If, when conducting a review of the insurer's eligibility process and
documentation, the Department discovers that some application records do not
have complete documentation attached or on their face appear invalid the
Department will identify such children for further review of eligibility by the
insurer.
If the number of children with incomplete applications or documentation
who are subsequently determined to be ineligible is significant, this may
constitute a pattern and practice of enrolling or recertifying children who are
ineligible. If this is determined, the insurer shall be required to repay, to
the Bad Debt and Charity Care Pool, all subsidy payments made on behalf of these
ineligible children. The insurer also may be subject to removal from the program
once all eligible children can be orderly transitioned to other insurers, if it
is established that a pattern and practice of enrolling or recertifying children
who are ineligible exists.
Improper enrollment based on a good faith reliance on documentation which
appears accurate on its face shall not constitute a pattern or practice of
enrolling or recertifying children who are ineligible and shall not subject the
insurer to repayment of premiums or removal from the program.
Page 5
ATTACHMENT I
CHILD HEALTH PLUS
CHANGES NEEDED TO CURRENT APPLICATION FORMS
1. ADDITION OF ATTESTATION/ACKNOWLEDGEMENT STATEMENT:
As required by New York State, I attest to the following statements:
- - I certify that all statements contained in this application are true and
accurate.
- - I hereby certify that I have provided complete and accurate information on
the source and nature of all health care coverage the child is receiving.
- - I understand that if the child becomes enrolled in Child Health Plus, it
is my responsibility to notify (insurer name), of any change which may
make the child ineligible for subsidized coverage in the Child Health Plus
program, including changes in income, residency or insurance coverage,
within 60 days.
- - I understand that I may be liable for any premiums paid on behalf of the
child which are a result of my willful misstatement of information on this
application or failure to report any subsequent changes in information
within 60 days of such change.
- - I further understand that my income may be subject to verification by the
Department of Taxation and Finance if (insurer name) has reasonable cause
to believe that the income information provided is false.
____________________________ ________
Parent or Guardian Signature Date
2. ADDITION OF QUESTIONS REGARDING OTHER INSURANCE:
The application must contain the question, "Does the child have any other
health insurance or Medicaid?" which is answered yes or no. If yes, a section
must be completed identifying the source of insurance, policy number and
coverage amounts. A copy of the policy or adequate documentation of benefits
such as a summary of benefits, a statement/letter from the other insurance
company indicating the benefits and deductible or a statement/letter from the
employer indicating the benefits and deductible must also be submitted and,
retained as documentation.
3. ADDITION OF QUESTIONS RELATING TO INCOME TAX RETURNS:
- Question asking if the previous year's tax return was filed.
- Question asking if previous year's tax return is available.
- Question asking if the responsible party's financial status has
changed subsequent to filling the tax return.
- if the responsible adult indicates that a tax return was filed and
is available, a copy must be attached to the application.
4. REQUEST FOR SOCIAL SECURITY NUMBERS
State law requires that social security numbers of each parent and legally
responsible adult who is a member of the household and whose income is available
to and being received by or on behalf of the child must be reported on the
application to the insurer if available. The application must contain a question
asking if a social security number for each parent or responsible adult is
available. If the responsible adult indicates that a social security number is
available, the number must be provided on the application.
CHILD HEALTH PLUS
ADDITIONAL REQUIRED DOCUMENTATION
1) PROOF OF RESIDENCY - i.e. school records, utility bill or any mail addressed
to the individual which has been postmarked.
2) INCOME - Prior year's tax return for each parent and legally responsible
adult whose income is available to and being received by or on behalf of the
child, regardless of current income status.
Note that, as described in the policy memorandum, if income level has changed
since last year's income, documentation supporting the current income will be
needed in addition to the prior year tax return.
ATTACHMENT 2
CHILD HEALTH PLUS
REPORT ON REASONS FOR DENIED APPLICANTS
AND DISENROLLMENTS
Instructions: Insurer must report the number of applicants and enrollees
determined ineligible for participation in the Child Health Plus Program and the
reasons for the determination. This should include applicants initially
determined ineligible, those not enrolled at recertification due to the fact
that they are determined ineligible, those disenrolled at the close of the
presumptive eligibility period and disenrollment which occurs at any other
point during the year. This report must be received by the Department on a
quarterly basis within 30 days after the close of the quarter. The reports
should be sent to:
Bureau of Community Health Insurance and Finance Systems
Child Health Plus Program
New York State Department of Health
Corning Tower Building, Room 1168
Empire State Plaza
Albany, New York 12237-0721
INSURER: _________________________________ QUARTER: ____________________________
I. New Applicants
A. Ineligible due to:
Age _____________
Income _____________
Equivalent insurance ____________________
Residency ______________
B. Failure to pay $25 enrollment fee (if applicable) __________________
C. Miscellaneous/Other ___________________
II. After Presumptive Eligibility Period
A. Lack of sufficient documentation _________________
B. Failure to pay $25 enrollment fee (if applicable) __________________
C. Miscellaneous/Other ______________
III. At Recertification
A. Ineligible due to :
Age _______________
Income _________________
Equivalent Insurance___________________________
Residency _____________________
B. Lack of sufficient documentation ____________________
C. Failure to pay $25 enrollment fee (if applicable) _________________
D. Family voluntarily chose not to re-enroll __________________________
E. Miscellaneous/Other __________________________
IV. Disenrollment at any Other Point During the Year
A. Insurer notified of any change in status of responsible party:
Income _____________
Residency _____________
Equivalent insurance ______________________
B. Family voluntarily chose to disenroll ___________________________
C. Miscellaneous/Other___________________________
APPENDIX C
UNIVERSITY OF ROCHESTER
FINAL REPORT TO LEGISLATURE
NEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-11
DATE February 1994
SUBJECT: Child Health Plus - Supplemental Form Data Analysis
A self-administered, optional reporting tool was developed by the
Department to collect data to learn some descriptive information about the
population of Child Health plus applicants. The report was used to collect
data from applicants from the inception of the program through January,
1993. The attached report is an analyses of the collected data.
A few notes contained in the report deserve highlighting:
- The majority of the Child Health Plus population are eligible
due to loss of insurance from loss of employment, or Medicaid
eligibility;
- Most report themselves as in good health;
- The average income of applicants is approximately $16,000,
and;
- The population represents a fairly even distribution by age.
The great majority of Child Health Plus members are white and
english speaking.
Attachment
CHILD HEALTH PLUS
SUPPLEMENTAL FORM DATA ANALYSIS
PLAN INCEPTION THROUGH JANUARY, 1993
New York State Department of Health
Bureau of Community Health Insurance
and Finance Systems
November, 1993
MEW YORK STATE - DEPARTMENT OF HEALTH
[CHILD HEALTH PLUS LOGO]
ADVISORY MEMORANDUM NUMBER A-11
DATE February 1994
SUBJECT: Child Health Plus - Supplemental Form Data Analysis
A self-administered, optional reporting tool was developed by the
Department to collect data to learn some descriptive information about the
population of Child Health Plus applicants. The report was used to collect
data from applicants from the inception of the program through January,
1993. The attached report is an analyses of the collected data.
A few notes contained in the report deserve highlighting:
- The majority of the Child Health Plus population are eligible
due to loss of insurance from loss of employment, or Medicaid
eligibility;
- Most report themselves as in good health;
- The average income of applicants is approximately $16,000,
and;
- The population represents a fairly even distribution by age.
The great majority of Child Health Plus members are white and
english speaking.
Attachment
CHILD HEALTH PLUS
SUPPLEMENTAL FORM DATA ANALYSIS
PLAN INCEPTION THROUGH JANUARY, 1993
New York State Department of Health
Bureau of Community Health Insurance
and Finance Systems
November, 1993
OVERVIEW
The Supplemental Form was an optional data collection tool developed by
the Department to collect data in a uniform manner from Child Health Plus
applicants on demographic, marketing, prior utilization, access, and health
status elements. All but one insurer submitted forms. The form went into use at
the inception of the program and was collected until April, 1993. At that time
the insurers were instructed to stop including the form with the enrollment
packet, but to mail in any forms which they received from previous applicants.
To date, approximately 30,000 forms have been received and entered. The data in
the following tables and graphs is based upon 26,000 forms collected from plan
inception through January, 1993.
While some plans submitted one form per family, others submitted a form
for each child applicant. The results include applicants to Child Health Plus,
not just those who were accepted. Therefore, the number of forms received does
not equal the number of children enrolled. In a few instances, more forms were
received than the insurer enrolled. Other insurers submitted forms for just
those that were accepted into the program. In addition, the data is
self-reported and may not reflect actual use. Not all respondents answered every
question on the form. The results were tallied by completed question and not
completed form. The graphs only include those applicants who answered the
questions.
When more than one answer was given in questions five and six regarding
locus of care, the lowest level of care was entered. For question four, how
coverage was lost, if left/lost job was checked with other items, the question
was coded for left/lost job. For question seven, some people checked "has no
problem" and wrote in: don't need an appointment for the emergency room. If more
than one language was checked for question eight and one was English, the
question was coded for English. Also, if more than one race/ethnicity was
checked for question nine, the question was coded as other. In many instances
the items to be checked by the insurer in the FOR OFFICE ONLY section were left
blank.
SUMMARY OF FINDINGS
- Most of the applicants learned of Child Health Plus through a
friend/relative.
- Two-thirds to 90 percent of applicants did not have health insurance
and most lost their coverage because parent lost/left their job.
- Most of the applicants had a source of care for an injury or illness
(physician office, clinic, health center).
- Three-fourths of the applicants reported no problem getting access
to care.
- Close to 90 percent of the applicants spoke English, with Spanish
and Chinese being spoken in New York City in two plans.
- Almost three-fourths of the applicants report being
white/non-hispanic.
- Less than 10 percent of applicants were under the age of 1 year with
the remainder fairly evenly split between the age categories of 1-5
and 6-12.
- The male and female applicants were evenly split.
- Approximately 30 percent of the applicants report having an ER visit
in the 12 months prior to application with the average number of
visits 1.8 of those report having visits.
- Less than five percent of applicants reported having an overnight
hospital admission in the 12 months prior to application; however
those who did report admissions averaged 1.5 admissions.
- Over 85 percent of applicants reported having visits to a clinic,
doctor or health center in the 12 months prior to application. of
those who reported visits, the average number was [ILLEGIBLE]
visits.
- The majority of applicants reported their health status as good or
better. Less than one-half of one percent reported their health
status as poor.
- The average income for applicants reporting income is $16,189 per
family.
- The average number of adults per family is about 2, the average
number of children less than 13 per family is about 2, the average
number of children older than 13 is about 1.5 with the overall
average family size about 4.
EVALUATION OF CHILD HEALTH PLUS
IN
NEW YORK STATE
SUMMARY
by
THE ROCHESTER CHILD HEALTH STUDIES GROUP
Peter G. Szilagyi, MD, MPH
Jack Zwanziger,PhD
Lance E. Rodewald, MD
Jane L. Holl, MD
Dana B. Mukamel, PhD
Sarah Trafton, JD
Laura Pollard
Andrew Dick, PhD
Lynne Jarrell, MS
Richard F. Raubertas, PhD
April 1996
Departments of:
Pediatrics
Community and Preventive Medicine
Emergency Medicine
UNIVERSITY OF ROCHESTER
CONTENTS
NUMBER PAGE
I Background 1
II Evaluation Methods 1
III Findings
4
A. Profile of Children in Child Health Plus
4
B. Access to Health Care 6
C. Utilization of Health care 6
D. Quality of Health Care 9
E. Expenditures and the Uncompensated Care Pool
9
F. Evaluation of Marketing and Outreach 11
G. Evaluation of Insurer performance in Determination of Eligibility
for Child Health Plus 11
IV Recommendations 12
A. Recommendations for programmatic Changes 14
B. Issues for Future Study 16
LIST OF TABLES
PAGE
TABLE TITLE OF TABLE NUMBER
1 Legislative Objectives for Evaluation of Child Health Plus 2
2 Methods for Data Collection 3
3 Insurance Coverage for Children in New York State (1993) - By Region 5
4 Number of Children Enrolled in Child Health Plus, Eligible for child
Health Plus, and Potential Child Health Plus-Eligible Children 5
5 Effects of Child Health Plus on Utilization of Primary Care Services:
Analysis of Medical Charts for Preschool Children (0-5 yr.) 7
6 Effects of Child Health Plus on Utilization of Primary Care and Specialty
Services: Analysis of Parent Interviews 8
7 Effect of Child Health Plus on Hospitalizations 9
LIST OF FIGURES
FIGURE TITLE OF FIGURE
1 Percent of Children by Race and Ethnicity
2 Percent of Children by Poverty Level
3 Percent of Children With Health Insurance Prior to Child Health Plus by
Insurance Type
4 Percent of Children Who Have Specific Type of Primary Care Home During
Child Health Plus and Number of Minutes to Provider
5 Percent of Children Who Changed Primary Care Providers After Enrolling in
Child Health Plus
6 Number of Visits per Member per Year During Child Health Plus By Region
7 Percent of Children Who Saw a Specialist, Year Before and Year During
Child Health Plus
8 Number of Hospitalization Reported, Year Before and Year During Child
Health Plus
9 Percent of Children Who Were Up-to-Date on Immunizations, Before and
During Child Health Plus
10 Change in Child's Health Care Due to Child Health Plus (Children with
Chronic Conditions)
11 Change in Child's Health Status Due to Child Health Plus (Children with
Chronic Conditions)
12 Child Health Plus Expenditures per Member per Year by Region
13 Child Health Plus Expenditures per Member Year by Visit Type and Plan Type
(Upstate Regions Only)
EVALUATION OF CHILD HEALTH PLUS
SUMMARY
I. BACKGROUND
A large number of children in New York State are uninsured or
underinsured. Between 1989 and 1993, the rate of uninsured children in New York
increased from 8.7 percent to 10.7 percent, and in the United States to 13.5
percent. In New York State and in the United States, children who are uninsured
are from working poor families. Hispanic and African-American children are more
likely to be uninsured than Caucasian children. Prior studies have found that
uninsured children suffer from inadequate access to health care, and in some
cases have poorer health outcomes.
Child Health Plus was first included in Chapters 922 and 923 of the Laws
of 1990 as a statewide program designed to: provide primary and preventive
health insurance coverage to low income children, increase eligible children's
access to primary and preventive health care services, improve the health status
of enrolled children, and reduce and more efficiently target outpatient bad debt
and charity care expenditures in New York State. The Child Health Plus benefit
package covers most ambulatory care, including preventive care, ambulatory
surgery, emergency care, prescription drugs, some other outpatient services, but
does not include hospitalizations. Fifteen insurance plans participate in Child
Health Plus (four indemnity plans and eleven managed care plans). Two marketing
organizations have contracts to promote the program, one in New York City and
another for the rest of the state.
Financing of Child Health Plus comes from the Statewide Bad Debt and
Charity Care pool established under the New York Prospective Hospital
Reimbursement Methodology, as well as from premium contributions from families
($25 per child per year up to a $100 maximum per family per year). Only families
of the partially subsidized children whose family income is between 160 percent
and 222 percent of the federal poverty level must contribute the $25 to the
premium. Children are eligible for Child Health Plus if they (1) were born on or
after June 1, 1980 and are under the age of fifteen, (2) reside in New York
State in a household having a gross income at or below 222 percent of the
federal poverty level, (3) are not eligible for Medicaid, and (4) do not have
equivalent coverage. Families with gross incomes that exceed 222 percent of the
federal poverty level can purchase Child Health Plus for the cost of the full
premium (ranging from $498 to $798 per year). The program has grown rapidly,
from a first-year enrollment of 2,000 children in January, 1992, to a current
enrollment of 103,407 in September, 1995.
As a means of determining whether the program's goals have been met,
legislation required a comprehensive evaluation. Chapter 731, Laws of 1993, as
amended by Chapter 170, Laws of 1994, authorized the Commissioner to solicit
proposals to evaluate the program, and outlined specific evaluation objectives.
II. EVALUATION METHODS
The Rochester Child Health Studies Group was selected in August, 1994 to
conduct the evaluation of Child Health Plus. The evaluation occurred over a
15-month time period. Table 1 shows the legislative objective: for the
evaluation:
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
1
TABLE 1
LEGISLATIVE OBJECTIVE FOR THE EVALUATION OF CHILD HEALTH PLUS
TO EVALUATE:
1. The overall effect of Child Health Plus on access to, utilization and
quality of primary and preventive health care services, including, but not
limited to, patterns of service utilization, geographic availability of
service providers, possible reductions in uncompensated care as a result
of the program, and enrollee satisfaction with program administration,
services and quality;
2. The impact of the child health insurance program on the health status of
program participants, including the comparative impact on families that
have a child enrolled in the program and other children that are not
eligible and do not have coverage;
3. The effect of the child health insurance program on emergency room (ED)
utilization, including the effectiveness of preventing inappropriate
utilization;
4. The geographic accessibility of the child health insurance program,
including the availability and accessibility of service providers, premium
levels and premium increases;
5. The effect of community-based and statewide outreach education efforts;
6. The results of a statistically valid sampling of cases verifying
certification and recertification of eligibility for subsidy payments
under this title including but not limited to data on failure by approved
organizations to adequately verify enrollee eligibility;
7. Any recommendations for programmatic changes to improve the child health
insurance program based on program evaluation and enrollee satisfaction
data;
8. A cost and patient outcome comparison of indemnity plans and managed care
plans offered under this program.
The evaluation focused on children who had enrolled in Child Health Plus
between July 1, 1992 and June 30, 1993, and who were enrolled for a minimum of
nine continuous months. This allowed us to evaluate a recent [ILLEGIBLE] of
children on Child Health Plus who also had sufficient experience with Child
Health Plus to permit accurate determinations of any effect of the program on
health care and outcomes.
We employed several methods and data sources to answer the eight
legislative questions. These methods are shown in the Table 2:
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
2
TABLE 2
METHODS FOR DATA COLLECTION
Parent Interviews To determine characteristics of the population, sources of
(N=2,507 children) health care both before Child Health Plus and during enrollment
(N=2,126 Total Unique families) in Child Health Plus, experience with Child Health Plus
(N=1291 Preschool children) and with medical care, and the impact of Child Health
(N=358 Children with Asthma) Plus on enrolled children's health care and health status.
(N=152 Children with Attention [Objectives 1-5,7,8]
Deficit Disorder)
Supplemental Interview To obtain additional information about parent experiences
(N-121 Children) with and opinions about insurance, and their willingness to
pay for Child Health Plus. [Objectives 1-2]
Medical Chan Reviews To measure, for the 1-year period before enrollment in
(N=633 Preschool children) Child Health Plus and the 1-year period during enrollment
(N=159 Children with Asthma) in Child Health Plus: (1) utilization of primary,
(N=49 Children with Attention subspecialty, and emergency care, (2) quality of care,
Deficit Disorder) and (3) costs of care. Chart reviews were performed for
young children (birth to 6 years of age), and for
patients with asthma and attention deficit disorder
(ADD). The latter two conditions were chosen because
asthma is the most common chronic medical condition of
childhood and ADD is one of the most common chronic
developmental conditions. [Objectives 1-5,7,8]
Health Care Provider Survey To evaluate marketing of Child Health Plus to providers,
(N= 117 Providers) the impact of Child Health Plus on primary care practices,
and the changes in utilization of services by Child Health
Plus patients. [Objectives 1,2,4,5]
Individual-level Claims Analysis To Measure utilization and costs of care. [Objectives
(N=1478 Children) 1-5,7,8]
Marketing and Outreach To evaluate the effectiveness of marketing and
Evaluation community-based and statewide outreach efforts, both
downstate and upstate. [Objective 5]
Insurance Plan Chart Reviews To measure documented compliance with requirements
(N=2,250 Children; 4226 Episodes of for eligibility certification for each of the 15
enrollment) insurance plans. [Objective 6]
Analysis of Existing Datasets Analysis of: (1) the Current Population Survey to estimate
the number of Children eligible for Child Health Plus, (2)
the Child Heath Plus billing file for patient selection,
(3) SPARCS dataset for estimating costs of admissions,and
(4) the National Health Interview Survey for population
comparisons. [Objectives 1-6, 8]
Case Study Interviews with key informants from insurance plans, New York
State DOH, and community organizations, and parents, to assess
their experience with Child Health Plus and the implementation
of Child Health Plus. [Objectives 1-8]
In order to assess regional differences, the Child Health Plus population
was divided into 4 regions: (1) New York City, (2) New York City Suburbs, (3)
Upstate Urban region, and (4) Upstate Rural region. A stratified sampling
technique was used to sample sufficient patients from each region. Patients were
selected irrespective of whether they were in an indemnity or managed care
insurance plan type. To perform a comprehensive evaluation of the effect of
Child Health Plus on the measures listed above it was necessary to obtain
detailed information for time periods both before and after enrollment in Child
Health Plus; otherwise it would have been difficult to estimate whether Child
Health Plus had any effect at all.
The study methodology allowed us to evaluate key questions for the entire
Child Health Plus population in New York State; by region for each of the four
regions; by plan type
ROCHESTER CHILD HEALTH STUDIES GROUP. EVALUATION OF CHILD PLUS
FINAL REPORT
3
(indemnity or managed care); for each of three groups of children: preschool
children (ages 0-5 yrs), children with asthma (the most common chronic medical
disease of childhood), and children with attention deficit disorder (one of the
most common chronic developmental conditions); and by level of insurance
Coverage prior to Child Health Plus (either insured or uninsured). Plan type was
evaluated for the two upstate regions because almost all children in the two
downstate regions belonged to managed care plans. Weighting techniques were used
to estimate state-wide proportions and averages for key outcome measures.
Children who had been enrolled in Child Health Plus for less than 9 months
were not included in this evaluation for several reasons. First, an effect of
Child Health Plus is unlikely for children who were enrolled for only a few
months. Second, the twelve percent of children who were enrolled for only one or
two months probably represent presumptive enrollees who did not remain in the
program beyond the presumptive period. Following initial application, families
are given two months to supply supporting documentation for eligibility; this
period of presumptive eligibility thus includes some children who were not
enrolled in Child Health Plus beyond the two month period. Twenty-three percent
of children were enrolled for 3-8 months; the findings from this evaluation may
not be applicable to these children.
Informed consent was obtained from parents for all children included in
the study. Parents who spoke only Spanish or Chinese (3 main dialects) were
included since interviewers were available for these languages. There were a
small number of parents whom we were unable to interview because of language
difficulties.
Because of a lower rate of successful contact of parents in New York City,
a separate substudy was performed in New York City to determine whether the
children included in the main study were representative of the New York City
Child Health Plus population. We subcontracted with an outreach organization in
Manhattan (Alianza Dominicana) who attempted to contact 100 randomly selected
children who were part of the sample that we had not been able to contact;
methods for contact in the substudy included visits to homes and nearby health
centers. Alianza was able to contact 31 children (31%). There were no major
differences between key characteristics of the Alianza sample and
characteristics of the remainder of the New York City sample. Thus, it appears
that the New York City sample is representative of children enrolled in Child
Health Plus in New York City.
Medical chart reviews were performed either on-site throughout New York
State, or by review of 1,335 photocopied charts obtained with parent and
provider permission. Claims and encounter data were obtained from 13 plans for
children for whom informed consent had been obtained. A uniform dataset was
developed by aggregating individual claims to the visit level. Information about
provider type and location was included. Average visits and costs per member per
month were calculated. Multivariate analysis was performed to determine if there
were differences between indemnity and managed care plans, controlling for
patient characteristics.
III. FINDINGS
A. PROFILE OF CHILDREN IN CHILD HEALTH PLUS
Although enrollment in Child Health Plus has increased dramatically, many
eligible children are not enrolled (see Tables 3 and 4). Using analysis of the
Current Population Survey (CPS) and our parent interview, we found that in 1993,
37 percent of children throughout New
ROCHESTER CHILD HEALTH STUDIES GROUP. EVALUATION OF CHILD PLUS
FINAL REPORT
4
York State who were eligible for Child Health Plus were enrolled (see Table
4). Enrollment in Child Health Plus varied by region, with lower percentages in
New York City (29 percent of eligibles) than the rest of New York State (50
percent of eligibles). Increasing the Child Health Plus age limit to 17 years
would increase the eligible population by about 50 percent (based on 1993 CPS
data). Hispanic children and African-American children, and children in the
lowest eligible income levels were slightly under-represented in the Child
Health Plus population.
TABLE 3
INSURANCE COVERAGE FOR CHILDREN IN NEW YORK STATE (1993) -- BY REGION
PRIVATE & CHILD HEALTH
CHAMPUS MEDICAID PLUS UNINSURED TOTAL
------- ---------- ---- --------- -----
STATE TOTAL 2,047,373 903,092 71,031 274,388 3,002,902
REGION 1 606,819 519,501 29,883 133,273 1,170,818
REGION 2 515,288 72,055 14,070 59,006 623,025
REGION 3 729,237 230,065 19,833 60,507 948,319
REGION 4 196,029 81,471 7,245 21,602 260,740
Child Health Plus data are based on Child Health Plus enrollment files from
March of the following year, (e.g., 1993 Child Health Plus enrollment is based
on March 1994 enrollment file.) All Child Health Plus data are based on
information from Child Health Plus enrollment files.
*Region 1 is New York City; Region 2 is the suburban area around New York City;
Region 3 includes upstate urban counties (SMSA areas); and Region 4 includes
upstate rural counties (non-SMSA areas).
TABLE 4
NUMBER OF CHILDREN ENROLLED IN CHPLUS, ELIGIBLE FOR CHPLUS, AND
POTENTIAL CHPLUS-ELIGIBLE CHILDREN
PERCENT OF CHILD
CHILD HEALTH CHILD HEALTH HEALTH PLUS-
PLUS- PLUS-ELIGIBLE ELIGIBLE ENROLLED ADDITIONAL ADDITIONAL
ENROLLED POPULATION IN CHILD HEALTH CHILDREN CHILDREN
REGION POPULATION 0 TO 12 YEARS PLUS 13 TO 15 YEARS 16 TO 18 YEARS
------ ------------ ------------- ---- -------------- --------------
NEW YORK CITY 29,883 104,146 29% 42,032 29,292
OTHER 3 REGIONS 41,148 88,186 50% 20,339 27,048
------ ------- -- ------ ------
ALL NYS 71,031 192,332 37% 62,371 56,340
As shown in Figure 1, the majority of children on Child Health Plus are
Caucasian, with a greater proportion of African-American, Hispanic, and Asian
children found in New York City than in other regions. Families on Child Health
Plus are working poor: 91 percent have a working parent, mostly employed in
non-professional, non-managerial occupations. Figure 2 shows income levels: 78
percent had family gross incomes below 160 percent of the federal poverty level.
Eighty-six percent of children had a parent who completed 12th grade. More than
half of children were uninsured before enrollment in Child Health Plus (Figure
3), and nearly two-thirds had no prior insurance coverage for preventive care.
Half of children had lost their prior insurance because of loss of
employment-related insurance benefits or because insurance was too costly. Four
percent of parents stated their child received Medicaid concurrently with Child
Health Plus, and six percent purchased concurrent inpatient coverage.
Parents expressed a desire for three types of increased benefits: dental
care (50 percent of parents), inpatient coverage (28%), and increasing the age
limit (13%). Ten percent had
ROCHESTER CHILD HEALTH STUDIES GROUP. EVALUATION OF CHILD PLUS
FINAL REPORT
5
services denied and 15 percent had payments denied; denials were slightly more
common in indemnity plans than in managed care plans (some reported "denials"
were for services not covered by Child Health Plus). Based on 121 parents
interviewed for the Supplemental Interview, most parents preferred Child Health
Plus to Medicaid, and most expressed a willingness to pay a $3 copayment for
doctor visits, a annual premium of up to $240, and an annual deductible of up to
$ 100.
B. ACCESS TO HEALTH CARE.
Access to the Child Health Plus program was similar across regions, and
was relatively easy according to parents (though complex according to insurers).
Enrollment in Child Health Plus slightly improved access to sources of both
preventive care and sick care, with greatest improvements in New York City
(where base line levels were lowest). After enrollment in Child Health Plus, 99
percent of children had a regular source for preventive care and for sick care.
Child Health Plus resulted in an increase of 6 percent in the proportion of
children who had a preventive "home" (11 percent in New York City), and an
increase of 3 percent in the proportion of children who had a sick "home " (6
percent in New York City).
Enrollment in Child Health Plus increased the proportion of children
seeing private doctors from 59 percent to 65 percent, and increased the
proportion of children using health centers from 13 percent to 25 percent (see
Figure 4). Children in New York City, and children in managed care plans were
more likely to use health centers. Parents reported a relatively short travel
time to reach their child's primary care provider (Figure 4).
Child Health Plus resulted in some discontinuity of health care for many
patients, primarily because many of their prior primary care physicians were
not Child Health Plus providers. As Figure 5 shows, 51 percent of patients
switched primary care physicians upon enrollment in Child Health Plus. A major
reason for the switch was that providers were not participating in the networks
of the Child Health Plus insurers.
The vast majority of parents found that during Child Health Plus access to
primary care services was easy: more than 85 percent of parents reported that it
was easy to reach their doctor by telephone, make an appointment, get to the
office, and get prescriptions. Access to emergency and specialty care during
Child Health Plus was also rated extremely easy by more than 80 percent of
parents. Levels of access were slightly higher in the two upstate regions than
in the downstate regions, (for getting to the office, and ease of use of the
emergency department), and slightly higher for children in indemnity plans than
children in managed care plans (for reaching their doctor by phone, and getting
referrals). However, the overall levels of access were extremely high in all
regions and for both plan types.
C. UTILIZATION OF HEALTH CARE
Parents of 91 percent of children stated that their child utilized a
primary care provider for a service during the year after enrollment in Child
Health Plus; these high levels were confirmed by both medical chart reviews and
claims analyses. Child Health Plus enrollees averaged 5.2 visits to a health
care provider, 80 percent to primary care providers, 9.6 percent to specialists,
5.1 percent for ambulatory surgery, 2 percent for emergency department (ED), and
2 percent for independent radiology and laboratory services. Visit rates were
highest in the upstate urban region (5.9 visits per member per year) and lowest
in the New York City suburb region (4.6 visits per member per year). The rate of
emergency department (ED) visits was much
ROCHESTER CHILD HEALTH STUDIES GROUP. EVALUATION OF CHILD PLUS
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6
higher in the two upstate regions than in the two downstate regions. Overall,
utilization was very similar between indemnity and managed care plans, except
that specialty care was slightly lower under managed care plans (0.7 visits per
member year) than indemnity plans (1.1 visits per member year).
Based on medical chart reviews, We found that preschool children had high
rates of primary care visits during Child Health Plus. Seventy percent made at
least one primary care visit during the year on Child Health Plus and 90 percent
made at least one visit of any type to their primary care provider. Figure 6
shows the number of visits per member per year during Child Health Plus for
preschool children (ages 0-5 years) according to region. On average, preschool
children made 1.3 preventive visits, 3.7 acute visits, 1.3 follow-up visits,
0.38 chronic illness visits, and 6.7 total primary care visits per year, this is
a high number of primary care visits. Children in the upstate rural region had
the lowest number of visits, while children in the New York City suburban region
had the highest number of visits.
Child Health Plus resulted in substantial increases in almost all types of
primary care visits, as shown in Tables 5 and 6. Controlling for age, family
size, region, plan type, and prior insurance, the effect of Child Health Plus
(Table 5) was to add 0.38 preventive care visits per year, 1.9 acute care
visits, 0.45 follow-up visits, 0.25 chronic care visits, and 3.0 total primary
care visits. Child Health Plus resulted in significant reductions in use of
health department clinics for immunizations, by 88 percent. Child Health Pius
increased the likelihood of preschool children using their primary care
providers for preventive and for sick care (Table 6). The effect of Child Health
Plus was greatest in New York City, where baseline utilization (for patients
before Child Health Plus) was the lowest. For acute care visits and total
primary care visits only, the effect of Child Health Plus was slightly greater
for managed care plans than for indemnity plans.
TABLE 5
EFFECTS OF CHILD HEALTH PLUS ON UTILIZATION OF PRIMARY CARE SERVICES
ANALYSIS OF MEDICAL CHARTS FOR PRESCHOOL CHILDREN (0-5 YR.)
CHANGE IN VISITS
DUE TO CHILD
VISIT TYPE HEALTH PLUS P VALUE
---------- ----------- -------
# PREVENTIVE VISITS PER YEAR + 0.38 <.001*
# ACUTE VISITS PER YEAR + 1.9 <.001*
# FOLLOW-UP VISITS PER YEAR + 0.45 <.001*
# CHRONIC CARE VISITS PER YEAR + 0.25 <.001*
# NURSING VISITS IN OFFICE PER YEAR + 0.046 .07
# TOTAL PRIMARY CARE VISITS PER YEAR + 3.0 <.001*
HAD A HEALTH DEPARTMENT IMMUNIZATION -8.8% <.001*
DURING THE YEAR (YES OR NO)
* REPRESENTS STATISTICALLY SIGNIFICANT DIFFERENCES
ROCHESTER CHILD HEALTH STUDIES GROUP. EVALUATION OF CHILD PLUS
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7
TABLE 6
EFFECTS OF CHILD HEALTH PLUS ON UTILIZATION OF PRIMARY CARE AND SPECIALTY
SERVICES
ANALYSIS OF PARENT INTERVIEWS FOR ALL CHILDREN ON CHILD HEALTH PLUS (0-12 YR.)
CHANGE IN PERCENT OR
NUMBER OF VISITS
DUE TO
VISIT TYPE CHILD HEALTH PLUS P VALUE
---------- ----------------- -------
HAD A PREVENTIVE CARE HOME + 5.9% < .001*
USED PREVENTIVE CARE HOME + 2.7% .04
HAD SICK CARE HOME + 3.3% < .001*
USED SICK CARE HOME + 3.0% < .001*
* REPRESENTS STATISTICALLY SIGNIFICANT DIFFERENCES
According to parent interviews, specialty care increased markedly due to
Child Health Plus, from a rate of 13 percent use of specialists during the year
before Child Health Plus enrollment to 29 percent during the year on Child
Health Plus (see Figure 7). Claims analysis confirmed high rates of specialty
utilization. There were no significant differences across regions or between
plan types in the effect of Child Health Plus on utilization of specialty care.
There were somewhat conflicting findings about the effect of Child Health
Plus on Emergency Department (ED) utilization depending on the source of
information (interviews or medical chart reviews). Parents reported an increase
in ED utilization (by 0.11 ED visits per child per year, controlling for other
variables; p< .001). However, the medical records showed no such increase (no
significant effect of Child Health Plus on ED visits). In addition, claims data
contained only about one-third the number of ED visits noted by parents. On the
whole, we believe the best source of information for ED utilization is medical
charts rather than parent interviews. Thus, we conclude that there was no
significant effect of Child Health Plus on ED utilization. There was also no
evidence that Child Health Plus decreased ED utilization. While ED utilization
was not changed by Child Health Plus, children made an average of 1.1 to 2.3
more illness visits to their primary care provider because of Child Health Plus.
This increase in illness visits probably represents previously unmet demand for
illness care. That increase in illness care was borne almost entirely by primary
care providers during Child Health Plus.
Figure 8 shows the number of hospitalizations reported by parents
during the year before and the year during Child Health Plus. For all regions of
the state, the average number of hospitalizations per year was 0.072 before
Child Health Plus, and 0.042 during Child Health Plus. Based on information from
parent interviews, Child Health Plus reduced hospitalization rates by 4 percent,
and reduced the probability of being hospitalized by up to 2 percent
(controlling for age, family size, region, plan type, and prior insurance--see
Table 7). However, these results may have some inaccuracies; for example,
hospitalizations were not included on claims files to allow for verification.
More comprehensive studies are needed (with large sample sizes) to adequately
evaluate the effect of Child Health Plus on hospitalizations.
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
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Table 7
EFFECT OF CHILD HEALTH PLUS ON HOSPITALIZATIONS
VISIT TYPE FROM PARENT INTERVIEWS EFFECT OF CHILD
FOR ALL CHILDREN (0-12 YR) HEALTH PLUS P VALUE
- -------------------------- ----------- -------
# HOSPITALIZATIONS -0.04 < .001*
PROBABILITY OF HOSPITALIZATION -2.0% .002
* REPRESENTS STATISTICALLY SIGNIFICANT DIFFERENCES
D. QUALITY OF HEALTH CARE
Based on measures of access, which are often used in quality assessments,
Child Health Plus resulted in clinically and statistically meaningful
improvements in access to preventive services. Immunization rates for Child
Health Plus enrollees were similar to rates for most poor populations. However,
as shown in Figure 9, Child Health Plus did not result in improved immunization
rates based on medical chart reviews of all sources of care.
One-third of parents stated that Child Health Plus improved their child's
quality of care, and almost no parent stated that Child Health Plus resulted in
poorer quality of care. Similarly, one-third of parents perceived that Child
Health Plus improved their child's health status, and almost no parent perceived
a worsening of health status due to Child Health Plus. More than 90 percent of
parents in all regions and plan types were satisfied with the Child Health Plus
program, with their insurer, and with their primary care doctor.
Primary care providers gave relatively poor ratings for the promotion of
Child Health Plus to their patients and to providers. However, providers gave
high ratings for the impact of Child Health Plus on improving preventive visits
by their patients who had enrolled in the program.
For children with either of the two chronic conditions (asthma and
attention deficit disorder), more than one-third of parents perceived that both
their child's quality of care and their child's health status had both improved
because of Child Health Plus, and almost none perceived worsening because of
Child Health Plus (see Figures 10 and 11). Most parents stated that their
children with chronic illnesses had easy access to their primary care providers,
to specialists, and to the emergency department if needed. The number of visits
to both primary care providers and specialists increased markedly after
enrollment in Child Health Plus for these patients. Overall, results from
interviews and chart reviews suggested improved quality of care for the three
vulnerable subgroups: preschool children, children with asthma and children with
attention deficit disorder.
E. EXPENDITURES AND THE UNCOMPENSATED CARE POOL
Approximately half of Child Health Plus expenditures were for primary
health care services. As shown in Figure 12, there were substantial differences
in average expenditures (for medical care) per member year across regions:
statewide average expenditures were estimated at $477.36 per member year.
Expenditures were highest in the upstate urban region ($615.72) and lowest in
the New York City Suburb region ($407.04).
Expenditures per member year were higher for managed care plans ($633.62
per member per year) compared with indemnity plans ($492.85 per member per
year), as seen in Figure 13. However, these differences were due to differences
in population characteristics. After
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
9
controlling for enrollee characteristics we found no differences in expenditures
between indemnity and managed care plans. Child characteristics that were
significant in the cost equation and were controlled for in the comparison of
managed care and indemnity plans were: age, length of enrollment in Child Health
Plus, race, household income, being underinsured prior to Child Health Plus, and
utilization of the Emergency department, hospitalization, and specialist
services prior to Child Health Plus (all of these variables were obtained by
interview).
Using the interview, we estimated the effect that Child Health Plus had on
the probability of a hospitalization. We found that for the respondents to our
survey, representing the population eligible for the study (enrollment in Child
Health Plus between July 1, 1992 and June 30, 1993, that lasted at least nine
months), the probability of admission was decreased by 2.0 percentage points,
with no significant differences in the size of this effect for the four regions
of our study. Applying this change in the probability of an admission to the
entire Child Health Plus population for the calendar year 1993, we estimate that
the Child Health Plus program reduced the number of admissions for uninsured
children by 1.054 admissions. We assumed that the avoided admissions have the
same average cost as those that occurred. Using 1993 SPARCS data, we aggregated
the number of admissions for uninsured children under 13 years of age and their
corresponding charges, resulting in an average charge per admission of $5,588.
We multiplied the number of admissions avoided through the Child Health Plus
program by this average charge per admission to find the total charges avoided.
Then, applying a statewide average cost to charge ratio for 1993, we estimated
the total costs that hospitals avoided in 1993 as a result of the program. Using
this approach, we found that Child Health Plus had a total effect on inpatient
costs of approximately $4,000.000.
We also used claims data to calculate the average payment per member per
month for outpatient hospital services in each region, and multiplied this
number by the number of member months in each region. We estimate that Child
Health Plus paid $3,900,000 for outpatient services in 1993.
To estimate what the effect on hospital finances would have been in the
absence of Child Health Plus, we estimated two opposing effects resulting from
its presence: (1) shift of the non-ED outpatient utilization away from hospital
clinics toward physician offices (obtained from the interview), and (2) increase
in overall utilization (calculated from chart reviews). Combining these two
factors, we find that outpatient usage would have been higher in the absence of
Child Health Plus. By applying a statewide average outpatient revenue to cost
ratio to the difference between the forgone revenue (in the absence of Child
Health Plus) and the payments by Child Health Plus for non-ED outpatient
services, we estimate that hospital outpatient costs would have been higher by
$1,100,000.
The combined effect of increased outpatient revenue and reduced outpatient
costs due to Child Health Plus is approximately $5,000,000, although the cost
savings are likely to be somewhat inflated as discussed in Chapter 8 of the
complete report. Child Health Plus had a substantial effect on hospital
finances, both by reducing admissions and by decreasing the net financial need
of hospital outpatient services. While the impact of Child Health Plus on the
uncompensated care pool is likely to be substantial, the program is far from
self-financing--the costs of the additional ambulatory services; are greater
than the above savings.
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F. EVALUATION OF MARKETING AND OUTREACH
It was not possible to directly measure the effectiveness of the marketing
contractors because the linkage between Child Health Plus enrollment and
marketing activity is weak. A perception of both marketing contractors and
insurers is that Child Health Plus enrollment consistently approached program
limits. (Enrollment was frozen statewide once, in the Summer of 1992. Insurers
were able to appeal for increases in allocation of slots on an individual basis,
preventing a repeat of the enrollment "freeze.") The concern expressed by
marketing contractors and insurers alike was that demand would exceed program
resources. Child Health Plus was not designed to accomodate all eligible
children in the State, thus outreach efforts were adjusted according to
contractor and insurer knowledge of enrollment levels and space available. An
additional limitation that was reported by marketing contractors and insurers
was the limit on administrative expenditures at 10 percent for insurers. Some
plans reported that the staff available to process incoming applications was
only one half-time individual. If the number of applications exceeded the staff
resources available to process applications, the result was a longer waiting
period for potential applicants' coverage to be approved and instituted. The
extent to which marketing contributed to heightend demand for Child Health Plus
is not clear. Most parents heard about Child Health Plus from a friend, school,
or their doctor, and very few heard about Child Health Plus from a marketing
activity (such as TV, mailing or community meeting.).
Although the marketing contractors submitted new workplans to the state
effective with each contract extension, it was the marketing contractors'
perception that they lacked sufficient flexibility to revise marketing
strategies as the program developed and as they gained experience with marketing
Child Health Plus. Clearly it would be consistent with the social marketing
paradigm to encourage this flexibility to develop new strategies. Thus, contract
renewal terms and eveluation of marketing contractors, performance of activities
in the future should allow for revision of marketing strategies both over the
length of the marketing contract as well as with contract extensions.
Both marketing contractors engaged in major activities, including
targeting schools, health centers, producing large volumes of mailings, and
organizing many meetings and presentations, which more than 16,000 people
attended. Their contracts did not require contractors to demonstrate success in
increased enrollment to these activities. Health care providers gave poor
ratings to the overall promotion of Child Health Plus to their patients and to
the physician community. Children from minority populations and from the lowest
eligible income categories (160-222% of federal poverty level) were
under-represented in Child Health Plus, suggesting the need for more aggressive
marketing and outreach to these populations.
G. EVALUATION OF INSURER PERFORMANCE IN DETERMINATION OF ELIGIBILITY FOR
CHILD HEALTH PLUS
We randomly selected 150 children from each of the fifteen Child Health
Plus insurers and requested enrollment records from insurers. Children were
eligible if they were enrolled for a minimum of three months, with an initial
enrollment date between July 1, 1993 and June 30, 1994. All documents in the
enrollment records were reviewed, either on-site at insurer offices or using
photocopies of records. Documentation for 3,557 episodes of enrollment (both
original enrollment and recertification) was received for the 2,250 randomly
selected children. Insurer documentation was reviewed for completeness (presence
of appropriate documents) across six elements as required for Child Health Plus
eligibility: date of birth, residence in New York State
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
11
(which was not required to be documented until July, 1994), income and family
size documentation (to calculate percent of federal poverty level), insurance
verification, concurrent insurance (to determine if equivalent to Child Health
Plus), and Medicaid referral if appropriate. We also determined accuracy of
information on the Child Health Plus application form, compared with source of
documents supplied by insurers.
Chapter 10 of the complete report shows results for each insurer. The
criteria for verification of Date of Birth state that documentation must be
provided upon initial enrollment, but need not be provided again at the time of
recertification. Thus, the results for Date of Birth were computed by child,
using the denominator 150 (number of children sampled from each insurance
plan). Date of Birth was documented for 1,953 (87%) of the 2,250 randomly
selected children. The remainder of outcomes were calculated by episode of
enrollment (the difference is that each child may have multiple episodes of
enrollment due to recertification). For the 2,250 children sampled, 3,557
episodes were documented. Residence (again, not required to be documented until
July, 1994) matched for 61 percent of episodes, and federal poverty level for 73
percent of episodes; there were wide variations across plans. When documentation
was present, the information was almost always recorded accurately on the Child
Health Plus application form. Concurrent insurance was identified in only 4
percent of cases, similar to results from our interview. For 81 percent of cases
having concurrent insurance, there was not enough information supplied to
determine the type of concurrent insurance.
Medicaid referrals were documented in 19 percent of episodes. (Not all
children who apply for Child Health Plus appear to the insurer to be eligible
for Medicaid, thus referrals are not expected in 100% of cases.) Documentation
of referrals to Medicaid may not reflect the actual numbers of referrals that
are made; according to the NYSDOH, most plans make more referrals than are
documented. While the precise percentage of this sample that was Medicaid
eligible is unknown, we did cross-check the accuracy of insurers' calculation of
federal poverty level by calculating the percent of federal poverty level for
each family based on income documentation supplied; in 95 percent of documented
episodes, our calculation of percent of federal poverty level matched the
calculation by the insurer. Thus, insurers were quite accurate in recording
percent of federal poverty level when supporting documentation was present.
Insurers stated that the application process was complicated for families,
and that documentation of eligibility was often problematic because of patient
problems with lack of appropriate documents. Most parents, however, reported
that the application process was easy. Multiple documents and income worksheets
were utilized. The Child Health Plus application form has undergone revisions
over the past several years.
IV. RECOMMENDATIONS
This evaluation found that Child Health Plus was successful in meeting its
objectives. It has provided insurance to a large number of poor children from
primarily working families, most of whom were previously uninsured or
underinsured, or who would otherwise not be able to afford private insurance.
Child Health Plus resulted in increased access to primary care and specialty
care. It resulted in increased utilization of primary care, substantially
increased utilization of specialty care, no substantial change in emergency
department care, and a probable reduction in hospitalizations. Child Health Plus
improved the quality of care based on several dimensions such as preventive care
visit rates and use of appropriate services by children with chronic conditions,
but had no significant impact on other dimensions such as immunization
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
12
rates. The majority of parents reported that Child Health Plus improved their
child's health care, and a significant number reported that Child Health Plus
improved the health status of their child. Finally, parents reported a high
level of satisfaction with the program and with the ease of use of most aspects
of the program.
The evaluation also found that in 1993, 37 percent of children eligible
for Child Health Plus were enrolled in the program (29 percent of eligibles from
New York City and 50 percent from the other regions). Children from families
having the lowest income levels and minority children were under-represented in
Child Health Plus. Since Child Health Plus was found to have beneficial effects
on improving access to health care, utilization of primary care services, and on
some measures of quality of care a large number of eligible children could
benefit from enrollment in the program.
The evaluation illuminated potential areas for improvement in the
operations of Child Health Plus. Physicians identified a need for better
promotion of Child Health Plus to their patients and improved education of
parents about the program and its requirements. Parents noted a strong desire
for an increased benefit package in three areas: dental coverage, inpatient
coverage, and expansion of age limits. In fact, the lack of coverage for
inpatient services potentially compromises physicians' ability to provide
optimal care. Many parents reported that their child switched primary care
physicians after enrolling in Child Health Plus, which resulted in discontinuity
of care. The primary reason for changing providers, as reported by parents, was
that the prior physician did not accept Child Health Plus (55%), (i.e. prior
physicians were not participating in the networks of Child Health Plus
insurers). Results of the assessment of insurer documentation of eligibility
varied widely across plans; increased accountability may equalize performance.
Insurers were concerned about the frequency and scope of reporting required by
the Department of Health and about the complexity of the application process;
most parents, on the other hand, did not indicate problems with the application
process. Several aspects of Child Health Plus marketing worked well, however,
others could be improved including determination of marketing effectiveness and
more focused strategies targeting minority and poor populations. Marketing
contractors as well as insurers noted constraints of program requirements that
limited their abilities to adapt to changes in the Child Health Plus program.
The Child Health Plus program is a rapidly expanding program, with
enrollment increasing every year. While it was a relatively small program
several years ago, it is now a large-scale statewide program. Child Health Plus
has a dual role, providing both short-term "stopgap" insurance for some
families, and long-term coverage for many families. Given the overall success of
Child Health Plus, its rapid growth, its relatively successful model of
public-private partnership, and the likelihood of long-standing need for the
program, we believe it may be appropriate to redesign the Child Health Plus
program now in terms of its desired population size, benefit package and
structure, operations, and types and numbers of insurers. In keeping with the
public-private nature of the Child Health Plus program, New York State should
begin to handle the Child Health Plus program in a manner similar to that of
large purchasers of health benefits: monitoring access, utilization, quality and
costs, and restructuring the program to meet both the changing needs of clients
and our improved understanding of the impact of the program.
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
13
With the above findings and interpretations, we make recommendations
1 to 4:
A. RECOMMENDATIONS FOR PROGRAMMATIC CHANGES
1. NEW YORK STATE SHOULD ATTEMPT TO ENROLL A HIGHER PROPORTION OF ELIGIBLE
CHILDREN INTO CHILD HEALTH PLUS.
- TARGETED EFFORTS SHOULD BE IMPLEMENTED IN NEW YORK CITY, WHERE
THE PROPORTION OF ELIGIBLE CHILDREN ACTUALLY ENROLLED IN CHILD
HEALTH PLUS IS LOWER THAN THE REST OF THE STATE.
- PARTICULAR EMPHASIS SHOULD BE PLACED ON ENROLLING CHILDREN
FROM MINORITY FAMILIES AND FROM THE LOWEST INCOME CATEGORIES
WITHIN CHILD HEALTH PLUS ELIGIBILITY.
2. NEW YORK STATE SHOULD IMPROVE THE PROMOTION OF CHILD HEALTH PLUS.
- KEY SITES ARE PHYSICIAN'S OFFICES (MOST CHILDREN IDENTIFIED A
SOURCE OF CARE PRIOR TO CHILD HEALTH PLUS), SCHOOL, AND
COMMUNITY SETTINGS.
- MARKETING CONTRACTORS SHOULD DEVELOP BETTER STRATEGIES TO
REACH MINORITIES AND OTHER SPECIAL POPULATIONS.
- MARKETING CONTRACTORS SHOULD FUNCTION AS EDUCATORS, WITH THE
GOAL OF INCREASING THE KNOWLEDGE OF POTENTIAL APPLICANTS ABOUT
THE VALUE OF HEALTH INSURANCE AND PREVENTIVE HEALTH CARE, THE
VALUE AND USE OF HEALTH INSURANCE, AND THE APPLICATION PROCESS
(INCLUDING DOCUMENTATION OF ELIGIBILITY).
- CONTRACT RENEWAL TERMS AND EVALUATION OF MARKETING
CONTRACTORS' PERFORMANCE OF ACTIVITIES IN THE FUTURE SHOULD
ALLOW FOR REVISION OF MARKETING STRATEGIES BOTH OVER THE
LENGTH OF THE MARKETING CONTRACT AS WELL AS WITH CONTRACT
EXTENSIONS.
- MARKETING OBJECTIVES SHOULD BE CLEARLY DEFINED, AND INCLUDE
CLEARLY DEFINED AND CONSISTENT MECHANISMS FOR EVALUATING THE
EFFECTIVENESS OF THE MARKETING STRATEGIES (LINKING ACTIVITIES
TO CHILD HEALTH PLUS ENROLLMENT).
- MARKETING CONTRACTORS SHOULD UTILIZE A COMMON REPORTING
STRUCTURE.
3. NEW YORK STATE SHOULD EXPAND THE SCOPE OF CHILD HEALTH PLUS BENEFITS (IN
THE FOLLOWING ORDER OF PRIORITIES):
- AGE LIMITS SHOULD BE INCREASED.
- INPATIENT CARE SHOULD BE ADDED TO THE BASIC BENEFIT PACKAGE.
- DENTAL COVERAGE SHOULD BE ADDED TO THE BASIC BENEFIT PACKAGE.
4. NEW YORK STATE SHOULD CONSIDER RESTRUCTURING THE CHILD HEALTH PLUS PROGRAM
TO FACILITATE:
- ENTRY OF NEW INSURERS AND PROVIDERS;
- BETTER DOCUMENTATION OF ELIGIBILITY, INCLUDING ACCOUNTABILITY
FOR BETTER PERFORMANCE;
- EXPANSION OF THE BASIC BENEFIT PACKAGE (AS LISTED IN #3
ABOVE); AND
- ENHANCEMENT OF MARKETING EFFORTS.
As the purchaser of insurance, the State of New York must ensure that
Child Health Plus insurance plans are maintaining acceptable standards of access
and quality of care while controlling costs. Much as large employers are in the
process of developing reporting requirements that will allow them to evaluate
the insurance plans used by their employees, New York State must develop such
measures that are designed for the Child Health Plus population and for its
program objectives. Most of these measures are likely to be the same as ones
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
14
currently included in health insurance plan "Report Cards"; others may have to
be program-specific. These reports will have to be provided periodically,
enabling the state to monitor plan performance. In turn, Child Health Plus
enrollees will be able to use these reports in their selection of plans.
5. NEW YORK STATE SHOULD ESTABLISH CONSISTENT AND EFFECTIVE MECHANISMS FOR
ROUTINE MONITORING OF CHILD HEALTH PLUS, OR REEXAMINE CURRENT MECHANISMS
FOR USEFULNESS IN PROVIDING MEANINGFUL INFORMATION ABOUT THE FOLLOWING
COMPONENTS:
- ACCESS TO CARE;
- SPECIFIC MEASURES OF QUALITY OF HEALTH CARE; AND
- UTILIZATION AND COSTS OF CARE
MECHANISMS TO FACILITATE MONITORING INCLUDE:
- ON ENROLLMENT, PARENTS SHOULD BE ASKED TO PROVIDE CONSENT FOR
ONGOING CONFIDENTIAL REVIEWS OF MEDICAL RECORDS AND INSURANCE
CLAIMS BY THE STATE, WITH THE ASSURANCE THAT INDIVIDUAL-LEVEL
INFORMATION WILL NOT BE REPORTED OR RELEASED. THIS WOULD
PROVIDE AN AUDIT CAPABILITY FOR NEW YORK STATE.
- INSURERS SHOULD BE REQUIRED TO REPORT TO THE STATE THE SAME
WAY THEY REPORT TO ANY OTHER PAYER. THE STATE MAY CHOOSE TO
MANDATE A UNIFORM STRUCTURE FOR SUCH REPORTING.
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
FINAL REPORT
15
B. ISSUES FOR FUTURE STUDY
The current evaluation was not able to assess every aspect of the Child
Health Plus program. A number of key questions or issues were raised regarding
the health care of children on Child Health Plus. These issues include:
1. DIFFERENCES BETWEEN VARIOUS TYPES OF MANAGED CARE ORGANIZATIONS SHOULD BE
EXAMINED. The category "managed care" (with no further distinction) may be
too broad, since there are many variations in service delivery systems and
financial structures within managed care.
2. REASONS FOR THE LARGE PROPORTION OF PATIENTS WHO SWITCHED PROVIDERS AT
ENROLLMENT IN CHILD HEALTH PLUS SHOULD BE INVESTIGATED FURTHER. Switching
is a marker for discontinuity of care which potentially compromises
quality of care, and it should be minimized. Avenues for expanding options
for enrollees have been recommended above.
3. THE STATE SHOULD INVESTIGATE ALTERNATIVES FOR RESTRUCTURING CHILD HEALTH
PLUS TO ENSURE THAT EXPANSION TO NEW INSURERS IS ADEQUATE, RESULTING IN
CHOICE OF SEVERAL CHILD HEALTH PLUS INSURERS WITHIN EACH GEOGRAPHIC AREA.
4. FURTHER STUDY SHOULD FOCUS ON BARRIERS TO ENROLLMENT AND CARE FOR MINORITY
AND OTHER SUBPOPULATIONS, PARTICULARLY IN NEW YORK CITY. Such barriers may
attenuate the benefits of any insurance coverage, including Child Health
Plus. Strategies to overcome such barriers should be developed and
implemented.
5. STUDIES SHOULD EVALUATE THE APPROPRIATENESS OF CARE RECEIVED BY CHILD
HEALTH PLUS BENEFICIARIES, INCLUDING EMERGENCY DEPARTMENT USE, SPECIALTY
CARE, PRESCRIPTION DRUG USE, AND HOSPITALIZATIONS.
6. STUDIES SHOULD EVALUATE THE ABILITY AND WILLINGNESS OF PARENTS TO
CONTRIBUTE TO THE COST OF CARE VIA COPAYMENTS, MONTHLY PREMIUMS, OR ANNUAL
DEDUCTIBLES. While some inferences are available from the current study,
this evaluation was not designed to answer these questions and larger
sample sizes are needed to address the issue of cost-sharing.
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD PLUS
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16
Figure 1
PERCENT OF CHILDREN BY
RACE AND ETHNICITY
PARENT INTERVIEWS -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 2
PERCENT OF CHILDREN BY POVERTY LEVELS
PARENT INTERVIEWS -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 3
PERCENT OF CHILDREN WITH HEALTH INSURANCE PRIOR
TO CHILD HEALTH PLUS BY PRIOR INSURANCE TYPE
PARENT INTERVIEWS -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 4
PERCENT OF CHILDREN WHO HAVE SPECIFIC
TYPE OF PRIMARY CARE HOME DURING CHILD
HEALTH PLUS AND NUMBER OF MINUTES TO PROVIDER
PARENT INTERVIEW -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 5
PERCENT OF CHILDREN WHO CHANGED PRIMARY CARE
PROVIDERS AFTER ENROLLING IN CHILD HEALTH PLUS
PARENT INTERVIEW -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 6
NUMBER OF VISITS PER MEMBER PER YEAR
DURING CHPLUS BY REGION
MEDICAL CHART REVIEW -- PRESCHOOL CHILDREN (0-5 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 7
PERCENT OF CHILDREN WHO SAW A SPECIALIST
YEAR BEFORE AND YEAR DURING CHPLUS
PARENT INTERVIEW -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 8
NUMBER OF HOSPITALIZATIONS REPORTED
YEAR BEFORE AND YEAR DURING CHPLUS
PARENT INTERVIEW -- ALL CHILDREN (0-12 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 9
PERCENT OF CHILDREN UP-TO-DATE ON
IMMUNIZATIONS BY REGION
MEDICAL CHART REVIEW -- PRESCHOOL CHILDREN (0-5 YRS)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 10
PARENT REPORT OF CHANGE IN CHILD'S
HEALTH CARE
CHILDREN WITH CHRONIC CONDITIONS
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 11
PARENT REPORT OF CHANGE IN CHILD'S
HEALTH STATUS
CHILDREN WITH CHRONIC CONDITIONS
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 12
CHILD HEALTH PLUS EXPENDITURES PER
MEMBER PER YEAR BY REGION
CLAIMS ANALYSIS -- ALL AGES
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
Figure 13
CHILD HEALTH PLUS EXPENDITURES PER
MEMBER YEAR BY VISIT TYPE AND PLAN TYPE
(UPSTATE REGIONS ONLY)
[BAR CHART]
[PLOT POINTS TO COME]
ROCHESTER CHILD HEALTH STUDIES GROUP EVALUATION OF CHILD HEALTH PLUS
FINAL REPORT
APPENDIX D
QUARTERLY ENROLLMENT REPORT
NEW YORK STATE UNINSURED
PROJECT
QUARTERLY REPORT
CHILD HEALTH PLUS
REGIONAL PILOT PROJECTS
SECOND QUARTER, 1996
[LOGO]
N.Y.S. DEPARTMENT OF HEALTH
DIVISION OF HEALTH CARE FINANCING
BUREAU OF HEALTH ECONOMICS
NEW YORK STATE DEPARTMENT OF HEALTH
CHILD HEALTH PLUS
PROGRAM INFORMATION/USING THE DATA
Child Health Plus is a statewide program funded by an annual assessment from the
Statewide Bad Debt and Charity Care Pool. Direct subsidies are paid to fifteen
participating insurers to provide outpatient health insurance coverage to
children meeting certain eligibility criteria related to the child's age, family
income and health insurance status. Children born on or after June 1, 1980 and
under the age of 15 are eligible to enroll. Recent legislation now allows
children who had enrolled prior to their 15th birthday to remain in Child Health
Plus until age 16.
The Child Health Plus Quarterly Report contains summary data of the insurers'
enrollment progress and subscriber demographic information. The report is
derived from monthly enrollment data submitted by each insurer and aggregated on
a quarterly basis for the report period. The enrollment data presented on page 3
reflects only those children for whom a subsidy payment was made. The data
provided on pages 4 and 5 includes subsidized and non-Subsidized
enrollees.
INSURER SERVICE AREA
NEW YORK CITY METROPOLITAN AREA
Westchester PHSP Westchester, Rockland
The Bronx Health Plan, Inc. Bronx, Manhattan
Group Health Insurance, Inc. Bronx, selected zip codes in
Manhattan
Health Insurance Plan of Queens, Suffolk, Nassau
Greater New York
Health Plus Brooklyn, Richmond
Centercare (Manhattan PHSP) Manhattan
Empire Blue Cross/Blue Shield New York City, Long Island, Columbia,
Delaware, Dutchess, Orange, Putnam,
Rockland, Sullivan, Ulster and
Westchester counties
Blue Shield of Northeast NY Dutchess, Orange, Putnam,
Sullivan, and Ulster counties
1
UPSTATE
Community Health Plan Albany, Clinton, Columbia, Delaware,
Dutchess, Essex, Greene, Orange, Otsego,
Putnam, Rensselaer, Saratoga Schenectady,
Schoharie, Ulster, Warren and Washington
counties
Community Health Plan/ Madison, Cayuga, Tioga,
Health Services Medical Tompkins, Oswego, Herkimer,
Corp. (HSMC) Cortland, Oneida, Broome
and Onondaga counties
Community Health Plan/ Erie, Niagara,
Health Care Plan (HCP) Cattaraugus and Wyoming
Empire Blue Cross/Blue Shield Albany, Essex, Fulton, Greene,
Montgomery, Rensselaer, Saratoga,
Schenectady, Schoharie, Warren and
Washington counties
Blue Shield of Northeast NY Albany, Clinton, Columbia, Essex,
Fulton, Greene, Montgomery,
Rensselaer, Saratoga, Schenectady,
Schoharie, Warren and Washington
counties
Blue Cross/Blue Shield Chenango, Clinton,
Utica-Watertown, Inc. Delaware, Essex, Franklin, Fulton,
Hamilton, Herkimer, Jefferson, Lewis,
Madison (east), Montgomery, Oneida,
Oswego, Otsego and St. Lawrence counties
Blue Cross/Blue Shield Broome, Cayuga,
of Central NY, Inc. Chemung, Cortland, Madison (west),
Onondaga, Schuyler, Steuben, Tioga and
Tompkins counties
Blue Cross/Blue Shield of Livingston, Monroe,
Rochester Ontario, Seneca, Wayne and Yates counties
Blue Cross/Blue Shield of Allegany, Cattaraugus,
Western NY, Inc. Chautaugua, Erie, Genesee, Niagara,
Orleans and Wyoming counties
2
CHILD HEALTH PLUS ENROLLMENT
JUNE, 1996
[BAR CHART]
[PLOT POINTS TO COME]
ALL PLANS SUBSIDIZED ENROLLMENT 105,518 ADDITIONAL 603 NON-SUBSIDIZED
CHILDREN ALSO IN PROGRAM FOR A TOTAL ENROLLMENT OF 106.121
3
CHILD HEALTH PLUS ENROLLMENT
BY SUBSIDY AND AGE
SECOND QUARTER, 1996
[ENROLLMENT BY SUBSIDY LEVEL PIE CHART] [ENROLLMENT BY AGE PIE CHART]
[PLOT POINTS TO COME] [PLOT POINTS TO COME]
TOTAL ENROLLEES: 106,121
4
CHILD HEALTH PLUS ENROLLMENT
JANUARY 1994 - JUNE 1996
[LINE GRAPH]
[PLOT POINTS TO COME]
5
NEW YORK STATE DEPARTMENT OF HEALTH
REGIONAL PILOT PROJECTS
PROGRAM INFORMATION/USING THE DATA
The Regional Pilot Projects were developed to test, on a limited regional
basis, health care coverage models for possible application on a statewide
basis. The program is funded by an annual distribution from the Statewide Bad
Debt and Charity Care Pool.
There are two types of regional pilot programs: an individual subsidy
program and an employer incentive program. The first assists individuals and
families in purchasing health coverage through a direct subsidy. The second
assists employers in purchasing health care coverage for their employees.
Currently, there are four insurers participating in five Regional Pilot
Projects: three are individual subsidy programs and two are employer based.
The Regional Pilot Project Quarterly Report contains summary data on the
insurers' enrollment progress and descriptions of the employer groups
participating in the Employer Incentive Programs. The report is derived from
monthly enrollment data submitted by each insurer and aggregated on a quarterly
basis for the report period. Enrollment reflects subsidized subscribers and
their dependents receiving coverage through the Regional Pilot Projects.
INSURER SERVICE AREA
Community Health Plan Capital District, Hudson Valley and
Cooperstown Region
Health Insurance Plan of Brooklyn
Greater New York
The Bronx Health Plan, Inc. Bronx
Empire Blue Cross/Blue Shield
Downstate Selected zip codes in the upper west
side of Manhattan
Upstate Essex, Hamilton, Saratoga, Warren and
Washington counties
6
REGIONAL PILOT PROJECT
SUBSIDIZED ENROLLMENT
THROUGH JUNE, 1996
[REGIONAL PILOT PROJECT SUBSIDIZED ENROLLMENT BY PLAN BAR CHART]
[PLOT POINTS TO COME]
[REGIONAL PILOT PROJECT SUBSIDIZED ENROLLMENT BAR CHART]
[PLOT POINTS TO COME]
7
REGIONAL PILOT PROJECT
MONTHLY ENROLLMENT
JUNE, 1992 THROUGH JUNE, 1996
[LINE GRAPH]
[PLOT POINTS TO COME]
ALL PLANS TOTAL ENROLLMENT 8,178
8
REGIONAL PILOT PROJECT EMPLOYER BASED
PERCENTAGE OF ENROLLED FIRMS BY TYPE
THROUGH SECOND QUARTER, 1996
[COMMUNITY HEALTH PLAN PIE CHART] [HEALTH INSURANCE PLAN PIE CHART]
[PLOT POINT TO COME] [PLOT POINT TO COME]
9
REGIONAL PILOT PROJECT EMPLOYER BASED
PERCENTAGE OF FIRMS BY NUMBER OF EMPLOYEES
THROUGH SECOND QUARTER, 1996
[COMMUNITY HEALTH PLAN PIE CHART] [HEALTH INSURANCE PLAN PIE CHART]
[PLOT POINTS TO COME] [PLOT POINTS TO COME]
10
APPENDIX E
BENEFIT PACKAGE
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRO-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 1
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- ------------------- -------------------------------- ---------------------------------- ----------------------
Pediatric Well child care visits in Includes all services related to No copayment or
Health Promotion accordance with visitation visits. Includes immunizations, deductibles.
visits. schedule established by well child care, health education,
American Academy of tuberculin testing (mantoux),
Pediatrics, and the New York hearing testing, dental and
State Department of Health developmental screening, clinical
recommended immunization laboratory and radiological tests,
schedule. eye screening, and lead screening.
Inpatient Hospital As a registered bed patient No benefits will be provided for any No copayment or
Medical or Surgical for treatment of an Illness, out-of-hospital days, or if deductibles
Care injury or condition which inpatient care was not necessary;
cannot be treated on an no benefits are provided after
outpatient basis. The hospital discharge; benefits are paid in
must be a short-term, acute full for accommodations in a
care facility and New York semi-private room. Includes 365
State licensed. days per year coverage for
inpatient hospital services and
services provided by physicians and
other professional personnel for
covered inpatient services: bed and
board, including special diet and
nutritional therapy; general,
special and critical care nursing
service, but not private duty nursing
services, facilities, services,
supplies and equipment related to
surgical operations, recovery
facilities, anesthesia, and
facilities for intensive or special
care (but not services of the
surgeons or anesthesiologists unless
they are employees of the hospital
and their services are included in
the hospital bill); oxygen and other
inhalation therapeutic services and
supplies; drugs and medications that
are not experimental; sera,
biologicals, vaccines, intravenous
preparations, dressings, casts, and
materials for diagnostic studies;
blood products, except when
participation in a volunteer blood
replacement program is available to
the insured or covered person, and
services and equipment related to
their administration; facilities,
services, supplies and equipment
related to physical medicine and
occupational therapy and
rehabilitation; facilities, services,
supplies and equipment related to
diagnostic studies and the monitoring
of physiologic functions, including
but not limited to laboratory,
pathology, cardiographic, endoscopic,
radiologic and
electro-encephalographic studies and
examinations; facilities, services,
supplies and equipment related to
radiation and nuclear therapy;
facilities, services, supplies and
equipment related to emergency
medical care; chemotherapy; any
additional medical, surgical, or
related services, supplies and
equipment that are customarily
furnished by the hospital.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 2
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- --------------------- ---------------------------------- ----------------------------------- ------------------------------------
Professional Services Provides services on ambulatory No limitations. Includes wound $2 copayment for physician office
for Diagnosis and basis by a covered provider for dressing and casts to immobilize visits except for well-child care.
Treatment of Illness medically necessary diagnosis and fractures for the immediate
and Injury treatment of sickness and injury treatment of the medical condition.
and other conditions. Includes all Injections and medications provided
services related to visits. at the time of the office visit or
Professional services are provided therapy will be covered. Includes
on outpatient basis and inpatient audiometric testing where deemed
basis. medically necessary.
Outpatient Surgery Procedures performed within the The utilization review process must No copayments or deductibles
provider's office will be covered ensure that the ambulatory surgery
as well as "ambulatory surgery is appropriately provided.
procedures" which may be performed
in a hospital-based ambulatory
surgery service or a freestanding
ambulatory surgery center.
Durable Medical All DME must be medically necessary DME limited to wheelchairs, canes, No copayments or deductibles
Equipment and ordered by a plan physician. crutches, walkers and commodes.
Diagnostic and Prescribed ambulatory clinical No limitations. No copayment or deductibles
Laboratory laboratory tests and diagnostic
Tests. x-rays.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 3
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- ------------------------------------------------------------------------------------------------------------------------------------
Therapeutic Services. Ambulatory radiation No limitations. These therapies must be No copayment or
therapy, chemotherapy. medically necessary and under the supervision deductibles.
Injections and medications or referral of a licensed physician. Short term
provided at time of physical and occupational therapies will be
therapy (i.e., covered when ordered by a physician. No procedure
chemotherapy) will or services considered experimental will be
also be covered. reimbursed.
Hemodialysis Determination of the need for services and
whether home based or facility based treatment
is appropriate.
Pre-surgical testing All tests, (laboratory, Benefits are available if a physician orders the No copayments or
x-ray, etc) necessary tests; proper diagnosis and treatment require the deductibles
prior to inpatient or tests; and the surgery takes place within 7 days
outpatient surgery. after the testing. If surgery is can celled
because of pre-surgical test findings or as a
result of a Second Opinion on Surgery, the cost
of the tests will be covered.
Outpatient visits for Services must be provided Provides at least 60 outpatient visits per year. No copayment or
mental health and for the by certified and/or A minimum of 20 of the 60 visits may be used for deductibles.
diagnosis and treatment licensed professionals. family therapy visits related to the alcohol
of alcoholism and abuse. A maximum of 20 of the 60 visits may be
substance abuse. for mental health.
Prescription Drugs. Prescription medications Prescriptions must be medically necessary. May be $1.00 - $3.00 per
must be authorized by a limited to generic medications where medically prescription.
professional licensed to acceptable. Includes family planning or
write prescriptions. contraceptive medications or devices. All
medications used for preventive and therapeutic
purposes will be covered. Vitamin coverage need
not be mandated except when necessary to treat a
diagnosed Illness or condition.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
[ILLEGIBLE]4
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- --------------------- ----------------------------------- ----------------------------------- ----------------------
Home Health The care and treatment of a covered Home care shall be provided by a No copayment or
Care Services person who is under the care of a certified home health agency deductibles.
physician but only if possessing a valid certificate of
hospitalization or confinement in a approval issued pursuant to article
skilled nursing facility would thirty-six of the public health
otherwise have been required if law. Home care shall consist of one
home care was not provided and the or more of the following: part-time
plan covering the home health or intermittent home nursing care
service is established and approved by or under the supervision of a
in writing by such physician. registered professional nurse
(R.N.), part-time or intermittent
home health aide services which
consist primarily of caring for the
patient, physical, occupational or
speech therapy if provided by the
home health agency and medical
supplies, drugs and medications
prescribed by a physician, and
laboratory services by or on behalf
of a certified home health agency
to the extent such items would have
been covered or provided under the
contract if the covered person had
been hospitalized or confined in a
skilled nursing facility. The
contract must provide at least
forty such visits in any
calendar year.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 5
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- --------------------- ----------------------------------- ----------------- -----------------------------------
Emergency For services to treat an emergency No limitations. A $35.00 copayment may be imposed
Medical condition in hospital facilities. if the emergency room visit was
Services. For the purpose of this provision, made for a condition or illness not
"emergency condition" means a meeting the guidelines described in
medical or behavioral condition, the scope of coverage. This
the onset of which is sudden, that copayment may be waived if given
manifests itself by symptoms of the medical options available, the
sufficient severity, including emergency room was the most
severe pain, that a prudent appropriate site of service. A
layperson, possessing an average copayment of $35.00 is permissible
knowledge of medicine and health, when the beneficiary does not
could reasonably expect the inform the insurer within 24 hours
absence of immediate medical of use of such a service.
attention to result in (A)
placing the health of the person
afflicted with such condition in
serious jeopardy, or in the case
of a behavioral condition placing
the health of such person or
others in serious jeopardy, or
(B) serious impairment to such
person's bodily functions: (C)
serious dysfunction of any bodily
organ or part of such person; or
(D) serious disfigurement of such
person.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 6
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- ---------------- ----------------- ----------------- ----------------------
Maternity Care Inpatient hospital coverage for at least 48 No limitations; (however subsidized $2 copayment for
hours after childbirth for any delivery other children requiring maternity care physician office visits.
than a C-Section and in at least 96 hours services will be referred to Medicaid). All other services carry
following a C-Section. Also coverage of parent no copayment or
education, assistance and training in breast or deductible.
bottle feeding and any necessary maternal and
newborn clinical assessments. The mother shall
have the option to be discharged earlier than
the 48/96 hours, provided that at least one
home care visit is covered post-discharge.
Prenatal, labor and delivery care Is covered.
Dental Care Treatment in connection with accidental injury As stated No copayments or
to sound natural teeth within 12 months of the deductibles
accident.
Diabetic Insulin, Blood glucose monitors, blood As prescribed by a physician or other No copayments or
Supplies and glucose monitors for legally blind, data licensed health care provider legally deductibles
equipment management systems, test strips for authorized to prescribe under title
monitors and visual reading, urine test eight of the education law.
strips, insulin, injection aids,
cartridges for legally blind syringes,
insulin pumps and appurtenances thereto,
insulin infusion devices, oral agents.
CHILD HEALTH PLUS BENEFITS PACKAGE
(NO PRE-EXISTING CONDITION LIMITATIONS PERMITTED)
PAGE 7
GENERAL COVERAGE SCOPE OF COVERAGE LEVEL OF COVERAGE COPAYMENTS/DEDUCTIBLES
- ---------------- ----------------- ----------------- ----------------------
Diabetic Education and Diabetes self-management education Limited to visits medically necessary No copayments or
Home Visits (including diet); reeducation or where a physician diagnoses a significant deductibles.
refresher. Home visits for diabetic change in the patient's symptoms or
monitoring and/or education. conditions which necessitate changes in a
patient's self-management or where
reeducation is necessary. May be provided
by a physician or other licensed health
care provider legally authorized to
prescribe under title eight of the
education law, or their staff, as part of
an office visit for diabetes diagnosis or
treatment, or by a certified diabetes
nurse educator, certified nutritionist,
certified dietitian or registered
dietitian upon the referral of a
physician or other licensed health care
provider legally authorized to prescribe
under title eight of the education law
and may be limited to group settings
wherever practicable.
CHILD HEALTH PLUS
[ILLEGIBLE]
The following services will not be covered:
- - Experimental medical or surgical procedures.
- - Experimental drugs.
- - Inpatient Mental Health, Substance or Alcohol Abuse Services.
- - Drugs which can be bought without prescription, except as defined.
- - Private duty nursing.
- - Hospice services.
- - Home health care, except as defined.
- - Care in connection with the detection and correction by manual or
mechanical means of structural imbalance, distortion or subluxation in the
human body for the purpose of removing nerve interference and the effects
thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of or in the vertebral column.
- - Services in a skilled nursing facility or rehabilitation facility.
- - Cosmetic, plastic, or reconstructive surgery, except as defined.
- - In vitro fertilization, artificial insemination or other means of
conception and infertility services.
- - Services covered by another payment source.
- - Speech and hearing services, other than audiometric testing when deemed
medically necessary.
- - Durable Medical Equipment and Medical Supplies, except as defined.
- - Non-Emergency Transportation.
- - Dental care, except as defined.
- - Personal or comfort items.
- - Vision examinations performed by an optometrist for the purpose of
determining the need for corrective lenses, and If needed, to provide a
prescription other than ophthalmologic visits for diagnostic purposes.
- - Eyeglasses and hearing aids.
NEW YORK RECOMMENDED CHILDHOOD VACCINATION SCHEDULE
(ENDORSED BY NYS AND NYC DEPARTMENTS OF HEALTH)
Immunizations should be received at the earliest recommended age
A check [X] means your child is due for an immunization
1 2 4 6 12 15 4-6 11-12
AGE BIRTH MONTH MONTHS MONTHS MONTHS MONTHS MONTHS YEARS YEARS
--- ----- ----- ------ ------ ------ ------ ------ ----- -----
VACCINE
Hepatitis B(1) [X] [X] [X]
(Birth-2 (1-4 mo) (6-18 mo) [X](1)
mo)
Diphtheria and tetanus [X] [X] [X] [X] [X] [X]
toxoids and (acellular) (12-18 mo) (11-16 yr.Td)
pertussis vaccine(3)
Haemophilus influenzae
type b(4) [X] [X] [X](4) [X](4)
(12-15 mo)
Polio(5) [X] [X] [X]
(6-18 mo) [X]
Measles-mumps-rubella [X]
(12-15 mo)(4) [X]
Varicella-zoster [X] [X](7)
(12-18 mo)
Footnote explanations are printed on the reverse side.
( ) Indicates range of recommended ages for vaccination.
CHILDHOOD DISEASES ARE PREVENTABLE
- - The major childhood diseases are dangerous and can be crippling or even
deadly. THEY CAN BE PREVENTED WITH A COMPLETE SERIES OF IMMUNIZATIONS
GIVEN AT THE EARLIEST RECOMMENDED AGE.
- - Bring your child's official immunization record card to every visit with
a health care provider or WIC center. WIC STAFF WILL EXPECT CHILDREN TO BE
IMMUNIZED AT THE EARLIEST RECOMMENDED AGE.
- - Start at birth and continue to follow this schedule.
- - Your child may be eligible for low cost vaccines through the Vaccines for
Children Program.
- - Contact your health care provider or the local health department (see list
on reverse side) for assistance in locating providers in your community
who immunize. Or.in New York City, call 1-800-325-CHILD (English);
1-800-945-NINO (Spanish); elsewhere in New York State 1-800-522-5006
1. Infants born to HBsAg-negative mothers should receive 2.5 (mu)g of
Recombivax HB(R) (Merck) or 10 (mu)g of Engerix B(R) (Smith/Kline
Beecham). The second dose should be administered at least one month after
the first dose. Infants born to HBsAg-positive mothers should receive 0.5
ml hepatitis B immune globulin (HBIG) within 12 hours of birth, and either
5 (mu)g of Recombivax HB (R) or 10 (mu)g of Engerix-B(R) at a separate
site. The second dose is recommended at age one to two months and the
third dose at six months. Infants born to mothers whose HBsAg status is
unknown should receive either 5 (mu)g of Recombivax HB(R) or 10 (mu)g of
Engerix-B(R) within 12 hours of birth. The second dose of vaccine is
recommended at age one month and the third dose at age six months.
2. Adolescents who have not received three doses of hepatitis B vaccine
should initiate or complete the series at age 11-12 years. The second dose
should be administered at least one month after the first dose, and the
third dose should be administered at least four months after the first
dose and at least two months after the second dose.
3. The fourth dose of diphtheria and tetanus toxoids and pertussis vaccine
(DTP) may be administered at age 12 months, if at least six months have
elapsed since the third dose of DTP. Tripedix (R) (Connaught) diphtheria
and tetanus and acellular pertussis vaccine (DTaP) is licensed for the
first four doses for children aged two months, four months,six months, and
15-20 months. ACEL-IMUNE (R) (Lederle) dephtheria and tetanus and
acellular pertussis vaccine (DTaP) is only licensed for the fourth and
fifth vaccine dose (s) for children aged > or = 15 months. Tetanus and
diphtheria toxoids, adsorbed, for adult use (Td) is recommended at age
11-12 years if at least five years have elapsed since the last dose of
DTP, DTaP or diphtheria and tetanus toxoids, adsorbed, for pediatric use
(DT).
4. Three Haemophilus influenzoe type b (Hib) conjugate vaccines are licensed
for infant use. If pedvax HIB (R) (Merck) Haemophilus b conjugate vaccine
(PRP.OMP) is administered at ages two and four months, a dose at six
months is not required. After completing the primary series, any Hib
conjugate vaccine may be used as a booster.
5. Oral poliovirus vaccine (OPV) is recommended for routine infant
vaccination. Inactivated poliovirus vaccine (IPV) is recommended for
persons with a congenital or acquired Immune deficiency disease or an
altered immune status as a result of disease or immunosuppressive therapy,
as well as their household contacts, and is an acceptable alternative for
other persons. The primary three-dose series for IPV should be given with
a minimum interval of four weeks between the first and second doses and
six months between the second and third doses.
6. 12 months in NYC. 12.15 months in the rest of the state.
7. Unvaccinated children who lack a reliable history of chickenpox should be
vaccinated at age 11-12 years.
Use of trade names and commercial sources is for identification only and does
not imply endorsement by the New York State or New York City Health Departments.
Influenza vaccine is recommended for children in high-risk groups between the
ages of six months and 18 years of age. High risk would include children who
have long-term heart or lung problems, kidney disease, cystic fibrosis or a
chronic metabolic disease such as diabetes, anemia or asthma.
Pneumococcal vaccine is recommended for children who are two years of age or
older in high-risk groups. High risk would include individuals who have abnormal
or removed spleens, sickle cell disease, nephrotic syndrome, cerebral spinal
fluid leaks or who have disease or take drugs that lower their body's resistance
to infection.
Source: Advisory Committee on Immunization Practices, American Academy of
Pediatrics and American Academy of Family Physicians.
COUNTY HEALTH DEPARTMENTS
Albany (518) 447-4612 Franklin (518) 483-6767 Onondaga (315) 435-3236 Steuben (607) 776-9631
Allegany (716) 268-9256 Fulton (518) 762-0720 Ontario (716) 396-4343 Suffolk (516) 853-3055
Broome (607) 778-2804 Genesee (716) 344-8506 Orange (914) 291-2330 Sullivan (914) 292-0100
Cattaraugus (716) 373-8050 Greene (518) 943-6591 Orleans (716) 589-3269 Tioga (607) 687-8600
Cayuga (315) 253-1404 Hamilton (518) 648-6141 Oswego (315) 349-3547 Tompkins (607) 274-6616
Chautauqua (716) 753-4491 Herkimer (315) 866-7122 Otsego (607) 547-4230 Ulster (914) 340-3070
Chemung (607) 737-2028 Jefferson (315) 782-9289 Putnam (914) 278-6086 Warren (518) 761-6415
Chenango (607) 337-1660 Lewis (315) 376 5449 Rensselaer (518) 270-2655 Washington (518) 746-2400
Clinton (518) 565 4848 Livingston (716) 243-7290 Rockland (914) 364-2662 Wayne (315) 946-5749
Columbia (518) 828 3358 Madison (315) 363-5490 St.Lawrence (315) 265-3730 Westchester (914) 593-5062
Cortland (607) 753-5203 Monroe (716) 274-6151 Saratoga (518) 584-7460 Wyoming (716) 786-8890
Delaware (607) 746-3166 Montgomery (518) 853-3531 Schenectady (518) 346-2187 Yates (315) 536-5160
Dutchess (914) 486-3419 Nassau (516) 571-1680 Schoharie (518) 295-8474
Erie (716) 858-6450 Niagara (716) 694-5454
RECOMMENDATIONS FOR PREVENTIVE PEDIATRIC HEALTH CARE
COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE
Each child and family is unique; therefore, these Recommendations for
Preventive Pedlatric Health Care are designed for the care of children who are
receiving competent parenting, have no manifestations of any important health
problems, and are growing and developing in satisfactory fashion. Additional
visits may become necessary it circumstances suggest variations from normal.
These guidelines represent a consensus by the Committee on Practice and
Ambulatory Medicine in consultation with national committees and sections of the
American Academy of Pediatrics. The Committee emphasizes the great importance
of continuity of care in comprehensive health supervision and the need to avoid
fragmentation of care.
A prenatal visit is recommended for parents who are at high risk, for first time
parents, and for those who request a conference. The prenatal visit should
include anticipatory guidance and pertinent medical history. Every infant should
have a newborn evaluation after birth.
INFANCY(3) EARLY CHILDHOOD(3) MIDDLE CHILDHOOD(3)
AGE(4) NEWBORN(1) 2.4d(2) By 1mo 2mo 4mo 6mo 9mo 12mo 15mo 18mo 24mo 3y 4y 5y 6y 8y 10y
HISTORY
Initial/Interval - - - - - - - - - - - - - - - - -
MEASUREMENTS
Height and Weight - - - - - - - - - - - - - - - - -
Head Circumference - - - - - - - - - - - - - - - - -
Blood Pressure
SENSORY SCREENING
Vision S S S S S S S S S S S O(5) O O S S O
Hearing(6) S/O S S S S S S S S S S O O O S S O
DEVELOPMENTAL/ - - - - - - - - - - - - - - - - -
BEHAVIORAL
ASSESSMENT(7)
PHYSICAL
EXAMINATION(8) - - - - - - - - - - - - - - - - -
PROCEDURES -
GENERAL(9)
Hereonary/Metabolic
Screening(10)
Immunization(11) - - - - - - -
Lead Screening(12) - -
Hematocnt or
Hemoglobin - -
Unnalysis
PROCEDURES-PATIENTS -
AT RISK
Tuberculin Test(15) - - - - - - - - - -
Cholesterol Screening
(16) - - - - - - - - - -
STD Screening(17)
Pelvic Exam(18)
ANTICIPATORY
GUIDANCE(19) - - - - - - - - - - - - - - - - -
Injury Prevention
(20) - - - - - - - - - - - - - - - - -
INITIAL DENTAL
REFERRAL(21) -
ADOLESCENCE(3)
AGE(4) 11y 12y 13y 14y 15y 16y 17y 18y 19y 20y 21y
HISTORY
Initial/Interval - - - - - - - - - - -
MEASUREMENTS
Height and Weight - - - - - - - - - - -
Head Circumference
Blood Pressure - - - - - - - - - - -
SENSORY SCREENINGs
Vision S O S S O S S O S S S
Hearing(6) S O S S O S S O S S S
DEVELOPMENTAL/
BEHAVIORAL
ASSESSMENT(7) - - - - - - - - - - -
PHYSICAL
EXAMINATION(8) - - - - - - - - - - -
PROCEDURES -
GENERAL(9)
Hereonary/Metabolic
Screening(10)
Immunization(11) -
Lead Screening(12)
Hematocnt or
Hemoglobin -
Unnalysis -
PROCEDURES-PATIENTS
AT RISK
Tuberculin Test(15) - - - - - - - - - - -
Cholesterol Screening
(16) - - - - - - - - - - -
STD Screening(17) - - - - - - - - - - -
Pelvic Exam(18) - - - - - - - - - - -
ANTICIPATORY
GUIDANCE(19) - - - - - - - - - - -
Injury Prevention
(20) - - - - - - - - - - -
INITIAL DENTAL
REFERRAL(21)
1 Breastleading encouraged and instruction and support offered.
2 For newborns discharged in less than 48 hours after delivery.
3 Development,psychosocial and chronic disease issues for children and
adolescents may require frequent counseling and treatment visits separate
from preventive care visits.
4 If a child comes under care lot the last time at any point on the schedule
or if any items are not accompunished at the suggested age. The schedule
should be brought up to date at the earliest possible time.
5 If the patient is uncooperative rescreen within six months.
6 Some experts recommand objective appraisal of hearing in the newborn
period. The joint committee on infant Hearing has identified patients at
significant risk for hearing loss. All children meating these criteria
should be objectively screened. See the Joint Committee on infant Hearing
1994 Position Statement.
7 By history and appropriate physical examination if suspicious by specific
objective development testing.
8 At each visit, a complete physical examination is essential with infant
totally unclothed older child undressed and suitably draped.
9 These may be modified depending upon entry point into schedule and
individual need.
10 Metabolic screening lag thyroid hemoglonopathes PKU galaclosemias should
be done according to state law.
11 Schedule(s) per the Committee on Infectious Diseases published
periodically in Pediatics. Every visit should be an opportunity to update
and complete a child's immunications.
12 Blood lead screen per AAP statement Lead Poisoning From Screening to
Primary Prevention [1993].
13 All menstrating adolescents should be screened.
14 Conduct dispatch unnalysis for lauhcoyetes for male and female
adolescents.
15 TB testing per AAP statement "Screening for Tuberculosis an infants and
Children" (1994). Testing should be done upon recognition of high risk
factors of results are negative but high risk situation continues. Testing
should be repeated on an annual basis.
16 Cholesterol screening for high risk patients per AAP "Statement on
Cholesterol" (1992) of family history cannot be ascertained and other risk
factors are present, screening should be at the discretion of the
physician.
17 All sexually active patients should be screened for sexually transmitted
diseases (STDs)
18 All sexually active females should have a palvic examination . A palvic
examination and routine pap smear should be offered as part of preventive
health maintenance between the ages of 18 and 21 years.
19 Appropriate discussion and counseling should be an integral part of each
visit for care.
20 From birth to age 12 refer to AAP's injury prevention program (TIPPs) as
described in " A Guide to Safety Counselling in Office Practice"(1994).
21 Earlier initial dental evaluations may be appropriate for some children.
Subsequent examinations as prescribed by dentist.
Key: - - to be performed
- to be performed for patients at risk
S - subjective by history
- objective by a standard testing method
-- > - the range during which a service may be provided, with the dot
indicating the preferred age.
< --
NB : Special chemical, Immunologic and endocrine testing is usually carried
out upon specific indications. Testing other than newborn (eg. inborn
errors of metabolism, sichie disease, etc.) is discrationary with the
physician.
The recommendations in this publication do not indicate and exclusive course of
treatment or serve as a standard of medical care. Variations,taking into account
individual circumstances, may be appropriate.
- - 1995 American Academy of Padistrics.
APPENDIX F
PROCEDURES AND REQUIREMENTS FOR
FILING OF RATES AND RATE FILING
GUIDELINES
Section 52.33 TITLE 11 INSURANCE
Section 52.33 Letter of submission.
A letter of submission in duplicate (single copy for individual forms
intended for delivery by domestic insurers exclusively outside New York) shall
be included in the filing, signed by a representative of the company authorized
to submit forms for filing or approval, containing the following:
(a) the identifying form number of each form submitted;
(b) if the form is a policy, the kind of accident and health by reference to
the statutory and regulatory authority therefore; and the kind of policy as
defined in section 52.5, 52.6, 52.7, 52.8, 52.9, 52.10 or 52.11 of this Part;
(c) a statement whether the form is new or supersedes an approved or filed
form or forms:
(d) if the form supersedes an approved or filed form, the form number and date
of approval or filing of the superseded form and any material differences from
the superseded form. If approval of the superseded form is still pending, the
form number, control number assigned by the department and the submission date;
(e) if the form had previously been submitted for preliminary review, a
reference to the previous submission and a statement setting out either:
(1) that the form agree precisely with the previous submission; or
(2) the differences from the form submitted for preliminary review;
(f) if the form is submitted in accordance with subdivision (c) of section
52.32 of this Part, identification of the prefiled group coverage;
(g) if the form is other than a policy, give the form number and approval date
of the policy or policies with which it will be used; however, if the form is
for general use, the department may accept a description of the type of policy
with which it may be used in lieu of the form number and approval date;
(h) if the form is a policy, the form numbers and dates of approval of any
applications previously approved to be used with the policy unless the
application is required to be attached to the policy upon submission;
(i) if the policy is designed to be used with insert page forms, a statement
of the insert page forms which must always be included in the policy and a list
of all optional pages, together with an explanation of their use;
(j) if the form of a domestic insurer is intended for delivery exclusively
outside New York:
(1) a statement explaining differences in provisions and premiums,
if any, from substantially comparable forms submitted or approved for delivery
in New York or a statement that the form is not readily comparable to any form
submitted or approved for delivery in New York; and
(2) the name of each state or jurisdiction in which the form is to
be delivered. Prompt notice shall be given to the department by a domestic
insurer whenever a form issued for delivery exclusively outside New York is
disapproved or approval is withdrawn by any state or jurisdiction.
HISTORICAL NOTE
Sec. filed Nov. 17.1972; repealed, new filed April 2, 1982
eff. Jan. 1, 1983.
Section 52.40 PROCEDURES AND REQUIREMENTS FOR FILING OF RATES.
The following provisions shall apply with respect to rates:
(a) GENERAL. (1) Supporting material for all rate filings shall be
separately set forth in an actuarial memorandum or covering letter
accompanying the rates being filed.
(2) All policies, forms manuals, schedules and other material
submitted shall be in duplicate.
(3) Rate changes, additions and deletions shall be made by
substituting, deleting or adding numbered pages to the rate manual or
schedule of rates.
316 Insurance (Reissued 7/95) 1-1-95
CHAPTER III POLICY CERTIFICATE PROVISIONS Section 52.40
(4) If a rate filing precedes the filing of a form, reference should
be made to the rate control number when the form is submitted. Subsequent
correspondence should refer to both control numbers.
(b) Prohibited rating practices. (1) No rates for any policy shall be
predicated on a level premium age-at-issue basis except:
(i) with respect to conversion policies issued in accordance
with sections 162 and 164 of the Insurance Law ; or
(ii) when the policy form is guaranteed renewable, is
noncancellable or provides that nonrenewal is subject to the consent
of the superintendent. Such consent may be given only with respect
to an entire class of insured upon request in writing and
determination by the superintendent that such nonrenewal is in the
best interests of the public.
(2) No rates for any policy shall be predicated upon a reduced
initial premium which is less than the pro rate portion of the applicable
annual premium.
(c) Required rate filings for individual insurance including franchise,
blanket insurance, and community-rated contacts of article IX-C corporations.
The following rules shall apply with respect to rates for individual insurance
including franchise, blanket insurance, and community-rated contracts of
article IX-C corporations:
(1) A rate filing shall accompany every policy, and rider or
endorsement affecting benefits, submitted to the department for approval.
Any subsequent change in rates applicable to any such policy, rider or
endorsement originally delivered or issued for delivery in New York shall
also be submitted to the department. If a rider or endorsement affects
benefits but does not result in a change of rates, a statement of such
fact shall constitute the rate filing.
(2) Every insurer shall file and maintain two current New York rate
manuals in convenient form. The active rate manual shall include rates for
policy forms currently available and being actively marketed, the inactive
rate manual shall include the currently applicable rates on policy forms
no longer available or being actively marketed where such rates have been
approved or filed subsequent to the effective date of this Part. Each
manual shall include the following:
(i) name of the insurer on each page:
(ii) index in alpha-numeric form number order;
(iii) identification by form number of each policy, rider or
endorsement to which the rates apply, and a list of riders and
endorsements which can be attached;
(iv) the schedule of rates, including, if any, policy fees,
rate changes at renewal, variations based upon age, sex, occupation
or other classification, separate charges for optional or
miscellaneous benefits, and if rates are graded by age, a statement
of whether the rates are level based on age-at-issue or attained age
at time of renewal;
(v) an outline of the essential benefits, coverage's,
limitations, exclusions, renewal conditions, limit of the related
policy forms, and the expected benefit ratio, defined in section
52.54(b) of this Part, which will be used under section 52.44 of
this Part in the monitoring of actual loss ratios.
(vi) an outline of the general rules pertaining to
underwriting limitations with respect to age, amounts and
classifications of eligible risks and, in the case of a rider or
endorsement, a complete list of the policy forms with which it will
be used;
(vii) an outline of the general underwriting rules and methods
of marketing the policy form, including, with respect to article
IX-C corporations, a rule providing that no community-rated contract
may be issued to a group whose experience under a group insurance
policy with any insurer, including such article IX-C corporation
indicates a rate in excess of the then current community rate;
however, this rule does, not apply to a group which does not have a
sufficient number of employees or members to qualify, under the
article IX-C corporation's underwriting rules, for experience
rating;
(viii) an occupational classification section or separate
manual; and
1-1-95 (Reissued 7/95) 317 Insurance
Section 52.40 TITLE 11 INSURANCE
(ix) the additional premium for impaired risks on a specified
impairment or class basis; applicable rate schedules may be stated
in dollar amounts or percentages of the standard premium; if classes
are used, the maximum classification for each impairment shall be
set forth.
(3) Every article IX-C corporation shall file and maintain current
the schedule of allowances used in connection with its contract forms.
(d) Rate filings for individual insurance, including franchise and blanket
insurance written by commercial carriers, and rate filings for community-rated
contracts of article 43 corporations and health maintenance organizations. All
rate filings subject to this subdivision shall include the following:
(1) With respect to rates accompanying the filing of new policy
forms, to the extent appropriate:
(i) the specific formulas and assumptions used in calculating
gross premiums;
(ii) the expected claim costs;
(iii) identification of morbidity and mortality tables or
experience studies used, sufficient explanation for evaluation of
their validity, including copies of such tables if they are not
currently published;
(iv) the published data of other insurers;
(v) with respect to article IX-C corporations, percentage
breakdown of the rates to show expected claims costs expenses,
contributions to statutory reserves and surplus;
(vi) the range of commission rates and other fees payable to
agents, brokers, salesmen or other persons except regularly salaried
employees, stated separately for new and renewal business;
(vii) identification of specific rate manual pages being
submitted or already on file applicable to each form and any pages
being replaced or withdrawn;
(viii) identification of any occupational classification
manual being submitted or already on file applicable to each form;
(ix) the expected future loss ratio, the loss ratio which will
be monitored under section 52.44 of this Part, and the related
minimum under section 52.45 of this Part. The expected future loss
ratio may recognize expected future dividends beyond the second
policy year as benefits, provided modifications are made in the
applicable minimum loss ratio, as described in section 52.45(e) of
his Part. Such dividends may be recognized as an offset to expected
premiums without such modifications to the applicable minimums.
Dividends expected to be paid within the first two policy years may
be recognized if the company agrees not to change the dividend scale
until two years from first issue:
(x) the expected less ratio by policy duration, where policy
years three and later may be combined;
(xi) demonstration of compliance with the gross premium
differential limitations as described in section 51.41 of this Part;
and
(xii) methods and assumptions to be used in approximating
earned premiums by duration for section 52.43(a)(1)(iii) of this
Part, if exact methods will not be used.
(2) With respect to rate revisions or additions to previously
approved rate filings of commercial carriers to the extent appropriate:
(i) complete experience since inception, both yearly and in
total, including the most recent calendar year if the submission is
as of May 1st or later. Include written and earned premiums,
dividends incurred, paid and incurred claims, each reserve, and
earned/incurred loss ratios;
(ii) complete experience, as above, but with premiums adjusted
to a single rate schedule, identifying the schedule, whether
experience is nationwide or New York State only, and the reserve
bases for each year:
318 Insurance (Reissued 7/95) 1-1-95
CHAPTER III POLICY, CERTIFICATE PROVISIONS SECTION 52.40
(iii) if applicable to policies issued prior to July 1, 1959,
the method of compliance with chapters 945 and 946, Laws of 1958
(Metcalf laws);
(iv) derivation of the proposed revision in detail. This
should include demonstration using interest assumptions from the
applicable expected future loss ratio calculations, that:
(a) the expected future loss ratio, using the experience
in subparagraph (ii) of this paragraph, projected through the
period when rates will be effective, is at least as large as
the larger benefit or loss ratio used in disclosure statements
for the form and that it meets the requirement of section
52.45 of this part. If expected dividends are included in the
calculation as benefits, then the demonstration must be that
the projected expected future loss ratio be a least as large
as the disclosed loss ratio when modified by section 52.45(e)
of this part;
(b) the expected lifetime loss ratio is at least as
large as the disclosed loss ratio. This demonstration may use
future dividends as in (a) and past dividends as benefits. If
no policy was issued subsequent to the effective date of the
ninth amendment to this regulation, no modification in
accordance with section 52.45(e) is necessary. Otherwise, such
modifications are necessary;
(c) for policies issued prior to January 1, 1983, the
minimum anticipated loss ratio applicable to the policy at
time of issue is to be used in place of the disclosed loss
ratio referred to in clauses (a) and (b) of this subparagraph;
(v) description, in detail, of policy benefits;
(vi) complete history of previous rate revisions;
(vii) first and last years of policy issue and date of
original form approval;
(viii) expected future loss ratio, expected lifetime loss
ratio, and expected loss ratios by duration, as of the date of
filing and as originally filed and the basis of each. If no such
loss ratios have been filed, the anticipated loss ratio as
originally filed;
(ix) a statement that the rates approved by the superintendent
will be applied to all policies originally delivered or issued for
delivery in New York, regardless of place of current residence;
(x) the accumulated value of each item in subparagraph (i) of
this paragraph, except for reserves, such accumulation being made
from the midpoint of each calendar year to December 31st of the most
recent year for which data is submitted. Such accumulation shall
employ the interest assumptions used in the applicable expected
future loss ratio calculation, and shall be used in the
demonstration required by subparagraph (iv) of this paragraph;
(xi) when a requested rate revision has been accepted for
approval, revised rate manual pages reflecting the revision. If the
revision is expressed as a percentage of existing rates, and the
rates are part of the inactive rate manual, the insurer may file a
single "multiplier" manual page duly referenced in the table of
contents, which reflects the approved percentage revision to be
applied to the manual pages which follow in lieu of a complete set
of revised rate manual pages.
(3) With respect to applications for revisions of previously
approved rates of article 43 corporations and health maintenance
organizations:
(i) information with respect to claim or utilization
frequencies, claim costs and expenses shown for all contracts and
riders, or for each coverage separately if more than one coverage is
provided by a contract or rider, for a period of at least two years
prior to the calendar year in which the new rates are effective,
even though rates for some contracts, riders or coverages are not
being changed;
(ii) the information required in subparagraph (i) of this
paragraph projected for a period not more than two years beyond the
effective date of the new rates;
(iii) a summary of projected changes in claim or utilization
frequency, average claim costs and expenses;
1-1-95 (Reissued 7/95) 319 Insurance
SECTION 52.40 TITLE 11 INSURANCE
(iv) the current financial condition of the corporation and
the financial condition projected to the effective date of the new
rates and to the end of the period during which the new rates will
be in effect;
(v) the projected operating results for the period during
which the new rates will be in effect, showing premiums, claims and
expenses;
(vi) such additional information as may be needed in order to
assist the superintendent in determining whether the application
shall become effective as filed, shall become effective as modified,
or shall be disapproved;
(vii) as respects rate adjustment applications where such
adjustment is only requested to reflect anticipated payments to or
from the demographic or specified medical condition pooling funds,
such applications shall contain such information as may be needed in
order to assist the superintendent in determining the amount of the
adjustment which is necessary in order to recognize such payments.
Such information shall be in lieu of the material requested in
subparagraphs (i), (ii), (iii) and (vi) of this paragraph; and
(viii) a jurat subscribed to by the corporation's president or
chief executive officer, treasurer or chief financial officer, and
chief actuary or, if the corporation has no chief actuary, the
person responsible for preparing this rate application. All
testimony of the corporation's directors, employees, agents or
representatives made at any public hearing ordered by the
superintendent with respect to the terms of this application shall
be subscribed to under oath. The form of this jurat shall be as
follows: (Note: Modify jurat if any of these persons are not in the
employment of the insurer or HMO.)
(insert name) , president (or chief executive officer) .(insert
name) , treasurer or chief financial officer) ,(insert name)
chief actuary (or person responsible for preparing this
application), of the (name of insurer or HMO) being duly sworn, each
deposes and says that they are the above described employees of the
said insurer or HMO and hereby affirm that the information in this
premium rate application including all schedules and exhibits
thereto has been prepared in accordance with the applicable
provisions of Parts 52,360 and 361 of Title 11 of the Official
Compilation of Codes, Rules and Regulations of the State of New York
(Regulations 62, 145 and 146) and the most recent instructions of
the New York State Insurance Department and to the best of their
knowledge and belief is accurate and complete.
__________________ __________________ __________________
President Treasurer Chief Actuary
Subscribed and sworn to before
me this day of
(e) Required rate filings for group insurance including master group
contracts of article IX-C corporations. The following rules shall apply with
respect to rates for group insurance including master group contracts of article
IX-C corporations:
(1) A rate filing shall accompany every policy, and rider or
endorsement affecting benefits submitted to the department for approval
unless schedules of rates or formulas applicable to such forms have been
previously filed, in which case the rates shall be identified by reference
to specific page number([ILLEGIBLE]) of the manual, formulas or schedules
on file. If the filing contains rate manual pages, the requirements
contained in paragraph (2) of this subdivision for group rate manual
submissions must be satisfied.
(2) Group rate manual submissions.
(i) Every insurer shall file and maintain current a schedule
of manual rates or formulas which, to the extent applicable, shall
include the following:
(a) the name of insurer on each page;
320 Insurance (Reissued 7/95) 1-1-95
CHAPTER III POLICY, CERTIFICATE PROVISIONS SECTION 52.40
(b) table of contents;
(c) an outline of the essential benefits, coverages,
limitations and exclusions to [ILLEGIBLE]. the rate applies;
(d) a schedule of the premium rates, rules and
classification of risks including any loading for age, sex and
industry;
(e) a definition of single risk for purpose of size
discounts;
(f) a definition and schedule of premium discounts for
self-administration or self-accounting;
(g) the manner of computation and instruction for
interpolating and extrapolating rates; and
(h) a schedule of commissions and fees.
(ii) The submission of rate manual pages should include the
following information separate from the rate manual pages:
(a) specific reference to sections, pages and edition
dates of rates submitted, deleted or revised; and
(b) justification of rates being submitted or revised,
including reference to relevant information used in the
development of such justification and a demonstration that the
applicable minimum loss ratio of section 52.45 of this Part
will be met.
(3) Filings of forms on a one-case basis shall include the following
information:
(i) insurer's name;
(ii) name and location of policyholder;
(iii) form number if a policy or, if a rider, the policy form
number to which the rider is attached;
(iv) an outline of the essential benefits, coverages,
limitations and exclusions to which the rate applies;
(v) if rates are derived from or contained in the group rate
manual, the specific page number(s) where the applicable rates are
found and the actual rates being used;
(vi) if rates for the form are neither derived from nor
contained in the group rate manual, the actual rate being used, the
nature and extent of any deviation from the manual rate and
justification for such deviation; and
(vii) a statement of consistency with filed rates.
(4) Every article IX-C corporation shall file and maintain current
the schedule of allowances used in connection with its contract forms.
(f) Experience-rated group insurance of insurers other than article 43
corporations. The following rules shall apply to the readjustment of the rate of
premium for those policies rated in accordance with subsections (g), (h) and (j)
of section 4235 of the Insurance Law.
(1) Policies may be experience-rated in accordance with a written
plan or formula approved by the board of directors of the insurer or
designee thereof, provided that:
(i) any such plan or formula shall not unfairly discriminate
between groups with similar risk characteristics (other than claim
experience, health status or duration since issue) with respect to
credibility factors, stop-loss limits or other rate fluctuation
controls;
(ii) the subparagraph of section 4235(c)(1) under which
coverage is written or the current availability of a particular plan
of insurance underwritten by the insurer for any such group are not
acceptable risk classification factors under any such plan or
formula, however, age, sex, occupation, location, industry, family
composition and other factors affecting utilization and expense are
acceptable risk classification factors; and
(iii) any such plan or formula shall not permit the selective
nonrenewal of a group or insured person thereunder solely because of
claim experience or health status.
1-1-95 (Reissued 7/95) 321 Insurance
SECTION 52.40 TITLE 11 INSURANCE
(2) Except as provided in paragraph (3) of this subdivision,
policies insuring less than 50 persons at the inception of the
experience-rating period, excluding dependents, may be experience-rated
in accordance with a plan or formula accepted for filing by the
superintendent, provided that:
(i) any such plan or formula shall not result in a renewal
rate for any group which is more than 50 percent higher than the
rate determined under the insurer's rate manual for new business
filed pursuant to subdivision (e) of this section for a group with
similar risk characteristics, notwithstanding claim experience,
health status or duration since issue. Where a policy form is no
longer available or actively marketed, the percentage change in the
maximum rate for each rating period shall not exceed the percentage
change in the new business rate for the same rating period for the
policy form with benefits most nearly comparable to the benefits
under the policy form which is no longer available or actively
marketed;
(ii) any such plan or formula shall not result in a rate
change for any group on renewal which exceeds the sum of:
(a) the percentage change in the new business rate for
such similar group from the first day of the prior period to
the first day of the new period, adjusted to reflect changes
in coverage or the group's risk characteristics,
notwithstanding claim experience, health status, or duration
since issue; and
(b) 15 percent adjusted pro rata for rating periods less
than one year. Where a policy form is no longer available or
actively marketed, the maximum rate change on renewal shall
not exceed the maximum renewal rate change as described in the
previous sentence for the current actively marketed policy
form with benefits most nearly comparable to the benefits
under the policy form which is no longer available or actively
marketed;
(iii) any such plan or formula shall not permit the use of a
group's claims experience, health status or duration since issue in
readjusting the rate of premium until the number of employee or
member life/years of experience equals or exceeds 50 and shall
adjust a group's incurred claims to remove unexpected,
nonrecurring, catastrophic claims; and
(iv) any such plan or formula shall describe the risk
classification factors, underwriting rules and participation
requirements as well as transition rules applicable to existing
groups with significant composition changes or to the negotiated
takeover of one or more classes of policies of another insurer.
(3) The rate of premium for policies insuring less than 50 persons
at the inception of the rating period, excluding dependents, shall not be
readjusted based upon claim experience, health status or duration of
coverage since issue where:
(i) each person covered must satisfy the insurer's evidence of
insurability requirements when initially eligible for coverage under
the policy; or
(ii) the group or persons representing such group are not
provided with reasonable written disclosure as part of the
solicitation and sales materials, of the extent to which a group's
claims experience, health status or duration since issue will be
used by the insurer to establish or adjust the rate of premium for
such group.
(4) Experience of a preceding insurer or insurers may be relied on
to the extent such experience is available according to a plan or formula
filed with the department to produce higher or lower rates than those
otherwise applicable in the first policy year.
(5) Any provision contained in the policy with respect to
retrospective rate adjustment or retention by the insurer shall be based
on specific factors used in retrospective rating formulas or plans filed
with the department.
(6) For purposes of this subdivision, the terms group and policy
shall also refer to employers which establish or participate in groups
described in subparagraph (B), (D) or (H) of section 4235(c)(1) of the
Insurance Law and to the insurance written thereunder which insures the
employees of such employers.
322 Insurance (Reissued 7/95) 1-1-95
CHAPTER III POLICY CERTIFICATE PROVISIONS SECTION 52.40
(7) The superintendent may accept for filing a plan or formula, or
an amendment thereof which does not comply with one or more of the rules
contained in this subdivision satisfactory demonstration that such
noncompliance is reasonably related to the [ILLEGIBLE[ condition of the
insurer and will not result in rates which are unreasonable, inequitable
or untair under the circumstances.
(g) Experience-rated group insurance of article IX-C corporations. The
following rules shall apply to the adjustment of the rate of premium based on
the experience of any contract of master group insurance as provided for under
section 253(6)(a) of the Insurance Law:
(1) Contracts of master group insurance may be experience-rated only
in accordance with a formula or plan previously furnished to the
department. Such formula or plan shall include a retention designed to
provide for a contribution to surplus.
(2) Any such plan or formula of experience rating may include
provision for a rate stabilization reserve provided that the terms under
which the rate stabilization reserve is created are included in the master
group contract or separate written agreement previously approved by the
department and which upon termination of the group contract impose an
obligation on the plan in respect to the application of the funds
represented by such reserve.
(3) Experience of a preceding insurer or insurers may be relied on
to the extent available according to a plan or formula filed with the
department to produce higher or lower rates than those otherwise
applicable in the first policy year.
(h) Special rules for rates applicable to benefits under the disability
benefits law. The following rules shall be applicable with respect to policies
providing statutory benefits pursuant to article IX of the Workers' Compensation
Law:
(1) Rate schedules for groups of 50 or more insured persons shall be
based on a premium for each $10 of weekly benefit or a percentage of
weekly payroll. Such weekly payroll shall be limited to two times the
maximum weekly disability benefits law benefit per employee.
(2) For groups of less than 50 insured persons, a simplified rate
structure such as monthly per capita rates may be used.
(i) Special rules for franchise insurance rates. The following rules shall
apply to rates for franchise insurance:
(1) Rates shall not unfairly discriminate between cases of the same
class. Rates may recognize age, sex, occupation, location, industry,
marital status, family composition and other factors affecting
utilization.
(2) With respect to employee-employer franchise, rates shall be
self-supporting and reasonably related to the mortality and morbidity
assumptions used by the insurer for group insurance, execpt where it is
demonstrated to the satisfaction of the superintendent that some other
basis is appropriate.
(3) With respect to association or union franchise:
(i) Rates shall be self-supporting and shall be reasonably
related to the mortality and morbidity assumptions used by the
insurer for individual insurance, except where it is demonstrated to
the satisfaction of the superintendent that some other basis is
appropriate. Rates may differ from those used for comparable
individual accident and health insurance if it is shown to the
satisfaction of the superintendent that any difference results from
demonstrable savings in marketing, underwriting, policy issue and
administrative expenses. If no comparable plan of individual
insurance is filed or approved for the insurer, rates used by the
insurer for comparable group insurance shall be deemed to be
self-supporting if it is shown to the satisfaction of the
superintendent that marketing, underwriting, policy issue,
administrative, mortality and morbidity costs will not exceed those
for such group insurance.
(ii) Franchise cases may be experience-rated on the basis of
an equitable plan or formula approved by the superintendent
applicable to all franchise cases of the same class.
(j) Group commissions, compensations, fees and allowances. Schedules of
rates of commissions, compensation, fees and allowances required to be filed
under section 221(7) of the
1-1-95 (Reissued 7/95) 323 Insurance
SECTION 52.40 TITLE 11 INSURANCE
Insurance Law shall be filed as part of the group rate manual and shall contain
at least the following information:
(1) the basis upon which such schedules apply (e.g., a percentage of
the annual premium, a dollar amount per certificate, or a dollar amount
per $100 of weekly indemnity);
(2) if applicable to premiums, the premiums to which they apply
(e.g.. monthly, annual, first year or renewal);
(3) any variations in the application of such schedules based on
policy years, alternative scales, grading, type of coverage, category of
agent, territories or any other variable including a clear explanation of
the variable;
(4) if based on administrative services, the nature of the services
and the allowances therefor; and
(5) the applicability of any revisions and identification of pages
being added, deleted or substituted.
(k) Special rules for the submission of rates and supporting documentation
applicable to individual and group Medicare supplement policies. The following
rules shall be applicable in addition to the other requirements of this section.
(1) All filings of rates and rating schedules shall demonstrate that
expected claims in relation to premiums comply with the requirements of
section 52.45(i) of this Part when combined with actual experience to
date. Filings of rate revisions shall identify the number of persons
insured under the New York issued policies or certificates for which
revision is requested and shall also demonstrate that the anticipated loss
ratio over the entire future period for which the revised rates are
computed to provide coverage can be expected to meet the appropriate loss
ratio standards.
(2) An issuer of Medicare supplement policies and certificates
issued before or after May 1, 1992 in this State shall file annually with
the submission required in paragraph (3) of this subdivision its rates,
rating schedule and supporting documentation including ratios of incurred
losses to earned premiums by policy duration for approval by the
superintendent in accordance with the filing requirements and procedures
prescribed by the superintendent. The supporting documentation shall also
demonstrate in accordance with actuarial standards of practice using
reasonable assumptions that the appropriate loss ratio standards can be
expected to be met over the entire period for which rates are computed.
Such demonstration shall exclude active life reserves. An expected
third-year loss ratio which is greater than or equal to the applicable
percentage shall be demonstrated for policies and certificates in force
less than three years.
(3) As soon as practicable, but prior to the effective date of
enhancements in Medicare benefits, every issuer of Medicare supplement
policies or certificates in this State shall file with the superintendent,
in accordance with the applicable filing procedures of this State:
(i) appropriate premium adjustments necessary to produce loss
ratios as anticipated for the current premium for the applicable
policies or certificates. Such supporting documents as necessary to
justify the adjustment shall accompany the filing; and
(ii) an issuer shall make such premium adjustments as
necessary to produce an expected loss ratio under such policy or
certificate as will conform with minimum loss ratio standards for
Medicare supplement policies and which are expected to result in a
loss ratio at least as great as that originally anticipated in the
rates used to produce current premiums by the issuer for such
Medicare supplement policies or certificates.
(4) Except for nonprofit health service, hospital service or medical
expense indemnity corporations, no premium adjustment which would modify
the loss ratio experience under the policy other than the adjustments
described in paragraph (3) of this subdivision shall be made with respect
to the policy at any time other than upon its renewal date or anniversary
date, as may be approved by the superintendent.
(5) In addition to any other requirement of the Insurance Law, the
superintendent shall order that a public hearing be held with respect to
the terms of a filing or application by or on behalf of an issuer for an
increase in premiums for Medicare supplement insurance policies or
324 Insurance (Reissued 7/95) 1-1-95
CHAPTER III POLICY. CERTIFICATE PROVISIONS SECTION 52.42
certificates when such rate filing or application is for an increase of
more than 15 percent in a 12-month period or such increase will be made on
a policy or certificate form covering 10,[ILLEGIBLE] or more insureds in
New York State. Public notice of such hearing shall be furnished
[ILLEGIBLE] manner consistent with the requirements of section 4308(c)(2)
of the Insurance Law.
HISTORICAL NOTE
Sec. filed April 6, 1973; repealed, new filed April 2, 1982;
amds. filed: June 26, 1984 as emergency measure, expired 60 days
after filing; Sept. 14, 1984; Jan. 29, 1991; March 12, 1992; Aug.
16, 1993 as emergency measure; Oct 19, 1993 eff. Nov. 3, 1993.
Amended (d).
SECTION 52.41 GROSS PREMIUM DIFFERENTIALS BASED ON SEX.
(a) The following requirements are established to limit maximum gross
premium differentials between males and females for all accident and health
policies or coverages where the insurance premium is paid by the insured:
(1) Net or gross premium assumptions may differentiate between the
sexes only for factors based on differences in morbidity or mortality
between males and females.
(2) Lapse and average size assumptions may not differ between males
and females unless the insurer demonstrates to the satisfaction of the
superintendent that the difference has a relationship to the morbidity or
mortality assumptions such that the resulting rates are not unfairly
discriminatory.
(b) Net premium differentials shall be determined on one or more of the
following bases:
(1) a statistical analysis of the company's own experience, if
credible;
(2) published credible experience, such as the morbidity studies of
the Society of Actuaries and the studies made by the New York Insurance
Department;
(3) any other valid data; or
(4) any combination of paragraph (1), (2) or (3) of this
subdivision.
(c) Gross premium differentials between sexes in the same premium cell may
reflect only the net premium differentials and those expenses which are directly
related to the amount of premiums or claims (e.g., premium taxes, commissions,
some claims administration expense). All other loadings for expenses shall be in
the same amounts in dollars for both sexes. A company may utilize a simplified
loading system if it can demonstrate that such system does not produce gross
premium differentials which are generally greater than those generated by the
method prescribed in this section, nor appreciably greater for any cell in the
premium scale.
(d) Unisex rates are approvable for individual accident and health
insurance if all rates for such individual insurance coverages offered by the
company are charged on a unisex basis, unless the insurer demonstrates to the
satisfaction of the superintendent that use of unisex rates for only some
coverages is not unfairly discriminatory. This limitation does not apply to
group, blanket or franchise insurance.
HISTORICAL NOTE
Sec. filed April 27, 1977; repealed, new filed April 2, 1982 eff. Jan, 1, 1983.
SECTION 52.42 HEALTH MAINTENANCE ORGANIZATION (HMO) CONTRACT FORMS AND PREMIUM
RATES.
(a) Requirement for prior approval of forms and rates. (1) Contracts,
certificates, applications, riders and endorsements used by an HMO to
provide benefits and their proposed rates must be filed with and approved
by the superintendent in accordance with section 4308 of the Insurance
Law.
(2) Reasonable differentials between group and direct payment rates
may be established to reflect differences in marketing costs as well as
different administrative costs in collecting payments from direct pay
contract holders.
(3) The premium adjustments of all community rated contracts are
subject to the provisions of section 4308 of the Insurance Law.
1-1-95 Reissued 7/95) 325 Insurance
APPENDIX F
CHILD HEALTH PLUS INSURANCE PLAN
RATE FILING GUIDELINES
The rate filing shall consist of the following:
1. An outline of the essential benefits, coverage, limitations and
exclusions.
2. Premium rate sheets.
3. Actuarial memorandum that will include the following:
a. The specific formulas, methods, and assumptions used in calculating
premium rates including information on utilization frequencies,
average charges, gross PMPM cost, co-payment PMPM, and net PMPM
cost. Identify the sources of the claim cost data used and any
modifications made thereto.
b. Please identify any special assumptions you have made with respect
to:
i. children under one year of age; and
ii. children ages 15 to 19.
c. Comparison of the proposed rates with the currently approved rates,
as applicable, for similar benefits and populations. Relate the
basic assumptions in item a. above to those of the currently
approved rates and support any variations in assumptions with
actuarial justifications.
d. Experience, if any, on an existing Child Health Plus plan.
e. Expected incurred loss ratio.
f. Expense components of the premium (administrative expenses,
contribution to statutory reserves and surplus, etc.)
g. Certification by your actuary (or appropriate financial officer)
stating that the rate filing is in compliance with the applicable
laws and regulations of the State of New York and that the proposed
rates are reasonable in relation to the benefits provided.
4. Identify the specific counties that you propose to cover with this plan.
5. All rate filing material shall be in duplicate and each page of the rate
filing shall display the name of the corporation and subscriber contract
number.
6. Please provide a telephone number and facsimile number of your actuary or
other person(s) best able to respond to questions concerning your filing.
Attached are examples of an acceptable rate filing and premium rate
sheets.
PREMIUM RATE DEVELOPMENT FOR CHILD PLAN NAME: __________________________
HEALTH PLUS INSURANCE PLAN
BASE PERIOD - ACTUAL EXPERIENCE MEMBER MONTHS: ______________________
- -----------------------------------------------------------------------------------------------------------------------
SERVICE ACTUAL AVERAGE PMPM CO-PAYMENT CO-PAY NET
FREQUENCY CHARGE PMPM PMPM
- -----------------------------------------------------------------------------------------------------------------------
- -----------------------------------------------------------------------------------------------------------------------
Hospital Services
- -----------------------------------------------------------------------------------------------------------------------
Inpatient Utilization
(Admissions)
- -----------------------------------------------------------------------------------------------------------------------
Emergency Room
- -----------------------------------------------------------------------------------------------------------------------
Hospital Outpatient
- -----------------------------------------------------------------------------------------------------------------------
Radiotherapy/Chemotherapy
- -----------------------------------------------------------------------------------------------------------------------
Outpatient Surgery
- -----------------------------------------------------------------------------------------------------------------------
Ambulance
- -----------------------------------------------------------------------------------------------------------------------
Physician
- -----------------------------------------------------------------------------------------------------------------------
Ambulatory Office Visits
- -----------------------------------------------------------------------------------------------------------------------
PCP
- -----------------------------------------------------------------------------------------------------------------------
Admission Fee
- -----------------------------------------------------------------------------------------------------------------------
Specialty
- -----------------------------------------------------------------------------------------------------------------------
Inpatient Hospital Visits
- -----------------------------------------------------------------------------------------------------------------------
Emergency Room Visits
- -----------------------------------------------------------------------------------------------------------------------
Miscellaneous Office Visits
- -----------------------------------------------------------------------------------------------------------------------
Surgery
- -----------------------------------------------------------------------------------------------------------------------
Inpatient
- -----------------------------------------------------------------------------------------------------------------------
Outpatient
- -----------------------------------------------------------------------------------------------------------------------
X-Ray
- -----------------------------------------------------------------------------------------------------------------------
Anesthesia
- -----------------------------------------------------------------------------------------------------------------------
Eye Refraction
- -----------------------------------------------------------------------------------------------------------------------
Outpt Alcohol & Subs Abuse
- -----------------------------------------------------------------------------------------------------------------------
Mental Health
- -----------------------------------------------------------------------------------------------------------------------
Obstetrics - Delivery
- -----------------------------------------------------------------------------------------------------------------------
Obstetrics - Non-Deliveries
- -----------------------------------------------------------------------------------------------------------------------
DME
- -----------------------------------------------------------------------------------------------------------------------
Diagnostic & Laboratory Tests
- -----------------------------------------------------------------------------------------------------------------------
Other Medical
- -----------------------------------------------------------------------------------------------------------------------
Prescription Drug
- -----------------------------------------------------------------------------------------------------------------------
Total Cost
- -----------------------------------------------------------------------------------------------------------------------
Expenses
Administrative Expenses
2% Statutory Contribution
- -----------------------------------------------------------------------------------------------------------------------
TOTAL EXPENSES
- -----------------------------------------------------------------------------------------------------------------------
SAMPLE FILING
I. OUTLINE OF BENEFITS
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX
PREMIUM RATE SHEET(S)
ABC Corporation
Child Health Plus Insurance Plan
Form Number XYZ
III. ACTUARIAL MEMORANDUM
A. Derivation of rates
1. Description of rating approach
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
2. Sources of frequency and average charges
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
3. Premium rate development (See attached premium rate sheets)
B. Comparison with currently approved rates for similar benefits,
justification of differentials in basis assumptions, etc.
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXCXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXCXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX
C. Expected Incurred Loss Ratio = 90%
D. Expense Components of Premium
Administrative Expenses X%
Contribution to Statutory Reserves and Surplus Y%
--
TOTAL 10%
E. Actuarial Certification
I certify that this rate filing is in compliance with the applicable
laws and regulations of the State of New York and that the proposed
rates are reasonable in relation to the benefits provided.
______________________________
(Actuary's Signature) (Date)
______________________________
(Print/Type Name)
______________________________
(Print/Type Title)
IV. COUNTIES COVERED
This plan will cover the following counties:
County A
County B
County C
PREMIUM RATE DEVELOPMENT FOR CHILD HEALTH PLAN NAME:_________________________
PLUS INSURANCE PLAN RATE PERIOD MEMBER MONTHS:_______________________
- ------------------------------------------------------------------------------------------------------------------------------------
FREQUENCY AVERAGE STANDARD CO-PAY NET
SERVICE PROJECTED CHARGE PMPM CO-PAYMENT PMPM PMPM
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital Services $0
- ------------------------------------------------------------------------------------------------------------------------------------
Inpatient Utilization (Admissions) $0
- ------------------------------------------------------------------------------------------------------------------------------------
Emergency Room $0
- ------------------------------------------------------------------------------------------------------------------------------------
Hospital Outpatient $0
- ------------------------------------------------------------------------------------------------------------------------------------
Radiotherapy/Chemotherapy $0
- ------------------------------------------------------------------------------------------------------------------------------------
Outpatient Surgery $0
- ------------------------------------------------------------------------------------------------------------------------------------
Ambulance $0
- ------------------------------------------------------------------------------------------------------------------------------------
Physician
- ------------------------------------------------------------------------------------------------------------------------------------
Ambulatory Office Visits
- ------------------------------------------------------------------------------------------------------------------------------------
PCP $2
- ------------------------------------------------------------------------------------------------------------------------------------
Admission Fee $0
- ------------------------------------------------------------------------------------------------------------------------------------
Specialty $2
- ------------------------------------------------------------------------------------------------------------------------------------
Inpatient Hospital Visits $0
- ------------------------------------------------------------------------------------------------------------------------------------
Emergency Room Visits $0
- ------------------------------------------------------------------------------------------------------------------------------------
Miscellaneous Office Visits $2
- ------------------------------------------------------------------------------------------------------------------------------------
Surgery
- ------------------------------------------------------------------------------------------------------------------------------------
Inpatient $0
- ------------------------------------------------------------------------------------------------------------------------------------
Outpatient $0
- ------------------------------------------------------------------------------------------------------------------------------------
X-Ray $0
- ------------------------------------------------------------------------------------------------------------------------------------
Anesthesia $0
- ------------------------------------------------------------------------------------------------------------------------------------
Eye Refraction $0
- ------------------------------------------------------------------------------------------------------------------------------------
Outpt Alcohol & Subs Abuse $0
- ------------------------------------------------------------------------------------------------------------------------------------
Mental Health $0
- ------------------------------------------------------------------------------------------------------------------------------------
Obstetrics - Delivery $0
- ------------------------------------------------------------------------------------------------------------------------------------
Obstetrics - Non-Deliveries $2
- ------------------------------------------------------------------------------------------------------------------------------------
DME $0
- ------------------------------------------------------------------------------------------------------------------------------------
Diagnostic & Laboratory Tests $0
- ------------------------------------------------------------------------------------------------------------------------------------
Other Medical $0
- ------------------------------------------------------------------------------------------------------------------------------------
Prescription Drug $3
- ------------------------------------------------------------------------------------------------------------------------------------
Total Cost $0
- ------------------------------------------------------------------------------------------------------------------------------------
Expenses
Administrative Expenses
2% Statutory Contribution
- ------------------------------------------------------------------------------------------------------------------------------------
TOTAL EXPENSES
- ------------------------------------------------------------------------------------------------------------------------------------
PREMIUM RATE DEVELOPMENT FOR CHILD HEALTH PLAN NAME:_______________________
PLUS INSURANCE PLAN MEMBER MONTHS:___________________
PREMIUM RATE SUMMARY
BASE YEAR - ACTUAL RATE YEAR VARIANCE
SERVICE (PMPM) (PMPM) (PMPM)
- ---------------------------------------------------------------------------------------------------------------
Hospital Services
- ---------------------------------------------------------------------------------------------------------------
Inpatient Utilization (Admissions)
- ---------------------------------------------------------------------------------------------------------------
Emergency Room
- ---------------------------------------------------------------------------------------------------------------
Hospital Outpatient
- ---------------------------------------------------------------------------------------------------------------
Radiotherapy/Chemotherapy
- ---------------------------------------------------------------------------------------------------------------
Outpatient Surgery
- ---------------------------------------------------------------------------------------------------------------
Ambulance
- ---------------------------------------------------------------------------------------------------------------
Physician
- ---------------------------------------------------------------------------------------------------------------
Ambulatory Office Visits
- ---------------------------------------------------------------------------------------------------------------
PCP
- ---------------------------------------------------------------------------------------------------------------
Admission Fee
- ---------------------------------------------------------------------------------------------------------------
Specialty
- ---------------------------------------------------------------------------------------------------------------
Inpatient Hospital Visits
- ---------------------------------------------------------------------------------------------------------------
Emergency Room Visits
- ---------------------------------------------------------------------------------------------------------------
Miscellaneous Office Visits
- ---------------------------------------------------------------------------------------------------------------
Surgery
- ---------------------------------------------------------------------------------------------------------------
Inpatient
- ---------------------------------------------------------------------------------------------------------------
Outpatient
- ---------------------------------------------------------------------------------------------------------------
X-Ray
- ---------------------------------------------------------------------------------------------------------------
Anesthesia
- ---------------------------------------------------------------------------------------------------------------
Eye Refraction
- ---------------------------------------------------------------------------------------------------------------
Outpt Alcohol & Subs Abuse
- ---------------------------------------------------------------------------------------------------------------
Mental Health
- ---------------------------------------------------------------------------------------------------------------
Obstetrics - Delivery
- ---------------------------------------------------------------------------------------------------------------
Obstetrics - Non-Deliveries
- ---------------------------------------------------------------------------------------------------------------
DME
- ---------------------------------------------------------------------------------------------------------------
Diagnostic & Laboratory Tests
- ---------------------------------------------------------------------------------------------------------------
Other Medical
- ---------------------------------------------------------------------------------------------------------------
Prescription Drug
- ---------------------------------------------------------------------------------------------------------------
Total Cost
- ---------------------------------------------------------------------------------------------------------------
Expenses
Administrative Expenses
2% Statutory Contribution
- ---------------------------------------------------------------------------------------------------------------
TOTAL PREMIUM PMPM
- ---------------------------------------------------------------------------------------------------------------
APPENDIX G
REPORTING FORMAT
CHILD HEALTH PLUS
REPORT ON REASONS FOR DENIED APPLICANTS
AND DISENROLLMENTS
Instructions: Insurer must report the number of applicants and enrollees
determined ineligible for participation in the Child Health Plus Program and the
reasons for the determination. This should include applicants initially
determined ineligible, those not enrolled at recertification due to the fact
that they are determined ineligible, those disenrolled at the close of the
presumptive eligibility period and disenrollment which occurs at any other point
during the year. This report must be received by the Department on a quarterly
basis within 30 days after the close of the quarter. The reports should be sent
to:
Bureau of Health Economics
Child Health Plus Program
New York State Department of Health
Corning Tower Building, Room 1110
Empire State Plaza
Albany, New York 12237-0722
INSURER: ___________________________________ QUARTER: ______________
I. New Applicants
A. Ineligible due to:
Age _____
Income __________
Equivalent insurance _____________
Residency _____________
B. Failure to pay the family Share of Premium (if applicable)
_______
C. Miscellaneous/Other _______________________________
II. After Presumptive Eligibility Period
A. Lack of sufficient documentation _________
B. Failure to pay the family Share of Premium (if applicable)
___________
C. Miscellaneous/Other____________
`III. At Recertification
A. Ineligible due to:
Age ______________
Income ___________________
Equivalent insurance _____________________________________
Residency __________________________
B. Lack of sufficient documentation____________________________________
B. Failure to pay the family Share of Premium (if applicable) _________
C. Miscellaneous/Other ________________________________________
D. Family voluntarily chose not to re-enroll___________________________
E. Miscellaneous/Other _____________________________________________
IV. Disenrollment at any Other point During the Year
A. Insurer notified of any change in status of responsible party:
Income _________________________
Residency _______________________________
Equivalent insurance ______________________________________
B. Family voluntarily chose to disenroll ______________________________
C. Miscellaneous/Other ________________________________________________
CHILD HEALTH PLUS
MONTHLY ENROLLMENT REPORT
General Instructions
1. The Child Health Plus Monthly Enrollment Report is intended to provide a
snap shot of enrollment and disenrollment activity AS OF THE FIRST (1ST)
DAY OF THE MONTH IDENTIFIED AS THE "REPORT PERIOD" in the heading of the
report form. For example, for the Report Period December 1, 1996, the data
reported for the current period will reflect enrollment and disenrollment
as of December 1, 1996. This should equal the number of enrollees for whom
a premium was billed this month plus any non-subsidized enrollees.
2. The Report Period and Name of Insurer must be recorded on this report
form. The contact person and phone number of that person should also be
completed on the bottom of this report.
3. The report is to be completed each month and is DUE IN THIS OFFICE NO
LATER THAN THE 10TH BUSINESS DAY OF THE REPORT PERIOD MONTH. The completed
form is to be returned to:
CHILD HEALTH PLUS MONTHLY ENROLLMENT REPORT
BUREAU OF HEALTH ECONOMICS
NEW YORK STATE DEPARTMENT OF HEALTH
CORNING TOWER, ROOM 1110
EMPIRE STATE PLAZA
ALBANY, NY 12237-0722
4. If you have questions about the report form or these instructions, please
call Ms. Rosemary DeSanta of the above referenced bureau at (518)
473-7883.
The form requests enrollment/disenrollment information broken down by age
category (under 1 yr., 1-5 yrs., 6-12 yrs. and 13-16 yrs.) and income level
(<120% FPL, 120%-160% FPL, >160%-222% and +222%) as follows:
1. NET ENROLLMENT FROM THE PREVIOUS MONTH (COLUMN A): Specify the number of
children who were actively enrolled effective the first (1st) day of the
calendar month immediately preceding the Report Period Month. In the
example above where December is the Report Period Month, the insurer
would record enrollment effective as of November 1, 1996.
2. ADJUSTMENTS (COLUMN B) Please use this Column for transfer's between
groups, either because of an age change or subsidy level change. Also add
or deduct those children who were not included in previous reports or who
were included more than once.
3. COLUMN C IS AN ADJUSTED ENROLLMENT FIGURE. It represents a Net Adjusted
Enrollment figure which will include those children who were added and
deducts those who should not be included.
4. NEW ENROLLEES WITH COVERAGE EFFECTIVE FOR THIS REPORT PERIOD (COLUMN D):
Specify the number of children whose enrollment became effective on the
first (1st) day of the month identified as the Report Period Month --
i.e., their applications were processed to completion during the calendar
month immediately preceding the Report Period Month, they were found to be
eligible for enrollment in Child Health Plus (including those
presumptively eligible) and their enrollment became effective on the first
day of the month identified as the Report Period.
5. NUMBER DISENROLLED FOR THIS REPORT PERIOD (COLUMN E) : Specify the number
of children whose disenrollment from Child Health Plus was processed to
completion during the calendar month immediately preceding the Report
Period Month. Hence, these children are no longer enrolled in Child Health
Plus effective on the first (1st) day of the month identified as the
Report Period.
6. NET ENROLLMENT WITH COVERAGE EFFECTIVE FOR THIS REPORT PERIOD (COLUMN F):
Specify the net number of children actively enrolled in Child Health Plus
as of the first (1st) day of the month identified as the Report
Period. This column equals the net enrollment from the previous month
(Column A) add or subtract the numbers as necessary as adjustments to
previous month's reports (Column B) which results in an adjusted
enrollment number (Column C). To this, add the new enrollees with
coverage effective for this report period (Column D) minus the number
disenrolled for this report period (Column E) which will result in the net
enrollment with coverage effective the first of the report period (Column
F).
Reconciliation:
The reconciliation to premium billing section at the bottom of this page MUST be
completed. The total enrollment for the current month (which is indicated in
Column F, Row 5) less the number enrolled for the current month which are not
subsidized (which is indicated on 4.C. subtotal) should equal the number of
enrollees for whom a premium was billed for the current month. This number must
reconcile with the monthly billing information submitted for premium payment.
ANY DIFFERENCE MUST BE EXPLAINED IN DETAIL. Additional sheets may be attached to
this page for providing necessary explanations.
10/10/96
CHILD HEALTH PLUS MONTHLY ENROLLMENT REPORT
REPORT PERIOD: MONTH _________ YEAR 19_____
NAME OF INSURER ______________________________________________
A
NET B C D F
ENROLLMENT ADJUSTMENTS ADJUSTED NEW ENROLLEE E NET ENROLL
FROM TO PREVIOUS ENROLLMENT W/COVERAGE NUMBER W/COVERAGE
PREV. MONTH MONTH'S PREVIOUS EFFECTIVE DISENROLLED EFFECT. THIS
(Same as Col.F REPORT MONTH THIS REPORT THIS REPORT RPT. PERIOD
prev. month) (+ or -) (Col.A +/- B=C) PERIOD PERIOD (Col.C+D-E=F)
-------------- ----------- --------------- ------------ ----------- -------------
1. INCOME < 120% FPL AGE:
a. 0 < 1 yr.
b. 1 - 5 yrs.
c. 6 - 12 yrs.
d. 13 - 16 yrs.
Subtotal
2. INCOME 120% - 160% FPL AGE:
a. 0 < 1 yr.
b. 1 - 5 yrs.
c. 6 - 12 yrs.
d. 13 - 16 yrs.
Subtotal
3. INCOME 160% - 222% FPL AGE:
a. 0 < 1 yr.
1 - 5 yrs.
c. 6 - 12 yrs.
d. 13 - 16 yrs.
Subtotal
4. TOTAL INCOME <= 222% FPL:
5. INCOME + 222% FPL AGE:
a. 0 < 1 yr.
b. 1 - 5 yrs.
c. 6 - 12 yrs.
d. 13 - 16 yrs.
Subtotal
6. TOTAL
RECONCILIATION TO PREMIUM BILLING
*Please explain any differences between current monthly billing and the number
of subsidized enrollees. (Attatch an additional sheet if necessary.)
Contact Person: _______________________
Telephone #: ( ) ______________________
NEW YORK STATE DEPARTMENT OF HEALTH
BUREAU OF HEALTH ECONOMICS
CHILD HEALTH PLUS
ANNUAL STATEMENT
OF
CALENDAR YEAR ENDING DECEMBER 31, 19___
This document should be completed and submitted on an annual basis
directly to the New York State Department of Health. This report is due within
ninety days of the close of the calendar year. Any questions or inquiries
regarding this document should be directed to the Bureau of Health Economics at
(518) 473-7883.
A copy of this report should be submitted to:
New York State Department of Health
Bureau of Health Economics
The Nelson A. Rockefeller Empire State Plaza
Corning Tower Building - Room 1110
Albany, New York 12237-0722
Attach a management narrative to this report which describes any significant
problems or occurrences during the covered time period. Include a brief summary
of the work completed during the report period relative to marketing, outreach
and program implementation. Note changes in any major elements of the plan, such
as service area, service delivery systems, enrollment, financial arrangements,
management structure, etc.
Due Date: 90 days after the end of the calendar year.
(10/96)
STATE OF NEW YORK
DEPARTMENT OF HEALTH
CHILD HEALTH PLUS
ANNUAL REPORT
Name of Insurer:________________________________________________________________
Start Date:_____________________________________________________________________
Contract Period: From_____________________To____________________________________
Report Period: From______________________To____________________________________
Mailing Address: (Organization Name, Street, City, State, Zip Code)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Contact Person:_________________________________________________________________
Title:__________________________________________________________________________
Telephone Number;(___)__________________________________________________________
Chief Executive Officer or Executive Director
Name:___________________________________________________________________________
Title:__________________________________________________________________________
Telephone Number:(__)___________________________________________________________
Certification Statement:
certify that all information and statements made in this annual report are true,
complete and current the best of my knowledge.
_____________________________ ______________
Signature, Executive Director Date
(10/96)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
DIVISION OF HEALTH CARE FINANCING
ANNUAL CHILD HEALTH PLUS STATEMENT
INTRODUCTION
Plans and insurers participating in Child Health Plus are required to file this
report with the Department of Health no later than 90 days after the close of
the calendar year, December 31. The report includes a statement of revenues and
expenses, and enrollment and utilization reporting by age and income categories
for the children enrolled by the plan. Copies of the report should be submitted
to the New York State Department of Health, Bureau of Health Economics, as shown
on the face page.
GENERAL
1. There are several categories that are not applicable to Child Health Plus
activities and therefore should not be completed, e.g. inpatient expenses
and utilization. Such categories are shaded as an aid in completing this
report.
2. Include enrollment, disenrollment and utilization activity for children 17
years of age in the 15 less than 17 years category. Generally, this should
include these children who have turned 17 and are covered until the end of
the month in which they turned 17 since they were 16 on the first day of
the month being covered.
3. Unanswered questions and blank lines or schedules will not be accepted as
meaning anything. If no answers or entries are to be made, write "None",
"Not Applicable (N/A)", or "-0-" in the space provided.
4. Any item which cannot be readily classified under one of the printed items
should be entered as special item and adequately described.
5. If additional supporting statements or schedules are added in connection
with answering interrogatories or providing information on the financial
statement, the additions should be properly keyed to the item being
answered Example- "Other Revenue, line 7") and indicate the reporting date
and the name of the Plan.
6. If this report does not contain the information asked for in the blanks or
is not prepared in accordance with these instructions, it will not be
accepted.
(10/96)
INSTRUCTIONS FOR COMPLETING ANNUAL CHILD HEALTH PLUS STATEMENT
TABLE ONE:
Child Health Plus Enrollment Summary By Age and Income Classes
Complete this form for each of the age and income class distinctions for which
you had members enrolled. Explain any variances in excess of 10% of projected
enrollment.
TABLE TWO:
Disenrollment From Plan
This table aggregates the disenrollments from the plan by number of children
disenrolled and reason for disenrollment. All other reasons for disenrollment
which are not specified on the table and have been classified as "Other" should
be explained in the appropriate space provided.
TABLE THREE:
Statement of Revenue and Expenses
Report full accrued revenues and expenses, as defined below, in the format
indicated for the period. Full expenses, whether or not the plan ultimately
bears financial responsibility, should be shown. For example, the full emergency
room expenses are shown in the "ER" line. Offsets to these expenses such as
C.O.B. and the Insurance Recoveries are shown as revenue. Similarly, full
physician services expenses are shown with a year end adjustment for withholds
or other offsets returned to the plan as a contra category.
1. MEMBER MONTHS - A member month is equivalent to one person for whom the
plan has recognized capitation-based premium revenue for one month.
REVENUE
2a. NYS Premium - Revenue received from NYS which is recognized on a prepaid
basis for Child Health Plus enrollees for provision of a specified range
of health services over a defined period of time, normally one month. if
advance payments are made to the plan for more than one reporting period,
only that portion of the payment applicable to the reporting period should
be shown.
2b. Subscriber Premium - Revenue received from program subscribers recognized
on a prepaid basis for enrollees for provision of a specified range of
health services over a defined period of time, normally one month. Include
premium revenue received from both subsidized and non-subsidized
enrollees.
(10/96)
2c. Employer Premium - Revenue received from employers participating in the
small business regional pilot projects recognized on a prepaid basis for
enrollees for provision of a specified range of health services over a
defined period of time, normally one month. Include premium revenue
received from subsidized and non-subsidized enrollees.
2d. Total Premium - This amount equates to total premium revenue received for
the report period (Rows 2A, 2B and 2C).
3. Copayments and Deductibles - Revenue recognized by the insurer/plan for
provision of health services by plan providers that require a partial
contribution by program enrollees.
4. Interest - Interest earned from all sources, including the Federal loan in
escrow and reserve accounts.
5. C.O.B. and Subrogation - Income from Coordination of Benefits and
Subrogation.
6. Reinsurance Recoveries - Income from the settlement of stop-loss
(reinsurance) claims.
7. Other Revenue - Revenue from sources not covered in the previous revenue
accounts, such as recovery of bad debts or gain on sales of capital
assets, etc.
8. Total Revenue - Total of the above revenue accounts. (Sum of lines 2d thru
7)
EXPENSES
Medical and Hospital: - Expenses for covered health service delivery including
the following components.
9. Inpatient (N/A) - Inpatient hospital costs of routine and ancillary
services for plan members while confined to an acute care hospital. Does
not include out of area hospitalization.
Routine hospital service includes regular room and board (including
intensive care units, coronary care units, and other special inpatient
hospital units), dietary and nursing services, medical surgical supplies,
medical social services, and the use of certain equipment and facilities
for which the provider does not customarily make a separate charge.
Ancillary services may also include laboratory, radiology, drugs, delivery
room and physical therapy services. Ancillary services may also include
other special items and services for which charges are customarily made in
addition to a routine service charge.
Charges for non-plan physician services provided in a hospital are
included in this line item only if included as an undefined portion of
charges by a hospital to the plan. (If separately itemized or billed,
physician charges should be included in physician referral services).
(10/96)
10. Primary Care Physician - Expenses for primary care physician services
and/or clinic service provided under contractual arrangement to the plan
including the following:
- - Salaries, including fringe benefits, paid to physician for delivery of
medical services;
- - Capitated payments paid by the insurer/plan to physicians or clinic for
delivery of medical services to plan subscribers;
- - Fees paid by the insurer/plan to physicians on a fee-for-service basis for
delivery of medical services to plan subscribers.
11. Physician Referral Services - Expenses for specialist physicians.
12a. Other Professional Services: - Compensation, including fringe benefits,
paid by the plan to non-physician providers engaged in the delivery of
medical services and to personnel engaged in activities in direct support
of the provision of medical services. This includes psychologists,
podiatrists, extenders, nurses, nurse practitioners, nurse midwives,
clinical personnel such as ambulance drivers, technicians,
paraprofessionals, janitors, quality assurance analysts, administrative
supervisors, secretaries to medical personnel, and medical record clerks.
12b. Special Therapy - Expenses for all therapeutic services provided,
including but not limited to, physician therapy, occupational therapy,
chemotherapy, radiation therapy and hemodialysis.
13. Emergency Room - Expenses for emergency room costs incurred by plan
members for which [ILLEGIBLE] insurer/plan is responsible on a
fee-for-service basis.
14. Out-Of-Area, Other: - Expenses for other non-contracted health delivery
services and out-of-area service costs for emergency physician and
hospital.
15. Drug and Alcohol Treatment - Expenses for all outpatient treatment and
diagnosis of alcohol and substance abuse, including expenses for a maximum
of 20 family visits.
16. Dental (N/A) - Expenses for all dental services provided.
17. Pharmacy - Expenses for prescription and non-prescription pharmacy
services provided.
18. Family Planning - Expenses for all family planning services provided by
the plan.
19. Home Health Care Services (N/A) - Expenses for home health services
provided including therapeutic and preventive nursing services, home
health aide services, and rehabilitation therapies.
20. Transportation (N/A) - Expense for all emergency and non-emergency medical
transportation.
(10/96)
21. Diagnostic Tests, Laboratory an X-Rays -"The cost of all diagnostic tests,
laboratory and X-Rays for which the plan is separately billed.
22. Vision Care Including Eyeglasses (N/A) - The cost of testing the vision
and prescribing glasses to correct eye defects. This category includes the
cost of eyeglasses but excludes physician costs related to the treatment
of disease or injury to the eye.
23. Other Medical - Costs directly associated with the delivery of medical
services under plan arrangement which are not appropriately assignable to
the medical expense categories defined above; e.g., costs of medical
supplies, medical administration expense (except compensation),
malpractice insurance, etc.
24. Reinsurance Expense - Expenses for Reinsurance or "Stop-loss" insurance
made to a contracted re-insurer.
25. Incentive Pool Adjustment - A contra category for adjusting the full
medical expenses reported. For example, physician withholds retained by
the plan should be included here. Adjustments should be made on annual
reports only.
26. Total Medical and Hospital - Total of all medical and hospital expenses.
ADMINISTRATION - Costs associated with the overall management and operation of
the plan including following components:
27. Compensation - All expenses for administrative services including
compensation and fringe benefits for personnel time devoted to or in
direct support of administration. Include expenses for management
contracts. Do not include marketing expenses here.
28. Interest Expenses - Interest paid during period applicable to this
program.
29. Occupancy, Depreciation and Amortization - Expenses associated with
administrative services including:
- The costs of occupancy to the plan entity that are directly
associated with plan administration. Included in occupancy are an
allocation of facility fire and theft insurance, utilities,
maintenance, lease, etc. Do not include marketing expenses in this
category;
- The amount of depreciation and amortization expenses that is
directly associated with the provision of administrative services.
Depreciation expense is the incremental consumption of the value of
a fixed asset during the asset's useful life. Amortization expense
is the allocation of the cost of certain assets over their estimated
service lives; e.g., leasehold improvements.
(10/96)
30. Marketing - Expenses directly related to marketing activities including
advertising, printing, marketing representative compensation and fringe
benefits, commissions, broker fees, trav occupancy, and other expenses
allocated to the marketing activity.
31. Other - Costs which are not appropriately assigned to the health plan
administration categories defined above. Included are costs to update
subscriber records, servicing of subscriber inquiries and complaints,
claims adjudication and payment, legal, audit, data processing,
accounting, insurance, bad debts, all taxes except federal income taxes,
etc. Do not include marketing expenses.
32. Total Administration - Total of the above categories.
33. Total Expenses - Total of Medical and Hospital and Administration
Expenses.
34. Income (Loss) - Excess or deficiency of total revenues over total
expenses.
35. Extraordinary item - A nonrecurring gain or loss that meets the following
criteria:
- - The event must be unusual; that is, it should be highly abnormal and
unrelated to, or only incidentally related to, the ordinary activities of
the entity;
- - The event must occur infrequently; that is, it should be of a type that
would not reasonably be expected to recur in the foreseeable future.
The following gains and losses are specifically not extraordinary:
- - Write-down or write-off of accounts receivable, inventory, or intangible
assets;
- - Gains or losses from changes in the value of foreign currency;
- - Gains or losses from the disposal of fixed assets;
- - Effects of a strike;
- - Adjustments of accruals on long-term contracts.
36. Provision for Taxes - State and federal taxes for period (for-profit
organizations only).
37. Net Income (Loss) - Excess or deficiency of total revenues over total
expenses less state and federal taxes for the period.
(10/96)
TABLE FOUR:
Administrative Expenses - Costs associated with the overall management and
operation of the plan. Included are the administrative services of professional
staff as well as cost associated with maintaining the physical plant of the
plan.
Full-Time Equivalent (F.T.E.) - A numerical expression of the time for which
full time and part time staff are compensated. Full time equals the definition
of a work week set by the plan, but must be between 35 and 40 hours per week.
Please report the number of FTE's in column A for the applicable personnel
categories.
Salary - The monetary value paid to an employee for the provision of services.
In column B, please report total salary expenses either paid or accrued for the
applicable personnel categories during the report period.
Non-Salary - Costs associated with expenditures incurred which are not related
to direct personnel services (ie, purchased and contract services, supplies, and
general costs). In column C, please report all non-salary related administrative
expenses.
The sum of columns B and C should equal column D. The total administrative
expense shown at the bottom of column D should equal the total shown on line 32
of Table Three, Statement of Revenues and Expenses.
(Illegible) expenses which are not specified on this table and have been
classified as "Other" should be explained in the appropriate space provided.
TABLE FIVE:
AMBULATORY CARE AND ANCILLARY UTILIZATION - TOTAL VISITS, PROCEDURES ETC.
Actual Utilization
Please report the number of actual visits/procedures for ambulatory care and
ancillary services received by program enrollees during the report period by the
categories listed for the applicable age groups. In addition, for each category
listed, enter the sum total utilization rate per member per year for the report
period. Per member per year utilization is defined as follows:
Rate per Member Per Year = (total visits/member months) *12.
Accrued Utilization
Below the entry for Rate Per Member Per Year-Actual, enter the total number of
accrued visits, procedures, etc., including the plan's estimate of incurred but
not reported utilization, for each of the service categories listed. The
utilization Rate per Member Per Year-Accrued should also be entered.
(10/96)
TABLE SIX:
CLAIMS ANALYSIS
Section A: Claims Incurred
Claims incurred shall include medical expenses for services provided in the
report period which are either paid or unpaid and are reflected in lines 9, 10,
11, and 13 of the Statement of Revenue and Expenses in Table Three.
The sum of the amounts reported in columns B, C, and D should equal the amounts
reported in column A.
Enter in column B all payments actually made during the year for inpatient care,
primary physician services, physician referral services and emergency room
services provided in the report period.
Enter in column C the amount of claims which have been reported but not paid
during the report period.
Enter in column D the amount of claims that the plan estimates have been
incurred during the report period but not reported by providers.
Section B: Claims Unpaid
Enter in column A the amount of reported unpaid claims incurred during prior
years for each of the categories of service indicated.
Enter in column B the amount of reported unpaid claims incurred during the
current year for each of the categories of service indicated.
Enter in column C the amount of incurred but not reported claims during prior
years for the categories of service indicated.
Enter in column D the amount of incurred but not reported claims during the
current year for the categories of service indicated.
The cum of columns A, B, C, and D should equal column E.
(10/96)
TABLE SEVEN:
EMERGENCY ROOM VISITS
Please report the number of paid and denied emergency room claims by age group,
emergency status and reasons for denial.
TABLE EIGHT:
USER RATES OF SERVICE
Please report the number of users and non-users of medical services by age
group.
(10/96)
CHILD HEALTH PLUS
TABLE ONE
ENROLLMENT SUMMARY BY AGE/INCOME CLASSES
F
A Projected G
Number of B C D E Member Months Variance
Enrollees at New Enrollees Disenrollments Net Enrollees Total For Report From
End of Prior Year During Report Period At End of Year Member Months Period Projected*
----------------- ----------------------------- -------------- ------------- ------------- ----------
INCOME < 120% FPL
AGE
a. 0 < 1 yr.
b. 1 < 6 yrs.
c. 6 < 13 yrs.
d. 13 < 15 yrs.
e. 15 < 17 yrs.
INCOME 120% - 160%, FPL
AGE:
a. 0 < 1 yr.
b. 1 < 6 yrs.
c. 6 < 13 yrs.
d. 13 < 15 yrs.
e. 15 < 17 yrs.
INCOME + 222% FPL.
AGE:
a. 0 < 1 yr.
b. 1 < 6 yrs.
c. 6 < 13 yrs.
d. 13 < 15 yrs.
e. 15 < 17 yrs.
TOTAL
Explain total variances in excess of 10% of projection:
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE TWO
DISENROLLMENT FROM PLAN
REASON FOR DISENROLLMENT NUMBER OF CHILDREN DISENROLLED
- ------------------------ ------------------------------
Obtained Equivalent Coverage
Also Enrolled in Medicaid
Moved From Service Area
Age 13 Years or Older
Presumptively Enrolled-Found Ineligible*
Other**
TOTAL
* DETAIL OF PRESUMPTIVELY ENROLLED WHO WERE
FOUND INELIGIBLE NUMBER OF INELIGIBLE BY CATEGORY:
- ---------------- ---------------------------------
Age
Income
Equivalent Coverage
Medicaid Eligible
Other
**Explanation of Other:
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
- --------------------------------------------------------------------------------
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE THREE
ANNUAL STATEMENT OF REVENUES AND EXPENSES
ALL UNFAVORABLE VARIANCES IN EXCESS OF .50 PMPM MUST BE EXPLAINED ON A SEPARATE
PAGE
E F
A B C D ACTUAL VARIANCE
BUDGET ACTUAL VARIANCE BUDGET PMPM PMPM PMPM
------ ------ -------- ----------- ------ --------
1. Member Months
REVENUE:
2a. NYS Premium
b. Subscriber Premium
c. Employer Premium
d. Total Premium Revenues
3. Copay & Deductible
4. Interest
5. C.O.B. & Subrogation
6. Reinsurance Recoveries
7. Other Revenue
8. TOTAL REVENUE
EXPENSES
Medical and Hospital:
9. Inpatient
10. Primary Care Physician
11. Physician Specialty Services
12a.Other Professional Services
b.Special Therapies
13. Emergency Room
14. Out-of-Area, Other
15. Drug & Alcohol Treatment
16. Dental
17. Pharmacy/Prescription Drugs
18. Family Planning
19. Home Health Care
20. Transportation
21. Diagnostic Test, Lab & X-Ray
22. Vision Care Inc. Eyeglasses
23. Other Medical
24. Reinsurance Expenses
25. Incentive Pool Adjustment
26. Total Medical & Hospital
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE THREE
(CONTINUED)
ALL UNFAVORABLE VARIANCES IN EXCESS OF .50 PMPM MUST BE EXPLAINED ON A SEPARATE
PACE
E F
A B C D ACTUAL VARIANCE
BUDGET ACTUAL VARIANCE BUDGET PMPM PMPM PMPM
------ ------ -------- ----------- ------ --------
ADMINISTRATION
27. Compensation
28. Interest Expense
29. Occupancy, Deprecation & Amortization
30. Marketing
31. Other
32. TOTAL ADMINISTRATION
33. TOTAL EXPENSES
34. INCOME (LOSS)
35. Extraordinary Item
36. Provision for taxes
37. NET INCOME (LOSS)
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE FOUR
ADMINISTRATIVE EXPENSES
A B C D
FTE's SALARY NON-SALARY TOTAL EXPENSES
----- ------ ---------- --------------
Depreciation & Amortization
Occupancy
Lease/Rental Expense
Office Equipment/Supplies
Interest
Finance
Marketing
Legal
MIS
Management/Administration
* Other
Total Administrative Expense
* Please provide detail on administrative expenses included in this category:
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
Note: Total Administrative Expense should equal Column B line 32 of Table 3.
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE FIVE
AMBULATORY CARE AND ANCILLARY UTILIZATION - TOTAL VISITS, PROCEDURES ETC.
A. AMBULATORY CARE
C E
Physician D Mental Health, H I
A B Referral Special Drug & Alcohol F G Family Ambulatory
Age Group Emergency Room Primary Care Services Therapy Therapy Vision Care Dental Planning Surgery
- --------- -------------- ------------ --------- ------- -------------- ----------- ------ -------- ----------
0 < 1yr.
1 < 6 yrs.
6 < 13 yrs.
13 < 15 yrs.
15 < 17 yrs.
TOTALS - ACTUAL
Rate Per Member
Per Year - ACTUAL
TOTALS - ACCRUED*
Rate Per Member
Per Year - ACCRUED*
B. OTHER SERVICES
A
Diagnostic
Tests, C D F G
Labs and B Medical Supplies Medical E Other Total Number
Age Group X-rays Pharmacy and Equip. Transportation Home Health Care Professional Immunizations
- --------- ---------- -------- ---------------- -------------- ---------------- ------------ -------------
0 < 1 yr.
1 < 6 yrs.
6 < 13 yrs.
13 < 15 yrs.
15 < 17 yrs.
TOTALS - ACTUAL
Rate Per Member
Per Year - ACTUAL
TOTALS - ACCRUED*
Rate Per Member
Per Year - ACCRUED*
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE SIX
CLAIMS ANALYSIS
A. CLAIMS INCURRED
(D)
Category of Service (C) Claims Incurred
Revenue & Expense Statement (A) (B) Claims Reported But Not
(Table Three) Total Expense Claims Paid But Not Paid Reported (IBNR)
- --------------------------------------------- ------------- ----------- --------------- ---------------
1. lnpatient....line 9
2. Primary Care...line 10
3. Physician Specialty Services .... line 11
4. Emergency Room....line 13
5. All Other Medical
6. TOTAL
B. CLAIMS UNPAID
(C) (D)
(A) (B) Incurred But Not Reported (E)
Reported Claims That Are Unpaid ON CLAIMS INCURRED TOTAL UNPAID
On Claims Incurred On Claims Incurred On Claims Incurred DURING CURRENT CLAIMS
Category of Service During Prior Years During Current Year During Prior Years YEAR (A + B + C + D)
- ------------------------------- ------------------ ------------------- ------------------ ------------------ ---------------
1. Inpatient
2. Primary Care
3. Physician Specialty Services
4. Emergency Room
5. All Other Medical
6. TOTAL
Plan Name: ______________ Year Ending: _______________
CHILD HEALTH PLUS
TABLE SEVEN
EMERGENCY ROOM VISITS
NUMBER OF PAID CLAIMS
-------------------------------------------------------
APPROPRIATE ER INAPPROPRIATE ER TOTAL NUMBER OF DENIED
Category of Service USAGE USAGE TOTAL PAID CLAIMS CLAIMS
- ----------------------- -------------- ---------------- ----------------- ----------------------
0 < 1 YR.
1 < 6 YRS.
6 < 13 YRS.
13 < 15 YRS.
15 < 17 YRS.
TOTAL
TABLE EIGHT
USER RATES OF SERVICE
USERS NON-USERS
----------------------------------------------- ------------------------------------------
NUMBER MEMBERS WHO USED MEDICAL SERVICES DURING NUMBER MEMBERS WHO DID NOT USE ANY MEDICAL
Category of Service PERIOD SERVICES DURING PERIOD TOTAL
- ------------------- ----------------------------------------------- ------------------------------------------ -----
0 < 1 YR.
1 < 6 YRS.
6 < 13 YRS.
13 < 15 YRS.
15 < 17 YRS.
TOTAL
APPENDIX H
MODEL APPLICATION
CHILD HEALTH PLUS
Model Application
CHILD HEALTH PLUS IS A NEW YORK STATE SUBSIDIZED HEALTH INSURANCE PROGRAM FOR
CHILDREN WHO:
Live in New York State;
Under the age of 19;
Not eligible for Medicaid; and
Do not have equivalent health care coverage.
TO APPLY FOR CHILD HEALTH PLUS, A PARENT OR RESPONSIBLE ADULT MUST:
Complete and sign an application for each child and supply proof of:
THE CHILD'S AGE: birth certificate, hospital record, passport, Visa,
school record, or religious record;
RESIDENCE IN NEW YORK STATE: recent (within 3 months) utility bill, rent
receipt, or tax bill. You must supply proof of physical address not of a
mailing address i.e. a post office box number.
INCOME TAX RETURN: If questions l0a and b were answered yes, a signed copy
of the previous year's tax return must be submitted.
HOUSEHOLD INCOME: If household income has changed since the tax return was
filed, then additionally one of the following should be submitted for each
parent and responsible adult who is a member of the household who has
income: a W-2, at least three paycheck stubs, an unemployment stub, copy
of social security check or letter from social security or a letter from
employer written on company letterhead. A self-statement of income will be
accepted only in cases where there is no other means of documenting
income.
You must also show proof of other income: if you receive child support or
alimony, you must submit a copy of the court order or statement from the
person paying the support or alimony or a copy of a support or alimony
check; if you are self-employed, a copy of your quarterly tax return; if
in the military, a copy of your pay statement or a leave and earnings
statement; if you receive veteran's benefits, you must submit a copy of
your benefit check or correspondence with the Veteran's Administration; if
you receive worker's compensation, you must submit a copy of your award
letter or a check stub; and if you receive income from rent, you must
submit a copy of a current check or statement from your tenant.
OTHER INSURANCE: If the child has any other health care coverage, supply
one of the following: copy of policy,
summary of benefits, statement/letter from the other insurance company
indicating the benefits and the deductibles, or a statement/letter from
your employer indicating the benefits and the deductible.
PREMIUM COSTS:
There is no family contribution when households' gross annual, combined
incomes are below 120% of the gross non-farm federal poverty level. These
income levels are updated annually. A copy of the current federal poverty
level guidelines is attached. For families whose gross annual income is
120% or above, the family contribution is as follows:
Between 120 and 159% of the gross, non-farm federal poverty level,
$9 per child per month up to a maximum of $36 per family per month.
Between 160 and 222% of the gross, non-farm federal poverty level,
$13 per child per month up to a maximum of $52 per family per month.
If the household's gross annual income is over 222% of the non-farm
federal poverty level, the family must pay the entire premium
amount.
At least one months family share of the premium for each applicant must be
paid at the time of application. The balance due will be billed on a
monthly basis one month prior to the period it covers.
PRIMARY CARE PHYSICIAN:
You must choose a primary care physician (PCP) from the Primary Care
Physician Directory included with this application.
RECERTIFICATION:
You must recertify your child every year before their anniversary date by
submitting an application and the required documentation. We will send you
the forms to be completed and the information needed prior to that date.
If you do not recertify by submitting an application and necessary
documentation prior to the child's anniversary date, your child will be
disenrolled from Child Health Plus at midnight on the last day of the
month prior to their anniversary date. If you do not receive a
recertification application 45 days before your child's recertification
date, it is your responsibility to contact us to obtain the required
forms.
DEPARTMENTS OF SOCIAL SERVICES AND TAXATION AND FINANCE VERIFICATION:
The New York State Department of Health reserves the right to confer with
the Department of Social Services to determine the Medicaid eligibility
status of the child applying for Child Health Plus and with the Department
of Taxation and Finance to verify household income.
If a subsidized enrollee becomes pregnant while enrolled in Child Health Plus,
it is your responsibility to apply for Medicaid within 30 days of discovering
the pregnancy as this change in circumstance would result in the pregnant
individual being eligible for Medicaid under the Prenatal Care Assistance
Program (PCAP).
By completing this application you will be applying for the Child Health Plus
program. The information entered on pages 1 and 2 of this form will be used for
the purposes of determining eligibility for this program.
YOU WILL BE NOTIFIED WHEN YOUR CHILD'S COVERAGE BECOMES EFFECTIVE. UNTIL YOU
RECEIVE IDENTIFICATION CARDS FOR THE CHILD, THERE IS NO CHILD HEALTH PLUS
COVERAGE. If you have questions or need help in completing this application,
call xxx-xxx-xxxx.
1. Name of Person Completing This Application:
Last:______________First:__________________Middle Initial:________________
Address:__________________________________________________________________
State:__________Zip Code:______________Home Phone Number ( )_____________
Relationship to Child: / /Self / /Parent
/ /Legal Guardian / /Other (specify)__________________________
2. Child's Home Address:_____________________________________________________
State:__________Zip Code:____________Home Phone Number: ( )______________
Work Number of Father:_____________________Mother_________________________
Emergency Contact: Name_____________________________Phone No._____________
3. Billing Address (if different):___________________________________________
State:_______________________Zip Code:____________________
4. Does the child have any other health insurance coverage?
/ /Yes / /No If yes, complete the following:
Child's Social Name of Type of
Security No. Insurance Coverage:
or Company or Impatient,
Child's Identification Health Outpatient Deductible
Name No. Plan or Both per Person
- ------- -------------- ---------- ---------- ----------
_______ ______________ __________ __________ __________
5. Is the child enrolled in Medicaid? / / Yes / / No
6. Is anyone in the family receiving Public Assistance or SSI? / / Yes / / No
If yes explain ___________________________________________________________
___________________________________________________________
7. Is the child currently enrolled in Child Health Plus? / / Yes / / No
If yes______________________________Eff. date of Termination______________
Name of Insurer
8. Are there any other children in the household enrolled in Child Health
Plus? / /Yes / /No If yes, complete the following:
Child's Name of Child
Child's Name Identification No. Health Plus Insurer
- ------------ ------------------ -------------------
____________ __________________ ___________________
____________ __________________ ___________________
____________ __________________ ___________________
____________ __________________ ___________________
9. How many people are in your household?
Parents_______________Children under 19__________Over 19__________________
Other Adults________________Total Household Members_______________________
10. a. Was the previous year's tax return filed? / /Yes / /No
b. Is the previous year's tax return available? / /Yes / /No
c. Has the household income changed since the tax return was filed?
/ /Yes / /No If yes, explain_____________________________________________
11. Complete the following chart for the child's household:
Social Applying
Family/ Name: Security for
House- Last, Date Number, Child
hold First, of if Health Annual
Member Middle Int Birth Sex available Plus? Income
- ------- ---------- ----- --- --------- -------- ------
Father
Mother
Head of
House
Child 1
Child 2
Child 3
Child 4
Other
Adult 1
Other
Adult 2
Total
Income
12. Is any other income available to the child? / / Yes / /No
If yes: Amount: __________________________ Source_________________________
13. Total Annual Household Income ____________________________________________
14. Primary Care Physician Name_______________________________________________
DECLARATION:
As required by New York State, I attest to the following statements:
I certify that:
All statements contained in this application are true and accurate. I have
provided complete and accurate information on the source and nature of all
health care coverage the child is receiving.
I understand that:
If the child becomes enrolled in Child Health Plus, it is my
responsibility to notify (insurer name), of any change which may make the
child ineligible for subsidized coverage in the Child Health Plus program,
including changes in income, residency or insurance coverage, within 60
days.
I may be liable for any premiums paid on behalf of the child which are a
result of my willful misstatement of information on this application or
failure to report any subsequent changes in information within 60 days of
such change.
The income of each parent and legally responsible adult in the
child(ren)'s household may be subject to verification by the Department of
Taxation and Finance if (insurer name) has reasonable cause to believe
that the income information provided is false.
"Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose
of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a
civil penalty not to exceed five thousand dollars and the stated value of
the claim for each such violation."
_______________________________________________ __________________
Parent, Guardian or Responsible Adult Signature Date
_______________________________________________
Relationship to Child(ren)
REMEMBER:
YOU MUST ATTACH PROOF OF:
The child(ren)'s age
The child(ren)'s New York State Residency
Last year's income tax return (if available)
The household's income
A copy of the insuranYce policy, if the child has other health
coverage
FOR OFFICE USE ONLY: Reviewer:____________
Presumptively Eligible: / /Yes / /No
/ /Fully Subsidized / / Partially Subsidized / /Unsubsidized
More than 4 children applying? / /Yes / /No
1st months family contribution paid? / /Yes / /No
Amount Paid_______
Referral to Medicaid? / /Yes / /No / /Not Applicable
APPENDIX I
STANDARD CLAUSES
FOR ALL
NEW YORK STATE CONTRACTS
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, licensor, 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 and 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 $5,000 ($20,000 for certain S.U.N.Y. and C.U.N.Y.
contracts), of 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, 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 not its subcontractors shall, by reason of race, creed, color,
disability, sex or national origin: (a) discriminate in hiring against any New
York State citizen who is qualified and available to perform the work; or (b)
discriminate against or intimidate any employee hired for the performance of
work under this contract. If this is a building service contract as defined in
Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
Contractor agrees that neither it not its subcontractors shall, by reason of
race, creed, color, national origin, age, sex or disability: (a) discriminate in
hiring against any New York State citizen who is qualified and available to
perform the work; or (b) discriminate against or intimidate any employee hired
for the performance of work under this contract. Contractor is subject to fines
of $50.00 per person per day for any violation of Section 220-e or Section 239
as well as possible termination of this contract and forfeiture of all moneys
due hereunder for a second or subsequent violation.
6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor's employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State Labor
Department. Furthermore, Contractor and its subcontractors must pay at least the
prevailing wage rate and pay or provide the prevailing supplements, including
the premium rates for overtime pay, as determined by the State Labor Department
in accordance with the Labor Law.
7. NON-COLLUSIVE BIDDING 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 contract's execution, such contract, amendment or modification thereto shall
be rendered forfeit and void. The Contractor shall so notify the State
Comptroller within five (5) business days of such conviction, determination or
disposition of appeal (2 NYCRR 105.4).
9. SET-OFF RIGHTS. The State shall have all of its common law, equitable
and statutory rights of set-off. These rights shall include, but not be limited
to, the State's option to withhold for the purposes of set-off any moneys due to
the Contractor under this contract up to any amounts due and owing to the State
with regard to this contract, any other contract with any State department or
agency including any contract for a term commencing prior to the term of this
contract, plus any amounts due and owing to the State for any other reason
including, without limitation, tax delinquencies, fee delinquencies or monetary
penalties relative thereto. The State shall exercise its set-off rights in
accordance with normal State practices including, in cases of set-off pursuant
to an audit, the finalization of such audit by the State agency, its
representatives, or the State Comptroller.
10. RECORDS. The Contractor shall establish and maintain complete and
accurate books, records, documents, accounts and other evidence directly
pertinent to performance under this contract (hereinafter, collectively, "the
Records"). The Records must be kept for the balance of the calendar year in
which they were made and for six (6) additional years thereafter. The State
Comptroller, the Attorney General and any other person or entity authorized to
conduct an examination, as well as the agency or agencies involved in this
contract, shall have access to the Records during normal business hours at an
office of the Contractor 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 his invoice or New York State standard voucher, must
give the reason or reasons why the payee does not have such number or numbers.
(b) PRIVACY NOTIFICATION.
(1) The authority to request the above personal information from
a seller of goods or services or a lessor of real or personal property, and the
authority to maintain such information, is found in Section 5 of the State Tax
Law. Disclosure of this information by the seller or lessor to the State is
mandatory. The principal purpose for which the information is collected is to
enable the State to identify individuals, businesses, and others who have been
delinquent in filing tax returns or may have understated their tax liabilities
and to generally identify persons affected by the taxes administered by the
Commissioner of Taxation and Finance. The information will be used for tax.
administration purposes and for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit
of the agency contracting to purchase the goods or services or lease the real or
personal property covered by this contract or lease. The information is
maintained in New York State's Central Accounting System by the Director of
State Accounts, Office of the State Comptroller, AESOB, Albany, New York 12236.
12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN: In accordance
with Section 312 of the Executive Law, if this contract is: (i) a written
agreement or purchase order instrument, providing for a total expenditure in
excess of $25,000.00, whereby a contracting agency is committed to expend or
does expend funds in return for labor, services, supplies, equipment, materials
or any combination of the foregoing, to be performed for, or rendered or
furnished to the contracting agency; or (ii) a written agreement in excess of
$100,000.00 whereby a contracting agency is committed to expend or does expend
funds for the acquisition, construction, demolition, replacement, major repair
or renovation of real property and
improvements thereon; or (iii) a written agreement in excess of $100,000.00
whereby the owner of a State assisted housing project is committed to expend or
does expend funds for the acquisition, construction, demolition, replacement,
major repair or renovation of real property and improvements thereon for such
project, then:
(a) The contractor will not discriminate against employees or
applicants for employment because of race, creed, color, national
origin, sex, age, disability or marital status, and will undertake
or continue existing programs of affirmative action to ensure that
minority group members and women are afforded equal employment
opportunities without discrimination. Affirmative action shall mean
recruitment, employment, job assignment, promotion, upgradings,
demotion, transfer, layoff, or termination and rates of pay or other
forms of compensation;
(b) at the request of the contracting agency, the Contractor shall
request each employment agency, labor union, or authorized
representative of workers with which it has a collective bargaining
or other agreement or understanding, to furnish a written statement
that such employment agency, labor union or representative will not
discriminate on the basis of race, creed, color, national origin,
sex, age, disability or marital status and that such union or
representative will affirmatively cooperate in the implementation of
the contractor's obligations herein; and
(c) the Contractor shall state, in all solicitations or
advertisements for employees, that, in the performance of the State
contract, all qualified applicants will be afforded equal employment
opportunities without discrimination because of race, creed, color,
national origin, sex, age, disability or marital status.
Contractor will include the provisions of "a", "b" and "c", above, in
every subcontract over $25,000.00 for the construction, demolition, replacement,
major repair, renovation, planning or design of real property and improvements
thereon (the "Work") except where the Work is for the beneficial use of the
Contractor. Section 312 does not apply to: (i) work, goods or services unrelated
to this contract; or (ii) employment outside New York State; or (iii) banking
services, insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any federal
law concerning equal employment opportunity which effectuates the purpose of
this section. The contracting agency shall determine whether the imposition of
the requirements of the provisions 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 Governor's Office of Minority and Women's Business
Development pertaining hereto.
13. CONFLICTING TERMS. In the event of a conflict between the terms of the
contract (including any and all attachments thereto and amendments thereof) and
the terms of this Appendix A, the terms of this Appendix A shall control.
14. GOVERNING LAW. This contract shall be governed by the laws of the
State of New York except where the Federal supremacy clause requires otherwise.
15. LATE PAYMENT. Timeliness of payment and any interest to be paid to
Contractor for late payment shall be governed by Article 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, or 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.
August, 1989
APPENDIX J
ELECTRONIC BILLING PROCESS
NEW YORK STATE DEPARTMENT OF HEALTH
Child Health Plus
Monthly Voucher Bill and
Adjustment Guidelines
This document provides instructions for the submission of monthly voucher
bills and adjustments to the Department of Health for the State's share of the
premium costs for children enrolled in Child Health Plus.
MONTHLY VOUCHER BILLS
Contractors should submit their monthly voucher bill data files by the
tenth business day of the month for which payment is being claimed. The billing
data files should be based on the actual number of children enrolled in the
program during the month for which payment is being claimed. The billing data
files should contain a record for each child enrolled during the month for which
payment is being claimed as well as a record for each child disenrolled.
Contractors must also submit a State of New York Standard Voucher for
receipt by the Department of Health by the tenth business day of the month.
Samples of the data file layout and the standard voucher form, as well as
instructions for completing them are enclosed (Exhibits A through D).
ADJUSTMENTS
Adjustments should be submitted in conjunction with monthly voucher bills.
Adjustment data files should document any overpayments or underpayments relating
to the addition or deletion of enrollees, changes in coverage, audit citations,
and any other adjustments relating to monthly voucher bills submitted during a
previous period.
Contractors should submit adjustments on a monthly basis. Samples of the
data file layout and instructions for completion are enclosed (Exhibits E
through F).
SUBMITTING MONTHLY VOUCHER BILLS AND ADJUSTMENTS
Please review all New York State Standard Vouchers and all billing and
adjustment data files for completeness and accuracy. Submissions containing
errors may be returned for correction.
1
Billing and adjustment data files should be submitted, via the Department
of Health's electronic mail network, by the tenth business day of the month for
which payment is being claimed.
All corresponding New York State Standard Vouchers should be submitted for
receipt by the Department of Health by the seventh business day of the month,
and should be accompanied by a brief cover letter which identifies the name and
telephone number of the individual to be contacted in the event that questions
arise regarding the bill and/or adjustment.
Mail completed New York State Standard Vouchers to:
Suzanne Moore, Ph.D.
Director
Bureau of Health Economics
New York State Department of Health
Corning Tower Building, Room 1110
Empire State Plaza
Albany, New York 12237-0722
2
Exhibit A
NEW YORK STATE DEPARTMENT OF HEALTH
CHILD HEALTH PLUS
INSTRUCTIONS FOR COMPLETING FORMS AND DATA FILES REQUIRED
FOR THE SUBMISSION OF MONTHLY VOUCHER BILLS
A. COMPLETE A STATE OF NEW YORK STANDARD VOUCHER FORM (EXHIBIT B), photocopies
are acceptable.
Complete the Standard Voucher form as follows:
ORIGINATING AGENCY: Enter "New York State Department of Health"
ORIGINATING AGENCY CODE: Enter "12000"
P-CONTRACT: Enter your State contract number.
PAYEE ID: Enter your organization's Federal Tax Identification number (your
voucher will not be processed without this number).
PAYEE NAME, ADDRESS, CITY, STATE AND ZIP CODE: Enter the complete name and
address, including zip code, of the person or organization to appear on the
check.
DESCRIPTION OF MATERIAL/SERVICE:
Enter Child Health Plus Program.
Monthly voucher bill for the month ending _______/________/_______ (Enter the
appropriate date).
Enter the Data Control Number (DCN) assigned to the billing data file submitted
electronically to substantiate the monthly billing amount claimed on the
standard voucher form.
If an adjustment is being submitted in conjunction with the monthly voucher
bill, enter:
Adjustment for the period ending _____/______/_______ (Enter the appropriate
data).
Enter the DCN assigned to the adjustment data file submitted electronically to
substantiate the adjustment amount claimed on the standard voucher form.
AMOUNT: Add the amounts entered into the field labeled, "State Share" on your
billing data file, Exhibit C, and enter the result.
3
If an adjustment is being submitted in conjunction with the monthly voucher
bill, add the amounts entered into the field labeled, "Adj_SS" on your
adjustment data file, Exhibit F, and enter the result.
TOTAL AND NET: Enter the sum of the amounts entered above.
NOTE: Please verify that the dollar amounts claimed on the standard voucher form
for all bills and adjustments equal the sum of the amounts entered into the
fields labeled "State Share" and "Adj_SS" on the billing and adjustment data
files submitted via the Department's electronic mail network. If the standard
voucher and data files are not in agreement, payment cannot be processed.
PAYEE CERTIFICATION:
The person authorized to process monthly voucher bills must sign and date the
standard voucher form. Enter the title of the person authorized to sign the form
and the name of the company.
B. SUPPORTING DOCUMENTATION - BILLING DATA FILE (EXHIBIT C)
Each monthly billing amount claimed on a New York State Standard Voucher
must be substantiated by a data file containing information for children
enrolled in the program during the month for which payment is being claimed, as
well as a record for each child disenrolled. The data file should contain the
following information for each child. The specifications for the file layout are
provided as Exhibit C. The data files must be submitted via the Department's
electronic mail network.
FOR THE PERIOD ENDING: Enter the last day of the month for which payment is
being claimed. Entry must be six digits and in date format (MMDDYY). Check to
ensure a valid date was entered.
PLAN IDENTIFIER (NAME): Enter your organization's plan identifier, Exhibit G.
Entry must be left justified. Check to ensure the correct plan identifier was
entered.
CONTRACT NUMBER: Enter your State contract number, Exhibit G. Check to ensure
the correct contract number was entered.
SOCIAL SECURITY NUMBER: Enter the individual's Federal Tax Identification
number (if available). The Federal Tax Identification number must be nine
digits. If a Federal Tax Identification number is not available, projects must
assign a unique identifier. The first character in an assigned identifier must
be alphabetic. The assigned identifier may be nine characters or less. The
Federal Tax Identification number or assigned identifier shall be used for all
billing and claims processing functions. Entry must be left justified. Check
to ensure an entry was made in this field.
4
LAST NAME: Enter the individual's last name. Entry may be alphanumeric and
seventeen characters or less. Entry must be left justified. Check to ensure an
entry was made in this field.
FIRST NAME: Enter the individual's first name. Entry may be alphanumeric and ten
characters or less. Entry must be left justified. Check to ensure an entry was
made in this field.
MIDDLE INITIAL: Enter the individual's middle initial. Entry may be alphabetic
(A through Z) or blank. Check to ensure the entry is alphabetic or blank.
BIRTH DATE: Enter the individual's date of birth. Entry must be six digits and
in date format (MMDDYY). Check to ensure the child listed is less than thirteen
years of age on the last day of the previous month and that a valid date was
entered.
SEX: Enter the individual's gender. Entry must be M or F. Check to ensure M or F
was entered.
P.O. BOX OR HOUSE NUMBER AND STREET ADDRESS: Enter the individual's residential
street address. Entry may be alphanumeric and thirty-five characters or less.
Entry must be left justified. Check to ensure an entry was made in this field.
CITY: Enter the individual's city of residence. Entry may be alphanumeric and
fifteen characters or less. Entry must be left justified. Check to ensure an
entry was made in this field.
COUNTY: Enter the individual's county of residence as specified on the listing
of counties and corresponding codes, Exhibit D. Entry must be a numeral and two
digits. Check to ensure a valid code, Exhibit D, that is within the contractors
service area was entered.
STATE: Enter the individual's state of residence. Entry must be NY. Check to
ensure NY was entered.
ZIP CODE: Enter the individual's residential zip code. Entry must be a five
digit numeral. Check to ensure a valid New York State zip code within the
contractor's service area was entered.
APPLICATION NUMBER: Enter the application number assigned to the individual and
entered onto the supplemental enrollment form during the enrollment process.
Entry may be alphanumeric and nine characters or less. Entry must be left
justified.
5
ORIGINAL ENROLLMENT DATE: Enter the effective date of health insurance coverage.
Entry must be six digits and in date format (MMDDYY). Check to ensure a valid
date was entered and the entry represents a date that occurred on or after the
date the contractor began enrolling children and before the date entered into
the field labeled "PERIOD". Do not change the original enrollment date for the
duration of the child's Child Health Plus coverage. NOTE: All children must be
enrolled effective the first day of the month.
TERMINATION DATE: Enter the date that health insurance coverage is terminated.
Entry must be six digits and in date format (MMDDYY). If a date has been
entered, check to ensure a valid date was entered and the entry represents a
date that occurred after the date entered into the field labeled "Enrollment
Date" for that child. If the entry represents a date that occurred before the
date entered into the field labeled "PERIOD", check to ensure 0 was entered into
the field labeled "State Share of Premium". If the entry represents a date that
occured on or after the date entered into the field labeled "PERIOD", check to
ensure a numeral was entered into the field labeled "STATE SHARE". NOTE: All
children must be terminated on the last day of the month.
STATE SHARE OF PREMIUM: Enter the State's share of the monthly premium. This
must be a signed numeric field and eleven digits or less. Entry must be right
justified. (e.g. -$35.00 should be entered as -3500, +$35.00 should be entered
as 3500). Check to ensure the State's share of a valid premium rate or 0 was
entered.
NOTE: Please add the amounts entered into this field and verify that the result
is equal to the billing amount entered onto the State of New York Standard
Voucher form. Also, please verify that the DCN assigned to the data file was
entered onto the standard voucher form.
CURRENT ENROLLMENT/RECERTIFICATION DATE: Enter the current enrollment or
recertification date. Entry must be 6 digits and in date format (MMDDYY). Check
to ensure a valid date was entered and the entry represents a date that occurred
on or after the date the contractor began enrolling children and before the date
entered into the field labeled "PERIOD". NOTE: All children must be enrolled and
recertified effective the first day of the month.
TELEPHONE NUMBER: Enter the individual's area code and telephone number. Entry
must be numeric and ten numerals. (Not a required entry).
6
HOUSEHOLD/FAMILY IDENTIFIER: Enter the individual's household/family identifier.
All children in a household must be assigned an identifier. The identifier must
be identical for all members of a household/family. A unique identifier must be
assigned to each household/family. Entry may be alphanumeric and nine characters
or less. Entry must be left justified. Check to ensure entry was made in this
field.
PRESUMPTIVE ELIGIBILITY: This field identifies whether or not the child entered
Child Health Plus through the presumptive eligibility process. Enter a "P" if
the child was enrolled presumptively. If the child did not enroll presumptively,
leave this field blank.
PAYMENT CATEGORY: Enter the individual's subsidy level. Entry must be an F, A,
B, or S. (F=Full Subsidy, P=Partial Subsidy (120% - 160% FPL), B=Partial Subsidy
(160% - 222% FPL), and, S=Selfpay). Check to ensure F, A, B, or S was entered.
7
SEE INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING
C 92 (Rev. 6/94)
STANDARD VOUCHER EXHIBIT
B
[ILLEGIBLE]
OF
NEW YORK
Voucher No.
[ILLEGIBLE] Agency Orig. Agency Code Interest Eligible (Y/N) 2 P-Contract
New York State Department of Health 12000 123456
Payment Date (MM) (DD) (YY) OSC Use Only Liability Date (MM) (DD) (YY)
/ / / /
3 Payee ID Additional Zip Code Route Payee Amount MIR Date (MM) (DD) (YY)
123456789 / /
4 PAYEE NAME (Limit to 30 spaces) IRS Code IRS Amount
XYZ Insurance Company
PAYEE NAME (Limit to 30 spaces) Stat. Type Statistic Indicator-Dept. Indicator-Statewide
Attn: John Smith, President
Address (Limit to 30 spaces) 5 Ref/Inv. No. (Limit to 20 spaces)
30 Park Place
Address (Limit to 30 spaces) Ref/Inv. Date (MM) (DD) (YY)
Room 160 / /
City (Limit to 20 spaces) (Limit to 2 spaces) - State Zip Code
Albany NY 12208
6 Purchase Description of Material'Service
Order No. If items are too numerous to be incorporated into the block below.
and Date use Form AC 93 and carry total forward. Quantity Unit Price Amount
- ---------- ------------------------------------------------------------------ -------- ---- ----- ------
CHILD HEALTH PLUS PROGRAM 01/31/96
BILLING FILE DCN#_________________________________________________
# OF SUBSCRIBERS APPROVED RATE
__________________________ X __________________________ ______________________
__________________________ X __________________________ ______________________
__________________________ X __________________________ ______________________
ADJUSTMENT FILE DCN #_____________________________________________ SUB-TOTAL BILL
==================
ITEM/DESCRIPTION PERIOD OF ADJ. # SUBSCRIBERS APPROVED RATE
Retroactive adjust _________________________________________ _______ X __________________ ________________
Duplicate adjusts __________________________________________ _______ X __________________ ________________
SUB-TOTAL.ADJUSTMENT
====================
PAYEE CERTIFICATION:
I certify that the above bill is just, true and correct; that part thereof has been paid Total TOTAL BILL
except as stated and that the balance is actually due and owing, and that taxes from which Discount
the State is exempt are excluded. %
/S/ [ILLEGIBLE] DIRECTOR ACCTS RECEIVABLE
- --------------------------------- --------------------------------
Payee's Signature in Ink Title
1/3/96 XYZ INSURANCE COMPANY
- ------------- ------------------------------------------------------------------------------------- TOTAL MONTHLY
Date Name of Company Net BILLING
FOR AGENCY USE ONLY STATE COMPTROLLER'S PRE-AUDIT
------------------- -----------------------------
Merchandise Received I certify that this voucher is correct and just. and payment is approved
and the goods or services rendered or furnished are for use in the
services and performance of the official functions and duties of this Certified
agency. For Payment of
Date Verified Net Amount
-----------------------------------------------------------------------
Authorized Signature
Page No. Audited
By Date Title Special Approval By___________
(as Required)
EXPENDITURE LIQUIDATION
Cost Center Code Accum
pt. Cost Center Unit Var Yr Object Dept. Statewide Amount Orig. Agency PO/Contract Line [ILLEGIBLE]
- --------------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------------
- --------------------------------------------------------------------------------------------------------------------------------
OSC [ ]Check if Continuation
Exhibit C
NEW YORK STATE DEPARTMENT OF HEALTH
CHILD HEALTH PLUS PROGRAM
File Layout for the Submission of Monthly Voucher Bills
FILE NAME: Child Health Plus Billing/Data Date: Page 1 of 1
Field Position Field
No. Field Label To From Size Pic Field Description/Remarks
- ----- ----------- -- ---- ---- --- -------------------------
1 PERIOD 1 6 6 9 For the period ending (MMDDYY)
2 PLAN IDENTIFIER 7 43 37 X Plan Identifier (NAME)
3 CON - NO 44 49 6 9 Contract Number
4 SS - NO 50 58 9 X Social Security Number
5 LAST NAME 59 75 17 X Last Name
6 FIRST NAME 76 85 10 X First Name
7 M 86 86 1 X Middle Initial
8 BIRTHDAY 87 92 6 9 Birth Date (MMDDYY)
9 S 93 93 1 X Sex Code
10 ADDRESS 94 128 35 X PO Box or House Number and Street Address
11 CITY 129 143 15 X City
12 CO 144 145 2 9 County Code
13 ST 146 147 2 X State
14 ZIP 148 152 5 9 Zip Code
15 APP-NO 153 161 9 X Application Number
16 0-ENR-D 162 167 6 9 Original Enrollment Date (MMDDYY)
17 TERM-D 168 173 6 9 Termination Date (MMDDYY)
18 STATE SHARE 174 184 11 9 State Share Premium (SIGNED NUMERIC)
19 O - ENR - D 185 190 6 9 Current Enrollment/Recertification Date (MMDDYY)
20 TEL - NO 191 200 10 X Telephone Number
21 FAMILY - ID 201 209 9 X Family Identifier
22 PRESUMPTIVE ELIG 210 210 1 X Presumptive Eligibility
23 PAY CATEGORY 211 211 1 X Payment Category
Exhibit D
COUNTY CODES
CODE COUNTY CODE COUNTY
- ---- ------ ---- ------
1 Albany 33 Orange
2 Allegany 34 Orleans
3 Broome 35 Oswego
4 Cattaraugus 36 Otsego
5 Cayuga 37 Putnam
6 Chautauqua 38 Rensselaer
7 Chemung 39 Rockland
8 Chenango 40 St. Lawrence
9 Clinton 41 Saratoga
10 Columbia 42 Schenectady
11 Cortland 43 Schoharie
12 Delaware 44 Schuyler
13 Dutchess 45 Seneca
14 Erie 46 Steuben
15 Essex 47 Suffolk
16 Franklin 48 Sullivan
17 Fulton 49 Tioga
18 Genesee 50 Tompkins
19 Greene 51 Ulster
20 Hamilton 52 Warren
21 Herkimer 53 Washington
22 Jefferson 54 Wayne
23 Lewis 55 Westchester
24 Livingstone 56 Wyoming
25 Madison 57 Yates
26 Monroe 58 Bronx
27 Montgomery 59 Kings
28 Nassau 60 New York
29 Niagara 61 Queens
30 Oneida 62 Richmond
31 Onondaga
32 Ontario
Exhibit E
NEW YORK STATE DEPARTMENT OF HEALTH
Child Health Plus
Instructions for Completing
Data - Files for Adjustments
A. SUPPORTING DOCUMENTATION (Exhibit F)
Each adjustment amount claimed on a New York State Standard Voucher must
be substantiated by a data file containing information for each child for whom
an adjustment is necessary. The data file should contain the following
information for each child. The specifications for the file layout are provided
as Exhibit F. The data files must be submitted via the Department's electronic
mail network.
FOR THE PERIOD ENDING: Enter the last day of the period for which the
adjustments are being billed. Entry must be six digits and in date format
(MMDDYY). Check to ensure a valid date was entered.
PLAN IDENTIFIER (NAME): Enter your organization's plan identifier, Exhibit G.
Entry must be left justified. Check to ensure the correct plan identifier was
entered.
CONTRACT NUMBER: Enter your State contract number, Exhibit G. Check to ensure
the correct contract number was entered.
SOCIAL SECURITY NUMBER: Enter the individual's Federal Tax Identification number
(if available). The Federal Tax Identification number must be nine digits. If a
Federal Tax Identification number is not available, projects must assign a
unique identifier. The first character in an assigned identifier must be
alphabetic. The assigned identifier may be nine characters or less. Entry must
be left justified. Check to ensure an entry was made in this field.
LAST NAME: Enter the individual's last name. Entry may be alphanumeric and
seventeen characters or less. Entry must be left justified. Check to ensure an
entry was made in this field.
FIRST NAME: Enter the individual's first name. Entry may be alphanumeric and ten
character or less. Entry must be left justified. Check to ensure an entry was
made in this field.
MIDDLE INITIAL: Enter the individual's middle initial. Entry may be alphabetic
or blank. Check to ensure the entry is alphabetic (A through Z) or blank.
8
Period of Adjustment:
- - From: Enter the date representing the first day of the period for which
the adjustment is being claimed. Entry must be the first day of the month.
Entry must be six digits and in date format (MMDDYY). Check to ensure a
valid date was entered and the entry represents a date that occurred on or
after the date the contractor began enrolling children and no later than
the date entered into the field labeled "PERIOD".
- - To: Enter the date representing the last day of the period for which the
adjustment is being claimed. Entry must be the last day of the month.
Entry must be six digits and in date format (MMDDYY). Check to ensure a
valid date was entered and the entry represents a date that occurred
after the date entered into the field labeled "FROM" for that child and no
later than the date entered into the field labeled "PERIOD".
e.g. Individual's coverage terminated effective 03/01/91. State was billed
for the period 03/01/91 through 04/30/91. Enter 030191 in the column
labeled "from" and 043091 in the column labeled "to".
ADJUSTMENT TO STATE SHARE: Enter the State's share of the adjustment amount.
This must be a signed numeric field and eleven digits or less. Entry must be
right justified. (e.g. +$35.62 should be entered as 3562, - $35.62 should be
entered as -3562). Check to ensure a numeral was entered.
NOTE: Please add the amounts entered into this field and verify that the result
is equal to the adjustment amount entered onto the New York State Standard
Voucher form. Also, please verify that the DCN assigned to the data file was
entered onto the standard voucher form.
9
Exhibit F
NEW YORK STATE DEPARTMENT OF HEALTH
CHILD HEALTH PLUS PROGRAM
File Layout for the Submission of Adjustments
FILE NAME: Child Health Plus Adjustment Date: Page 1 of 1
Field Position Field
No. Field Label To From Size Pic Field Description/Remarks
- ----- ----------- -- ---- ---- --- -------------------------
l PERIOD 1 6 6 9 For the period ending (MMDDYY)
2 PLAN IDENTIFIER 7 43 37 X Plan Identifier (NAME)
3 CON - NO 44 49 6 9 Contract Number
4 SS - NO 50 58 9 X Social Security Number
5 LAST NAME 59 75 17 X Last Name
6 FIRST NAME 76 85 10 X First Name
7 M 86 86 1 X Middle Initial
8 FROM 87 92 6 9 Period of Adjustment "from" Date (MMDDYY)
9 TO 93 98 6 9 Period of Adjustment "to" Date (MMDDYY)
10 ADJ_SS 99 109 11 9 Adjustment to State Share (Signed Numeric Field)
APPENDIX K
BUDGET FORMS
PROJECT BUDGET
PERSONNEL EXPENSES
Budget Form 1
PERSONNEL EXPENSES:
(1) (2) (3) (4) (5)
Annual Fringe # of Entire
Title Salary Benefits % FTE Months Expense Project
- ----- ------ -------- ----- ------ ---------------
Subtotal for personnel
(1) Annual Salary should be listed for salaried personnel and should reflect
the amount which would be paid for a full-time equivalent employee for 12
months. For consultants, give the rate/hour. Please label each item, for
example: Annual Salary - AS and Rate/Hour - R/H.
(2) Fringe Benefits should be calculated on the annual salary amount from
column (1) and the percent given.
(3) Use only for salaried personnel. List the percentage of time the person
will be working, for example, a person working 20 hours/week of a 40 hour
work week should be shown as 50% of a full-time equivalent (FTE) in this
column.
(4) List the total of months for the contract period that the salaried person
is working and label it (mos.). For consultants, list the number of hours
which the person is contracted to provide and label (hrs.).
(5) For salaried personnel, the "Entire Project Expense" should reflect the
annual salary (1) plus fringe benefits (2) times the percentage FTE (3)
(i.e., 0.5 for half-time), adjusted by the number of months (4). For
consultants, the "Entire Project Expense" should reflect the rate/hour (1)
times the number of hours (4). Note that the consultants, (2) and (3) are
not acceptable.
PROJECT BUDGET
NON-PERSONNEL EXPENSES
Budget Form 2
NON - PERSONNEL EXPENSES:*
Items and unit cost Project Total
- ------------------------ -------------
- ---------------------------------------------------------------------
Subtotal for Non - Personnel
Subtotal for Personnel (from Budget Form 1)
GRAND TOTAL (Personnel + Non Personnel)
*Include equipment and supplies, travel to sites, other travel, and any other
non-personnel items. List the unit cost, number of units, and total cost.
APPENDIX L
BIDDER'S SUMMARY
OF PROPOSAL
CHILD HEALTH PLUS
APPLICANT SUMMARY
INSURER RFP
APPLICANT INFORMATION:
Organization Name: _____________________________________________________________
Date of Incorporation: _________________________________
Federal Identification Number: _________________________
Charity Registration Number: ___________________________
DESIGNATED PRIMARY CONTACT:
Name: __________________________________________________
Position/Title: ________________________________________
Address: _______________________________________________
_______________________________________________
_______________________________________________
Telephone: (__)_________________
Fax: (__)_______________________
PROJECT INFORMATION:
Project Name (If Different): ___________________________________________________
Proposal Submission Date: _________________
Premium Requested: Annual : $______________ Monthly:$___________________________
Service Area Requested (By County) : ___________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Projected Year End Enrollment: Year 1: _________________
Year 2: _________________
Year 3: _________________
TOTAL: _________________
ORGANIZATION NAME: ___________________________________
Projected Amount Requested: Year 1: $_______________ (April 1-December 1, 1997)
Projected Annual Request: Year 2: $_______________ (January 1-December 31, 1998)
Projected Annual Request: Year 3: $_______________ (January 1-December 31, 1999)
TOTAL: $_______________
SUBCONTRACT INFORMATION:
Subcontractor Organization: __________________________
Federal Identification Number: _______________________
Primary Contact: _____________________________________
Address: _____________________________________________
_____________________________________________
_____________________________________________
Telephone: (__)_______________________________________
On a separate sheet, please list the name, position, address, telephone number
and affiliation of any other project subcontractors.
ORGANIZATION NAME: ___________________________________
PLAN OUTLINE
ACTIVITIES :
Tasks to be
performed to
STATEMENT OF achieve the Person(s) OUTCOMES/
OBJECTIVE: 1 objectives TIME FRAME: Responsible PRODUCT
- ------------ ------------ ----------- ----------- ---------
1a. 1a.
1b. 1b.
1c. 1c.
1d. 1d.
1e. 1e.
STATEMENT OF
OBJECTIVE: 2
2a. 2a.
2b. 2b.
2c. 2c.
2d. 2d.
2e. 2e.
APPENDIX M
STANDARD CONTRACT/BID
INSERT FORM
STOCK ITEM SPECIFICATION FORM
OF PROPOSAL
BIDDER'S NAME:_______________________________________________________
RFP 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 that holds a 10% or
greater ownership interest in the bidder, either:
- has business operations in Northern Ireland: Y __ N __
- 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
nondiscrimination 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 __ 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%".
1
- It is the policy of New York State to maximize opportunities for the
participation of New York State business enterprises, including
minority-and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.
- Information on the availability of New York State subcontractors and
suppliers is available from:
NYS Department of Economic Development
Division for Small Business
(518) 474 - 7756
- A directory of minority- and women-owned business enterprises is
available from:
NYS Department of Economic Development
Minority and Women's Business Development
Division
(518) 474-6346
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.
2
CHECKLIST TO DETERMINE "REASONABLE" EFFORT
BY BIDDERS/CONTRACTORS FOR CONTRACTS OF $1 MILLION OR MORE
A copy of this form should be completed and retained on file by the
Contractor. The completed form should be available for review for the duration
of the contract.
The contractor:
1. has a copy of the NYS Directory of Certified Minority and
Women-Owned Business Enterprises? Y __ N __
2. has solicited quotes from firms listed in the Directory? Y __ N __
3. has contacted the NYS Department of Economic Development to obtain
listings of NYS subcontractors and suppliers for products and
services currently purchased from out-of-state/foreign firms?
Y __ N __
4. has utilized other sources to identify NYS subcontractors and
suppliers (such as Thomas Register, in-house vendor list)?
Y __ N __ (If YES, Source: _______________)
5. has placed advertisements in NYS newspapers? Y __ N __
6. has participated in vendor outreach conferences? Y __ N __
7. has provided New York State residents notice of new employment
opportunities resulting from this contract through listing any such
positions with the Job Service Division of the NYS Department of
Labor, or providing such notification by another method? Y __ N __
3
NEW YORK STATE DEPARTMENT OF HEALTH
STOCK ITEM SPECIFICATION FORM
(Submission of this form is optional)
Whenever possible, practical, feasible and consistent with open
competitive bidding, the stock item specifications of manufacturers, producers
and/or assemblers located in New York State are used in the preparation of bid
documents for the commodity requirements of State agencies. Companies are
responsible for updating information as changes are made in their stocked items'
technology and/or design.
The DOH maintains Stock Item Specification Forms and corresponding
specifications for a two year period; it is anticipated that within that time
companies will refile with updated information. These forms and updates may be
submitted to:
New York State
Department of Health
Purchase Unit
Corning Tower Room 1354
Albany, New York 12237-0016
Please provide the information requested below, sign and date this form
where indicated, and submit the completed form and accompanying specifications
to the address given above.
1. Company Name and Principal Place of Business:
2. Number of persons employed at above location:____
3. Stocked Item (only one per form):
4. Production of Stocked Item (Name and address of Manufacturer,
Producer, and/or assembler):
5. Product Specification (briefly below, or attach specification):
4
To the best of my knowledge, the information provided is accurate. It may
be used by the State for the purpose of helping to retain jobs, business and
industry presently in the State of New York and attracting new business and
industry to the State of New York. False statements knowingly made herein are
punishable as a Class A misdemeanor under Section 210.45 of the Penal Law of the
State of New York.
Company Representative (please print):
Title and Telephone:
Signature and Date:
5
APPENDIX B-1
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
BUREAU OF HEALTH ECONOMICS
CHILD HEALTH PLUS PROGRAM
INSURANCE PLAN REQUEST FOR PROPOSAL
QUESTIONS AND ANSWERS
SUBMITTED IN WRITING BY DECEMBER 30, 1996
BIDDERS CONFERENCE:
FRIDAY, JANUARY 10, 1997
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 2
INTRODUCTION
This document contains answers to questions submitted by health plans with
respect to the Child Health Plus Insurance Plan Request for Proposal (RFP). The
questions and answers are grouped by evaluation category into three sections:
I. General Technical,
II. Network Comprehensiveness, and
III. Fiscal Evaluation Criteria.
The questions and answers presented here are questions which were
submitted in writing to the Department by December 30, 1996. Questions which
were handed in by insurance plans at the bidder's conference will be mailed to
everyone who submitted a letter of intent by January 23, 1997.
Plans are reminded that in many instances, similar questions were asked by
multiple organizations. Where this occurred, the State in some cases selected
one or more representative questions to answer, rather than responding in
writing to every question asked. In doing so, the State has made a good faith
effort to ensure that all material issues raised by health plans are being
responded to in as complete a manner as possible.
It is important to read this document in its entirety to assure that you
are informed about all policy statements being made with respect to individual
issues.
To the extent to which the answers contained in this document are in
conflict with information provided in the RFP, these answers shall control.
PART I -
GENERAL TECHNICAL QUESTIONS
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 4
I. GENERAL TECHNICAL QUESTIONS
A. ENROLLMENT/[ILLEGIBLE]
1*. UNDER THE CURRENT PROGRAM, AN, APPLICANT WHO ONLY HAS INPATIENT COVERAGE
IS DEEMED ELIGIBLE FOR CHILD HEALTH PLUS SINCE SUCH COVERAGE IS NOT
CONSIDERED "EQUIVALENT HEALTH INSURANCE COVERAGE." UNDER THE NEW PROGRAM,
WITH INCLUSION OF INPATIENT CARE, WILL SUCH APPLICANTS BE INELIGIBLE FOR
CHILD HEALTH PLUS ENROLLMENT? IF YES, DOES THIS MEAN THAT CURRENT
ENROLLEES WHO HAVE SEPARATE INPATIENT COVERAGE MUST BE DISENROLLED FROM
CHILD HEALTH PLUS UPON IMPLEMENTATION OF THE NEW PROGRAM?
The current equivalent coverage policy will be revised prior to implementation
of the expanded program. It is likely that if a policy was not deemed equivalent
in the current program, it will not be equivalent in the expanded program as it
is anticipated that the current definition will merely be expanded to include
inpatient. A policy would still not be equivalent if it only covered inpatient
care.
2. CAN THE EDUCATIONAL ORIENTATION AND APPLICATION PROCESS BE CONDUCTED OVER
THE PHONE OR BY MAIL?
The current application process is typically conducted by mail. Completed
applications cannot be taken over the phone because documentation must be
submitted and the parent/guardian or legally responsible adult must provide an
original signature. Educational orientation may be conducted over the phone with
follow-up written information sent to enrollees.
3. WHAT SHOULD CURRENT CHILD HEALTH PLUS INSURERS DO WHEN SUBSCRIBERS RESPOND
PRIOR TO THE APPROVAL OF THE PROPOSAL?
Children should be enrolled using the existing eligibility review criteria prior
to implementation of the expanded program. Upon implementation, new enrollees
will be evaluated based upon new income levels. The plan will be allowed a 90
day period to transition existing enrollees to the expanded program by
determining their family contribution levels and collecting premiums. If the
family income level does not require a family contribution or if the first
month's family contribution is paid prior to implementation, the child can
transition upon implementation of the expanded program. Others will have up to
90 days to make payment and transition to the expanded program.
4. ARE MARRIED MEMBERS ALLOWED TO ENROLL IN CHILD HEALTH PLUS?
Married members are allowed to enroll if they meet all eligibility criteria.
However,
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 5
coverage will be on an individual, rather than family, basis.
5. ARE MOTHERS WITH CHILDREN [ILLEGIBLE] ENROLL IN CHILD HEALTH PLUS?
IF SO, WILL CHILD HEALTH PLUS COVERAGE [ILLEGIBLE] BE ON AN INDIVIDUAL
RATHER THAN FAMILY BASIS?
Mothers with children are allowed to enroll if they meet all eligibility
criteria. However, coverage will always be on an individual, rather than family,
basis.
6. CAN A CHILD HEALTH PLUS PLAN REQUIRE A SIX-MONTH "LOCK IN" PERIOD FOR
ENROLLMENT? IF YES, WILL THE STATE ENSURE PAYMENT OF AT LEAST ITS PORTION
OF THE PREMIUM DURING THE LOCK-IN PERIOD ONCE INITIAL ELIGIBILITY HAS BEEN
DETERMINED?
A Child Health Plus cannot require a six-month "lock-in" period for enrollment.
7*. ARE THERE ANY NOTIFICATION REQUIREMENTS OR PROTOCOLS TO FOLLOW WHEN
DISENROLLLNG A CHILD HEALTH PLUS MEMBER FOR NON-PAYMENT OF THE PREMIUM
(I.E. PROPER DOCUMENTATION OF ADEQUATE NOTICE, OUTREACH ATTEMPTS, ETC.?)
Based upon general insurance practices no notice is required for non-payment of
premium. However, a plan may choose to notify a family if they have been
disenrolled for nonpayment.
8*. WITH REGARD TO THE ISSUE OF MEMBER DISENROLLMENT DUE TO NON-PAYMENT OF
PREMIUMS, THE DEPARTMENT HAS TRADITIONALLY ASKED INSURERS TO BE LENIENT IN
DEALING WITH THIS SITUATION. WILL THE DEPARTMENT BE MORE EXPLICIT IN ITS
DIRECTIVE ON THIS ISSUE?
Non-payment of premium is cause for automatic disenrollment. Disenrollment would
occur on the last day for which premium has been paid by an insurer. Legislation
allows an insurer flexibility in the temporal aspects of collection. However, it
is at the discretion of the family as to what payment schedule they choose to
abide by.
9*. FOR PREGNANT ENROLLEES: SHOULD A MEMBER BE AUTOMATICALLY DISENROLLED FROM
CHILD HEALTH PLUS WHEN THE PLAN FINDS OUT THAT SHE IS PREGNANT?
A member should not be automatically disenrolled from the Child Health Plus
program once the plan finds out she is pregnant. However, once a plan discovers
an enrollee is pregnant, that individual should be referred to Medicaid
(presumptive eligibility provider, local DSS Medicaid office, or outstation) as
a subsidized enrollee under Child Health Plus should qualify for the Medicaid
program. It should also be noted that a newborn child will also qualify for
Medicaid coverage. Plans should specify the
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 6
identification procedure(s) that will be implemented to expedite the referral of
a pregnant women to the Medicaid program. For example, a plan may require their
prenatal care providers to automatically notify the [ILLEGIBLE] a pregnant
women, covered by the Child Health Plus program, presents, for her first
prenatal visit.
10. HOW "DELINQUENT" DOES A MEMBER HAVE TO BE BEFORE THE PLAN TAKES ACTION TO
DISENROLL HIM OR HER?
Any delinquency is grounds for immediate disenrollment. All family contributions
to the premium must be paid in advance to the period in which coverage is in
effect.
11. IN THE RFP THE STATE REQUESTS THAT THE BIDDER DETAIL PROVISIONS AND OR
ARRANGEMENTS FOR OFFERING CONVERSION OF BENEFITS IN THE EVENT OF
TERMINATION OF COVERAGE UNDER THE PLAN, OR FOR CHILDREN WHO AGE OUT OF THE
PROGRAM. PLEASE CLARIFY WHAT PROVISIONS AND OR ARRANGEMENTS ARE REQUIRED.
SECTION II.K.3 OF THE RFP STATES, "IF THE CONTRACTOR IS UNABLE TO OFFER A
CONVERSION POLICY FROM THEIR OWN ORGANIZATION, THEN THEY MUST PROVIDE
INFORMATION ON THE INSURANCE OPTIONS AVAILABLE WITH ANOTHER ORGANIZATION
TO SUCH CHILDREN" IN THIS EVENT, IS THE PLAN REQUIRED TO MAKE CONTRACTUAL
ARRANGEMENTS WITH OTHER INSURANCE ORGANIZATIONS TO OFFER NON-CHILD HEALTH
PLUS PRODUCTS, OR IS THE PLAN REQUIRED TO SIMPLY PROVIDE A LIST OF
AVAILABLE PLANS (INCLUDING ADDRESSES AND TELEPHONE NUMBERS)?
For organizations, such as Prepaid Health Services Plans, who cannot offer
conversion options, the plan should have information available on other
insurance options for enrollees who age out of the Child Health Plus program. If
an individual or child is ineligible due to income, Child Health Plus coverage
can be purchased at the un-subsidized level (i.e., full premium price). The
plan is not required to make contractual arrangements with other organizations
to offer non-Child Health Plus products.
12. AT WHAT POINT DO WE DISENROLL A PREGNANT MEMBER? EFFECTIVE AT THE END OF
THE MONTH IN WHICH REFERRAL TO A PRESUMPTIVE ELIGIBILITY PROVIDER IS
MADE?
Individuals are not to be disenrolled because they become pregnant.
Disenrollment occurs when the insurer is advised that woman has been enrolled in
Medicaid. Such disenrollment is effective at midnight on the last day of a
month.
B. ELIGIBILITY
13*. THE CHILD'S EFFECTIVE DATE FOR COVERAGE IN THE RFP IS STATED TO BE THE
FIRST DAY OF THE MONTH. PLEASE EXPLAIN FURTHER. FOR MEDICAID MANAGED CARE,
A PERSON ENROLLED BEFORE THE 15TH OF THE MONTH BECOMES EFFECTIVE THE
FIRST
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 7
DAY OF THE FOLLOWING MONTH. (i.e., ENROLLS MAY 6 - EFFECTIVE JUNE 1). IF
THE PERSON ENROLLS AFTER THE 15TH, THE COVERAGE EFFECTIVE DATE WILL BE THE
FIRST DAY OF THE SECOND FOLLOWING MONTH (i.e., ENROLLS [ILLEGIBLE]
EFFECTIVE JULY 1). FOR CHILD HEALTH PLUS, WILL THE SAME BE TRUE?
Under Child Health Plus, all enrollment is effective the first day of the
month and disenrollment is effective midnight the last day of the month. There
is no retroactive enrollment or disenrollment allowed under the program. The
effective month of coverage is dependent on the insurer's internal processing
procedures and cut-off dates. For example, a plan may process applications
between the first and the 25th day of the month for the first day of the
following month while applications processed from the 26th of the month to the
last day of the month for the first day of the month two months following the
application. An insurer's specific enrollment policies needs to be presented in
their proposal.
14*. CAN SDOH EXPLAIN IN MORE DETAIL WHAT IT EXPECTS IN TERMS OF PROVIDING
INFORMATION ON THE "INSURANCE OPTIONS AVAILABLE WITH ANOTHER ORGANIZATION"
WHEN THE CHILD AGES OUT OF THE CHILD HEALTH PLUS PROGRAM, OR IS INELIGIBLE
DUE TO INCOME?
For organizations, such as Prepaid Health Services Plans, who cannot offer
conversion options, the plan should have information available on other
insurance options for enrollees who age out of the Child Health Plus program. If
an individual or child is ineligible due to income, Child Health Plus coverage
can be purchased at the un-subsidized level (i.e., full premium price).
15*. IT IS OUR UNDERSTANDING THAT THE CURRENT SIXTY (60) DAY PRESUMPTIVE
ELIGIBILITY PERIOD WILL ALSO BE AVAILABLE UNDER THE NEW PROGRAM. ARE THERE
ANY CHANGES TO THE PRESUMPTIVE ELIGIBILITY PROCEDURES?
There are no changes to presumptive eligibility procedures contemplated at this
time.
16. WHO IS RESPONSIBLE FOR THE COST OF MEDICAL CARE IF A PLAN IS NOTIFIED BY
THE STATE THAT A CHILD HEALTH PLUS ENROLLEE IS NOT ELIGIBLE AT A TIME WHEN
THE CHILD IS HOSPITALIZED AND RECEIVING INPATIENT CARE?
This situation should never occur as the individual insurer, not the State,
would be making the eligibility determination. The plan would not be responsible
for services rendered if the child was not enrolled.
17. ARE THE RESPONSES PROVIDED IN THE ADVISORY MEMORANDUM STILL CORRECT?
SPECIFICALLY, IS THE INFORMATION REGARDING INAPPROPRIATE EMERGENCY ROOM
USE AND PRESUMPTIVE ELIGIBILITY UP TO DATE?
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 8
Advisory memoranda currently in effect will be reviewed and updated, as needed,
prior to implementation of the program. However, the policies regarding
inappropriate emergency room use and presumptive eligibility are not expected to
change.
18. WILL THE NEW REGULATIONS APPLY ONLY TO NEW ENROLLMENT EFFECTIVE MAY 1,
1997?
New eligibility requirements for equivalent coverage and family contribution
level changes will apply to all program enrollees. However, existing insurers
will be allowed a 90-day period beyond the date of program implementation to
transition existing enrollees to the expanded program.
19. IF A CHILD HAS A PERIOD OF PRESUMPTIVE ELIGIBILITY UNDER THE CURRENT
PROGRAM, WILL HE OR SHE BE ALLOWED ANOTHER PRESUMPTIVE PERIOD UNDER THE
NEW PROGRAM?
If a child has a period of presumptive eligibility under the current program,
they will not be allowed another presumptive period under the new program.
20. WHAT ARE THE PRESUMPTIVE ELIGIBILITY PROCEDURES FOR CHILDREN WHO HAVE NOT
PAID THE FIRST MONTH PREMIUM?
There are no presumptive eligibility procedures for children who have not paid
the first month of premium as a child cannot be enrolled without payment of the
first month.
21. WHAT IS THE NEW DEFINITION FOR EQUIVALENT COVERAGE? WOULD BLUE CROSS AND
BLUE SHIELD OF ROCHESTER AREA'S VALUE MED PROGRAM BE CONSIDERED EQUIVALENT
COVERAGE?
The equivalent coverage definition will be revised prior to implementation of
the expanded program.
22. FOR THOSE CHILDREN THAT ARE CURRENTLY IN CHILD HEALTH PLUS AND HAVE OTHER
INSURANCE COVERAGE THAT TO DATE HAS NOT BEEN CONSIDERED EQUIVALENT
COVERAGE, WHAT ARE THE PROCEDURES FOR REVIEW OF THESE POLICIES AND ARE
THERE SUBSEQUENT PROCEDURES IF THESE POLICIES ARE CONSIDERED EQUIVALENT
UNDER THE NEW PROGRAM?
A revised equivalent coverage policy will be formulated prior to implementation
of the expanded program. It is likely that if a policy was not deemed equivalent
in the current program, it will not be equivalent in the expanded program as
it is anticipated that the current definition will merely be expanded to include
inpatient.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 9
23. WILL AN ENROLLEE BE DEEMED ELIGIBLE BY THE STATE FOR A FULL YEAR, EVEN IF
THE ENROLLEE BECOMES INELIGIBLE SOONER BUT FAILS TO REPORT SUCH
INELIGIBILITY TO THE PLAN?
The State does not make an eligibility determination, it is up to the insurance
contractor to make an eligibility determination. It is the responsibility of the
individual to report any changes in circumstance that may make the individual
ineligible for subsidized coverage within sixty (60) days of such change.
24. IF ONLY ONE PERIOD OF PRESUMPTIVE ELIGIBILITY PER CHILD IS ALLOWED, HOW
WOULD MANAGED CARE PLANS KNOW WHETHER THE PRESUMPTIVE ELIGIBILITY
PROVISION HAS ALREADY BEEN USED BY ANOTHER MANAGED CARE PLAN?
One period of presumptive eligibility per child, per plan, is allowed.
25. WHAT HAPPENS IF A PREGNANT WOMAN REFERRED TO A PRESUMPTIVE ELIGIBILITY
PROVIDER NEVER GOES TO THE PROVIDER FOR DETERMINATION OF PRESUMPTIVE
ELIGIBILITY OR IS FOUND INELIGIBLE FOR MEDICAID, BUT HAS BEEN DISENROLLED
FROM CHILD HEALTH PLUS?
If a pregnant women does not go to the provider for determination of presumptive
eligibility, she is not disenrolled from the Child Health Plus program. Because
a woman is not disenrolled until she is enrolled in Medicaid, she would have
maintained her coverage under Child Health Plus.
26. WHAT, IF ANY, DOCUMENTATION OF ESTABLISHED LINKAGES WITH PRESUMPTIVE
ELIGIBILITY PROVIDERS MUST APPLICANTS SUBMIT WITH THEIR PROPOSALS?
Such documentation can include, but not be limited to, a listing of such
providers within an insurer's proposed service area(s).
27. WHEN SIGNED TAX FORMS ARE SUBMITTED AS PROOF OF INCOME, CAN THE ADDRESS ON
THESE FORMS ALSO BE USED AS PROOF OF ADDRESS (IN LIEU OF REQUESTING OTHER
DOCUMENTATION), IF THE ADDRESS ON THE FORM IS THE SAME AS THAT ON THE
APPLICATION?
Such documentation is acceptable only if it had been signed and sent within
three (3) months of the individual's application to the Child Health Plus
program.
28. IS COMPLETION OF A HEALTH SCREENING FORM (BEYOND THAT WHICH A PCP FILLS
OUT DURING THE INITIAL PHYSICAL EXAMINATION OF A NEW MEMBER) REQUIRED OR
OPTIONAL?
Completion of such a form is optional.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 10
29. IN REGARDS TO "PRESUMPTIVE ELIGIBILITY PROVIDERS" LISTED ON PAGE 15, WHAT
DOES THE DEPARTMENT OF HEALTH CONSIDER TO BE A "SUFFICIENT NUMBER" OF
PRESUMPTIVE ELIGIBILITY PROVIDERS?
The number of presumptive eligibility providers with which a plan affiliates is
left to the bidder based on how many such providers the bidder believes is
necessary to fulfill the objective of this aspect of the program.
30. APPENDIX B. ADVISORY MEMORANDUM 2/1/92, PAGE 6. THERE ARE REFERENCES TO
UNDOCUMENTED ALIENS IN RELATIONSHIP TO THE SELF-DECLARATION OF INCOME.
WILL THERE BE REPERCUSSIONS FROM THE WELFARE REFORM BILL ON THE CHILD
HEALTH PLUS COVERAGE OF CHILDREN WHO MAY BE UNDOCUMENTED ALIENS?
The State has yet to pass legislation implementing the provisions of the
Welfare Reform Bill. Plans will be expected to comply with any future
requirements resulting from the any welfare reform legislation enacted by the
State.
C. RECERTIFICATION
31*. WHEN MUST THE ANNUAL RECERTIFICATION OF ELIGIBILITY BE CONDUCTED? CAN
RECERTIFICATION BE SPACED OUT OVER THE YEAR? MUST ELIGIBILITY BE
TERMINATED IF THE ENROLLEE FAILS TO MAKE TIMELY RECERTIFICATION?
Annual recertification must occur on or prior to the year anniversary of
coverage. An enrollees recertification date is determined by their effective
month of coverage, and will vary by individual according to such anniversary
date. An enrollee must have their coverage terminated if they fail to make
timely recertification.
32. WHEN WILL THE NEW PROGRAMMATIC CHANGES BECOME EFFECTIVE FOR CHILD HEALTH
PLUS SUBSCRIBERS WHO ARE ALREADY ENROLLED IN THE CURRENT PROGRAM AND
CERTIFIED BEYOND MAY 1, 1997?
For subscribers already enrolled in the program, existing insurers will be
allowed a 90 day period after implementation of the expanded program to
transition enrollees. Insurers should try to transition current enrollees to the
expanded program as quickly as possible.
33. WILL CURRENT SUBSCRIBERS BE GRANDFATHERED IN? (FOR EXAMPLE, WILL THOSE
CHILDREN RECEIVING THE CURRENT PROGRAM AT FULL SUBSIDY CONTINUE AT FULL
SUBSIDY UNTIL THEIR CURRENT RECERTIFICATION DATE.)
Current subscribers will be allowed to maintain their current recertification
date and do not need to reapply to the program. Insurers must review income
levels and
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 11
determine what family contribution level will be required. Insurers will have an
additional 90 days from the date of program implementation to collect family
contributions for existing enrollees and to transition them to the expanded
program. If an existing enrollee fails to make the required family contribution
within this period, he or she will be disenrolled. If the family income level
does not require a family contribution or if the first months family
contribution is paid prior to implementation, the child can transition to the
expanded program at implementation. Others will have up to 90 days to make
payment and transition to the expanded program.
34. THE MAY, 1997 RECERTIFICATION ARE DUE TO BE MAILED FEBRUARY 1, 1997. ARE
THERE ANY CHANGES TO THIS RECERTIFICATION PROCESS?
The current recertification process will remain in effect. Upon implementation
of the expanded program, new family contribution levels will go into effect.
Insurers will be given a 90 day period to notify families of existing enrollees
of the revised family contribution levels and to collect premiums, where
applicable.
35. WILL THERE BE A LIMIT TO THE NUMBER OF REINSTATEMENTS A FAMILY MAY HAVE
DURING THE COURSE OF THE YEAR?
The Department is currently considering a reenrollment process in the instances
where an enrollee is cancelled because of nonpayment of premium. Plans will be
notified of the new policy when the Department completes its review.
36. IF FAMILIES ARE REQUIRED TO PAY PREMIUMS ON A MONTHLY BASIS, IS IT LIKELY
THAT THERE WILL BE A SUBSTANTIAL NUMBER OF CANCELLATIONS EACH MONTH FOR
NON-PAYMENT OF PREMIUM. WILL REINSTATEMENTS BE ALLOWED AFTER CANCELLATION
FOR NON-PAYMENT OF PREMIUM? IF SO, WHAT ARE THE GUIDELINES AND PROCEDURES?
The Department is currently considering a reenrollment process in the instances
where an enrollee is cancelled because of nonpayment of premium. Plans will be
notified of the new policy when the Department completes its review.
D. BENEFIT PACKAGE
37. PLEASE CLARIFY - SPEECH AND HEARING SERVICES ARE NOT COVERED EXCEPT FOR
AUDIOMETRIC TESTING WHEN MEDICALLY NECESSARY. DOES THIS MEAN THAT THE PLAN
WOULD COVER THE AUDIOMETRIC TESTING THAT WOULD BE DONE PERIODICALLY AS
PART OF THE CHILD'S SPEECH AND HEARING THERAPY REGIMEN?
Audiometric testing performed periodically as part of a child's speech and
hearing
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 12
therapy regimen are not covered. Audiometric testing performed to rule out or
diagnose a medical condition is covered.
38. PLEASE CLARIFY - CO-PAYS. IF A MEMBER IS DELINQUENT ON CO-PAYS, DOES THIS
COUNT TOWARDS DELINQUENCY OF PREMIUM PAYMENT?
There is no relation between delinquency of co-payments and premium payments.
Co-payments are made to the provider of service, not the insurer.
39. ARE ABORTIONS AND STERILIZATIONS COVERED IF MEDICALLY NECESSARY? IF NOT
MEDICALLY NECESSARY?
Pregnant members should be referred to Medicaid. Consistent with the Insurance
Law requirements, elective abortion and voluntary sterilizations are not
required to be covered.
40. IS "SPEECH THERAPY" COVERED OR NOT? APPENDIX E, UNDER "LEVEL OF COVERAGE"
FOR HOME HEALTH CARE SEEMS TO INDICATE THAT IT IS COVERED, BUT IT IS ALSO
LISTED AS AN EXCLUDED BENEFIT.
Speech therapy as a "stand alone" benefit is not covered. However, as is
currently required by Insurance Law, speech therapy which is part of an
authorized home health care visit which is provided by the certified home health
care agency is covered within the parameters of that visit.
41*. NON-EMERGENCY TRANSPORTATION IS LISTED AS AN EXCLUDED BENEFIT. PLEASE
DEFINE EMERGENCY TRANSPORTATION. IN ADDITION TO AMBULANCE, DOES IT INCLUDE
MEDICALLY NECESSARY AMBULETTE TRANSPORTATION? DOES IT INCLUDE TAXI
TRANSPORTATION WHEN AN AFTER HOURS EMERGENCY ROOM VISIT IS AUTHORIZED BY
THE PLAN THAT DOES NOT REQUIRE AN AMBULANCE, BUT THE MEMBER NEEDS
TRANSPORTATION"?
The schedule of non-covered services should include all forms of transportation
since transportation is NOT a covered benefit under the Child Health Plus
program.
42. IN THE BENEFIT PACKAGE, INPATIENT HOSPITAL MEDICAL OR SURGICAL CARE, LEVEL
OF COVERAGE INDICATES THAT THE SERVICES OF SURGEONS AND ANESTHESIOLOGISTS
ARE ONLY COVERED IF INCLUDED IN THE HOSPITAL BILL. WHY AREN'T THESE
SERVICES COVERED IF BILLED SEPARATELY AS LONG AS THEY ARE MEDICALLY
NECESSARY? AS WRITTEN, THIS LIMITATION WOULD PREVENT HIP FROM USING
ANESTHESIOLOGY GROUPS AND SURGEONS WITH WHICH WE CONTRACT, BUT WHO ARE NOT
HOSPITAL EMPLOYEES.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 13
The intent of the language in the benefit package description was not to exclude
the services of surgeons and anesthesiologist if billed separately. Such
services are as covered.
43. ARE THE SERVICES OF ANESTHESIOLOGISTS COVERED FOR OUTPATIENT SURGERY?
Services of the anesthesiologist for outpatient surgery are covered under the
general benefit of "outpatient surgery". All costs associated with such surgery
are covered.
44*. PLEASE DESCRIBE THE SCOPE OF THE OBSTETRICAL AND GYNECOLOGICAL SERVICES
THAT ARE TO BE PROVIDED BY THE PLAN FOR CHILD HEALTH PLUS ENROLLEES.
The scope of OB/GYN services to be provided by the insurer are those identified
under the maternity care provision of Appendix E, as well as those required by
PHL Section 4406-b and DOH Memorandum Series 95-17, dated December 6, 1995.
45*. DOES THE OUTPATIENT MENTAL HEALTH BENEFIT INCLUDE COLLATERAL VISITS FOR
FAMILY MEMBERS WHO ARE NOT COVERED BY CHILD HEALTH PLUS?
The outpatient mental health benefit package does not include collateral visits
for family members who are not covered by Child Health Plus. Only the outpatient
alcohol/substance abuse treatment benefit contains a family visit requirement.
46*. THE SIXTY (60) VISIT LIMIT FOR CHEMICAL DEPENDENCY AND MENTAL HEALTH HAVE
A MINIMUM OF TWENTY (20) VISITS FOR FAMILY THERAPY FOR ALCOHOL ABUSE AND A
MAXIMUM OF TWENTY (20) VISIT FOR MENTAL HEALTH. DO ANY OF THE VISITS HAVE
TO BE RESERVED FOR SPECIFIED ME? CAN ALL OF THE VISITS BE USED FOR
CHEMICAL DEPENDENCY, OR DO SOME HAVE TO BE RESERVED FOR MENTAL HEALTH? IS
IT FIRST BILLED, FIRST PAID?
The visits in this category do not have to be reserved for specific use but are
first billed, first paid.
47*. THE COVERED DURABLE MEDICAL EQUIPMENT ITEMS APPEARS TO BE FOR A MEDICARE
POPULATION RATHER THAN A PEDIATRIC POPULATION. THE PLANS' MEDICAID
EXPERIENCE SUGGESTS ITEMS SUCH AS NEBULIZERS SHOULD BE COVERED. IS THEN
ANY FLEXIBILITY AS TO THE ITEMS REQUIRED FOR COVERAGE UNDER THIS BENEFIT?
There is no flexibility as to the items covered under this category. Only the
items listed will be covered.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 14
48. ARE THERE ANY LIMITATIONS ON BENEFIT ENHANCEMENT?
No enhancments should be offered to the benefit package. The benefit package is
[ILLEGIBLE] Child Health Plus program providers.
49*. COULD PLANS OPT NOT TO IMPOSE THE PHYSICIAN CO-PAYMENT?
There will be a $2 copayment required for all physician visits, except those
provided on an inpatient basis, for well child care, or as other prohibited by
Insurance Law.
50. PLEASE EXPLAIN THE TERM "SHORT TERM" AS IT IS USED WITH PHYSICAL AND
OCCUPATIONAL THERAPIES.
The term is intentionally undefined to allow insurers the discretion to
provide the benefit at a level they typically offer to non-Child Health Plus
members. Acceptable levels have included a twenty visit per calendar standard as
well as no specific visit limitations but a requirement that the condition in
question be subject to significant clinical improvement through relatively short
term therapy.
E. COORDINATION WITH THE MEDICAID PROGRAM
51*. THE RFP MENTIONS THAT THE CHILD HEALTH PLUS ENROLLMENT FILES ARE
COMPARED TO THE STATE'S MEDICAID ENROLLMENT FILES TO DETERMINE IF A CHILD
IS CURRENTLY ENROLLED IN BOTH PROGRAMS. HOW WILL THE INSURER BE NOTIFIED
OF THE CHILD'S INELIGIBILITY? WILL THE CHILD HEALTH PLUS PROGRAM
TERMINATION IN COVERAGE BE RETROACTIVE, SAME DAY AS DISCOVERY, OR AT THE
END OF THE MONTH?
As stated in the RFP, the Child Health Plus billing/enrollment file is compared
to the current Medicaid enrollment file on a monthly basis to produce a list of
children dually enrolled in both programs. Each insurer receives a letter
transmitting their list of dually enrolled children. The insurer must inform the
parent/guardian of the child's dual enrollment status using a letter provided by
the Department. In this letter, the family is given ten business days from the
date of the letter to respond with proof of Medicaid disenrollment or Medicaid
spend down. If this cannot be provided, the child must be disenrolled from
Child Health Plus within 60 days from the first day of the month where the match
was performed.
52*. UNDER THE CURRENT PROGRAM, INSURERS ARE REQUIRED TO REFER APPLICANTS
WHO APPEAR ELIGIBLE FOR MEDICAID TO THE MEDICAID PROGRAM. APPLICANTS
ARE NOT REQUIRED, HOWEVER, TO APPLY FOR MEDICAID, NOR TO DEMONSTRATE
THAT THEY HAVE BEEN REJECTED BY MEDICAID IN ORDER TO BE ELIGIBLE FOR
CHILD HEALTH PLUS ENROLLMENT. CONTRARY TO WHAT HAD BEEN INDICATED BY
SDOH AT THE
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 15
SEPTEMBER INSURERS' MEETING, THE RFP APPEARS TO CONTINUE THE CURRENT
PRACTICE, I.E., UNDER THE NEW PROGRAM, INSURERS MUST MAKE MEDICAID
REFERRALS [ILLEGIBLE] APPROPRIATE, BUT ONLY THOSE CHILDREN WHO ARE
ACTUALLY "ON MEDICAID SHALL BE INELIGIBLE FOR CHILD HEALTH PLUS. IS
THIS UNDERSTANDING CORRECT?
The existing policy where children who appear Medicaid eligible must be referred
by the insurer to Medicaid will remain in effect. Applicants who appear Medicaid
eligible will not be required to produce documentation of Medicaid denial in
order to be eligible to enroll in Child Health Plus.
53. IS THE ON-SITE REVIEW SEPARATE AND IN ADDITION TO THE MEDICAID ANNUAL
REVIEW? WILL ANY EFFORTS BE MADE TO COORDINATE THE TWO VISITS?
The on-site reviews which will be conducted for the Child Health Plus program
are separate and in addition to the Medicaid annual review. The Child Health
Plus site visit will be for the purposes of reviewing Child Health Plus
applications and enrollment documentation.
54*. PLEASE CLARIFY WHAT INFORMATION YOU ARE LOOKING FOR IN RESPONSE TO THE
REQUEST THAT WE DISCUSS HOW CHILD HEALTH PLUS WILL "INTERACT" WITH OTHER
INSURANCE PRODUCTS, INCLUDING MEDICAID.
With regard to interaction of Child Health Plus insurers with other products,
including Medicaid, the plan should discuss areas such as referral of children
that appear Medicaid eligible to the Medicaid program and how that process will
occur, review of other policies the child may be covered under to determine if
coverage is equivalent, coordination of benefits if coverage is not equivalent,
coordination of duplicates among other Child Health Plus plans, assisting
enrollees who move from the service area of one plan to another to avoid a lapse
in coverage, and implementation of the joint Child Health Plus/Medicaid/WIC
application.
55*. IS IT CORRECT THAT PREGNANT TEENS WHO DO NOT QUALIFY FOR MEDICAID ARE
COVERED FOR PRENATAL CARE AND DELIVERY?
Subsidized enrollees under Child Health Plus who become pregnant should be
qualified for the Medicaid program. However, if an enrollee chooses not to apply
to the Medicaid program, or the enrollee is not subsidized, maternity care is a
covered benefit.
56. FOR INSURERS WHO ARE LICENSED HEALTH MAINTENANCE ORGANIZATIONS, DO MANAGED
CARE RULES APPLY FOR THE CHILD HEALTH PLUS PROGRAM? SPECIFICALLY, IS IT
REASONABLE FOR THE HMO TO EXPECT CHILD HEALTH PLUS MEMBERS TO
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 16
FOLLOW THE SAME BASIC REFERRAL POLICIES THAT HMO AND MEDICAID MANAGED CARE
MEMBERS ABIDE? IF YES, WILL THE INSURER BE ALLOWED TO DISENROLL ENROLLEES
WHO [ILLEGIBLE] SHOW" OR CREATE DISTURBANCES AT SCHEDULED DOCTOR
APPOINTMENT [ILLEGIBLE] HABITUALLY MISUSE THE HMO'S REFERRAL SYSTEM
DESPITE THE EDUCATION EFFORTS OF THE INSURER?
It is reasonable for the HMO/insurer to expect Child Health Plus members to
follow the same referral policies that non-Child health Plus members are
required to follow. The subscriber contract and any other member education
document should clearly set forth the insurers protocol for receipt of covered
services.
With respect to disenrolling a recalcitrant enrollee, the Insurance Department,
after consulting with the Department of Health and recognizing the HMOs dual
role as provider and payor of health care services, did permit HMOs the option
of adopting termination provisions to address the non-compliant enrollee.
However, it has always been understood that such termination provisions would
only be invoked in the most egregious of circumstance. For example, where an
enrollee's persistent refusal to follow recommended treatment has resulted in an
irreparable breach of the provider-patient relationship, termination may be
invoked. Also, where an enrollee is physically or verbally threatening to HMO
staff or providers, termination may be pursued. It was never contemplated that
an HMO invoke termination for "no shows" or the misuse of the referral system.
The HMOs recourse in this latter case is to deny coverage for the unauthorized
service.
57. IN SITUATIONS WHERE ENROLLEES ARE COVERED BY TWO INSURANCE POLICIES, IS
THE CHILD HEALTH PLUS POLICY ALWAYS CONSIDERED SECONDARY PAYER TO THE
OTHER POLICY?
With the exception of Medicaid, Child Health Plus is always considered the
secondary payer to the other policy when an enrollee is covered by two insurance
policies. However, if a child is enrolled in Medicaid and Child Health Plus for
the period covered by both, prior to disenrollment from Child Health Plus,
Medicaid will be the secondary payer to Child Health Plus.
58. BECAUSE THE STAFFING REQUIREMENTS ARE VERY SIMILAR FOR MEMBER/CUSTOMER
SERVICE FOR CHILD HEALTH PLUS AND MEDICAID, IS IT POSSIBLE FOR THE CHILD
HEALTH PLUS TWENTY-FOUR HOUR 1800 PHONE LINE TO BE THE SAME NUMBER AS THE
TWENTY-FOUR 1-800 PHONE LINE FOR MEDICAID?
It is possible to use the same Member/Customer Service hotline for Child Health
Plus and Medicaid.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 17
59*. ON PAGE 47 OF THE RFP IN THE [ILLEGIBLE] ENTITLED "R. TRADEMARK," THE RFP
INDICATES THAT EACH INSURER [ILLEGIBLE] THE NYSDOH DESIGNATED LOGO FOR
CHILD HEALTH PLUS IN ANY [ILLEGIBLE] DOES THIS INCLUDE THE ID CARD WHICH
ALL MEMBERS RECEIVE? PLEASE [ILLEGIBLE] IN ACCORDANCE WITH THE NYSDOH'S
POSITION, MEDICAID MEMBERS HAVE THE SAME ID CARD AS COMMERCIAL MEMBERS. IF
THE STATE REQUIRES THE CHILD HEALTH PLUS LOGO ON MEMBERS' ID CARDS: 1) IT
IS AN OPPOSING POSITION TO THE ONE REQUIRED FOR MEDICAID MEMBERS; AND 2)
IT MAY CREATE A LARGE ADMINISTRATIVE EXPENSE TO PLANS -(I.E., ORDERING NEW
ID CARD STOCK, PROGRAMMING COMPUTERS, ETC.).
After further consideration, the Child Health Plus logo does not have to be
included on a subscriber's identification card. The State will require an
identification process of the Child Health Plus program on an enrollees card
(e.g., stick-on tabs may be used). The State designated logo should be used on
all marketing materials, subscriber contracts, and on any appropriate
correspondence with enrollees related to the program.
60. IS THE STATE MANDATING THE USE OF THE CHILD HEALTH PLUS NAME ON THE PLAN'S
BENEFIT CARD OR THE ACTUAL LOGO?
After further consideration of the cost to insurers of such a mandate, the State
withdraws its mandate to have plans use the Child Health Plus logo on benefit
cards.
61*. FOR PREGNANT ENROLLEES: CAN A MEDICAID MANAGED CARE PROVIDER WHICH ALSO
COVERS CHILD HEALTH PLUS EASILY TRANSFER PREGNANT MEMBERS OVER TO THEIR
MEDICAID MANAGED CARE PROGRAM, OR IS THE PLAN OBLIGATED TO OFFER OTHER
PRENATAL CARE OPTIONS?
However, once a plan discovers an enrollee is pregnant, that individual should
be referred to Medicaid (presumptive eligibility provider, local DSS Medicaid
office, or outstation) as a subsidized enrollee under Child Health Plus should
qualify for the Medicaid program. It should also be noted that a newborn child
will also qualify for Medicaid coverage. Plans should specify the identification
procedure(s) that will be implemented to expedite the referral of a pregnant
women to the Medicaid program. For example, a plan may require their prenatal
care providers to automatically notify the plan when a pregnant women, covered
by the Child Health Plus program, presents for her first prenatal visit.
62*. IS THE CHILD HEALTH PLUS PROGRAM GOVERNED BY THE SAME STATE, AND WHERE
APPLICABLE, CITY MARKETING GUIDELINES?
All insurers must perform their own marketing and outreach activities in
accordance
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 18
with the guidelines found in the RFP. There will also be an independent Child
Health Plus marketing and outreach contractor in place as well as independent
Department of Health marketing activities.
63. WHAT PROCEDURES WILL BE ADOPTEED TO ENSURE A "SEAMLESS" TRANSITION BETWEEN
MEDICAID AND CHILD HEALTH PLUS? FOR EXAMPLE, WILL A MEDICAID MANAGED CARE
ENROLLEE BE DEEMED PRESUMPTIVELY ELIGIBLE FOR CHILD HEALTH PLUS AT THE
TIME S/HE IS DISENROLLED FROM MEDICAID?
A child who is disenrolled from Medicaid must apply and complete a Child Health
Plus application and can be presumptively enrolled if the application is
complete, signed, and the applicant appears to meet all eligibility requirements
but lacks documentation. However, they will not be deemed presumptively enrolled
if they do not apply for the Child Health Plus program.
64*. CAN A CHILD HEALTH PLUS PROVIDER REACH OUT DIRECTLY TO FORMER MEDICAID
MANAGED CARE ENROLLEES WHO HAVE BECOME DISENROLLED FROM THAT PLAN'S
MEDICAID PROGRAM?
A Child Health Plus provider can reach out directly to former Medicaid managed
care enrollees who have become disenrolled from the plans Medicaid managed care
program.
65*. WILL A CHILD HEALTH PLUS ENROLLEE WHO BECOMES ELIGIBLE FOR MEDICAID BE
AUTOMATICALLY ENROLLED IN THE SAME PLAN?
A Child Health Plus enrollee who become eligible for Medicaid will not
automatically be enrolled in the same plan. The child must first be determined
eligible for Medicaid and then select a Medicaid managed care plan.
66. MAY AN ENROLLEE CHOOSE TO MAKE SUCH "AUTOMATIC" TRANSITIONS AT THE TIME
S/HE ENROLLS IN EITHER MEDICAID MANAGED CARE OR CHILD HEALTH PLUS?
An enrollee may not choose to make such an automatic transition at the time of
enrollment in either Medicaid or Child Health Plus.
F. CONTRACT ISSUES
67*. THE CURRENT CHILD HEALTH PLUS SUBSCRIBER AGREEMENTS, UNDER DEPARTMENT OF
HEALTH REGULATIONS, ARE FOR ONE YEAR FROM THE DATE OF ENROLLMENT.
CONSEQUENTLY, THE MAJORITY OF CHILD HEALTH PLUS ENROLLEES WILL HAVE AN
EXISTING SUBSCRIBER AGREEMENT AT THE TIME WHEN THE BENEFIT PACKAGE
CHANGES WHICH EXPIRES AFTER THE BEGINNING OF THE NEW CONTRACT.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 19
A. WILL EXISTING CONTRACTS CONTINUE THROUGH THE EXPIRATION DATE WITH
THE EXISTING BENEFIT PACKAGE OR
B. WILL EXISTING CONTRACTS BE TERMINATED/[ILLEGIBLE] TO INCLUDE THE
ADDITIONAL BENEFITS AND WILL ENROLLEES BE ASPECTED TO PAY THE
MONTHLY PREMIUM AND COPAYMENTS? IF YES:
(1) WILL ENROLLEES WHO DO NOT PAY THE MONTHLY PREMIUM BE
TERMINATED FROM THE PROGRAM? IF SO, HAS THE NYSDOH CONDUCTED A
SURVEY OR STUDY TO ESTIMATE THE NUMBER OF CURRENT CHILD HEALTH
PLUS ENROLLEES WHO WILL NO LONGER BE IN THE PROGRAM DUE TO
NON-PAYMENT OF PREMIUM?
The current Child Health Plus subscriber agreements are not technically one year
contracts. The contract will continue in force until termination for one of the
reasons set forth in the contract. It is anticipated that the existing contracts
will be terminated and replaced by the new contract if the existing insurer
continues in the Child Health Plus program. Existing Child Health Plus
enrollees will be transitioned to the expanded program prior to their
recertification date. Insurers participating in the current program and the
expanded program will be given a 90 day period to transition enrollees to the
expanded program. Existing enrollees will not need to submit a new application
for the expanded program and will be allowed to maintain their current
recertification date. However, insurers will be required to review income levels
on all existing enrollment to determine new family contribution levels. If
enrollees fail to make the required family contribution, they will be terminated
from the program. If family income level does not require a family contribution,
or if the first month's family contribution is paid prior to the implementation
of the expanded program, the child can transition to the expanded program at
implementation. Others will have up to 90 days to make payment and transition to
the expanded program.
If the family income level does not require a family contribution or if the
first months family contribution is paid prior to implementation, the child can
transition to expanded program at implementation. Others will have up to 90 days
to make payment and transition to the expanded program.
68*. HOW WILL THE STATE ESTABLISH THE MAXIMUM COMPENSATION AMOUNT FOR EACH
CONTRACT?
Maximum compensation will be established based upon the number of approved
organizations, their enrollment projections, and the total available funding for
the program.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 20
69. WILL THE MAXIMUM COMPENSATION AMOUNT FOR A CHILD HEALTH PLUS CONTRACT BE
ESTABLISHED FOR THE ENTIRE CONTRACT PERIOD THROUGH DECEMBER 31, 1999, OR
WILL THE AMOUNT BE NEGOTIATED ON AN ANNUAL BASIS, ALONG [ILLEGIBLE] ANNUAL
RATE FILING?
Contracts for successful bidders will be for the period May 1, 1997 through
December 31, 1999, however, the funding amounts for each contract year will be
identified and will be subject to adjustment by the State as needed based on
enrollment trends and premiums.
70. WILL THE STATE FREEZE A CONTRACTOR'S ENROLLMENT IF THE MAXIMUM
COMPENSATION IS REACHED?
Contract provisions will allow DOH to change funding levels (subject to
available program funding) as needed if a plan's enrollment exceeds their
maximum funding level. If in the aggregate the Child Health Plus program reaches
its approved funding levels then enrollment freezes could be implemented.
71*. THEM RFP INDICATES THAT THE CONTRACT PERIOD WILL BE FROM MAY 1, 1997
THROUGH DECEMBER 31, 1999, A 32 MONTH PERIOD. WILL PLAN CONTRACTS WITH THE
NYSDOH BE FOR THE SAME 32 MONTH PERIOD OR WILL CONTRACTS BE AWARDED ON A
YEAR TO YEAR BASIS?
a. IF THE CONTRACT AWARD PERIODS ARE FOR ONE YEAR ONLY, HOW ARE PLANS
EXPECTED TO REACH A FINANCIAL BREAK EVEN WITHIN THAT PERIOD
(ESPECIALLY IN LIGHT OF THE LOW ADMINISTRATIVE PERCENTAGE ALLOWED IN
THE RFP).
Contracts for successful bidders will be for the period May 1, 1997 through
December 31, 1999, however, the funding amounts for each contract year will be
identified and will be subject to adjustment by the State as needed based on
enrollment trends and premiums.
72*. PAGE 44, SECTION K. DO APPLICANTS DEVISE THEIR OWN ADDITIONAL REPORTING
FORMATS, OR ARE THE REQUIRED REPORTS LIMITED TO THE THREE OUTLINED IN
APPENDIX G?
At the present time, the forms contained in Appendix G are draft documents which
summarize what the DOH anticipates to be comprehensive reporting formats for
essential data elements which need to be collected for monitoring and
evaluation of the expanded program. Applicants do not devise their own report
forms and DOH will provide final reporting documents to selected contractors
prior to implementation.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 21
73. SUBCONTRACTS: DOES SECTION III, J "SOLE SOURCE RESPONSIBILITY" REFER TO
ADMINISTRATIVE SUBCONTRACTS, MEDICAL SERVICES SUBCONTRACTS (PROVIDER
CONTRACTS) OR BOTH? PLEASE IDENTIFY THE KIND OF SUBCONTRACTS OR SERVICE IN
WHICH SDOH IS INTERESTED.
This refers to subcontracts relevant to any and all of the insurer's operation
and performance of the requirements of the Child Health Plus program.
G. PROPOSAL SUBMISSION
74. PLEASE DESCRIBE IN DETAIL THE INFORMATION YOU WOULD LIKE US TO INCLUDE IN
THE PLAN OUTLINE CONTAINED IN APPENDIX L.
The data summary sheet which is provided should be completed by the bidder.
However, please disregard the plan outline as it is no longer necessary to
provide that information.
75. WHEN APPROPRIATE, CAN WE SUBSTITUTE (AS AN EXHIBIT) A DOCUMENT THAT
ANSWERS THE QUESTION RATHER THAN DRAFTING A WRITTEN RESPONSE? FOR EXAMPLE,
CAN WE SUBMIT OUR QUALITY ASSURANCE PLAN, WHICH OUTLINES ALL THE
STANDARDS, POLICIES AND PROCEDURES THAT APPLY TO OUR CHILD HEALTH PLUS
PROGRAM AS AN EXHIBIT IN LIEU OF DRAFTING A TEXTUAL RESPONSE.
A document that answers specific questions in the RFP can be used in place of
drafting a written response to that question.
76. WE ASSUME THAT PHSPS, AS WELL AS HMOS, LICENSED UNDER ARTICLE 44 ARE
ELIGIBLE ORGANIZATIONS, CORRECT?
Yes. However, Prepaid Health Services Plans (PHSPs) licensed under Article 44 of
the Public Health Law are eligible organizations only if the operating
certificate of the PHSP allows for non-Medicaid enrollment.
77. WHAT SPECIFIC DOCUMENTATION DOES THE STATE REQUIRE TO DEMONSTRATE
COMPLIANCE WITH THE NON-CONCLUSIVE BIDDING REQUIREMENT ON PAGE 47 OF THE
RFP?
There is no specific documentation required by the State, but it must be stated
clearly in the bidders proposal that there were no special agreements made
between parties in the formulation of the bid and that the bid which is
submitted was reached in accordance with Section 139-d of State Finance Law and
is free from fraud and collusion.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 22
At this time it is important to note that there was a typographical error in the
RFP. The section should read Non-collusive, not non-conclusive.
78. ARE APPLICANTS EXPECTED TO SUBMIT PROOF OF WORKERS' COMPENSATION INSURANCE
WITH THEIR RFP RESPONSES, OR, ONLY IF APPROVED, PRIOR TO EXECUTION OF THE
STATE CONTRACT?
Proof of Worker's Compensation Insurance should be provided with the response
to the RFP.
79. WHY DOES THE STATE NEED FIFTEEN (15) COPIES OF THE PROPOSAL? THAT SEEMS
EXCESSIVE COMPARED TO THAT REQUIRED BY OTHER STATE RFPS (E.G., THE
MEDICAID MANAGED CARE RFP), AND TRANSLATES INTO AN ENORMOUS AMOUNT OF
PAPER AND DELIVERY COSTS. WOULD THE STATE CONSIDER REDUCING THE NUMBER OF
COPIES?
The State cannot reduce the number of copies because of the following needs:
seven (7) copies of the proposal must be submitted to the Office of the State
Comptroller (OSC). The additional copies are needed for contract managers and
the members of the review teams.
80. THE RFP (PAGE 50) ASKS PLANS TO IDENTIFY THEIR "CAPABILITY TO MEET THE
DEPARTMENT'S ELECTRONIC PREMIUM PAYMENT," AND REFERS TO APPENDIX J.
HOWEVER, APPENDIX J,"ELECTRONIC BILLING PROCESS" DOES NOT CONTAIN THE
DEPARTMENT'S SPECIFICATIONS FOR ELECTRONIC PREMIUM PAYMENTS.
Appendix J of the RFP outlines an example of the draft data guidelines and data
elements. The draft file layout is to give the bidder's an idea of what elements
will be required by the State. A formalized data specification layout will be
provided to all selected bidders.
81. ON PAGE 9 OF THE RFP IN THE SECTION ENTITLED "A. ELIGIBLE ORGANIZATIONS,"
THE SECOND BULLET POINT STATES "A CORPORATION OR HEALTH MAINTENANCE
ORGANIZATION LICENSED UNDER ARTICLE 43 OF THE INSURANCE LAW." DOES THIS
MEAN THAT AN HMO LICENSED BY ARTICLE 44 OF THE PUBLIC HEALTH LAW AND
ARTICLE 43 OF THE INSURANCE LAW MAY PROPOSE TO OPERATE A CHILD HEALTH PLUS
PROGRAM IN A COUNTY OUTSIDE OF ITS ARTICLE 44 TERRITORY? WHAT IS THE
SERVICE AREA TO WHICH THE PROPOSAL APPLIES?
If an insurer has dual licensure they need to choose one license under which to
apply to the Child Health Plus program. The service area it will be permitted to
serve will depend on the license under which it applies.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 23
82. ON PAGE 59 OF THE RFP IN THE SECTION ENTITLED "C. PROJECT DESIGN AND
TIME PLAN FOR IMPLEMENTATION," THE NYSDOH REQUESTS CURRICULUM VITAE OF KEY
PERSONNEL. WILL A RESUME BE ACCEPTABLE? IF NOT, COULD A DESCRIPTION OF THE
STATE'S REQUEST BE INCLUDED IN THE RESPONSE TO THE BIDDER'S QUESTIONS?
A resume or a Curriculum Vitae will be acceptable.
83. WE NEED THE MOST CURRENT LIST OF SCHOOL-BASED HEALTH CENTERS IN NEW YORK
STATE.
A list of current school based health care centers will be provided to you by
the Department as an attachment to the written response to questions.
84. WE NEED THE MOST CURRENT LIST OF PRESUMPTIVE ELIGIBILITY PROVIDERS.
A list of the most current presumptive eligibility providers will be provided to
you by the Department as an attachment to the written response to questions.
85. ENROLLMENT PROJECTIONS ARE TO BE PROVIDED FOR WHAT PERIOD OF TIME?
Enrollment projections should be included for the full contract period of May 1,
1997 through December 31, 1999. These projections should also be broken down by
county/borough, calendar year and monthly within the calendar year.
86. CAN SDOH PROVIDE A LIST OF MEDICAID "OUTSTATIONS"?
The Department will provide a list of Medicaid outstations as an attachment to
the written response to questions.
87. WITH REGARD TO THE PROVISION OF A "TIMELINE" FOR PROGRAM IMPLEMENTATION,
FOR MATURE CHILD HEALTH PLUS PROVIDERS, DOES THIS PERTAIN TO THE
IMPLEMENTATION OF CHANGES IN THE PROGRAM?
The timeline for program implementation for purposes of this RFP refers to
implementation of programmatic changes.
88. RESOURCES THAT WILL BE COMMITTED TO IMPLEMENTING AND OPERATING THIS
PROGRAM. WHAT TYPE OF RESOURCES DOES THIS REFER TO: FINANCIAL, STAFF,
PROGRAMMATIC?
Resources refer to financial, staff and programmatic areas.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 24
89. SHOULD THE INDIVIDUAL RESPONSES TO QUESTIONS BE DIVIDED BY TABS? ARE THERE
ANY INSTRUCTIONS REGARDING TABS FOR ATTACHMENTS AND APPENDICES?
Use of tabs or any other organizing aid, which facilitates the review of a
proposal, is welcome.
90. IN THE GENERAL REQUIREMENTS SECTION, PARAGRAPH 1, THE INSTRUCTIONS STATE
THAT "THE BIDDER SHOULD STATE HOW THE ENROLLMENT, MARKETING AND OTHER
OPERATING PLANS MAY CHANGE DURING THE LENGTH OF THE PROGRAM". IS THIS A
QUESTION THAT SHOULD BE ANSWERED WITH A SEPARATE NARRATIVE UNDER THE
GENERAL REQUIREMENTS SECTION OR SHOULD THIS INFORMATION BE INCORPORATED
WITH THE RESPONSES TO OTHER QUESTIONS?
The proposal should follow the outline offered in Section IV of the RFP.
Specifies about a bidder's proposal, such as the aspects of plan operations
noted in this question, should be provided under sections of the proposal.
91. THE RFP STATES THAT A NARRATIVE DESCRIPTION OF THE ORGANIZATION, INCLUDING
THE PARENT COMPANY AND ALL SUBSIDIARY COMPANIES SHOULD BE PROVIDED. SHOULD
THIS NARRATIVE BE INCLUDED AS PART OF APPENDIX I, OR SHOULD IT BE INCLUDED
IN THE RESPONSES TO THE QUESTIONS? A SIMILAR NARRATIVE IS REQUESTED IN
CONJUNCTION WITH APPENDIX III. SHOULD THIS NARRATIVE BE INCLUDED WITH THE
APPENDIX OR SHOULD IT BE INCLUDED AS PART OF THE QUESTIONS?
A narrative description of the organization should be provided in Appendix I.
Appendix III addresses the plan's financial operations, not organizational
descriptions.
92. GIVEN THE COST AND LABOR INTENSIVE PROCESS ASSOCIATED WITH THE RFP
APPLICATION, HOW WILL NON-MEDICAID PLANS BE EVALUATED FOR PARTICIPATION IN
THE CHILD HEALTH PLUS PROGRAM (I.E. WILL IT ONLY BE CONSIDERED AFTER THE
MEDICAID CERTIFIED PLANT ARE EVALUATED)?
All submissions will be given the attention and consideration they are due and
will be evaluated on the same criteria. However, the evaluation of network
composition will reflect the appropriate Medicaid managed care criteria
applicable to the Child Health Plus program objectives.
93. SECTION L, 2 ON PAGE 37 OF THE RFP STATES THAT "INSURERS MUST SUBMIT A
GENERAL PLAN OF A MARKETING PROGRAM OUTLINE WITH THEIR PROPOSAL ALONG WITH
A COMPLETE DESCRIPTION OF HOW THEY EXPECT TO CONDUCT COMMUNITY OUTREACH
AND MARKETING ACTIVITIES". "GENERAL PLAN" AND "OUTLINE" SEEM CONTRADICTORY
TO "COMPLETE DESCRIPTION".
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 25
The bidder should submit a general plan of a marketing proposal, not an outline.
94. PLEASE CLARIFY THE DIFFERENCE AND EXACTLY WHAT SDOH EXPECTS APPLICANTS TO
SUBMIT WITH THEIR PROPOSALS.
Bidders should include in their proposals a plan which describes the marketing
services and resources devoted to this plan.
95. WHAT INFORMATION MUST BE INCLUDED IN THE "TRANSMITTAL LETTER".
Transmittal letters should include, but not be limited to, the bidder's name,
address, and phone number, including appropriate contact person(s); a statement
that the plan and all provisions of the offer price are to remain in effect for
one-hundred and twenty (120) days from the date of the letter; and be signed by
an official of the organization authorized to bind the bidder to the
requirements of the RFP.
96. IN SECTION IV, B, 3, B, PLEASE CLARIFY THE DIFFERENCE, IF ANY, BETWEEN THE
USE OF THE WORDS "PROGRAM" AND "PROJECT" IN THE FORTH, FIFTH AND SIXTH
BULLETS. DO BOTH REFER TO THE ACTUAL PROGRAM IMPLEMENTED AFTER CONTRACT
AWARD?
The words "program" and "project" have been used here interchangeably.
97. THERE IS REDUNDANT INFORMATION REQUESTED IN THE BULLETS UNDER SECTION IV,
C (E.G., ONE BULLETS REQUESTS "EXPECTED NUMBER OF COVERED LIVES AND
ANOTHER THE "NUMBER OF INDIVIDUALS EXPECTED TO BE SERVED; AND TWO BULLETS
REQUEST THE COUNTIES TO BE SERVED). CAN APPLICANTS USE THEIR JUDGEMENT IN
ELIMINATING SUCH REDUNDANCIES OR DOES SDOH WANT THIS INFORMATION INCLUDED
IN THE RESPONSES TO THE EACH BULLET WHERE REQUESTED?
These appear to be redundancies, and bidders may use their best judgment in
responding to the information requested.
98. WHY DOES THE EVALUATION CRITERIA SECTION OF THE RFP (SECTION V) INDICATE
THAT SDOH WILL EVALUATE PROPOSALS BASED ON INFORMATION NOT
REQUESTED/REQUIRED TO BE INCLUDED IN PROPOSALS AS PER SECTION IV.
While the DOH requests or requires certain specific information be included in
submissions, the DOH is free to consider any information voluntarily offered by
a bidder and which may enhance the evacuation of that bidder's proposal.
99. WITH REGARD TO THE REQUIREMENT TO LIST NAME AND ADDRESS OF APPROPRIATE
OFFICERS, WILL BUSINESS ADDRESSES SUFFICE IN RESPONDING TO THE QUESTION?
Business addresses of appropriate officers will suffice.
PART II -
NETWORK COMPREHENSIVENESS
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 27
II. NETWORK QUESTIONS
A. [ILLEGIBLE] SUBMISSION
100*. WHAT FORMAT SHOULD WE USE TO DESCRIBE OUR PROVIDER NETWORK? FOR EXAMPLE,
CAN WE USE THE SPREADSHEET FORMATS THAT WERE REQUIRED FOR THE RECENT
MEDICAID MANAGED CARE REQUEST FOR PROPOSALS? IF SO, CAN WE USE THE CODING
SPECIFIED IN THE "DATA DICTIONARY FOR MANAGED CARE PROVIDER NETWORK
INFORMATION, VERSION 1.0" AS PUBLISHED BY THE SDOH OFFICE OF MANAGED CARE?
Insurers currently participating in the NYS Medicaid Managed Care initiative are
not required to submit descriptions of their provider networks except for
aspects of their networks which may not be reflected in their submission to the
DOH's Office of Managed Care which are due January 23, 1997. Applicants that are
not participants in the Medicaid Managed Care initiative should submit provider
network composition information on diskette (.WK3 or Excel) as required by the
Child Health Plus request for proposal, preferably following the spreadsheet
formats developed by the Office of Managed Care. These formats will be made
available to applicants by forwarding a request to the Bureau of Health
Economics.
101. MANY OF THE RFP REQUIREMENTS ARE EQUIVALENT TO THOSE IN THE RECENTLY
COMPLETED MEDICAID MANAGED CARE PROCUREMENT PROCESS. HEALTH PLANS WHICH
ARE APPROVED UNDER THAT PROCUREMENT, THEREFORE, HAVE ALREADY MET THE
DEPARTMENT'S EXTENSIVE MEDICAID MANAGED CARE REQUIREMENTS. PLEASE CLARIFY
EXACTLY WHAT INFORMATION MUST BE PROVIDED BY THESE PLANS IN RESPONSE TO
THE CHILD HEALTH PLUS RFP, ESPECIALLY RELATED TO THE PROVIDER NETWORK,
QUALITY ASSURANCE, UTILIZATION REVIEW, MANAGED CARE MECHANISMS, PROVIDER
SUB-CONTRACTS, AND OTHER FEATURES WHICH ARE EQUIVALENT TO THOSE OF THE
MEDICAID PROGRAM. WILL THE STATE CONSIDER "DEEMED" STATUS FOR
PROGRAM-EQUIVALENT FEATURES OF SUCH PLANS, I.E., IS MEDICAID APPROVAL
SUFFICIENT EVIDENCE OF PROVIDER NETWORK, ETC., THUS WAIVING THE NECESSITY
TO DISCUSS THOSE FEATURES, IN DETAIL, IN THE CHILD HEALTH PLUS RESPONSE?
Only the network composition component of the Medicaid managed care participant
will be used for evaluation by the Child Health Plus program. The network
composition evaluation will be done on data submitted to the Office of Managed
Care on January 23, 1997. All other aspects of the RFP need to be addressed
within a bidder's proposal.
102. THE RFP STATES THAT HEALTH PLANS MUST INSTITUTE A PROCESS FOR OBTAINING
AND VERIFYING THE NAMES OF HOSPITALS, HMOS, PHPS, AND MEDICAL GROUPS WITH
WHICH THE PROVIDER HAS BEEN ASSOCIATED, AS WELL AS INFORMATION FROM
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 28
OTHER HMOS OR HOSPITALS REGARDING PROFESSIONAL MISCONDUCT OR MEDICAL
MALPRACTICE, AND ASSOCIATED JUDGEMENTS/SETTLEMENTS, AND ANY REPORTS OF
PROFESSIONAL [ILLEGIBLE] BY A HOSPITAL PURSUANT TO NYS PUBLIC HEALTH LAW
SECTION 2803-E. [ILLEGIBLE], THE STATE HAS NOT REQUIRED PLANS TO OBTAIN
INFORMATION FROM HMOS, PHPS, AND MEDICAL GROUPS. IS IT SUFFICIENT TO
OBTAIN THIS INFORMATION FROM THE NEW YORK STATE DEPARTMENT OF HEALTH AND
THE EDUCATION DEPARTMENT, AS WELL AS FROM THE INDIVIDUAL PHYSICIANS,
RATHER THAN REQUIRE THE HEALTH PLAN TO OBTAIN THIS INFORMATION DIRECTLY
FROM HMOS, PHPS, AND MEDICAL GROUPS?
To the extent possible, information about potential providers should be obtained
from all possible sources. Health plans must describe the process used for
credentialling/recredentialling.
103. WILL THERE BE AN ON-SITE REVIEW OF THE PLAN BY DEPARTMENT OF HEALTH PRIOR
TO THE CONTRACT AWARD?
None are planned at this time. However, the State reserves the right to conduct
an on-site review.
104. APPLICANT IS ASKED TO IDENTIFY THE ADDITIONAL NUMBER OF CHILD HEALTH PLUS
ENROLLEES THAT THE PRIMARY CARE PROVIDERS ARE WILLING TO ACCEPT. PLEASE
CLARIFY WHETHER YOU ARE ASKING FOR AN AGGREGATE NUMBER OF ENROLLEES FOR
THE PCPS IN A COUNTY'S NETWORK OR ARE YOU ASKING FOR A SPECIFIC NUMBER BY
PCP?
We are asking for a specific number by PCP.
105. ON PAGE 50 OF THE RFP IN THE SECTION ENTITLED "C. PLAN AND PROJECT
DESIGN," THE SECOND BULLET POINT REFERS TO IDENTIFYING AN ADDITIONAL
NUMBER OF CHILD HEALTH PLUS ENROLLEES THAT A PROVIDER IS WILLING TO
ACCEPT. DURING THE READINESS REVIEW PROCESS FOR MEDICAID, THE NYSDOH
PROVIDED A DEFAULT NUMBER IF THE PLAN INDICATED A PROVIDER HAD AN OPEN
PANEL. IS THIS DEFAULT NUMBER APPLICABLE TO THE CHILD HEALTH PLUS
PROPOSAL?
No. You must provide the number of enrollees that each PCP is willing to accept.
If no number is provided, that PCP will not be counted in your network.
B. EXPANSION / SERVICE AREA
106*. IF A PLAN IS APPROVED BY NYSDOH TO EXPAND INTO ADDITIONAL
COUNTIES/BOROUGHS AND THERE IS AN ADEQUATE PEDIATRIC NETWORK IN THESE
COUNTIES/BOROUGHS WILL THE PLAN BE ABLE TO EXPAND ITS CHILD HEALTH PLUS
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 29
SERVICE AREA (AS IS CURRENTLY PERMITTED UNDER THE EXISTING CHILD HEALTH
PLUS PROGRAM)?
Yes, however the plan needs to secure approval from the State before offering
the Child Health Plus program in the expanded service area. The State reserves
the right to limit an insurer's service area in the Child Health Plus program
even though the insurer may be certified.
107* IS THERE ANY GEOGRAPHIC SERVICE AREA REQUIREMENTS, SUCH AS INSURERS
COVERING THE SAME SERVICE AREA FOR CHILD HEALTH PLUS AS WELL AS ITS OTHER
LINES OF BUSINESS?
No such requirement exists. However, if applicable, insurers can only
participate in Child Health Plus in service areas in which they are certified to
operate. The Department expects that proposed service areas will cover the
entire county.
108*. IS THERE A TARGETED NUMBER OF CHILD HEALTH PLUS INSURERS THAT THE
DEPARTMENT OF HEALTH HOPES TO ACHIEVE OR LIMIT IN EACH COUNTY?
There is no targeted number of insurers to be approved. However, the State
reserves the right to limit an insurer's service area or, on the other hand, to
waive certain restrictions to permit any expansion of coverage where deemed
necessary.
109. WHAT INFORMATION WOULD YOU LIKE US TO PROVIDE IN RESPONSE TO THE REQUEST
THAT WE DESCRIBE THE GEOGRAPHIC ACCESSIBILITY OF OUR PROVIDERS TO OUR
MEMBERS? DO YOU WANT A MAP OF OUR PROVIDER LOCATIONS? IS THERE A SPECIFIC
FORMAT YOU WOULD LIKE US TO USE IN MAPPING OUR PROVIDER NETWORK?
For non-Medicaid managed care plans, maps can be submitted which provide some
indication of potential enrollee clusters, the locations of network providers,
and approximate travel times or distances between these clusters and providers.
Separate maps depicting provider types (e.g., primary care, specialties,
hospitals, etc.) are preferred.
C. QARR AND OTHER STANDARDS
110*. THE PROPOSED REPORTING REQUIREMENTS (RFP PAGE 45) REFER TO "NEW BORN CARE"
UTILIZATION MEASURES. IT IS OUR UNDERSTANDING THAT, SINCE CHILD HEALTH
PLUS IS AN INDIVIDUAL ENROLLMENT PROGRAM (I.E., THERE IS NO "FAMILY"
COVERAGE) AND THERE IS NO RETROACTIVE ENROLLMENT, THERE IS NO MECHANISM
FOR A NEWBORN TO BE ENROLLED FROM DATE OF BIRTH. IS THIS CORRECT? IF SO,
HOW CAN THERE BE ANY "NEWBORN CARE" MEASUREMENTS IN THIS PROGRAM?
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 30
This measure was included due to the remote possibility of a newborn having a
prolonged hospital stay after becoming enrolled in Child Health Plus. However,
newborn coverage would not be retroactive to any [ILLEGIBLE] prior to the actual
enrollment date. If upon further analysis reporting of such measures is
determined to be of marginal, if any, usefulness, consideration can be given to
removing them from future reporting.
111*. ON PAGE 24 OF THE RFP IN THE SECTION ENTITLED "(9) SERVICE ACCESSIBILITY,"
THE NARRATIVE STATES THAT "HEALTH PLANS WILL BE EXPECTED TO TAKE ALL
NECESSARY MEASURES TO ENSURE COMPLIANCE WITH THE ACCESS STANDARDS ISSUED."
PRESENTLY, PHP MONITORS ACCESS WITH PERIODIC SATISFACTION SURVEYS OF A
SAMPLE OF EACH PCP'S PATIENTS. IS THIS METHOD ACCEPTABLE TO THE STATE AND
TRANSFERABLE TO THE CHILD HEALTH PLUS POPULATION?
Periodic satisfaction surveys can be considered part of a program intended to
monitor compliance with access standards. However, an insurer will be
responsible for taking all necessary measures to ensure compliance with these
standards. Such measures may include appointment availability and 24-hour access
studies.
112*. ON PAGE 25 OF THE RFP IN THE SECTION ENTITLED "(E) DAYS TO APPOINTMENT,"
WILL THERE BE ANY STANDARDS GOVERNING PRENATAL, NEWBORN OR FAMILY PLANNING
HEALTH CARE TO ABIDE BY?
Such standards include: initial prenatal visits within three weeks during the
first trimester and two weeks thereafter initial visit for newborns to their PCP
within two weeks of hospital discharge; and initial family planning visits
within two weeks.
113*. WHEN WILL THE FIRST SET OF QARR-LIKE INDICATORS BE DUE AND FOR WHAT
ENROLLMENT PERIOD?
The set of QARR indicators presented in the RFP is provided as a proposed set of
variables that will be more definitively developed over time. It is expected
that insurers will be required to submit the first set of indicators, which will
reflect the first year's enrollment period (from the implementation date of May
1, 1997), during the third quarter of calendar year 1998.
114*. THE CHART ON PAGE 45 INDICATES THE DATA MUST BE REPORTED ON MATERNITY CARE
FOR MEMBERS. DOES THE STATE ANTICIPATE THAT A PREGNANT FEMALE WILL BE
ENROLLED IN CHILD HEALTH PLUS AS WELL AS PCAP? IF YES, HOW WILL HEALTH
PLANS OBTAIN ENCOUNTER DATA IN ORDER TO MEET THE REQUIREMENTS LISTED ON
PAGE 45?
No. Although a provider may be both a Medicaid and a Child Health Plus provider,
an
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 31
individual will be enrolled in either Medicaid or Child Health Plus, not both.
115*. THE "QUALITY" SECTION OF THE REPORTING TABLE ON PAGE [ILLEGIBLE] OF THE
RFP INDICATES THAT "LOW BIRTH WEIGHT, AND WELL CHILD [ILLEGIBLE] VISITS IN
THE FIRST YEAR OF LIFE" AND "PREGNANT AT TIME OF ENROLLMENT" NEEDS TO BE
REPORTED. ADDITIONALLY, THE "UTILIZATION" SECTION OF THE SAME TABLE
INDICATES THAT NEWBORN CARE NEEDS TO BE REPORTED. ARE THE ABOVE REPORTING
REQUIREMENTS NEEDED TO ACCOUNT FOR THE PREGNANT WOMEN AND NEWBORNS WHO ARE
ENROLLED DUE TO INELIGIBILITY FOR MEDICAID?
Yes, in the situation where an individual either is not enrolled in Medicaid or
chooses not to enroll in Medicaid.
116*. WHY WILL PLANS BE REQUIRED TO REPORT THIS DATA GIVEN SDOH'S EXPECTATION
THAT SUCH A SMALL NUMBER OF PREGNANT WOMEN AND CHILDREN UNDER 1 YEAR WILL
BE ENROLLED OR STAY ENROLLED IN CHILD HEALTH PLUS?
Such data are considered important indicators of quality of services offered by
a provider network and are required variables for other enrollees covered by
non-public services. However, if analyses indicates that such data is not of
significant effect, consideration will be given to eliminating reporting
requirements.
D. NETWORK COMPOSITION / SELECTION
117* CAN WE INCLUDE ALL OF OUR CONTRACTED MEDICAID PROVIDERS IN THE NETWORK
SUBMISSION IF THEY HAVE ORALLY CONFIRMED THEIR WILLINGNESS TO EXTEND THEIR
CONTRACT TO THE CHILD HEALTH PLUS PROGRAM? IS IT NECESSARY TO HAVE A
SIGNED LETTER OF INTENT FROM EACH PROVIDER BY THE TIME OF THE NETWORK
SUBMISSION?
The insurer should identify in their submission those providers who have signed
at least a letter of intent to participate in the Child Health Plus program or
have previously contract to provide services to any product lines of the
insurer. Insurers will be required to demonstrate that providers who have filed
a letter of intent are under contract for Child Health Plus program services at
the time of contract negotiations.
118. PLEASE PROVIDE GUIDANCE FOR THE MEASURE WE SHOULD USE TO DETERMINE THE
ADDITIONAL NUMBER OF CHILD HEALTH PLUS ENROLLEES THAT A PRIMARY CARE
PROVIDER IS WILLING TO ACCEPT. IS THERE A MAXIMUM ALLOWABLE PANEL SIZE?
SHOULD WE ASSUME THAT THE MAXIMUM CAPACITY FOR CHILD HEALTH PLUS AND
MEDICAID ENROLLEES CANNOT EXCEED 1,500 PER PROVIDER?
The maximum allowable panel size of 1,500 enrollees is applicable to the
Medicaid
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 32
Managed Care program only.
119. CAN FEMALES SELECT AN OB/GYN AS A SECOND PRIMARY CARE PROGRAM?
Health plans, at their option, may permit OB/GYN providers to serve as PCPs,
subject to DOH qualifications. Plans must also permit direct access for female
members to obstetrics and gynecology services pursuant to Public Health Law
Section 4406-b(1).
120* GIVEN THAT PLANS MUST PERMIT DIRECT ACCESS TO OBSTETRICAL AND
GYNECOLOGICAL SERVICES PURSUANT TO PHL SECTION 4406-b, CAN PLANS LIMIT THE
REIMBURSEMENT TO THESE PROVIDERS TO THE AMOUNT THAT WOULD HAVE BEEN PAID
TO A COMPARABLE IN-NETWORK PROVIDER?
The provisions concerning direct access to obstetrical and gynecological
services pursuant to PHL Section 4406-b, are limited to in-network providers and
therefore reimbursement arrangements would be in place.
121* WILL SUBSCRIBERS HAVE THE OPTION OF SELECTING A CLINIC OR HEALTH CENTER IN
ADDITION TO A PRIMARY CARE PROVIDER?
Staff or group practice or center-based models may require that enrollees first
select a site (clinic or health center) and subsequently select a PCP from among
those available at the site.
122. WILL A BIDDER RECEIVE CREDIT FOR PAST SUCCESSFUL EXPERIENCE IN
ADMINISTERING A CHILD HEALTH PLUS PLAN IF IT NOW PROPOSES AN ENTIRELY NEW
NETWORK?
Additional "credit" is not awarded to current insurers.
123* WHAT PEDIATRIC SPECIALISTS ARE NECESSARY FOR A CHILD HEALTH PLUS NETWORK?
A network must include an array of pediatric specialists required to meet the
medical needs of enrollees.
124. For Primary CARE Providers you must identify the additional number of
CHILD HEALTH PLUS ENROLLEES THE PROVIDER IS WILLING TO ACCEPT. DOES THIS
QUESTION REFER TO EXISTING PLANT AND PROVIDER NETWORKS WHICH ARE ALREADY
SERVING CHILD HEALTH PLUS ENROLLEES? SPECIFICALLY, COMMUNITY PREMIER PLUS
WILL BEGIN OPERATIONS IN THE FIRST QUARTER OF 1997, AND ITS PRIMARY CARE
PROVIDERS DO NOT YET SERVE CHILD HEALTH PLUS ENROLLEES. IN THIS CASE, DOES
COMMUNITY PREMIER PLUS PROVIDE AN ESTIMATE OF THE TOTAL NUMBER OF CHILD
HEALTH PLUS ENROLLEES THAT THESE PROVIDERS COULD SERVE?
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 33
Insurers are required to identify the total number of Child Health Plus
enrollees that each PCP is willing to accept.
125. WHAT IS THE MEDICAID CERTIFICATE OF AUTHORITY?
The certificate of authority that is required pertains to the Article 44
certificate of authority that is issued by the NYSDOH for an entity to operate a
HMO or PHSP. It is not specific to the Medicaid program.
126. NOTIFICATION TO MEMBERS MUST BE PROVIDED WITHIN 30 DAYS OR 3 DAYS AS
REQUIRED IN CURRENT PARTNERSHIP PLAN AGREEMENTS (PAGE 22, SECTION 3(h)).?
Health plans must notify their members of any of the following PCP changes
within thirty (30) business days of the effective date of change: office
address/telephone number change; office hours change; and separation from plan
(termination from network).
127. PAGE 25, SECTION 9(d). WOULDN'T PLANS HAVE TO REQUIRE NOTIFICATION WITHIN
24 HOURS GIVEN $35 CO-PAYMENT? WHAT OBLIGATIONS MUST A PLAN INCUR FOR
PAYMENT OF OUT-OF-NETWORK EMERGENCY MEDICAL CARE? IS IT ACCEPTABLE TO
LIMIT SUCH PAYMENTS, EVEN FOR EMERGENCY CARE, EITHER TO MEDICAID RATES OR
TO A PERCENTAGE OF REASONABLE AND CUSTOMARY CHARGES?
Under the statute, insurers have the option of imposing a $35 copayment on
emergency room services when the member fails to provide notice to the insurer
of receipt of emergency services within 24 hours. The 24 hours is viewed as a
minimum. An insurer can allow for a longer period of time in which notice must
be given.
Covered emergency services received "out of network" are viewed as authorized
out of plan care. The enrollee incurs no financial liability beyond that which
would have been incurred if a participating provider were used, i.e., the
copayment, if applicable. Thus, the insurer may not limit its payment for
out-of-network services to Medicaid rates or to a percentage of UCR unless the
out of network provider agrees
E. SCHOOL BASED HEALTH CENTERS
128*. ON PAGE 55, SECTION 3 OF THE REQUEST FOR PROPOSAL, THE INCLUSION OF
SCHOOL-BASED HEALTH CENTERS IS MENTIONED AS A CRITERIA FOR EVALUATION OF
THE ACCESSIBILITY OF THE NETWORK. IS THE STATE GOING TO PROVIDE GUIDANCE
TO THE PLANS FOR CONTRACTING WITH SCHOOL-BASED HEALTH CENTERS?
Contract guidelines will be made available shortly which can be used for the
Child Health Plus program. In year one of the program, insurers are encouraged
but not required to contract with school-based health centers. Such contracts
are required in the second and subsequent years of the Child Health Plus
contract.
129* IS THERE A REQUIRED PERCENTAGE OF SCHOOL-BASED HEALTH CENTERS WITH WHICH
BIDDERS MUST CONTRACT IN YEAR 1 OF THE CHILD HEALTH PLUS PROGRAM? ARE THE
CONTRACT EXPECTATIONS COMPARABLE TO THOSE UNDER PARTNERSHIP PLAN
GUIDELINES?
No. In year one, insurers are encouraged but not required to contract with
school-based health centers. Such contracts are required in the second and
subsequent years of the Child Health Plus contract. The contract expectations
are comparable to those under the Partnership Plan.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 35
PART III-
FISCAL EVALUATION
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 36
PREMIUM / FISCAL
130. ARE THE PARENTS OF CHILDREN ENROLLED IN CHILD HEALTH PLUS PROGRAM
INSULATED FROM LIABILITY, BY OPERATION OF LAW, FOR THE COST OF MEDICAL
CARE DELIVERED TO THEIR CHILDREN AS PARTICIPANTS IN THIS PROGRAM TO THE
EXTENT THAT THESE COSTS EXCEED THE AMOUNT THAT PROVIDERS ARE PAID AS
REIMBURSEMENT?
This situation should never occur as the insurance carrier will have
arrangements in place with participating providers for reimbursement of
services. However, parents of enrollees are not insulated from costs of services
not covered under the program.
131. THE BILL TO THE STATE MAY BE SENT BEFORE THE SUBSCRIBER HAS PAID THAT
MONTHLY PREMIUM. THIS MAY RESULT IN A CANCELLATION FOR NON-PAYMENT WHERE
THE SUBSCRIBER'S PAID TO DATE AND THE STATE'S PAID TO DATE ARE NOT EQUAL.
HOW SHOULD THE CANCELLATION FOR NON-PAYMENT BE HANDLED? (CLAIMS MAY HAVE
BEEN PAID DURING THE PERIOD THAT THE SUBSCRIBER WAS ACTIVE WITH THE STATE,
YET THE SUBSCRIBER'S PREMIUM PORTION WAS NOT PAID.)
Since all family contributions to premium must be paid in advance, an insurer
would not be billing the State for the remaining portion of the premium if the
family contribution was not paid. Cancellation for non-payment should be
immediate to avoid retroactive disenrollment.
132* IT IS OUR UNDERSTANDING THAT AT LEAST ONE (1) MONTH OF THE FAMILY'S SHARE
OF THE PREMIUM FOR EACH APPLICANT MUST BE PAID AT THE TIME OF APPLICATION.
THE BALANCE DUE WILL BE PAID ON A MONTHLY BASIS ONE (1) MONTH BEFORE THE
PERIOD IT COVERS TO ALLOW FOR A THIRTY (30) DAY GRACE PERIOD PRIOR TO THE
EFFECTIVE DATE OF COVERAGE. WILL FAMILIES OR INSURERS HAVE THE OPTION OF
SELECTING A DIFFERENT BILLING CYCLE (I.E., QUARTERLY, SEMI-ANNUALLY, OR
ANNUALLY)?
Insurers may offer families the option of quarterly, semi-annual, or annual
modes in addition to a monthly mode of payment, but the choice of mode lies with
the family. A monthly mode option must always be available.
133* "GRACE PERIODS" GENERALLY REFER TO A PERIOD OF TIME, AFTER A PAYMENT IS
DUE, DURING WHICH PAYMENT MAY BE MADE WITHOUT PENALTY OR DISENROLLMENT.
THE RFP (PAGE 16) APPEARS TO DEFINE THE SUBSCRIBER PREMIUM PAYMENT GRACE
PERIOD AS THE 30 DAYS PRIOR TO THE PAYMENT DUE DATE. THIS WOULD MEAN THAT
THE INSURER MUST TERMINATE COVERAGE FOR A CHILD HEALTH PLUS ENROLLEE IF
THE PREMIUM CONTRIBUTION IS NOT PREPAID, I.E., RECEIVED BY THE FIRST MONTH
FOR THE MONTH COVERED BY THAT PAYMENT. IS THIS CORRECT? IF SO,
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 37
IT IS NOT ONLY DIFFICULT TO ADMINISTER, IT IS ALSO A MORE SEVERE PAYMENT
RULE THAT APPLIES TO THE STATE WHICH, ACCORDING TO THE RFP, WOULD NOT PAY
THE SUBSIDY PORTION OF THE PREMIUM UNTIL AT LEAST THE MONTH FOLLOWING THE
MONTH OF COVERAGE. WHAT IS THE RATIONALE FOR THIS INEQUITY IN PAYMENT
RULES BETWEEN THE SUBSCRIBER AND THE STATE? IS THE STATE WILLING TO
RECONSIDER THE GRACE PERIOD PROVISION?
The RFP states that the family contribution to the premium is due 30 days in
advance for the period of coverage. However, the insurer may allow the family an
additional 30 days to submit the payment. For example, for coverage for the
month of October, payment is due on September 1. However, the family has until
September 30 to submit the payment without disenrollment. The rationale for
requiring advance payment on behalf of the family is to avoid retroactive
disenrollment for failure to pay subsequent to the covered period and so that
families do not insure medical expenses for a period where the family fails to
make payment and was disenrolled resulting in denied claims for that period.
134. WHAT ARE THE PROCEDURES FOR THE $25.00 ANNUAL FEE ALREADY PAID BY
SUBSCRIBERS WHO HAVE BEEN APPROVED BEYOND MAY 1, 1997?
If the family requests a refund of any unused portion of the $25.00 annual
premium family contribution the plan must pay the refund.
135. WILL RETROACTIVE BILLING BE ALLOWED?
No retroactive billing will be allowed.
136. DOES THE PLAN HAVE THE OPTION TO WAIVE THE PREMIUM IN ANY SPECIAL
CIRCUMSTANCE?
No. The intent of legislation was to have families contribute to the cost of
the premium.
137. PAGE 16, SECTION I. THE RFP STATES THAT MEMBER PREMIUMS MUST BE PAID 30
DAYS IN ADVANCE, BUT THAT ONLY ONE MONTH'S PREMIUM MUST BE TENDERED AT THE
TIME OF ENROLLMENT? WON'T IT BE NECESSARY TO COLLECT TWO MONTHS' PREMIUM
AT THE TIME OF ENROLLMENT IN ORDER TO MAINTAIN THE PRINCIPLE OF ADVANCE
PAYMENT?
The first month's premium must be paid with the application. The next month's
premium will be required prior to the last day of the first month of coverage.
138. PAGE 33, SECTION 3. ARE THERE ANY PARAMETERS FOR AN ACCEPTABLE POLICY
REGARDING TERMINATION FOR NON-PAYMENT OF PREMIUMS? MAY A PLAN
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 38
IMMEDIATELY TERMINATE AN ENROLLEE FOR NON-PAYMENT, SUBJECT TO THE GENERAL
REQUIREMENTS OF THE INSURANCE LAW?
Insurance Law does not require notification of termination due to nonpayment of
premium. Termination may be immediate as of the last day for which the premium
has been paid.
139*. WHAT INFORMATION WOULD YOU LIKE US TO PROVIDE IN RESPONSE TO THE REQUEST
THAT WE DETAIL THE ARRANGEMENTS FOR THE REIMBURSEMENT OF PARTICIPATING
PROVIDERS? IS THERE A SPECIFIC FORMAT YOU WOULD LIKE US TO USE IN
DETAILING THESE ARRANGEMENTS?
We need to know the specific payment arrangements that will be used to
compensate your providers and any related fee schedules or payment rates that
will be used for payment purposes. For example, if primary care providers are
paid on a global capitation basis you need to identify the specific components
of the payment model including monthly payment levels, utilization targets etc.
If specialist are paid on a discounted fee for service basis you need to
identify what fee schedule you are using (e.g. RBRVS) and the level of
compensation. The fee schedule(s) however, do not have to be transmitted to the
Department. The compensation arrangements can be presented in narrative format.
All shared risk or profit management should be described as well any reinsurance
or stop-loss available to providers.
140. FOR THE FINANCIAL RATE FILING, CAN THE PLAN PROPOSE DIFFERENT RATES FOR
DIFFERENT AGE/SEX CLASSES OR IS THE PROPOSAL ONLY FOR ONE GLOBAL RATE FOR
ALL PARTICIPANTS? IS THERE ANY CAP ON THE ADMINISTRATIVE SHARE THAT WILL
BE ALLOWED?
Since this product is considered a community rated product the plan must propose
a single global rate for all participants. The administrative portion of the
rate proposal will be reviewed in relation to the overall rate request. However,
the rate filing guidelines require that the actuarial memorandum include the
specific formulas, methods, and assumptions used in calculating the premium
rates and requires identification of any special assumptions with respect to
children under one year of age and children ages 15-19.
141*. PLEASE CLARIFY WHETHER THE FINANCIAL RESERVE REQUIREMENTS WILL BE BASED
UPON ANTICIPATED ENROLLMENT AND HOW THEY SHOULD BE COMPUTED? AT WHAT
POINT MUST THESE RESERVES BE PUT IN ESCROW?
The financial reserve and escrow requirements, as they pertain to Health
Maintenance Organizations and Prepaid Health Service Plans, are set forth in
Article 44 of the Public Health Law and Part 98 of the Commissioner of
Health's Rules and
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 39
Regulations. The reserve requirement is based on current year premium revenue.
The escrow requirement is based on total projected health care expenditures for
the upcoming year.
142. PLEASE SPECIFY THE CONTENTS TO BE INCLUDED IN THE ACTUARIAL MEMORANDUM.
The contents of the actuarial memorandum are identified in Appendix F of the
Request for Proposal.
143. PLEASE CLARIFY HOW POINTS WILL BE AWARDED BASED UPON THE "FISCAL
EVALUATION CRITERIA". FOR EXAMPLE, CAN A PLAN RECEIVE A FULL 20 POINTS IF
ITS PREMIUM RATE PROPOSAL IS OBJECTIVELY "REASONABLE IN RELATION TO THE
BENEFITS PROVIDED", EVEN IF THE PROPOSED PREMIUM RATE IS SOMEWHAT HIGHER
THAN THAT PROPOSED BY OTHER PLANS OFFERING THE SAME BENEFITS?
While the scoring algorithm for the evaluation criteria was identified in the
proposal, the specific weighting scheme for each section of the proposal has not
been finalized at this time.
144. WILL THE DEPARTMENT OF HEALTH PROVIDE BUDGET, RATE CALCULATION, AND
PROVIDER SPREADSHEETS, TO ASSIST INSURERS INTERESTED IN RESPONDING TO THE
RFP?
An example of a provider rate filing has been included as Attachment F in the
proposal. The Department will not provide any additional rate filing materials
except for the data reports that are being made available.
145*. IS AN ACTUARIAL DATA BOOK AVAILABLE FOR ANALYSIS?
The Department will forward the following data reports to all insurers that
submitted a letter of intent within the required time frame.
- 1992 Maternal, Child & Adolescent Health Profile - (please
note: selected hospital inpatient discharge tables have been
updated using 1994 data);
- A schedule listing the current approved Child Health Plus
premiums;
- A schedule listing the December 1996 Child Health Plus
enrollment by county; and
- A schedule projecting the number of uninsured children for New
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 40
York City and rest of state by age and federal poverty level
based on the 1995 Current Population Survey (CPS).
In addition to the above, data reports, the Department is also making
available for public inspection and photocopying the 1995 annual financial and
statistical reports filed by the current Child Health Plus insurers. To date,
thirteen 1995 annual reports have been filed with the Department. The reports
can be accessed by calling the Departments' Records Access Officer Gene
Therriault, at (518) 474-8734 for an appointment.
146*. AS LISTED IN THE APPENDIX F, PROCEDURES FOR PREMIUM RATE FILING, PREMIUM
RATE DEVELOPMENT FORM, PLEASE EXPLAIN WHAT COMPRISES THE 2% STATUTORY
CONTRIBUTION.
The 2% reference in the premium rate development form does not apply to the
Child Health Plus program.
147. TO WHAT EXTENT WILL THE RATE FILING BE A FACTOR IN THE SELECTION PROCESS
(i.e. IS THERE AN ACCEPTABLE RANGE OF PREMIUMS, AS THERE WAS WITH THE
MEDICAID MANAGED CARE PROCUREMENT PROCESS)?
As stated in the RFP, all proposals will be evaluated on a competitive basis
based on the scoring algorithm that was identified. Premiums submitted as part
of this process will be evaluated for their reasonableness in relation to the
benefits provided.
148.* WE WANT TO ENCOURAGE GOOD PRENATAL CARE, THEREFORE DOES THE $2.00
PHYSICIAN CO-PAYMENT APPLY TO OBSTETRICAL CARE, OR IS IT WAIVED IN THIS
SITUATION?
The statute states that, with limited exception, a $2 co-payment shall be
imposed on a per visit basis for physician services. To the extent that the
prenatal visit constitutes a visit for physician services, the $2 co-payment may
not be waived.
149. WILL THE BUREAU OF HEALTH ECONOMICS BE PROVIDING ANY RATE GUIDELINES, OR
INSTRUCTIONS REGARDING THE CALCULATION OF RATES?
The Department will not be providing any additional guidelines or instructions
regarding the calculation of the rates. The rate filing guidelines are presented
in Appendix F of the proposal.
150. ARE PLANS REQUIRED TO CARRY STOP-LOSS INSURANCE FOR CHILD HEALTH PLUS?
Plans that are governed by Article 44 of the Public Health Law are generally
required
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 41
to have stop-loss or re-insurance coverage.
151* SDOH HAS RECOGNIZED THAT THE [ILLEGIBLE] OF HEALTH CARE VARIES FROM ONE
REGION TO THE NEXT, AS WELL AS FROM [ILLEGIBLE] PREMIUM GROUP (AGE AND
SEX) TO THE NEXT. CONSEQUENTLY, EACH REGION AND PREMIUM GROUP HAS
DIFFERENT RATES. ARE APPLICANTS TO PROPOSE UNIFORM RATES ACROSS ALL
COUNTIES OR DIFFERENT RATES FOR EACH COUNTY/REGION? FOR ENROLLEES IN
DIFFERENT PREMIUM GROUPS (AGE AND SEX)?
Since this product is considered a community rated product, the plan must
propose a single global rate for all participants within a region. The rates can
be varied by county/region as actuarial justified and in accordance with State
Insurance regulations. However, the rate filing guidelines require that the
actuarial memorandum include the specific formulas, methods, and assumptions
used in calculating the premium rates and requires identification of any special
assumptions with respect to children under one year of age and children ages
15-19.
152* ARE THE CO-PAYS FOR EMERGENCY ROOM USAGE AND PHARMACY REQUIRED OR
OPTIONAL?
The co-payments identified in the proposal for emergency room usage and pharmacy
are optional, however, if co-payments are proposed, they cannot exceed $3 for
prescriptions and nutritional supplements, as defined in the benefit package, or
$35 for failure to notify an insurer within 24 hours of emergency room use
and/or inappropriate emergency room visits.
153. PLEASE CLARIFY THE LINK BETWEEN THE NEW YORK STATE/FAMILY'S SHARE PREMIUM
REVENUE AND THE BUDGET FORM 1, APPENDIX K. SHOULD THE BUDGET ALSO INCLUDE
ESTIMATED MEDICAL EXPENSES?
The reference to submission of an agency's budget on page 51 of the proposal
relates only to the administrative costs of the organization submitting the
proposal. The proposal inappropriately referenced the inclusion of the family's
share of the premium and New York State' premium. Do not include these items or
medical expenses on the budget forms in Appendix K.
154*. IS IT NECESSARY FOR APPLICANTS TO PROVIDE SALARY INFORMATION FOR ALL THE
PERSONNEL (BOTH DIRECTED AND ALLOCATED) IN BUDGET FORM 1 ?
Salary information and related fringe benefit costs must be reported for
personnel who are directly charged to the program. Salary and related fringe
benefit costs can be allocated for indirect personnel however, the statistical
bases which supports the allocation must be provided.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 42
155* APPLICANTS ARE TO PROVIDE ACTUAL EXPERIENCE FOR THE BASE PERIOD (APPENDIX
F). WHAT IS THE "BASE PERIOD"? HOW CAN APPLICANTS PROVIDE ACTUAL
EXPERIENCE FOR INPATIENT BENEFITS WHEN IT [ILLEGIBLE] HERETOFORE NOT BEEN
A COVERED BENEFIT?
The base period is the most current 12 month period, or other period, for which
actual data is available. The Department recognizes that applicants will be
using other inpatient or ambulatory information as a basis for their projections
where specific Child Health Plus experience may be insufficient for premium
development. Utilization and cost variances between the base period (actual
experience) and rate period should be detailed in the actuarial memorandum.
156. UNDER MEDICAID MANAGED CARE, SCHOOL BASED HEALTH CENTERS WILL NOT BE
INCLUDED IN THE BENEFIT PACKAGE BEFORE THE NEXT MEDICAID PROCUREMENT. GOOD
UTILIZATION DATA HAS BEEN UNAVAILABLE. HOW WILL THESE SERVICES, THEREFORE,
BE FACTORED INTO THE CHILD HEALTH PLUS PREMIUM?
The New York State School Health Program and the Department's Office of Managed
Care are working with managed care plans and school based health centers to
[ILLEGIBLE], utilization data which will be available to estimate primary care
needs.
157. REFERENCE IS MADE THAT THERE IS LANGUAGE REGARDING PAYMENT AND REPORTING
REQUIREMENTS. WILL THERE BE MANDATED PAYMENT LEVELS? IF SO, WHAT ARE THEY?
WHAT ARE THE REPORTING REQUIREMENTS?
Mandated payment levels will not be specified in the model contract. The
reporting requirements have not been finalized at this time.
158. IF THE PROGRAM IS BEING ADMINISTERED VIA A MANAGEMENT SERVICES
ARRANGEMENT, IS IT ACCEPTABLE TO SHOW THE ADMINISTRATIVE BUDGET AS THE
AMOUNT PAID TO THE MANAGEMENT SERVICES COMPANY?
The administrative budget would reflect the amount paid to the management
services company as a sub contracted administrative expense however, the cost
for specific administrative functions (i.e. data processing, marketing, legal,
accounting etc.) need to be identified in a supporting schedule.
159. EVALUATION OF THE CHILD HEALTH PLUS IN NEW YORK STATE SUMMARY, PAGE 5,
TABLES 3 & 4: REFERENCE CHILD HEALTH PLUS ELIGIBLES BY REGION. IS THIS
INFORMATION AVAILABLE BY ZIP CODE AND/OR BOROUGH?
No. This information is not available by zip code and/or borough.
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 43
160. APPENDIX K APPEARS TO CONTAIN ONLY ONE SCHEDULE RELATED TO PERSONNEL
COSTS. ARE OTHER SCHEDULES GOING TO BE ADDED?
Appendix K is a double sided copy. Please turn the page over to complete the non
personnel related expense section.
161* PLEASE CLARIFY WHAT THE DEPARTMENT WOULD LIKE SUBMITTED IN RESPONSE TO THE
REQUEST TO "DEMONSTRATE THE FINANCIAL FEASIBILITY OF YOUR ORGANIZATION'S
PROPOSED CHILD HEALTH PLUS PROGRAM, INCLUDING THE FINANCIAL REQUIREMENTS
OF THE NEW YORK STATE INSURANCE LAW AND PUBLIC HEALTH LAW".
The Department is requesting that revenue and expense projections be provided
for the Child Health Plus program for 1997 and 1998. In addition, the applicant
must identify the current financial condition of the corporation (latest
available certified financial statements are acceptable) and the financial
condition projected to the end of the first period (e.g. 12/31/97) during which
the new rates will be effective. The plan must demonstrate that it is able to
meet reserve and escrow requirements in its financial projections as well.
162. WHAT COUNTIES COMPRISE EACH NEW YORK STATE REGION?
The Department does not have sufficient information to respond to this question.
163. ARE APPLICANTS TO PROJECT ONE TOTAL ENROLLMENT NUMBER OR ENROLLMENT FOR
EACH COUNTY THEY PROPOSED TO SERVE AND TOTAL ENROLLMENT FOR ALL COUNTIES?
The applicant needs to identify projected enrollment for each county they
propose to serve and total projected enrollment for all counties.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
DIVISION OF HEALTH CARE FINANCING
BUREAU OF HEALTH ECONOMICS
CHILD HEALTH PLUS PROGRAM
INSURANCE PLAN REQUEST FOR PROPOSAL
QUESTIONS AND ANSWERS
RECEIVED AT BIDDER'S CONFERENCE
BIDDER'S CONFERENCE:
FRIDAY, JANUARY 10, 1997
INTRODUCTION
This document contains answers to questions submitted by health plans with
respect to the Child Health. Plus Insurance Plan Request for Proposal (RFP). The
questions and answers are grouped in this document as follows:
I. General Technical - Read at Bidder's Conference;
II. Network Comprehensiveness - Read at Bidder's Conference;
III. Fiscal Evaluation Criteria - Read at Bidder's Conference; and
IV. Additional Questions - Not Read at Bidder's Conference.
The questions and answers presented here are questions which were
submitted in writing on index cards to the Department at the Bidder's Conference
held in Albany, New York on January 10, 1997. All of these questions were
received at the bidder's conference, however, some were not presented at the
Bidder's Conference because they required additional research and discussion.
(Answers to the questions that were submitted by plans and received by the
Department by December 30, 1996 is a separate document which all plans received
at the Bidder's Conference and/or a separate mailing after the Bidder's
Conference.)
Plans are reminded that in many instances, similar questions were asked by
multiple organizations. Where this occurred, the State in some cases selected
one or more representative questions to answer, rather than responding in
writing to every question asked. In doing so, the State has made a good faith
effort to ensure that all material issues raised by health plans are being
responded to in as complete a manner as possible.
It is important to read this document in its entirety to assure that you
are informed about all policy statements being made with respect to individual
issues.
To the extent to which answers contained in this document are in conflict
with information provided at the Bidder's Conference, and in the RFP, these
answers shall control.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 3
1. GENERAL TECHNICAL
(READ AT BIDDER'S CONFERENCE)
A1. MUST THE MODEL SUBSCRIBER APPLICATION BE USED AS IS?
No, as stated in the RFP, each insurer will be allowed to use an
application form that is unique to their plan, but the variables
identified in the Model will need to be collected.
A2. REGARDING EMERGENCY SERVICES, IF THE ENROLLEE FAILS TO NOTIFY THE PLAN
WITHIN 24 HOURS OF A VISIT FOR A "TRUE EMERGENCY," CAN THE $35 COPAYMENT
BE CHARGED?
Yes.
A3. CAN IT BE LESS THAN $35?
Yes.
A4. WHEN A MEMBER IS DELINQUENT ON PREMIUM PAYMENT, THERE IS A 30 DAY GRACE
PERIOD. IF A MEMBER HAS NOT PAID FOR JANUARY, THEY ARE STILL CONSIDERED
ACTIVE MEMBERS UNTIL JANUARY 30TH. IF PAYMENT IS NOT RECEIVED, THEY ARE
TERMINATED EFFECTIVE JANUARY 1ST. HOWEVER, THE PLAN WOULD HAVE SUBMITTED A
BILL FOR THIS MEMBER ON JANUARY 10TH. DO YOU MEAN THESE MEMBERS SHOULD BE
RECONCILED IN FEBRUARY OR IS IT THAT WE SHOULD BE BILLING THE STATE ON
FEBRUARY 10TH FOR JANUARY MEMBERSHIP?
The payment for January coverage would be due on December 1st with 30
days grace ending December 31st. Failure to pay by December 31st would
result in disenrollment on December 31 as the last day of paid coverage.
Therefore, there would not be any retroactive disenrollment nor would the
state be billed for January in this case.
A5. IT IS OUR UNDERSTANDING THAT THERE ARE SOME EXCLUSIONS IN THE CURRENT
PHARMACY BENEFIT. IS THAT TRUE? IF SO, WILL THOSE EXCLUSIONS REMAIN IN THE
NEW PROGRAM?
Any pharmaceutical the state has previously excluded will continue to be
excluded.
A6. WHAT IS CONSIDERED SUFFICIENT DOCUMENTATION OF INCOME AND OVER WHAT
TIMEFRAME IS ONE MONTH OF PAY STUBS THAT WAS EARNED WITHIN THE PAST THREE
MONTHS SUFFICIENT?
Advisory memorandum A-1 and A-16 address documentation of income sources.
Most recent tax returns must be submitted if available. If income has
changed since the last tax return was filed, then other documentation must
be submitted to support current income. Three months would be an
acceptable current period. Therefore, one month of paystubs earned within
the past 3 months would be sufficient.
A7. DOES THE PLAN OR THE STATE DETERMINE THE CUTOFF DATE FOR APPLICATIONS FOR
THE EFFECTIVE MONTH OF MEMBERSHIP?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 4
For processing applications, the plan will utilize their internal
procedures and cutoff dates which must be acceptable to the Department of
Health.
A8. IS THERE A LIMIT TO THE NUMBER OF PARTICIPATING PLANS IN EACH
COUNTY/REGION?
No, there is no absolute limit. However, we will be accepting plans based
on need to assure adequate statewide coverage.
A9. WILL EXISTING ENROLLEES BE GIVEN THE OPPORTUNITY TO SWITCH PLANS ON 5/1/97
IF THERE ARE NEW ENTRANTS IN THE MARKETPLACE?
Yes.
A10. DOES THE STATE HAVE ESTIMATES OF ELIGIBLE CHILDREN FOR CHILD HEALTH PLUS
BY COUNTY OR REGION?
No, the CPS data set does not break down the uninsured any further
geographically then New York City and the rest of the State.
A11. FOR PLANS THAT ALREADY HAVE A CHILD HEALTH PLUS CONTRACT: WE MUST SIGN AN
ADDENDUM TO OUR EXISTING CONTRACT? WHAT IS THE TERM OF THIS CONTRACT AND
WHEN WILL THE DEPARTMENT OF HEALTH ISSUE THE CONTRACT EXTENSION?
New contracts will be issued to those plans selected for the expanded
program.
A12. IN AREAS WITH MORE THAN ONE PARTICIPATING PLAN, WILL THE OUTREACH
ORGANIZATION INCLUDE ALL PLANS ON ITS EFFORTS OR WILL STEERAGE OCCUR BY
SOME CRITERIA?
The outreach organization will provide families with a list of all
insurers available in their area.
A13. IN REFERENCE TO THE RESPONSE TO QUESTION 8, WHAT IS MEANT BY "IT IS AT
THE DISCRETION OF THE FAMILY AS TO WHAT PAYMENT SCHEDULE THEY CHOOSE TO
ABIDE BY?" THE RFP STATES THAT PAYMENT IS ON A MONTHLY BASIS.
Insurers will have the option of offering alternative modes of premium
payment, for example, quarterly, annually or semi-annually, in addition to
a monthly rate. It is up to the family to decide the mode from the options
offered by the insurer.
A14. PLEASE CLARIFY WHETHER CHILDREN UNDER AGE ONE MAY ENROLL IN CHILD HEALTH
PLUS?
Children under age one may enroll in Child Health Plus. However, if family
income is below 222% of gross Federal Poverty Level, then the children
should be referred to Medicaid.
A15. BACK TO QUESTION 59 AND THE RESPONSE READ TODAY, DOES THE PROGRAM NAME
"CHILD
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 5
HEALTH PLUS" IMPRINTED ON A CARD SUFFICE AS AN IDENTIFICATION
PROCESS ON ID CARDS?
Yes.
A16. IS THERE DATA ON THE NUMBER OF CHILDREN DISENROLLED FROM CHILD HEALTH PLUS
DUE TO NON-PAYMENT OF PREMIUMS?
No data is available at this time regarding disenrollment due to
non-payment. However, under the current system, with the exception of
families between 160 and 222 of gross Federal Poverty Level with multiple
children, the $25 family contribution must be paid with application prior
to enrollment. For families with multiple children, only the first $25
must be paid initially. The $25 for remaining children is paid based upon
procedures of the individual plan.
A17. MAY A MEDICAID MANAGED CARE PLAN ASSUME PRESUMPTIVE ELIGIBILITY FOR A
MEDICAID MEMBER WHERE THE ROSTER INDICATES THE CASE HAS BEEN CLOSED?
No, children cannot be assumed presumptive eligible for Child Health Plus
just because they were disenrolled from Medicaid? The family must apply to
Child Health Plus, submit a completed and signed application. However if
the child appears eligible but lacks documentation needed to support the
application, the child can be enrolled presumptively for sixty (60) days.
A18. WILL THE STATE TRANSMIT INFORMATION FOR A PLAN'S MEDICAID MEMBERS THAT
WOULD INDICATE THAT A CASE IS CLOSED DUE TO INCOME REASONS?
No, the state will not transmit data as to reason for closure of Medicaid
case as cases are closed at the local district.
A19. QUESTION 41 OF BIDDER'S CONFERENCE DOCUMENT STATES THAT NO FROM OF
TRANSPORTATION IS COVERED BY CHILD HEALTH PLUS. HOWEVER, THE BENEFIT
PACKAGE EXCLUSIONS ONLY REFER TO "NON-EMERGENCY" TRANSPORTATION, AND THE
RATE FILING WORKSHEET IN APPENDIX F INCLUDES A LINE FOR AMBULANCE SERVICE.
IS AMBULANCE USE FOR AN EMERGENCY A COVERED BENEFIT?
The exclusions to the benefit package should have indicated that all
transportation is excluded. The rate filling application should not have
emergency transportation included.
A20. WILL THERE BE AN ON-SITE REVIEW OF SELECTED BIDDERS PRIOR TO PROGRAM START
UP?
On site review is not planned. However, the Department of Health reserves
the right to do a site visit if questions should arise.
A21. MUST PLANS HAVE THE ABILITY TO BILL ELECTRONICALLY BY THE TIME PROPOSALS
ARE SUBMITTED OR BY THE PROGRAM START DATE?
Plans must guarantee within their proposal that they have the ability to
submit electronic
CHILD HEALTH PLUS INSURANCE PLAN REP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 6
billing data by implementation date.
A22. PLEASE RE-CLARIFY - CAN A PLAN DENY A MEDICALLY APPROPRIATE ER VISIT FOR
FAILURE TO NOTIFY THE PLAN OF THE VISIT?
The plan may impose a $35 copayment for failure to notify.
A23. ARE MEDICAID DRG RATES AVAILABLE TO PARTICIPATING PLANS BY STATUTE?
Yes, this is available under FOIL (Freedom of Information Law).
A24. PLEASE CLARIFY: IS THERE AN APPLICATION FEE OF $25 AS THERE IS IN THE
CURRENT PROGRAM?
No, the application/enrollment fee has been replaced by the statutory
family contribution to premium.
A25. WHAT ARE THE PRESCRIPTION DRUG EXCLUSIONS?
The exclusions would be those typically permitted under Insurance Law and
Regulation such as those for experimental or investigational drugs, drugs
prescribed for a cosmetic purpose, etc.
A26. WHEN THE ENROLLEE AGES OUT OF A HEALTH PLAN, THE PLAN IS THEN RESPONSIBLE
TO OFFER THEM A CONVERSION PACKAGE; ARE THERE ANY SPECIFIC BENEFITS THAT
HAVE TO BE OFFERED?
No, those plans capable of issuing conversion coverage must make the
contract they generally offer available to Child Health Plus enrollees.
A27. IF THE PLAN ASSESSES THE $35 ER CO-PAY FOR FAILURE TO NOTIFY PLAN OF AN ER
VISIT ON INAPPROPRIATE ER VISIT AND THE MEMBER IS DELINQUENT, DOES THIS
DELINQUENCY APPLY TO THE DELINQUENCY OF THE PREMIUM?
No, failure to pay a copayment is unrelated to failure to pay a premium.
A28. MAY A CHILD BE ENROLLED IN CHILD HEALTH PLUS PRIOR TO BIRTH AS IS
CURRENTLY THE CASE UNDER MEDICAID.
No, in order for enrollment in Child Health Plus, the family must submit
an application with the child's name and date of birth as well as required
documentation. Enrollment is established for the first day of a future
month unlike Medicaid who enrolls retroactive to the date of application
and at any point within the month. There is no family coverage in this
program, only individual coverage.
A29. WHAT HAPPENS WHEN A CHILD WHO IS RECEIVING CHILD HEALTH PLUS SERVICES
BECOMES ELIGIBLE FOR MEDICAID AND THE PLAN DOES NOT KNOW ABOUT THE
MEDICAID COVERAGE FOR SEVERAL MONTHS? ARE WE TO RETURN PREMIUMS? ARE WE TO
DISENROLL RETROACTIVELY?
CHILD HEALTH PLUS INSURANCE PLAN REP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 7
The Department has a procedure to match Child Health Plus
enrollment/billing files against the Medicaid enrollment file to identify
children dually enrolled in both programs. The Department notifies the
plans of the dual enrollment status of these children and advises the plan
to disenroll children prospectively for a future month and not
retroactively. The premium for the month where the child is identified as
a duplicate is not recouped.
A30. PLEASE CLARIFY WHAT BIRTH CONTROL/PRESCRIPTIONS, DEVICES, AND SUPPLIES ARE
COVERED IN CHILD HEALTH PLUS.
Any family planning services or birth control/prescriptions, devices and
supplies that are prescribed by a qualified, participating provider are
covered.
A31. HOW WILL DOH CHOOSE QUALIFIED PLAN - MINIMUM SCORE, # PLANS PER COUNTY, #
IN THE WHOLE STATE?
Total score of all parts of the proposal will be considered. A ranking
will be assigned. Plans will be chosen in order to ensure an adequate
statewide coverage.
A32. WHAT FACTORS WILL BE EVALUATED IN DETERMINING THE EFFECTIVENESS OF PLANS
IN TARGETING MINORITY POPULATION?
We will evaluate the reasonableness of the plan's proposed marketing plan
and outreach efforts with respect to achieving their projected enrollments
and particularly including under-represented minorities in the current
program.
A33. CLARIFY CHILD HEALTH PLUS COVERAGE FOR CHILDREN LESS THAN 1 IF THE MOTHER
DOESN'T OBTAIN MEDICAID COVERAGE FOR HIM/HER.
A child maintains Child Health Plus enrollment until he or she is enrolled
in Medicaid.
A34. APPENDIX D HAS A PIE CHART THAT SHOWS THE SECOND QUARTER 1996 ENROLLMENT
BY SUBSIDY AND AGE. TWO OF THE AGE CATEGORIES AN 0-1 AND 1-5. DOES THE 0-1
CATEGORY REPRESENT CHILDREN UNDER 12 MONTHS? IF SO, THIS SEEMS TO BE
INCONSISTENT WITH PAGE 13 OF THE RFP WHICH SAID THAT THERE IS VERY LITTLE
ENROLLMENT UNDER AGE 1 (PIE CHART SHOWS 5.4% OF ENROLLMENT 0-1). PLEASE
CLARIFY THIS.
Under the new program, it is expected that insurers' referrals to Medicaid
for this population will be more aggressive than under the existing
program.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 8
II. NETWORK COMPREHENSIVENESS
(READ AT [ILLEGIBLE] CONFERENCE)
A35. UNDER ELIGIBLE ORGANIZATIONS, PLEASE DEFINE: A COMPREHENSIVE HEALTH
SERVICE PLAN OPERATING UNDER THE REGULATIONS OF THE DEPARTMENT OF HEALTH.
These organizations are Article 44 health maintenance organizations and
prepaid health services plans.
A36. RE: PAGE 57 - EVALUATION CRITERIA PLEASE EXPLAIN WHAT IS EXPECTED FOR
INFORMATION. THE RFP ALREADY DESCRIBES THE BENEFIT PACKAGE. PMPMs WILL BE
IN THE RATE SUBMISSION.
The benefit package evaluation will be based on the narrative description
of the benefit package which should be provided in the proposal.
A37. RE: PATIENT EDUCATION. THE TITLE STATES "PATIENT" EDUCATION BUT THE TERM
"PUBLIC" EDUCATION IS USED WITHIN THE SECTION. PLEASE CLARITY.
These terms are used interchangeably
A38. QUESTION #62 INDICATES THAT "INSURERS MUST PERFORM THEIR OWN MARKETING AND
OUTREACH IN ACCORDANCE WITH THE GUIDELINES IN THE RFP. MAY THE INSURERS
SUB-CONTRACT WITH COMMUNITY BASED ORGANIZATIONS TO CONDUCT THIS OUTREACH?
Yes. However, the insurer remains responsible for assuring that the
sub-contractor performs these activities consistent with program
requirements. In addition, the proposal should include the actual outreach
and education strategies that may be subcontracted.
A39. YOUR ANSWER TO QUESTION #100 REFERS TO A PROVIDER NETWORK SUBMISSION "DUE
JANUARY 23, 1997." IS THIS THE QUARTERLY PROVIDER NETWORK SUBMISSION FOR
MEDICAID MANAGED CARE PLANS OR IS IT SOME OTHER SUBMISSION?
It is the quarterly provider network submission for Medicaid Managed Care
plans.
A40. FOR PLANS WHO SUBMITTED THE LETTER OF INTENT WITHIN THE APPROPRIATE TIME
FRAME, WHEN CAN WE EXPECT TO RECEIVE THE DATA REPORTS MENTIONED IN
QUESTION 145?
These reports are included in your packet.
A41. RE: QUESTION 121 - HOW MUCH TIME IS PERMITTED TO ELAPSE BETWEEN SELECTION
OF A CENTER AND SELECTION OF A SPECIFIC PCP FROM THAT CENTER.
The Child Health Plus program does not intend to specify any time limits
in this selection. However, since PCPs coordinate care and are required to
be available 24 hours per day, 7 days per week, it is in the insurer's and
enrollee's best interest that PCP selection or
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 9
assignment occur shortly after enrollment.
A42. ARE WE EXPECTED TO POLL EACH AND EVERY PARTICIPATING PCP TO DETERMINE THE
NUMBER OF CHILD HEALTH PLUS ENROLLEES HE OR SHE IS WILLING TO ACCEPT? WILL
YOU ACCEPT WHATEVER NUMBER THE PCP SUPPLIES, EVEN IF IT FILES IN THE FACE
OF REASON?
Non-Medicaid managed care plans will need to provide PCP specific
enrollment information with their submissions. The numbers provided by
each PCP should realistically reflect that the PCP can actually
accommodate those enrollees. For Managed care plans participating in the
Partnership Plan, the quarterly provider network submission will be used
to assess PCP capacity.
A43. DO THE PLANS NEED TO PROVIDE ENROLLMENT PROJECTIONS BY REGION OR WILL
OVERALL PROJECTIONS SUFFICE?
Enrollment projections should be submitted by county.
A44. PLEASE CLARIFY THAT APPLICANTS WILL NEED TO SUBMIT A COMPREHENSIVE LIST OF
PHARMACIES AND LABS AS PART OF APPENDIX L.
The applicant summary forms contained in Appendix L must be completed for
any subcontracted provider.
A45. THE ANSWER TO QUESTION #118 SAYS THAT 1500 MAX IS APPLICABLE TO MEDICAID
ONLY, BUT DOES THIS MEAN THERE'S NO MAXIMUM FOR CHILD HEALTH PLUS? (I.E..
SO THAT A PROVIDER CAN HAVE 1500 FOR MEDICAID AND ANOTHER 1000 FOR CHILD
HEALTH PLUS?)
Yes. However, plans must abide by appointment availability standards and
networks will be monitored to assure service accessibility.
A46. WILL THE STATE ALLOW PAPER SUBMISSIONS OF SOME OF THE NETWORK IF THE PLAN
HAS DIFFICULTY IN SUBMITTING COMPLETE NETWORK INFORMATION IN THE FORMAT
REQUIRED BY THE STATE JANUARY 23, 1997.
Medicaid managed care plans must submit their provider network information
by January 23, 1997 in the format specified by the Office of Managed Care.
For non-Medicaid managed care plans, network submissions may be in paper
medium, however, we prefer the spreadsheet format previously specified.
A47. FOR MEDICAID MANAGED CARE PLANS, WILL THE STATE DETERMINE EACH PCP's
ADDITIONAL CAPACITY BASED ON THE 1/23/97 QUARTERLY PROVIDER NETWORK
SUBMISSION, OR ARE THE PLANS EXPECTED TO DETERMINE THIS CAPACITY?
SPECIFICALLY, WHAT DOES THE MEDICAID MANAGED CARE PLAN NEED TO SUBMIT
UNDER PROVIDER NETWORK? (ASIDE FROM NETWORK CHANGES AFTER THE 1/23/97
SUBMISSION.)
The 1/23/97 quarterly network submission to the Office of Managed Care
will be utilized
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 10
to determine adequacy of network as well as capacity to serve Child Health
Plus enrollees. No additional network information is required for managed
care plans participating in the Medicaid program.
A48. THE RFP REQUESTS THAT PLANS IDENTIFY ANY SERVICES TO BE PROVIDED BY
SUBCONTRACTORS, INCLUDING PROVIDERS, PHARMACEUTICAL AND DIAGNOSTIC
LABORATORY NETWORKS. PLEASE PROVIDE A DEFINITION OF "SUBCONTRACTORS" AND
EXPLAIN HOW THIS QUESTION DIFFERS FROM THE QUESTION ON PAGE 50 OF THE RFP,
"IDENTIFY THE PROVIDER NETWORK (BY TYPE, NUMBER, AND COUNTY)..."
Plans may have to enter into subcontracts for certain services which are
not part of their existing network. The insurer should identify which
services - physician, hospital, laboratory, pharmacy, home health care,
etc. - will be subcontracted.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 11
III. FISCAL EVALUATION
(READ AT BIDDER'S CONFERENCE)
A49. IS IT A REGULATORY REQUIREMENT FOR A LICENSED ACTUARY TO SIGN OFF ON THE
RATE SUBMISSION OR CAN ANY QUALIFIED FINANCIAL STAFF PERSON PERFORM THIS
FUNCTION?
The actuarial memorandum should be signed by a member of the American
Academy of Actuaries or a Fellow of the Society of Actuaries. Attestation
from other financial officers of the plan will be acceptable provided they
are able to demonstrate appropriate qualifications and experience. An FSA
signature can be from an independent actuarial firm or an employee of the
plan.
A50. PLEASE CONFIRM THE PERIOD OF TIME THAT THE RATE PROPOSAL WILL COVER?
We would anticipate that the rate proposals will be for a 12 month period
but should at least be through December 31, 1997.
A51. WHAT SHOULD WE ANTICIPATE THE PREMIUM RECEIVABLE LAG TO BE?
Billing are required monthly and the Department will process bills within
30 days. Please refer to sections 5 on pages 30 and 31 for the specific
billing timelines.
A52. IS REINSURANCE AVAILABLE FROM THE STATE?
No. Reinsurance is not available from the state.
A53. CAN THE FORM IN APPENDIX K BE COMPUTED BY FUNCTIONAL AREA (E.G., MMIS
CLAIMS ETC.) RATHER THAN BY LISTING OF INDIVIDUAL PERSONNEL?
The key administrative staff need to be identified on the form. All
support staff can be grouped by functional area.
A54. PER THE DRAFT RATE FILING GUIDELINES UNDER APPENDIX F OF THE RFP, IS THE
EXPECTED INCURRED LOSS RATIO MANDATED TO BE 90% OR MAY PLANS PROVIDE
ALTERNATE PROJECTIONS?
No. plans may provide alternate projections. The 90% referenced in
Appendix F was for illustrative purposes.
A55. WILL FAMILY PLANNING SERVICES BE CONSIDERED FOR A REIMBURSEMENT CARVE-OUT,
AND/OR MAY PLANS SUBCONTRACT WITH OTHER PLANS TO PROVIDE FAMILY PLANNING
SERVICES?
Plans may subcontract with other plans to provide services subject to
approval by the State DOH.
A56. CPS DATA IS NOT BROKEN DOWN BY COUNTY. WHEN WILL PLANS RECEIVE COUNTY
SPECIFIC INFORMATION?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 12
The state released CPS data for New York City and rest of state by age and
income category at the bidders conference on January 10, 1997. No
[ILLEGIBLE] breakdown will be provided by the state.
A57. ARE THERE ASSUMPTIONS REGARDING TREND FACTORS FOR OUTLYING YEARS?
No. We are not offering any actuarial assumptions regarding trend factors.
However, we do expect the plans to provide them in their bid.
A58. WHY IS AN ACTUARIAL CERTIFICATION NEEDED FOR THIS PROGRAM WHEN IT WAS NOT
REQUIRED FOR MEDICAID?
It is required by New York State Insurance regulation.
A59. PERTAINING TO QUESTION 162 ABOUT RATING REGIONS- WHEN WILL THIS BE
AVAILABLE? WHAT COUNTIES WILL BE INCLUDED IN WHAT REGIONS?
Please refer to question #151. The rates can be varied by county/region as
actuarially justified...
A60. STATUTORY CONTRIBUTION- SINCE THE 2% CONTRIBUTION DOES NOT APPLY TO CHILD
HEALTH PLUS, I ASSUME THAT A 1% CONTRIBUTION IS ACCEPTABLE. IS THIS SO?
Statutory contributions are described in State Insurance Law Section 4310.
A61. BASE PERIOD TO RATE PERIOD -- IS IT ACCEPTABLE TO HAVE A BASE PERIOD OF
1995 AND A RATE PERIOD OF 5/12/97? (1995 IS TOO INCOMPLETE TO SERVE AS A
BASE PERIOD).
Please refer to question 155. The most current available credible data
should be used, however the data need not be for a calendar year period.
A62. THE STATE HAS CAPPED THE MAXIMUM FAMILY CONTRIBUTION AT FOUR CHILDREN?
HOWEVER, WILL THE STATE BE PAYING THE PLANS AN INDIVIDUAL PREMIUM FOR EACH
WHERE THERE ARE MORE THAN FOUR CHILDREN IN THE FAMILY? WILL IT BE THE SAME
SUBSIDIZED PREMIUM AMOUNT AS THE OTHER CHILDREN OR WILL IT BE A HIGHER
AMOUNT THAT ADDS IN THE CONTRIBUTION THE FAMILY WOULD HAVE MADE IF THE
HOUSEHOLD HAD FOUR KIDS OR LESS?
The insurer will bill the State the total premium for all children that
are fully subsidized. However, for partially subsidized children, the
insurer will "net out" the monthly family contribution that is required
for each child from the total premium to arrive at the State share. In
those instances where more than four children from a partially subsidized
family are enrolled in a plan, there is no family contribution offset to
the total premium for the fifth or more child(ren).
A63. ARE THE RATES TO BE AGE ADJUSTED IN ANY WAY?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 13
No, please refer to question #140 for additional information.
A64. CAN CONSULTANTS (ACTUARIES) NOT AFFILIATED WITH A PLAN RECEIVE COPIES OF
THE DATA?
Yes, it will be made available. Please call the Bureau of Health
Economics.
A65. CAN YOU PROVIDE A PHONE NUMBER FOR THE BUREAU OF HEALTH ECONOMICS?
As listed on page 41 of the RFP, the official phone for inquiries
regarding this RFP process is (518)486-7897.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 14
IV. ADDITIONAL QUESTIONS
(NOT READ AT BIDDER'S CONFERENCE)
A66. DOES NYHCRA ALLOW CHILD HEALTH PLUS PLANS THE ABILITY TO PAY MEDICAID DRGs
FOR INPATIENT CARE, OR MUST THE REIMBURSEMENT BE NEGOTIATED?
The New York State Health Care Reform Act of 1996 (HCRA of 1996) allows
any Child Health Plus insurer to negotiate an inpatient rate with
hospitals. The rate can be based on the DRG but that is between the payer
and provider.
A67. CAN A HEALTH CARE PROVIDER PAY ALL OR PART OF A MEMBER'S PREMIUM ON THEIR
BEHALF TO ASSIST THEM IN REMAINING ENROLLED IN CHILD HEALTH PLUS?
The insurer will only bill the family for the family contribution of the
premium, not a third party. However, if someone chooses to pay the family
contribution on behalf of the family, that is permitted. If the "health
care provider" referenced in this question is the insurer, the insurer
does not have the option to waive the family contribution to the premium
as legislative intent was to have families contribute to the cost of the
premium.
A68. CAN AN INSURER CHOOSE TO COVER CHILDREN WITHIN THE < 19 GROUP, i.e., 0-14
FOR EXAMPLE?
An insurer cannot choose to cover only a subset of the Child Health Plus
population of less than 19 year of age.
A69. IN APPENDIX L, BIDDER'S SUMMARY OF PROPOSAL, WHAT IS A CHARITY
REGISTRATION NUMBER? DOES THIS APPLY ONLY TO NOT-FOR-PROFITS?
Charitable organizations are required to be registered with the Secretary
of State pursuant to Article 7-A of the New York State Executive Law. The
charity registration number is proof that an organization has registered
with the Secretary of State.
A70. RELATED TO QUESTION 67 REGARDING CURRENT MEMBERS IN THE PROGRAM
TRANSITIONS TO THE EXPANDED PROGRAM, IF A MEMBER EITHER PAYS A PARTIAL OR
FULL PREMIUM, WILL THE AMOUNT THEY-PAID AT THE LAST RECERTIFICATION DATE
NEED TO BE CREDITED TO ANY REMAINING MONTHS NEW PREMIUM AMOUNTS, i.e.,
MEMBER PAYS $25 PER YEAR NOW. RECERTIFIED IN JANUARY AND PAID $25. AS OF
JULY, THEY NEED TO PAY $9 PER MONTH (OR $36 UNTIL THE END OF THE YEAR).
DOES THIS AMOUNT NEED TO BE ADJUSTED AGAINST THE $25 ALREADY PAID?
If the family requests a refund of any unused portion of the $25 annual
premium contribution, the plan must pay the refund. If the family and the
insurer wish to apply this to the newly required family contribution
rather than refund the unused portion, this can be done. However, the
insurer must document this in the enrollment file.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 15
A71. EQUIVALENT COVERAGE: PLEASE CONFIRM THAT ANY DIFFERENCE IN COVERAGE
BETWEEN CHILD HEALTH PLUS AND ANOTHER COVERAGE IS CONSIDERED
NON-EQUIVALENT COVERAGE DESPITE HOW SIMILAR THE TWO WOULD BE.
The current definition of equivalent coverage is stated in Child Health
Plus Advisory Memoranda A-12 found in Appendix B of the Request for
Proposals(RFP). A revised equivalent coverage policy will be formulated
prior to the implementation of the expanded program. It is anticipated
that under the expanded program, the current definition will merely be
expanded to include inpatient care.
A72. DO THE NYHCRA SURCHARGES AND/OR ASSESSMENTS APPLY TO THE CHILD HEALTH PLUS
PROGRAM?
The New York State Health Care Reform Act surcharges and/or assessments
currently apply to the Child Health Plus program.
A73. RFP ASKS FOR RESOURCES COMMITTED TO IMPLEMENT/OPERATE: IF PLAN ALREADY
OPERATIONAL, DO WE JUST STATE HUMAN RESOURCES CURRENTLY IN PLACE? IS THE
"MANAGEMENT TEAM" ALSO THE PERSONS RESPONSIBLE IN EACH DEPARTMENT?
If a plan is currently a Child Health Plus insurer, they can state that
the resources to operate the expanded program are in place. The
"management team" should be a list of the persons responsible in each
Department.
A74. WHAT FACTORS WILL BE EVALUATED IN DETERMINING THE EFFECTIVENESS OF PLANS
IN TARGETING MINORITY POPULATIONS?
As part of the response to the Request for Proposals, the bidder must
submit a general plan for marketing the program along with a description
of how community outreach and marketing activities will be conducted to
attract applicants. This should include a discussion of the strategies the
bidder will use to target minority populations in their service area. The
overall marketing plan will be evaluated as a component of the General
Technical Evaluation Criteria.
A75. A RECENT SURVEY WE CONDUCTED ON OUR CURRENT CHILD HEALTH PLUS ENROLLEES
REVEALED THAT MANY FAMILIES, ESPECIALLY THOSE WITH MORE THAN ONE CHILD,
WOULD NOT ENROLL IN THE NEW PROGRAM DUE TO THE REQUIRED PREMIUM
CONTRIBUTION. CLIENTS CURRENTLY ENROLLING IN OUR PLAN - PLUS THOSE WHO
WILL ENROLL BETWEEN NOW AND MAY 1ST - MAY ACCUSE US OF "BAIT AND SWITCH"
TECHNIQUES, i.e., WE "SELL" THEM A FREE PROGRAM, AND THEN CHANGE IT TO ONE
WITH A PREMIUM CONTRIBUTION REQUIREMENT. THIS SITUATION WILL CAST OUR PLAN
AND THE STATE IN A POOR LIGHT. WHAT IS THE STATE WILLING AND ABLE TO DO TO
ADDRESS, AVOID, AND/OR MINIMIZE THE POTENTIAL NEGATIVE CONSEQUENCES OF
THIS SITUATION?
The dollar amounts are defined by Statute.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 16
A76. A RECENT SURVEY WE CONDUCTED OF OUR CHILD HEALTH PLUS SUBSCRIBERS REVEALED
EXTREME PRICE SENSITIVITY, i.e., OVER 50% OF RESPONDENTS INDICATED THEY
WOULD BE UNWILLING AND/OR UNABLE TO MAKE THE REQUIRED PREMIUM
CONTRIBUTIONS, AND, THEREFORE, WOULD NOT ENROLL THEIR CHILDREN. ONE
IMPLICATION OF THIS FUNDING IS POTENTIAL ADVERSE SELECTION. WILL THE STATE
FACTOR THIS INTO THE EVALUATION OF RATE FILINGS?
The State will consider all supportable actuarial methods and assumptions
utilized in the rate making process as submitted by bidders.
A77. DOES THE STATE HAVE PARTICULAR REQUIREMENTS FOR CHILD HEALTH PLUS PROVIDER
CONTRACTS, AS IT DOES FOR MEDICAID MANAGED CARE? DO INSURERS HAVE TO
SUBMIT MODEL CONTRACTS TO SDOH FOR REVIEW AND APPROVAL?
There are no specific requirements for Child Health Plus provider
contracts other than those contract provisions that are otherwise required
of health plans (e.g. enrollee non liability language, access to medical
records etc.)
A78. CURRENT CHILD HEALTH PLUS INSURERS RECEIVED CONTRACT EXTENSIONS FROM JULY
1, 1996 THROUGH DECEMBER 31, 1996, WHEN WILL DOH ISSUE EXTENSIONS FOR THE
PERIOD OF JANUARY 1, 1997 - JUNE 30, 1997?
It is anticipated that DOH will issue contract extensions to current Child
Health Plus insurers within the next month. These extensions will be for
the period January 1, 1997 through September 30, 1997 to allow for
transition of current enrollees to the expanded program. If a current
insurer is selected to continue in the expanded program, the terms of the
new contract will supersede the extension.
A79. ARE THERE GUIDELINES RELATIVE TO THE RATIO BETWEEN PROVIDER SERVICES STAFF
AND ENROLLEES?
There are no guidelines relative to the ratio between provider services
staff and enrollees.
A80. SHOULD THE CHILD HEALTH PLUS PREMIUM RATE INCLUDE THE GME ADD ON?
The New York State Health Care Reform Act surcharges and/or assessments
currently apply to the Child Health Plus program.
A81. WHAT IS THE DEFINITION OF SCHOOL BASED HEALTH CENTER?
A school-based health center is a clinic established at a school site.
It's purpose is to provide convenient access to medical and/or behavioral
services to the children.
A82. HOW SHOULD OLDER CHILDREN LIVING ON THEIR OWN BE ENROLLED? WHAT SHOULD BE
USED AS INCOME VERIFICATION? CAN THE TEENS SIGN THEIR OWN APPLICATION?
WHAT WOULD THE INSURERS DO ABOUT PROOF OF RESIDENCY IN THE CASE OF
HOMELESS CHILDREN?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 17
The issue of older children living on their own is currently under
investigation by the Department's Office of Counsel. A policy concerning
this issue and the related issues surrounding it will be issued prior to
implementation of the expanded program. With regard to the question of
proof of residency in the case of homeless children, legislation requires
proof of New York State residency. No specific provision is made for
homeless children.
A83. THE RFP STATES THAT ROUTINE OB/GYN VISITS WILL NOT BE COVERED. WILL THE
OB/GYN MANDATE REGARDING ANNUAL VISITS AND PAP SMEARS FOR WOMEN 18 YEARS
AND OVER BE COVERED?
Consistent with Insurance Law, a pelvic exam, pap smear and the laboratory
testing related to the pap smear must be offered as a routine, preventive
benefit for women 18 years and older. For females under age 18, this
service would be covered for purposes of diagnosis and treatment of
illness or injury. Pelvic exams and pap smears that are performed more
than once a year for diagnosis of illness or injury are also a covered
benefit. As stated in the American Academy of Pediatric Guidelines found
in Appendix E of the RFP, all sexually active patients should be screened
for sexually transmitted diseases and should have a pelvic exam.
A84. THE RFP STATES THAT ENROLLEES MUST PAY THEIR PREMIUM CONTRIBUTION MONTHLY,
AND THAT THEY WILL BE ALLOWED A 30 DAY GRACE PERIOD. ENROLLEES WHO HAVE
NOT PAID THEIR CONTRIBUTION WITHIN THIS TIME WILL BE RETROACTIVELY
DISENROLLED. RETROACTIVE DISENROLLMENT PRESENTS SEVERAL ISSUES, FOR
EXAMPLE, WHAT WILL INSURERS BE REQUIRED TO DO IN THE EVENT THAT THEY
RECEIVE CLAIMS FOR THIS PERIOD?
The RFP states that family contributions to premium must be paid 30 days
in advance of the period of coverage. However, the insurer may allow the
family an additional 30 days to submit payment before disenrolling the
child from the program. Family contributions are due in advance to avoid
retroactive disenrollment as retroactive enrollment and disenrollment is
not permitted under this program.
A85. WE WOULD LIKE TO BE ABLE TO PROVIDE CONTINUOUS COVERAGE VIA CHILD HEALTH
PLUS TO THOSE TERMINATING FROM MEDICAID DUE TO LOSS OF ELIGIBILITY DUE TO
INCOME REASONS. WHAT PRELIMINARY INFORMATION WOULD BE REQUIRED FOR
PRESUMPTIVE ELIGIBILITY AND IN WHAT TIME FRAME IF WE ARE TO TRY TO AVOID
ANY GAPS IN MEMBERSHIP? WOULD THE PREMIUM PAYMENT ALSO BE REQUIRED AT THE
TIME OF APPLICATION?
To be deemed presumptively eligible under Child Health Plus, a family must
submit a completed, signed enrollment application to a participating
insurer. The insurer must determine that the applicant appears to meet all
eligibility requirements but lacks the documentation necessary to support
the application. Plans will enroll children based on their internal
processing cut-off dates. Enrollment will be for the first day of the
month with no retroactive enrollment permitted. The first month's family
premium contribution is required prior to enrollment. If an individual
submits an application to Child Health Plus knowing they will be
disenrolled from Medicaid at a point during that month, the child can
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 18
apply to Child Health Plus in advance of the disenrollment. For example,
if a child is due to be disenrolled from Medicaid for the 15th of a
particular month, the child can apply in advance for Child Health Plus and
can enroll for the first day of the month if the application is completed
and any required family contribution is paid prior to the insurer's
internal processing schedule to avoid a lapse in coverage.
A86. CONVERSELY, WHAT ACTIONS CAN BE TAKEN TO ELIMINATE ANY GAPS IN COVERAGE
FOR A CHILD HEALTH PLUS MEMBER WHO IS APPLYING FOR MEDICAID? THERE IS
USUALLY A GAP OF TIME BETWEEN WHEN THE RECIPIENT IS EFFECTIVE FOR MEDICAID
AND WHEN THEY CAN BE ENROLLED IN A PLAN.
if a Child Health Plus member applies for Medicaid, there will not be a
gap in coverage as the member would not be disenrolled from Child Health
Plus until after they are enrolled in Medicaid. The enrollee would also be
retroactively enrolled in Medicaid back to the date of application.
A87. THE INCOME TABLES START WITH A HOUSEHOLD OF ONE. IS IT TO BE ASSUMED THAT
THE NUMBER IN THE HOUSEHOLD REFERS TO THE NUMBER OF CHILDREN AND NO ADULTS
ARE TO BE COUNTED?
Income guidelines are based on the family's gross household income. The
number in the household refers to both the number of children and the
number of adults residing in the households.
A88. SHOULD A NEW HOUSEHOLD BUDGET BE CALCULATED FOR A PREGNANT TEEN BASED ON
THE UNBORN AND HER FINANCIAL RESPONSIBILITY FOR IT. THAT IS, IF SHE
CHOOSES NOT TO APPLY FOR MEDICAID?
No, a household budget should not be calculated for a pregnant teen which
includes an unborn child.
APPENDIX B-2
BIDDER'S NAME: WellCare of New York, Inc.
RFP 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 that holds a 10% or greater
ownership interest in the bidder, either:
- has business operations in Northern Ireland: Y [ ] N [X]
- 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
nondiscrimination 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 [X]
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%".
1
INTRODUCTION
This document contains answers to questions submitted by health plans with
respect to the Child Health Plus Insurance Plan Request for Proposal (RFP). The
questions and answers are grouped in this document as follows:
I. General Technical - Read at Bidder's Conference;
II. Network Comprehensiveness - Read at Bidder's Conference;
III. Fiscal Evaluation Criteria - Read at Bidder's Conference; and
IV. Additional Questions - Not Read at Bidder's Conference.
The questions and answers presented here are questions which were
submitted in writing on index cards to the Department at the Bidder's Conference
held in Albany, New York on January 10, 1997. All of these questions were
received at the bidder's conference, however, some were not presented at the
Bidder's Conference because they required additional research and discussion.
(Answers to the questions that were submitted by plans and received by the
Department by December 30, 1996 is a separate document which all plans received
at the Bidder's Conference and/or a separate mailing after the Bidder's
Conference.)
Plans are reminded that in many instances, similar questions were asked by
multiple organizations. Where this occurred, the State in some cases selected
one or more representative questions to answer, rather than responding in
writing to every question asked. In doing so, the State has made a good faith
effort to ensure that all material issues raised by health plans are being
responded to in as complete a manner as possible.
It is important to read this document in its entirety to assure that you
are informed about all policy statements being made with respect to individual
issues.
To the extent to which answers contained in this document are in conflict
with information provided at the Bidder's Conference, and in the RFP, these
answers shall control.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 3
I. GENERAL TECHNICAL
(READ AT BIDDER'S CONFERENCE)
A1. MUST THE MODEL SUBSCRIBER APPLICATION BE USED AS IS?
No, as stated in the RFP, each insurer will be allowed to use an
application form that is unique to their plan, but the variables
identified in the Model will need to be collected.
A2. REGARDING EMERGENCY SERVICES, IF THE ENROLLEE FAILS TO NOTIFY THE PLAN
WITHIN 24 HOURS OF A VISIT FOR A "TRUE EMERGENCY " CAN THE $35 COPAYMENT
BE CHARGED?
YES.
A3. CAN IT BE LESS THAN $35?
Yes.
A4. WHEN A MEMBER IS DELINQUENT ON PREMIUM PAYMENT, THERE IS A 30 DAY GRACE
PERIOD. IF A MEMBER HAS NOT PAID FOR JANUARY, THEY ARE STILL CONSIDERED
ACTIVE MEMBERS UNTIL JANUARY 30TH. IF PAYMENT IS NOT RECEIVED, THEY ARE
TERMINATED EFFECTIVE JANUARY 1ST. HOWEVER, THE PLAN WOULD HAVE SUBMITTED A
BILL FOR THIS MEMBER ON JANUARY 10TH. DO YOU MEAN THESE MEMBERS SHOULD BE
RECONCILED IN FEBRUARY OR IS IT THAT WE SHOULD BE BILLING THE STATE ON
FEBRUARY 10TH FOR JANUARY MEMBERSHIP?
The payment for January coverage would be due on December 1st with 30 days
grace ending December 31st. Failure to pay by December 31st would result
in disenrollment on December 31 as the last day of paid coverage.
Therefore, there would not be any retroactive disenrollment nor would the
state be billed for January in this case.
A5. IT IS OUR UNDERSTANDING THAT THERE ARE SOME EXCLUSIONS IN THE CURRENT
PHARMACY BENEFIT. IS THAT TRUE? IF SO, WILL THOSE EXCLUSIONS REMAIN IN THE
NEW PROGRAM?
Any pharmaceutical the state has previously excluded will continue to be
excluded.
A6. WHAT IS CONSIDERED SUFFICIENT DOCUMENTATION OF INCOME AND OVER WHAT
TIMEFRAME IS ONE MONTH OF PAY STUBS THAT WAS EARNED WITHIN THE PAST THREE
MONTHS SUFFICIENT?
Advisory memorandum A-1 and A-16 address documentation of income sources.
Most recent tax returns must be submitted if available. If income has
changed since the last tax return was filed, then other documentation must
be submitted to support current income. Three months would be an
acceptable current period. Therefore, one month of paystubs earned within
the past 3 months would be sufficient.
A7. DOES THE PLAN OR THE STATE DETERMINE THE CUTOFF DATE FOR APPLICATIONS FOR
THE EFFECTIVE MONTH OF MEMBERSHIP?
CHILD HEALTH PLUS INSURANCE PLAN
BIDDER'S CONFERENCE QUESTIONS AND ANSWERS PAGE 43
160. APPENDIX K APPEARS TO CONTAIN ONLY ONE SCHEDULE RELATED TO PERSONNEL
COSTS. ARE OTHER SCHEDULES GOING TO BE ADDED?
Appendix K is a double sided copy. Please turn the page over to complete the non
personnel related expense section.
161 PLEASE CLARIFY WHAT THE DEPARTMENT WOULD LIKE SUBMITTED IN RESPONSE TO THE
REQUEST TO "DEMONSTRATE THE FINANCIAL FEASIBILITY OF YOUR ORGANIZATION'S
PROPOSED CHILD HEALTH PLUS PROGRAM, INCLUDING THE FINANCIAL REQUIREMENTS
OF THE NEW YORK STATE INSURANCE LAW AND PUBLIC HEALTH LAW".
The Department is requesting that revenue and expense projections be provided
for the Child Health Plus program for 1997 and 1998. In addition, the applicant
must identify the current financial condition of the corporation (latest
available certified financial statements are acceptable) and the financial
condition projected to the end of the first period (e.g. 12/31/97) during which
the new rates will be effective. The plan must demonstrate that it is able to
meet reserve and escrow requirements in its financial projections as well.
162. WHAT COUNTIES COMPRISE EACH NEW YORK STATE REGION?
The Department does not have sufficient information to respond to this question.
163. ARE APPLICANTS TO PROJECT ONE TOTAL ENROLLMENT NUMBER OR ENROLLMENT FOR
EACH COUNTY THEY PROPOSED TO SERVE AND TOTAL ENROLLMENT FOR ALL COUNTIES?
The applicant needs to identify projected enrollment for each county they
propose to serve and total projected enrollment for all counties.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH SYSTEMS MANAGEMENT
DIVISION OF HEALTH CARE FINANCING
BUREAU OF HEALTH ECONOMICS
CHILD HEALTH PLUS PROGRAM
INSURANCE PLAN REQUEST FOR PROPOSAL
QUESTIONS AND ANSWERS
RECEIVED AT BIDDER'S CONFERENCE
BIDDER'S CONFERENCE:
FRIDAY, JANUARY 10, 1997
- It is the policy of New York State to maximize opportunities for the
participation of New York State business enterprises, including
minority- and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.
- Information on the availability of New York State subcontractors and
suppliers is available from:
NYS Department of Economic Development
Division for Small Business
(518) 474-7756
- A directory of minority- and women-owned business enterprises is
available from:
NYS Department of Economic Development
Minority and Women's Business Development Division
(518) 474-6346
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.
2
CHECKLIST TO DETERMINE "REASONABLE" EFFORT
BY BIDDERS/CONTRACTORS FOR CONTRACTS OF $1 MILLION OR MORE
A copy of this form should be completed and retained on file by the
Contractor. The completed form should be available for review for the duration
of the contract.
The contractor:
1. has a copy of the NYS Directory of Certified Minority and
Women-Owned Business Enterprises? Y [ ] N [X]
2. has solicited quotes from firms listed in the Directory?
Y [ ] N [X]
3. has contacted the NYS Department of Economic Development to obtain
listings of NYS subcontractors and suppliers for products and
services currently purchased from out-of-state/foreign firms?
Y [X] N [ ]
4. has utilized other sources to identify NYS subcontractors and
suppliers (such as Thomas Register, in-house vendor list)?
Y [X] N [ ] (If YES, Source: in-house vendor list)
5. has placed advertisements in NYS newspapers? Y [X] N [ ]
6. has participated in vendor outreach conferences? Y [ ] N [ ]
7. has provided New York State residents notice of new employment
opportunities resulting from this contract through listing any such
positions with the Job Service Division of the NYS Department of
Labor, or providing such notification by another method? Y [X] N [ ]
3
NEW YORK STATE DEPARTMENT OF HEALTH
STOCK ITEM SPECIFICATION FORM
(Submission of this form is optional)
Whenever possible, practical, feasible and consistent with open
competitive bidding, the stock item specifications of manufacturers, producers
and/or assemblers located in New York State are used in the preparation of bid
documents for the commodity requirements of State agencies. Companies are
responsible for updating information as changes are made in their stocked items'
technology and/or design.
The DOH maintains Stock Item Specification Forms and corresponding
specifications for a two year period; it is anticipated that within that time
companies will refile with updated information. These forms and updates may be
submitted to:
New York State
Department of Health
Purchase Unit
Corning Tower Room 1354
Albany, New York 12237-0016
Please provide the information requested below, sign and date this form
where indicated, and submit the completed form and accompanying specifications
to the address given above.
1. Company Name and Principal Place of Business:
2. Number of persons employed at above location: 273
3. Stocked Item (only one per form):
4. Production of Stocked Item (Name and address of Manufacturer,
Producer, and/or assembler):
5. Product Specification (briefly below, or attach specification):
WellCare of New York, Inc. (WCNY), a Health Maintenance Organization (HMO)
licensed as an Article 44 for-profit corporation under the New York Public
Health Law, is a subsidiary of The WellCare Management Group, Inc. (WCMG).
4
To the best of my knowledge, the information provided is accurate. It
may be used by the State for the purpose of helping to retain jobs, business and
industry presently in the State of New York and attracting new business and
industry to the State of New York. False statements knowingly made herein are
punishable as a Class A misdemeanor under Section 210.45 of the Penal Law of the
State of New York.
Company Representative (please print):Donald A. [ILLEGIBLE]
Title and Telephone:
Signature and Date:[ILLEGIBLE] 9/26/97
5
APPENDIX D
SCHEDULE OF DELIVERABLES
Relevant Dates
Ongoing Marketing Plans
a. Design and develop marketing materials as approved by
DOH.
b. Implement marketing strategies specified in the
proposal/workplan and consistent with subsequently issued
STATE guidelines.
c. Coordinate marketing and outreach activities consistent
with the designated STATE Outreach CONTRACTOR and the STATE
DOH Mass Media Marketing Campaign.
Ongoing Enrollment Activities
a. Design and finalize revised enrollment process and forms.
b. Hire enrollment staff as necessary.
c. Develop and finalize eligibility determination
mechanisms.
d. Implement enrollment process. The CONTRACTOR may process
new enrollment applications in accordance with its own
internal processing schedule. However, the cut off date for
processing new applications effective the first day of the
following month can be no earlier than the 20th day of the
previous month and for recertification, any application
received through the last day of the twelve(12) month
enrollment period must be processed as a recertification
effective the first day of the following month.
e. Participate in the development and implementation of the
Medicaid linkage and referral process with State and local
agencies in order to maximize the use of Medicaid for
eligible children. The referral process shall include use of
the Medicaid screening and referral form provided by the
STATE, a copy of which must be maintained in the
enrollment file and use of the joint Medicaid, WIC and Child
Health Plus enrollment form.
f. Participate in the monthly match process to eliminate
duplicate enrollment in Child Health Plus and Medicaid. The
STATE may recoup premiums from the CONTRACTOR when a
Medicaid/Child Health Plus duplicate is identified and not
disenrolled from Child Health Plus within the specified
timeframe.
g. Capture data on marketing and enrollment outcomes.
h. Capture data on demographic characteristics of enrollees.
Ongoing Quality Assurance
a. Adapt and finalize quality assurance and utilization
review mechanisms.
b. Maintain quality assurance and utilization review
mechanisms in accordance with STATE issued guidelines and/or
advisory memoranda in cooperation with STATE designated
CONTRACTORS and provide requested data to STATE and any
designated CONTRACTORS.
Ongoing Billing/Electronic Mail
a. Implement billing processing systems such that:
The CONTRACTOR shall prepare and submit to the STATE
monthly voucher bills and adjustments pursuant to this
AGREEMENT through the electronic mail system.
Ongoing Insurance Coverage/Miscellaneous
a. Provide insurance coverage for enrollees.
b. Implement project such that health services are provided
to enrollees. Continue enrollment and marketing programs as
needed in cooperation with other STATE CONTRACTORS and the
DOH Mass Media Marketing Campaign as directed by
the STATE.
c. Initiate the collection of utilization data on enrollees.
d. Monitor program enrollment to ensure that enrollment does
not reach a number that would result in exceeding the annual
funding allocation as specified in Appendix E.
e. Meet data requirements of an independent evaluator as
needed.
Ongoing Reporting Requirements
a. Initiate subsidy process with STATE. Thereafter, the
submittal of monthly voucher bills and supporting
documentation shall be on a monthly basis, pursuant to this
AGREEMENT.
b. Cost and utilization data reports shall be submitted at
least on a semi-annual and annual basis, based on a calendar
year, due seventy five (75) days after the close of the
second quarter and one hundred and twenty (120) days after
the close of the calendar year, respectively, using the
forms and format supplied by the STATE.
c. Submit other reports as required by Appendix F.
d. Conform with additional reporting requirements imposed by
the STATE which are based on need or as legislatively
mandated.
December 31, 1999 Conclusion of insurance coverage for enrollees unless
continuation of the Child Health Plus program is approved by
the New York State Legislature.
January 1, 2000 Initiate conversion coverage as stipulated in the request
for proposals, proposal/workplan and benefit contract.
April 1, 2000 Final report due from the CONTRACTOR.
December 31, 2001 Data relating to the Child Health Plus program shall be
maintained and retained by the CONTRACTOR until this date.
APPENDIX E
FINANCIAL INFORMATION
Wellcare shall receive, for the period effective the date of this contract
through December 31, 1997, an amount up to, but not to exceed, the sum of
$802,430 to provide and administer a Child Health Plus program for uninsured
children in the counties identified in Appendix A-2, Section II B 1 of this
AGREEMENT or as modified by the STATE. The premium identified below will be
valid at least through December 31, 1997. Premiums may be modified periodically
under the Child Health Plus program subject to approval of a request from the
CONTRACTOR through the New York State Department of Health and the State
Insurance Department. In the absence of an approved premium modification by the
New York State Department of Health and the State Insurance Department, the
premium contained herein or any subsequent premium (whichever is in effect),
shall continue as the premium for the STATE's subsidy through December 31, 1999.
Payment of this amount is based on the CONTRACTOR meeting the responsibilities
provided in this AGREEMENT.
Wellcare shall receive, for the period of January 1, 1998 through December 31,
1998, an amount up to, but not to exceed, the sum of $2,681,222 to provide and
administer a Child Health Plus program for uninsured children in the counties
identified in Appendix A-2, Section II B 1 of this AGREEMENT or as modified by
the STATE. Payment of this amount is based on the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.
Wellcare shall receive, for the period of January 1, 1999 through December 31,
1999, an amount up to, but not to exceed, the sum of $3,720,880 to provide and
administer a Child Health Plus program for uninsured children in the counties
identified in Appendix A-2, Section II B 1 of this AGREEMENT or as modified by
the STATE. Payment of this amount is based on the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.
Premium Information:
Upstate Counties
- - For Upstate counties defined as Albany, Broome, Columbia, Delaware,
Dutchess, Greene, Orange, Otsego, Rensselaer, Rockland, Schoharie, Sullivan and
Ulster the total monthly premium shall be: $75.93.
- - The State Share of the total monthly premium shall be $75.93 or the total
monthly premium for children in families with gross household income less than
120% of the federal poverty level.
- - The State Share of the total monthly premium shall be $66.93 or the total
monthly premium minus $9 for children in families with gross household income
between 120 and 159% of the federal poverty level.
- - The State Share of the total monthly premium shall be $62.93 or the total
monthly premium minus $13 for children in families with gross household income
between 160 and 222% of the federal
poverty level.
Downstate Counties
- - For Downstate counties defined as Kings, New York and Queens, the total
monthly premium shall be: $93.81.
- - The State Share of the total monthly premium shall be $93.81 or the total
monthly premium for children in families with gross household income less than
120% of the federal poverty level.
- - The State Share of the total monthly premium shall be $84.81 or the total
monthly premium minus $9 for children in families with gross household income
between 120 and 159% of the federal poverty level.
- - The State Share of the total monthly premium shall be $80.81 or the total
monthly premium minus $13 for children in families with gross household income
between 160 and 222% of the federal poverty level.
APPENDIX F
PAYMENT AND REPORTING SCHEDULE
I. Payment and Reporting Terms and Conditions
A. The STATE may, at its discretion, make an advance payment to the
CONTRACTOR, during the initial or any subsequent PERIOD, in an amount to be
determined by the STATE but not to exceed twenty five percent of the maximum
amount indicated in the budget as set forth in the most recently approved
Appendix E. If this payment is to be made, it will be due thirty calendar days,
excluding legal holidays, after the later of either:
- the first day of the contract term specified in the Initial
Contract Period identified on the face page of the AGREEMENT
or, if renewed, in the PERIOD identified in the Appendix X, OR
- if this contract is wholly or partially supported by Federal
funds, availability of the federal funds;
provided, however, that the STATE has not determined otherwise in a written
notification to the CONTRACTOR suspending a Written Directive associated with
this AGREEMENT, and that a proper voucher for such advance has been received in
the STATE's designated payment office. If no advance payment is to be made, the
initial payment under this AGREEMENT shall be due thirty calendar days,
excluding legal holidays, after the later of either:
- the end of the first quarterly period of this AGREEMENT; or
- if this contract is wholly or partially supported by federal
funds, availability of the federal funds;
provided, however, that a proper voucher for this payment has been received in
the STATE's designated payment office.
B. No payment under this AGREEMENT, other than advances as authorized
herein, will be made by the STATE to the CONTRACTOR unless proof of performance
of required services or accomplishments is provided. If the CONTRACTOR fails to
perform the services required under this AGREEMENT the STATE shall, in addition
to any remedies available by law or equity, recoup payments made but not earned,
by set-off against any other public funds owed to CONTRACTOR.
C. Any optional advance payment(s) shall be applied by the STATE to
future payments due to the CONTRACTOR for services provided during initial or
subsequent PERIODS. Should funds for subsequent PERIODS not be appropriated or
budgeted by the STATE for the purpose herein specified, the STATE shall, in
accordance with Section 41 of the State Finance Law, have no liability under
this AGREEMENT to the CONTRACTOR, and this AGREEMENT shall be considered
terminated and cancelled.
D. The CONTRACTOR will be entitled to receive payments for work, projects,
and services rendered as detailed and described in the program
workplan/proposal, Appendix C. All payments shall be in conformance with the
rules and regulations of the Office of the State Comptroller.
E. The CONTRACTOR will provide the STATE with the reports of progress or
other specific work products pursuant to this AGREEMENT as described in this
Appendix F, below. In addition, a final report must be submitted by the
CONTRACTOR no later than March 31, 2000. All required reports or other work
products developed under this AGREEMENT must be completed as provided by the
agreed upon work schedule in a manner satisfactory and acceptable to the STATE
in order for the CONTRACTOR to be eligible for payment.
F. By the tenth (10th) business day of the month, the CONTRACTOR shall
submit to the STATE monthly billing information electronically to the Department
of Health through an electronic mail (E-Mail) account established by the
Department of Health. In addition, an original signed voucher must be submitted
to the Department of Health by the tenth (10th) business day of the month.
Reimbursement shall be based on the actual number of children enrolled in the
program during the month for which payment is being claimed who are eligible for
a subsidy. All billing adjustments shall include a listing by enrollee of any
change in enrollment occurring in that period. The CONTRACTOR shall submit
vouchers to the State's designated payment office located in the New York State
Department of Health.
In no event shall the amount received by the CONTRACTOR exceed the budget
amount approved by the STATE as stated in Appendix E, and, if actual
disbursements by the CONTRACTOR are less than such sum, the amount payable by
the STATE to the CONTRACTOR shall not exceed the amount of actual disbursements.
All contract advances in excess of actual disbursements will be recouped by
the STATE prior to the end of the applicable budget period.
II. Reporting Requirements
The CONTRACTOR is responsible for submitting reports to DOH as defined in
the Appendix G of the RFP (Appendix B) contained herein. Additional reporting
requirements may be imposed based on need or legislative requirements. The
following are the reports currently required:
A. Monthly enrollment reports which detail new and ongoing enrollment and
disenrollment. These reports are due by the tenth (10th) business day of the
report period month.
B. Quarterly report on the reasons for denied applicants and disenrollment due
thirty (30) days after the close of the quarter.
C. Semi-annual and annual financial and utilization reports. The semi-annual
report is due seventy five (75) days after the close of the second quarter and
the annual report is due one hundred and twenty (120) days after the end of the
calendar year.
D. An annual progress report detailing marketing and enrollment outcomes,
demographic characteristics of enrollees and utilization outcomes. This report
will be required ninety (90) days after the close of the calendar year.
E. Plans must provide quality performance data which is consistent with the New
York State Department of Health Quality Assurance Reporting Requirements (QARR)
data specifications, on an annual basis for the Child Health Plus population.
Some of the general QARR data categories which will be required to be collected
include membership, utilization, quality, access, member satisfaction and
general plan management.
F. The CONTRACTOR will submit a final report, as required by the contract,
reporting on all aspects of the program, detailing how the use of funds were
utilized in achieving the goals set forth in the program workplan/proposal.
This report will be due ninety (90) days after the close of the contract period.
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:_________________________
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 4
For processing applications, the plan will utilize their internal
procedures and cutoff dates which must be acceptable to the Department of
Health.
A8. IS THERE A LIMIT TO THE NUMBER OF PARTICIPATING PLANS IN EACH
COUNTY/REGION?
No, there is no absolute limit. However, we will be accepting plans based
on need to assure adequate statewide coverage.
A9. WILL EXISTING ENROLLEES BE GIVEN THE OPPORTUNITY TO SWITCH PLANS ON 5/1/97
IF THERE AN NEW ENTRANTS IN THE MARKETPLACE?
Yes.
A10. DOES THE STATE HAVE ESTIMATES OF ELIGIBLE CHILDREN FOR CHILD HEALTH PLUS
BY COUNTY OR REGION?
No, the CPS data set does not break down the uninsured any further
geographically then New York City and the rest of the State.
A11. FOR PLANS THAT ALREADY HAVE A CHILD HEALTH PLUS CONTRACT: WE MUST SIGN AN
ADDENDUM TO OUR EXISTING CONTRACT? WHAT IS THE TERM OF THIS CONTRACT AND
WHEN WILL THE DEPARTMENT OF HEALTH ISSUE THE CONTRACT EXTENSION?
New contracts will be issued to those plans selected for the expanded
program.
A12. IN AREAS WITH MORE THAN ONE PARTICIPATING PLAN, WILL THE OUTREACH
ORGANIZATION INCLUDE ALL PLANS ON ITS EFFORTS OR WILL STEERAGE OCCUR BY
SOME CRITERIA?
The outreach organization will provide families with a list of all
insurers available in their area.
A13. IN REFERENCE TO THE RESPONSE TO QUESTION 8, WHAT IS MEANT BY "IT IS AT THE
DISCRETION OF THE FAMILY AS TO WHAT PAYMENT SCHEDULE THEY CHOOSE TO ABIDE
BY?" THE RFP STATES THAT PAYMENT IS ON A MONTHLY BASIS.
Insurers will have the option of offering alternative modes of premium
payment, for example, quarterly, annually or semi-annually, in addition to
a monthly rate. It is up to the family to decide the mode from the options
offered by the insurer.
A14. PLEASE CLARIFY WHETHER CHILDREN UNDER AGE ONE MAY ENROLL IN CHILD HEALTH
PLUS?
Children under age one may enroll in Child Health Plus. However, if family
income is below 222% of gross Federal Poverty Level, then the children
should be referred to Medicaid.
A15. BACK TO QUESTION 59 AND THE RESPONSE READ TODAY, DOES THE PROGRAM NAME
"CHILD
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 5
HEALTH PLUS" IMPRINTED ON A CARD SUFFICE AS AN IDENTIFICATION PROCESS ON
ID CARDS?
Yes.
A16. IS THERE DATA ON THE NUMBER OF CHILDREN DISENROLLED FROM CHILD HEALTH PLUS
DUE TO NON-PAYMENT OF PREMIUMS ?
No data is available at this time regarding disenrollment due to
non-payment. However, under the current system, with the exception of
families between 160 and 222 of gross Federal Poverty Level with multiple
children, the $25 family contribution must be paid with application prior
to enrollment. For families with multiple children, only the first $25
must be paid initially. The $25 for remaining children is paid based upon
procedures of the individual plan.
A17. MAY A MEDICAID MANAGED CARE PLAN ASSUME PRESUMPTIVE ELIGIBILITY FOR A
MEDICAID MEMBER WHERE THE ROSTER INDICATES THE CASE HAS BEEN CLOSED?
No, children cannot be assumed presumptive eligible for Child Health Plus
just because they were disenrolled from Medicaid? The family must apply to
Child Health Plus, submit a completed and signed application. However if
the child appears eligible but lacks documentation needed to support the
application, the child can be enrolled presumptively for sixty (60) days.
A18. WILL THE STATE TRANSMIT INFORMATION FOR A PLAN'S MEDICAID MEMBERS THAT
WOULD INDICATE THAT A CASE IS CLOSED DUE TO INCOME REASONS?
No, the state will not transmit data as to reason for closure of Medicaid
case as cases are closed at the local district.
A19. QUESTION 41 OF BIDDER'S CONFERENCE DOCUMENT STATES THAT NO FROM OF
TRANSPORTATION IS COVERED BY CHILD HEALTH PLUS. HOWEVER, THE BENEFIT
PACKAGE EXCLUSIONS ONLY REFER TO "NON-EMERGENCY" TRANSPORTATION, AND THE
RATE FILING WORKSHEET IN APPENDIX F INCLUDES A LINE FOR AMBULANCE SERVICE.
IS AMBULANCE USE FOR AN EMERGENCY A COVERED BENEFIT?
The exclusions to the benefit package should have indicated that all
transportation is excluded. The rate filling application should not have
emergency transportation included.
A20. WILL THERE BE AN ON-SITE REVIEW OF SELECTED BIDDERS PRIOR TO PROGRAM START
UP?
On site review is not planned. However, the Department of Health reserves
the right to do a site visit if questions should arise.
A21. MUST PLANS HAVE THE ABILITY TO BILL ELECTRONICALLY BY THE TIME PROPOSALS
ARE SUBMITTED OR BY THE PROGRAM START DATE?
Plans must guarantee within their proposal that they have the ability to
submit electronic
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 6
billing data by implementation date.
A22. PLEASE RE-CLARIFY - CAN A PLAN DENY A MEDICALLY APPROPRIATE ER VISIT FOR
FAILURE TO NOTIFY THE PLAN OF THE VISIT?
The plan may impose a $35 copayment for failure to notify.
A23. ARE MEDICAID DRG RATES AVAILABLE TO PARTICIPATING PLANS BY STATUTE?
Yes, this is available under FOIL (Freedom of Information Law).
A24. PLEASE CLARIFY: IS THERE AN APPLICATION FEE OF $25 AS THERE IS IN THE
CURRENT PROGRAM?
No, the application/enrollment fee has been replaced by the statutory
family contribution to premium.
A25. WHAT ARE THE PRESCRIPTION DRUG EXCLUSIONS?
The exclusions would be those typically permitted under Insurance Law and
Regulation such as those for experimental or investigational drugs, drugs
prescribed for a cosmetic purpose, etc.
A26. WHEN THE ENROLLEE AGES OUT OF A HEALTH PLAN, THE PLAN IS THEN RESPONSIBLE
TO OFFER THEM A CONVERSION PACKAGE; ARE THERE ANY SPECIFIC BENEFITS THAT
HAVE TO BE OFFERED?
No, those plans capable of issuing conversion coverage must make the
contract they generally offer available to Child Health Plus enrollees.
A27. IF THE PLAN ASSESSES THE $35 ER CO-PAY FOR FAILURE TO NOTIFY PLAN OF AN ER
VISIT ON INAPPROPRIATE ER VISIT AND THE MEMBER IS DELINQUENT, DOES THIS
DELINQUENCY APPLY TO THE DELINQUENCY OF THE PREMIUM?
No, failure to pay a copayment is unrelated to failure to pay a premium.
A28. MAY A CHILD BE ENROLLED IN CHILD HEALTH PLUS PRIOR TO BIRTH AS IS
CURRENTLY THE CASE UNDER MEDICAID.
No, in order for enrollment in Child Health Plus, the family must submit
an application with the child's name and date of birth as well as required
documentation. Enrollment is established for the first day of a future
month unlike Medicaid who enrolls retroactive to the date of application
and at any point within the month. There is no family coverage in this
program, only individual coverage.
A29. WHAT HAPPENS WHEN A CHILD WHO IS RECEIVING CHILD HEALTH PLUS SERVICES
BECOMES ELIGIBLE FOR MEDICAID AND THE PLAN DOES NOT KNOW ABOUT THE
MEDICAID COVERAGE FOR SEVERAL MONTHS? ARE WE TO RETURN PREMIUMS? ARE WE TO
DISENROLL RETROACTIVELY?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 7
The Department has a procedure to match Child Health Plus
enrollment/billing files against the Medicaid enrollment file to identify
children dually enrolled in both programs. The Department notifies the
plans of the dual enrollment status of these children and advises the plan
to disenroll children prospectively for a future month and not
retroactively. The premium for the month where the child is identified as
a duplicate is not recouped.
A30. PLEASE CLARIFY WHAT BIRTH CONTROL/PRESCRIPTIONS, DEVICES, AND SUPPLIES ARE
COVERED IN CHILD HEALTH PLUS.
Any family planning services or birth control/prescriptions, devices and
supplies that are prescribed by a qualified, participating provider are
covered.
A31. HOW WILL DOH CHOOSE QUALIFIED PLAN - MINIMUM SCORE, # PLANS PER COUNTY, #
IN THE WHOLE STATE?
Total score of all parts of the proposal will be considered. A ranking
will be assigned. Plans will be chosen in order to ensure an adequate
statewide coverage.
A32. WHAT FACTORS WILL BE EVALUATED IN DETERMINING THE EFFECTIVENESS OF PLANS
IN TARGETING MINORITY POPULATION?
We will evaluate the reasonableness of the plan's proposed marketing plan
and outreach efforts with respect to achieving their projected enrollments
and particularly including under-represented minorities in the current
program.
A33. CLARIFY CHILD HEALTH PLUS COVERAGE FOR CHILDREN LESS THAN 1 IF THE MOTHER
DOESN'T OBTAIN MEDICAID COVERAGE FOR HIM/HER.
A child maintains Child Health Plus enrollment until he or she is enrolled
in Medicaid.
A34. APPENDIX D HAS A PIE CHART THAT SHOWS THE SECOND QUARTER 1996 ENROLLMENT
BY SUBSIDY AND AGE. TWO OF THE AGE CATEGORIES ARE 0-1 AND 1-5. DOES THE
0-1 CATEGORY REPRESENT CHILDREN UNDER 12 MONTHS? IF SO, THIS SEEMS TO BE
INCONSISTENT WITH PAGE 13 OF THE RFP WHICH SAID THAT THERE IS VERY LITTLE
ENROLLMENT UNDER AGE 1 (PIE CHART SHOWS 5.4% OF ENROLLMENT 0-1). PLEASE
CLARIFY THIS.
Under the new program, it is expected that insurers' referrals to Medicaid
for this population will be more aggressive than under the existing
program.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 8
II. NETWORK COMPREHENSIVENESS
(READ AT [ILLEGIBLE] CONFERENCE)
A35. UNDER ELIGIBLE ORGANIZATIONS, PLEASE DEFINE: A COMPREHENSIVE HEALTH
SERVICE PLAN OPERATING UNDER THE REGULATIONS OF THE DEPARTMENT OF HEALTH.
These organizations are Article 44 health maintenance organizations and
prepaid health services plans.
A36. RE: PAGE 57 - EVALUATION CRITERIA PLEASE EXPLAIN WHAT IS EXPECTED FOR
INFORMATION. THE RFP ALREADY DESCRIBES THE BENEFIT PACKAGE. PMPMS WILL BE
IN THE RATE SUBMISSION.
The benefit package evaluation will be based on the narrative description
of the benefit package which should be provided in the proposal.
A37. RE: PATIENT EDUCATION. THE TITLE STATES "PATIENT" EDUCATION BUT THE TERM
"PUBLIC" EDUCATION IS USED WITHIN THE SECTION. PLEASE CLARIFY.
These terms are used interchangeably.
A38. QUESTION #62 INDICATES THAT "INSURERS MUST PERFORM THEIR OWN MARKETING AND
OUTREACH IN ACCORDANCE WITH THE GUIDELINES IN THE RFP. MAY THE INSURERS
SUB-CONTRACT WITH COMMUNITY BASED ORGANIZATIONS TO CONDUCT THIS OUTREACH?
Yes. However, the insurer remains responsible for assuring that the
sub-contractor performs these activities consistent with program
requirements. In addition, the proposal should include the actual outreach
and education strategies that may be subcontracted.
A39. YOUR ANSWER TO QUESTION #100 REFERS TO A PROVIDER NETWORK SUBMISSION "DUE
JANUARY 23, 1997", IS THIS THE QUARTERLY PROVIDER NETWORK SUBMISSION FOR
MEDICAID MANAGED CARE PLANS OR IS IT SOME OTHER SUBMISSION?
It is the quarterly provider network submission for Medicaid Managed Care
plans.
A40. FOR PLANS WHO SUBMITTED THE LETTER OF INTENT WITHIN THE APPROPRIATE TIME
FRAME, WHEN CAN WE EXPECT TO RECEIVE THE DATA REPORTS MENTIONED IN
QUESTION 145?
These reports are included in your packet.
A41. RE: QUESTION 121 - HOW MUCH TIME IS PERMITTED TO ELAPSE BETWEEN SELECTION
OF A CENTER AND SELECTION OF A SPECIFIC PCP FROM THAT CENTER.
The Child Health Plus program does not intend to specify any time limits
in this selection. However, since PCPs coordinate care and are required to
be available 24 hours per day, 7 days per week, it is in the insurer's and
enrollee's best interest that PCP selection or
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 9
assignment occur shortly after enrollment.
A42. ARE WE EXPECTED TO POLL EACH AND EVERY PARTICIPATING PCP TO DETERMINE THE
NUMBER OF CHILD HEALTH PLUS ENROLLEES HE OR SHE IS WILLING TO ACCEPT? WILL
YOU ACCEPT WHATEVER NUMBER THE PCP SUPPLIES, EVEN IF IT FLIES IN THE FACE
OF REASON?
Non-Medicaid managed care plans will need to provide PCP specific
enrollment information with their submissions. The numbers provided by
each PCP should realistically reflect that the PCP can actually
accommodate those enrollees. For Managed care plans participating in the
Partnership Plan, the quarterly provider network submission will be used
to assess PCP capacity.
A43. DO THE PLANS NEED TO PROVIDE ENROLLMENT PROJECTIONS BY REGION OR WILL
OVERALL PROJECTIONS SUFFICE?
Enrollment projections should be submitted by county.
A44. PLEASE CLARIFY THAT APPLICANTS WILL NEED TO SUBMIT A COMPREHENSIVE LIST OF
PHARMACIES AND LABS AS PART OF APPENDIX L.
The applicant summary forms contained in Appendix L must be completed for
any sub-contracted provider.
A45. THE ANSWER TO QUESTION #118 SAYS THAT 1500 MAX IS APPLICABLE TO MEDICAID
ONLY, BUT DOES THIS MEAN THERE'S NO MAXIMUM FOR CHILD HEALTH PLUS? (I.E.
SO THAT A PROVIDER CAN HAVE 1500 FOR MEDICAID AND ANOTHER 1000 FOR CHILD
HEALTH PLUS?)
Yes. However, plans must abide by appointment availability standards and
networks will be monitored to assure service accessibility.
A46. WILL THE STATE ALLOW PAPER SUBMISSIONS OF SOME OF THE NETWORK IF THE PLAN
HAS DIFFICULTY IN SUBMITTING COMPLETE NETWORK INFORMATION IN THE FORMAT
REQUIRED BY THE STATE JANUARY 23, 1997.
Medicaid managed care plans must submit their provider network information
by january 23, 1997 in the format specified by the Office of Managed Care.
For non-Medicaid managed care plans, network submissions may be in paper
medium, however, we prefer the spreadsheet format previously specified.
A47. FOR MEDICAID MANAGED CARE PLANS, WILL THE STATE DETERMINE EACH PCP'S
ADDITIONAL CAPACITY BASED ON THE 1/23/97 QUARTERLY PROVIDER NETWORK
SUBMISSION, OR ARE THE PLANS EXPECTED TO DETERMINE THIS CAPACITY?
SPECIFICALLY, WHAT DOES THE MEDICAID MANAGED CARE PLAN NEED TO SUBMIT
UNDER PROVIDER NETWORK? (ASIDE FROM NETWORK CHANGES AFTER THE 1/23/97
SUBMISSION.)
The 1/23/97 quarterly network submission to the Office of Managed care
will be utilized
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 10
to determine adequacy of network as well as capacity to serve Child Health
Plus enrollees. No additional network information is required for managed
care plans participating in the Medicaid program.
A48. THE RFP REQUESTS THAT PLANS IDENTIFY ANY SERVICES TO BE PROVIDED BY
SUBCONTRACTORS, INCLUDING PROVIDERS, PHARMACEUTICAL AND DIAGNOSTIC
LABORATORY NETWORKS. PLEASE PROVIDE A DEFINITION OF "SUBCONTRACTORS" AND
EXPLAIN HOW THIS QUESTION DIFFERS FROM THE QUESTION ON PAGE 50 OF THE RFP,
"IDENTIFY THE PROVIDER NETWORK (BY TYPE, NUMBER, AND COUNTY)..."
Plans may have to enter into subcontracts for certain services which are
not part of their existing network. The insurer should identify which
services-physician, hospital, laboratory, pharmacy, home health care, etc.
- will be subcontracted.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 11
III. FISCAL EVALUATION
(READ AT BIDDER'S CONFERENCE)
A49. IS IT A REGULATORY REQUIREMENT FOR A LICENSED ACTUARY TO SIGN OFF ON THE
RATE SUBMISSION OR CAN ANY QUALIFIED FINANCIAL STAFF PERSON PERFORM THIS
FUNCTION?
The actuarial memorandum should be signed by a member of the American
Academy of Actuaries or a Fellow of the Society of Actuaries. Attestation
from other financial officers of the plan will be acceptable provided they
are able to demonstrate appropriate qualifications and experience. An FSA
signature can be from an independent actuarial firm or an employee of the
plan.
A50. PLEASE CONFIRM THE PERIOD OF TIME THAT THE RATE PROPOSAL WILL COVER?
We would anticipate that the rate proposals will be for a 12 month period
but should at least be through December 31, 1997.
A51. WHAT SHOULD WE ANTICIPATE THE PREMIUM RECEIVABLE LAG TO BE?
Billing are required monthly and the Department will process bills within
30 days. please refer to sections 5 on pages 30 and 31 for the specific
billing timelines.
A52. IS REINSURANCE AVAILABLE FROM THE STATE?
No. Reinsurance is not available from the state.
A53. CAN THE FORM IN APPENDIX K BE COMPUTED BY FUNCTIONAL AREA (E.G., MMIS
CLAIMS ETC.) RATHER THAN BY LISTING OF INDIVIDUAL PERSONNEL?
The key administrative staff need to be identified on the form. All
support staff can be grouped by functional area.
A54. PER THE DRAFT RATE FILING GUIDELINES UNDER APPENDIX F OF THE RFP, IS THE
EXPECTED INCURRED LOSS RATIO MANDATED TO BE 90% OR MAY PLANS PROVIDE
ALTERNATE PROJECTIONS?
No, plans may provide alternate projections. The 90% referenced in
Appendix F was for illustrative purposes.
A55. WILL FAMILY PLANNING SERVICES BE CONSIDERED FOR A REIMBURSEMENT CARVE-OUT,
AND/OR MAY PLANS SUBCONTRACT WITH OTHER PLANS TO PROVIDE FAMILY PLANNING
SERVICES ?
Plans may subcontract with other plans to provide services subject to
approval by the State DOH.
A56. CPS DATA IS NOT BROKEN DOWN BY COUNTY. WHEN WILL PLANS RECEIVE COUNTY
SPECIFIC INFORMATION?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 12
The state released CPS data for New York City and rest of state by age and
income category at the bidders conference on January 10, 1997. No other
breakdown will be provided by the state.
A57. ARE THERE ASSUMPTIONS REGARDING TREND FACTORS FOR OUTLYING YEARS?
No. We are not offering any actuarial assumptions regarding trend factors.
However, we do expect the plans to provide them in their bid.
A58. WHY IS AN ACTUARIAL CERTIFICATION NEEDED FOR THIS PROGRAM WHEN IT WAS NOT
REQUIRED FOR MEDICAID?
It is required by New York State Insurance regulation.
A59. PERTAINING TO QUESTION 162 ABOUT RATING REGIONS- WHEN WILL THIS BE
AVAILABLE? WHAT COUNTIES WILL BE INCLUDED IN WHAT REGIONS?
Please refer to question #151. The rates can be varied by county/region as
actuarially justified...
A60. STATUTORY CONTRIBUTION- SINCE THE 2% CONTRIBUTION DOES NOT APPLY TO CHILD
HEALTH PLUS, I ASSUME THAT A 1% CONTRIBUTION IS ACCEPTABLE. IS THIS SO?
Statutory contributions are described in State Insurance Law Section 4310.
A61. BASE PERIOD TO RATE PERIOD -- IS IT ACCEPTABLE TO HAVE A BASE PERIOD OF
1995 AND A RATE PERIOD OF 5/12/97? (1995 IS TOO INCOMPLETE TO SERVE AS A
BASE PERIOD).
Please refer to question 155. The most current available credible data
should be used, however the data need not be for a calendar year period.
A62. THE STATE HAS CAPPED THE MAXIMUM FAMILY CONTRIBUTION AT FOUR CHILDREN?
HOWEVER, WILL THE STATE BE PAYING THE PLANS AN INDIVIDUAL PREMIUM FOR EACH
WHERE THERE ARE MORE THAN FOUR CHILDREN IN THE FAMILY? WILL IT BE THE SAME
SUBSIDIZED PREMIUM AMOUNT AS THE OTHER CHILDREN OR WILL IT BE A HIGHER
AMOUNT THAT ADDS IN THE CONTRIBUTION THE FAMILY WOULD HAVE MADE IF THE
HOUSEHOLD HAD FOUR KIDS OR LESS?
The insurer will bill the State the total premium for all children that
are fully subsidized. However, for partially subsidized children, the
insurer will "net out" the monthly family contribution that is required
for each child from the total premium to arrive at the State share. In
those instances where more than four children from a partially subsidized
family are enrolled in a plan, there is no family contribution offset to
the total premium for the fifth or more child(ren).
A63. AT THE RATES TO BE AGE ADJUSTED IN ANY WAY?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 13
No, please refer to question #140 for additional information.
A64. CAN CONSULTANTS (ACTUARIES) NOT AFFILIATED WITH A PLAN RECEIVE COPIES OF
THE DATA?
Yes, it will be made available. Please call the Bureau of Health
Economics.
A65. CAN YOU PROVIDE A PHONE NUMBER FOR THE BUREAU OF HEALTH ECONOMICS?
As listed on page 41 of the RFP, the official phone for inquiries
regarding this RFP process is (518)486-7897.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 14
IV. ADDITIONAL QUESTIONS
(NOT READ AT BIDDER'S CONFERENCE)
A66. DOES NYHCRA ALLOW CHILD HEALTH PLUS PLANS THE ABILITY TO PAY MEDICAID DRGS
FOR INPATIENT CARE, OR MUST THE REIMBURSEMENT BE NEGOTIATED?
The New York State Health Care Reform Act of 1996 (HCRA of 1996) allows
any Child Health Plus insurer to negotiate an inpatient rate with
hospitals. The rate can be based on the DRG but that is between the Payer
and provider.
A67. CAN A HEALTH CARE PROVIDER PAY ALL OR PART OF A MEMBER'S PREMIUM ON THEIR
BEHALF TO ASSIST THEM IN REMAINING ENROLLED IN CHILD HEALTH PLUS?
The insurer will only bill the family for the family contribution of the
premium, not a third party. However, if someone chooses to pay the family
contribution on behalf of the family, that is permitted. If the "health
care provider" referenced in this question is the insurer, the insurer
does not have the option to waive the family contribution to the premium
as legislative intent was to have families contribute to the cost of the
premium.
A68. CAN AN INSURER CHOOSE TO COVER CHILDREN WITHIN THE <19 GROUP, I.E., 0-14
FOR EXAMPLE?
An insurer cannot choose to cover only a subset of the Child Health Plus
population of less than 19 year of age.
A69. IN APPENDIX L, BIDDER'S SUMMARY OF PROPOSAL, WHAT IS A CHARITY
REGISTRATION NUMBER? DOES THIS APPLY ONLY TO NOT-FOR-PROFITS?
Charitable organizations are required to be registered with the Secretary
of State pursuant to Article 7-A of the New York State Executive Law. The
charity registration number is proof that an organization has registered
with the Secretary of State.
A70. RELATED TO QUESTION 67 REGARDING CURRENT MEMBERS IN THE PROGRAM
TRANSITIONS TO THE EXPANDED PROGRAM, IF A MEMBER EITHER PAYS A PARTIAL OR
FULL PREMIUM, WILL THE AMOUNT THEY-PAID AT THE LAST RECERTIFICATION DATE
NEED TO BE CREDITED TO ANY REMAINING MONTHS NEW PREMIUM AMOUNTS, I.E.,
MEMBER PAYS $25 PER YEAR NOW. RECERTIFIED IN JANUARY AND PAID $25. AS OF
JULY, THEY NEED TO PAY $9 PER MONTH (OR $36 UNTIL THE END OF THE YEAR).
DOES THIS AMOUNT NEED TO BE ADJUSTED AGAINST THE $25 ALREADY PAID?
If the family requests a refund of any unused portion of the $25 annual
premium contribution, the plan must pay the refund. If the family and the
insurer wish to apply this to the newly required family contribution
rather than refund the unused portion, this can be done. However, the
insurer must document this in the enrollment file.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 15
A71. EQUIVALENT COVERAGE: PLEASE CONFIRM THAT ANY DIFFERENCE IN COVERAGE
BETWEEN CHILD HEALTH PLUS AND ANOTHER COVERAGE IS CONSIDERED
NON-EQUIVALENT COVERAGE DESPITE HOW SIMILAR THE TWO WOULD BE.
The current definition of equivalent coverage is stated in Child Health
Plus Advisory Memoranda A-12 found in Appendix B of the Request for
Proposals(RFP). A revised equivalent coverage policy will be formulated
prior to the implementation of the expanded program. It is anticipated
that under the expanded program, the current definition will merely be
expanded to include inpatient care.
A72. DO THE NYHCRA SURCHARGES AND/OR ASSESSMENTS APPLY TO THE CHILD HEALTH PLUS
PROGRAM?
The New York State Health Care Reform Act surcharges and/or assessments
currently apply to the Child Health Plus program.
A73. RFP ASKS FOR RESOURCES COMMITTED TO IMPLEMENT/OPERATE: IF PLAN ALREADY
OPERATIONAL, DO WE JUST STATE HUMAN RESOURCES CURRENTLY IN PLACE? IS THE
"MANAGEMENT TEAM" ALSO THE PERSONS RESPONSIBLE IN EACH DEPARTMENT?
If a plan is currently a Child Health Plus insurer, they can state that
the resources to operate the expanded program are in place. The
"management team" should be a list of the persons responsible in each
Department.
A74. WHAT FACTORS WILL BE EVALUATED IN DETERMINING THE EFFECTIVENESS OF PLANS
IN TARGETING MINORITY POPULATIONS?
As part of the response to the Request for Proposals, the bidder must
submit a general plan for marketing the program along with a description
of how community outreach and marketing activities will be conducted to
attract applicants. This should include a discussion of the strategies the
bidder will use to target minority populations in their service area. The
overall marketing plan will be evaluated as a component of the General
Technical Evaluation Criteria.
A75. A RECENT SURVEY WE CONDUCTED ON OUR CURRENT CHILD HEALTH PLUS ENROLLEES
REVEALED THAT MANY FAMILIES, ESPECIALLY THOSE WITH MORE THAN ONE CHILD,
WOULD NOT ENROLL IN THE NEW PROGRAM DUE TO THE REQUIRED PREMIUM
CONTRIBUTION. CLIENTS CURRENTLY ENROLLING IN OUR PLAN - PLUS THOSE WHO
WILL ENROLL BETWEEN NOW AND MAY 1ST - MAY ACCUSE US OF "BAIT AND SWITCH"
TECHNIQUES, I.E., WE "SELL" THEM A FREE PROGRAM, AND THEN CHANGE IT TO ONE
WITH A PREMIUM CONTRIBUTION REQUIREMENT. THIS SITUATION WILL CAST OUR PLAN
AND THE STATE IN A POOR LIGHT. WHAT IS THE STATE WILLING AND ABLE TO DO TO
ADDRESS, AVOID, AND/OR MINIMIZE THE POTENTIAL NEGATIVE CONSEQUENCES OF
THIS SITUATION?
The dollar amounts are defined by Statute.
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 16
A76. A RECENT SURVEY WE CONDUCTED OF OUR CHILD HEALTH PLUS SUBSCRIBERS REVEALED
EXTREME PRICE SENSITIVITY, I.E., OVER 50% OF RESPONDENTS INDICATED THEY
WOULD BE UNWILLING AND/OR UNABLE TO MAKE THE REQUIRED PREMIUM
CONTRIBUTIONS, AND, THEREFORE, WOULD NOT ENROLL THEIR CHILDREN. ONE
IMPLICATION OF THIS FUNDING IS POTENTIAL ADVERSE SELECTION. WILL THE STATE
FACTOR THIS INTO THE EVALUATION OF RATE FILLINGS?
The State will consider all supportable actuarial methods and assumptions
utilized in the rate making process as submitted by bidders.
A77. DOES THE STATE HAVE PARTICULAR REQUIREMENTS FOR CHILD HEALTH PLUS PROVIDER
CONTRACTS, AS IT DOES FOR MEDICAID MANAGED CARE? DO INSURERS HAVE TO
SUBMIT MODEL CONTRACTS TO SDOH FOR REVIEW AND APPROVAL?
There are no specific requirements for Child Health Plus provider
contracts other than those contract provisions that are otherwise required
of health plans (e.g. enrollee non liability language, access to medical
records etc.)
A78. CURRENT CHILD HEALTH PLUS INSURERS RECEIVED CONTRACT EXTENSIONS FROM JULY
1, 1996 THROUGH DECEMBER 31, 1996, WHEN WILL DOH ISSUE EXTENSIONS FOR THE
PERIOD OF JANUARY 1, 1997, JUNE 30, 1997
It is anticipated that DOH will issue contract extensions to current Child
Health Plus insurers within the next month. These extensions will be for
the period January 1, 1997 through September 30, 1997 to allow for
transition of current enrollees to the expanded program. If a current
insurer is selected to continue in the expanded program, the terms of the
new contract will supersede the extension.
A79. ARE THERE GUIDELINES RELATIVE TO THE RATIO BETWEEN PROVIDER SERVICES STAFF
AND ENROLLEES?
There are no guidelines relative to the ratio between provider services
staff and enrollees.
A80. SHOULD THE CHILD HEALTH PLUS PREMIUM RATE INCLUDE THE GME ADD ON?
The New York State Health Care Reform Act surcharges and/or assessments
currently apply to the Child Health Plus program.
A81. WHAT IS THE DEFINITION OF SCHOOL BASED HEALTH CENTER?
A school-based health center is a clinic established at a school site.
It's purpose is to provide convenient access to medical and/or behavioral
services to the children.
A82. HOW SHOULD OLDER CHILDREN LIVING ON THEIR OWN BE ENROLLED? WHAT SHOULD BE
USED AS INCOME VERIFICATION? CAN THE TEENS SIGN THEIR OWN APPLICATION?
WHAT WOULD THE INSURERS DO ABOUT PROOF OF RESIDENCY IN THE CASE OF
HOMELESS CHILDREN?
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 17
The issue of older children living on their own is currently under
investigation by the Department's Office of Counsel. A policy concerning
this issue and the related issues surrounding it will be issued prior to
implementation of the expanded program. With regard to the question of
proof of residency in the case of homeless children, legislation requires
proof of New York State residency. No specific provision is made for
homeless children.
A83. THE RFP STATES THAT ROUTINE OB/GYN VISITS WILL NOT BE COVERED. WILL THE
OB/GYN MANDATE REGARDING ANNUAL VISITS AND PAP SMEARS FOR WOMEN 18 YEARS
AND OVER BE COVERED?
Consistent with Insurance Law, a pelvic exam, pap smear and the laboratory
testing related to the pap smear must be offered as a routine, preventive
benefit for women 18 years and older. For females under age 18, this
service would be covered for purposes of diagnosis and treatment of
illness or injury. Pelvic exams and pap smears that are performed more
than once a year for diagnosis of illness or injury are also a covered
benefit. As stated in the American Academy of Pediatric Guidelines found
in Appendix E of the RFP, all sexually active patients should be screened
for sexually transmitted diseases and should have a pelvic exam.
A84. THE RFP STATES THAT ENROLLEES MUST PAY THEIR PREMIUM CONTRIBUTION MONTHLY,
AND THAT THEY WILL BE ALLOWED A 30 DAY GRACE PERIOD. ENROLLEES WHO HAVE
NOT PAID THEIR CONTRIBUTION WITHIN THIS TIME WILL BE RETROACTIVELY
DISENROLLED. RETROACTIVE DISENROLLMENT PRESENTS SEVERAL ISSUES, FOR
EXAMPLE, WHAT WILL INSURERS BE REQUIRED TO DO IN THE EVENT THAT THEY
RECEIVE CLAIMS FOR THIS PERIOD?
The RFP states that family contributions to premium must be paid 30 days
in advance of the period of coverage. However, the insurer may allow the
family an additional 30 days to submit payment before disenrolling the
child from the program. Family contributions are due in advance to avoid
retroactive disenrollment as retroactive enrollment and disenrollment is
not permitted under this program.
A85. WE WOULD LIKE TO BE ABLE TO PROVIDE CONTINUOUS COVERAGE VIA CHILD HEALTH
PLUS TO THOSE TERMINATING FROM MEDICALID DUE TO LOSS OF ELIGIBILITY DUE TO
INCOME REASONS. WHAT PRELIMINARY INFORMATION WOULD BE REQUIRED FOR
PRESUMPTIVE ELIGIBILITY AND IN WHAT TIME FRAME IF WE ARE TO TRY TO AVOID
ANY GAPS IN MEMBERSHIP? WOULD THE PREMIUM PAYMENT ALSO BE REQUIRED AT THE
TIME OF APPLICATION?
To be deemed presumptively eligible under Child Health Plus, a family must
submit a completed, signed enrollment application to a participating
insurer. The insurer must determine that the applicant appears to meet all
eligibility requirements but lacks the documentation necessary to support
the application. Plans will enroll children based on their internal
processing cut-off dates. Enrollment will be for the first day of the
month with no retroactive enrollment permitted. The first month's family
premium contribution is required prior to enrollment. If an individual
submits an application to Child Health Plus knowing they will be
disenrolled from Medicaid at a point during that month, the child can
CHILD HEALTH PLUS INSURANCE PLAN RFP
ADDITIONAL QUESTIONS AND ANSWERS PAGE 18
apply to Child Health Plus in advance of the disenrollment. For example,
if a child is due to be disenrolled from Medicaid for the 15th of a
particular month, the child can apply in advance for Child Health Plus and
can enroll for the first day of the month if the application is completed
and any required family contribution is paid prior to the insurer's
internal processing schedule to avoid a lapse in coverage.
A86. CONVERSELY, WHAT ACTIONS CAN BE TAKEN TO ELIMINATE ANY GAPS IN COVERAGE
FOR A CHILD HEALTH PLUS MEMBER WHO IS APPLYING FOR MEDICAID? THERE IS
USUALLY A GAP OF TIME BETWEEN WHEN THE RECIPIENT IS EFFECTIVE FOR MEDICAID
AND WHEN THEY CAN BE ENROLLED IN A PLAN.
If a Child Health Plus member applies for Medicaid, there will not be a
gap in coverage as the member would not be disenrolled from Child Health
Plus until after they are enrolled in Medicaid. The enrollee would also be
retroactively enrolled in Medicaid back to the date of application.
A87. THE INCOME TABLES START WITH A HOUSEHOLD OF ONE. IS IT TO BE ASSUMED THAT
THE NUMBER IN THE HOUSEHOLD REFERS TO THE NUMBER OF CHILDREN AND NO ADULTS
ARE TO BE COUNTED?
Income guidelines are based on the family's gross household income. The
number in the household refers to both the number of children and the
number of adults residing in the households.
A88. SHOULD A NEW HOUSEHOLD BUDGET BE CALCULATED FOR A PREGNANT TEEN BASED ON
THE UNBORN AND HER FINANCIAL RESPONSIBILITY FOR IT. THAT IS, IF SHE
CHOOSES NOT TO APPLY FOR MEDICAID?
No, a household budget should not be calculated for a pregnant teen which
includes an unborn child.
[DOH LOGO] STATE OF NEW YORK
DEPARTMENT OF HEALTH
Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza
Albany, New York 12237
Antonia C. Novello, M.D., M.P.H., Dr.P.H. Dennis P. Whalen
Commissioner Executive Deputy Commissioner
DATE: Aug. 10, 2004
CONTRACT #: C014386
CONTRACTOR: WELLCARE OF NEW YORK, INC.
CONTRACT PERIOD: Oct. 01, 1997 - Dec. 31, 2004
Attached is your copy of the approved contract. The Contract number must
appear on all vouchers and correspondence.
Reports of the Expenditures and Budget Statements should be submitted as
outlined in the Contract.
In accordance with the contract, properly completed vouchers and/or
programmatic questions should be addressed to the State's designated payment
office as stated in the Contract.
Failure of the contracting Agency to comply with payment provisions as set
forth in the approved Contract may result in non-payment.
An additional supply of vouchers to be used in submitting claims may be
obtained by written request from the Office of the State Comptroller, Supply
Room, 110 State Street, 2nd Floor, Albany, New York 12236.
New York State Department of Health
Contract Unit
Page 2
Please note the following new information regarding payments:
OSC now offers Electronic Payments. Payments formerly made by
check can be made by electronic funds transfer through the
Automated Clearinghouse (ACH) network, and with OSC optional
e-mail notification service, you will receive advance notice
of your electronic payments. Additional information is
available on-line at http://www.osc.state.ay.us/epay/how.htm
or by calling 518-474-4032.
STATE OF NEW YORK
AGREEMENT
Section I.B.1. is revised to read as follows:
I. Conditions of Agreement
B.1. This AGREEMENT is extended through December 31, 2004.
APPENDIX E
FINANCIAL INFORMATION
Sections A is revised to read as follows:
A. WellCare of New York, Inc. shall receive, for the period July 1, 2004
through December 31, 2004 an amount up to, but not to exceed, $ 5,900,000.00 to
provide and administer a Child Health Plus program for uninsured children in the
counties identified in Appendix A-2, Section II.B.1 of this AGREEMENT or as
modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting
the responsibilities provided in this AGREEMENT.
Additional Premium Information:
For Columbia, Greene, Albany:
The total monthly premium shall be: $ 96.63
The State share of the total monthly premium shall be $ 96.63 or the total
monthly premium for children in families with gross household income less
than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives (AI/AN).
The State share of the total monthly premium shall be $ 87.63 or the total
monthly premium minus $9 for children in families with gross household
income between 160% and 222% of the federal poverty level with a maximum
of $27 per month per family. The State share is the total monthly premium
less $9 for each of the first three children. For additional children, the
State share is the total monthly premium.
The State share of the total monthly premium shall be $ 81.63 or the total
monthly premium minus $15 for children in families with gross household
income between 223% and 250% of the federal poverty level with a maximum
of $45 per month per family. The State share is the total monthly premium
less $15 for each of the first three children. For additional children,
the State share is the total monthly premium.
For Rensselaer:
The total monthly premium shall be: $ 95.93
The State share of the total monthly premium shall be $ 95.93 or the total
monthly premium for children in families with gross household income less
than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives- AI/AN.
The State share of the total monthly premium shall be $ 86.93 or the total
monthly
premium minus $9 for children in families with gross household income
between 160% and 222% of the federal poverty level with a maximum of $27
per month per family. The State share is the total monthly premium less $9
for each of the first three children. For additional children, the State
share is the total monthly premium.
The State share of the total monthly premium shall be $ 80.93 or the total
monthly premium minus $15 for children in families with gross household
income between 223% and 250% of the federal poverty level with a maximum
of $45 per month per family. The State share is the total monthly premium
less $15 for each of the first three children. For additional children,
the State share is the total monthly premium.
For Bronx, Kings, New York, Queens:
The total monthly premium shall be: $ 20.84
The State share of the total monthly premium shall be $ 120.84 or the
total monthly premium for children in families with gross household income
less than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives (AI/AN).
The State share of the total monthly premium shall be $ 111.84 or the
total monthly premium minus $9 for children in families with gross
household income between 160% and 222% of the federal poverty level with a
maximum of $27 per month per family. The State share is the total monthly
premium less $9 for each of the first three children. For additional
children, the State share is the total monthly premium.
The State share of the total monthly premium shall be $ 105.84 or the
total monthly premium minus $15 for children in families with gross
household income between 223% and 250% of the federal poverty level with a
maximum of $45 per month per family. The State share is the total monthly
premium less $15 for each of the first three children. For additional
children, the State share is the total monthly premium.
For Dutchess, Orange, Rockland, Ulster, Sullivan:
The total monthly premium shall be: $ 97.62
The State share of the total monthly premium shall be $ 97.62 or the total
monthly premium for children in families with gross household income less
than 160% of the federal poverty level and children who are American
Indians or Alaskan Natives (AI/AN).
The State share of the total monthly premium shall be $ 88.62 or the total
monthly premium minus $9 for children in families with gross household
income between 160%
and 222% of the federal poverty level with a maximum of $27 per month per
family. The State share is the total monthly premium less $9 for each of
the first three children. For additional children, the State share is the
total monthly premium.
The State share of the total monthly premium shall be $ 82.62 or the total
monthly premium minus $15 for children in families with gross household
income between 223% and 250% of the federal poverty level with a maximum
of $45 per month per family. The State share is the total monthly premium
less $15 for each of the first three children. For additional children,
the State share is the total monthly premium.
In the absence of an approved premium modification by the Department of
Health and State Insurance Department, the premium above or subsequent premium
approved (whichever is in effect) shall continue as the State's subsidy through
December 31, 2004.
Appendix L
PRIVACY AND CONFIDENTIALITY
Section II is revised as follows:
II. Effective April 14, 2003, the CONTRACTOR shall comply with the
following agreement:
Federal Health Insurance Portability and Accountability Act (HIPAA)
Business Associate Agreement ("Agreement")
This Business Associate Agreement between the New York State Department of
Health and Wellcare of New York, Inc., hereinafter referred to as the Business
Associate, is effective on April 14, 2003 to December 31, 2004.
APPENDIX X
AGENCY CODE 12000 CONTRACT NO. C-014386
PERIOD 10/1/1997 TO 12/31/04 FUNDING AMOUNT FOR PERIOD $71,010,771.00
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department of Health, having its principal office at Corning Tower, Empire State
Plaza, Albany, NY, (hereinafter referred to as the STATE), and WELLCARE OF NEW
YORK, INC. hereinafter referred to as the CONTRACTOR), for modification of
Contract Number C-014386 as reflected in the attached provisions to Section
I.B.I. of the Agreement and Appendices E and L, and to extend the period of the
contract through December 31, 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/ Judith Arnold
----------------------------- -----------------------------
Todd S. Farha Judith Arnold
----------------------------- -----------------------------
Printed Name Printed Name
Title: President & Chief Title: Deputy Commissioner
Executive Officer Division of Planning,
Policy, and Resource
Development
Date: June 3, 2004 Date: 6/7/04
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 FLORIDA ) SS.:
)
County of Hillsborough )
On the 3rd day of June 2004, before me personally appeared Jodd S. Farha, to me
known, who being by me duly sworn, did depose and say that he resides at
[ILLEGIBLE], Florida, that he is the President & CEO of the [ILLEGIBLE] the
corporation described herein which executed the foregoing instrument; and that
he signed his name thereto by order of the board of directors of said
corporation.
(Notary) Kathleen R. Casey
STATE COMPTROLLER SIGNATURE [SEAL]
_________________________________ Title: ______________________________
Date: _______________________________
[APPROVED
DEPT. OF AUDIT & CONTROL
AUG 04 2004
ILLEGIBLE]