Exhibit 10.50.1
MEDICAID MANAGED CARE
AND FAMILY HEALTH PLUS
MODEL CONTRACT
October 1, 2005
AGREEMENT BETWEEN
The City of New York
And
CarePlus, L.L.C.
This Agreement is made by and between
The City of New York
Acting through,
Department of Health and Mental Hygiene ["DOHMH"]
Located at
161 William Street, 5th floor
New York, NY 10038
And
CarePlus, L.L.C.
Located At
360 West 31st Street, Fifth Floor
New York, NY 10001
RECITALS
October 1, 2005
Page 1 of 2
STATE OF NEW YORK
MEDICAID AND FAMILY HEALTH PLUS
PARTICIPATING MANAGED CARE PLAN AGREEMENT
This AGREEMENT is hereby made by and between the New York City Department of
Health and Mental Hygiene (DOHMH) and CarePlus, L.L.C. located at: 360 West 31st
Street, Fifth Floor, New York, NY 10001.
RECITALS
WHEREAS, pursuant to Title XIX of the Federal Social Security Act, codified
as 42 U.S.C. Section 1396 et seq. (the Social Security Act), and Title 11 of
Article 5 of the New York State Social Services Law (SSL), a comprehensive
program of medical assistance for needy persons exists in the State of New York
(Medicaid); and
WHEREAS, pursuant to Title 11 of Article 5 of the SSL, the Commissioner of
Health has established a managed care program under the medical assistance
program, known as the Medicaid Managed Care (MMC) Program; and
WHEREAS, pursuant to Title 11-D of Article 5 of the SSL, a health insurance
program known as Family Health Plus (FHPlus) has been created for Eligible
Persons who do not qualify for Medicaid; and
WHEREAS, organizations certified under Article 44 of the New York State
Public Health Law (PHL) are eligible to provide comprehensive health services
through comprehensive health services plans to Eligible Persons as defined in
Titles 11 and 11-D of the SSL, MMC and FHPlus Programs, respectively; and
WHEREAS, the Contractor is organized under the laws of New York State and
is certified under Article 44 of the PHL and has offered to provide covered
health services to Eligible Persons residing in the geographic area specified in
Appendix M of this Agreement (Service Area, Benefit Package Options, and
Enrollment Elections); and
WHEREAS, the SDOH and DOHMH have determined that the Contractor meets the
qualifications established for participation in the MMC Program or the FHPlus
Program or both to provide the applicable health care coverage to Eligible
Persons in the geographic area specified in Appendix M of this Agreement; and
WHEREAS, Chapter 364-j(5)(d) of the SSL authorizes the local department of
social services in a city with a population of over two million to contract with
managed care providers who meet the qualifications for participation in the MMC
Program and since in the City of New York such authority has been delegated to
the DOHMH;
NOW THEREFORE, the parties agree as follows:
RECITALS
October 1, 2005
Page 2 of 2
TABLE OF CONTENTS FOR MODEL CONTRACT
Recitals
Section 1 Definitions
Section 2 Agreement Term, Amendments, Extensions, and General Contract
Administration Provisions
2.1 Term
2.2 Amendments
2.3 Approvals
2.4 Entire Agreement
2.5 Renegotiation
2.6 Assignment and Subcontracting
2.7 Termination
a. DOHMH Initiated Termination
b. Contractor and DOHMH Initiated Termination
c. Contractor Initiated Termination
d. Termination Due to Loss of Funding
2.8 Close-Out Procedures
2.9 Rights and Remedies
2.10 Notices
2.11 Severability
Section 3 Compensation
3.1 Capitation Payments
3.2 Modification of Rates During Contract Period
3.3 Rate Setting Methodology
3.4 Payment of Capitation
3.5 Denial of Capitation Payments
3.6 SDOH Right to Recover Premiums
3.7 Third Party Health Insurance Determination
3.8 Payment for Newborns
3.9 Supplemental Maternity Capitation Payment
3.10 Contractor Financial Liability
3.11 Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care
(MMC) Enrollees
3.12 Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees
3.13 Residential Health Care Facility Stop-Loss for MMC Enrollees
3.14 Stop-Loss Documentation and Procedures for the MMC Program
3.15 Family Health Plus (FHPlus) Reinsurance
3.16 Tracking Visits Provided by Indian Health Clinics - Applies to MMC
Program Only
Section 4 Service Area
Section 5 Reserved
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Section 6 Enrollment
6.1 Populations Eligible for Enrollment
6.2 Enrollment Requirements
6.3 Equality of Access to Enrollment
6.4 Enrollment Decisions
6.5 Auto Assignment - For MMC Program Only
6.6 Prohibition Against Conditions on Enrollment
6.7 Newborn Enrollment
6.8 Effective Date of Enrollment
6.9 Roster
6.10 Automatic Re-Enrollment
Section 7 Lock-In Provisions
7.1 Lock-In Provisions in MMC Mandatory Local Social Services Districts
and for Family Health Plus
7.2 Disenrollment During a Lock-In Period
7.3 Notification Regarding Lock-In and End of Lock-In Period
7.4 Lock-In and Change in Eligibility Status
Section 8 Disenrollment
8.1 Disenrollment Requirements
8.2 Disenrollment Prohibitions
8.3 Disenrollment Requests
a. Routine Disenrollment Requests
b. Non-Routine Disenrollment Requests
8.4 Contractor Notification of Disenrollments
8.5 Contractor's Liability
8.6 Enrollee Initiated Disenrollment
8.7 Contractor Initiated Disenrollment
8.8 LDSS Initiated Disenrollment
Section 9 Guaranteed Eligibility
9.1 General Requirements
9.2 Right to Guaranteed Eligibility
9.3 Covered Services During Guaranteed Eligibility
9.4 Disenrollment During Guaranteed Eligibility
Section 10 Benefit Package Requirements
10.1 Contractor Responsibilities
10.2 Compliance with State Medicaid Plan and Applicable Laws
10.3 Definitions
10.4 Child Teen Health Program/Adolescent Preventive Services
10.5 Foster Care Children - Applies to MMC Program Only
10.6 Child Protective Services
10.7 Welfare Reform - Applies to MMC Program Only
10.8 Adult Protective Services
10.9 Court-Ordered Services
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10.10 Family Planning and Reproductive Health Services
10.11 Prenatal Care
10.12 Direct Access
10.13 Emergency Services
10.14 Medicaid Utilization Thresholds (MUTS)
10.15 Services for Which Enrollees Can Self-Refer
a. Mental Health and Chemical Dependence Services
b. Vision Services
c. Diagnosis and Treatment of Tuberculosis
d. Family Planning and Reproductive Health Services
e. Article 28 Clinics Operated by Academic Dental Centers
10.16 Second Opinions for Medical or Surgical Care
10.17 Coordination with Local Public Health Agencies
10.18 Public Health Services
a. Tuberculosis Screening, Diagnosis and Treatment; Directly Observed
Therapy (TB/DOT)
b. Immunizations
c. Prevention and Treatment of Sexually Transmitted Diseases
d. Lead Poisoning - Applies to MMC Program Only
10.19 Adults with Chronic Illnesses and Physical or Developmental Disabilities
10.20 Children with Special Health Care Needs
10.21 Persons Requiring Ongoing Mental Health Services
10.22 Member Needs Relating to HIV
10.23 Persons Requiring Chemical Dependence Services
10.24 Native Americans
10.25 Women, Infants, and Children (WIC)
10.26 Urgently Needed Services
10.27 Dental Services Provided by Article 28 Clinics Operated by Academic
Dental Centers Not Participating in Contractor's Network- Applies to
MMC Program Only
10.28 Hospice Services
10.29 Prospective Benefit Package Change for Retroactive SSI
Determinations - Applies to MMC Program Only
10.30 Coordination of Services
Section 11 Marketing
11.1 Information Requirements
11.2 Marketing Plan
11.3 Marketing Activities
11.4 Prior Approval of Marketing Materials and Procedures
11.5 Corrective and Remedial Actions
Section 12 Member Services
12.1 General Functions
12.2 Translation and Oral Interpretation
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
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Section 13 Enrollee Rights and Notification
13.1 Information Requirements
13.2 Provider Directories/Office Hours for Participating Providers
13.3 Member ID Cards
13.4 Member Handbooks
13.5 Notification of Effective Date of Enrollment
13.6 Notification of Enrollee Rights
13.7 Enrollee's Rights
13.8 Approval of Written Notices
13.9 Contractor's Duty to Report Lack of Contact
13.10 LDSS Notification of Enrollee's Change in Address
13.11 Contractor Responsibility to Notify Enrollee of Effective Date of
Benefit Package Change
13.12 Contractor Responsibility to Notify Enrollee of Termination, Service
Area Changes and Network Changes
Section 14 Action and Grievance System
14.1 General Requirements
14.2 Actions
14.3 Grievance System
14.4 Notification of Action and Grievance System Procedures
14.5 Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
Section 15 Access Requirements
15.1 General Requirement
15.2 Appointment Availability Standards
15.3 Twenty-Four (24) Hour Access
15.4 Appointment Waiting Times
15.5 Travel Time Standards
15.6 Service Continuation
a. New Enrollees
b. Enrollees Whose Health Care Provider Leaves Network
15.7 Standing Referrals
15.8 Specialist as a Coordinator of Primary Care
15.9 Specialty Care Centers
15.10 Cultural Competence
Section 16 Quality Management
16.1 Internal Quality Management Program
16.2 Standards of Care
Section 17 Monitoring and Evaluation
17.1 Right To Monitor Contractor Performance
17.2 Cooperation During Monitoring And Evaluation
17.3 Cooperation During On-Site Reviews
17.4 Cooperation During Review of Services by External Review Agency
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Section 18 Contractor Reporting Requirements
18.1 General Requirements
18.2 Time Frames for Report Submissions
18.3 SDOH Instructions for Report Submissions
18.4 Liquidated Damages
18.5 Notification of Changes in Report Due Dates, Requirements or Formats
18.6 Reporting Requirements
18.7 Ownership and Related Information Disclosure
18.8 Public Access to Reports
18.9 Professional Discipline
18.10 Certification Regarding Individuals Who Have Been Debarred or
Suspended by Federal or State Government
18.11 Conflict of Interest Disclosure
18.12 Physician Incentive Plan Reporting
Section 19 Records Maintenance and Audit Rights
19.1 Maintenance of Contractor Performance Records
19.2 Maintenance of Financial Records and Statistical Data
19.3 Access to Contractor Records
19.4 Retention Periods
Section 20 Confidentiality
20.1 Confidentiality of Identifying Information about Enrollees, Potential
Enrollees, and Prospective Enrollees
20.2 Medical Records of Foster Children
20.3 Confidentiality of Medical Records
20.4 Length of Confidentiality Requirements
Section 21 Provider Network
21.1 Network Requirements
21.2 Absence of Appropriate Network Provider
21.3 Suspension of Enrollee Assignments to Providers
21.4 Credentialing
21.5 SDOH Exclusion or Termination of Providers
21.6 Application Procedure
21.7 Evaluation Information
21.8 Choice/Assignment of Primary Care Providers (PCPs)
21.9 Enrollee PCP Changes
21.10 Provider Status Changes
21.11 PCP Responsibilities
21.12 Member to Provider Ratios
21.13 Minimum PCP Office Hours
a. General Requirements
b. Waiver of Minimum Hours
21.14 Primary Care Practitioners
a. General Limitations
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b. Specialists and Sub-specialists as PCPs
c. OB/GYN Providers as PCPs
d. Certified Nurse Practitioners as PCPs
21.15 PCP Teams
a. General Requirements
b. Registered Physician Assistants as Physician Extenders
c. Medical Residents and Fellows
21.16 Hospitals
a. Tertiary Services
b. Emergency Services
21.17 Dental Networks
21.18 Presumptive Eligibility Providers
21.19 Mental Health and Chemical Dependence Services Providers
21.20 Laboratory Procedures
21.21 Federally Qualified Health Centers (FQHCs)
21.22 Provider Services Function
21.23 Pharmacies - Applies to FHPlus Program Only
Section 22 Subcontracts and Provider Agreements
22.1 Written Subcontracts
22.2 Permissible Subcontracts
22.3 Provision of Services Through Provider Agreements
22.4 Approvals
22.5 Required Components
22.6 Timely Payment
22.7 Restrictions on Disclosure
22.8 Transfer of Liability
22.9 Termination of Health Care Professional Agreements
22.10 Health Care Professional Hearings
22.11 Non-Renewal of Provider Agreements
22.12 Notice of Participating Provider Termination
22.13 Physician Incentive Plan
Section 23 Fraud and Abuse
23.1 General Requirements
23.2 Prevention Plans and Special Investigation Units
Section 24 Americans With Disabilities Act (ADA) Compliance Plan
Section 25 Fair Hearings
25.1 Enrollee Access to Fair Hearing Process
25.2 Enrollee Rights to a Fair Hearing
25.3 Contractor Notice to Enrollees
25.4 Aid Continuing
25.5 Responsibilities of SDOH
25.6 Contractor's Obligations
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Section 26 External Appeal
26.1 Basis for External Appeal
26.2 Eligibility For External Appeal
26.3 External Appeal Determination
26.4 Compliance With External Appeal Laws and Regulations
26.5 Member Handbook
Section 27 Intermediate Sanctions
27.1 General
27.2 Unacceptable Practices
27.3 Intermediate Sanctions
27.4 Enrollment Limitations
27.5 Due Process
Section 28 Environmental Compliance
Section 29 Energy Conservation
Section 30 Independent Capacity of Contractor
Section 31 No Third Party Beneficiaries
Section 32 Indemnification
32.1 Indemnification by Contractor
32.2 Indemnification by DOHMH
Section 33 Prohibition on Use of Federal Funds for Lobbying
33.1 Prohibition of Use of Federal Funds for Lobbying
33.2 Disclosure Form to Report Lobbying
33.3 Requirements of Subcontractors
Section 34 Non-Discrimination
34.1 Equal Access to Benefit Package
34.2 Non-Discrimination
34.3 Equal Employment Opportunity
34.4 Native Americans Access to Services From Tribal or Urban Indian
Health Facility
Section 35 Compliance with Applicable Laws
35.1 Contractor and DOHMH Compliance With Applicable Laws
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void
Contract Provisions
35.3 Certificate of Authority Requirements
35.4 Notification of Changes In Certificate of Incorporation
35.5 Contractor's Financial Solvency Requirements
35.6 Compliance With Care For Maternity Patients
35.7 Informed Consent Procedures for Hysterectomy and Sterilization
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35.8 Non-Liability of Enrollees For Contractor's Debts
35.9 DOHMH Compliance With Conflict of Interest Laws
35.10 Compliance With New York State Public Health Law (PHL) Regarding
External Appeals
Section 36 New York State Standard Contract Clauses and Local Standard Clauses
Signature Page
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APPENDICES
A. New York State Standard Clauses
B. Certification Regarding Lobbying
C. New York State Department of Health Requirements for the Provision of
Family Planning and Reproductive Health Services
D. New York State Department of Health Marketing Guidelines
E. New York State Department of Health Member Handbook Guidelines
F. New York State Department of Health Action and Grievance System
Requirements for the MMC and FHPlus Programs
G. New York State Department of Health Requirements for the Provision of
Emergency Care and Services
H. New York State Department of Health Requirements for the Processing of
Enrollments and Disenrollments in the MMC and FHPlus Programs
I. New York State Department of Health Guidelines for Use of Medical Residents
and Fellows
J. New York State Department of Health Guidelines for Contractor Compliance
with the Federal ADA
K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services
L. Approved Capitation Payment Rates
M. Service Area, Benefit Options and Enrollment Elections
N. New York City Specific Contracting Requirements
O. Requirements for Proof of Workers' Compensation and Disability Benefits
Coverage
P. RESERVED
Q. RESERVED
R. New York City Standard Local Clauses
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1. DEFINITIONS
"AUTO-ASSIGNMENT" means a process by which an MMC Eligible Person, as this
term is defined in this Agreement, who is mandated to enroll in the MMC
Program, but who has not selected and enrolled in an MCO within sixty (60)
days of receipt of the mandatory notice sent by the LDSS, is assigned to an
MCO offering an MMC product in the MMC Eligible Person's county of fiscal
responsibility in accordance with the auto-assignment algorithm determined
by the SDOH.
"BEHAVIORAL HEALTH SERVICES" means services to address mental health
disorders and/or chemical dependence.
"BENEFIT PACKAGE" means the covered services for the MMC and/or FHPlus
Programs, described in Appendix K of this Agreement, to be provided to the
Enrollee, as Enrollee is defined in this Agreement, by or through the
Contractor, including optional Benefit Package services, if any, as
specified in Appendix M of this Agreement.
"CAPITATION RATE" means the fixed monthly amount that the Contractor
receives for an Enrollee to provide that Enrollee with the Benefit Package.
"CHEMICAL DEPENDENCE SERVICES" means examination, diagnosis, level of care
determination, treatment, rehabilitation, or habilitation of persons
suffering from chemical abuse or dependence, and includes the provision of
alcohol and/or substance abuse services.
"CHILD/TEEN HEALTH PROGRAM" OR "C/THP" means the program of early and
periodic screening, including inter-periodic, diagnostic and treatment
services (EPSDT) that New York State offers all Eligible Persons under
twenty-one (21) years of age. Care and services are provided in accordance
with the periodicity schedule and guidelines developed by the New York
State Department of Health. The services include administrative services
designed to help families obtain services for children including outreach,
information, appointment scheduling, administrative case management and
transportation assistance, to the extent that transportation is included in
the Benefit Package.
"COMPREHENSIVE HIV SPECIAL NEEDS PLAN" OR "HIV SNP" means an MCO certified
pursuant to Section forty-four hundred three-c (4403-c) of Article 44 of
the PHL which, in addition to providing or arranging for the provision of
comprehensive health services on a capitated basis, including those for
which Medical Assistance payment is authorized pursuant to Section three
hundred sixty-five-a (365-a) of the SSL, also provides or arranges for the
provision of specialized HIV care to HIV positive persons eligible to
receive benefits under Title XIX of the federal Social Security Act or
other public programs.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-1
"COURT-ORDERED SERVICES" means those services that the Contractor is
required to provide to Enrollees pursuant to orders of courts of competent
jurisdiction, provided however, that such ordered services are within the
Contractor's Benefit Package and reimbursable under Title XIX of the
Federal Social Security Act (SSA), SSL Section 364-j(4)(r).
"DAYS" means calendar days except as otherwise stated.
"DESIGNATED THIRD PARTY CONTRACTOR" means an MCO with which the SDOH has
contracted to provide Family Planning and Reproductive Health Services for
FHPlus Enrollees of a MCO that does not include such services in its
Benefit Package.
"DETOXIFICATION SERVICES" means Medically Managed Detoxification Services
and Medically Supervised Inpatient and Outpatient Withdrawal Services as
defined in Appendix K of this Agreement.
"DISENROLLMENT" means the process by which an Enrollee's membership in the
Contractor's MMC or FHPlus product terminates.
"EFFECTIVE DATE OF DISENROLLMENT" means the date on which an Enrollee may
no longer receive services from the Contractor, pursuant to Section 8.5
and Appendix H of this Agreement.
"EFFECTIVE DATE OF ENROLLMENT" means the date on which an Enrollee may
begin to receive services from the Contractor, pursuant to Section 6.8(e)
and Appendix H of this Agreement.
"ELIGIBLE PERSON" means either an MMC Eligible Person or a FHPlus Eligible
Person as these terms are defined in this Agreement.
"EMEDNY" means the electronic Medicaid system of New York State for
eligibility verification and Medicaid provider claim submission and
payments.
"EMERGENCY MEDICAL CONDITION" means a medical or behavioral condition, the
onset of which is sudden, that manifests itself by symptoms of sufficient
severity, including severe pain, that a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the
absence of immediate medical attention to result in: (i) placing the health
of the person afflicted with such condition in serious jeopardy, or in the
case of a pregnant woman, the health of the woman or her unborn child or,
in the case of a behavioral condition, placing the health of the person or
others in serious jeopardy; or (ii) serious impairment to such person's
bodily functions; or (iii) serious dysfunction of any bodily organ or part
of such person; or (iv) serious disfigurement of such person.
"EMERGENCY SERVICES" means health care procedures, treatments or services
needed to evaluate or stabilize an Emergency Medical Condition including
psychiatric stabilization and medical detoxification from drugs or alcohol.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-2
"ENROLLEE" means either an MMC Enrollee or FHPlus Enrollee as these terms
are defined in this Agreement.
"ENROLLMENT" means the process by which an Enrollee's membership in the
Contractor's MMC or FHPlus product begins.
"ENROLLMENT BROKER" means the state and/or county-contracted entity that
provides Enrollment, education, and outreach services to Eligible Persons;
effectuates Enrollments and Disenrollments in MMC and FHPlus; and provides
other contracted services on behalf of the SDOH and the LDSS.
"ENROLLMENT FACILITATOR" means an entity under contract with SDOH, and its
agents, that assists children and adults to complete the Medicaid, Family
Health Plus, Child Health Plus, Special Supplemental Food Program for WIC,
and Prenatal Care Assistance Program (PCAP) application and the enrollment
and recertification processes, to the extent permitted by federal and state
law and regulation. This includes assisting individuals in completing the
required application form, conducting the face-to-face interview, assisting
in the collection of required documentation, assisting in the MCO selection
process, and referring individuals to WIC or other appropriate sites.
"EXPERIENCED HIV PROVIDER" means an entity grant-funded by the SDOH AIDS
Institute to provide clinical and/or supportive services or an entity
licensed or certified by the SDOH to provide HIV/AIDS services.
"FACILITATED ENROLLMENT" means the enrollment infrastructure established by
SDOH to assist children and adults in applying for Medicaid, Family Health
Plus, Child Health Plus, WIC, or PCAP using a joint application, and
recertifying for these programs, as allowed by federal and state law and
regulation.
"FAMILY HEALTH PLUS" OR "FHPLUS" means the health insurance program
established under Title 11-D of Article 5 of the SSL.
"FHPLUS ELIGIBLE PERSON" means a person whom the LDSS, state or federal
government determines to have met the qualifications established in state
or federal law necessary to receive FHPlus benefits under Title 11-D of the
SSL and who meets all the other conditions for enrollment in the FHPlus
Program.
"FHPLUS ENROLLEE" means a FHPlus Eligible Person who either personally or
through an authorized representative, has enrolled in the Contractor's
FHPlus product.
"FISCAL AGENT" means the entity that processes or pays vendor claims on
behalf of the Medicaid state agency pursuant to an agreement between the
entity and such agency.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-3
"GUARANTEED ELIGIBILITY" means the period beginning on the Enrollee's
Effective Date of Enrollment with the Contractor and ending six (6) months
thereafter, during which the Enrollee may be entitled to continued
Enrollment in the Contractor's MMC or FHPlus product, as applicable,
despite the loss of eligibility as set forth in Section 9 of this
Agreement.
"HEALTH PROVIDER NETWORK" OR "HPN" means a closed communication network
dedicated to secure data exchange and distribution of health related
information between various health facility providers and the SDOH. HPN
functions include: collection of Complaint and Disenrollment information;
collection of financial reports; collection and reporting of managed care
provider networks systems (PNS); and the reporting of encounter data
systems (MEDS).
"HIV SPECIALIST PCP" means a Primary Care Provider that meets the
qualifications for HIV Specialist as defined by the Medical Care Criteria
Committee of the SDOH AIDS Institute.
"INPATIENT STAY PENDING ALTERNATE LEVEL OF MEDICAL CARE" means continued
care in a hospital pending placement in an alternate lower medical level of
care, consistent with the provisions of 18 NYCRR Section 505.20 and 10
NYCRR Part 85.
"INSTITUTION FOR MENTAL DISEASE" OR "IMD" means a hospital, nursing
facility, or other institution of more than sixteen (16) beds that is
primarily engaged in providing diagnosis, treatment or care of persons with
mental diseases, including medical attention, nursing care and related
services. Whether an institution is an Institution for Mental Disease is
determined by its overall character as that of a facility established and
maintained primarily for the care and treatment of individuals with mental
diseases, whether or not it is licensed as such. An institution for the
mentally retarded is not an Institution for Mental Disease.
"LOCAL PUBLIC HEALTH AGENCY" OR "LPHA" means the city or county government
agency responsible for monitoring the population's health, promoting the
health and safety of the public, delivering public health services and
intervening when necessary to protect the health and safety of the public.
"LOCAL DEPARTMENT OF SOCIAL SERVICES" OR "LDSS" means a city or county
social services district as constituted by Section 61 of the SSL.
"LOCK-IN PERIOD" means the period of time during which an Enrollee may not
change MCOs, unless the Enrollee can demonstrate Good Cause as established
in state law and specified in Appendix H of this Agreement.
"MANAGED CARE ORGANIZATION" OR "MCO" means a health maintenance
organization ("HMO") or prepaid health service plan ("PHSP") certified
under Article 44 of the PHL.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-4
"MARKETING" means any activity of the Contractor, subcontractor or
individuals or entities affiliated with the Contractor by which information
about the Contractor is made known to Eligible Persons or Prospective
Enrollees for the purpose of persuading such persons to enroll with the
Contractor.
"MARKETING REPRESENTATIVE" means any individual or entity engaged by the
Contractor to market on behalf of the Contractor.
"MEDICAL RECORD" means a complete record of care rendered by a provider
documenting the care rendered to the Enrollee, including inpatient,
outpatient, and emergency care, in accordance with all applicable federal,
state and local laws, rules and regulations. Such record shall be signed by
the medical professional rendering the services.
"MEDICALLY NECESSARY" means health care and services that are necessary to
prevent, diagnose, manage or treat conditions in the person that cause
acute suffering, endanger life, result in illness or infirmity, interfere
with such person's capacity for normal activity, or threaten some
significant handicap.
"MEMBER HANDBOOK" means the publication prepared by the Contractor and
issued to Enrollees to inform them of their benefits and services, how to
access health care services and to explain their rights and
responsibilities as an MMC Enrollee or an FHPlus Enrollee.
"MMC ELIGIBLE PERSON" means a person whom the LDSS, state or federal
government determines to have met the qualifications established in state
and federal law necessary to receive medical assistance under Title 11 of
the SSL and who meets all the other conditions for enrollment in the MMC
Program.
"MMC ENROLLEE" means an MMC Eligible Person who either personally or
through an authorized representative, has enrolled in, or has been
auto-assigned to, the Contractor's MMC product.
"NATIVE AMERICAN" means, for purposes of this Agreement, a person
identified in the Medicaid eligibility system as a Native American.
"NONCONSENSUAL ENROLLMENT" means Enrollment of an Eligible Person, other
than through Auto-assignment, newborn Enrollment or case addition, in an
MCO's MMC or FHPlus product without the consent of the Eligible Person or
consent of a person with the legal authority to act on behalf of the
Eligible Person at the time of Enrollment.
"NON-PARTICIPATING PROVIDER" means a provider of medical care and/or
services with which the Contractor has no Provider Agreement, as this term
is defined in this Agreement.
"PARTICIPATING PROVIDER" means a provider of medical care and/or services
that has a Provider Agreement with the Contractor.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-5
"PERMANENT PLACEMENT STATUS" means the status of an individual in a
Residential Health Care Facility (RHCF) when the LDSS determines that the
individual is not expected to return home based on medical evidence
affirming the individual's need for permanent RHCF placement.
"PHYSICIAN INCENTIVE PLAN" OR "PIP" means any compensation arrangement
between the Contractor or one of its contracting entities and a physician
or physician group that may directly or indirectly have the effect of
reducing or limiting services furnished to the contractor's Enrollees.
"POST-STABILIZATION CARE SERVICES" means covered services, related to an
Emergency medical Condition, that are provided after an Enrollee is
stabilized in order to maintain the stabilized condition, or to improve or
resolve the Enrollee's condition.
"POTENTIAL ENROLLEE" means an MMC Eligible Person who is not yet enrolled
in a MCO that is participating in the MMC Program.
"PREPAID CAPITATION PLAN ROSTER" OR "ROSTER" means the Enrollment list
generated on a monthly basis by SDOH by which LDSS and Contractor are
informed of specifically which Eligible Persons the Contractor will be
serving for the coming month, subject to any revisions communicated in
writing or electronically by SDOH, LDSS, or the Enrollment Broker.
"PRESUMPTIVE ELIGIBILITY PROVIDER" means a provider designated by the SDOH
as qualified to determine the presumptive eligibility for pregnant women to
allow them to receive prenatal services immediately. These providers assist
such women with the completion of the full application for Medicaid and
they may be comprehensive Prenatal Care Programs, Local Public Health
Agencies, Certified Home Health Agencies, Public Health Nursing Services,
Article 28 facilities, and individually licensed physicians and certified
nurse practitioners.
"PREVENTIVE CARE" means the care or services rendered to avert
disease/illness and/or its consequences. There are three levels of
preventive care: primary, such as immunizations, aimed at preventing
disease; secondary, such as disease screening programs aimed at early
detection of disease; and tertiary, such as physical therapy, aimed at
restoring function after the disease has occurred. Commonly, the term
"preventive care" is used to designate prevention and early detection
programs rather than treatment programs.
"PRIMARY CARE PROVIDER" OR "PCP" means a qualified physician, or certified
nurse practitioner or team of no more than four (4) qualified
physicians/certified nurse practitioners which provides all required
primary care services contained in the Benefit Package to Enrollees.
"PROSPECTIVE ENROLLEE" means any individual residing in the Contractor's
Service Area that has not yet enrolled in a MCO's MMC or FHPlus product.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-6
"PROVIDER AGREEMENT" means any written contract between the Contractor and
a Participating Provider to provide medical care and/or services to
Contractor's Enrollees.
"SCHOOL BASED HEALTH CENTERS" OR "SBHC" means SDOH approved centers which
provide comprehensive primary and mental health services including health
assessments, diagnosis and treatment of acute illnesses, screenings and
immunizations, routine management of chronic diseases, health education,
mental health counseling and treatment on-site in schools. Services are
offered by multi-disciplinary staff from sponsoring Article 28 licensed
hospitals and community health centers.
"SERIOUSLY EMOTIONALLY DISTURBED" OR "SED" means an individual through
seventeen (17) years of age who meets the criteria established by the
Commissioner of Mental Health, including children and adolescents who have
a designated diagnosis of mental illness under the most recent edition of
the diagnostic and statistical manual of mental disorders, and (1) whose
severity and duration of mental illness results in substantial functional
disability or (2) who require mental health services on more than an
incidental basis.
"SERIOUSLY AND PERSISTENTLY MENTALLY III" OR "SPMI" means an individual
eighteen (18) years or older who meets the criteria established by the
Commissioner of Mental Health, including persons who have a designated
diagnosis of mental illness under the most recent edition of the diagnostic
and statistical manual of mental disorders, and (1) whose severity and
duration of mental illness results in substantial functional disability or
(2) who require mental health services on more than an incidental basis.
"SUPPLEMENTAL MATERNITY CAPITATION PAYMENT" means the fixed amount paid to
the Contractor for the prenatal and postpartum physician care and hospital
or birthing center delivery costs, limited to those cases in which the
Contractor has paid the hospital or birthing center for the maternity stay,
and can produce evidence of such payment.
"SUPPLEMENTAL NEWBORN CAPITATION PAYMENT" means the fixed amount paid to
the Contractor for the inpatient birthing costs for a newborn enrolled in
the Contractor's MMC product, limited to those cases in which the
Contractor has paid the hospital or birthing center for the newborn stay,
and can produce evidence of such payment.
"TUBERCULOSIS DIRECTLY OBSERVED THERAPY" OR "TB/DOT" means the direct
observation of ingestion of oral TB medications to assure patient
compliance with the physician's prescribed medication regimen.
"URGENTLY NEEDED SERVICES" means covered services that are not Emergency
Services as defined in this Section, provided when an Enrollee is
temporarily absent from the Contractor's service area, when the services
are medically necessary and immediately required: (1) as a result of an
unforeseen illness, injury, or condition; and (2) it was not reasonable
given the circumstances to obtain the services through the Contractor's MMC
or FHPlus Participating Provider.
SECTION 1
(DEFINITIONS)
October 1, 2005
1-7
2. AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION
PROVISIONS
2.1 Term
a) This Agreement is effective October 1, 2005 and shall remain in
effect until September 30, 2007; or until the execution of an
extension, renewal or successor Agreement between the Contractor
and the DOHMH approved by the SDOH,, the US Department of Health
and Human Services (DHHS), and any other entities as required by
law or regulation, whichever occurs first.
b) This Agreement shall not be automatically renewed at its
expiration. The parties to the Agreement shall have the option to
renew this Agreement for an additional three (3) year term,
subject to the approval of SDOH, DHHS, and any other entities as
required by law or regulation.
c) The maximum duration of this Agreement is five (5) years;
provided however an extension to this Agreement beyond the five
year maximum may be granted for reasons including, but not
limited to, the following;
i) Negotiations for a successor agreement will not be completed
by the expiration date of the current Agreement; or
ii) The Contractor has submitted a termination notice and
transition of Enrollees will not be completed by the
expiration date of the current Agreement.
d) Notwithstanding the foregoing, this Agreement will automatically
terminate, in its entirety, or in relevant part, should federal
financial participation for the MMC and/or FHPlus Program expire.
2.2 Amendments
a) This Agreement may be modified only in writing. Unless otherwise
specified in this Agreement, modifications must be signed by the
parties and approved by the SDOH, and any other entities as
required by law or regulation, and approved by the DHHS prior to
the end of the quarter in which the amendment is to be effective.
b) DOHMH will make reasonable efforts to provide the Contractor with
notice and opportunity to comment with regard to proposed
amendment of this Agreement except when provision of advance
notice would result in the DOHMH and SDOH being out of compliance
with state or federal law.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-1
c) The Contractor will return the signed amendment or notify the
DOHMH that it does not agree with the terms of the amendment
within ten (10) business days of the date of the Contractor's
receipt of the proposed amendment.
2.3 Approvals
This Agreement and any amendments to this Agreement shall not be
effective or binding unless and until approved, in writing, by the
SDOH, the DHHS, and any other entity as required in law or regulation.
SDOH will provide a notice of such approval to the Contractor and the
DOHMH upon such approval.
2.4 Entire Agreement
a) This Agreement, including those attachments, schedules,
appendices, exhibits, and addenda that have been specifically
incorporated herein and written plans submitted by the Contractor
and maintained on file by SDOH and/or DOHMH pursuant to this
Agreement, contains all the terms and conditions agreed upon by
the parties, and no other Agreement, oral or otherwise, regarding
the subject matter of this Agreement shall be deemed to exist or
to bind any of the parties or vary any of the terms contained in
this Agreement. In the event of any inconsistency or conflict
among the document elements of this Agreement, such inconsistency
or conflict shall be resolved by giving precedence to the
document elements in the following order:
i) Appendix A, Standard Clauses for all New York State
Contracts;
ii) Appendix R, Local Standard Clauses for all New York City
Contracts;
iii) Appendix N, New York City Specific Requirements;
iv) The body of this Agreement;
v) The appendices attached to the body of this Agreement, other
than Appendix A, R and N;
vi) The Contractor's approved:
A) Marketing Plan on file with SDOH and DOHMH
B) Action and Grievance System Procedures on file with
SDOH
C) Quality Management Plan on file with SDOH
D) ADA Compliance Plan on file with SDOH and DOHMH
E) Fraud and Abuse Prevention Plan on file with SDOH.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-2
2.5 Renegotiation
The parties to this Agreement shall have the right to renegotiate the
terms and conditions of this Agreement in the event applicable local,
state or federal law, regulations or policy are altered from those
existing at the time of this Agreement in order to be in continuous
compliance therewith. This Section shall not limit the right of the
parties to this Agreement from renegotiating or amending other terms
and conditions of this Agreement. Such changes shall only be made with
the consent of the parties and the prior approval of the SDOH and
DHHS.
2.6 Assignment and Subcontracting
a) The Contractor shall not, without DOHMH and SDOH's prior written
consent, assign, transfer, convey, sublet, or otherwise dispose
of this Agreement; of the Contractor's right, title, interest,
obligations, or duties under the Agreement; of the Contractor's
power to execute the Agreement; or, by power of attorney or
otherwise, of any of the Contractor's rights to receive monies
due or to become due under this Agreement. DOHMH and SDOH agree
that they will not unreasonably withhold consent of the
Contractor's assignment of this Agreement, in whole or in part,
to a parent, affiliate or subsidiary corporation, or to a
transferee of all or substantially all of its assets. Any
assignment, transfer, conveyance, sublease, or other disposition
without DOHMH and SDOH's consent shall be void.
b) Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by a written agreement,
as set forth in Section 22 of this Agreement. The Contractor may
subcontract for provider services and management services. If
such written agreement would be between Contractor and a provider
of health care or ancillary health services or between Contractor
and an independent practice association, the agreement must be in
a form previously approved by SDOH. If such subcontract is for
management services as defined in 10 NYCRR Part 98, it must be
approved by SDOH prior to its becoming effective. Any subcontract
entered into by Contractor shall fulfill the requirements of 42
CFR Parts 434 and 438 to the extent regulations are or become
effective that pertain to the service or activity delegated under
such subcontract. Contractor agrees that it shall remain legally
responsible to DOHMH and to SDOH for carrying out all activities
under this Agreement and that no subcontract shall limit or
terminate Contractor's responsibility.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-3
2.7 Termination
a) DOHMH Initiated Termination
i) DOHMH shall have the right to terminate this Agreement, in
whole or in part; for either the Contractor's MMC or FHPlus
product if applicable or for either or both products in
specified counties of Contractor's service area as
identified in Appendix M, if the Contractor:
A) takes any action that threatens the health, safety, or
welfare of its Enrollees;
B) has engaged in an unacceptable practice under 18 NYCRR
Part 515 that affects the fiscal integrity of the MMC
or FHPlus Program or engaged in an unacceptable
practice pursuant to Section 27.2 of this Agreement;
C) has its Certificate of Authority suspended, limited or
revoked by SDOH;
D) materially breaches the Agreement or fails to comply
with any term or condition of this Agreement that is
not cured within twenty (20) days, or such longer
period as the parties may agree, of SDOH or DOHMH's
written request for compliance;
E) becomes insolvent;
F) brings a proceeding voluntarily, or has a proceeding
brought against it involuntarily, under Title 11 of the
U.S. Code (the Bankruptcy Code); or
G) knowingly has a director, officer, partner or person
owning or controlling more than five percent (5%) of
the Contractor's equity, or has an employment,
consulting, or other agreement with such a person for
the provision of items and/or services that are
significant to the Contractor's contractual obligation
who has been debarred or suspended by the federal,
state or local government, or otherwise excluded from
participating in procurement activities.
ii) The DOHMH will notify the Contractor of its intent to
terminate this Agreement for the Contractor's failure to
meet the requirements of this Agreement and provide
Contractor with a hearing prior to the termination.
iii) If SDOH suspends, limits or revokes Contractor's Certificate
of Authority under PHL Section 4404, and:
A) if such action results in the Contractor ceasing to
have authority to serve the entire contracted service
area, as defined by Appendix M of this Agreement, this
Agreement shall terminate on the date the Contractor
ceases to have such authority; or
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-4
B) if such action results in the Contractor retaining
authority to serve some portion of the contracted
service area, the Contractor shall continue to offer
its MMC and/or FHPlus products under this Agreement in
any designated geographic areas not affected by such
action, and shall terminate its MMC and/or FHPlus
products in the geographic areas where the Contractor
ceases to have authority to serve.
iv) No hearing will be required if this Agreement terminates due
to SDOH suspension, limitation or revocation of the
Contractor's Certificate of Authority.
v) Prior to the effective date of the termination the DOHMH
shall notify Enrollees of the termination, or delegate
responsibility for such notification to the Contractor, and
such notice shall include a statement that Enrollees may
disenroll immediately without cause.
b) Contractor and DOHMH Initiated Termination
The Contractor and the DOHMH each shall have the right to
terminate this Agreement in its entirety, for either the
Contractor's MMC or FHPlus product if applicable, or for either
or both products in specified counties of the Contractor's
service area as identified in Appendix M, in the event that SDOH
and the Contractor fail to reach agreement on the monthly
Capitation Rates. In such event, the party exercising its right
shall give the other party and SDOH written notice specifying the
reason for and the effective date of termination, which shall not
be less time than will permit an orderly transition of Enrollees,
but no more than ninety (90) days.
c) Contractor Initiated Termination
i) The Contractor shall have the right to terminate this
Agreement in its entirety, for either the Contractor's MMC
or FHPlus product if applicable, or for either or both
products in specified counties of the Contractor's service
area as identified in Appendix M, in the event that DOHMH
materially breaches the Agreement or fails to comply with
any term or condition of this Agreement that is not cured
within twenty (20) days, or within such longer period as the
parties may agree, of the Contractor's written request for
compliance. The Contractor shall give DOHMH written notice
specifying the reason for and the effective date of the
termination, which shall not be less time than will permit
an orderly transition of Enrollees, but no more than ninety
(90) days.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-5
ii) The Contractor shall have the right to terminate this
Agreement, in its entirety, for either the Contractor's MMC
or FHPlus product if applicable, or for either or both
products in specified counties of the Contractor's service
area as specified in Appendix M, in the event that its
obligations are materially changed by modifications to this
Agreement and its Appendices by SDOH or DOHMH. In such
event, Contractor shall give DOHMH and SDOH written notice
within thirty (30) days of notification of changes to the
Agreement or Appendices specifying the reason and the
effective date of termination, which shall not be less time
than will permit an orderly transition of Enrollees, but no
more than ninety (90) days.
iii) The Contractor shall have the right to terminate this
Agreement in its entirety, for either the Contractor's MMC
or FHPlus product if applicable, or for either or both
products in specified counties of the Contractor's service
area as identified in Appendix M, if the Contractor is
unable to provide services pursuant to this Agreement
because of a natural disaster and/or an act of God to such a
degree that Enrollees cannot obtain reasonable access to
services within the Contractor's organization, and, after
diligent efforts, the Contractor cannot make other
provisions for the delivery of such services. The Contractor
shall give SDOH and DOHMH written notice of any such
termination that specifies:
A) the reason for the termination, with appropriate
documentation of the circumstances arising from a
natural disaster and/or an act of God that preclude
reasonable access to services;
B) the Contractor's attempts to make other provision for
the delivery of services; and
C) the effective date of the termination, which shall not
be less time than will permit an orderly transition of
Enrollees, but no more than ninety (90) days.
d) Termination Due To Loss of Funding
In the event that State and/or Federal funding used to pay for
services under this Agreement is reduced so that payments cannot
be made in full, this Agreement shall automatically terminate,
unless both parties agree to a modification of the obligations
under this Agreement. The effective date of such termination
shall be ninety (90) days after the Contractor receives written
notice of the reduction in payment, unless available funds are
insufficient to continue payments in full during the ninety (90)
day period, in which case DOHMH shall give the Contractor written
notice of the earlier date upon which the Agreement shall
terminate. A reduction in State and/or Federal funding cannot
reduce monies due and owing to the Contractor on or before the
effective date of the termination of the Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-6
2.8 Close-Out Procedures
a) Upon termination or expiration of this Agreement in its entirety,
for either the Contractor's MMC or FHPlus product is applicable,
or for either or both products in specified counties of the
Contractor's service area as identified in Appendix M, and in the
event that it is not scheduled for renewal, the Contractor shall
comply with close-out procedures that the Contractor develops in
conjunction with DOHMH and that the DOHMH, and the SDOH have
approved. The close-out procedures shall include the following:
i) The Contractor shall promptly account for and repay funds
advanced by SDOH for coverage of Enrollees for periods
subsequent to the effective date of termination;
ii) The Contractor shall give DOHMH, SDOH, and other authorized
federal, state or local agencies access to all books,
records, and other documents and upon request, portions of
such books, records, or documents that may be required by
such agencies pursuant to the terms of this Agreement;
iii) If this Agreement is terminated in its entirety, the
Contractor shall submit to DOHMH, SDOH, and authorized
federal, state or local agencies, within ninety (90) days of
termination, a final financial statement, made by a
certified public accountant, unless the Contractor requests
of DOHMH and receives written approval from SDOH, DOHMH and
all other governmental agencies from which approval is
required, for an extension of time for this submission;
iv) The Contractor shall establish an appropriate plan
acceptable to and prior approved by the DOHMH and SDOH for
the orderly transition of Enrollees. This plan shall include
the provision of pertinent information to identified
Enrollees who are: pregnant; currently receiving treatment
for a chronic or life threatening condition; prior approved
for services or surgery; or whose care is being monitored by
a case manager to assist them in making decisions which will
promote continuity of care; and
v) SDOH shall promptly pay all claims and amounts owed to the
Contractor.
b) Any termination of this Agreement by either the Contractor or
DOHMH shall be done by amendment to this Agreement, unless the
Agreement is terminated by the DOHMH due to conditions in Section
2.7(a)(i) or Appendix A of this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-7
2.9 Rights and Remedies
The rights and remedies of DOHMH and the Contractor provided expressly
in this Section shall not be exclusive and are in addition to all
other rights and remedies provided by law or under this Agreement.
2.10 Notices
All notices to be given under this Agreement shall be in writing and
shall be deemed to have been given when mailed to, or, if personally
delivered, when received by the Contractor, DOHMH, and the SDOH at the
following addresses:
For DOHMH:
New York City Department of Health and Mental Hygiene
125 Worth Street, CN # 29C
New York, NY 10013
ATTN: Assistant Commissioner
Division of Health Care Access and Improvement
For SDOH:
New York State Department of Health
Empire State Plaza
Corning Tower, Room 2074
Albany, NY 12237-0065
For the Contractor:
CarePlus, L.L.C.
360 West 31st Street, Fifth Floor
New York, NY 10001
ATTN: Executive Officer
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-8
2.11 Severability
If this Agreement contains any unlawful provision that is not an
essential part of this Agreement and that was not a controlling or
material inducement to enter into this Agreement, the provision shall
have no effect and, upon notice by either party, shall be deemed
stricken from this Agreement without affecting the binding force of
the remainder of this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 2005
2-9
3. COMPENSATION
3.1 Capitation Payments
a) Compensation to the Contractor shall consist of a monthly
capitation payment for each Enrollee and the Supplemental
Capitation Payments as described in Section 3.1 (d), where
applicable.
b) The monthly Capitation Rates are attached hereto as Appendix L,
which is hereby made a part of this Agreement as if set forth
fully herein.
c) The monthly capitation payments, and the Supplemental Newborn
Capitation Payment and the Supplemental Maternity Capitation
Payment, when applicable, to the Contractor shall constitute full
and complete payments to the Contractor for all services that the
Contractor provides, except for payments due the Contractor as
set forth in Sections 3.11, 3.12, and 3.13 of this Agreement for
MMC Enrollees.
d) Capitation Rates shall be effective for the entire contract
period, except as described in Section 3.2.
3.2 Modification of Rates During Contract Period
a) Any technical modification to Capitation Rates during the term of
this Agreement, as agreed to by the Contractor, including but not
limited to, changes in reinsurance or the Benefit Package, shall
be deemed incorporated into this Agreement without further action
by the parties, upon approval by SDOH and upon written notice by
SDOH to the DOHMH.
b) Any other modification to Capitation Rates, as agreed to by SDOH
and the Contractor, during the term of the Agreement shall be
deemed incorporated into this Agreement, without further action
by the parties upon approval of such modifications by the SDOH
and the State Division of Budget, and upon written notice by SDOH
and DOHMH.
c) In the event that the SDOH and the Contractor fail to reach
agreement on the modifications to the monthly Capitation Rates,
the SDOH will provide formal written notice to the Contractor and
the DOHMH of the amount and effective date of the modified
Capitation Rates approved by the State Division of the Budget.
The Contractor shall have the option of terminating this
Agreement if such approved modified Capitation Rates are not
acceptable. In such cases, the Contractor shall give written
notice to the SDOH and the DOHMH within thirty (30) days of the
date of the formal written notice of the modified Capitation
Rates from SDOH specifying the reasons for and effective date of
termination. The effective date of termination shall be ninety
(90) days from the date of the Contractor's written notice,
unless the SDOH determines that
SECTION 3
(COMPENSATION)
October 1, 2005
3-1
an orderly disenrollment can be accomplished in fewer days.
During the period commencing with the effective date of the SDOH
modified Capitation Rates, through the effective date of
termination of the Agreement, the Contractor shall have the
option of continuing to receive capitation payments at the
expired Capitation Rates or at the modified Capitation Rates
approved by the SDOH and the Division of the Budget for the rate
period.
If the Contractor fails to exercise its right to terminate in
accordance with (c) above, then the modified Capitation Rates approved
by SDOH and the State Division of Budget shall be deemed incorporated
into this Agreement without further action by the parties as of the
effective date of the modified Capitation Rates, as established by
SDOH and approved by the State Division of Budget.
3.3 Rate Setting Methodology
a) Capitation rates shall be determined prospectively and shall not
be retroactively adjusted to reflect actual Medicaid
fee-for-service data or Contractor experience for the time period
covered by the rates. Capitated rates in effect as of April 1,
2006 and thereafter, shall be certified to be actuarially sound
in accordance with 42 CFR Section 438.6(c).
b) Notwithstanding the provisions set forth in Section 3.3(a) above,
the DOHMH reserves the right to terminate this Agreement, in its
entirety for either the Contractor's MMC or FHPlus product if
applicable, or for either or both products in specified counties
of the Contractor's service area as set forth in Appendix M,
pursuant to Section 2.7 of this Agreement, upon determination by
SDOH that the aggregate monthly Capitation Rates are not cost
effective.
3.4 Payment of Capitation
a) The monthly capitation payments for each Enrollee are due to the
Contractor from the Effective Date of Enrollment until the
Effective Date of Disenrollment of the Enrollee or termination of
this Agreement, whichever occurs first. The Contractor shall
receive a full month's capitation payment for the month in which
Disenrollment occurs. The Roster generated by SDOH with any
modification communicated electronically or in writing by the
LDSS or the Enrollment Broker prior to the end of the month in
which the Roster is generated, shall be the Enrollment list for
purposes of eMedNY premium billing and payment, as discussed in
Section 6.9 and Appendix H of this Agreement.
b) Upon receipt by the Fiscal Agent of a properly completed claim
for monthly capitation payments submitted by the Contractor
pursuant to this Agreement, the Fiscal Agent will promptly
process such claim for payment and use its best efforts to
complete such processing within thirty (30) business days from
date of receipt of the claim by the Fiscal Agent. Processing of
Contractor
SECTION 3
(COMPENSATION)
October 1, 2005
3-2
claims shall be in compliance with the requirements of 42 CFR
Section 447.45. The Fiscal Agent will also use its best efforts
to resolve any billing problem relating to the Contractor's
claims as soon as possible. In accordance with Section 41 of the
New York State Finance Law (State Finance Law), the State and New
York City shall have no liability under this Agreement to the
Contractor or anyone else beyond funds appropriated and available
for this Agreement.
3.5 Denial of Capitation Payments
If the US Centers for Medicare and Medicaid Services (CMS) denies
payment for new Enrollees, as authorized by SSA Section 1903(m)(5) and
42 CFR Section 438.730 (e), or such other applicable federal statutes
or regulations, based upon a determination that Contractor failed
substantially to provide medically necessary items and services,
imposed premium amounts or charges in excess of permitted payments,
engaged in discriminatory practices as described in SSA Section
1932(e)(1)(A)(iii), misrepresented or falsified information submitted
to CMS, SDOH, LDSS, the Enrollment Broker, or an Enrollee, Prospective
Enrollee, or health care provider, or failed to comply with federal
requirements (i.e., 42 CFR Section 422.208 and 42 CFR Section 438.6
(h) relating to the Physician Incentive Plans), SDOH and LDSS will
deny capitation payments to the Contractor for the same Enrollees for
the period of time for which CMS denies such payment.
3.6 SDOH Right to Recover Premiums
The parties acknowledge and accept that the SDOH has a right to
recover premiums paid to the Contractor for MMC Enrollees listed on
the monthly Roster who are later determined for the entire applicable
payment month, to have been in an institution; to have been
incarcerated; to have moved out of the Contractor's service area
subject to any time remaining in the MMC Enrollee's Guaranteed
Eligibility period; or to have died. SDOH has a right to recover
premiums for FHPlus Enrollees listed on the Roster who are determined
to have been incarcerated; to have moved out of the Contractor's
service area or their county of fiscal responsibility; or to have
died. In any event, the State may only recover premiums paid for MMC
and/or FHPlus Enrollees listed on a Roster if it is determined by the
SDOH that the Contractor was not at risk for provision of Benefit
Package services for any portion of the payment period.
3.7 Third Party Health Insurance Determination
The Contractor will make diligent efforts to determine whether
Enrollees have third party health insurance (TPHI). The LDSS is also
responsible for making diligent efforts to determine if Enrollees have
TPHI and to maintain third party information on the WMS/eMedNY Third
Party Resource System. The Contractor shall make good faith efforts to
coordinate benefits with and collect TPHI recoveries from other
insurers, and must inform the LDSS of any known changes
SECTION 3
(COMPENSATION)
October 1, 2005
3-3
in status of TPHI insurance eligibility within thirty (30) days of
learning of a change in TPHI. The Contractor may use the Roster as one
method to determine TPHI information. The Contractor will be permitted
to retain one hundred percent (100%) of any reimbursement for Benefit
Package services obtained from TPHI. Capitation Rates are net of TPHI
recoveries. In no instances may an Enrollee be held responsible for
disputes over these recoveries.
3.8 Payment For Newborns
a) The Contractor shall be responsible for all costs and services
included in the Benefit Package associated with an Enrollee's
newborn, unless the child is Excluded from Medicaid Managed Care
pursuant to Appendix H of this Agreement, or the Contractor does
not offer a MMC product in the mother's local social services
district.
b) The Contractor shall receive a capitation payment from the first
day of the newborn's month of birth and, in instances where the
Contractor pays the hospital or birthing center for the newborn
stay, a Supplemental Newborn Capitation Payment.
c) Capitation Rate and Supplemental Newborn Capitation Payment for a
newborn will begin the month following certification of the
newborn's eligibility and enrollment, retroactive to the first
day of the month in which the child was born.
d) The Contractor cannot bill for a Supplemental Newborn Capitation
Payment unless the newborn hospital or birthing center payment
has been paid by the Contractor. The Contractor must maintain on
file evidence of payment to the hospital or birthing center of
the claim for the newborn stay. Failure to have supporting
records may, upon an audit, result in recoupment of the
Supplemental Newborn Capitation Payment by SDOH.
3.9 Supplemental Maternity Capitation Payment
a) The Contractor shall be responsible for all costs and services
included in the Benefit Package associated with the maternity
care of an Enrollee.
b) In instances where the Enrollee is enrolled in the Contractor's
MMC or FHPlus product on the date of the delivery of a child, the
Contractor shall be entitled to receive a Supplemental Maternity
Capitation Payment. The Supplemental Maternity Capitation Payment
reimburses the Contractor for the inpatient and outpatient costs
of services normally provided as part of maternity care,
including antepartum care, delivery and post-partum care. The
Supplemental Maternity Capitation Payment is in addition to the
monthly Capitation Rate paid by the SDOH to the Contractor for
the Enrollee.
SECTION 3
(COMPENSATION)
October 1, 2005
3-4
c) In instances where the Enrollee was enrolled in the Contractor's
MMC or FHPlus product for only part of the pregnancy, but was
enrolled on the date of the delivery of the child, the Contractor
shall be entitled to receive the entire Supplemental Maternity
Capitation Payment. The Supplemental Capitation payment shall not
be pro-rated to reflect that the Enrollee was not enrolled in the
Contractor's MMC or FHPlus product for the entire duration of the
pregnancy.
d) In instances where the Enrollee was enrolled in the Contractor's
MMC or FHPlus product for part of the pregnancy, but was not
enrolled on the date of the delivery of the child, the Contractor
shall not be entitled to receive the Supplemental Maternity
Capitation Payment, or any portion thereof.
e) Costs of inpatient and outpatient care associated with maternity
cases that end in termination or miscarriage shall be reimbursed
to the Contractor through the monthly Capitation Rate for the
Enrollee and the Contractor shall not receive the Supplemental
Maternity Capitation Payment.
f) The Contractor may not bill a Supplemental Maternity Capitation
Payment until the hospital inpatient or birthing center delivery
is paid by the Contractor, and the Contractor must maintain on
file evidence of payment of the delivery, plus any other
inpatient and outpatient services for the maternity care of the
Enrollee to be eligible to receive a Supplemental Maternity
Capitation Payment. Failure to have supporting records may, upon
audit, result in recoupment of the Supplemental Maternity
Capitation Payment by the SDOH.
3.10 Contractor Financial Liability
Contractor shall not be financially liable for any services rendered
to an Enrollee prior to his or her Effective Date of Enrollment.
3.11 Inpatient Hospital Stop-Loss Insurance for MMC Enrollees
a) The Contractor must obtain stop-loss coverage for inpatient
hospital services for MMC Enrollees. A Contractor may elect to
purchase stop-loss coverage from New York State. In such cases,
the Capitation Rates paid to the Contractor shall be adjusted to
reflect the cost of such stop-loss coverage. The cost of such
coverage shall be determined by SDOH.
b) Under NYS stop-loss coverage, if the hospital inpatient expenses
incurred by the Contractor for an individual MMC Enrollee during
any calendar year reaches $50,000, the Contractor shall be
compensated for eighty percent (80%) of the cost of hospital
inpatient services in excess of this amount up to a maximum of
$250,000. Above that amount, the Contractor will be compensated
for one hundred percent (100%) of cost. All compensation shall
SECTION 3
(COMPENSATION)
October 1, 2005
3-5
be based on the lower of the Contractor's negotiated hospital
rate or Medicaid rates of payment.
[ ] The Contractor has elected to have NYS provide stop-loss
reinsurance for MMC Enrollees.
OR
[X] The Contractor has not elected to have NYS provide stop-loss
reinsurance for MMC Enrollees.
3.12 Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees
a) The Contractor will be compensated for medically necessary and
clinically appropriate Medicaid reimbursable mental health
treatment outpatient visits by MMC Enrollees in excess of twenty
(20) visits during any calendar year at rates set forth in
contracted fee schedules. Any Court-Ordered Services for mental
health treatment outpatient visits by MMC Enrollees which specify
the use of Non-Participating Providers shall be compensated at
the Medicaid rate of payment.
b) The Contractor will be compensated for medically necessary and
clinically appropriate inpatient mental health services and/or
Chemical Dependence Inpatient Rehabilitation and Treatment
Services to MMC Enrollees, as defined in Appendix K of this
Agreement, in excess of a combined total of thirty (30) days
during a calendar year at the lower of the Contractor's
negotiated inpatient rate or Medicaid rate of payment.
c) Detoxification Services for MMC Enrollees in Article 28 inpatient
hospital facilities are subject to the stop-loss provisions
specified in Section 3.11 of this Agreement.
3.13 Residential Health Care Facility Stop-Loss for MMC Enrollees
The Contractor will be compensated for medically necessary and
clinically appropriate Medicaid reimbursable inpatient Residential
Health Care Facility services, as defined in Appendix K of this
Agreement, provided to MMC Enrollees in excess of sixty (60) days
during a calendar year at the lower of the Contractor's negotiated
rates or Medicaid rate of payment.
SECTION 3
(COMPENSATION)
October 1, 2005
3-6
3.14 Stop-Loss Documentation and Procedures for the MMC Program
The Contractor must follow procedures and documentation requirements
in accordance with the New York State Department of Health stop-loss
policy and procedure manual. The State has the right to recover from
the Contractor any stop-loss payments that are later found not to
conform to these SDOH requirements.
3.15 FHPlus Reinsurance
The Contractor shall purchase reinsurance coverage unless it can
demonstrate to SDOH's satisfaction the ability to self insure.
3.16 Tracking Visits Provided by Indian Health Clinics - Applies to MMC
Program Only
The SDOH shall monitor all visits provided by tribal or Indian health
clinics or urban Indian health facilities or centers to enrolled
Native Americans, so that the SDOH can reconcile payment made for
those services, should it be deemed necessary to do so.
SECTION 3
(COMPENSATION)
October 1, 2005
3-7
4. SERVICE AREA
The Contractor's service area for Medicaid Managed Care and/or FHPlus shall
consist of the county(ies) described in Appendix M of this Agreement, which
is hereby made a part of this Agreement as if set forth fully herein. Such
service area is the specific geographic area within which Eligible Persons
must reside to enroll in either the Contractor's Medicaid Managed Care
and/or FHPlus product.
SECTION 4
(SERVICE AREA)
October 1, 2005
4-1
5. RESERVED
SECTION 5
OCTOBER 1, 2005
5-1
6. ENROLLMENT
6.1 Populations Eligible for Enrollment
a) Medicaid Managed Care Populations
All Eligible Persons who meet the criteria in Section 364-j of
the SSL and/or New York State's Operational Protocol for the
Partnership Plan and who reside in the Contractor's service area,
as specified in Appendix M of this Agreement, shall be eligible
for Enrollment in the Contractor's Medicaid Managed Care product.
b) Family Health Plus Populations
All Eligible Persons who meet the criteria listed in Section
369-ee of the SSL and/or New York State's Operational Protocol
for the Partnership Plan and who reside in the Contractor's
service area, as specified in Appendix M of this Agreement, shall
be eligible for Enrollment in the Contractor's Family Health Plus
product.
6.2 Enrollment Requirements
The Contractor agrees to conduct Enrollment of Eligible Persons in
accordance with the policies and procedures set forth in Appendix H of
this Agreement, which is hereby made a part of this Agreement as if
set forth fully herein.
6.3 Equality of Access to Enrollment
The Contractor shall accept Enrollments of Eligible Persons in the
order in which the Enrollment applications are received without
restriction and without regard to the Eligible Person's age, sex,
race, creed, physical or mental handicap/developmental disability,
national origin, sexual orientation, type of illness or condition,
need for health services or to the Capitation Rate that the Contractor
will receive for such Eligible Person.
6.4 Enrollment Decisions
An Eligible Person's decision to enroll in the Contractor's MMC or
FHPlus product shall be voluntary except as otherwise provided in
Section 6.5 of this Agreement.
SECTION 6
(ENROLLMENT)
October 1, 2005
6-1
6.5 Auto Assignment - For MMC Program Only
An MMC Eligible Person whose Enrollment is mandatory under the
Medicaid Managed Care Program and who fails to select and enroll in an
MCO within sixty (60) days of receipt of notice of mandatory
Enrollment may be assigned by the SDOH or the LDSS to the Contractor's
MMC product pursuant to SSL Section 364-j and in accordance with
Appendix H of this Agreement.
6.6 Prohibition Against Conditions on Enrollment
Unless otherwise required by law or this Agreement, neither the
Contractor nor LDSS shall condition any Eligible Person's Enrollment
into the Contractor's MMC or FHPlus product upon the performance of
any act. Neither the Contractor nor the LDSS shall suggest in any way
that failure to enroll in the Contractor's MMC or FHPlus product may
result in a loss of benefits, except in the case of the FHPlus Program
when the Contractor is the sole MCO offering a FHPlus product in the
Enrollee's county of fiscal responsibility;
6.7 Newborn Enrollment
a) All newborn children not Excluded from Enrollment in the MMC
Program pursuant to Appendix H of this Agreement, shall be
enrolled in the MCO in which the newborn's mother is an Enrollee,
effective from the first day of the child's month of birth,
unless the MCO in which the mother is enrolled does not offer a
MMC product in the mother's county of fiscal responsibility.
b) In addition to the responsibilities set forth in Appendix H of
this Agreement, the Contractor is responsible for coordinating
with the LDSS the efforts to ensure that all newborns are
enrolled in the Contractor's MMC product, if applicable.
c) The SDOH and LDSS shall be responsible for ensuring that timely
Medicaid eligibility determination and Enrollment of the newborns
is effected consistent with state laws, regulations, and policy
and with the newborn Enrollment requirements set forth in
Appendix H of this Agreement.
6.8 Effective Date of Enrollment
a) For MMC Enrollees, the Contractor and the LDSS are responsible
for notifying the MMC Enrollee of the expected Effective Date of
Enrollment.
b) For FHPlus Enrollees, the Contractor must notify the FHPlus
Enrollee of the Effective Date of Enrollment.
SECTION 6
(ENROLLMENT)
October 1, 2005
6-2
c) Notification may be accomplished through a "Welcome Letter." To
the extent practicable, such notification must precede the
Effective Date of Enrollment.
d) In the event that the actual Effective Date of Enrollment
changes, the Contractor, and for MMC Enrollees, the LDSS, must
notify the Enrollee of the change.
e) As of the Effective Date of Enrollment, and until the Effective
Date of Disenrollment, the Contractor shall be responsible for
the provision and cost of all care and services covered by the
Benefit Package and provided to Enrollees whose names appear on
the Prepaid Capitation Plan Roster, except as hereinafter
provided.
i) Contractor shall not be liable for the cost of any services
rendered to an Enrollee prior to his or her Effective Date
of Enrollment.
ii) Contractor shall not be liable for any part of the cost of a
hospital stay for a MMC Enrollee who is admitted to the
hospital prior to the Effective Date of Enrollment in the
Contractor's MMC product and who remains hospitalized on the
Effective Date of Enrollment; except when the MMC Enrollee,
on or after the Effective Date of Enrollment, 1) is
transferred from one hospital to another; or 2) is
discharged from one unit in the hospital to another unit in
the same facility and under Medicaid fee-for-service payment
rules, the method of payment changes from: a) Diagnostic
Related Group (DRG) case-based rate of payment per discharge
to a per diem rate of payment exempt from DRG case-based
payment rates, or b) from a per diem payment rate exempt
from DRG case-based payment rates either to another per diem
rate, or a DRG case-based payment rate. In such instances,
the Contractor shall be liable for the cost of the
consecutive stay.
iii) Contractor shall not be liable for any part of the cost of a
hospital stay for an FHPlus Enrollee who is admitted to the
hospital prior to the Effective Date of Enrollment in the
Contractor's FHPlus product and who has not been discharged
as of the Effective Date of Enrollment, up to the date the
FHPlus Enrollee is discharged.
iv) Except for newborns, an Enrollee's Effective Date of
Enrollment shall be the first day of the month on which the
Enrollee's name appears on the Roster for that month.
SECTION 6
(ENROLLMENT)
October 1, 2005
6-3
6.9 Roster
a) The first and second monthly Rosters generated by SDOH in
combination shall serve as the official Contractor Enrollment
list for purposes of eMedNY premium billing and payment, subject
to ongoing eligibility of the Enrollees as of the first (1st) day
of the Enrollment month. Modifications to the Roster may be made
electronically or in writing by the LDSS or the Enrollment
Broker. If the LDSS or Enrollment Broker notifies the Contractor
in writing or electronically of changes in the Roster and
provides supporting information as necessary prior to the
effective date of the Roster, the Contractor will accept that
notification in the same manner as the Roster.
b) The LDSS is responsible for making data on eligibility
determinations available to the Contractor and SDOH to resolve
discrepancies that may arise between the Roster and the
Contractor's Enrollment files in accordance with the provisions
in Appendix H of this Agreement.
c) All Contractors must have the ability to receive Rosters
electronically.
6.10 Automatic Re-Enrollment
a) An Enrollee who loses Medicaid or FHPlus eligibility and who
regains eligibility for either Medicaid or FHPlus within a three
(3) month period, will be automatically prospectively re-enrolled
in the Contractor's MMC or FHPlus product unless:
i) the Contractor does not offer such product in the Enrollee's
county of fiscal responsibility; or
ii) the Enrollee indicates in writing that he/she wishes to
enroll in another MCO or, if permitted, receive coverage
under Medicaid fee-for-service.
SECTION 6
(ENROLLMENT)
October 1, 2005
6-4
7. LOCK-IN PROVISIONS
7.1 Lock-In Provisions in MMC Mandatory Local Social Services Districts
and for Family Health Plus
All MMC Enrollees residing in local social service districts where
Enrollment in the MMC Program is mandatory and all FHPlus Enrollees
are subject to a twelve (12) month Lock-In Period following the
Effective Date of Enrollment, with an initial ninety (90) day grace
period in which to disenroll without cause and enroll in another MCO's
MMC or FHPlus product, if available.
7.2 Disenrollment During a Lock-In Period
An Enrollee subject to Lock-In may disenroll from the Contractor's MMC
or FHPlus product during the Lock-In Period for Good Cause as defined
in Appendix H of this Agreement.
7.3 Notification Regarding Lock-In and End of Lock-In Period
The LDSS, either directly or through the Enrollment Broker, is
responsible for notifying Enrollees of their right to change MCOs in
the Enrollment confirmation notice sent to individuals after they have
selected an MCO or been auto-assigned (the latter being applicable to
areas where the mandatory MMC Program is in effect). The SDOH or its
designee will be responsible for providing a notice of end of Lock-In
and the right to change MCOs at least sixty (60) days prior to the
first Enrollment anniversary date as outlined in Appendix H of this
Agreement.
7.4 Lock-In and Change in Eligibility Status
Enrollees who lose Medicaid or FHPlus eligibility and regain
eligibility for either Medicaid or FHPlus within a three (3) month
period, will not be subject to a new Lock-in Period unless they opt to
change MCOs pursuant to Section 6.10 of this Agreement.
SECTION 7
(LOCK-IN PROVISIONS)
October 1, 2005
7-1
8. DISENROLLMENT
8.1 Disenrollment Requirements
a) The Contractor agrees to conduct Disenrollment of an Enrollee in
accordance with the policies and procedures for Disenrollment set
forth in Appendix H of this Agreement.
b) LDSSs are responsible for making the final determination
concerning Disenrollment requests.
8.2 Disenrollment Prohibitions
Enrollees shall not be disenrolled from the Contractor's MMC or FHPlus
product based on any of the factors listed in Section 34
(Non-Discrimination) of this Agreement.
8.3 Disenrollment Requests
a) Routine Disenrollment Requests
The LDSS is responsible for processing Routine Disenrollment
requests to take effect as specified in Appendix H of this
Agreement. In no event shall the Effective Date of Disenrollment
be later than the first (1st) day of the second (2nd) month after
the month in which an Enrollee requests a Disenrollment.
b) Non-Routine Disenrollment Requests
i) Enrollees with an urgent medical need to disenroll from the
Contractor's MMC or FHPlus product may request an expedited
Disenrollment by the LDSS. An MMC Enrollee who requests a
return to Medicaid fee-for-service based on his/her HIV, End
State Renal disease (ESRD) or SPMI/SED status is
categorically eligible for an expedited Disenrollment on the
basis of urgent medical need.
ii) Enrollees with a complaint of Nonconsensual Enrollment may
request an expedited Disenrollment by the LDSS.
iii) In districts where homeless individuals are Exempt, as
described in Appendices H and M of this Agreement, homeless
MMC Enrollees residing in the shelter system may request an
expedited Disenrollment by the LDSS.
SECTION 8
(DISENROLLMENT)
October 1, 2005
8-1
iv) Retroactive Disenrollments may be warranted in rare
instances and may be requested of the LDSS as described in
Appendix H of this Agreement.
v) Substantiation of non-routine Disenrollment requests by the
LDSS will result in Disenrollment in accordance with the
timeframes as set forth in Appendix H of this Agreement.
8.4 Contractor Notification of Disenrollments
a) Notwithstanding anything herein to the contrary, the Roster,
along with any changes sent by the LDSS to the Contractor in
writing or electronically, shall serve as official notice to the
Contractor of Disenrollment of an Enrollee. In cases of expedited
and retroactive Disenrollment, the Contractor shall be notified
of the Enrollee's Effective Date of Disenrollment by the LDSS.
b) In the event that the LDSS intends to retroactively disenroll an
Enrollee on a date prior to the first day of the month of the
Disenrollment request, the LDSS is responsible for consulting
with the Contractor prior to Disenrollment. Such consultation
shall not be required for the retroactive Disenrollment of
Supplemental Security Income (SSI) infants where it is clear that
the Contractor was not a risk for the provision of Benefit
Package services for any portion of the retroactive period.
c) In all cases of retroactive Disenrollment, including
Disenrollments effective the first day of the current month, the
LDSS is responsible for noticing the Contractor at the time of
Disenrollment of the Contractor's responsibility to submit to the
SDOH's Fiscal Agent voided premium claims for any months of
retroactive Disenrollment where the Contractor was not at risk
for the provision of Benefit Package services during the month.
8.5 Contractor's Liability
a) The Contractor is not responsible for providing the Benefit
Package under this Agreement on or after the Effective Date of
Disenrollment except as hereinafter provided:
i) The Contractor shall be liable for any part of the cost of a
hospital stay for a MMC Enrollee who is admitted to the
hospital prior to the Effective Date of Disenrollment from
the Contractor's MMC product and who remains hospitalized on
the Effective Date of Disenrollment; except when the MMC
Enrollee, on or after the Effective Date of Disenrollment,
1) is transferred from one hospital to another; or 2) is
discharged from one unit in the hospital to another unit in
the same facility and under Medicaid fee-for-service payment
rules, the method of payment changes from: a) DRG case-based
rate of payment per discharge to a per diem rate of payment
SECTION 8
(DISENROLLMENT)
October 1, 2005
8-2
exempt from DRG case-based payment rates, or b) from a per
diem payment rate exempt from DRG case-based payment rates
to either another per diem rate, or a DRG case-based payment
rate. In such instances, the Contractor shall not be liable
for the cost of the consecutive stay. For the purposes of
this paragraph, "hospital stay" does not include a stay in a
hospital that is a) certified by Medicare as a long-term
care hospital and b) has an average length of stay for all
patients greater than ninety-five (95) days as reported in
the Statewide Planning and Research Cooperative System
(SPARCS) Annual Report 2002; in such instances, Contractor
liability will cease on the Effective Date of Disenrollment.
ii) The Contractor shall be liable for any part of the cost of a
hospital stay for a FHPlus Enrollee who is admitted to the
hospital prior to the Effective Date of Disenrollment from
the Contractor's FHPlus product and who has not been
discharged as of the Effective Date of Disenrollment, up to
the date the FHPlus Enrollee is discharged.
b) The Contractor shall notify the LDSS that the Enrollee remains in
the hospital and provide the LDSS with information regarding his
or her medical status. The Contractor is required to cooperate
with the Enrollee and the new MCO (if applicable) on a timely
basis to ensure a smooth transition and continuity of care.
8.6 Enrollee Initiated Disenrollment
a) An Enrollee subject to Lock-In as described in Section 7 of this
Agreement may initiate Disenrollment from the Contractor's MMC or
FHPlus product for Good Cause as defined in Appendix H of this
Agreement at any time during the Lock-In period by filing an oral
or written request with the LDSS.
b) Once the Lock-In Period has expired, the Enrollee may disenroll
from the Contractor's MMC or FHPlus product at any time, for any
reason.
8.7 Contractor Initiated Disenrollment
a) The Contractor may initiate an involuntary Disenrollment if an
Enrollee engages in conduct or behavior that seriously impairs
the Contractor's ability to furnish services to either the
Enrollee or other Enrollees, provided that the Contractor has
made and documented reasonable efforts to resolve the problems
presented by the Enrollee.
b) Consistent with 42 CFR Section 438.56 (b), the Contractor may not
request Disenrollment because of an adverse change in the
Enrollee's health status, or because of the Enrollee's
utilization of medical services, diminished mental capacity, or
uncooperative or disruptive behavior resulting from the
Enrollee's special needs (except where continued Enrollment in
the Contractor's MMC
SECTION 8
(DISENROLLMENT)
October 1, 2005
8-3
or FHPlus product seriously impairs the Contractor's ability to
furnish services to either the Enrollee or other Enrollees).
c) Contractor initiated Disenrollments must be carried out in
accordance with the requirements and timeframes described in
Appendix H of this Agreement.
d) Once an Enrollee has been disenrolled at the Contractor's
request, he/she will not be re-enrolled with the Contractor's MMC
or FHPlus product unless the Contractor first agrees to such
re-enrollment.
8.8 LDSS Initiated Disenrollment
a) The LDSS is responsible for promptly initiating Disenrollment
when:
i) an Enrollee is no longer eligible for MMC or FHPlus; or
ii) the Guaranteed Eligibility period ends and an Enrollee is no
longer eligible for MMC or FHPlus benefits; or
iii) an Enrollee is no longer the financial responsibility of the
LDSS; or
iv) an Enrollee becomes ineligible for Enrollment pursuant to
Section 6.1 of this Agreement; or
v) an Enrollee has moved outside the service area covered by
this Agreement, unless Contractor can demonstrate that:
A) the Enrollee has made an informed choice to continue
Enrollment with the Contractor and that Enrollee will
have sufficient access to the Contractor's provider
network; and
B) fiscal responsibility for Medicaid or FHPlus coverage
remains in the county of origin.
SECTION 8
(DISENROLLMENT)
October 1, 2005
8-4
9. GUARANTEED ELIGIBILITY
9.1 General Requirements
SDOH, the LDSS and the Contractor will follow the policies in this
section subject to state and federal law and regulation.
9.2 Right to Guaranteed Eligibility
a) New Enrollees, other than those identified in Section 9.2(b)
below, who would otherwise lose Medicaid or FHPlus eligibility
during the first six (6) months of Enrollment will retain the
right to remain enrolled in the Contractor's MMC or FHPlus
product, as applicable, under this Agreement for a period of six
(6) months from their Effective Date of Enrollment.
b) Guaranteed Eligibility is not available to the following
Enrollees:
i) Enrollees who lose eligibility due to death, moving out of
State, or incarceration;
ii) Female MMC Enrollees with a net available income in excess
of medically necessary income but at or below two hundred
percent (200%) of the federal poverty level who are only
eligible for Medicaid while they are pregnant and then
through the end of the month in which the sixtieth (60th)
day following the end of the pregnancy occurs.
c) If, during the first six (6) months of Enrollment in the
Contractor's MMC product, an MMC Enrollee becomes eligible for
Medicaid only as a spend-down, the MMC Enrollee will be eligible
to remain enrolled in the Contractor's MMC product for the
remainder of the six (6) month Guaranteed Eligibility period.
During the six (6) month Guaranteed Eligibility period, an MMC
Enrollee eligible for spend-down and in need of wrap-around
services has the option of spending down to gain full Medicaid
eligibility for the wrap-around services. In this situation, the
LDSS is responsible for monitoring the MMC Enrollee's need for
wrap-around services and manually setting coverage codes as
appropriate.
d) FHPlus Enrollees who become eligible for Medicaid benefits
without an income or resource spend-down will not be entitled to
a Guaranteed Eligibility period.
e) Enrollees who lose and regain Medicaid or FHPlus eligibility
within a three (3) month period will not be entitled to a new
period of six (6) months Guaranteed Eligibility.
SECTION 9
(GUARANTEED ELIGIBILITY)
October 1, 2005
9-1
9.3 Covered Services During Guaranteed Eligibility
The services covered during the Guaranteed Eligibility period shall be
those contained in the Benefit Package, as specified in Appendix K of
this Agreement. MMC enrollees shall also be eligible to receive Free
Access to family planning and reproductive health services as set
forth in Section 10.10 of this Agreement and pharmacy services on a
Medicaid fee-for-service basis during the Guaranteed Eligibility
period.
9.4 Disenrollment During Guaranteed Eligibility
a) An Enrollee-initiated Disenrollment from the Contractor's MMC or
FHPlus product terminates the Guaranteed Eligibility period.
b) During the Guarantee Eligibility period, an Enrollee may not
change MCOs.
SECTION 9
(GUARANTEED ELIGIBILITY)
October 1, 2005
9-2
10. BENEFIT PACKAGE REQUIREMENTS
10.1 Contractor Responsibilities
Contractor must provide or arrange for the provision of all services
set forth in the Benefit Package for MMC Enrollees and FHPlus
Enrollees subject to any exclusions or limitations imposed by federal
or state Law during the period of this Agreement. SDOH and LDSS shall
assure that Medicaid services covered under the Medicaid
fee-for-service program but not covered in the Benefit Package are
available to and accessible by MMC Enrollees.
10.2 Compliance with State Medicaid Plan and Applicable Laws
a) All services provided under the Benefit Package to MMC Enrollees
must comply with all the standards of the State Medicaid Plan
established pursuant to Section 363-a of the SSL and shall
satisfy all other applicable requirements of the SSL and PHL.
b) Benefit Package Services provided by the Contractor through its
FHPlus product shall comply with all applicable requirements of
the PHL and SSL.
10.3 Definitions
The Contractor agrees to the definitions of "Benefit Package" and
"Non-Covered Services" contained in Appendix K, which is incorporated
by reference as if set forth fully herein.
10.4 Child Teen Health Program/Adolescent Preventive Services
a) The Contractor and its Participating Providers are required to
provide the Child Teen Health Program (C/THP) services outlined
in Appendix K of this Agreement and comply with applicable Early
and Periodic Screening, Diagnostic and Treatment (EPSDT)
requirements specified in 42 CFR Part 441, sub-part B, 18NYCRR
Part 508 and the New York State Department of Health C/THP
manual. The Contractor and its Participating Providers are
required to provide C/THP services to Enrollees under twenty-one
(21) years of age when:
i) The care or services are essential to prevent, diagnose,
prevent the worsening of, alleviate or ameliorate the
effects of an illness, injury, disability, disorder or
condition.
ii) The care or services are essential to the overall physical,
cognitive and mental growth and developmental needs of the
Enrollee.
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iii) The care or service will assist the Enrollee to achieve or
maintain maximum functional capacity in performing daily
activities, taking into account both the functional capacity
of the Enrollee and those functional capacities that are
appropriate for individuals of the same age as the Enrollee.
b) The Contractor shall base its determination on medical and other
relevant information provided by the Enrollee's PCP, other health
care providers, school, local social services, and/or local
public health officials that have evaluated the Enrollee.
c) The Contractor and its Participating Providers must comply with
the C/THP program standards and must do at least the following
with respect to all Enrollees under age 21:
i) Educate Enrollees who are pregnant women or who are parents
of Enrollees under age 21 about the program and its
importance to a child's or adolescent's health.
ii) Educate Participating Providers about the program and their
responsibilities under it.
iii) Conduct outreach, including by mail, telephone, and through
home visits (where appropriate), to ensure children are kept
current with respect to their periodicity schedules.
iv) Schedule appointments for children and adolescents pursuant
to the periodicity schedule, assist with referrals, and
conduct follow-up with children and adolescents who miss or
cancel appointments.
v) Ensure that all appropriate diagnostic and treatment
services, including specialist referrals, are furnished
pursuant to findings from a C/THP screen.
vi) Achieve and maintain an acceptable compliance rate for
screening schedules during the contract period.
d) In addition to C/THP requirements, the Contractor and its
Participating Providers are required to comply with the American
Medical Association's Guidelines for Adolescent Preventive
Services which require annual well adolescent preventive visits
which focus on health guidance, immunizations, and screening for
physical, emotional, and behavioral conditions.
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10.5 Foster Care Children - Applies to MMC Program Only
The Contractor shall comply with the health requirements for foster
children specified in 18 NYCRR Section 441.22 and Part 507 and any
subsequent amendments thereto. These requirements include thirty (30)
day obligations for a comprehensive physical and behavioral health
assessment and assessment of the risk that the child may be HIV+ and
should be tested.
10.6 Child Protective Services
The Contractor shall comply with the requirements specified for child
protective examinations, provision of medical information to the child
protective services investigation and court ordered services as
specified in 18 NYCRR Part 432, and any subsequent amendments thereto.
Medically necessary services must be covered, whether provided by the
Contractor's Participating Providers or not. Non-Participating
Providers will be reimbursed at the Medicaid fee schedule by the
Contractor.
10.7 Welfare Reform - Applies to MMC Program only
a) The LDSS is responsible for determining whether each public
assistance or combined public assistance/Medicaid applicant is
incapacitated or can participate in work activities. As part of
this work determination process, the LDSS may require medical
documentation and/or an initial mental and/or physical
examination to determine whether an individual has a mental or
physical impairment that limits his/her ability to engage in work
(12 NYCRR Section 1300.2(d)(13)(i)). The LDSS may not require the
Contractor to provide the initial district mandated or requested
medical examination necessary for an Enrollee to meet welfare
reform work participation requirements.
b) The Contractor shall require that the Participating Providers in
its MMC product, upon MMC Enrollee consent, provide medical
documentation and health, mental health and chemical dependence
assessments as follows:
i) Within ten (10) days of a request of an MMC Enrollee or a
former MMC Enrollee currently receiving public assistance or
who is applying for public assistance, the MMC Enrollee's or
a former MMC Enrollee's PCP or specialist provider, as
appropriate, shall provide medical documentation concerning
the MMC Enrollee or former MMC Enrollee's health or mental
health status to the LDSS or to the LDSS' designee. Medical
documentation includes but is not limited to drug
prescriptions and reports from the MMC Enrollee's PCP or
specialist provider. The Contractor shall include the
foregoing as a responsibility of the PCP and specialist
provider in its provider contracts or in their provider
manuals.
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ii) Within ten (10) days of a request of an MMC Enrollee, who
has already undergone, or is scheduled to undergo, an
initial LDSS required mental and/or physical examination,
the MMC Enrollee's PCP shall provide a health, or mental
health and/or chemical dependence assessment, examination or
other services as appropriate to identify or quantify an MMC
Enrollee's level of incapacitation. Such assessment must
contain a specific diagnosis resulting from any medically
appropriate tests and specify any work limitations. The
LDSS, may, upon written notice to the Contractor, specify
the format and instructions for such an assessment.
c) The Contractor shall designate a Welfare Reform liaison who shall
work with the LDSS or its designee to (1) ensure that MMC
Enrollees receive timely access to assessments and services
specified in this Agreement and (2) ensure completion of reports
containing medical documentation required by the LDSS.
d) The Contractor will continue to be responsible for the provision
and payment of Chemical Dependence Services in the Benefit
Package for MMC Enrollees mandated by the LDSS under Welfare
Reform if such services are already underway and the LDSS is
satisfied with the level of care and services.
e) The Contractor is not responsible for the provision and payment
of Chemical Dependence Inpatient Rehabilitation and Treatment
Services for MMC Enrollees mandated by the LDSS as a condition of
eligibility for Public Assistance or Medicaid under Welfare
Reform (as indicated by Code 83) unless such services are already
under way as described in (d) above.
f) The Contractor is not responsible for the provision and payment
of Medically Supervised Inpatient and Outpatient Withdrawal
Services for MMC Enrollees mandated by the LDSS under Welfare
Reform (as indicated by Code 83) unless such services are already
under way as described in (d) above.
g) The Contractor is responsible for the provision and payment of
Medically Managed Detoxification Services ordered by the LDSS
under Welfare Reform.
h) The Contractor is responsible for the provision of services in
Sections 10.9, 10.15 (a) and 10.23 of this Agreement for MMC
Enrollees requiring LDSS mandated Chemical Dependence Services.
10.8 Adult Protective Services
The Contractor shall cooperate with LDSS in the implementation of 18
NYCRR Part 457 and any subsequent amendments thereto with regard to
medically necessary health and mental health services, including
referrals for mental health and/or chemical dependency evaluations,
and all Court Ordered Services for
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adults. Court-ordered services that are included in the Benefit
Package must be covered, whether provided by the Contractor's
Participating Provider or not. Non-Participating Providers will be
reimbursed at the Medicaid fee schedule by the Contractor.
10.9 Court-Ordered Services
a) The Contractor shall provide any Benefit Package services to
Enrollees as ordered by a court of competent jurisdiction,
regardless of whether the court order requires such services to
be provided by a Participating Provider or by a Non-Participating
Provider. Non-Participating Providers shall be reimbursed by the
Contractor at the Medicaid fee schedule. The Contractor is
responsible for court-ordered services to the extent that such
court-ordered services are covered by the Benefit Package and
reimbursable by Medicaid or Family Health Plus, as applicable.
b) Court Ordered Services are those services ordered by the court
performed by, or under the supervision of a physician, dentist,
or other provider qualified under State law to furnish medical,
dental, behavioral health (including mental health and/or
Chemical Dependence), or other Benefit Package covered services.
The Contractor is responsible for payment of those services as
covered by the Benefit Package, even when provided by
Non-Participating Providers.
10.10 Family Planning and Reproductive Health Services
a) Nothing in this Agreement shall restrict the right of Enrollees
to receive Family Planning and Reproductive Health services, as
defined in Appendix C of this Agreement, which is hereby made a
part of this Agreement as if set forth fully herein.
i) MMC Enrollees may receive such services from any qualified
Medicaid provider, regardless of whether the provider is a
Participating or a Non-Participating Provider, without
referral from the MMC Enrollee's PCP and without approval
from the Contractor.
ii) FHPlus Enrollees may receive such services from any
Participating Provider if the Contractor includes Family
Planning and Reproductive Health services in its Benefit
Package, or directly from a provider affiliated with the
Designated Third Party Contractor if such services are not
included in the Contractor's Benefit Package, as specified
in Appendix M of this Agreement, without referral from the
FHP Enrollee's PCP and without approval from the Contractor.
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b) The Contractor shall permit Enrollees to exercise their right to
obtain Family Planning and Reproductive Health services.
i) If the Contractor includes Family Planning and Reproductive
Health services in its Benefit Package, the Contractor shall
comply with the requirements in Part C.2 of Appendix C of
this Agreement, including assuring that Enrollees are fully
informed of their rights.
ii) If the Contractor does not include Family Planning and
Reproductive Health services in its Benefit Package, the
Contractor shall comply with the requirements of Part C.3 of
Appendix C of this Agreement, including assuring that
Enrollees are fully informed of their rights.
10.11 Prenatal Care
The Contractor is responsible for arranging for the provision of
comprehensive Prenatal Care Services to all pregnant Enrollees
including all services enumerated in Subdivision 1, Section 2522 of
the PHL in accordance with 10 NYCRR Section 85.40 (Prenatal Care
Assistance Program).
10.12 Direct Access
The Contractor shall offer female Enrollees direct access to primary
and preventive obstetrics and gynecology services, follow-up care as a
result of a primary and preventive visit, and any care related to
pregnancy from Participating Providers of her choice, without referral
from the PCP as set forth in PHL Section 4406-b(l).
10.13 Emergency Services
a) The Contractor shall maintain coverage utilizing a toll free
telephone number twenty-four (24) hours per day seven (7) days
per week, answered by a live voice, to advise Enrollees of
procedures for accessing services for Emergency Medical
Conditions and for accessing Urgently Needed Services. Emergency
mental health calls must be triaged via telephone by a trained
mental health professional.
b) The Contractor agrees that it will not require prior
authorization for services in a medical or behavioral health
emergency. The Contractor agrees to inform its Enrollees that
access to Emergency Services is not restricted and that Emergency
Services may be obtained from a Non-Participating Provider
without penalty. Nothing herein precludes the Contractor from
entering into contracts with providers or facilities that require
providers or facilities to provide notification to the Contractor
after Enrollees present for Emergency Services and are
subsequently stabilized. The Contractor must pay for
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services for Emergency Medical Conditions whether provided by a
Participating Provider or a Non-Participating Provider, and may
not deny payments for failure of the Emergency Services provider
or Enrollee to give notice.
c) Emergency Services rendered by Non-Participating Providers: The
Contractor shall advise its Enrollees how to obtain Emergency
Services when it is not feasible for Enrollees to receive
Emergency Services from or through a Participating Provider. The
Contractor shall bear the cost of providing Emergency Services
through Non-Participating Providers.
d) The Contractor agrees to abide by requirements for the provision
and payment of Emergency Services and Post-stabilization Care
Services which are specified in Appendix G, which is hereby made
a part of this Agreement as if set forth fully herein.
10.14 Medicaid Utilization Thresholds (MUTS)
MMC Enrollees may be subject to MUTS for outpatient pharmacy services
which are billed to Medicaid fee-for-service and for dental services
provided without referral at Article 28 clinics operated by academic
dental centers as described in Section 10.27 of this Agreement. MMC
Enrollees are not otherwise subject to MUTS for services included in
the Benefit Package.
10.15 Services for Which Enrollees Can Self-Refer
a) Mental Health and Chemical Dependence Services
i) The Contractor will allow Enrollees to make a self referral
for one mental health assessment from a Participating
Provider and one chemical dependence assessment from a
Detoxification or Chemical Dependence Participating Provider
in any calendar year period without requiring
preauthorization or referral from the Enrollee's Primary
Care Provider. For the MMC Program, in the case of children,
such self-referrals may originate at the request of a school
guidance counselor (with parental or guardian consent, or
pursuant to procedures set forth in Section 33.21 of the
Mental Hygiene Law), LDSS Official, Judicial Official,
Probation Officer, parent or similar source.
ii) The Contractor shall make available to all Enrollees a
complete listing of their participating mental health and
Chemical Dependence Services providers. The listing should
specify which provider groups or practitioners specialize in
children's mental health services.
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iii) The Contractor will also ensure that its Participating
Providers have available and use formal assessment
instruments to identify Enrollees requiring mental health
and Chemical Dependence Services, and to determine the types
of services that should be furnished.
iv) The Contractor will implement policies and procedures to
ensure that Enrollees receive follow-up Benefit Package
services from appropriate providers based on the findings of
their mental health and/or Chemical Dependence
assessment(s), consistent with Section 15.2(a)(x) and (xi)
of this Agreement.
v) The Contractor will implement policies and procedures to
ensure that Enrollees are referred to appropriate Chemical
Dependence providers based on the findings of the Chemical
Dependence assessment by the Contractor's Participating
Provider, consistent with Section 15.2(a)(x) and (xi) of
this Agreement.
b) Vision Services
The Contractor will allow its Enrollees to self-refer to any
Participating Provider of vision services (optometrist or
ophthalmologist) for refractive vision services as described in
Appendix K of this Agreement.
c) Diagnosis and Treatment of Tuberculosis
Enrollees may self-refer to public health agency facilities for
the diagnosis and/or treatment of TB as described in Section
10.18(a) of this Agreement.
d) Family Planning and Reproductive Health Services
Enrollees may self-refer to family planning and reproductive
health services as described in Section 10.10 and Appendix C of
this Agreement.
e) Article 28 Clinics Operated by Academic Dental Centers
MMC Enrollees may self-refer to Article 28 clinics operated by
academic dental centers to obtain covered dental services as
described in Section 10.27 of this Agreement.
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10.16 Second Opinions for Medical or Surgical Care
The Contractor will allow Enrollees to obtain second opinions for
diagnosis of a condition, treatment or surgical procedure by a
qualified physician or appropriate specialist, including one
affiliated with a specialty care center. In the event that the
Contractor determines that it does not have a Participating Provider
in its network with appropriate training and experience qualifying the
Participating Provider to provide a second opinion, the Contractor
shall make a referral to an appropriate Non-Participating Provider.
The Contractor shall pay for the cost of the services associated with
obtaining a second opinion regarding medical or surgical care,
including diagnostic and evaluation services, provided by the
Non-Participating Provider.
10.17 Coordination with Local Public Health Agencies
The Contractor will coordinate its public health-related activities
with the Local Public Health Agency (LPHA) consistent with the SDOH
MCO and Public Health Guidelines. Coordination mechanisms and
operational protocols for addressing public health issues will be
negotiated with the LPHA and be customized to reflect local public
health priorities. Negotiations must result in agreements regarding
required Contractor activities related to public health as set forth
in Appendix N of this Agreement as if set forth fully herein.
10.18 Public Health Services
a) Tuberculosis Screening, Diagnosis and Treatment; Directly
Observed Therapy (TB\DOT):
i) Tuberculosis Screening, Diagnosis and Treatment services are
included in the Benefit Package as set forth in Appendix K.3
(3) (e) of this Agreement.
A) It is the State's preference that Enrollees receive TB
diagnosis and treatment through the Contractor to the
extent that Participating Providers experienced in this
type of care are available.
B) The SDOH will coordinate with the LPHA to evaluate the
Contractor's protocols against State and local
guidelines and to review the tuberculosis treatment
protocols and networks of Participating Providers to
verify their readiness to treat Tuberculosis patients.
State and local departments of health will also be
available to offer technical assistance to the
Contractor in establishing TB policies and procedures.
C) The Contractor is responsible for screening, diagnosis
and treatment of TB, except for TB/DOT services.
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D) The Contractor shall inform all Participating Providers
of their responsibility to report TB cases to the LPHA.
ii) Enrollees may self-refer to Local Public Health Agency
facilities for the diagnosis and/or treatment of TB.
A) The Contractor agrees to reimburse public health
clinics when physician visit and patient management or
laboratory and radiology services are rendered to
Enrollees within the context of TB diagnosis and
treatment.
B) The Contractor will make best effort to negotiate fees
for these services with the LPHA. If no agreement has
been reached, the Contractor agrees to reimburse the
public health clinics for these services at rates
determined by SDOH.
C) The LPHA is responsible for: 1) giving notification to
the Contractor before delivering TB related services,
if so required in the public health agreement
established pursuant to Section 10.17 of this
Agreement, unless these services are ordered by a court
of competent jurisdiction; 2) making reasonable efforts
to verify with the Enrollee's PCP that he/she has not
already provided TB care and treatment; and 3)
providing documentation of services rendered along with
the claim.
D) Prior authorization for hospital admission may not be
required by the Contractor for an admission pursuant to
a court order or an order of detention issued by the
local commissioner or director of public health.
E) The Contractor shall provide the LPHA with access to
health care practitioners on a twenty-four (24) hour a
day, seven (7) day a week basis who can authorize
inpatient hospital admissions. The Contractor shall
respond to the LPHA's request for authorization within
the same day.
F) The Contractor will not be financially liable for
treatments rendered to Enrollees who have been
institutionalized as a result of a local health
commissioner's order due to non-compliance with TB care
regimens.
iii) Directly Observed Therapy (TB/DOT) is not included in the
Benefit Package as set forth in Appendix K.3 (3) (e) and K.4
of this Agreement.
A) The Contractor will not be capitated or financially
liable for these costs.
B) The Contractor agrees to make all reasonable efforts to
ensure communication, cooperation and coordination with
TB/DOT providers regarding clinical care and services.
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C) MMC Enrollees may use any Medicaid fee-for-service
TB/DOT provider.
iv) HIV counseling and testing provided to a MMC Enrollee during
a TB related visit at a public health clinic, directly
operated by a LPHA, will be covered by Medicaid fee for
service at rates established by SDOH.
b) Immunizations
i) Immunizations are included in the Benefit Package as
provided in Appendix K of this Agreement.
A) The Contractor is responsible for all costs associated
with vaccine purchase and administration associated
with adult immunizations.
B) The Contractor is responsible for all costs associated
with vaccine administration associated with childhood
immunizations. The Contractor is not responsible for
vaccine purchase costs associated with childhood
immunizations and will inform all Participating
Providers that the vaccines may be obtained free of
charge from the Vaccine for Children Program.
ii) Enrollees may self refer to the LPHA facilities for their
immunizations.
A) The Contractor agrees to reimburse the LPHA when an
Enrollee has self referred for immunizations.
B) The Contractor will make best effort to negotiate fees
for these services with the LPHA. If no agreement has
been reached, the Contractor agrees to reimburse the
public health clinics for these services at rates
determined by SDOH.
C) The LPHA is responsible for making reasonable efforts
to
(1) determine the Enrollee's managed care membership
status; and
(2) ascertain the Enrollee's immunization status.
Reasonable efforts shall consist of client
interviews, medical records and, when available,
access to the Immunization Registry. When an
Enrollee presents a membership card with a PCP's
name, the LPHA is responsible for calling the PCP.
If the LPHA is unable to verify the immunization
status from the PCP, the LPHA is responsible for
delivering the service as appropriate.
c) Prevention and Treatment of Sexually Transmitted Diseases
The Contractor will be responsible for ensuring that its
Participating Providers educate their Enrollees about the risk
and prevention of sexually transmitted disease (STD). The
Contractor also will be responsible for ensuring that its
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Participating Providers screen and treat Enrollees for STDs and
report cases of STD to the LPHA and cooperate in contact
investigation, in accordance with existing state and local laws
and regulations. HIV counseling and testing provided to an MMC
Enrollee during an STD related visit at a public health clinic,
directly operated by a LPHA, will be covered by Medicaid
fee-for-service at rates established by SDOH.
d) Lead Poisoning - Applies to MMC Program Only
The Contractor will be responsible for carrying out and ensuring
that its Participating Providers comply with lead poisoning
screening and follow-up as specified in 10 NYCRR Sub-part 67-1.
The Contractor shall require its Participating Providers to
coordinate with the LPHA to assure appropriate follow-up in terms
of environmental investigation, risk management and reporting
requirements.
10.19 Adults with Chronic Illnesses and Physical or Developmental
Disabilities
a) The Contractor will implement all of the following to meet the
needs of its adult Enrollees with chronic illnesses and physical
or developmental disabilities:
i) Satisfactory methods for ensuring that the Contractor is in
compliance with the ADA and Section 504 of the
Rehabilitation Act of 1973. Program accessibility for
persons with disabilities shall be in accordance with
Section 24 of this Agreement.
ii) Clinical case management which uses satisfactory
methods/guidelines for identifying persons at risk of or
having, chronic diseases and disabilities and determining
their specific needs in terms of specialist physician
referrals, durable medical equipment, home health services,
self-management education and training, etc. The Contractor
shall:
A) develop protocols describing the Contractor's case
management services and minimum qualification
requirements for case management staff;
B) develop and implement protocols for monitoring
effectiveness of case management based on patient
outcomes;
C) develop and implement protocols for monitoring service
utilization, including emergency room visits and
hospitalizations, with adjustment of severity of
patient conditions;
D) provide regular information to Participating Providers
on the case management services available to Enrollees
and the criteria for referring Enrollees for case
management services.
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iii) Satisfactory methods/guidelines for determining which
patients are in need of case management services, including
establishment of severity thresholds, and methods for
identification of patients including monitoring of
hospitalizations and ER visits, provider referrals, new
Enrollee health screenings ands self referrals by Enrollees.
iv) Guidelines for determining specific needs of Enrollees in
case management, including specialist physician referrals,
durable medical equipment, home health services, self
management education and training, etc.
v) Satisfactory systems for coordinating service delivery with
Non-Participating Providers, including behavioral health
providers for all Enrollees.
vi) Policies and procedures to allow for the continuation of
existing relationships with Non-Participating Providers,
consistent with PHL Section 4403(6)(e) and Section 15.6 of
this Agreement.
10.20 Children with Special Health Care Needs
a) Children with special health care needs are those who have or are
suspected of having a serious or chronic physical, developmental,
behavioral, or emotional condition and who also require health
and related services of a type or amount beyond that required by
children generally. The Contractor will be responsible for
performing all of the same activities for this population as for
adults. In addition, the Contractor will implement the following
for these children:
i) Satisfactory methods for interacting with school districts,
preschool services, child protective service agencies, early
intervention officials, behavioral health, and developmental
disabilities service organizations for the purpose of
coordinating and assuring appropriate service delivery.
ii) An adequate network of pediatric providers and
sub-specialists, and contractual relationships with tertiary
institutions, to meet such children's medical needs.
iii) Satisfactory methods for assuring that children with
serious, chronic, and rare disorders receive appropriate
diagnostic work-ups on a timely basis.
iv) Satisfactory arrangements for assuring access to specialty
centers in and out of New York State for diagnosis and
treatment of rare disorders.
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v) A satisfactory approach for assuring access to allied health
professionals (Physical Therapists, Occupational Therapists,
Speech Therapists, and Audiologists) experienced in dealing
with children and families.
10.21 Persons Requiring Ongoing Mental Health Services
a) The Contractor will implement all of the following for its
Enrollees with chronic or ongoing mental health service needs:
i) Inclusion of all of the required provider types listed in
Section 21 of this Agreement.
ii) Satisfactory methods for identifying Enrollees requiring
such services and encouraging self-referral and early entry
into treatment.
iii) Satisfactory case management systems or satisfactory case
management.
iv) Satisfactory systems for coordinating service delivery
between physical health, chemical dependence, and mental
health providers, and coordinating services with other
available services, including Social Services.
v) The Contractor agrees to participate in the local planning
process for serving Enrollees with mental health needs to
the extent requested by the DOHMH. At the discretion of
DOHMH, the Contractor will develop linkages with local
governmental units on coordination, procedures and standards
related to mental health services and related activities.
10.22 Member Needs Relating to HIV
a) The Contractor must inform MMC Enrollees newly diagnosed with HIV
infection or AIDS, who are known to the Contractor, of their
enrollment options including the ability to return to the
Medicaid fee-for-service program or to disenroll from the
Contractor's MMC product and to enroll into HIV SNPs, if such
plan is available.
b) The Contractor will inform Enrollees about HIV counseling and
testing services available through the Contractor's Participating
Provider network; HIV counseling and testing services available
when performed as part of a Family Planning and Reproductive
Health encounter; and anonymous counseling and testing services
available from SDOH, LPHA clinics and other New York City
programs. Counseling and testing rendered outside of a Family
Planning and Reproductive Health encounter, as well as services
provided as the result of an HIV+ diagnosis, will be furnished by
the Contractor in accordance with standards of care.
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c) The Contractor agrees that anonymous testing may be furnished to
the Enrollee without prior approval by the Contractor and may be
conducted at anonymous testing sites. Services provided for HIV
treatment may only be obtained from the Contractor during the
period the Enrollee is enrolled in the Contractor's MMC or FHPlus
product.
d) To adequately address the HIV prevention needs of uninfected
Enrollees, as well as the special needs of Enrollees with HIV
infection, the Contractor shall have in place all of the
following:
i) Methods for promoting HIV prevention to all Enrollees. HIV
prevention information, both primary as well as secondary,
should be tailored to the Enrollee's age, sex, and risk
factor(s) (e.g., injection drug use and sexual risk
activities), and should be culturally and linguistically
appropriate. HIV primary prevention means the reduction or
control of causative factors for HIV, including the
reduction of risk factors. HIV Primary prevention includes
strategies to help prevent uninfected Enrollees from
acquiring HIV, i.e., behavior counseling for HIV negative
Enrollees with risk behavior. Primary prevention also
includes strategies to help prevent infected Enrollees from
transmitting HIV infection, i.e., behavior counseling with
an HIV infected Enrollee to reduce risky sexual behavior or
providing antiviral therapy to a pregnant, HIV infected
female to prevent transmission of HIV infection to a
newborn. HIV Secondary Prevention means promotion of early
detection and treatment of HIV disease in an asymptomatic
Enrollee to prevent the development of symptomatic disease.
This includes: regular medical assessments; routine
immunization for preventable infections; prophylaxis for
opportunistic infections; regular dental, optical,
dermatological and gynecological care; optimal
diet/nutritional supplementation; and partner notification
services which lead to the early detection and treatment of
other infected persons. All Enrollees should be informed of
the availability of HIV counseling, testing, referral and
partner notification (CTRPN) services.
ii) Policies and procedures promoting the early identification
of HIV infection in Enrollees. Such policies and procedures
shall include at a minimum: assessment methods for
recognizing the early signs and symptoms of HIV disease;
initial and routine screening for HIV risk factors through
administration of sexual behavior and drug and alcohol use
assessments; and the provision of information to all
Enrollees regarding the availability of HIV CTRPN services
from Participating Providers or as part of a Family Planning
and Reproductive Health services visit pursuant to Appendix
C of this Agreement, and the availability of anonymous CTRPN
services from New York State, New York City and the LPHA.
SECTION 10
(BENEFIT PACKAGE REQUIREMENTS)
October 1, 2005
10-15
iii) Policies and procedures that require Participating Providers
to provide HIV counseling and recommend HIV testing to
pregnant women in their care. The HIV counseling and testing
provided shall be done in accordance with Article 27 of the
PHL. Such policies and procedures shall also direct
Participating Providers to refer any HIV positive women in
their care to clinically appropriate services for both the
women and their newborns.
iv) A network of providers sufficient to meet the needs of its
Enrollees with HIV. Satisfaction of the network requirement
may be accomplished by inclusion of HIV specialists within
the network or the provision of HIV specialist consultation
to non-HIV specialists serving as PCPs for persons with HIV
infection; inclusion of Designated AIDS Center Hospitals or
other hospitals experienced in HIV care in the Contractor's
network; and contracts or linkages with providers funded
under the Ryan White CARE Act. The Contractor shall inform
Participating Providers about how to obtain information
about the availability of Experienced HIV Providers and HIV
Specialist PCPs.
v) Case Management Assessment for Enrollees with HIV Infection.
The Contractor shall establish policies and procedures to
ensure that Enrollees who have been identified as having HIV
infection are assessed for case management services. The
Contractor shall arrange for any Enrollee identified as
having HIV infection and needing case management services to
be referred to an appropriate case management services
provider, including Contractor provided case management,
and/or, with appropriate consent of the Enrollee, HIV
community-based psychosocial case management services and/or
COBRA Comprehensive Medicaid Case Management (CMCM) services
for MMC Enrollees.
vi) The Contractor shall require its Participating Providers to
report positive HIV test results and diagnoses and known
contacts of such persons to the New York State Commissioner
of Health. In New York City, these shall be reported to the
New York City Commissioner of Health. Access to partner
notification services must be consistent with 10 NYCRR Part
63.
vii) The Contractor's Medical Director shall review Contractor's
HIV practice guidelines at least annually and update them as
necessary for compliance with recommended SDOH AIDS
Institute and federal government clinical standards. The
Contractor will disseminate the HIV Practice Guidelines or
revised guidelines to Participating Providers at least
annually, or more frequently as appropriate.
SECTION 10
(BENEFIT PACKAGE REQUIREMENTS)
October 1, 2005
10-16
10.23 Persons Requiring Chemical Dependence Services
a) The Contractor will have in place all of the following for its
Enrollees requiring Chemical Dependence Services:
i) A Participating Provider network which includes of all the
required provider types listed in Section 21 of this
Agreement.
ii) Satisfactory methods for identifying Enrollees requiring
such services and encouraging self-referral and early entry
into treatment and methods for referring Enrollees to the
New York State Office of Alcoholism and Substance Abuse
Services (OASAS) for appropriate services beyond the
Contractor's Benefit Package (e.g., halfway houses).
iii) Satisfactory systems of care, including Participating
Provider networks and referral processes sufficient to
ensure that emergency services, including crisis services,
can be provided in a timely manner.
iv) Satisfactory case management systems.
v) Satisfactory systems for coordinating service delivery
between physical health, chemical dependence, and mental
health providers, and coordinating services received from
Participating Providers with other services, including
Social Services.
vi) The Contractor also agrees to participate in the local
planning process for serving persons with chemical
dependence, to the extent requested by the DOHMH. At the
discretion of DOHMH, the Contractor will develop linkages
with local governmental units on coordination procedures and
standards related to Chemical Dependence Services and
related activities.
10.24 Native Americans
If an Enrollee is a Native American and the Enrollee chooses to access
primary care services through his/her tribal health center, the PCP
authorized by the Contractor to refer the Enrollee for services
included in the Benefit Package must develop a relationship with the
Enrollee's PCP at the tribal health center to coordinate services for
said Native American Enrollee.
10.25 Women, Infants, and Children (WIC)
The Contractor shall develop linkage agreements or other mechanisms to
refer Enrollees who are pregnant and Enrollees with children younger
than five (5) years of age to WIC local agencies for nutritional
assessments and supplements.
SECTION 10
(BENEFIT PACKAGE REQUIREMENTS)
October 1, 2005
10-17
10.26 Urgently Needed Services
The Contractor is financially responsible for Urgently Needed
Services. Urgently Needed Services are covered only in the United
States, the Commonwealth of Puerto Rico, the U.S. Virgin Islands,
Guam, American Samoa, the Northern Mariana Islands and Canada. The
Contractor may require the Enrollee or the Enrollee's designee to
coordinate with the Contractor or the Enrollee's PCP prior to
receiving care.
10.27 Dental Services Provided by Article 28 Clinics Operated by Academic
Dental Centers Not Participating in Contractor's Network - Applies to
MMC Program Only
a) Consistent with Chapter 697 of Laws of 2003 amending Section
364-j of the Social Services Law, dental services provided by
Article 28 clinics operated by academic dental centers may be
accessed directly by MMC Enrollees without prior approval and
without regard to network participation.
b) If dental services are part of the Contractor's Benefit Package,
the Contractor will reimburse non-participating Article 28
clinics operated by academic dental centers for covered dental
services provided to MMC Enrollees at approved Article 28
Medicaid clinic rates in accordance with the protocols issued by
the SDOH.
10.28 Hospice Services
a) For FHPlus only: the Contractor shall provide a coordinated
hospice program of home and inpatient services which provides
non-curative medical and support services for FHPlus Enrollees
certified by a physician to be terminally ill with a life
expectancy of six months or less. Hospices must be certified
under Article 40 of the New York State Public Health Law.
b) MMC Enrollees receive coverage for hospice services through the
Medicaid fee-for-service program.
10.29 Prospective Benefit Package Change for Retroactive SSI Determinations
- Applies to MMC Program Only
The Benefit Package and associated Capitation Rate for MMC Enrollees
who become SSI or SSI related retroactively shall be changed
prospectively as of the effective date of the Roster on which the
Enrollee's status change appears.
SECTION 10
(BENEFIT PACKAGE REQUIREMENTS)
October 1, 2005
10-18
10.30 Coordination of Services
a) The Contractor shall coordinate care for Enrollees, as
applicable, with:
i) the court system (for court ordered evaluations and
treatment);
ii) specialized providers of health care for the homeless, and
other providers of services for victims of domestic
violence;
iii) family planning clinics, community health centers, migrant
health centers, rural health centers;
iv) WIC, Head Start, Early Intervention;
v) programs funded through the Ryan White CARE Act;
vi) other pertinent entities that provide services out of
network;
vii) Prenatal Care Assistance Program (PCAP) Providers;
viii) local governmental units responsible for public health,
mental health, mental retardation or Chemical Dependence
Services;
ix) specialized providers of long term care for people with
developmental disabilities; and
x) School-based health centers.
b) Coordination may involve contracts or linkage agreements (if
entities are willing to enter into such an agreement), or other
mechanisms to ensure coordinated care for Enrollees, such as
protocols for reciprocal referral and communication of data and
clinical information on MCO Enrollees.
SECTION 10
(BENEFIT PACKAGE REQUIREMENTS)
October 1, 2005
10-19
11. MARKETING
11.1 Information Requirements
a) The Contractor shall provide Prospective Enrollees, upon request,
with pre-enrollment and post-enrollment information pursuant to
PHL Section 4408 and SSL Section 364-j.
b) The Contractor shall provide Prospective Enrollees, upon request,
with the most current and complete listing of Participating
Providers, as described in Section 13.2(a) of this Agreement, in
hardcopy, along with any updates to that listing.
c) The Contractor shall provide Potential Enrollees with
pre-enrollment and post-enrollment information pursuant to 42 CFR
Section 438.10(e).
d) The Contractor must inform Potential Enrollees that oral
interpretation service is available for any language and that
information is available in alternate formats and how to access
these formats.
11.2 Marketing Plan
a) The Contractor shall have a Marketing plan that has been
prior-approved by the SDOH and the DOHMH that describes the
Marketing activities the Contractor will undertake within the
service area, as specified in Appendix M of this Agreement,
during the term of this Agreement.
b) The Marketing plan and all Marketing activities must comply with
the Marketing Guidelines which are set forth in Appendix D and
any New York City Specific marketing requirements as set forth in
Appendix N, which are hereby made a part of this Agreement as if
set forth fully herein.
c) The Marketing plan shall be kept on file in the offices of the
Contractor, the DOHMH, and the SDOH. The Marketing plan may be
modified by the Contractor subject to prior written approval by
the SDOH and the DOHMH. The SDOH and DOHMH must take action on
the changes submitted within sixty (60) calendar days of
submission or the Contractor may deem the changes approved.
11.3 Marketing Activities
Marketing activities by the Contractor shall conform to the approved
Marketing Plan.
SECTION 11
(MARKETING)
October 1, 2005
11-1
11.4 Prior Approval of Marketing Materials and Procedures
The Contractor shall submit all procedures and materials related to
Marketing to Prospective Enrollees to the SDOH for prior written
approval, as described in Appendix D of this Agreement. The Contractor
shall not use any procedures or materials that the SDOH has not
approved. Marketing materials shall be made available by the
Contractor throughout its entire service area. Marketing materials may
be customized for specific counties and populations within the
Contractor's service area. All Marketing activities should provide for
equitable distribution of materials without bias toward or against any
group.
11.5 Corrective and Remedial Actions
a) If the Contractor's Marketing activities do not comply with the
Marketing Guidelines set forth in Appendix D of this Agreement or
the Contractor's approved Marketing plan, the SDOH and/or the
DOHMH, may take the actions described in (i), (ii) and (iii)
below to protect the interests of Enrollees and the integrity of
the MMC and FHPlus Programs. The Contractor shall take the
corrective and remedial actions directed by the SDOH and/or DOHMH
within the specified timeframes.
i) If the Contractor or its representative commits a first time
infraction of the Marketing Guidelines and/or the
Contractor's approved Marketing plan, and the SDOH and/or
the DOHMH deem the infraction to be minor or unintentional
in nature, the SDOH and/or the DOHMH may issue a warning
letter to the Contractor.
ii) If the Contractor engages in Marketing activities that SDOH
and/or DOHMH determines, in it sole discretion, to be an
intentional or serious breach of the Marketing Guidelines or
the Contractor's approved Marketing plan, or a pattern of
minor breaches, SDOH and/or the DOHMH may require the
Contractor to, and the Contractor shall, prepare and
implement a corrective action plan acceptable to SDOH and/or
DOHMH within a specified timeframe. In addition, or
alternatively, SDOH and the DOHMH, in consultation with
SDOH, may impose sanctions, including monetary penalties, as
permitted by law.
iii) If the Contractor commits further infractions, fails to pay
monetary penalties within the specified timeframe, fails to
implement a corrective action plan in a timely manner or
commits an egregious first-time infraction, the SDOH, or
DOHMH, in consultation with the SDOH, may in addition to any
other legal remedy available to SDOH and/or DOHMH in law or
equity:
SECTION 11
(MARKETING)
October 1, 2005
11-2
A) direct the Contractor to suspend its Marketing
activities for a period up to the end of the Agreement
period;
B) suspend new Enrollments, other than newborns, for a
period up to the remainder of the Agreement period; or
C) terminate this Agreement pursuant to termination
procedures described in Section 2.7 of this Agreement.
SECTION 11
(MARKETING)
October 1, 2005
11-3
12. MEMBER SERVICES
12.1 General Functions
a) The Contractor shall operate a Member Services Department during
regular business hours, which must be accessible to Enrollees via
a toll-free telephone line. Personnel must also be available via
a toll-free telephone line (which can be the member services
toll-free line or separate toll-free lines) not less than during
regular business hours to address complaints and utilization
review inquiries. In addition, the Contractor must have a
telephone system capable of accepting, recording or providing
instruction in response to incoming calls regarding complaints
and utilization review during other than normal business hours
and measures in place to ensure a response to those calls the
next business day after the call was received.
b) At a minimum, the Member Services Department must be staffed at a
ratio of at least one (1) full time equivalent Member Service
Representative for every four thousand (4,000) or fewer
Enrollees.
c) Member Services staff must be responsible for the following:
i) Explaining the Contractor's rules for obtaining services and
assisting Enrollees in making appointments.
ii) Assisting Enrollees to select or change Primary Care
Providers.
iii) Fielding and responding to Enrollee questions and
complaints, and advising Enrollees of the prerogative to
complain to the SDOH and LDSS at any time.
iv) Clarifying information in the member handbook for Enrollees.
v) Advising Enrollees of the Contractor's complaint and appeals
program, the utilization review process, and Enrollee's
rights to a fair hearing or external review.
vi) Clarifying for MMC Enrollees current categories of
exemptions and exclusions. The Contractor may refer to the
LDSS or the Enrollment Broker, where one is in place, if
necessary, for more information on exemptions and
exclusions.
12.2 Translation and Oral Interpretation
a) The Contractor must make available written marketing and other
informational materials (e.g., member handbooks) in a language
other than English whenever at least five percent (5%) of the
Prospective Enrollees of
SECTION 12
(MEMBER SERVICES)
October 1, 2005
12-1
the Contractor in any county of the service area speak that
particular language and do not speak English as a first language.
b) In addition, verbal interpretation services must be made
available to Enrollees and Potential Enrollees who speak a
language other than English as a primary language. Interpreter
services must be offered in person where practical, but otherwise
may be offered by telephone.
c) The SDOH will determine the need for other than English
translations based on county-specific census data or other
available measures.
12.3 Communicating with the Visually, Hearing and Cognitively Impaired
The Contractor also must have in place appropriate alternative
mechanisms for communicating effectively with persons with visual,
hearing, speech, physical or developmental disabilities. These
alternative mechanisms include Braille or audio tapes for the visually
impaired, TTY access for those with certified speech or hearing
disabilities, and use of American Sign Language and/or integrative
technologies.
SECTION 12
(MEMBER SERVICES)
October 1, 2005
12-2
13. ENROLLEE RIGHTS AND NOTIFICATION
13.1 Information Requirements
a) The Contractor shall provide new Enrollees with the information
identified in PHL Section 4408, SSL Section 364-j, SSL Section
369-ee and 42 CFR Section 438.10 (f) and (g).
b) The Contractor shall provide such information to the Enrollee
within fourteen (14) days of the Effective Date of Enrollment.
The Contractor may provide such information to the Enrollee
through the Member Handbook referenced in Section 13.4 of this
Agreement.
c) The Contractor must provide Enrollees with an annual notice that
this information is available to them upon request.
d) The Contractor must inform Enrollees that oral interpretation
service is available for any language and that information is
available in alternative formats and how to access these formats.
13.2 Provider Directories/Office Hours for Participating Providers
a) The Contractor shall maintain and update, on a quarterly basis, a
listing by specialty of the names, addresses and telephone
numbers of all Participating Providers, including facilities.
Such a list/directory shall include names, office addresses,
telephone numbers, board certification for physicians,
information on language capabilities and wheelchair accessibility
of Participating Providers. The list should also identify
providers that are not accepting new patients.
b) New Enrollees must receive the most current complete listing in
hardcopy, along with any updates to such listing.
c) Enrollees must be notified of updates in writing at least
annually in one of the following methods: (1) provide updates in
hardcopy; (2) provide a new complete listing/directory in
hardcopy; or (3) provide written notification that a new complete
listing/directory is available and will be provided upon request
either in hardcopy, or electronically if the Contractor has the
capability of providing such data in an electronic format and the
data is requested in that format by an Enrollee.
d) In addition, the Contractor must make available to the LDSS the
office hours for Participating Providers. This requirement may be
satisfied by providing a copy of the list or Provider Directory
described in this Section with the addition of office hours or by
providing a separate listing of office hours for Participating
Providers.
SECTION 13
(ENROLLEE RIGHTS AND NOTIFICATION)
October 1, 2005
13-1
13.3 Member ID Cards
a) The Contractor must issue an identification card to the Enrollee
containing the following information:
i) the name of the Enrollee's clinic (if applicable);
ii) the name of the Enrollee's PCP and the PCP's telephone
number (if an Enrollee is being served by a PCP team, the
name of the individual shown on the card should be the lead
provider);
iii) the member services toll free telephone number;
iv) the twenty-four (24) hour toll free telephone number that
Enrollees may use to access information on obtaining
services when his/her PCP is not available; and
v) for ID Cards issued after October 1, 2004, the Enrollee's
Client Identification Number (CIN).
b) PCP information may be embossed on the card or affixed to the
card by a sticker.
c) The Contractor shall issue an identification card within fourteen
(14) days of an Enrollee's Effective Date of Enrollment. If
unforeseen circumstances, such as the lack of identification of a
PCP, prevent the Contractor from forwarding the official
identification card to new Enrollees within the fourteen (14) day
period, alternative measures by which Enrollees may identify
themselves such as use of a Welcome Letter or a temporary
identification card shall be deemed acceptable until such time as
a PCP is either chosen by the Enrollee or auto assigned by the
Contractor. The Contractor agrees to implement an alternative
method by which individuals may identify himself/herself as
Enrollees prior to receiving the card (e.g., using a "welcome
letter" from the Contractor) and to update PCP information on the
identification card. Newborns of Enrollees need not present ID
cards in order to receive Benefit Package services from the
Contractor and its Participating Providers. The Contractor is not
responsible for providing Benefit Package services to newborns
Excluded from the MMC Program pursuant to Appendix H of this
Agreement, or when the Contractor does not offer an MMC product
in the mother's county of fiscal responsibility.
13.4 Member Handbooks
The Contractor shall issue to a new Enrollee within fourteen (14) days
of the Effective Date of Enrollment a Member Handbook, which is
consistent with the SDOH guidelines described in Appendix E, which is
hereby made a part of this Agreement as if set forth fully herein.
SECTION 13
(ENROLLEE RIGHTS AND NOTIFICATION)
October 1, 2005
13-2
13.5 Notification of Effective Date of Enrollment
The Contractor shall inform each Enrollee in writing within fourteen
(14) days of the Effective Date of Enrollment of any restriction on
the Enrollee's right to terminate enrollment. The initial enrollment
information and the Member Handbook shall be adequate to convey this
notice.
13.6 Notification of Enrollee Rights
a) The Contractor agrees to make all reasonable efforts to contact
new Enrollees, in person, by telephone, or by mail, within thirty
(30) days of their Effective Date of Enrollment. "Reasonable
efforts" are defined to mean at least three (3) attempts, with
more than one method of contact being employed. Upon contacting
the new Enrollee(s), the Contractor agrees to do at least the
following:
i) Inform the Enrollee about the Contractor's policies with
respect to obtaining medical services, including services
for which the Enrollee may self-refer pursuant to Section
10.15 of this Agreement, and what to do in an emergency.
ii) Conduct a brief health screening to assess the Enrollee's
need for any special health care (e.g., prenatal or
behavioral health services) or language/communication needs.
If a special need is identified, the Contractor shall assist
the Enrollee in arranging for an appointment with his/her
PCP or other appropriate provider.
iii) Offer assistance in arranging an initial visit to the
Enrollee's PCP for a baseline physical and other preventive
services, including an assessment of the Enrollee's
potential risk, if any, for specific diseases or conditions.
iv) Inform new Enrollees about their rights for continuation of
certain existing services.
v) Provide the Enrollee with the Contractor's toll free
telephone number that may be called twenty-four (24) hours a
day, seven (7) days a week if the Enrollee has questions
about obtaining services and cannot reach his/her PCP (this
telephone number need not be the Member Services line and
need not be staffed to respond to Member Services-related
inquiries). The Contractor must have appropriate mechanisms
in place to accommodate Enrollees who do not have telephones
and therefore cannot readily receive a call back.
SECTION 13
(ENROLLEE RIGHTS AND NOTIFICATION)
October 1, 2005
13-3
vi) Advise Enrollee about opportunities available to learn about
the Contractor's policies and benefits in greater detail
(e.g., welcome meeting, Enrollee orientation and education
sessions).
vii) Assist the Enrollee in selecting a primary care provider if
one has not already been chosen.
13.7 Enrollee's Rights
a) The Contractor shall, in compliance with the requirements of 42
CFR Section 438.6(i)(1) and 42 CFR Part 489 Subpart I, maintain
written policies and procedures regarding advance directives and
inform each Enrollee in writing at the time of enrollment of an
individual's rights under State law to formulate advance
directives and of the Contractor's policies regarding the
implementation of such rights. The Contractor shall include in
such written notice to the Enrollee materials relating to advance
directives and health care proxies as specified in 10 NYCRR Part
98 and Section 700.5. The written information must reflect
changes in State law as soon as possible, but no later than
ninety (90) days after the effective date of the change.
b) The Contractor shall have policies and procedures that protect
the Enrollee's right to:
i) receive information about the Contractor and managed care;
ii) be treated with respect and due consideration for his or her
dignity and privacy;
iii) receive information on available treatment options and
alternatives, presented in a manner appropriate to the
Enrollee's condition and ability to understand;
iv) participate in decisions regarding his or her health care,
including the right to refuse treatment;
v) be free from any form of restraint or seclusion used as a
means of coercion, discipline, convenience or retaliation,
as specified in Federal regulations on the use of restraints
and seclusion; and
vi) If the privacy rule, as set forth in 45 CFR Parts 160 and
164 Subparts A and E, applies, request and receive a copy
of his or her medical records and request that they be
amended or corrected, as specified in 45 CFR Sections
164.524 and 164.526.
SECTION 13
(ENROLLEE RIGHTS AND NOTIFICATION)
October 1, 2005
13-4
c) The Contractor's policies and procedures must require that
neither the Contractor nor its Participating Providers adversely
regard an Enrollee who exercises his/her rights in 13.7(b) above.
13.8 Approval of Written Notices
The Contractor shall submit the format and content of all written
notifications described in this Section to SDOH for review and prior
approval by SDOH in consultation with DOHMH. All written notifications
must be written at a fourth (4th) to sixth (6th) grade level and in at
least ten (10) point print.
13.9 Contractor's Duty to Report Lack of Contact
The Contractor must inform the LDSS of any Enrollee it is unable to
contact within ninety (90) days of Enrollment using reasonable efforts
as defined in Section 13.6 of the Agreement and who have not presented
for any health care services through the Contractor or its
Participating Providers.
13.10 LDSS Notification of Enrollee's Change in Address
The LDSS is responsible for notifying the Contractor of any known
change in address of Enrollees.
13.11 Contractor Responsibility to Notify Enrollee of Effective Date of
Benefit Package Change
The Contractor must provide written notification of the effective date
of any Contractor-initiated, SDOH and DOHMH approved Benefit Package
change to Enrollees. Notification to Enrollees must be provided at
least thirty (30) days in advance of the effective date of such
change.
13.12 Contractor Responsibility to Notify Enrollee of Termination, Service
Area Changes and Network Changes
a) With prior notice to and approval of the SDOH and DOHMH, the
Contractor shall inform each Enrollee in writing of any
withdrawal by the Contractor from the MMC or FHPlus Program
pursuant to Section 2.7 of this Agreement, withdrawal from the
service area encompassing the Enrollee's zip code, and/or
significant changes to the Contractor's Participating Provider
network pursuant to Section 21.1(d) of this Agreement, except
that the Contractor need not notify Enrollees who will not be
affected by such changes.
b) The Contractor shall provide the notifications within the
timeframes specified by SDOH, and shall obtain the prior approval
of the notification from SDOH in consultation with DOHMH.
SECTION 13
(ENROLLEE RIGHTS AND NOTIFICATION)
October 1, 2005
13-5
14. ACTION AND GRIEVANCE SYSTEM
14.1 General Requirements
a) The Contractor shall establish and maintain written Action
procedures and a comprehensive Grievance System that complies
with the Managed Care Action and Grievance System Requirements
for MMC and FHPlus Programs described in Appendix F, which is
hereby made a part of this Agreement as if set forth fully
herein. Nothing herein shall release the Contractor from its
responsibilities under PHL Section 4408-a or PHL Article 49 and
10 NYCRR Part 98 that is not otherwise expressly established in
Appendix F.
b) The Contractor's Action procedure and Grievance System shall be
approved by the SDOH and kept on file with the Contractor and
SDOH.
c) The Contractor shall not modify its Action procedure or Grievance
System without the prior written approval of SDOH, and shall
provide SDOH with a copy of the approved modification within
fifteen (15) days of its approval.
14.2 Actions
a) The Contractor must have in place effective mechanisms to ensure
consistent application of review criteria for Service
Authorization Determinations and consult with the requesting
provider when appropriate.
b) If the Contractor subcontracts for Service Authorization
Determinations and utilization review, the Contractor must ensure
that its subcontractors have in place and follow written policies
and procedures for delegated activities regarding processing
requests for initial and continuing authorization of services
consistent with Article 49 of the PHL, 10 NYCRR Part 98, 42 CFR
Part 438, Appendix F of this Agreement, and the Contractor's
policies and procedures.
c) The Contractor must ensure that compensation to individuals or
entities that perform Service Authorization Determination and
utilization management activities is not structured to include
incentives that would result in the denial, limiting, or
discontinuance of medically necessary services to Enrollees.
d) The Contractor or its subcontractors may not arbitrarily deny or
reduce the amount, duration, or scope of a covered service solely
because of the diagnosis, type of illness, or Enrollee's
condition. The Contractor may place appropriate limits on a
service on the basis of criteria such as medical necessity or
utilization control, provided that the services furnished can
reasonably be expected to achieve their purpose.
SECTION 14
(ACTION AND GRIEVANCE SYSTEM)
October 1, 2005
14-1
14.3 Grievance System
a) The Contractor shall ensure that its Grievance System includes
methods for prompt internal adjudication of Enrollee Complaints,
Complaint Appeals and Action Appeals and provides for the
maintenance of a written record of all Complaints, Complaint
Appeals and Action Appeals received and reviewed and their
disposition, as specified in Appendix F of this Agreement.
b) The Contractor shall ensure that persons with authority to
require corrective action participate in the Grievance System.
14.4 Notification of Action and Grievance System Procedures
a) The Contractor will advise Enrollees of their right to a fair
hearing as appropriate and comply with the procedures established
by SDOH for the Contractor to participate in the fair hearing
process, as set forth in Section 25 of this Agreement. The
Contractor will also advise Enrollees of their right to an
External Appeal, in accordance with Section 26 of this Agreement.
b) The Contractor will provide written notice of the following
Complaint, Complaint Appeal, Action Appeal and fair hearing
procedures to all Participating Providers and subcontractors to
whom the Contractor has delegated utilization review and Service
Authorization Determination procedures at the time they enter
into an agreement with the Contractor:
i) the Enrollee's right to a fair hearing, how to obtain a fair
hearing, and representation rules at a hearing;
ii) the Enrollee's right to file Complaints, Complaint Appeals
and Action Appeals and the process and timeframes for
filing;
iii) the Enrollee's right to designate a representative to file
Complaints, Complaint Appeals and Action Appeals on his/her
behalf;
iv) the availability of assistance from the Contractor for
filing Complaints, Complaint Appeals and Action Appeals;
v) the toll-free numbers to file oral Complaints, Complaint
Appeals and Action Appeals;
vi) the Enrollee's right to request continuation of benefits
while an Action Appeal or state fair hearing is pending,
and, that if the Contractor's Action is upheld in a hearing,
the Enrollee may be liable for the cost of any continued
benefits;
SECTION 14
(ACTION AND GRIEVANCE SYSTEM)
October 1, 2005
14-2
vii) the right of the provider to reconsideration of an Adverse
Determination pursuant to Section 4903(6) of the PHL; and
viii) the right of the provider to appeal a retrospective Adverse
Determination pursuant to Section 4904(1) of the PHL.
14.5 Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
The Contractor must adhere to determinations resulting from Complaint,
Complaint Appeal and Action Appeal investigations conducted by SDOH.
SECTION 14
(ACTION AND GRIEVANCE SYSTEM)
October 1, 2005
14-3
15. ACCESS REQUIREMENTS
15.1 General Requirement
The Contractor will establish and implement mechanisms to ensure that
Participating Providers comply with timely access requirements,
monitor regularly to determine compliance and take corrective action
if there is a failure to comply.
15.2 Appointment Availability Standards
a) The Contractor shall comply with the following minimum
appointment availability standards, as applicable(1).
i) For emergency care: immediately upon presentation at a
service delivery site.
ii) For urgent care: within twenty-four (24) hours of request.
iii) Non-urgent "sick" visit: within forty-eight (48) to
seventy-two (72) hours of request, as clinically indicated.
iv) Routine non-urgent, preventive appointments: within four (4)
weeks of request.
v) Specialist referrals (not urgent): within four (4) to six
(6) weeks of request.
vi) Initial prenatal visit: within three (3) weeks during first
trimester, within two (2) weeks during the second trimester
and within one (1) week during the third trimester.
vii) Adult Baseline and routine physicals: within twelve (12)
weeks from enrollment. (Adults >21 years),
viii) Well child care: within four (4) weeks of request.
ix) Initial family planning visits: within two (2) weeks of
request.
x) Pursuant to an emergency or hospital discharge, mental
health or chemical dependence follow-up visits with a
Participating Provider (as included in the Benefit Package):
within five (5) days of request, or as clinically indicated.
xi) Non-urgent mental health or chemical dependence visits with
a Participating Provider (as included in the Benefit
Package): within two (2) weeks of request.
xii) Initial PCP office visit for newborns: within two (2) weeks
of hospital discharge.
- ----------
(1) These are general standards and are not intended to supersede sound
clinical judgement as to the necessity for care and services on a more
expedient basis, when judged clinically necessary and appropriate.
SECTION 15
(ACCESS REQUIREMENTS)
October 1, 2005
15-1
xiii) Provider visits to make health, mental health and chemical
dependence assessments for the purpose of making
recommendations regarding a recipient's ability to perform
work when requested by a LDSS: within ten (10) days of
request by an MMC Enrollee, in accordance with Section 10.7
of this Agreement.
15.3 Twenty-Four (24) Hour Access
a) The Contractor must provide access to medical services and
coverage to Enrollees, either directly or through their PCPs and
OB/GYNs, on a twenty- four (24) hour a day, seven (7) day a week
basis. The Contractor must instruct Enrollees on what to do to
obtain services after business hours and on weekends.
b) The Contractor may satisfy the requirement in Section 15.3(a) by
requiring their PCPs and OB/GYNs to have primary responsibility
for serving as an after hours "on-call" telephone resource to
members with medical problems. Under no circumstances may the
Contractor routinely refer calls to an emergency room.
15.4 Appointment Waiting Times
Enrollees with appointments shall not routinely be made to wait longer
than one hour.
15.5 Travel Time Standards
a) The Contractor will maintain a network that is geographically
accessible to the population to be served.
b) Primary Care
i) Travel time/distance to primary care sites shall not exceed
thirty (30) minutes from the Enrollee's residence in
metropolitan areas or thirty (30) minutes/thirty (30) miles
from the Enrollee's residence in non-metropolitan areas.
Transport time and distance in rural areas to primary care
sites may be greater than thirty (30) minutes/thirty (30)
miles from the Enrollee's residence if based on the
community standard for accessing care or if by Enrollee
choice.
ii) Enrollees may, at their discretion, select participating
PCPs located farther from their homes as long as they are
able to arrange and pay for transportation to the PCP
themselves.
SECTION 15
(ACCESS REQUIREMENTS)
October 1, 2005
15-2
c) Other Providers
Travel time/distance to specialty care, hospitals, mental health,
lab and x-ray providers shall not exceed thirty (30)
minutes/thirty (30) miles from the Enrollee's residence.
Transport time and distance in rural areas to specialty care,
hospitals, mental health, lab and x-ray providers may be greater
than thirty (30) minutes/thirty (30) miles from the Enrollee's
residence if based on the community standard for accessing care
or if by Enrollee choice.
15.6 Service Continuation
a) New Enrollees
i) If a new Enrollee has an existing relationship with a health
care provider who is not a member of the Contractor's
provider network, the Contractor shall permit the Enrollee
to continue an ongoing course of treatment by the
Non-Participating Provider during a transitional period of
up to sixty (60) days from the Effective Date of Enrollment,
if, (1) the Enrollee has a life-threatening disease or
condition or a degenerative and disabling disease or
condition, or (2) the Enrollee has entered the second
trimester of pregnancy at the Effective Date of Enrollment,
in which case the transitional period shall include the
provision of post-partum care directly related to the
delivery up until sixty (60) days post partum. If the new
Enrollee elects to continue to receive care from such
Non-Participating Provider, such care shall be authorized by
the Contractor for the transitional period only if the
Non-Participating Provider agrees to:
A) accept reimbursement from the Contractor at rates
established by the Contractor as payment in full, which
rates shall be no more than the level of reimbursement
applicable to similar providers within the Contractor's
network for such services; and
B) adhere to the Contractor's quality assurance
requirements and agrees to provide to the Contractor
necessary medical information related to such care; and
C) otherwise adhere to the Contractor's policies and
procedures including, but not limited to procedures
regarding referrals and obtaining pre-authorization in
a treatment plan approved by the Contractor.
ii) In no event shall this requirement be construed to require
the Contractor to provide coverage for benefits not
otherwise covered.
SECTION 15
(ACCESS REQUIREMENTS)
October 1, 2005
15-3
b) Enrollees Whose Health Care Provider Leaves Network
i) The Contractor shall permit an Enrollee, whose health care
provider has left the Contractor's network of providers, for
reasons other than imminent harm to patient care, a
determination of fraud or a final disciplinary action by a
state licensing board that impairs the health professional's
ability to practice, to continue an ongoing course of
treatment with the Enrollee's current health care provider
during a transitional period, consistent with PHL Section
4403(6)(e).
ii) The transitional period shall continue up to ninety (90)
days from the date the provider's contractual obligation to
provide services to the Contractor's Enrollees terminates;
or, if the Enrollee has entered the second trimester of
pregnancy, for a transitional period that includes the
provision of post-partum care directly related to the
delivery through sixty (60) days post partum. If the
Enrollee elects to continue to receive care from such
Non-Participating Provider, such care shall be authorized by
the Contractor for the transitional period only if the
Non-Participating Provider agrees to:
A) accept reimbursement from the Contractor at rates
established by the Contractor as payment in full, which
rates shall be no more than the level of reimbursement
applicable to similar providers within the Contractor's
network for such services;
B) adhere to the Contractor's quality assurance
requirements and agrees to provide to the Contractor
necessary medical information related to such care; and
C) otherwise adhere to the Contractor's policies and
procedures including, but not limited to procedures
regarding referrals and obtaining pre-authorization in
a treatment plan approved by the Contractor.
iii) In no event shall this requirement be construed to require
the Contractor to provide coverage for benefits not
otherwise covered.
15.7 Standing Referrals
The Contractor will implement policies and procedures to allow for
standing referrals to specialist physicians for Enrollees who have
ongoing needs for care from such specialists, consistent with PHL
Section 4403(6)(b).
SECTION 15
(ACCESS REQUIREMENTS)
October 1, 2005
15-4
15.8 Specialist as a Coordinator of Primary Care
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or degenerative and disabling
disease or condition, which requires prolonged specialized medical
care, to receive a referral to a specialist, who will then function as
the coordinator of primary and specialty care for that Enrollee,
consistent with PHL Section 4403(6)(c).
15.9 Specialty Care Centers
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or a degenerative and disabling
condition or disease, which requires prolonged specialized medical
care to receive a referral to an accredited or designated specialty
care center with expertise in treating the life-threatening or
degenerative and disabling disease or condition, consistent with PHL
Section 4403(6)(d).
15.10 Cultural Competence
The Contractor will participate in the State's efforts to promote the
delivery of services in a culturally competent manner to all
Enrollees, including those with limited English proficiency and
diverse cultural and ethnic backgrounds.
SECTION 15
(ACCESS REQUIREMENTS)
October 1, 2005
15-5
16. QUALITY MANAGEMENT
16.1 Internal Quality Management Program
a) Contractor must operate a quality management program which is
approved by SDOH and which includes methods and procedures to
control the utilization of services consistent with Article 49 of
the PHL and 42 CFR Part 456. Enrollee's records must include
information needed to perform utilization review as specified in
42 CFR Sections 456.111 and 456.211. The Contractor's approved
quality management program must be kept on file by the
Contractor. The Contractor shall not modify the quality
management program without the prior written approval of the
SDOH.
b) The Contractor shall incorporate the findings from reports in
Section 18 of this Agreement into its quality management program.
Where performance is less than the statewide average or another
standard as defined by the SDOH and developed in consultation
with DOHMH, MCOs and appropriate clinical experts, the Contractor
will be required to develop and implement a plan for improving
performance that is approved by the SDOH and that specifies the
expected level of improvement and timeframes for actions expected
to result in such improvement. In the event that such approved
plan proves to be impracticable or does not result in the
expected level of improvement, the Contractor shall, in
consultation with SDOH, develop alternative plans to achieve
improvement, to be implemented upon SDOH approval. If requested
by SDOH, the Contractor agrees to meet with the SDOH and DOHMH to
review improvement plans and quality performance.
16.2 Standards of Care
a) The Contractor must adopt practice guidelines consistent with
current standards of care, complying with recommendations of
professional specialty groups or the guidelines of programs such
as the American Academy of Pediatrics, the American Academy of
Family Physicians, the US Task Force on Preventive Care, the New
York State Child/Teen Health Program (C/THP) standards for
provision of care to individuals under age twenty-one (21), the
American Medical Association's Guidelines for Adolescent and
Preventive Services, the US Department of Health and Human
Services Center for Substance Abuse Treatment, the American
College of Obstetricians and Gynecologists, the American Diabetes
Association, and the AIDS Institute clinical standards for adult,
adolescent, and pediatric care.
b) The Contractor must ensure that its decisions for utilization
management, enrollee education, coverage of services, and other
areas to which the practice guidelines apply are consistent with
the guidelines.
SECTION 16
(QUALITY ASSURANCE)
OCTOBER 1, 2005
16-1
c) The Contractor must have mechanisms in place to disseminate any
changes in practice guidelines to its Participating Providers at
least annually, or more frequently, as appropriate.
d) The Contractor shall develop and implement protocols for
identifying Participating Providers who do not adhere to practice
guidelines and for making reasonable efforts to improve the
performance of these providers.
e) Annually, the Contractor shall select a minimum of two practice
guidelines and monitor the performance of appropriate
Participating Providers (or a sample of providers) against such
guidelines.
SECTION 16
(QUALITY ASSURANCE)
OCTOBER 1, 2005
16-2
17. MONITORING AND EVALUATION
17.1 Right to Monitor Contractor Performance
The SDOH or its designee, DOHMH and DHHS shall each have the right,
during the Contractor's normal operating hours, and at any other time
a Contractor function or activity is being conducted, to monitor and
evaluate, through inspection or other means, the Contractor's
performance, including, but not limited to, the quality,
appropriateness, and timeliness of services provided under this
Agreement.
17.2 Cooperation During Monitoring and Evaluation
The Contractor shall cooperate with and provide reasonable assistance
to the SDOH or its designee, DOHMH and DHHS in the monitoring and
evaluation of the services provided under this Agreement.
17.3 Cooperation During On-Site Reviews
The Contractor shall cooperate with SDOH and/or its designee, and
DOHMH in any on-site review of the Contractor's operations. SDOH shall
give the Contractor notification of the date(s) and survey format for
any full operational review at least forty-five (45) days prior to the
site visit. This requirement shall not preclude the DOHMH, the SDOH or
its designee from site visits upon shorter notice for other monitoring
purposes.
17.4 Cooperation During Review of Services by External Review Agency
The Contractor shall comply with all requirements associated with any
review of the quality of services rendered to its Enrollees to be
performed by an external review agent selected by the SDOH.
SECTION 17
(MONITORING AND EVALUATION)
October 1, 2005
17-1
18. CONTRACTOR REPORTING REQUIREMENTS
18.1 General Requirements
a) The Contractor must maintain a health information system that
collects, analyzes, integrates, and reports data. The system must
provide information on areas, including but not limited to,
utilization, Complaints and Appeals, and Disenrollments for other
than loss of Medicaid or FHPlus eligibility. The system must be
sufficient to provide the data necessary to comply with the
requirements of this Agreement.
b) The Contractor must take the following steps to ensure that data
received from Participating Providers is accurate and complete:
verify the accuracy and timeliness of reported data; screen the
data for completeness, logic and consistency; and collect
utilization data in standardized formats as requested by SDOH.
18.2 Time Frames for Report Submissions
Except as otherwise specified herein, the Contractor shall prepare and
submit to SDOH the "reports'required under this Agreement in an agreed
media format within sixty (60) days of the close of the applicable
semi-annual or annual reporting period, and within fifteen (15)
business days of the close of the applicable quarterly reporting
period.
18.3 SDOH Instructions for Report Submissions
SDOH, with notice to the DOHMH, will provide Contractor with
instructions for submitting the reports required by SDOH in Section
18.6 of this Agreement, including time frames, and requisite formats.
The instructions, time frames and formats may be modified by SDOH upon
sixty (60) days' written notice to the Contractor.
18.4 Liquidated Damages
The Contractor shall pay liquidated damages of $2,500 to SDOH if any
report required pursuant to this Section is materially incomplete,
contains material misstatements or inaccurate information, or is not
submitted in the requested format. The Contractor shall pay liquidated
damages of $2,500 to the SDOH if its monthly encounter data submission
is not received by the Fiscal Agent by the due date specified in
Section 18.6 (a) (iv) of this Agreement. The Contractor shall pay
liquidated damages of $500 to SDOH for each day other reports required
by this Section are late. The SDOH shall not impose liquidated damages
for a first time infraction by the Contractor unless the SDOH deems
the infraction to be a material misrepresentation of fact or the
Contractor fails to cure the first infraction within a reasonable
period of time upon notice from the SDOH. Liquidated
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-1
damages may be waived at the sole discretion of SDOH. Nothing in this
Section shall limit other remedies or rights available to SDOH and
DOHMH relating to the timeliness, completeness and/or accuracy of
Contractor's reporting submission.
18.5 Notification of Changes in Report Due Dates, Requirements or Formats
SDOH may extend due dates, or modify report requirements or formats
upon a written request by the Contractor to the SDOH, where the
Contractor has demonstrated a good and compelling reason for the
extension or modification. The determination to grant a modification
or extension of time shall be made by SDOH.
18.6 Reporting Requirements
a) The Contractor shall submit the following reports to SDOH (unless
otherwise specified). The Contractor will certify the data
submitted pursuant to this section as required by SDOH. The
certification shall be in the manner and format established by
SDOH and must attest, based on best knowledge, information, and
belief to the accuracy, completeness and truthfulness of the data
being submitted.
i) Annual Financial Statements:
Contractor shall submit Annual Financial Statements to SDOH.
The due date for annual statements shall be April 1
following the report closing date.
ii) Quarterly Financial Statements:
Contractor shall submit Quarterly Financial Statements to
SDOH. The due date for quarterly reports shall be forty-five
(45) days after the end of the calendar quarter.
iii) Other Financial Reports:
Contractor shall submit financial reports, including
certified annual financial statements, and make available
documents relevant to its financial condition to SDOH and
the State Insurance Department (SID) in a timely manner as
required by State laws and regulations, including but not
limited to PHL Sections 4403-a, 4404 and 4409, Title 10
NYCRR Part 98, and applicable SIL Sections 304, 305, 306,
and 310. The SDOH may require the Contractor to submit such
relevant financial reports and documents related to its
financial condition to the DOHMH.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-2
iv) Encounter Data:
The Contractor shall prepare and submit encounter data on a
monthly basis to SDOH through SDOH's designated Fiscal
Agent. Each provider is required to have a unique
identifier. Submissions shall be comprised of encounter
records or adjustments to previously submitted records,
which the Contractor has received and processed from
provider encounter or claim records of all contracted
services rendered to the Enrollee in the current or any
preceding months. Monthly submissions must be received by
the Fiscal Agent in accordance with the time frames
specified in the MEDS II data dictionary on the HPN to
assure the submission is included in the Fiscal Agent's
monthly production processing.
v) Quality of Care Performance Measures:
The Contractor shall prepare and submit reports to SDOH, as
specified in the Quality Assurance Reporting Requirements
(QARR). The Contractor must arrange for an NCQA-certified
entity to audit the QARR data prior to its submission to the
SDOH unless this requirement is specifically waived by the
SDOH. The SDOH will select the measures which will be
audited.
vi) Complaint and Action Appeal Reports:
A) The Contractor must provide the SDOH on a quarterly
basis, and within fifteen (15) business days of the
close of the quarter, a summary of all Complaints and
Action Appeals subject to PHL Section 4408-a received
during the preceding quarter via the Summary Complaint
Form on the HPN. The Summary Complaint Form has been
developed by the SDOH to categorize the type of
Complaints and Action Appeals subject to PHL Section
4408-a received by the Contractor.
B) The Contractor agrees to provide on a quarterly basis,
via Summary Complaint Form on the HPN, the total number
of Complaints and Action Appeals subject to PHL Section
4408-a that have been unresolved for more than
forty-five (45) days. The Contractor shall maintain
records on these and other Complaints, Complaint
Appeals and Action Appeals pursuant to Appendix F of
this Agreement. These records shall be readily
available for review by the SDOH and DOHMH upon
request.
C) Nothing in this Section is intended to limit the right
of the DOHMH, the SDOH or its designee to obtain
information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider
Complaint, Complaint Appeal or Action Appeal.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-3
vii) Fraud and Abuse Reporting Requirements:
A) The Contractor must submit quarterly, via the HPN
Complaint reporting format, the number of Complaints of
fraud or abuse made to the Contractor that warrant
preliminary investigation by the Contractor.
B) The Contractor also must submit to the SDOH the
following information on an ongoing basis for each
confirmed case of fraud and abuse it identifies through
Complaints, organizational monitoring, contractors,
subcontractors, providers, beneficiaries, Enrollees, or
any other source:
I) The name of the individual or entity that
committed the fraud or abuse;
II) The source that identified the fraud or abuse;
III) The type of provider, entity or organization that
committed the fraud or abuse;
IV) A description of the fraud or abuse;
V) The approximate dollar amount of the fraud or
abuse;
VI) The legal and administrative disposition of the
case, if available, including actions taken by law
enforcement officials to whom the case has been
referred; and
VII) Other data/information as prescribed by SDOH.
C) Such report shall be submitted when cases of fraud and
abuse are confirmed, and shall be reviewed and signed
by an executive officer of the Contractor.
viii) Participating Provider Network Reports:
The Contractor shall submit electronically to the HPN an
updated provider network report on a quarterly basis. The
Contractor shall submit an annual notarized attestation that
the providers listed in each submission have executed an
agreement with the Contractor to serve Contractor's MMC
and/or FHPlus Enrollees, as applicable. The report
submission must comply with the Managed Care Provider
Network Data Dictionary. Networks must be reported
separately for each county in which the Contractor operates.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-4
ix) Appointment Availability/Twenty-four (24) Hour Access and
Availability Surveys:
The Contractor will conduct a county specific (or service
area if appropriate) review of appointment availability and
twenty-four (24) hour access and availability surveys
annually. Results of such surveys must be kept on file and
be readily available for review by the SDOH or DOHMH, upon
request.
x) Clinical Studies:
A) The Contractor will participate in up to four (4) SDOH
sponsored focused clinical studies annually. The
purpose of these studies will be to promote quality
improvement.
B) The Contractor is required to conduct at least one (1)
internal performance improvement project each year in a
priority topic area of its choosing with the mutual
agreement of the SDOH and SDOH's external quality
review organization. The Contractor may conduct its
performance improvement project in conjunction with one
or more MCOs. The purpose of these projects will be to
promote quality improvement within the Contractor's MMC
and/or FHPlus product. SDOH will provide guidelines
which address study structure and reporting format.
Written reports of these projects will be provided to
the SDOH and validated by the external quality review
organization.
xi) Independent Audits:
The Contractor must submit copies of all certified financial
statements and QARR validation audits by auditors
independent of the Contractor to the SDOH within thirty (30)
days of receipt by the Contractor.
xii) New Enrollee Health Screening Completion Report:
The Contractor shall submit a quarterly report within thirty
(30) days of the close of the quarter showing the percentage
of new Enrollees for which the Contractor was able to
complete a health screening consistent with Section
13.6(a)(ii) of this Agreement.
xiii) Additional Reports:
Upon request by the SDOH, or as specified by DOHMH in
Appendix N, the Contractor shall prepare and submit other
operational data reports. Such requests will be limited to
situations in which the desired data is considered essential
and cannot be obtained through existing Contractor reports.
Whenever possible, the Contractor will be provided with
ninety
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-5
(90) days notice and the opportunity to discuss and comment
on the proposed requirements before work is begun. However,
the SDOH reserves the right to give thirty (30) days notice
in circumstances where time is of the essence.
18.7 Ownership and Related Information Disclosure
The Contractor shall report ownership and related information to SDOH,
and upon request to the Secretary of Health and Human Services and the
Inspector General of Health and Human Services, in accordance with 42
U.S.C. Sections 1320a-3 and 1396b(m)(4) (Sections 1124 and 1903(m)(4)
of the SSA).
18.8 Public Access to Reports
Any data, information, or reports collected and prepared by the
Contractor and submitted to NYS authorities in the course of
performing their duties and obligation under this Agreement will be
deemed to be a record of the SDOH subject to and consistent with the
requirements of Freedom of Information Law. This provision is made in
consideration of the Contractor's participation in the MMC and/or
FHPlus Program for which the data and information is collected,
reported, prepared and submitted.
18.9 Professional Discipline
a) Pursuant to PHL Section 4405-b, the Contractor shall have in
place policies and procedures to report to the appropriate
professional disciplinary agency within thirty (30) days of
occurrence of any of the following:
i) the termination of a health care Provider Agreement pursuant
to Section 4406-d of the PHL for reasons relating to alleged
mental and physical impairment, misconduct or impairment of
patient safety or welfare;
ii) the voluntary or involuntary termination of a contract or
employment or other affiliation with such Contractor to
avoid the imposition of disciplinary measures; or
iii) the termination of a health care Participating Provider
Agreement in the case of a determination of fraud or in a
case of imminent harm to patient health.
b) The Contractor shall make a report to the appropriate
professional disciplinary agency within thirty (30) days of
obtaining knowledge of any information that reasonably appears to
show that a health professional is guilty of professional
misconduct as defined in Articles 130 and 131-A of the New York
State Education Law (Education Law).
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-6
18.10 Certification Regarding Individuals Who Have Been Debarred Or
Suspended By Federal or State Government
a) Contractor will certify to the SDOH initially and immediately
upon changed circumstances from the last such certification that
it does not knowingly have an individual who has been debarred or
suspended by the federal or state government, or otherwise
excluded from participating in procurement activities:
i) as a director, officer, partner or person with beneficial
ownership of more than five percent (5%) of the Contractor's
equity; or
ii) as a party to an employment, consulting or other agreement
with the Contractor for the provision of items and services
that are significant and material to the Contractor's
obligations in the MMC Program and/or the FHPlus Program,
consistent with requirements of SSA Section 1932 (d)(l).
18.11 Conflict of Interest Disclosure
Contractor shall report to SDOH, in a format specified by SDOH,
documentation, including but not limited to, the identity of and
financial statements of person(s) or corporation(s) with an ownership
or contract interest in the Contractor, or with any subcontract(s) in
which the Contractor has a five percent (5%) or more ownership
interest, consistent with requirements of SSA Section 1903
(m)(2)(a)(viii) and 42 CFR Sections 455.100 - 455.104.
18.12 Physician Incentive Plan Reporting
The Contractor shall submit to SDOH annual reports containing the
information on all of its Physician Incentive Plan arrangements in
accordance with 42 CFR Section 438.6(h) or, if no such arrangements
are in place, attest to that fact. The contents and time frame of such
reports shall comply with the requirements of 42 CFR Sections 422.208
and 422.210 and be in a format provided by SDOH.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 2005
18-7
19. RECORDS MAINTENANCE AND AUDIT RIGHTS
19.1 Maintenance of Contractor Performance Records
a) The Contractor shall maintain and shall require its
subcontractors, including its Participating Providers, to
maintain appropriate records relating to Contractor performance
under this Agreement, including:
i) records related to services provided to Enrollees, including
a separate Medical Record for each Enrollee;
ii) all financial records and statistical data that DOHMH, LDSS,
SDOH and any other authorized governmental agency may
require, including books, accounts, journals, ledgers, and
all financial records relating to capitation payments, third
party health insurance recovery, and other revenue received
and expenses incurred under this Agreement;
iii) appropriate financial records to document fiscal activities
and expenditures, including records relating to the sources
and application of funds and to the capacity of the
Contractor or its subcontractors, including its
Participating Providers, if applicable, to bear the risk of
potential financial losses.
b) The record maintenance requirements of this Section shall survive
the termination, in whole or in part, of this Agreement.
19.2 Maintenance of Financial Records and Statistical Data
The Contractor shall maintain all financial records and statistical
data according to generally accepted accounting principles.
19.3 Access to Contractor Records
The Contractor shall provide DOHMH, SDOH, the Comptroller of the State
of New York, DHHS, the Comptroller General of the United States, and
their authorized representatives with access to all records relating
to Contractor performance under this Agreement for the purposes of
examination, audit, and copying (at reasonable cost to the requesting
party) of such records. The Contractor shall give access to such
records on two (2) business days prior written notice, during normal
business hours, unless otherwise provided or permitted by applicable
laws, rules, or regulations.
SECTION 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2005
19-1
19.4 Retention Periods
The Contractor shall preserve and retain all records relating to
Contractor performance under this Agreement in readily accessible form
during the term of this Agreement and for a period of six (6) years
thereafter except that the Contractor shall retain Enrollees' medical
records that are in the custody of the Contractor for six (6) years
after the date of service rendered to the Enrollee or cessation of
Contractor operation, and in the case of a minor, for six (6) years
after majority. The Contractor shall require and make reasonable
efforts to assure that Enrollees' medical records are retained by
providers for six (6) years after the date of service rendered to the
Enrollee or cessation of Contractor operation, and in the case of a
minor, for six (6) years after majority. All provisions of this
Agreement relating to record maintenance and audit access shall
survive the termination of this Agreement and shall bind the
Contractor until the expiration of a period of six (6) years
commencing with termination of this Agreement or if an audit is
commenced, until the completion of the audit, whichever occurs later.
If the Contractor becomes aware of any litigation, claim, financial
management review or audit that is started before the expiration of
the six (6) year period, the records shall be retained until all
litigation, claims, financial management reviews or audit findings
involved in the record have been resolved and final action taken.
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(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 2005
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20. CONFIDENTIALITY
20.1 Confidentiality of Identifying Information about Enrollees, Potential
Enrollees and Prospective Enrollees
All information relating to services to Enrollees, Potential Enrollees
and Prospective Enrollees which is obtained by the Contractor shall be
confidential pursuant to the PHL including PHL Article 27-F, the
provisions of Section 369(4) of the SSL, 42 U.S.C. Section 1396a(a)(7)
(Section 1902(a)(7) of the SSA), Section 33.13 of the Mental Hygiene
Law, and regulations promulgated under such laws, including 42 CFR
Part 2 pertaining to Alcohol and Substance Abuse Services. Such
information, including information relating to services provided to
Enrollees, Potential Enrollees and Prospective Enrollees under this
Agreement, shall be used or disclosed by the Contractor only for a
purpose directly connected with performance of the Contractor's
obligations. It shall be the responsibility of the Contractor to
inform its employees and contractors of the confidential nature of MMC
and/or FHPlus information, as applicable.
20.2 Medical Records of Foster Children
Medical records of Enrollees enrolled in foster care programs shall be
disclosed to local social service officials in accordance with
Sections 358-a, 384-a and 392 of the SSL and 18 NYCRR Section 507.1.
20.3 Confidentiality of Medical Records
Medical records of Enrollees pursuant to this Agreement shall be
confidential and shall be disclosed to and by other persons within the
Contractor's organization, including Participating Providers, only as
necessary to provide medical care, to conduct quality assurance
functions and peer review functions, or as necessary to respond to a
complaint and appeal under the terms of this Agreement.
20.4 Length of Confidentiality Requirements
The provisions of this Section shall survive the termination of this
Agreement and shall bind the Contractor so long as the Contractor
maintains any individually identifiable information relating to
Enrollees, Potential Enrollees and Prospective Enrollees.
SECTION 20
(CONFIDENTIALITY)
October 1, 2005
20-1
21. PROVIDER NETWORK
21.1 Network Requirements
a) The Contractor will establish and maintain a network of
Participating Providers.
i) In establishing the network, the Contractor must consider
the following: anticipated Enrollment, expected utilization
of services by the population to be enrolled, the number and
types of providers necessary to furnish the services in the
Benefit Package, the number of providers who are not
accepting new patients, and the geographic location of the
providers and Enrollees.
ii) The Contractor's network must contain all of the provider
types necessary to furnish the prepaid Benefit Package,
including but not limited to: hospitals, physicians (primary
care and specialists), mental health and substance abuse
providers, allied health professionals, ancillary providers,
DME providers, home health providers, and pharmacies, if
applicable.
iii) To be considered accessible, the network must contain a
sufficient number and array of providers to meet the diverse
needs of the Enrollee population. This includes being
geographically accessible (meeting time/distance standards)
and being accessible for the disabled.
b) The Contractor shall not include in its network any provider
i) who has been sanctioned or prohibited from participation in
Federal health care programs under either Section 1128 or
Section 1128A of the SSA; or
ii) who has had his/her licensed suspended by the New York State
Education Department or the SDOH Office of Professional
Medical Conduct.
c) The Contractor must require that Participating Providers offer
hours of operation that are no less than the hours of operation
offered to commercial members or, if the provider serves only MMC
Enrollees and/or FHPlus Enrollees, comparable to hours offered
for Medicaid fee-for-service patients.
d) The Contractor shall submit its network for SDOH to assess for
adequacy through the HPN prior to execution of this Agreement,
quarterly thereafter throughout the term of this Agreement, and
upon request by SDOH when SDOH determines there has been a
significant change that could affect adequate capacity and
quarterly thereafter.
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21-1
e) Contractor must limit participation to providers who agree that
payment received from the Contractor for services included in the
Benefit Package is payment in full for services provided to
Enrollees, except for the collection of applicable co-payments
from Enrollees as provided by law.
21.2 Absence of Appropriate Network Provider
In the event that the Contractor determines that it does not have a
Participating Provider with appropriate training and experience to
meet the particular health care needs of an Enrollee, the Contractor
shall make a referral to an appropriate Non-Participating Provider,
pursuant to a treatment plan approved by the Contractor in
consultation with the Primary Care Provider, the Non-Participating
Provider and the Enrollee or the Enrollee's designee. The Contractor
shall pay for the cost of the services in the treatment plan provided
by the Non-Participating Provider for as long as the Contractor is
unable to provide the service through a Participating Provider.
21.3 Suspension of Enrollee Assignments To Providers
The Contractor shall ensure that there is sufficient capacity,
consistent with SDOH standards, to serve Enrollees under this
Agreement. In the event any of the Contractor's Participating
Providers are no longer able to accept assignment of new Enrollees due
to capacity limitations, as determined by the SDOH, the Contractor
will suspend assignment of any additional Enrollees to such
Participating Provider until such provider is capable of further
accepting Enrollees. When a Participating Provider has more than one
(1) site, the suspension will be made by site.
21.4 Credentialing
a) Credentialing/Recredentialing Process
The Contractor shall have in place a formal process, consistent
with SDOH Recommended Guidelines for Credentialing Criteria, for
credentialing Participating Providers on a periodic basis (not
less than once every three (3) years) and for monitoring
Participating Providers performance.
b) Licensure
The Contractor shall ensure, in accordance with Article 44 of the
PHL, that persons and entities providing care and services for
the Contractor in the capacity of physician, dentist, physician
assistant, registered nurse, other medical professional or
paraprofessional, or other such person or entity satisfy all
applicable licensing, certification, or qualification
requirements under New York law and that the functions and
responsibilities of such persons and
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(PROVIDER NETWORK)
October 1, 2005
21-2
entities in providing Benefit Package services under this
Agreement do not exceed those permissible under New York law.
c) Minimum Standards
i) The Contractor agrees that all network physicians will meet
at least one (1) of the following standards, except as
specified in Section 21.15 (c) and Appendix I of this
Agreement:
A) Be board-certified or board-eligible in their area of
specialty;
B) Have completed an accredited residency program; or
C) Have admitting privileges at one (1) or more hospitals
participating in the Contractor's network.
21.5 SDOH Exclusion or Termination of Providers
If SDOH excludes or terminates a provider from its Medicaid program,
the Contractor shall, upon learning of such exclusion or termination,
immediately terminate the Provider Agreement with the Participating
Provider with respect to the Contractor's MMC and/or FHPlus product,
and agrees to no longer utilize the services of the subject provider,
as applicable. The Contractor shall access information pertaining to
excluded Medicaid providers through the SDOH HPN. Such information
available to the Contractor on the HPN shall be deemed to constitute
constructive notice. The HPN should not be the sole basis for
identifying current exclusions or termination of previously approved
providers. Should the Contractor become aware, through the HPN or any
other source, of an SDOH exclusion or termination, the Contractor
shall validate this information with the Office of Medicaid
Management, Bureau of Enforcement Activities and comply with the
provisions of this Section.
21.6 Application Procedure
a) The Contractor shall establish a written application procedure to
be used by a health care professional interested in serving as a
Participating Provider with the Contractor. The criteria for
selecting providers, including the minimum qualification
requirements that a health care professional must meet to be
considered by the Contractor, must be defined in writing and
developed in consultation with appropriately qualified health
care professionals. Upon request, the application procedures and
minimum qualification requirements must be made available to
health care professionals.
b) The selection process may not discriminate against particular
providers that serve high-risk populations or specialize in
conditions that require costly treatment.
c) The Contractor may not discriminate with regard to the
participation, reimbursement, or indemnification of any provider
who is acting within the
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(PROVIDER NETWORK)
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21-3
scope of his or her license or certification under applicable
State law, solely on the basis of that license or certification.
This does not preclude the Contractor from including providers
only to the extent necessary to meet its needs; or from
establishing different payment rates for different counties or
different specialists; or from establishing measures designed to
maintain the quality of services and control costs consistent
with its responsibilities.
d) If the Contractor does not approve an individual or group of
providers as Participating Providers, it must give the affected
providers written notice of the reason for its decision.
21.7 Evaluation Information
The Contractor shall develop and implement policies and procedures to
ensure that Participating Providers are regularly advised of
information maintained by the Contractor to evaluate their performance
or practice. The Contractor shall consult with health care
professionals in developing methodologies to collect and analyze
Participating Providers profiling data. The Contractor shall provide
any such information and profiling data and analysis to its
Participating Providers. Such information, data or analysis shall be
provided on a periodic basis appropriate to the nature and amount of
data and the volume and scope of services provided. Any profiling data
used to evaluate the performance or practice of a Participating
Provider shall be measured against stated criteria and an appropriate
group of health care professionals using similar treatment modalities
serving a comparable patient population. Upon presentation of such
information or data, each Participating Provider shall be given the
opportunity to discuss the unique nature of his or her patient
population which may have a bearing on the Participating Provider's
profile and to work cooperatively with the Contractor to improve
performance.
21.8 Choice/Assignment of Primary Care Providers (PCPs)
a) The Contractor shall offer each Enrollee the choice of no fewer
than three (3) Primary Care Providers within distance/travel time
standards as set forth in Section 15.5 of this Agreement.
b) Contractor must assign a PCP to Enrollees who fail to select a
PCP. The assignment of a PCP by the Contractor may occur after
written notification to the Contractor of the Enrollment (through
Roster or other method) and after written notification of the
Enrollee by the Contractor but in no event later than thirty (30)
days after notification of Enrollment, and only after the
Contractor has made reasonable efforts as set forth in Section
13.6 of this Agreement to contact the Enrollee and inform him/her
of his/her right to choose a PCP.
c) PCP assignments should be made taking into consideration the
following:
i) Enrollee's geographic location;
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October 1, 2005
21-4
ii) any special health care needs, if known by the Contractor;
and
iii) any special language needs, if known by the Contractor.
d) In circumstances where the Contractor operates or contracts with
a multi-provider clinic to deliver primary care services, the
Enrollee must choose or be assigned a specific provider or
provider team within the clinic to serve as his/her PCP. This
"lead" provider will be held accountable for performing the PCP
duties.
21.9 Enrollee PCP Changes
a) The Contractor must allow Enrollees the freedom to change PCPs,
without cause, within thirty (30) days of the Enrollee's first
appointment with the PCP. After the first thirty (30) days, the
Contractor may elect to limit the Enrollee to changing PCPs every
six (6) months without cause.
b) The Contractor must process a request to change PCPs and advise
the Enrollee of the effective date of the change within
forty-five (45) days of receipt of the request. The change must
be effective no later than the first (1st) day of the second
(2nd) month following the month in which the request is made.
c) The Contractor will provide Enrollees with an opportunity to
select a new PCP in the event that the Enrollee's current PCP
leaves the network or otherwise becomes unavailable. Such changes
shall not be considered in the calculation of changes for cause
allowed within a six (6) month period.
d) In the event that an assignment of a new PCP is necessary due to
the unavailability of the Enrollee's former PCP, such assignment
shall be made in accordance with the requirements of Section 21.8
of this Agreement.
e) In addition to those conditions and circumstances under which the
Contractor may assign an Enrollee a PCP when the Enrollee fails
to make an affirmative choice of a PCP, the Contractor may
initiate a PCP change for an Enrollee under the following
circumstances:
i) The Enrollee requires specialized care for an acute or
chronic condition and the Enrollee and Contractor agree that
reassignment to a different PCP is in the Enrollee's
interest.
ii) The Enrollee's place of residence has changed such that
he/she has moved beyond the PCP travel time/distance
standard.
iii) The Enrollee's PCP ceases to participate in the Contractor's
network.
iv) The Enrollee's behavior toward the PCP is disruptive and the
PCP has made all reasonable efforts to accommodate the
Enrollee.
v) The Enrollee has taken legal action against the PCP or the
PCP has taken legal action against the Enrollee.
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(PROVIDER NETWORK)
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21-5
f) Whenever initiating a change, the Contractor must offer affected
Enrollees the opportunity to select a new PCP in the manner
described in this Section.
21.10 Provider Status Changes
a) PCP Changes
i) The Contractor agrees to notify its Enrollees of any of the
following PCP changes:
A) Enrollees will be notified within fifteen (15) days
from the date on which the Contractor becomes aware
that such Enrollee's PCP has changed his or her office
address or telephone number.
B) If a PCP ceases participation in the Contractor's
network, the Contractor shall provide written notice
within fifteen (15) days from the date that the
Contractor becomes aware of such change in status to
each Enrollee who has chosen the provider as his or her
PCP. In such cases, the notice shall describe the
procedures for choosing an alternative PCP and, in the
event that the Enrollee is in an ongoing course of
treatment, the procedures for continuing care
consistent with subdivision 6(e) of PHL Section 4403.
C) Where an Enrollee's PCP ceases participation with the
Contractor, the Contractor must ensure that the
Enrollee selects or is assigned to a new PCP within
thirty (30) days of the date of the notice to the
Enrollee.
b) Other Provider Changes
In the event that an Enrollee is in an ongoing course of
treatment with another Participating Provider who becomes
unavailable to continue to provide services to such Enrollee, the
Contractor shall provide written notice to the Enrollee within
fifteen (15) days from the date on which the Contractor becomes
aware of the Participating Provider's unavailability to the
Enrollee. In such cases, the notice shall describe the procedures
for continuing care consistent with PHL Section 4403(6)(e) and
for choosing an alternative Participating Provider.
21.11 PCP Responsibilities
In conformance with the Benefit Package, the PCP shall provide health
counseling and advice; conduct baseline and periodic health
examinations; diagnose and treat conditions not requiring the services
of a specialist; arrange inpatient care, consultations with
specialists, and laboratory and radiological services when medically
necessary; coordinate the findings of consultants and laboratories;
and interpret such findings to the Enrollee and the Enrollee's family,
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(PROVIDER NETWORK)
October 1, 2005
21-6
subject to the confidentiality provisions of Section 20 of this
Agreement, and maintain a current medical record for the Enrollee. The
PCP shall also be responsible for determining the urgency of a
consultation with a specialist and shall arrange for all consultation
appointments within appropriate time frames.
21.12 Member to Provider Ratios
a) The Contractor agrees to adhere to the member-to-PCP ratios shown
below. These ratios are Contractor-specific, and assume the
practitioner is a full time equivalent (FTE) (defined as a
provider practicing forty (40) hours per week for the
Contractor):
i) No more than 1,500 Enrollees for each physician, or 2,400
for a physician practicing in combination with a registered
physician assistant or a certified nurse practitioner.
ii) No more than 1,000 Enrollees for each certified nurse
practitioner.
b) The Contractor agrees that these ratios will be prorated for
Participating Providers who represent less than a FTE to the
Contractor.
21.13 Minimum PCP Office Hours
a) General Requirements
A PCP must practice a minimum of sixteen (16) hours a week at
each primary care site.
b) Waiver of Minimum Hours
The minimum office hours requirement may be waived under certain
circumstances. A request for a waiver must be submitted by the
Contractor to the Medical Director of the Office of Managed Care
for review and approval; and the physician must be available at
least eight hours/week; the physician must be practicing in a
Health Provider Shortage Area (HPSA) or other similarly
determined shortage area; the physician must be able to fulfill
the other responsibilities of a PCP (as described in this
Section); and the waiver request must demonstrate there are
systems in place to guarantee continuity of care and to meet all
access and availability standards (24-hour/7 days per week
coverage, appointment availability, etc.).
21.14 Primary Care Practitioners
a) General Limitations
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(PROVIDER NETWORK)
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The Contractor agrees to limit its PCPs to the following primary
care specialties: Family Practice, General Practice, General
Pediatrics, and General Internal Medicine except as specified in
paragraphs (b), (c), and (d) of this Section.
b) Specialist and Sub-specialist as PCPs
The Contractor is permitted to use specialist and sub-specialist
physicians as PCPs when such an action is considered by the
Contractor to be medically appropriate and cost-effective. As an
alternative, the Contractor may restrict its PCP network to
primary care specialties only, and rely on standing referrals to
specialists and sub-specialists for Enrollees who require regular
visits to such physicians.
c) OB/GYN Providers as PCPs
The Contractor, at its option, is permitted to use OB/GYN
providers as PCPs, subject to SDOH qualifications.
d) Certified Nurse Practitioners as PCPs
The Contractor is permitted to use certified nurse practitioners
as PCPs, subject to their scope of practice limitations under New
York State Law.
21.15 PCP Teams
a) General Requirements
The Contractor may designate teams of physicians/certified nurse
practitioners to serve as PCPs for Enrollees. Such teams may
include no more than four (4) physicians/certified nurse
practitioners and, when an Enrollee chooses or is assigned to a
team, one of the practitioners must be designated as "lead
provider" for that Enrollee. In the case of teams comprised of
medical residents under the supervision of an attending
physician, the attending physician must be designated as the lead
physician.
b) Registered Physician Assistants as Physician Extenders
The Contractor is permitted to use registered physician
assistants as physician-extenders, subject to their scope of
practice limitations under New York State Law.
c) Medical Residents and Fellows
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(PROVIDER NETWORK)
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21-8
The Contractor shall comply with SDOH Guidelines for use of
Medical Residents and fellows as found in Appendix I, which is
hereby made a part of this Agreement as if set forth fully
herein.
21.16 Hospitals
a) Tertiary Services
The Contractor will establish hospital networks capable of
furnishing the full range of tertiary services to Enrollees.
Contractors shall ensure that all Enrollees have access to at
least one (1) general acute care hospital within thirty (30)
minutes/thirty (30) miles travel time (by car or public
transportation) from the Enrollee's residence unless none are
located within such a distance. If none are located within thirty
(30) minutes travel time/thirty (30) miles travel distance, the
Contractor must include the next closest site in its network.
b) Emergency Services
The Contractor shall ensure and demonstrate that it maintains
relationships with hospital emergency facilities, including
comprehensive psychiatric emergency programs (where available)
within and around its service area to provide Emergency Services.
21.17 Dental Networks
a) If the Contractor includes dental services in its Benefit
Package, the Contractor's dental network shall include
geographically accessible general dentists sufficient to offer
each Enrollee a choice of two (2) primary care dentists in their
Service Area and to achieve a ratio of at least one (1) primary
care dentist for each 2,000 Enrollees. Networks must also include
at least one (1) pediatric dentist and one (1) oral surgeon.
Orthognathic surgery, temporal mandibular disorders (TMD) and
oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral.
Periodontists and endodontists must also be available by
referral. The network should include dentists with expertise in
serving special needs populations (e.g., HIV+ and developmentally
disabled patients).
b) Dental surgery performed in an ambulatory or inpatient setting is
the responsibility of the Contractor whether dental services are
a covered benefit or not, as set forth in Appendix K.2 (25),
Dental Services, of this Agreement.
21.18 Presumptive Eligibility Providers
The Contractor must offer Presumptive Eligibility Providers the
opportunity to be Participating Providers in its MMC product. The
terms of the contract must be at
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(PROVIDER NETWORK)
October 1, 2005
21-9
least as favorable as the terms offered to other Participating
Providers performing equivalent services (prenatal care).
Contractors need not contract with every Presumptive Eligibility
Provider in their counties, but must contract with a sufficient
number to meet the distance/travel time standards defined for
primary care.
21.19 Mental Health and Chemical Dependence Services Providers
a) The Contractor will include a full array of mental health and
Chemical Dependence Services providers in its networks, in
sufficient numbers to assure accessibility to Benefit Package
services for both children and adults, using either individual,
appropriately licensed practitioners or New York State Office of
Mental Health (OMH) and Office of Alcohol and Substance Abuse
Services (OASAS) licensed programs and clinics, or both.
b) The State defines mental health and Chemical Dependence Services
providers to include the following: Individual Practitioners,
Psychiatrists, Psychologists, Psychiatric Nurse Practitioners,
Psychiatric Clinical Nurse Specialists, Licensed Certified Social
Workers, OMH and OASAS Programs and Clinics, and providers of
mental health and/or Chemical Dependence Services certified or
licensed pursuant to Article 31 or 32 of the Mental Hygiene Law,
as appropriate.
21.20 Laboratory Procedures
The Contractor agrees to restrict its laboratory provider network to
entities having either a CLIA certificate of registration or a CLIA
certificate of waiver.
21.21 Federally Qualified Health Centers (FQHCs)
a) In a county where Enrollment in the Contractor's MMC product is
voluntary, the Contractor is not required to contract with FQHCs.
However, when an FQHC is a Participating Provider of the
Contractor network, the Provider Agreement must include a
provision whereby the Contractor agrees to compensate the FQHC
for services provided to Enrollees at a payment rate that is not
less than the level and amount that the Contractor would pay
another Participating Provider that is not an FQHC for a similar
set of services.
b) In a county where Enrollment in the Contractor's MMC product is
mandatory and/or the Contractor offers a FHPlus product, the
Contractor shall contract with FQHCs operating in that county.
However, the Contractor has the option to make a written request
to the SDOH for an exemption from the FQHC contracting
requirement if the Contractor can demonstrate, with supporting
documentation, that it has adequate capacity and will provide a
comparable level of clinical and enabling services (e.g.,
outreach, referral services, social
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support services, culturally sensitive services such as training
for medical and administrative staff, medical and non-medical and
case management services) to vulnerable populations in lieu of
contracting with an FQHC in the county. Written requests for
exemption from this requirement are subject to approval by CMS.
c) When the Contractor is participating in a county where an MCO
that is sponsored, owned and/or operated by one or more FQHCs
exists, the Contractor is not required to include any FQHCs
within its network in that county.
21.22 Provider Services Function
a) The Contractor will operate a Provider Services function during
regular business hours. At a minimum, the Contractor's Provider
Services staff must be responsible for the following:
i) Assisting providers with prior authorization and referral
protocols.
ii) Assisting providers with claims payment procedures.
iii) Fielding and responding to provider questions and
complaints.
21.23 Pharmacies - Applies to FHPlus Program Only
a) For those counties in which the Contractor offers a FHPlus
product as specified in Appendix M of this Agreement, the
Contractor shall include pharmacies as Participating Providers in
its FHPlus product in sufficient numbers to meet the following
distance/travel time standards:
i) Non-Metropolitan areas - thirty (30 )miles/ thirty (30)
minutes from the FHPlus Enrollee's residence.
ii) Metropolitan areas - thirty (30) minutes from the FHPlus
Enrollee's residence by public transportation from the
FHPlus Enrollee's residence.
b) Transport time and distance in rural areas may be greater than
thirty (30) minutes or thirty (30) miles from the FHPlus
Enrollee's residence only if based on the community standard for
accessing care or if by FHPlus Enrollee choice. Where the
transport time and/or distances are greater, the exceptions must
be justified and documented by SDOH on the basis of community
standards.
c) The Contractor also must contract with twenty-four (24) hour
pharmacies and must ensure that all FHPlus Enrollees have access
to at least one such pharmacy within thirty (30) minutes travel
time (by car or public transportation) from the FHPlus Enrollee's
residence, unless none are located within such a distance. If
none are located within thirty (30) minutes travel
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time from the FHPlus Enrollee's residence, the Contractor must
include the closest site in its network.
d) For certain conditions, such as hemophilia, PKU, and cystic
fibrosis, the Contractor is encouraged to make pharmacy
arrangements with specialty centers treating these conditions,
when such centers are able to demonstrate quality and cost
effectiveness.
e) The Contractor may make use of mail order prescription
deliveries, where clinically appropriate and desired by the
FHPlus Enrollee.
f) The Contractor may utilize formularies and may employ the
services of a pharmacy benefit manager or utilization review
agent, provided that such manager or agent covers a prescription
drug benefit equivalent to the requirements for prescription drug
coverage described in Appendix K of this Agreement and maintains
an internal and external review process for medical exceptions.
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22. SUBCONTRACTS AND PROVIDER AGREEMENTS
22.1 Written Subcontracts
a) The Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by a written agreement.
b) If the Contractor enters into subcontracts for the performance of
work pursuant to this Agreement, the Contractor shall retain full
responsibility for performance of the subcontracted services.
Nothing in the subcontract shall impair the rights of the DOHMH
or the State under this Agreement. No contractual relationship
shall be deemed to exist between the subcontractor and the DOHMH
or the State.
c) The delegation by the Contractor of its responsibilities assumed
by this Agreement to any subcontractors will be limited to those
specified in the subcontracts.
22.2 Permissible Subcontracts
Contractor may subcontract for provider services as set forth in
Sections 2.6 and 21 of this Agreement and management services
including, but not limited to, marketing, quality assurance and
utilization review activities and such other services as are
acceptable to the SDOH. The Contractor must evaluate the prospective
subcontractor's ability to perform the activities to be delegated.
22.3 Provision of Services through Provider Agreements
All medical care and/or services covered under this Agreement, with
the exception of seldom used subspecialty and Emergency Services,
Family Planning Services, and services for which Enrollees can self
refer, pursuant to Section 10.15 of this Agreement, shall be provided
through Provider Agreements with Participating Providers.
22.4 Approvals
a) Provider Agreements shall require the approval of SDOH as set
forth in PHL Section 4402 and 10 NYCRR Part 98.
b) If a subcontract is for management services under 10 NYCRR Part
98, it must be approved by SDOH prior to its becoming effective.
c) The Contractor shall notify SDOH of any material amendments to
any Provider Agreement as set forth in 10 NYCRR Part 98.
SECTION 22
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22.5 Required Components
a) All subcontracts, including Provider Agreements, entered into by
the Contractor to provide program services under this Agreement
shall contain provisions specifying:
i) the activities and report responsibilities delegated to the
subcontractor; and provide for revoking the delegation, in
whole or in part, and imposing other sanctions if the
subcontractor's performance does not satisfy standards set
forth in this Agreement, and an obligation for the provider
to take corrective action.
ii) that the work performed by the subcontractor must be in
accordance with the terms of this Agreement; and
iii) that the subcontractor specifically agrees to be bound by
the confidentiality provisions set forth in this Agreement.
b) The Contractor shall impose obligations and duties on its
subcontractors, including its Participating Providers, that are
consistent with this Agreement, and that do not impair any rights
accorded to DOHMH, LDSS, SDOH, or DHHS.
c) No subcontract, including any Provider Agreement, shall limit or
terminate the Contractor's duties and obligations under this
Agreement.
d) Nothing contained in this Agreement shall create any contractual
relationship between any subcontractor of the Contractor,
including its Participating Providers, and SDOH, DOHMH, or LDSS.
e) Any subcontract entered into by the Contractor shall fulfill the
requirements of 42 CFR Part 438 that are appropriate to the
service or activity delegated under such subcontract.
f) The Contractor shall also require that, in the event the
Contractor fails to pay any subcontractor, including any
Participating Provider in accordance with the subcontract or
Provider Agreement, the subcontractor or Participating Provider
will not seek payment from the SDOH, LDSS, DOHMH, the Enrollees,
or persons acting on an Enrollee's behalf.
g) The Contractor shall include in every Provider Agreement a
procedure for the resolution of disputes between the Contractor
and its Participating Providers.
h) The Contractor shall ensure that all Provider Agreements entered
into with Providers require acceptance of a woman's Enrollment in
the Contractor's
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MMC or FHPlus product as sufficient to provide services to her
newborn, unless the newborn is excluded from Enrollment in the
MMC Program pursuant to Section 6.1 of this Agreement, or the
Contractor does not offer a MMC product in the mother's county of
fiscal responsibility.
i) The Contractor must monitor the subcontractor's performance on an
ongoing basis and subject it to formal review according to time
frames established by the State, consistent with State laws and
regulations, and the terms of this Agreement. When deficiencies
or areas for improvement are identified, the Contractor and
subcontractor must take corrective action.
22.6 Timely Payment
Contractor shall make payments to Participating Providers and to
Non-Participating Providers, as applicable, for items and services
covered under this Agreement on a timely basis, consistent with the
claims payment procedures described in SIL Section 3224-a.
22.7 Restrictions on Disclosure
a) The Contractor shall not by contract or written policy or written
procedure prohibit or restrict any health care provider from the
following:
i) Disclosing to any subscriber, Enrollee, patient, designated
representative or, where appropriate, Prospective Enrollee
any information that such provider deems appropriate
regarding:
A) a condition or a course of treatment with such
subscriber, Enrollee, patient, designated
representative or Prospective Enrollee, including the
availability of other therapies, consultations, or
tests; or
B) the provisions, terms, or requirements of the
Contractor's MMC or FHPlus products as they relate to
the Enrollee, where applicable.
ii) Filing a complaint, making a report or comment to an
appropriate governmental body regarding the policies or
practices of the Contractor when he or she believes that the
policies or practices negatively impact upon the quality of,
or access to, patient care.
iii) Advocating to the Contractor on behalf of the Enrollee for
approval or coverage of a particular treatment or for the
provision of health care services.
22.8 Transfer of Liability
No contract or agreement between the Contractor and a Participating
Provider shall contain any clause purporting to transfer to the
Participating Provider, other than a medical group, by indemnification
or otherwise, any liability relating to
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activities, actions or omissions of the Contractor as opposed to those
of the Participating Provider.
22.9 Termination of Health Care Professional Agreements
a) General Requirements
i) The Contractor shall not terminate a contract with a health
care professional unless the Contractor provides to the
health care professional a written explanation of the
reasons for the proposed termination and an opportunity for
a review or hearing as hereinafter provided. For purposes of
this Section, a health care professional is an individual
licensed, registered or certified pursuant to Title VIII of
the Education Law.
ii) These requirements shall not apply in cases involving
imminent harm to patient care, a determination of fraud, or
a final disciplinary action by a state licensing board or
other governmental agency that impairs the health care
professional's ability to practice.
b) Notice of Health Care Professional Termination
i) When the Contractor desires to terminate a contract with a
health care professional, the notification of the proposed
termination by the Contractor to the health care
professional shall include:
A) the reasons for the proposed action;
B) notice that the health care professional has the right
to request a hearing or review, at the provider's
discretion, before a panel appointed by the Contractor;
C) a time limit of not less than thirty (30) days within
which a health care professional may request a hearing;
and
D) a time limit for a hearing date which must be held
within thirty (30) days after the date of receipt of a
request for a hearing.
c) No contract or agreement between the Contractor and a health care
professional shall contain any provision which shall supersede or
impair a health care professional's right to notice of reasons
for termination and the opportunity for a hearing or review
concerning such termination.
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22.10 Health Care Professional Hearings
a) A health care professional that has been notified of his or her
proposed termination must be allowed a hearing. The procedures
for this hearing must meet the following standards:
i) The hearing panel shall be comprised of at least three
persons appointed by the Contractor. At least one person on
such panel shall be a clinical peer in the same discipline
and the same or similar specialty as the health care
professional under review. The hearing panel may consist of
more than three persons, provided however, that the number
of clinical peers on such panel shall constitute one-third
or more of the total membership of the panel.
ii) The hearing panel shall render a decision on the proposed
action in a timely manner. Such decision shall include
reinstatement of the health care professional by the
Contractor, provisional reinstatement subject to conditions
set forth by the Contractor or termination of the health
care professional. Such decision shall be provided in
writing to the health care professional.
iii) A decision by the hearing panel to terminate a health care
professional shall be effective not less than thirty (30)
days after the receipt by the health care professional of
the hearing panel's decision. Notwithstanding the
termination of a health care professional for cause or
pursuant to a hearing, the Contractor shall permit an
Enrollee to continue an on-going course of treatment for a
transition period of up to ninety (90) days, and post-partum
care, subject to the provider's agreement, pursuant to PHL
Section 4403(6)(e).
iv) In no event shall termination be effective earlier than
sixty (60) days from the receipt of the notice of
termination.
22.11 Non-Renewal of Provider Agreements
Either party to a Provider Agreement may exercise a right of
non-renewal at the expiration of the Provider Agreement period set
forth therein or, for a Provider Agreement without a specific
expiration date, on each January first occurring after the Provider
Agreement has been in effect for at least one year, upon sixty (60)
days notice to the other party; provided, however, that any
non-renewal shall not constitute a termination for the purposes of
this Section.
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22.12 Notice of Participating Provider Termination
a) The Contractor shall notify DOHMH and SDOH of any notice of
termination or non-renewal of an IPA or institutional network
Provider Agreement, or medical group Provider Agreement that
serves five percent (5%) or more of the enrolled population in a
LDSS and/or when the termination or non-renewal of the medical
group provider will leave fewer than two (2) Participating
Providers of that type within the LDSS, unless immediate
termination of the Provider Agreement is justified. The notice
shall include an impact analysis of the termination or
non-renewal with regard to Enrollee access to care.
b) The Contractor shall provide the notification required in (a)
above to the DOHMH and the SDOH ninety (90) days prior to the
effective date of the termination of the Provider Agreement or
immediately upon notice from such Participating Provider if less
than ninety (90) days.
c) The Contractor shall provide the notification required in (a)
above to the DOHMH and the SDOH if the Contractor and the
Participating Providers have failed to execute a renewal Provider
Agreement forty-five (45) days prior to the expiration of the
current Provider Agreement.
d) In addition to the notification required in (a) above, the
Contractor shall submit a contingency plan to DOHMH and SDOH, at
least forty-five (45) days prior to the termination or expiration
of the Provider Agreement, identifying the number of Enrollees
affected by the potential withdrawal of the provider from the
Contractor's network and specifying how services previously
furnished by the Participating Providers will be provided in the
event of its withdrawal from the Contractor's network. If the
Participating Provider is a hospital, the Contractor shall
identify the number of doctors that would not have admitting
privileges in the absence of such Participating hospital.
e) In addition to the notification required in (a) above, the
Contractor shall develop a transition plan for Enrollees who are
patients of the Participating Provider withdrawing from the
Contractor's network subject to approval by DOHMH and SDOH. DOHMH
and SDOH may direct the Contractor to provide notice to the
Enrollees who are patients of PCPs or specialists including
available options for the patients, and availability of
continuing care, consistent with Section 13.8 of this Agreement,
not less than thirty (30) days prior to the termination or
expiration of the Provider Agreement. In the event that Provider
Agreements are terminated or are not renewed with less than the
notice period required by this Section, the Contractor shall
immediately notify DOHMH and SDOH, and develop a transition plan
on an expedited basis and provide notice to affected Enrollees
upon DOHMH and SDOH consent to the transition plan and Enrollee
notice.
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f) Upon Contractor notice of failure to renew, or termination of, a
Provider Agreement, the DOHMH and the SDOH, in their sole
discretion, may waive the requirement of submission of a
contingency plan upon a determination by the DOHMH and SDOH that:
i) the impact upon Enrollees is not significant, and/or
ii) the Contractor and Participating Provider are continuing to
negotiate in good faith and consent to extend the Provider
Agreement for a period of time necessary to provide not less
than thirty (30) days notice to Enrollees.
g) DOHMH and SDOH reserve the right to take any other action
permitted by this Agreement and under regulatory or statutory
authority, including but not limited to terminating this
Agreement.
22.13 Physician Incentive Plan
a) If Contractor elects to operate a Physician Incentive Plan, the
Contractor agrees that no specific payment will be made directly
or indirectly to a Participating Provider that is a physician or
physician group as an inducement to reduce or limit medically
necessary services furnished to an Enrollee. Contractor agrees to
submit to SDOH annual reports containing the information on its
Physician Incentive Plan in accordance with 42 CFR Section
438.6(h). The contents of such reports shall comply with the
requirements of 42 CFR Sections 422.208 and 422.210 and be in a
format to be provided by SDOH.
b) The Contractor must ensure that any Provider Agreements for
services covered by this Agreement, such as agreements between
the Contractor and other entities or between the Contractor's
subcontracted entities and their contractors, at all levels
including the physician level, include language requiring that
the Physician Incentive Plan information be provided by the
sub-contractor in an accurate and timely manner to the
Contractor, in the format requested by SDOH.
c) In the event that the incentive arrangements place the
Participating physician or physician group at risk for services
beyond those provided directly by the physician or physician
group for an amount beyond the risk threshold of twenty five
percent (25%) of potential payments for covered services
(substantial financial risk), the Contractor must comply with all
additional requirements listed in regulation, such as: conduct
Enrollee/disenrollee satisfaction surveys; disclose the
requirements for the Physician Incentive Plans to its
beneficiaries upon request; and ensure that all physicians and
physician groups at substantial financial risk have adequate
stop-loss
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protection. Any of these additional requirements that are passed
on to the subcontractors must be clearly stated in their Provider
Agreement.
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23. FRAUD AND ABUSE
23.1 General Requirements
The Contractor shall comply with the Federal fraud and abuse
requirements of 42 CFR Section 438.608.
23.2 Prevention Plans and Special Investigation Units
If the Contractor has over 10,000 Enrollees in the aggregate in any
given year, the Contractor must file a Fraud and Abuse Prevention Plan
with the Commissioner of Health and develop a special investigation
unit for the detection, investigation and prevention of fraudulent
activities to the extent required by PHL Section 4414 and SDOH
regulations.
24. AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN
Contractor must comply with Title II of the ADA and Section 504 of the
Rehabilitation Act of 1973 for program accessibility, and must develop an
ADA Compliance Plan consistent with the SDOH Guidelines for MCO Compliance
with the ADA set forth in Appendix J, which is hereby made a part of this
Agreement as if set forth fully herein. Said plan must be approved by the
SDOH, in collaboration with the DOHMH, and be filed with the SDOH and the
DOHMH, and be kept on file by the Contractor.
25. FAIR HEARINGS
25.1 Enrollee Access to Fair Hearing Process
Enrollees may access the fair hearing process in accordance with
applicable federal and state laws and regulations. Contractors must
abide by and participate in New York State's Fair Hearing Process and
comply with determinations made by a fair hearing officer.
25.2 Enrollee Rights to a Fair Hearing
Enrollees may request a fair hearing regarding adverse LDSS
determinations concerning enrollment, disenrollment and eligibility,
and regarding the denial, termination, suspension or reduction of a
clinical treatment or other Benefit Package services by the
Contractor. For issues related to disputed services, Enrollees must
have received an adverse determination from the Contractor or its
approved utilization review agent either overriding a recommendation
to provide services by a Participating Provider or confirming the
decision of a Participating Provider to deny those services. An
Enrollee may also seek a fair hearing for a failure by the Contractor
to act with reasonable promptness with respect to such services.
Reasonable promptness shall mean compliance with the timeframes
established for review of grievances and utilization review in
Sections 44 and 49
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October 1, 2005
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of the Public Health Law, the grievance system requirements of 42 CFR
Part 438 and Appendix F of this Agreement.
25.3 Contractor Notice to Enrollees
a) Contractor must issue a written notice of Action and right to
fair hearing within applicable timeframes to any Enrollee when
taking an adverse Action and when making an Appeal determination
as provided in Appendix F of this Agreement.
b) Contractor agrees to serve notice on affected Enrollees by mail
and must maintain documentation of such.
25.4 Aid Continuing
a) Contractor shall be required to continue the provision of the
Benefit Package services that are the subject of the fair hearing
to an Enrollee (hereafter referred to as "aid continuing") if so
ordered by the NYS Office of Administrative Hearings (OAH) under
the following circumstances:
i) Contractor has or is seeking to reduce, suspend or terminate
a treatment or Benefit Package service currently being
provided;
ii) Enrollee has filed a timely request for a fair hearing with
OAH; and
iii) There is a valid order for the treatment or service from a
Participating Provider.
b) Contractor shall provide aid continuing until the matter has been
resolved to the Enrollee's satisfaction or until the
administrative process is completed and there is a determination
from OAH that Enrollee is not entitled to receive the service;
the Enrollee withdraws the request for aid continuing and/or the
fair hearing in writing; or the treatment or service originally
ordered by the provider has been completed, whichever occurs
first.
c) If the services and/or benefits in dispute have been terminated,
suspended or reduced and the Enrollee timely requests a fair
hearing, Contractor shall, at the direction of either SDOH or
LDSS, restore the disputed services and/or benefits consistent
with the provisions of Section 25.4 (b) of this Agreement.
25.5 Responsibilities of SDOH
SDOH will make every reasonable effort to ensure that the Contractor
receives timely notice in writing by fax, or e-mail, of all requests,
schedules and directives regarding fair hearings.
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October 1, 2005
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25.6 Contractor's Obligations
a) Contractor shall appear at all scheduled fair hearings concerning
its clinical determinations and/or Contractor-initiated
disenrollments to present evidence as justification for its
determination or submit written evidence as justification for its
determination regarding the disputed benefits and/or services. If
Contractor will not be making a personal appearance at the fair
hearing, the written material must be submitted to OAH and
Enrollee or Enrollee's representative at least three (3) business
days prior to the scheduled hearing. If the hearing is scheduled
fewer than three (3) business days after the request, Contractor
must deliver the evidence to the hearing site no later than one
(1) business day prior to the hearing, otherwise Contractor must
appear in person. Notwithstanding the above provisions,
Contractor may be required to make a personal appearance at the
discretion of the hearing officer and/or SDOH.
b) Despite an Enrollee's request for a State fair hearing in any
given dispute, Contractor is required to maintain and operate in
good faith its own internal Complaint and Appeal processes as
required under state and federal laws and by Section 14 and
Appendix F of this Agreement. Enrollees may seek redress of
Adverse Determinations simultaneously through Contractor's
internal process and the State fair hearing process. If
Contractor has reversed its initial determination and provided
the service to the Enrollee, Contractor may request a waiver from
appearing at the hearing and, in submitted papers, explain that
it has withdrawn its initial determination and is providing the
service or treatment formerly in dispute.
c) Contractor shall comply with all determinations rendered by OAH
at fair hearings. Contractor shall cooperate with SDOH efforts to
ensure that Contractor is in compliance with fair hearing
determinations. Failure by Contractor to maintain such compliance
shall constitute breach of this Agreement. Nothing in this
Section shall limit the remedies available to SDOH, DOHMH, LDSS
or the federal government relating to any non-compliance by
Contractor with a fair hearing determination or Contractor's
refusal to provide disputed services.
d) If SDOH investigates a Complaint that has as its basis the same
dispute that is the subject of a pending fair hearing and, as a
result of its investigation, concludes that the disputed services
and/or benefits should be provided to the Enrollee, Contractor
shall comply with SDOH's directive to provide those services
and/or benefits and provide notice to OAH and Enrollee as
required by Section 25.6(b) of this Agreement.
e) If SDOH, through its Complaint investigation process, or OAH, by
a determination after a fair hearing, directs Contractor to
provide a service that was initially denied by Contractor,
Contractor may either directly provide the service, arrange for
the provision of that service or pay for the provision of
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October 1, 2005
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that service by a Non-Participating Provider. If the services
were not furnished during the period the fair hearing was
pending, the Contractor must authorize or furnish the disputed
services promptly and as expeditiously as the Enrollee's health
condition requires.
f) Contractor agrees to abide by changes made to this Section of the
Agreement with respect to the fair hearing, Action, Service
Authorization, Complaint and Appeal processes by SDOH in order to
comply with any amendments to applicable state or federal
statutes or regulations.
g) Contractor agrees to identify a contact person within its
organization who will serve as a liaison to SDOH for the purpose
of receiving fair hearing requests, scheduled fair hearing dates
and adjourned fair hearing dates and compliance with State
directives. Such individual shall be accessible to the State by
e-mail; shall monitor e-mail for correspondence from the State at
least once every business day; and shall agree, on behalf of
Contractor, to accept notices to the Contractor transmitted via
e-mail as legally valid.
h) The information describing fair hearing rights, aid continuing,
Action, Service Authorization, utilization review, Complaint and
Appeal procedures shall be included in all MMC and FHPlus member
handbooks and shall comply with Section 14 and Appendices E and F
of this Agreement.
i) Contractor shall bear the burden of proof at hearings regarding
the reduction, suspension or termination of ongoing services. In
the event that Contractor's initial adverse determination is
upheld as a result of a fair hearing, any aid continuing provided
pursuant to that hearing request, may be recouped by Contractor.
26. EXTERNAL APPEAL
26.1 Basis for External Appeal
Enrollees are eligible to request an External Appeal when one or more
covered health care services have been denied by the Contractor on the
basis that the service(s) is not medically necessary or is
experimental or investigational.
26.2 Eligibility for External Appeal
An Enrollee is eligible for an External Appeal when the Enrollee has
exhausted the Contractor's internal utilization review procedure, has
received a final adverse determination from the Contractor, or the
Enrollee and the Contractor have agreed to waive internal Appeal
procedures in accordance with PHL Section 4914(2)2(a). A provider is
also eligible for an External Appeal of retrospective denials.
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October 1, 2005
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26.3 External Appeal Determination
The External Appeal determination is binding on the Contractor;
however, a fair hearing determination supersedes an External Appeal
determination for Enrollees.
26.4 Compliance with External Appeal Laws and Regulations
The Contractor must comply with the provisions of Sections 4910-4914
of the PHL and 10NYCRR Part 98 regarding the External Appeal program.
26.5 Member Handbook
The Contractor shall describe its Action and utilization review
policies and procedures, including a notice of the right to an
External Appeal together with a description of the External Appeal
process and the timeframes for External Appeal, in the Member
Handbook. The Member Handbook shall comply with Section 13 and the
Member Handbook Guidelines, Appendix E, of this Agreement.
27. INTERMEDIATE SANCTIONS
27.1 General
The Contractor is subject to the imposition of sanctions as authorized
by State and Federal law and regulation, including the SDOH's right to
impose sanctions for unacceptable practices as set forth in 18 NYCRR
Part 515 and civil and monetary penalties pursuant to 18 NYCRR Part
516 and 42 CFR Section 438.700, and such other sanctions and penalties
as are authorized by local laws and ordinances and resultant
administrative codes, rules and regulations related to the Medical
Assistance Program or to the delivery of the contracted for services.
27.2 Unacceptable Practices
a) Unacceptable practices for which the Contractor may be sanctioned
include but are not limited to:
i) Failing to provide medically necessary services that the
Contractor is required to provide under its contract with
the State.
ii) Imposing premiums or charges on Enrollees that are in excess
of the premiums or charges permitted under the MMC Program
or FHPlus Program.
iii) Discriminating among Enrollees on the basis of their health
status or need for health care services.
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October 1, 2005
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iv) Misrepresenting or falsifying information that it furnishes
to an Enrollee, Potential Enrollee, health care provider,
the State or to CMS.
v) Failing to comply with the requirements for Physician
Incentive Plans, as set forth in 42 CFR Sections 422.208 and
422.210.
vi) Distributing directly or through any agent or independent
contractor, Marketing materials that have not been approved
by the State or that contain false or materially misleading
information.
vii) Violating any other applicable requirements of SSA Sections
1903(m) or 1932 and any implementing regulations.
viii) Violating any other applicable requirements of 18 NYCRR or
10 NYCRR Part 98.
ix) Failing to comply with the terms of this Agreement.
27.3 Intermediate Sanctions
a) Intermediate Sanctions may include but are not limited to:
i) Civil monetary penalties.
ii) Suspension of all new enrollment, including auto
assignments, after the effective date of the sanction.
iii) Termination of the Agreement, pursuant to Section 2.7 of
this Agreement.
27.4 Enrollment Limitations
a) The DOHMH shall have the right, upon consultation with and notice
to the SDOH, to limit, suspend, or terminate enrollment
activities by the Contractor and/or enrollment into the
Contractor's plan upon ten (10) days written notice to the
Contractor. The written notice shall specify the action(s)
contemplated and the reason(s) for such action(s) and shall
provide the Contractor with an opportunity to submit additional
information that would support the conclusion that limitation,
suspension or termination of enrollment activities or enrollment
in the Contractor's plan is unnecessary. Nothing in this
paragraph limits other remedies available to the DOHMH under this
Agreement.
b) The SDOH shall have the right, upon notice to the DOHMH, to
limit, suspend or terminate Enrollment activities by the
Contractor and/or Enrollment into the Contractor's MMC and/or
FHPlus product upon ten (10) days written notice to the
Contractor. The written notice shall specify the action(s)
contemplated and
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October 1, 2005
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the reason(s) for such action(s) and shall provide the Contractor
with an opportunity to submit additional information that would
support the conclusion that limitation, suspension or termination
of Enrollment activities or Enrollment in the Contractor's MMC
and/or FHPlus product is unnecessary. Nothing in this paragraph
limits other remedies available to the SDOH or the DOHMH under
this Agreement.
27.5 Due Process
The Contractor will be afforded due process pursuant to Federal and
State Law and Regulations (42 CFR Section 438.710, 18 NYCRR Part 516,
and Article 44 of the PHL).
28. ENVIRONMENTAL COMPLIANCE
The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act (42 U.S.C.
Section 1857(h)), Section 508 of the Federal Water Pollution Control Act as
amended (33 U.S.C. Section 1368), Executive Order 11738, and the
Environmental Protection Agency ("EPA") regulations (40 CFR Part 15) that
prohibit the use of the facilities included on the EPA List of Violating
Facilities. The Contractor shall report violations "to SDOH and to the
Assistant Administrator for Enforcement of the EPA.
29. ENERGY CONSERVATION
The Contractor shall comply with any applicable mandatory standards and
policies relating to energy efficiency that are contained in the State
Energy Conservation regulation issued in compliance with the Energy Policy
and Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the Act.
30. INDEPENDENT CAPACITY OF CONTRACTOR
The parties agree that the Contractor is an independent Contractor and that
the Contractor, its agents, officers, and employees act in an independent
capacity and not as officers or employees of LDSS, DOHMH, SDOH or the DHHS.
31. NO THIRD PARTY BENEFICIARIES
ONLY the parties to this Agreement and their successors in interest and
assigns have any rights or remedies under or by reason of this Agreement.
32. INDEMNIFICATION
32.1 Indemnification by Contractor
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a) The Contractor shall indemnify, defend, and hold harmless the
SDOH, DOHMH and the LDSS, and their officers, agents, and
employees, and the Enrollees and their eligible dependents from:
i) any and all claims and losses accruing or resulting to any
and all Contractors, subcontractors, materialmen, laborers,
and any other person, firm, or corporation furnishing or
supplying work, services, materials, or supplies in
connection with the performance of this Agreement;
ii) any and all claims and losses accruing or resulting to any
person, firm, or corporation that may be injured or damaged
by the Contractor, its officers, agents, employees, or
subcontractors, including Participating Providers, in
connection with the performance of this Agreement;
iii) any liability, including costs and expenses, for violation
of proprietary rights, copyrights, or rights of privacy by
the Contractor, its officers, agents, employees or
subcontractors, arising out of the publication, translation,
reproduction, delivery, performance, use, or disposition of
any data furnished under this Agreement, or based on any
libelous or otherwise unlawful matter contained in such
data.
b) The DOHMH will provide the Contractor with prompt written notice
of any claim made against the DOHMH, and the Contractor, at its
sole option, shall defend or settle said claim. The DOHMH shall
cooperate with the Contractor to the extent necessary for the
Contractor to discharge its obligation under Section 32.1 (a).
c) The Contractor shall have no obligation under this section with
respect to any claim or cause of action for damages to persons or
property solely caused by the negligence of DOHMH, its employees,
or agents.
32.2 Indemnification by DOHMH
The DOHMH shall indemnify and hold harmless the Contractor and its
officers, agents, and employees from any loss or damage resulting from
actions by the DOHMH pursuant to the terms of Appendix R, Section 6.3
herein.
33. PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
33.1 Prohibition of Use of Federal Funds for Lobbying
The Contractor agrees, pursuant to 31 U.S.C. Section 1352 and 45 CFR
Part 93, that no Federally appropriated funds have been paid or will
be paid to any person by or on behalf of the Contractor for the
purpose of influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection
SECTION 23 - SECTION 36
October 1, 2005
-8-
with the award of any Federal contract, the making of any federal
grant, the making of any Federal loan, the entering into of any
cooperative agreement, or the extension, continuation, renewal,
amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement. The Contractor agrees to complete and submit
the "Certification Regarding Lobbying," Appendix B attached hereto and
incorporated herein, if this Agreement exceeds $100,000.
33.2 Disclosure Form to Report Lobbying
If any funds other than Federally appropriated funds have been paid or
will be paid to any person for the purpose of influencing or
attempting to influence an officer or employee of any agency, a Member
of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with the award of any Federal
contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, or the
extension, continuation, renewal, amendment, or modification of any
Federal contract, grant, loan, or cooperative agreement, and the
Agreement exceeds $100,000, the Contractor shall complete and submit
Standard Form-LLL "Disclosure Form to Report Lobbying," in accordance
with its instructions.
33.3 Requirements of Subcontractors
The Contractor shall include the provisions of this Section in its
subcontracts, including its Provider Agreements. For all subcontracts,
including Provider Agreements, that exceed $100,000, the Contractor
shall require the subcontractor, including any Participating Provider
to certify and disclose accordingly to the Contractor.
34. NON-DISCRIMINATION
34.1 Equal Access to Benefit Package
Except as otherwise provided in applicable sections of this Agreement
the Contractor shall provide the Medicaid Managed Care and/or Family
Health Plus Benefit Package(s) to MMC and/or FHPlus Enrollees,
respectively, in the same manner, in accordance with the same
standards, and with the same priority as members of the Contractor
enrolled under any other contracts.
34.2 Non-Discrimination
The Contractor shall not discriminate against Eligible Persons or
Enrollees for Medicaid Managed Care and/or Family Health Plus on the
basis of age, sex, race, creed, physical or mental
handicap/developmental disability, national origin, sexual
orientation, type of illness or condition, need for health services,
or Capitation Rate that the Contractor will receive for such Eligible
Persons or Enrollees.
SECTION 23 - SECTION 36
October 1, 2005
-9-
34.3 Equal Employment Opportunity
Contractor must comply with Executive Order 11246, entitled "Equal
Employment Opportunity", as amended by Executive Order 11375, and as
supplemented in Department of Labor regulations.
34.4 Native Americans Access to Services From Tribal or Urban Indian Health
Facility
The Contractor shall not prohibit, restrict or discourage enrolled
Native Americans from receiving care from or accessing: a) Medicaid
reimbursed health services from or through a tribal health or urban
Indian health facility or center and/or b) Family Health Plus covered
benefits from or through a tribal health or urban Indian health
facility or center which is included in the Contractor's network.
35. COMPLIANCE WITH APPLICABLE LAWS
35.1 Contractor and DOHMH Compliance With Applicable Laws
Notwithstanding any inconsistent provisions in this Agreement, the
Contractor and DOHMH shall comply with all applicable requirements of
the State Public Health Law; the State Social Services Law; Title XIX
of the Social Security Act; Title VI of the Civil Rights Act of 1964
and 45 CFR Part 80, as amended; Title IX of the Education Amendments
of 1972; Section 504 of the Rehabilitation Act of 1973 and 45 CFR Part
84, as amended; the Age Discrimination Act of 1975 and 45 CFR Part 91,
as amended; the ADA; Title XIII of the Federal Public Health Services
Act, 42 U.S.C Section 300e et seq., and the regulations promulgated
thereunder; the Health Insurance Portability and Accountability Act of
1996 (P.L. 104-191) and related regulations; and all other applicable
legal and regulatory requirements in effect at the time that this
Agreement is signed and as adopted or amended during the term of this
Agreement. The parties agree that this Agreement shall be interpreted
according to the laws of the State of New York.
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
Should any provision of this Agreement be declared or found to be
illegal or unenforceable, ineffective or void, then each party shall
be relieved of any obligation arising from such provision; the balance
of this Agreement, if capable of performance, shall remain in full
force and effect.
35.3 Certificate of Authority Requirements
The Contractor must satisfy conditions for issuance of a certificate
of authority, including proof of financial solvency, as specified in
10 NYCRR Part 98.
SECTION 23 - SECTION 36
October 1, 2005
-10-
35.4 Notification of Changes in Certificate of Incorporation
The Contractor shall notify SDOH and DOHMH of any amendment to its
Certificate of Incorporation or Articles of Organization pursuant to
10 NYCRR Part 98.
35.5 Contractor's Financial Solvency Requirements
The Contractor, for the duration of this Agreement, shall remain in
compliance with all applicable state requirements for financial
solvency for MCOs offering Medicaid Managed Care and/or Family Health
Plus products, as applicable. The Contractor shall continue to be
financially responsible as defined in PHL Section 4403(1)(c) and shall
comply with the contingent reserve fund and escrow deposit
requirements of 10 NYCRR Part 98 and must meet minimum net worth
requirements established by SDOH and the State Insurance Department.
The Contractor shall make provision, satisfactory to SDOH, for
protections for SDOH, LDSSs and the Enrollees in the event of
Contractor or subcontractor insolvency, including but not limited to,
hold harmless and continuation of treatment provisions in all provider
agreements which protect SDOH, LDSSs and Enrollees from costs of
treatment and assures continued access to care for Enrollees.
35.6 Compliance With Care for Maternity Patients
Contractor must comply with Section 2803-n of the PHL and Section 3216
(i) (10) (a) of the State Insurance Law related to hospital care for
maternity patients.
35.7 Informed Consent Procedures for Hysterectomy and Sterilization
The Contractor is required and shall require Participating Providers
to comply with the informed consent procedures for Hysterectomy and
Sterilization specified in 42 CFR Part 441, sub-part F, and 18 NYCRR
Section 505.13.
35.8 Non-Liability of Enrollees for Contractor's Debts
Contractor agrees that in no event shall the Enrollee become liable
for the Contractors debts as set forth in SSA Section 1932(b)(6).
SECTION 23 - SECTION 36
October 1, 2005
-11-
35.9 SDOH Compliance With Conflict of Interest Laws
DOHMH and its employees shall comply with Article 18 of the General
Municipal Law and all other appropriate provisions of New York State
law, local laws and ordinances and all resultant codes, rules and
regulations pertaining to conflicts of interest.
35.10 Compliance With PHL Regarding External Appeals
Contractor must comply with Article 49 Title II of the PHL regarding
external appeal of adverse determinations.
36. NEW YORK STATE STANDARD CONTRACT CLAUSES AND LOCAL STANDARD CLAUSES
The parties agree to be bound by the standard clauses for all New York
State contracts and standard clauses, if any, for local government
contracts contained in Appendix A and R, respectively, attached to and
incorporated into this Agreement as if set forth fully herein, and any
amendment thereto.
SECTION 23 - SECTION 36
October 1, 2005
-12-
This Agreement is effective October 1, 2005 and shall remain in effect until
September 30, 2007 or until the execution of an extension, renewal or successor
agreement as provided for in the Agreement.
In Witness Whereof, the parties have duly executed this Agreement on the dates
appearing below their respective signatures.
By By
---------------------------------- -------------------------------------
CarePlus, L.L.C. New York City Department of Health
and Mental Hygiene
Date 9/30/05 Date
-----------------------------------
Approval as to form and certification as to legal authority was granted by the
Corporation Counsel on: September 16, 2005.
SIGNATURE PAGE
October 1, 2005
STATE OF NEW YORK)
SS:
COUNTY OF NEW YORK
On this 30th day of September 2005, Harry Michelen came before me, to me
known and to be the CEO of Care Plus Health Plan, who is duly authorized to
execute the foregoing instrument on behalf of said corporation and s/he
acknowledged to me that s/he executed the same for the purpose therein
mentioned.
/s/ GERARD HARRINGTON
----------------------------------------
NOTARY PUBLIC
GERARD HARRINGTON
NOTARY Public, State of New York
No 01HA6102369
Qualified in NEW York County
CONMMISSION EXPIRES DEC. 8. 2017
STATE OF NEW YORK)
SS:
COUNTY OF NEW YORK
On this _____ day of ___________, 20__, _______________________ came before
me, to me known and known to be the _______________________ in the New York City
Department of Health and Mental Hygiene, who is duly authorized to execute the
foregoing instrument on behalf of the City and s/he acknowledged to me that s/he
executed the same for the purpose therein mentioned.
----------------------------------------
NOTARY PUBLIC
APPENDIX A
NEW YORK STATE STANDARD CLAUSES
APPENDIX A
October 1, 2005
STANDARD CLAUSES FOR HYS CONTRACTS APPENDIX A
STANDARD CLAUSES FOR NYS CONTRACTS
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree to
be bound by the following clauses which are hereby made a part of the contract
(the word "Contractor" herein refers to any party other than the State, whether
a contractor, licenser, licensee, lessor, lessee or any other party):
1. EXECUTORY CLAUSE. In accordance with Section 41 of the State Finance Law, the
State shall have no liability under this contract to the Contractor or to anyone
else beyond funds appropriated and available for this contract.
2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of the State Finance
Law, this contract may not be assigned by the Contractor or its right, title or
interest therein assigned, transferred, conveyed, sublet or otherwise disposed
of without the previous consent, in writing, of the State and any attempts to
assign the contract without the State's written consent are null and void. The
Contractor may, however, assign its right to receive payment without the State's
prior written consent unless this contract concerns Certificates of
Participation pursuant to Article 5-A of the State Finance Law.
3. COMPTROLLER'S APPROVAL. In accordance with Section 112 of the State Finance
Law (or, if this contract is with the State University or City University of New
York, Section 355 or Section 6218 of the Education Law), if this contract
exceeds $15,000 (or the minimum thresholds agreed to by the Office of the State
Comptroller for certain S.U.N.Y. and C.U.N.Y. contracts), or if this is an
amendment for any amount to a contract which, as so amended, exceeds said
statutory amount, or if, by this contract, the State agrees to give something
other than money when the value or reasonably estimated value of such
consideration exceeds $10,000, it shall not be valid, effective or binding upon
the State until it has been approved by the State Comptroller and filed in his
office. Comptroller's approval of contracts let by the Office of General
Services is required when such contracts exceed $30,000 (State Finance Law
Section 163.6.a).
4. WORKERS' COMPENSATION BENEFITS. In accordance with Section 142 of the State
Finance Law, this contract shall be void and of no force and effect unless the
Contractor shall provide and maintain coverage during the life of this contract
for the benefit of such employees as are required to be covered by the
provisions of the Workers' Compensation Law.
5. NON-DISCRIMINATION REQUIREMENTS. To the extent required by Article 15 of the
Executive Law (also known as the Human Rights Law) and all other State and
Federal statutory and constitutional non-discrimination provisions, the
Contractor will not discriminate against any employee or applicant for
employment because of race, creed, color, sex, national origin, sexual
orientation, age, disability, genetic predisposition or carrier status, or
marital status. Furthermore, in accordance with Section 220-e of the Labor Law,
if this is a contract for the construction, alteration or repair of any public
building or public work or for the manufacture, sale or distribution of
materials, equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it not
its subcontractors shall, by reason of race, creed, color, disability, sex, or
national origin: (a) discriminate in hiring against any New York State citizen
who is qualified and available to perform the work; or (b) discriminate against
or intimidate any employee hired for the performance of work under this
contract. If this is a building service contract as defined in Section 230 of
the Labor Law, then, in accordance with Section 239 thereof, Contractor agrees
that neither it nor its subcontractors shall by reason of race, creed, color,
national origin, age, sex or disability: (a) discriminate in hiring against any
New York State citizen who is qualified and available to perform the work; or
(b) discriminate against or intimidate any employee hired for the performance of
work under this contract. Contractor is subject to fines of $50.00 per person
per day for any violation of Section 220-e or Section 239 as well as possible
termination of this contract and forfeiture of all moneys due hereunder for a
second or subsequent violation.
6. WAGE AND HOURS PROVISIONS. If this is a public work contract covered by
Article 8 of the Labor Law or a building service contract covered by Article 9
thereof, neither Contractor's employees nor the employees of its subcontractors
may be required or permitted to work more than the number of hours or days
stated in said statutes, except as otherwise provided in the Labor Law and as
set forth in prevailing wage and supplement schedules issued by the State Labor
Department. Furthermore, Contractor and its subcontractors must pay at least the
prevailing wage rate and pay or provide the prevailing supplements, including
the premium rates for overtime pay, as determined by the State Labor Department
in accordance with the Labor Law.
7. NON-COLLUSIVE BIDDING CERTIFICATION. In accordance with Section 139-d of the
State Finance Law, if this contract was awarded based upon the submission of
bids, Contractor warrants, under penalty of perjury, that its bid was arrived at
independently and without collusion aimed at restricting competition. Contractor
further warrants that, at the time Contractor submitted its bid, an authorized
and responsible person executed and delivered to the State a non-collusive
bidding certification on Contractor's behalf.
8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with Section 220-f of the
Labor Law and Section 139-h of the State Finance Law, if this contract exceeds
$5,000, the Contractor agrees, as a material condition of the contract, that
neither the Contractor nor any substantially owned or affiliated person, firm,
partnership or corporation has participated, is participating, or shall
participate in an international boycott in violation of the federal Export
Administration Act of 1979 (50 USC App. Sections 2401 et seq.) or regulations
thereunder. If such Contractor, or any of the aforesaid affiliates of
Contractor, is convicted or is otherwise found to have violated said laws or
regulations upon the final determination of the United States Commerce
Department or any other appropriate agency of the United States subsequent to
the contract's execution, such contract, amendment or modification thereto shall
be rendered forfeit and void. The Contractor shall so notify the State
Comptroller within five (5) business days of such conviction, determination or
disposition of appeal (2NYCRR 105.4).
9. SET-OFF RIGHTS. The State shall have all of its common law, equitable and
statutory rights of set-off. These rights shall include, but not be limited to,
the State's option to withhold for the purposes of set-off any moneys due to the
Contractor under this contract up to any amounts due and owing to the State with
regard to this contract, any other contract with any State department or agency,
including any contract for a term commencing prior to the term of this contract,
plus any amounts due and owing to the State for any other reason including,
without limitation, tax delinquencies, fee delinquencies or monetary penalties
relative thereto. The State shall exercise its set-off rights in accordance with
normal State practices including, in cases of set-off pursuant to an audit, the
finalization of such audit by the State agency, its representatives, or the
State Comptroller.
10. RECORDS. The Contractor shall establish and maintain complete and accurate
books, records, documents, accounts and other evidence directly pertinent to
performance under this contract (hereinafter, collectively, "the Records"). The
Records must be kept for the balance of the calendar year in which they were
made and for six (6) additional years thereafter. The State Comptroller, the
Attorney General and any other person or entity authorized to conduct an
examination, as well as the agency or agencies involved in this contract, shall
have access to the Records during normal business hours at an office of the
Contractor
Page 1 May, 2003
STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
within the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and (ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.
11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICATION, (a) FEDERAL EMPLOYER
IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER. All invoices or New
York State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State agency
must include the payee's identification number, i.e., the seller's or lessor's
identification number. The number is either the payee's Federal employer
identification number or Federal social security number, or both such numbers
when the payee has both such numbers. Failure to include this number or numbers
may delay payment. Where the payee does not have such number or numbers, the
payee, on its invoice or New York State standard voucher, must give the reason
or reasons why the payee does not have such number or numbers.
(b) PRIVACY NOTIFICATION. (1) The authority to request the above personal
information from a seller of goods or services or a lessor of real or personal
property, and the authority to maintain such information, is found in Section 5
of the State Tax Law. Disclosure of this information by the seller or lessor to
the State is mandatory. The principal purpose for which the information is
collected is to enable the State to identify individuals, businesses and others
who have been delinquent in filing tax returns or may have understated their tax
liabilities and to generally identify persons affected by the taxes administered
by the Commissioner of Taxation and Finance. The information will be used for
tax administration purposes and for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.
12. EQUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN. In accordance with
Section 312 of the Executive Law, if this contract is: (i) a written agreement
or purchase order instrument, providing for a total expenditure in excess of
$25,000.00, whereby a contracting agency is committed to expend or does expend
funds in return for labor, services, supplies, equipment, materials or any
combination of the foregoing, to be performed for, or rendered or furnished to
the contracting agency; or (ii) a written agreement in excess of $100,000.00
whereby a contracting agency is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or renovation
of real property and improvements thereon; or (iii) a written agreement in
excess of $100,000.00 whereby the owner of a State assisted housing project is
committed to expend or does expend funds for the acquisition, construction,
demolition, replacement, major repair or renovation of real property and
improvements thereon for such project, then:
(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age, disability
or marital status, and will undertake or continue existing programs of
affirmative action to ensure that minority group members and women are afforded
equal employment opportunities without discrimination. Affirmative action shall
mean recruitment, employment, job assignment, promotion, upgrading, 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 11-A of the State
Finance Law to the extent required by law.
16. NO ARBITRATION. Disputes involving this contract, including the breach or
alleged breach thereof, may not be submitted to binding arbitration (except
where statutorily authorized), but must, instead, be heard in a court of
competent jurisdiction of the State of New York.
17. SERVICE OF PROCESS. In addition to the methods of service allowed by the
State Civil Practice Law & Rules ("CPLR"), Contractor hereby consents to service
of process upon it by registered or certified mail, return receipt requested.
Service hereunder shall be complete upon Contractor's actual receipt of process
or upon the State's receipt of the return thereof by the United States Postal
Service as refused or undeliverable. Contractor must promptly notify the State,
in writing, of each and every change of address to which service of process can
be made. Service by the State to the last known address shall be sufficient.
Contractor will have thirty (30) calendar days after service hereunder is
complete in which to respond.
Page 2 May, 2003
STANDARD CLAUSES FOR NYS CONTRACTS APPENDIX A
18. PROHIBITION ON PURCHASE OF TROPICAL HARDWOODS. The Contractor certifies and
warrants that all wood products to be used under this contract award will be in
accordance with, but not limited to, the specifications and provisions of State
Finance Law Section 165. (Use of Tropical Hardwoods) which prohibits purchase
and use of tropical hardwoods, unless specifically exempted, by the State or any
governmental agency or political subdivision or public benefit corporation.
Qualification for an exemption under this law will be the responsibility of the
contractor to establish to meet with the approval of the State.
In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be performed by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in Section 165 State
Finance Law. Any such use must meet with the approval of the State; otherwise,
the bid may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to meet
with the approval of the State.
19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance with the MacBride Fair
Employment Principles (Chapter 807 of the Laws of 1992), the Contractor hereby
stipulates that the Contractor either (a) has no business operations in Northern
Ireland, or (b) shall take lawful steps in good faith to conduct any business
operations in Northern Ireland in accordance with the MacBride Fair Employment
Principles (as described in Section 165 of the New York State Finance Law), and
shall permit independent monitoring of compliance with such principles.
20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New York State to
maximize opportunities for the participation of New York State business
enterprises, including minority and women-owned business enterprises as bidders,
subcontractors and suppliers on its procurement contracts.
Information on the availability of New York State subcontractors and suppliers
is available from:
NYS Department of Economic Development
Division for Small Business
30 South Pearl St -- 7th Floor
Albany, New York 12245
Telephone: 518-292-5220
A directory of certified minority and women-owned business enterprises is
available from:
NYS Department of Economic Development
Division of Minority and Women's Business Development
30 South Pearl St -- 2nd Floor
Albany, New York 12245
http://www.empire.state.ny.us
The Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or contract, as applicable, Contractors certify that whenever the total bid
amount is greater than $1 million:
(a) The Contractor has made reasonable efforts to encourage the participation of
New York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project, and
has retained the documentation of these efforts to be provided upon request to
the State;
(b) The Contractor has complied with the Federal Equal Opportunity Act of 1972
(P.L. 92-261), as amended;
(c) The Contractor agrees to make reasonable efforts to provide notification to
New York State residents of employment opportunities on this project through
listing any such positions with the Job Service Division of the New York State
Department of Labor, or providing such notification in such manner as is
consistent with existing collective bargaining contracts or agreements. The
Contractor agrees to document these efforts and to provide said documentation to
the State upon request; and
(d) The Contractor acknowledges notice that the State may seek to obtain offset
credits from foreign countries as a result of this contract and agrees to
cooperate with the State in these efforts.
21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are hereby notified that if
their principal place of business is located in a country, nation, province,
state or political subdivision that penalizes New York State vendors, and if the
goods or services they offer will be substantially produced or performed outside
New York State, the Omnibus Procurement Act 1994 and 2000 amendments (Chapter
684 and Chapter 383, respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15, 2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii. Contact
NYS Department of Economic Development for a current list of jurisdictions
subject to this provision.
22. PURCHASES OF APPAREL. In accordance with State Finance Law 162 (4-a), the
State shall not purchase any apparel from any vendor unable or unwilling to
certify that: (i) such apparel was manufactured in compliance with all
applicable labor and occupational safety laws, including, but not limited to,
child labor laws, wage and hours laws and workplace safety laws, and (ii) vendor
will supply, with its bid (or, if not a bid situation, prior to or at the time
of signing a contract with the Slate), if known, the names and addresses of each
subcontractor and a list of all manufacturing plants to be utilized by the
bidder.
Page 3 May, 2003
APPENDIX B
CERTIFICATION REGARDING LOBBYING
APPENDIX B
October 1, 2005
B-l
APPENDIX B
CERTIFICATION REGARDING LOBBYING
The undersigned certifies, to the best of his or her knowledge, that:
1. No Federal appropriated funds have been paid or will be paid to any person
by or on behalf of the Contractor for the purpose of influencing or
attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of a Member of Congress in connection with
the award of any Federal loan, the entering into of any cooperative
agreement, or the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative
agreement.
2. If any funds other than Federal appropriated funds have been paid or will
be paid to any person for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress in
connection with the award of any Federal contract, the making of any
Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, or the extension, continuation, renewal, amendment,
or modification of any Federal contract, grant, loan, or cooperative
agreement, and the Agreement exceeds $100,000, the Contractor shall
complete and submit Standard Form - LLL "Disclosure Form to Report
Lobbying," in accordance with its instructions.
3. The Contractor shall include the provisions of this section in all provider
Agreements under this Agreement and require all Participating providers
whose Provider Agreements exceed $100,000 to certify and disclose
accordingly to the Contractor.
This certification is a material representation of fact upon which reliance
was place when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
pursuant to U.S.C. Section 1352. The failure to file the required certification
shall subject the violator to a civil penalty of not less than $10,000 and not
more than $100,000 for each such failure.
DATE: 9/30/05
SIGNATURE:
--------------------------
TITLE: Chief Executive Officer
ORGANIZATION: CarePlus HealthPlan
APPENDIX B
October 1, 2005
B-2
APPENDIX C
NEW YORK STATE DEPARTMENT OF HEALTH
REQUIREMENTS FOR THE PROVISION OF
FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
C.1 DEFINITIONS AND GENERAL REQUIREMENTS FOR THE PROVISION OF FAMILY PLANNING
AND REPRODUCTIVE HEALTH SERVICES
C.2 REQUIREMENTS FOR MCOS THAT INCLUDE FAMILY PLANNING AND REPRODUCTIVE HEALTH
SERVICES IN THEIR BENEFIT PACKAGE
C.3 REQUIREMENTS FOR MCOS THAT DO NOT INCLUDE FAMILY PLANNING SERVICES AND
REPRODUCTIVE HEALTH SERVICES IN THEIR BENEFIT PACKAGE
APPENDIX C
October 1, 2005
C-l
C.1
DEFINITIONS AND GENERAL REQUIREMENTS FOR THE PROVISION OF
FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
1. FAMILY PLANNING AND REPRODUCTIVE HEALTH SERVICES
a) Family Planning and Reproductive Health services mean the offering,
arranging and furnishing of those health services which enable
Enrollees, including minors who may be sexually active, to prevent or
reduce the incidence of unwanted pregnancies.
i) Family Planning and Reproductive Health services include the
following medically-necessary services, related drugs and
supplies which are furnished or administered under the
supervision of a physician, licensed midwife or certified nurse
practitioner during the course of a Family Planning and
Reproductive Health visit for the purpose of:
A) contraception, including insertion/removal of an
intrauterine device (IUD), insertion/removal of
contraceptive implants, and injection procedures involving
Pharmaceuticals such as Depo-Provera;
B) sterilization;
C) screening, related diagnosis, and referral to a
Participating Provider for pregnancy;
D) medically-necessary induced abortions, which are procedures,
either medical or surgical, that result in the termination
of pregnancy. The determination of medical necessity shall
include positive evidence of pregnancy, with an estimate of
its duration.
ii) Family Planning and Reproductive Health services include those
education and counseling services necessary to render the
services effective.
iii) Family Planning and Reproductive Health services include
medically-necessary ordered contraceptives and pharmaceuticals:
A) For MMC Enrollees - The Contractor is responsible for
pharmaceuticals and medical supplies such as IUDS and
Depo-Provera that must be furnished or administered under
the supervision of a physician, licensed midwife, or
certified nurse practitioner during the course of a Family
Planning and Reproductive Health visit. Other pharmacy
prescriptions, medical supplies, and over the counter drugs
are not the responsibility of the Contractor and are to be
obtained when covered on the New York State list of Medicaid
APPENDIX C
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C-2
reimbursable drugs by the Enrollee from any appropriate
eMedNY-enrolled health care provider of the Enrollee's
choice.
B) For FHPlus Enrollees - The Contractor, if it includes such
services in its Benefit Package, or the Designated Third
Party Contractor that provides such services to FHPlus
Enrollees when the Contractor does not provide Family
Planning and Reproductive Health services, is responsible
for prescription contraceptives provided by a Participating
pharmacy, consistent with the pharmacy benefit package
described in Appendix K. The Contractor or the Designated
Third Party Contractor must cover at least one of every type
of the following methods of contraception:
I) Oral
II) Oral, emergency
III) Injectable
IV) Transdermal
V) Intravaginal
VI) Intravaginal, systemic
VII) Implantable
b) When clinically indicated, the following services may be provided as a
part of a Family Planning and Reproductive Health visit:
i) Screening, related diagnosis, ambulatory treatment and referral
as needed for dysmenorrhea, cervical cancer, or other pelvic
abnormality/pathology.
ii) Screening, related diagnosis and referral for anemia, cervical
cancer, glycosuria, proteinuria, hypertension and breast disease.
iii) Screening and treatment for sexually transmissible disease,
iv) HIV blood testing and pre- and post-test counseling.
2. FREE ACCESS TO SERVICES FOR MMC ENROLLEES
a) Free Access means MMC Enrollees may obtain Family Planning and
Reproductive Health services, and HIV blood testing and pre-and
post-test counseling when performed as part of a Family Planning and
Reproductive Health encounter, from either the Contractor, if it
includes such services in its Benefit Package, or from any appropriate
eMedNY-enrolled health care provider of the Enrollee's choice. No
referral from the PCP or approval by the Contractor is required to
access such services.
b) The Family Planning and Reproductive Health services listed above are
the only services which are covered under the Free Access policy.
Routine obstetric and/or
APPENDIX C
October 1, 2005
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gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care are not covered under the Free Access policy, and are
the responsibility of the Contractor.
3. ACCESS TO SERVICES FOR FHPLUS ENROLLEES
a) FHPlus Enrollees may obtain Family Planning and Reproductive Health
services, and HIV blood testing and pre-and post-test counseling when
performed as part of a Family Planning and Reproductive Health
Services encounter, from either the Contractor or through the
Designated Third Party Contractor, as applicable. No referral from the
PCP or approval by the Contractor is required to access such services.
b) The Contractor is responsible for routine obstetric and/or gynecologic
care, including hysterectomies, pre-natal, delivery and post-partum
care, regardless of whether Family Planning and Reproductive Health
services are included in the Contractor's Benefit Package.
APPENDIX C
October 1, 2005
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C.2
REQUIREMENTS FOR MCOS THAT INCLUDE FAMILY PLANNING AND REPRODUCTIVE
HEALTH SERVICES IN THEIR BENEFIT PACKAGE
1. NOTIFICATION TO ENROLLEES
a) If the Contractor includes Family Planning and Reproductive Health
services in its Benefit Package (as per Appendix M of this Agreement)
the Contractor must notify all Enrollees of reproductive age,
including minors who may be sexually active, at the time of Enrollment
about their right to obtain Family Planning and Reproductive Health
services and supplies without referral or approval. The notification
must contain the following:
i) Information about the Enrollee's right to obtain the full range
of Family Planning and Reproductive Health services, including
HIV counseling and testing when performed as part of a Family
Planning and Reproductive Health encounter, from the Contractor's
Participating Provider without referral, approval or
notification.
ii) MMC Enrollees must receive notification that they also have the
right to obtain Family Planning and Reproductive Health services
in accordance with MMC's Free Access policy as defined in C.1 of
this Appendix.
iii) A current list of qualified Participating Family Planning
Providers who provide the full range of Family Planning and
Reproductive Health services within the Enrollee's geographic
area, including addresses and telephone numbers. The Contractor
may also provide MMC Enrollees with a list of qualified
Non-Participating providers who accept Medicaid and who provide
the full range of these services.
iv) Information that the cost of the Enrollee's Family Planning and
Reproductive care will be fully covered, including when a MMC
Enrollee obtains such services in accordance with MMC's Free
Access policy.
2. BILLING POLICY
a) The Contractor must notify its Participating Providers that all claims
for Family Planning and Reproductive Health services must be billed to
the Contractor and not the Medicaid fee-for-service program.
b) The Contractor will be charged for Family Planning and Reproductive
Health services furnished to MMC Enrollees by eMedNY-enrolled
Non-Participating Providers at the applicable Medicaid rate or fee. In
such instances, Non-Participating Providers will bill Medicaid
fee-for-service and the SDOH will issue a confidential
APPENDIX C
October 1, 2005
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charge back to the Contractor. Such charge back mechanism will comply
with all applicable patient confidentiality requirements.
3. CONSENT AND CONFIDENTIALITY
a) The Contractor will comply with federal, state, and local laws,
regulations and policies regarding informed consent and
confidentiality and ensure Participating Providers comply with all of
the requirements set forth in Sections 17 and 18 of the PHL and 10
NYCRR Section 751.9 and Part 753 relating to informed consent and
confidentiality.
b) Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization
review and quality assurance unless the provider agreement with the
Contractor provides otherwise. The Contractor must ensure that an
Enrollee's use of Family Planning and Reproductive Health services
remains confidential and is not disclosed to family members or other
unauthorized parties without the Enrollee's consent to the disclosure.
4. INFORMING AND STANDARDS
a) The Contractor will inform its Participating Providers and
administrative personnel about policies concerning MMC Free Access as
defined in C. 1 of this Appendix, where applicable; HIV counseling and
testing; reimbursement for Family Planning and Reproductive Health
encounters; Enrollee Family Planning and Reproductive Health education
and confidentiality.
b) The Contractor will inform its Participating Providers that they must
comply with professional medical standards of practice, the
Contractor's practice guidelines, and all applicable federal, state,
and local laws. These include but are not limited to, standards
established by the American College of Obstetricians and
Gynecologists, the American Academy of Family Physicians, the U.S.
Task Force on Preventive Services and the New York State Child/Teen
Health Program. These standards and laws recognize that Family
Planning counseling is an integral part of primary and preventive
care.
APPENDIX C
October 1, 2005
C-6
C.3
REQUIREMENTS FOR MCOS THAT DO NOT
INCLUDE FAMILY PLANNING SERVICES AND REPRODUCTIVE HEALTH SERVICES IN THEIR
BENEFIT PACKAGE
1. REQUIREMENTS
a) The Contractor agrees to comply with the policies and procedures
stated in the SDOH-approved statement described in Section 2 below.
b) Within ninety (90) days of signing this Agreement, the Contractor
shall submit to the SDOH a policy and procedure statement that the
Contractor will use to ensure that its Enrollees are fully informed of
their rights to access a full range of Family Planning and
Reproductive Health services, using the following guidelines. The
statement must be sent to the Director, Office of Managed Care, NYS
Department of Health, Corning Tower, Room 2001, Albany, NY 12237.
c) SDOH may waive the requirement in (b) above if such approved statement
is already on file with SDOH and remains unchanged.
2. POLICY AND PROCEDURE STATEMENT
a) The policy and procedure statement regarding Family Planning and
Reproductive Health services must contain the following:
i) Enrollee Notification
A) A statement that the Contractor will inform Prospective
Enrollees, new Enrollees and current Enrollees that:
I) Certain Family Planning and Reproductive Health
services (such as abortion, sterilization and birth
control) are not covered by the Contractor, but that
routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum
care are covered by the Contractor;
II) Such Family Planning and Reproductive Health Services
that are not covered by the Contractor may be obtained
either through fee-for-service Medicaid providers for
MMC Enrollees; and/or, through the Designated Third
Party Contractor for FHPlus Enrollees;
III) No referral is needed for such services, and there will
be no cost to the Enrollee for such services.
APPENDIX C
October 1, 2005
C-7
IV) HIV counseling and testing services are available
through the Contractor and are also available as part
of a Family Planning and Reproductive Health encounter
when furnished by a fee-for-service Medicaid provider
to MMC Enrollees and through the Designated Third Party
Contractor to FHPlus Enrollees; and that anonymous
counseling and testing services are available from
SDOH, Local Public Health Agency clinics and other New
York City programs.
B) A statement that this information will be provided in the
following manner:
I) Through the Contractor's written Marketing materials,
including the Member Handbook. The Member Handbook and
Marketing materials will indicate that the Contractor
has elected not to cover certain Family Planning and
Reproductive Health services, and will explain the
right of all MMC Enrollees to secure such services
through fee-for-service Medicaid from any
provider/clinic which offers these services and accepts
Medicaid, and the right of all FHPlus Enrollees to
secure such services through the Designated Third Party
Contractor.
II) Orally at the time of Enrollment and any time an
inquiry is made regarding Family Planning and
Reproductive Health services.
III) By inclusion on any web site of the Contractor which
includes information concerning its MMC or FHPlus
product(s). Such information shall be prominently
displayed and easily navigated.
C) A description of the mechanisms to provide all new MMC
Enrollees with an SDOH approved letter explaining how to
access Family Planning and Reproductive Health services and
the SDOH approved list of Family Planning providers. This
material will be furnished by SDOH and mailed to the
Enrollee no later than fourteen (14) days after the
Effective Date of Enrollment.
D) A statement that if an Enrollee or Prospective Enrollee
requests information about these non-covered services, the
Contractor's Marketing or Enrollment representative or
member services department will advise the Enrollee or
Prospective Enrollee as follows:
I) Family Planning and Reproductive Health services such
as abortion, sterilization and birth control are not
covered by the Contractor and that only routine
obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum
care are the responsibility of the Contractor.
APPENDIX C
October 1, 2005
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II) MMC Enrollees can use their Medicaid card to receive
these non-covered services from any doctor or clinic
that provides these services and accepts Medicaid.
FHPlus Enrollees can receive these non-covered services
through the Designated Third Party Contractor under
contract with SDOH in the Enrollee's geographic area.
III) Each MMC Enrollee and Prospective MMC Enrollee who
calls will be mailed a copy of the SDOH approved letter
explaining the Enrollee's right to receive these
non-covered services, and an SDOH approved list of
Family Planning Providers who participate in Medicaid
in the Enrollee's community. These materials will be
mailed within two (2) business days of the contact.
IV) The Contractor will provide the name and phone number
of the Designated Third Party Contractor under SDOH
contract to provide such services to FHPlus Enrollees
and Prospective FHPlus Enrollees. It is the
responsibility of the Designated Third Party Contractor
to mail to each FHPlus Enrollee or Prospective FHPlus
Enrollee who calls, a copy of the SDOH approved letter
explaining the Enrollee's right to receive such
services, and an SDOH approved list of Family Planning
Providers and Pharmacies in the Designated Third Party
Contractor's network. The Designated Third Party
Contractor is responsible for mailing these materials
within fourteen (14) days of notice by the Contractor
of a new Enrollee in the Contractor's FHPlus product.
V) Enrollees can call the Contractor's member services
number for further information about how to obtain
these non-covered services. MMC Enrollees can also call
the New York State Growing-Up-Healthy Hotline
(1-800-522-5006) to request a copy of the list of
Medicaid Family Planning Providers. FHPlus Enrollees
can also call the Designated Third Party Contractor for
a list of Family Planning providers.
E) The procedure for maintaining a manual log of all requests
for such information, including the date of the call, the
Enrollee's client identification number (CIN), and the date
the SDOH approved letter and SDOH or LDSS approved list were
mailed, where applicable. The Contractor will review this
log monthly and upon request, submit a copy to SDOH.
ii) Participating Provider and Employee Notification
A) A statement that the Contractor will inform its
Participating Providers and administrative personnel about
Family Planning and Reproductive Health policies under MMC
Free Access, as defined in C.1 of this Appendix, and/or the
FHPlus Designated Third Party Contractor for FHPlus
Enrollees, HIV counseling and testing; reimbursement for
Family Planning and Reproductive
APPENDIX C
October 1, 2005
C-9
Health encounters; Enrollee Family Planning and Reproductive
Health education and confidentiality.
B) A statement that the Contractor will inform its
Participating Providers that they must comply with
professional medical standards of practice, the Contractor's
practice guidelines, and all applicable federal, state, and
local laws. These include but are not limited to, standards
established by the American College of Obstetricians and
Gynecologists, the American Academy of Family Physicians,
the U.S. Task Force on Preventive Services and the New York
State Child/Teen Health Program. These standards and laws
recognize that Family Planning counseling is an integral
part of primary and preventive care.
C) The procedure(s) for informing the Contractor's
Participating primary care providers, obstetricians, and
gynecologists that the Contractor has elected not to cover
certain Family Planning and Reproductive Health services,
but that routine obstetric and/or gynecologic care,
including hysterectomies, pre-natal, delivery and
post-partum care are covered; and that Participating
Providers may provide, make referrals, or arrange for
non-covered services in accordance with MMC's Free Access
policy, as defined in C.1 of this Appendix, and/or through
the SDOH-contracted Designated Third Party for FHPlus
Enrollees.
D) A description of the mechanisms to inform the Contractor's
Participating Providers that:
I) if they also participate in the fee-for-service
Medicaid program and they render non-covered Family
Planning and Reproductive Health services to MMC
Enrollees, they do so as a fee-for-service Medicaid
practitioner, independent of the Contractor.
II) if they also participate in the FHPlus Designated Third
Party Contractor's network and they render non-covered
Family Planning and Reproductive Health Services to
FHPlus Enrollees, they do so as a participating
provider with that MCO, independent of the Contractor.
E) A description of the mechanisms to inform Participating
Providers that, if requested by the Enrollee, or, if in the
provider's best professional judgment, certain Family
Planning and Reproductive Health services not offered
through the Contractor are medically indicated in accordance
with generally accepted standards of professional practice,
an appropriately trained professional should so advise the
Enrollee and either:
APPENDIX C
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I) offer those services to MMC Enrollees on a
fee-for-service basis as an eMedNY-enrolled provider,
or to FHPlus Enrollees as a Participating Provider of
the Designated Third Party Contractor; or
II) provide MMC Enrollees with a copy of the SDOH approved
list of Medicaid Family Planning Providers, and/or
provide FHPlus Enrollees with the name and number of
the Designated Third Party Contractor, or
III) give Enrollees the Contractor's member services number
to call to obtain either the list of Medicaid Family
Planning Providers or the name and number of the
Designated Third Party Contractor, as applicable.
F) A statement that the Contractor acknowledges that the
exchange of medical information, when indicated in
accordance with generally accepted standards of professional
practice, is necessary for the overall coordination of
Enrollees' care and assist Primary Care Providers in
providing the highest quality care to the Contractor's
Enrollees. The Contractor must also acknowledge that medical
record information maintained by Participating Providers may
include information relating to Family Planning and
Reproductive Health services provided under the
fee-for-service Medicaid program or under the Designated
Third Party contract with SDOH.
iii) Quality Assurance Initiatives
A) A statement that the Contractor will submit any materials to
be furnished to Enrollees and providers relating to access
to non-covered Family Planning and Reproductive Health
services to SDOH, Office of Managed Care for its review and
approval before issuance. Such materials include but are not
limited to Member Handbooks, provider manuals, and Marketing
materials.
B) A description of monitoring mechanisms the Contractor will
use to assess the quality of the information provided to
Enrollees.
C) A statement that the Contractor will prepare a monthly list
of MMC Enrollees who have been sent a copy of the SDOH
approved letter and the SDOH approved list of Family
Planning providers, and a list of FHPlus Enrollees who have
been provided with the name and telephone number of the
Designated Third Party Contractor in their geographic area.
This information will be available to SDOH upon request.
D) A statement that the Contractor will provide all new
employees with a copy of these policies. A statement that
the Contractor's orientation programs will include a
thorough discussion of all aspects of these policies and
procedures and that annual retraining programs for all
employees will be conducted to ensure continuing compliance
with these policies.
APPENDIX C
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C-ll
E) A description of the mechanisms to provide the Designated
Third Party Contractor with a monthly listing of all FHPlus
Enrollees within seven (7) days of receipt of the
Contractor's monthly Enrollment Roster and any subsequent
updates or adjustments. A copy of each file will also be
provided simultaneously to the SDOH.
3. CONSENT AND CONFIDENTIALITY
a) The Contractor must comply with federal, state, and local laws,
regulations and policies regarding informed consent and
confidentiality and ensure Participating Providers comply with all of
the requirements set forth in Sections 17 and 18 of the PHL and 10
NYCRR Section 751.9 and Part 753 relating to informed consent and
confidentiality.
b) Participating Providers and/or the Designated Third Party Contractor
Providers, may share patient information with appropriate Contractor
personnel for the purposes of claims payment, utilization review and
quality assurance, unless the provider agreement with the Contractor
provides otherwise. The Contractor must ensure that an Enrollee's use
of Family Planning and Reproductive Health services remains
confidential and is not disclosed to family members or other
unauthorized parties, without the Enrollee's consent to the
disclosure.
APPENDIX C
October 1, 2005
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APPENDIX D
NEW YORK STATE DEPARTMENT OF HEALTH
MARKETING GUIDELINES
D.1 MARKETING PLANS
D.2 MARKETING MATERIALS
D.3 MARKETING ACTIVITIES
APPENDIX D
October 1, 2005
D-l
MARKETING GUIDELINES
1. General
a) The purpose of these guidelines is to provide an operational framework
for localities and managed care organizations (MCOs) offering MMC or
FHPlus products in the development of MCO Marketing plans, materials,
and activities and to describe SDOH's Marketing rules, MCO Marketing
requirements, and prohibited practices.
b) If the Contractor's Marketing activities do not comply with the
Marketing Guidelines set forth in this Appendix or the Contractor's
approved Marketing plan, the SDOH and the DOHMH may take actions
pursuant to Section 11.5 of this Agreement in their sole discretion
deemed necessary to protect the interests of Prospective Enrollees,
Potential Enrollees and Enrollees and the integrity of the MMC and
FHPlus Programs.
c) This Appendix contains the following sections:
i) D.1, Marketing Plans;
ii) D.2, Marketing Materials; and
iii) D.3, Marketing Activities.
APPENDIX D
October 1, 2005
D-2
D.1
MARKETING PLANS
1. The Contractor shall develop a Marketing plan that meets SDOH guidelines
and any New York City specific marketing requirements as set forth in
Appendix N.
2. The SDOH, in consultation with DOHMH, is responsible for the review and
approval of the Contractor's Marketing plan.
3. Approved Marketing plans set forth the allowable terms and conditions and
the proposed activities that the Contractor intends to undertake during the
contract period.
4. The Contractor must have on file with the SDOH and the DOHMH, an SDOH and
DOHMH-approved Marketing plan prior to the contract award date or before
Marketing and enrollment begin, whichever is sooner. Subsequent changes to
the Marketing plan must be submitted to SDOH for approval, in consultation
with DOHMH, at least sixty (60) days before implementation.
5. The Marketing plan shall include: a stated Marketing goal and strategies;
Marketing activities; a description of the information provided by
marketers, including an overview of managed care; and staff training,
development and responsibilities. The following must be included in the
Contractor's description of materials to be used: distribution methods;
primary Marketing locations, and a listing of the kinds of community
service events the Contractor anticipates sponsoring and/or participating
in for the purposes of providing information and/or distributing Marketing
materials.
6. The Contractor must describe how it is able to meet the informational
needs, related to Marketing, for the physical and cultural diversity of
Prospective Enrollees. This may include, but not be limited to: a
description of the Contractor's provisions for Non-English speaking
Prospective Enrollees, interpreter services, alternate communication
mechanisms, including sign language, Braille, audio tapes, and/or use of
Telecommunications Device for the Deaf (TDD)/TTY services and how the
Contractor will make oral interpretation services available to Potential
Enrollees and Enrollees free of charge.
7. The Contractor shall describe measures for monitoring and enforcing
compliance with these Guidelines by its Marketing Representatives and its
Participating Providers including: the prohibition of door-to-door
solicitation and cold-call telephoning; a description of the development of
mailing lists of Prospective Enrollees that maintains client
confidentiality and that honors the client's express request for direct
contact by the Contractor; a description and planned means of distribution
of pre-enrollment gifts and incentives to Prospective Enrollees; and a
description of the training, compensation and supervision of its Marketing
Representatives.
APPENDIX D
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D-3
D.2
MARKETING MATERIALS
1. DEFINITIONS
a) Marketing materials generally include the concepts of advertising,
public service announcements, printed publications, and other
broadcast or electronic messages designed to increase awareness and
interest in the Medicaid Managed Care Program or the FHPlus Program
and/or the Contractor's MMC or FHPlus product. The target audience for
MMC Marketing materials is MMC Eligible Persons who are not enrolled
in a MCO offering a MMC product and who are living in the Contractor's
service area, if the Contractor offers a MMC product. The target
audience for FHPlus Marketing materials is low-income uninsured people
who do not qualify for Medicaid who are living in the Contractor's
service area, if the Contractor offers a FHPlus product.
b) Marketing materials include any information that references the MMC or
FHPlus Program, is intended for general distribution, and is produced
in a variety of print, broadcast, and direct Marketing mediums. These
generally include: radio, television, billboards, newspapers,
leaflets, informational brochures, videos, telephone book yellow page
ads, letters, and posters. Additional materials requiring Marketing
approval include a listing of items to be provided as nominal gifts or
incentives.
2. MARKETING MATERIAL REQUIREMENTS
a) Marketing materials must be written in prose that is understood at a
fourth-to sixth- grade reading level and must be printed in at least
ten (10) point type.
b) Marketing materials must be made available throughout the Contractor's
entire service area. Materials may be customized for specific counties
and populations within the Contractor's service area. All Marketing
activities should provide for equitable distribution of materials
without bias toward or against any group.
c) The Contractor must make available written Marketing and other
informational materials (e.g., member handbooks) in a language other
than English whenever at least five percent (5%) of the Prospective
Enrollees of the Contractor in any county of the service area speak
that particular language and do not speak English as a first language.
SDOH will inform the DOHMH and the DOHMH will inform the Contractor
when the five percent (5%) threshold has been reached. Marketing
materials to be translated include those key materials such as
informational brochures, that are produced for routine distribution
and that are included within the Contractor's Marketing plan. SDOH
will determine the need for other-than-English translations based on
county-specific census data or other available measures.
d) Alternate forms of communications must be provided for persons with
visual, hearing, speech, physical, or developmental disabilities.
These alternate forms
APPENDIX D
October 1, 2005
D-4
include Braille or audiotapes for the visually impaired, TTY access
for those with certified speech or hearing disabilities, and use of
American Sign Language and/or integrative technologies.
e) The Contractor's name, mailing address (and location, if different),
and toll-free phone number must be prominently displayed on the cover
of all multi-paged Marketing materials.
f) Marketing materials must not contain false, misleading, or ambiguous
information-- such as "You have been pre-approved for the XYZ Health
Plan," or "If you do not choose a plan you will lose your Medicaid
coverage," or "You get free, unlimited visits." Materials must not use
broad, sweeping statements.
g) The material must accurately reflect general information, which is
applicable to the average consumer of the MMC Program or FHPlus
Program.
h) The Contractor may not use logos or wording used by government
agencies if such use could imply or cause confusion about a connection
between a governmental agency and the Contractor.
i) Marketing materials may not make reference to incentives that may be
available to Enrollees after they enroll in the Contractor's MMC or
FHPlus product, such as "If you join the XYZ Plan, you will receive a
free baby carriage after you complete eight prenatal visits."
j) Marketing materials that are prepared for distribution or presentation
by the LDSS, Enrollment Broker, or SDOH-approved Enrollment
Facilitators, must be provided in a manner that is easily understood
and appropriate to the target audience. The material covered must
include sufficient information to assist the individual in making an
informed choice of MCO.
k) The Contractor shall advise Prospective Enrollees, in written
materials related to Enrollment, to verify with the medical services
providers they prefer, or have an existing relationship with, that
such medical services providers are Participating Providers of the
selected MCO and are available to serve the Enrollee.
l) Marketing materials shall not mention other MCOs offering MMC or
FHPlus products by name except for materials approved by SDOH and
developed to present available MCO choices in an unbiased manner, or
as part of a transition of Enrollees from an MCO that withdraws from
the MMC or FHPlus Program.
3. PRIOR APPROVALS
a) The SDOH, inconsultation with DOHMH, will review and approve the
Contractor's Marketing plan and all Marketing materials and
advertising.
APPENDIX D
October 1, 2005
D-5
i) The SDOH will coordinate its review and approval of materials
that are specific to New York City with the DOHMH.
b) The SDOH will adhere to a sixty (60) day "file and use" policy,
whereby materials submitted by the Contractor must be reviewed and
commented on within sixty (60) days of submission or the Contractor
may assume the materials have been approved if the reviewer has not
submitted any written comment.
4. DISSEMINATION OF OUTREACH MATERIALS
a) Upon request, the Contractor shall provide to the LDSS, Enrollment
Broker and/or SDOH-approved Enrollment Facilitators, sufficient
quantities of approved Marketing materials or alternative
informational materials that describe coverage in the LDSS
jurisdiction.
b) The Contractor shall, upon request, submit to the DOHMH, LDSS,
Enrollment Broker or SDOH-approved Enrollment Facilitators, current
provider directories, as described in Section 13.2 of this Agreement,
together with information that describes how to determine whether a
provider is presently available.
APPENDIX D
October 1, 2005
D-6
D.3
MARKETING ACTIVITIES
1. DESCRIPTION AND REQUIREMENTS
a) Marketing includes any occasion during which Marketing information and
material regarding MMC and FHPlus Programs and information about the
Contractor's MMC or FHPlus products are presented to Prospective
Enrollees. Marketing activities include verbal presentations or
distribution of written materials, which may or may not be accompanied
by the giving away of nominal gifts.
b) With prior DOHMH/LDSS approval, the Contractor may engage in Marketing
activities that include community-sponsored social gatherings,
provider-hosted informational sessions, or Contractor-sponsored
events. Events may include such activities as health fairs workshops
on health promotion, holiday parties, after school programs, raffles,
etc. These events must not be restricted to Potential Enrollees.
c) The Contractor may conduct media campaigns (i.e., distribution of
information/materials regarding the MMC and/or FHPlus Programs and/or
its specific MMC and/or FHPlus products to encourage Prospective
Enrollees to enroll in its MMC or FHPlus product.) All media
materials, including television, radio, billboards, subway and bus
posters, and electronic messages, must be pre-approved by the SDOH at
least thirty (30) days prior to the campaign.
d) The Contractor will be forthright in its presentations to allow
Prospective Enrollees to exercise an informed choice.
e) If Contractor does not include Family Planning and Reproductive Health
services in its Benefit Package, as specified in Appendix M of this
Agreement, the Marketing Representative must tell Prospective
Enrollees that:
i) certain Family Planning and Reproductive Health services (such as
abortion, sterilization and birth control) are not covered by the
Contractor but that routine obstetric and/or gynecologic care,
including hysterectomies, pre-natal, delivery and post-partum
care are covered by the Contractor;
ii) whenever needed, Family Planning and Reproductive Health services
may be obtained by MMC Enrollees through fee-for-service Medicaid
from any provider who accepts Medicaid, and by FHPlus Enrollees
from the Designated Third-Party Contractor (including the name
and phone number of the Designated Third Party Contractor for the
Prospective Enrollee's geographic area);
iii) no referral is needed for Family Planning and Reproductive Health
services; and
iv) there will be no cost to the Enrollee for Family Planning and
Reproductive Health services.
APPENDIX D
October 1, 2005
D-7
2. MARKETING SITES
a) With prior DOHMH/LDSS approval, the Contractor may distribute approved
Marketing material in such places as: an income support maintenance
center, community centers, markets, pharmacies, hospitals and other
provider sites, schools, health fairs, a resource center established
by the LDSS or the Enrollment Broker, and other areas where
Prospective Enrollees are likely to gather. The DOHMH/LDSS may require
the Contractor to provide a minimum of two weeks notice to the
DOHMH/LDSS regarding marketing at approved locations so that the
DOHMH/LDSS may fulfill its role in monitoring Contractor marketing
activities.
b) The Contractor shall comply with the applicable restrictions on
Marketing established in SSL Section 364-j(4)(e), SSL Section 369-ee
and the SDOH Marketing Guidelines. The Contractor shall not engage in
practices prohibited by law and regulation, including cold call
Marketing or door-to-door solicitation. Cold Call Marketing means any
unsolicited personal contact by the Contractor with a Prospective
Enrollee for the purpose of Marketing. The Contractor shall not market
to Prospective Enrollees at their homes without the permission of the
Prospective Enrollee.
c) The Contractor shall comply with LDSS written requirements regarding
scheduling, staffing, and on-site procedures when marketing at LDSS
sites.
d) The Contractor shall neither conduct Marketing nor distribute
Marketing materials in hospital emergency rooms, including emergency
room waiting areas, patient rooms or treatment areas (except for
waiting areas) or other sites as are prohibited by the Commissioner of
Health pursuant to SSL Section 364-j(4)(e) or SSL Section 369-ee for
FHPlus.
e) The Contractor may not require its Participating Providers to
distribute Contractor-prepared communications to their patients.
f) The Contractor shall instruct its Participating Providers regarding
the following requirements applicable to communications with their
patients about the MMC and FHPlus products offered by the Contractor
and other MCOs with which the Participating Providers may have
contracts:
i) Participating Providers who wish to let their patients know of
their affiliations with one or more MCOs must list each MCO with
whom they have contracts.
ii) Participating Providers may display the Contractor's Marketing
materials provided that appropriate notice is conspicuously
posted for all other MCOs with whom the Provider has a contract.
iii) Upon termination of a Provider Agreement with the Contractor, a
provider that has contracts with other MCOs that offer MMC or
FHPlus products may notify
APPENDIX D
October 1, 2005
D-8
his/her patients of the change in status and the impact of such
change on the patient.
3. MARKETING REPRESENTATIVES
a) The Contractor shall require its Marketing Representatives, including
employees assigned to market its MMC and FHPlus products, and
employees of Marketing subcontractors, to successfully complete a
training program about the basic concepts of managed care and the
Enrollees' rights and responsibilities relating to Enrollment in an
MCO's MMC or FHPlus product. The Contractor shall submit a copy of the
training curriculum for its Marketing Representatives to SDOH as part
of the Marketing plan. The Contractor shall be responsible for the
activities of its Marketing Representatives and the Marketing
activities of any subcontractor or management entity.
b) The Contractor shall ensure that its Marketing Representatives engage
in professional and courteous behavior in their interactions with LDSS
staff, staff from other health plans, Eligible Persons and Prospective
Enrollees. The Contractor shall neither participate nor encourage nor
accept inappropriate behavior by its Marketing Representatives,
including but not limited to interference with other MCO
presentations, talking negatively about another MCO, or participating
in a Medicaid or FHPlus client's verification interview with LDSS
staff.
c) The Contractor shall not offer compensation to Marketing
Representatives, including salary increases or bonuses, based solely
on the number of individuals they enroll. However, the Contractor may
base compensation of Marketing Representatives on periodic performance
evaluations which consider Enrollment productivity as one of several
performance factors during a performance period, subject to the
following requirements:
i) "Compensation" shall mean any remuneration required to be
reported as income or compensation for federal tax purposes;
ii) The Contractor may not pay a "commission" or fixed amount per
enrollment;
iii) The Contractor may not award bonuses more frequently than
quarterly, or for an annual amount that exceeds ten percent (10%)
of a Marketing Representative's total annual compensation.
d) The Contractor shall keep written documentation, including performance
evaluations tools, of the basis it uses for awarding bonuses or
increasing the salary of Marketing Representatives and employees
involved in Marketing and make such documentation available for
inspection by SDOH or the DOHMH.
APPENDIX D
October 1, 2005
D-9
4. RESTRICTED MARKETING ACTIVITIES
a) The Contractor shall not engage in the following practices:
i) misrepresenting the Medicaid fee-for-service, MMC Program or
FHPlus Program or the program or policy requirements of the LDSS
or the SDOH, in Marketing encounters or materials;
ii) purchasing or otherwise acquiring or using mailing lists of
Eligible Persons from third party vendors, including providers
and LDSS offices;
iii) using raffle tickets or event attendance or sign-in sheets to
develop mailing lists of Prospective Enrollees;
iv) offering incentives (i.e., any type of inducement whose receipt
is contingent upon the individual's Enrollment) of any kind to
Prospective Enrollees to enroll in the Contractor's MMC or FHPlus
product.
b) The Contractor may not discriminate against Eligible Persons or
Enrollees on the basis of age; sex; race; creed; physical or mental
handicap/developmental disability; national origin; sexual
orientation; type of illness or condition; need for health services;
or the Capitation Rate the Contractor will receive for such Eligible
Person. Health assessments may not be performed by the Contractor
prior to Enrollment. The Contractor may inquire about existing primary
care relationships of the applicant and explain whether and how such
relationships may be maintained. Upon request, each Prospective
Enrollee shall be provided with a listing of all the Contractor's
Participating Providers, including PCPs, specialists and facilities in
the Contractor's network. The Contractor may respond to a Prospective
Enrollee's question about whether a particular PCP, specialist or
facility is a Participating Provider of the Contractor in the network.
However, the Contractor shall not inquire about the types of
specialists utilized by the Prospective Enrollee.
c) The Contractor may offer nominal gifts of not more than five dollars
($5.00) in fair-market value as part of a health fair or other
Marketing activity to stimulate interest in the MMC or FHPlus Program
and/or the Contractor. Such gifts must be pre-approved by the SDOH,
and offered without regard to Enrollment. The Contractor must submit a
listing and description of intended items to be distributed at
Marketing activities as nominal gifts, including a listing of item
donors or co-sponsors for approval. The submission of actual samples
or photographs of intended nominal gifts will not be routinely
required, but must be made available upon request by the SDOH
reviewer.
d) The Contractor may offer its Enrollees rewards for completing a health
goal, such as finishing all prenatal visits, participating in a
smoking cessation session, attending initial orientation sessions upon
enrollment, and timely completion of immunizations or other health
related programs. Such rewards may not exceed fifty dollars ($50.00)
APPENDIX D
October 1, 2005
D-10
in fair-market value per Enrollee over a twelve (12) month period, and
must be related to a health goal. The Contractor may not make
reference to these rewards in its pre-enrollment Marketing materials
or discussions and all such rewards must be approved by the SDOH.
APPENDIX D
October 1, 2005
D-ll
APPENDIX E
NEW YORK STATE DEPARTMENT OF HEALTH
MEMBER HANDBOOK GUIDELINES
APPENDIX E
October 1, 2005
E-l
MEMBER HANDBOOK GUIDELINES
1. PURPOSE
a) This document contains Member Handbook guidelines for use by the
Contractor to develop handbooks for MMC and FHPlus Enrollees covered
under this Agreement.
b) These guidelines reflect the review criteria used by the SDOH Office
of Managed Care in its review of all MMC and FHPlus Member Handbooks.
Member Handbooks and addenda must be approved by SDOH prior to
printing and distribution by the Contractor.
2. SDOH MODEL MEMBER HANDBOOK
a) The SDOH Model Member Handbook includes all required information
specified in this Appendix, written at an acceptable reading level.
The Contractor may adapt the SDOH Model Member Handbook to reflect its
specific policies and procedures for its MMC or FHPlus product.
b) SDOH strongly recommends the Contractor use the SDOH Model Member
Handbook language for the following required disclosure areas in the
Contractor's Member Handbook:
i) access to Family Planning and Reproductive Health services;
ii) self referral policies;
iii) obtaining OB/GYN services;
iv) the definitions of medical necessity and Emergency Services;
v) protocols for Action, utilization review, Complaints, Complaint
Appeals, Action Appeals, External Appeals, and fair hearings;
vi) protocol for newborn Enrollment; and
vii) listing of Enrollee entitlements, including benefits, rights and
responsibilities, and information available upon request.
c) A copy of the SDOH Model Member Handbook is available from the SDOH
Office of Managed Care, Bureau of Intergovernmental Affairs.
APPENDIX E
October 1, 2005
E-2
3. GENERAL FORMAT
a) It is expected that most MCOs will develop separate handbooks for
their MMC and FHPlus Enrollees. The Contractor must include the
required contents as per Section 4 of this Appendix for both the MMC
and FHPlus Programs, as applicable, and list the information available
upon request in accordance with Section 5 of this Appendix in their
Member Handbooks.
b) The Contractor must write Member Handbooks in a style and reading
level that will accommodate the reading skills of many MMC and FHPlus
Enrollees. In general the writing should be at no higher than a
sixth-grade level, taking into consideration the need to incorporate
and explain certain technical or unfamiliar terms to assure accuracy.
The text must be printed in at least ten-point font, preferably
twelve-point font. The SDOH reserves the right to require evidence
that a handbook has been tested against the sixth-grade reading-level
standard.
c) The Contractor must make Member handbooks available in a language
other than English whenever at least five percent (5%) of the
Prospective Enrollees of the Contractor in any county in the
Contractor's service area speak that particular language and do not
speak English as a first language. Member handbooks must be made
accessible to non-English speaking and visually and hearing impaired
Enrollees.
4. REQUIREMENTS FOR HANDBOOK CONTENTS
a) General Overview (how the MMC or FHPlus product works)
i) Explanation of the Contractor's MMC or FHPlus product, including
what happens when an Eligible Person enrolls.
ii) Explanation of the Contractor-issued Enrollee ID card, obtaining
routine medical care, help by telephone, and general information
pertaining to the Contractor's MMC or FHPlus product, i.e.,
location of the Contractor, providers, etc.
iii) Invitation to attend scheduled orientation sessions and other
educational and outreach activities.
b) Provider Listings
i) The Contractor may include the following information in the
handbook, or as an insert to the handbook or produce this
information as a separate document and reference such document in
the handbook.
A) A current listing of providers, including facilities and
site locations.
APPENDIX E
October 1, 2005
E-3
B) Separate listings of Participating Providers that are
Primary Care Providers and specialty providers; including
location, phone number, and board certification status.
C) Listing also must include a notice of how to determine if a
Participating Provider is accepting new patients.
c) Voluntary or Mandatory Enrollment - For MMC Program Only
i) Must indicate whether Enrollment is voluntary or mandatory.
ii) If the Contractor offers a MMC product in both mandatory and
voluntary counties, an explanation of the difference, i.e.,
Disenrollment rules, etc.
d) Choice of Primary Care Provider
i) Explanation of the role of PCP as a coordinator of care, giving
some examples, and how to choose one for self and family.
ii) How to make an appointment with the PCP, importance of base line
physical, immunizations and well-child care.
iii) Explanation of different types of PCPs, i.e., family
practitioner, pediatrician, internist, etc.
iv) Notification that the Contractor will assign the Enrollee to a
PCP if one is not chosen in thirty (30) days.
v) OB/GYN choice rules for women.
e) Changing Primary Care Provider
i) Explanation of the Contractor's policy, timeframes, and process
related to an Enrollee changing his or her PCP. (Enrollees may
change PCPs thirty (30) days after the initial appointment with
their PCP, and the Contractor may elect to limit the Enrollee to
changing PCPs without cause to once every six months.)
ii) Explanation of process for changing OB/GYN when applicable.
iii) Explanation of requirements for choosing a specialist as PCP.
f) Referrals to Specialists (Participating or Non-Participating)
i) Explanation of specialist care and how referrals are
accomplished.
ii) Explanation of the process for changing specialists.
APPENDIX E
October 1, 2005
E-4
iii) Explanation of self-referral services, i.e., OB/GYN services, HIV
counseling and testing, eye exams, etc.
iv) Notice that an Enrollee may obtain a referral to a
Non-Participating Provider when the Contractor does not have a
Participating Provider with appropriate training or experience to
meet the needs of the Enrollee and the procedure for obtaining
such referrals.
v) Notice that an Enrollee with a condition that requires ongoing
care from a specialist may request a standing referral to such a
specialist and the procedure for obtaining such referrals.
vi) Notice that an Enrollee with a life-threatening condition or
disease or a degenerative and disabling condition or disease,
either of which requires specialized medical care over a
prolonged period of time, may request access to a specialist
possessing the credentials to be responsible for providing or
coordinating the Enrollee's medical care; and the procedure for
obtaining such a specialist.
vii) Notice that an Enrollee with a life-threatening condition or
disease, or a degenerative and disabling condition or disease,
either of which requires specialized medical care over a
prolonged period of time, may request access to a specialty care
center; and the procedure for obtaining such access.
g) Covered and Non-Covered Services
i) Benefits and services covered by the Contractor's MMC or FHPlus
product, including benefit maximums and limits.
ii) Definition of medical necessity, as defined in this Agreement,
and its use to determine whether benefits will be covered.
iii) Medicaid covered services that are not covered by the
Contractor's MMC product or are excluded from the MMC Program,
and how to access these services. (MMC Program Member Handbooks
only.)
iv) A description of services not covered by MMC, Medicaid
fee-for-service or the FHPlus Programs.
v) Prior Authorization and other requirements for obtaining
treatments and services.
vi) Access to Family Planning and Reproductive Health services, and
for MMC Program Member Handbooks, the Free Access policy for MMC
Enrollees, pursuant to Appendix C of this Agreement.
APPENDIX E
October 1, 2005
E-5
vii) HIV counseling and testing free access policy. (MMC Program
Member Handbooks only.)
viii) Direct access policy for dental services provided at Article 28
clinics operated by academic dental centers when dental is in the
Benefit Package. (MMC Program Member Handbooks only.)
ix) The Contractor's policy relating to emergent and non-emergent
transportation, including who to call and what to do if the
Contractor's MMC product does not cover emergent or non-emergent
transportation. (MMC Program Member Handbooks only.)
x) For FHPlus Program Member Handbooks, coverage of emergent
transportation and what to do if needed.
xi) Contractor's toll-free number for Enrollees to call for more
information.
xii) Any cost-sharing (e.g., copays for Contractor covered services).
h) Out of Area Coverage
Explanation of what to do and who to call if medical care is required
when Enrollee is out of his or her county of fiscal responsibility or
the Contractor's service area.
i) Emergency and Post Stabilization Care Access
i) Definition of Emergency Services, as defined in law and
regulation, including examples of situations that constitute an
emergency and situations that do not.
ii) What to do in an emergency, including notice that services in a
true emergency are not subject to prior approval.
iii) A phone number to call if the PCP is not available.
iv) Explanation of what to do in non-emergency situations (PCP,
urgent care, etc.).
v) Locations where the Contractor provides Emergency Services and
Post-stabilization Care Services.
vi) Notice to Enrollees that in a true emergency they may access
services at any provider of Emergency Services.
vii) Definition of Post-Stabilization care services and how to access
them.
APPENDIX E
October 1, 2005
E-6
j) Actions and Utilization Review
i) Circumstances under which Actions and utilization review will be
undertaken (in accordance with Appendix F of this Agreement).
ii) Toll-free telephone number of the utilization review department
or subcontractor.
iii) Time frames in which Actions and UR determinations must be made
for prospective, retrospective, and concurrent reviews.
iv) Right to reconsideration.
v) Right to file an Action Appeal, orally or in writing, including
expedited and standard Action Appeals processes and the
timeframes for Action Appeals.
vi) Right to designate a representative.
vii) A notice that all Adverse Determinations will be made by
qualified clinical personnel and that all notices will include
information about the basis of the determination, and further
Action Appeal rights (if any).
k) Enrollment and Disenrollment Procedures
i) Where appropriate, explanation of Lock-In requirements and when
an Enrollee may change to another MCO, or for MMC Enrollees if
permitted, return to Medicaid fee-for-service, for Good Cause, as
defined in Appendix H of this Agreement.
ii) Procedures for Disenrollment.
iii) LDSS or Enrollment Broker as appropriate phone number for
information on Enrollment and Disenrollment.
l) Rights and Responsibilities of Enrollees
i) Explanation of what an Enrollee has the right to expect from the
Contractor in the way of medical care and treatment of the
Enrollee as specified in Section 13.7 of this Agreement.
ii) General responsibilities of the Enrollee.
iii) Enrollee's potential financial responsibility for payment when
services are furnished by a Non-Participating Provider or are
furnished by any provider without required authorization or when
a procedure, treatment, or service is not a covered benefit. Also
note exceptions such as family planning and HIV
counseling/testing.
APPENDIX E
October 1, 2005
E-7
iv) Enrollee's rights under State law to formulate advance
directives.
v) The manner in which Enrollees may participate in the development
of Contractor policies.
m) Language
Description of how the Contractor addresses the needs of non-English
speaking Enrollees.
n) Grievance Procedures (Complaints)
i) Right to file a Complaint regarding any dispute between the
Contractor and an Enrollee (in accordance with Appendix F of the
Agreement).
ii) Right to file a Complaint orally.
iii) The Contractor's toll-free number for filing oral Complaints.
iv) Time frames and circumstances for expedited and standard
Complaints.
v) Right to appeal a Complaint determination and the procedures for
filing a Complaint Appeal.
vi) Time frames and circumstances for expedited and standard
Complaint Appeals
vii) Right to designate a representative.
viii) A notice that all determinations involving clinical disputes
will be made by qualified clinical personnel and that all notices
will include information about the basis of the determination,
and further appeal rights (if any).
ix) SDOH's toll-free number for medically related Complaints.
x) New York State Insurance Department number for certain complaints
relating to billing.
o) Fair Hearing
i) An explanation that the Enrollee has a right to a State fair
hearing and aid to continue in some situations and that the
Enrollee may be required to repay the Contractor for services
received if the fair hearing decision is adverse to the Enrollee.
ii) A description of situations when the Enrollee may ask for a fair
hearing as described in Section 25 of this Agreement, including:
a SDOH or LDSS decision
APPENDIX E
October 1, 2005
E-8
about the Enrollee staying in or leaving the Contractor's MMC or
FHPlus product; a Contractor determination that stops or limits
Medicaid benefits; and a Contractor's Complaint determination
that upholds a provider's decision not to order
Enrollee-requested services.
iii) An explanation of how to request a fair hearing (assistance
through member services, LDSS, State fair hearing contact).
p) External Appeals
i) A description of circumstances under which an Enrollee may
request an External Appeal.
ii) Timeframes for applying for External Appeal and for
decision-making.
iii) How and where to apply for an expedited appeal.
iv) A description of the expedited External Appeal timeframe.
v) The process for Contractor and Enrollee to agree on waiving the
Contractor's internal UR Appeals process.
q) Payment Methodologies
Description prepared annually of the types of methodologies the
Contractor uses to reimburse providers, specifying the type of
methodology used to reimburse particular types of providers or for the
provision of particular types of services.
r) Physician Incentive Plan Arrangements
The Member Handbook must contain a statement indicating the Enrollees
and Prospective Enrollees are entitled to ask if the Contractor has
special financial arrangements with physicians that can affect the use
of referrals and other services that they might need and how to obtain
this information.
s) How and Where to Get More Information
i) How to access a member services representative through a
toll-free number.
ii) How and when to contact LDSS for assistance.
5. OTHER INFORMATION AVAILABLE UPON ENROLLEE'S REQUEST
a) Information on the structure and operation of the Contractor's
organization. List of the names, business addresses, and official
positions of the membership of the board of directors, officers,
controlling persons, owners or partners of the Contractor.
APPENDIX E
October 1, 2005
E-9
b) Copy of the most recent annual certified financial statement of the
Contractor, including a balance sheet and summary of receipts and
disbursements prepared by a CPA.
c) Copy of the most recent individual, direct pay subscriber contracts.
d) Information relating to consumer complaints compiled pursuant to
Section 210 of the SIL.
e) Procedures for protecting the confidentiality of medical records and
other Enrollee information.
f) Written description of the organizational arrangements and ongoing
procedures of the Contractor's quality assurance program.
g) Description of the procedures followed by the Contractor in making
determinations about the experimental or investigational nature of
medical devices, or treatments in clinical trials.
h) Individual health practitioner affiliations with Participating
hospitals.
i) Specific written clinical review criteria relating to a particular
condition or disease and, where appropriate, other clinical
information which the Contractor might consider in its Service
Authorization or utilization review process.
j) Written application procedures and minimum qualification requirements
for health care providers to be considered by the Contractor.
k) Upon request, the Contractor is required to provide the following
information on the incentive arrangements affecting Participating
Providers to Enrollees, previous Enrollees and Prospective Enrollees:
i) Whether the Contractor's Provider Agreements or subcontracts
include Physician Incentive Plans (PIP) that affect the use of
referral services.
ii) Information on the type of incentive arrangements used.
iii) Whether stop-loss protection is provided for physicians and
physicians groups.
iv) If the Contractor is at substantial financial risk, as defined in
the PIP regulations, a summary of the required customer
satisfaction survey results.
APPENDIX E
October 1, 2005
E-10
APPENDIX F
NEW YORK STATE DEPARTMENT OF HEALTH
ACTION AND GRIEVANCE SYSTEM REQUIREMENTS
FOR MMC AND FHPLUS PROGRAMS
F.1 ACTION REQUIREMENTS
F.2 GRIEVANCE SYSTEM REQUIREMENTS
APPENDIX F
October 1, 2005
F-1
F.1
ACTION REQUIREMENTS
1. DEFINITIONS
a) Service Authorization Request means a request by an Enrollee, or a
provider on the Enrollee's behalf, to the Contractor for the provision
of a service, including a request for a referral or for a non-covered
service.
i) Prior Authorization Request is a Service Authorization Request by
the Enrollee, or a provider on the Enrollee's behalf, for
coverage of a new service, whether for a new authorization period
or within an existing authorization period, before such service
is provided to the Enrollee.
ii) Concurrent Review Request is a Service Authorization Request by
an Enrollee, or a provider on Enrollee's behalf, for continued,
extended or more of an authorized service than what is currently
authorized by the Contractor.
b) Service Authorization Determination means the Contractor's approval or
denial of a Service Authorization Request.
c) Adverse Determination means a denial of a Service Authorization
Request by the Contractor on the basis that the requested service is
not Medically Necessary or an approval of a Service Authorization
Request is in an amount, duration, or scope that is less than
requested.
d) An Action means an activity of a Contractor or its subcontractor that
results in:
i) the denial or limited authorization of a Service Authorization
Request, including the type or level of service;
ii) the reduction, suspension, or termination of a previously
authorized service;
iii) the denial, in whole or in part, of payment for a service;
iv) failure to provide services in a timely manner as defined by
applicable State law and regulation and Section 15 of this
Agreement; or
v) failure of the Contractor to act within the timeframes for
resolution and notification of determinations regarding
Complaints, Action Appeals and Complaint Appeals provided in this
Appendix.
APPENDIX F
October 1, 2005
F-2
2. GENERAL REQUIREMENTS
a) The Contractor's policies and procedures for Service Authorization
Determinations and utilization review determinations shall comply with
42 CFR Part 438 and Article 49 of the PHL, including but not limited
to the following:
i) Expedited review of a Service Authorization Request must be
conducted when the Contractor determines or the provider
indicates that a delay would seriously jeopardize the Enrollee's
life or health or ability to attain, maintain, or regain maximum
function. The Enrollee may request expedited review of a Prior
Authorization Request or Concurrent Review Request. If the
Contractor denies the Enrollee's request for expedited review,
the Contractor must handle the request under standard review
timeframes.
ii) Any determination to deny a Service Authorization Request or to
authorize a service in an amount, duration, or scope that is less
than requested, must be made by a licensed, certified, or
registered health care professional. If such Adverse
Determination was based on medical necessity, the determination
must be made by a clinical peer reviewer as defined by PHL
Section 4900(2)(a).
iii) The Contractor is required to provide notice by phone and in
writing to the Enrollee and to the provider of Service
Authorization Determinations, whether adverse or not, within the
timeframe specified in Section 3 below. Notice to the provider
must contain the same information as the Notice of Action for the
Enrollee.
iv) The Contractor is required to provide the Enrollee written notice
of any Action other than a Service Authorization Determinations
within the timeframe specified in Section 4 below.
3. TIMEFRAMES FOR SERVICE AUTHORIZATION DETERMINATIONS
a) For Prior Authorization Requests, the Contractor must make a Service
Authorization Determination and notice the Enrollee of the
determination by phone and in writing as fast as the Enrollee's
condition requires and no more than:
i) In the case of an expedited review, three (3) business days after
receipt of the Service Authorization Request; or
ii) In all other cases, within three (3) business days of receipt of
necessary information, but no more than fourteen (14) days after
receipt of the Service Authorization request.
b) For Concurrent Review Requests, the Contractor must make a Service
Authorization Determination and notice the Enrollee of the
determination by phone and in writing as fast as the Enrollee's
condition requires and no more than:
APPENDIX F
October 1, 2005
F-3
i) In the case of an expedited review, one (1) business day after
receipt of necessary information but no more than three (3)
business days after receipt of the Service Authorization Request;
or
ii) In all other cases, within one (1) business day of receipt of
necessary information, but no more than fourteen (14) days after
receipt of the Service Authorization Request.
c) Timeframes for Service Authorization Determinations may be extended
for up to fourteen (14) days if:
i) the Enrollee, the Enrollee's designee, or the EnroLlee's provider
requests an extension orally or in writing; or
ii) The Contractor can demonstrate or substantiate that there is a
need for additional information and how the extension is in the
Enrollee's interest. The Contractor must send notice of the
extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was
justified.
d) If the Contractor extended its review as provided in paragraph 3(c)
above, the Contractor must make a Service Authorization Determination
and notice the Enrollee by phone and in writing as fast as the
Enrollee's condition requires and within three (3) business days after
receipt of necessary information for Prior Authorization Requests or
within one (1) business day after receipt of necessary information for
Concurrent Review Requests, but in no event later than the date the
extension expires.
4. TIMEFRAMES FOR NOTICES OF ACTIONS OTHER THAN SERVICE AUTHORIZATIONS
DETERMINATIONS
a) When the Contractor intends to reduce, suspend, or terminate a
previously authorized service within an authorization period, it must
provide the Enrollee with a written notice at least ten (10) days
prior to the intended Action, except:
i) the period of advance notice is shortened to five (5) days in
cases of confirmed Enrollee fraud; or
ii) the Contractor may mail notice not later than date of the Action
for the following:
A) the death of the Enrollee;
B) a signed written statement from the Enrollee requesting
service termination or giving information requiring
termination or reduction of services (where the Enrollee
understands that this must be the result of supplying the
information);
C) the Enrollee's admission to an institution where the
Enrollee is ineligible for further services;
D) the Enrollee's address is unknown and mail directed to the
Enrollee is returned stating that there is no forwarding
address;
APPENDIX F
October 1, 2005
F-4
E) the Enrollee has been accepted for Medicaid services by
another jurisdiction; or
F) the Enrollee's physician prescribes a change in the level of
medical care.
b) The Contractor must mail written notice to the Enrollee on the date of
the Action when the Action is denial of payment, in whole or in part,
except as provided in paragraph F.I 6(b) below.
c) When the Contractor does not reach a determination within the Service
Authorization Determination timeframes described above, it is
considered an Adverse Determination, and the Contractor must send
notice of Action to the Enrollee on the date the timeframes expire.
5. FORMAT AND CONTENT OF NOTICES
a) The Contractor shall ensure that all notices are in writing, in easily
understood language and are accessible to non-English speaking and
visually impaired Enrollees. Notices shall include that oral
interpretation and alternate formats of written material for Enrollees
with special needs are available and how to access the alternate
formats.
i) Notice to the Enrollee that the Enrollee's request for an
expedited review has been denied shall include that the request
will be reviewed under standard timeframes, including a
description of the timeframes.
ii) Notice to the Enrollee regarding a Contractor-initiated extension
shall include:
A) the reason for the extension;
B) an explanation of how the delay is in the best interest of
the Enrollee;
C) any additional information the Contractor requires from any
source to make its determination;
D) the right of the Enrollee to file a Complaint (as defined in
Appendix F.2 of this Agreement) regarding the extension;
E) the process for filing a Complaint with the Contractor and
the timeframes within which a Complaint determination must
be made;
F) the right of an Enrollee to designate a representative to
file a Complaint on behalf of the Enrollee; and
G) the right of the Enrollee to contact the New York State
Department of Health regarding his or her Complaint,
including the SDOH's toll-free number for Complaints.
iii) Notice to the Enrollee of an Action shall include:
A) the description of the Action the Contractor has taken or
intends to take;
B) the reasons for the Action, including the clinical
rationale, if any;
C) the Enrollee's right to file an Action Appeal (as defined in
Appendix F.2 of this Agreement), including:
I) The fact that the Contractor will not retaliate or take
any discriminatory action against the Enrollee because
he/she filed an Action Appeal.
APPENDIX F
October 1, 2005
F-5
II) The right of the Enrollee to designate a representative
to file Action Appeals on his/her behalf;
D) the process and timeframe for filing an Action Appeal with
the Contractor, including an explanation that an expedited
review of the Action Appeal can be requested if a delay
would significantly increase the risk to an Enrollee's
health, a toll-free number for filing an oral Action Appeal
and a form, if used by the Contractor, for filing a written
Action Appeal;
E) a description of what additional information, if any, must
be obtained by the Contractor from any source in order for
the Contractor to make an Appeal determination;
F) the timeframes within which the Action Appeal determination
must be made;
G) the right of the Enrollee to contact the New York State
Department of Health with his or her Complaint, including
the SDOH's toll-free number for Complaints; and
H) the notice entitled "Managed Care Action Taken" for denial
of benefits or for termination or reduction in benefits, as
applicable, containing the Enrollee's fair hearing and aid
continuing rights.
I) For Actions based on issues of Medical Necessity or an
experimental or investigational treatment, the notice of
Action shall also include:
I) a clear statement that the notice constitutes the
initial adverse determination and specific use of the
terms "medical necessity" or
"experimental/investigational;"
II) a statement that the specific clinical review criteria
relied upon in making the determination is available
upon request; and
III) a statement that the Enrollee may be eligible for an
External Appeal.
6. CONTRACTOR OBLIGATION TO NOTICE
a) The Contractor must provide written Notice of Action to Enrollees and
providers in accordance with the requirements of this Appendix,
including, but not limited to, the following circumstances (except as
provided for in paragraph 6(b) below):
i) the Contractor makes a coverage determination or denies a request
for a referral, regardless of whether the Enrollee has received
the benefit;
ii) the Contractor determines that a service does not have
appropriate authorization;
iii) the Contractor denies a claim for services provided by a
Non-Participating Provider for any reason;
iv) the Contractor denies a claim or service due to medical
necessity;
v) the Contractor rejects a claim or denies payment due to a late
claim submission;
vi) the Contractor denies a claim because it has determined that the
Enrollee was not eligible for MMC or FHPlus coverage on the date
of service;
APPENDIX F
October 1, 2005
F-6
vii) the Contractor denies a claim for service rendered by a
Participating Provider due to lack of a referral;
viii) the Contractor denies a claim because it has determined it is
not the appropriate payor; or
ix) the Contractor denies a claim due to a Participating Provider
billing for Benefit Package services not included in the Provider
Agreement between the Contractor and the Participating Provider.
b) The Contractor is not required to provide written Notice of Action to
Enrollees in the following circumstances:
i) When there is a prepaid capitation arrangement with a
Participating Provider and the Participating Provider submits a
fee-for-service claim to the Contractor for a service that falls
within the capitation payment;
ii) if a Participating Provider of the Contractor itemizes or
"unbundles" a claim for services encompassed by a previously
negotiated global fee arrangement;
iii) if a duplicate claim is submitted by the Enrollee or a
Participating Provider, no notice is required, provided an
initial notice has been issued;
iv) if the claim is for a service that is carved-out of the MMC
Benefit Package and is provided to a MMC Enrollee through
Medicaid fee-for-service, however, the Contractor should notify
the provider to submit the claim to Medicaid;
v) if the Contractor makes a coding adjustment to a claim (up-coding
or down-coding) and its Provider Agreement with the Participating
Provider includes a provision allowing the Contractor to make
such adjustments;
vi) if the Contractor has paid the negotiated amount reflected in the
Provider Agreement with a Participating Provider for the services
provided to the Enrollee and denies the Participating Provider's
request for additional payment; or
vii) if the Contractor has not yet adjudicated the claim. If the
Contractor has pended the claim while requesting additional
information, a notice is not required until the coverage
determination has been made.
APPENDIX F
October 1, 2005
F-7
F.2
GRIEVANCE SYSTEM REQUIREMENTS
1. DEFINITIONS
a) A Grievance System means the Contractor's Complaint and Appeal
process, and includes a Complaint and Complaint Appeal process, a
process to appeal Actions, and access to the State's fair hearing
system.
b) For the purposes of this Agreement, a Complaint means an Enrollee's
expression of dissatisfaction with any aspect of his or her care other
than an Action. A "Complaint" means the same as a "grievance" as
defined by 42 CFR Section 438.400 (b).
c) An Action Appeal means a request for a review of an Action.
d) A Complaint Appeal means a request for a review of a Complaint
determination.
e) An Inquiry means a written or verbal question or request for
information posed to the Contractor with regard to such issues as
benefits, contracts, and organization rules. Neither Enrollee
Complaints nor disagreements with Contractor determinations are
Inquiries.
2. GRIEVANCE SYSTEM - GENERAL REQUIREMENTS
a) The Contractor shall describe its Grievance System in the Member
Handbook, and it must be accessible to non-English speaking, visually,
and hearing impaired Enrollees. The handbook shall comply with Section
13.4 and The Member Handbook Guidelines (Appendix E) of this
Agreement.
b) The Contractor will provide Enrollees with any reasonable assistance
in completing forms and other procedural steps for filing a Complaint,
Complaint Appeal or Action Appeal, including, but not limited to,
providing interpreter services and toll-free numbers with TTY/TDD and
interpreter capability.
c) The Enrollee may designate a representative to file Complaints,
Complaint Appeals and Action Appeals on his/her behalf.
d) The Contractor will not retaliate or take any discriminatory action
against the Enrollee because he/she filed a Complaint, Complaint
Appeal or Action Appeal.
APPENDIX F
October 1, 2005
F-8
e) The Contractor's procedures for accepting Complaints, Complaint
Appeals and Action Appeals shall include:
i) toll-free telephone number;
ii) designated staff to receive calls;
iii) "live" phone coverage at least 40 hours a week during normal
business hours;
iv) a mechanism to receive after hours calls, including either:
A) a telephone system available to take calls and a plan to
respond to all such calls no later than on the next business
day after the calls were recorded; or
B) a mechanism to have available on a twenty-four (24) hour,
seven (7) day a week basis designated staff to accept
telephone Complaints, whenever a delay would significantly
increase the risk to an Enrollee's health.
f) The Contractor must ensure that personnel making determinations
regarding Complaints, Complaint Appeals and Action Appeals were not
involved in previous levels of review or decision-making. If any of
the following applies, determinations must be made by qualified
clinical personnel as specified in this Appendix:
i) A denial of an Action Appeal based on lack of medical necessity.
ii) A Complaint regarding denial of expedited resolution of an Action
Appeal.
iii) A Complaint, Complaint Appeal, or Action Appeal that involves
clinical issues.
3. ACTION APPEALS PROCESS
a) The Contractor's Action Appeals process shall indicate the following
regarding resolution of Appeals of an Action:
i) The Enrollee, or his or her designee, will have no less than
sixty (60) business days from the date of the notice of Action to
file an Action Appeal. An Enrollee filing an Action Appeal within
ten (10) days of the notice of Action or by the intended date of
an Action, whichever is later, that involves the reduction,
suspension, or termination of previously approved services may
request "aid continuing" in accordance with Section 25.4 of this
Agreement.
ii) The Enrollee may file a written Action Appeal or an oral Action
Appeal. Oral Action Appeals must be followed by a written,
signed, Action Appeal. The Contractor may provide a written
summary of an oral Action Appeal to the Enrollee (with the
acknowledgement or separately) for the Enrollee to review, modify
if needed, sign and return to the Contractor. If the Enrollee or
provider requests expedited resolution of the Action Appeal, the
oral Action Appeal does
APPENDIX F
October 1, 2005
F-9
not need to be confirmed in writing. The date of the oral filing
of the Action Appeal will be the date of the Action Appeal for
the purposes of the timeframes for resolution of Action Appeals.
Action Appeals resulting from a Concurrent Review must be handled
as an expedited Action Appeal.
iii) The Contractor must send a written acknowledgement of the Action
Appeal within fifteen (15) days of receipt. If a determination is
reached before the written acknowledgement is sent, the
Contractor may include the written acknowledgement with the
notice of Action Appeal determination (one notice).
iv) The Contractor must provide the Enrollee reasonable opportunity
to present evidence, and allegations of fact or law, in person as
well as in writing. The Contractor must inform the Enrollee of
the limited time to present such evidence in the case of an
expedited Action Appeal. The Contractor must allow the Enrollee
or his or her designee, both before and during the Action Appeals
process, to examine the Enrollee's case file, including medical
records and any other documents and records considered during the
Action Appeals process. The Contractor will consider the
Enrollee, his or her designee, or legal estate representative of
a deceased Enrollee a party to the Action Appeal.
v) The Contractor must have a process for handling expedited Action
Appeals. Expedited resolution of the Action Appeal must be
conducted when the Contractor determines or the provider
indicates that a delay would seriously jeopardize the Enrollee's
life or health or ability to attain, maintain, or regain maximum
function. The Enrollee may request an expedited review of an
Action Appeal. If the Contractor denies the Enrollee's request
for an expedited review, the Contractor must handle the request
under standard Action Appeal resolution timeframes, make
reasonable efforts to provide prompt oral notice of the denial to
the Enrollee and send written notice of the denial within two (2)
days of the denial determination.
vi) The Contractor must ensure that punitive action is not taken
against a provider who either requests an expedited resolution or
supports an Enrollee's Appeal.
vii) Action Appeals of clinical matters must be decided by personnel
qualified to review the Action Appeal, including licensed,
certified or registered health care professionals who did not
make the initial determination, at least one of whom must be a
clinical peer reviewer, as defined by PHL Section 4900(2)(a).
Action Appeals of non-clinical matters shall be determined by
qualified personnel at a higher level than the personnel who made
the original determination.
4. TIMEFRAMES FOR RESOLUTION OF ACTION APPEALS
a) The Contractor's Action Appeals process shall indicate the following
specific timeframes regarding Action Appeal resolution:
APPENDIX F
October 1, 2005
F-10
i) The Contractor will resolve Action Appeals as fast as the
Enrollee's condition requires, and no later than thirty (30) days
from the date of the receipt of the Action Appeal.
ii) The Contractor will resolve expedited Action Appeals as fast as
the Enrollee's condition requires, within two (2) business days
of receipt of necessary information and no later than three (3)
business days of the date of the receipt of the Action Appeal.
iii) Timeframes for Action Appeal resolution may be extended for up to
fourteen (14) days if:
A) the Enrollee, his or her designee, or the provider requests
an extension orally or in writing; or
B) the Contractor can demonstrate or substantiate that there is
a need for additional information and the extension is in
the Enrollee's interest. The Contractor must send notice of
the extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to
demonstrate, upon SDOH's request, that the extension was
justified.
iv) The Contractor will make a reasonable effort to provide oral
notice to the Enrollee, his or her designee, and the provider
where appropriate, for expedited Action Appeals at the time the
Action Appeal determination is made.
v) The Contractor must send written notice to the Enrollee, his or
her designee, and the provider where appropriate, within two (2)
business days of the Action Appeal determination.
5. ACTION APPEAL NOTICES
a) The Contractor shall ensure that all notices are in writing and in
easily understood language and are accessible to non-English speaking
and visually impaired Enrollees. Notices shall include that oral
interpretation and alternate formats of written material for Enrollees
with special needs are available and how to access the alternate
formats.
i) Notice to the Enrollee that the Enrollee's request for an
expedited Action Appeal has been denied shall include that the
request will be reviewed under standard Action Appeal timeframes,
including a description of the timeframes. This notice may be
combined with the acknowledgement.
ii) Notice to the Enrollee regarding an Contractor-initiated
extension shall include:
A) the reason for the extension;
B) an explanation of how the delay is in the best interest of
the Enrollee;
C) any additional information the Contractor requires from any
source to make its determination;
D) the right of the Enrollee to file a Complaint regarding the
extension;
APPENDIX F
October 1, 2005
F-11
E) the process for filing a Complaint with the Contractor and
the timeframes within which a Complaint determination must
be made;
F) the right of an Enrollee to designate a representative to
file a Complaint on behalf of the Enrollee; and
G) the right of the Enrollee to contact the New York State
Department of Health regarding his or her their Complaint,
including the SDOH's toll-free number for Complaints.
iii) Notice to the Enrollee of Action Appeal Determination shall
include:
A) Date the Action Appeal was filed and a summary of the Action
Appeal;
B) Date the Action Appeal process was completed;
C) the results and the reasons for the determination, including
the clinical rationale, if any;
D) If the determination was not in favor of the Enrollee, a
description of Enrollee's fair hearing rights, if
applicable;
E) the right of the Enrollee to contact the New York State
Department of Health regarding his or her Complaint,
including the SDOH's toll-free number for Complaints; and
F) For Action Appeals involving Medical Necessity or an
experimental or investigational treatment, the notice must
also include:
I) a clear statement that the notice constitutes the final
adverse determination and specifically use the terms
"medical necessity" or "experimental/investigational;"
II) the Enrollee's coverage type;
III) the procedure in question, and if available and
applicable the name of the provider and
developer/manufacturer of the health care service;
IV) statement that the Enrollee is eligible to file an
External Appeal and the timeframe for filing;
V) a copy of the "Standard Description and Instructions
for Health Care Consumers to Request an External
Appeal" and the External Appeal application form;
VI) the Contractor's contact person and telephone number;
VII) the contact person, telephone number, company name and
full address of the utilization review agent, if the
determination was made by the agent; and
VIII) if the Contractor has a second level internal review
process, the notice shall contain instructions on how
to file a second level Action Appeal and a statement in
bold text that the timeframe for requesting an External
Appeal begins upon receipt of the final adverse
determination of the first level Action Appeal,
regardless of whether or not a second level of Action
Appeal is requested, and that by choosing to request a
second level Action Appeal, the time may expire for the
Enrollee to request an External Appeal.
APPENDIX F
October 1, 2005
F-12
6. COMPLAINT PROCESS
a) The Contractor' Complaint process shall include the following
regarding the handling of Enrollee Complaints:
i) The Enrollee, or his or her designee, may file a Complaint
regarding any dispute with the Contractor orally or in writing.
The Contractor may have requirements for accepting written
Complaints either by letter or Contractor supplied form. The
Contractor cannot require an Enrollee to file a Complaint in
writing.
ii) The Contractor must provide written acknowledgment of any
Complaint not immediately resolved, including the name, address
and telephone number of the individual or department handling the
Complaint, within fifteen (15) business days of receipt of the
Complaint. The acknowledgement must identify any additional
information required by the Contractor from any source to make a
determination. If a Complaint determination is made before the
written acknowledgement is sent, the Contractor may include the
acknowledgement with the notice of the determination (one
notice).
iii) Complaints shall be reviewed by one or more qualified personnel.
iv) Complaints pertaining to clinical matters shall be reviewed by
one or more licensed, certified or registered health care
professionals in addition to whichever non-clinical personnel the
Contractor designates.
7. TIMEFRAMES FOR COMPLAINT RESOLUTION BY THE CONTRACTOR
a) The Contractor's Complaint process shall indicate the following
specific timeframes regarding Complaint resolution:
i) If the Contractor immediately resolves an oral Complaint to the
Enrollee's satisfaction, that Complaint may be considered
resolved without any additional written notification to the
Enrollee. Such Complaints must be logged by the Contractor and
included in the Contractor's quarterly HPN Complaint report
submitted to SDOH in accordance with Section 18 of this
Agreement.
ii) Whenever a delay would significantly increase the risk to an
Enrollee's health, Complaints shall be resolved within
forty-eight (48) hours after receipt of all necessary information
and no more than seven (7) days from the receipt of the
Complaint.
iii) All other Complaints shall be resolved within forty-five (45)
days after the receipt of all necessary information and no more
than sixty (60) days from receipt of the Complaint. The
Contractor shall maintain reports of Complaints unresolved after
forty-five (45) days in accordance with Section 18 of this
Agreement.
APPENDIX F
October 1, 2005
F-13
8. COMPLAINT DETERMINATION NOTICES
a) The Contractor's procedures regarding the resolution of Enrollee
Complaints shall include the following:
i) Complaint Determinations by the Contractor shall be made in
writing to the Enrollee or his/her designee and include:
A) the detailed reasons for the determination;
B) in cases where the determination has a clinical basis, the
clinical rationale for the determination;
C) the procedures for the filing of an appeal of the
determination, including a form, if used by the Contractor,
for the filing of such a Complaint Appeal; and notice of the
right of the Enrollee to contact the State Department of
Health regarding his or her Complaint, including SDOH's
toll-free number for Complaints.
ii) If the Contractor was unable to make a Complaint determination
because insufficient information was presented or available to
reach a determination, the Contractor will send a written
statement that a determination could not be made to the Enrollee
on the date the allowable time to resolve the Complaint has
expired.
iii) In cases where delay would significantly increase the risk to an
Enrollee's health, the Contractor shall provide notice of a
determination by telephone directly to the Enrollee or to the
Enrollee's designee, or when no phone is available, some other
method of communication, with written notice to follow within
three (3) business days.
9. COMPLAINT APPEALS
a) The Contractor's procedures regarding Enrollee Complaint Appeals shall
include the following:
i) The Enrollee or designee has no less than sixty (60) business
days after receipt of the notice of the Complaint determination
to file a written Complaint Appeal. Complaint Appeals may be
submitted by letter or by a form provided by the Contractor.
ii) Within fifteen (15) business days of receipt of the Complaint
Appeal, the Contractor shall provide written acknowledgment of
the Complaint Appeal, including the name, address and telephone
number of the individual designated to respond to the Appeal. The
Contractor shall indicate what additional information, if any,
must be provided for the Contractor to render a determination.
iii) Complaint Appeals of clinical matters must be decided by
personnel qualified to review the Appeal, including licensed,
certified or registered health care
APPENDIX F
October 1, 2005
F-14
professionals who did not make the initial determination, at
least one of whom must be a clinical peer reviewer, as defined by
PHL Section 4900(2)(a).
iv) Complaint Appeals of non-clinical matters shall be determined by
qualified personnel at a higher level than the personnel who made
the original Complaint determination.
v) Complaint Appeals shall be decided and notification provided to
the Enrollee no more than:
A) two (2) business days after the receipt of all necessary
information when a delay would significantly increase the
risk to an Enrollee's health; or
B) thirty (30) business days after the receipt of all necessary
information in all other instances.
vi) The notice of the Contractor's Complaint Appeal determination
shall include:
A) the detailed reasons for the determination;
B) the clinical rationale for the determination in cases where
the determination has a clinical basis;
C) the notice shall also inform the Enrollee of his/her option
to also contact the State Department of Health with his/her
Complaint, including the SDOH's toll-free number for
Complaints;
D) instructions for any further Appeal, if applicable.
10. RECORDS
a) The Contractor shall maintain a file on each Complaint, Action Appeal
and Complaint Appeal. These records shall be readily available for
review by the SDOH, upon request. The file shall include:
i) date the Complaint was filed;
ii) copy of the Complaint, if written;
iii) date of receipt of and copy of the Enrollee's written
confirmation, if any;
iv) log of Complaint determination including the date of the
determination and the titles of the personnel and credentials of
clinical personnel who reviewed the Complaint;
v) date and copy of the Enrollee's Action Appeal or Complaint
Appeal;
vi) Enrollee or provider requests for expedited Action Appeals and
Complaint Appeals and the Contractor's determination;
vii) necessary documentation to support any extensions;
APPENDIX F
October 1, 2005
F-15
viii) determination and date of determination of the Action Appeals
and Complaint Appeals;
ix) the titles and credentials of clinical staff who reviewed the
Action Appeals and Complaint Appeals; and
x) Complaints unresolved for greater than forty-five (45) days.
APPENDIX F
October 1, 2005
F-16
APPENDIX G
SDOH REQUIREMENTS FOR THE PROVISION
OF EMERGENCY CARE AND SERVICES
APPENDIX G
October 1, 2005
G-l
SDOH REQUIREMENTS FOR THE
PROVISION OF EMERGENCY CARE AND SERVICES
1. DEFINITIONS
a) "EMERGENCY MEDICAL CONDITION" means a medical or behavioral condition,
the onset of which is sudden, that manifests itself by symptoms of
sufficient severity, including severe pain, that a prudent layperson,
possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to result
in:
i) placing the health of the person afflicted with such condition in
serious jeopardy or, in the case of a pregnant woman, the health
of the woman or her unborn child or, in the case of a behavioral
condition, placing the health of the person or others in serious
jeopardy; or
ii) serious impairment to such person's bodily functions; or
iii) serious dysfunction of any bodily organ or part of such person;
or
iv) serious disfigurement of such person.
b) "EMERGENCY SERVICES" means health care procedures, treatments or
services needed to evaluate or stabilize an Emergency Medical
Condition including psychiatric stabilization and medical
detoxification from drugs or alcohol.
c) "POST-STABILIZATION CARE SERVICES" means covered services, related to
an emergency medical condition, that are provided after an Enrollee is
stabilized in order to maintain the stabilized condition, or, under
the circumstances described in Section 3 below, to improve or resolve
the Enrollee's condition.
2. COVERAGE AND PAYMENT OF EMERGENCY SERVICES
a) The Contractor must cover and pay for Emergency Services regardless of
whether the provider that furnishes the services has a contract with
the Contractor.
b) The Contractor must advise Enrollees that they may access Emergency
Services at any Emergency Services provider.
c) Prior authorization for treatment of an Emergency Medical Condition is
never required.
APPENDIX G
October 1, 2005
G-2
d) The Contractor may not deny payment for treatment obtained in either
of the following circumstances:
i) An Enrollee had an Emergency Medical Condition, including cases
in which the absence of immediate medical attention would not
have had the outcomes specified in the definition of Emergency
Medical Condition above.
ii) A representative of the Contractor instructs the Enrollee to seek
Emergency Services.
e) A Contractor may not:
i) limit what constitutes an Emergency Medical Condition based on
lists of diagnoses or symptoms; or
ii) refuse to cover emergency room services based on the failure of
the provider or the Enrollee to give the Contractor notice of the
emergency room visit.
f) An Enrollee who has an Emergency Medical Condition may not be held
liable for payment of subsequent screening and treatment needed to
diagnose the specific condition or stabilize the patient.
g) The attending emergency physician, or the provider actually treating
the Enrollee, is responsible for determining when the Enrollee is
sufficiently stabilized for transfer or discharge, and that
determination is binding on the Contractor for payment.
3. COVERAGE AND PAYMENT OF POST-STABILIZATION CARE SERVICES
a) The Contractor is financially responsible for Post-stabilization Care
Services furnished by a provider within or outside the Contractor's
network when:
i) they are pre-approved by a Participating Provider, as authorized
by the Contractor, or other authorized Contractor representative;
ii) they are not pre-approved by a Participating Provider, as
authorized by the Contractor, or other authorized Contractor
representative, but administered to maintain the Enrollee's
stabilized condition within one (1) hour of a request to the
Contractor for pre-approval of further Post-stabilization Care
Services;
iii) they are not pre-approved by a Participating Provider, as
authorized by the Contractor, or other authorized Contractor
representative, but administered to maintain, improve or resolve
the Enrollee's stabilized condition if:
A) The Contractor does not respond to a request for
pre-approval within one (1) hour;
B) The Contractor cannot be contacted; or
APPENDIX G
October 1, 2005
G-3
C) The Contractor's representative and the treating physician
cannot reach an agreement concerning the Enrollee's care
and a plan physician is not available for consultation. In
this situation, the Contractor must give the treating
physician the opportunity to consult with a plan physician
and the treating physician may continue with care of the
patient until a plan physician is reached or one of the
criteria in 3(b) is met.
iv) The Contractor must limit charges to Enrollees for
Post-stabilization Care Services to an amount no greater than
what the organization would charge the Enrollee if he or she had
obtained the services through the Contractor.
b) The Contractor's financial responsibility to the treating emergency
provider for Post-stabilization Care Services it has not pre-approved
ends when:
i) A plan physician with privileges at the treating hospital assumes
responsibility for the Enrollee's care;
ii) A plan physician assumes responsibility for the Enrollee's care
through transfer;
iii) A Contractor representative and the treating physician reach an
agreement concerning the Enrollee's care or
iv) The Enrollee is discharged.
4. PROTOCOL FOR ACCEPTABLE TRANSFER BETWEEN FACILITIES
a) All relevant COBRA requirements must be met.
b) The Contractor must provide for an appropriate (as determined by the
emergency department physician) transfer method/level with personnel
as needed.
c) The Contractor must contact/arrange for an available, accepting
physician and patient bed at the receiving institution.
d) If a patient is not transferred within eight (8) hours to an
appropriate inpatient setting after the decision to admit has been
made, then admission at the original facility is deemed authorized.
5. TRIAGE FEES
For emergency room services that do not meet the definition of Emergency
Medical Condition, the Contractor shall pay the hospital a triage fee of
$40.00 in the absence of a negotiated rate.
APPENDIX G
October 1, 2005
G-4
6. EMERGENCY TRANSPORTATION
When emergency transportation is included in the Contractor's Benefit
Package, the Contractor shall reimburse the transportation provider for all
emergency ambulance services without regard to final diagnosis or prudent
layperson standards.
APPENDIX G
October 1, 2005
G-5
APPENDIX H
NEW YORK STATE DEPARTMENT OF HEALTH REQUIREMENTS
FOR THE PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
IN THE MMC AND FHPLUS PROGRAMS
APPENDIX H
October 1, 2005
H-l
SDOH REQUIREMENTS
FOR THE PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
IN THE MMC AND FHPLUS PROGRAMS
1. GENERAL
The Contractor's Enrollment and Disenrollment procedures shall be
consistent with these requirements, except that to allow LDSS and the
Contractor flexibility in developing processes that will meet the needs of
both parties, SDOH may allow modifications to timeframes and some
procedures. Where an Enrollment Broker exists, the Enrollment Broker may be
responsible for some or all of the LDSS responsibilities.
2. ENROLLMENT
a) SDOH Responsibilities:
i) The SDOH is responsible for monitoring LDSS program activities
and providing technical assistance to the LDSS and the Contractor
to ensure compliance with the State's policies and procedures.
ii) SDOH reviews and approves proposed Enrollment materials prior to
the Contractor publishing and disseminating or otherwise using
the materials.
b) LDSS Responsibilities:
i) The LDSS has the primary responsibility for the Enrollment
process.
ii) Each LDSS determines Medicaid and FHPlus eligibility. To the
extent practicable, the LDSS will follow up with Enrollees when
the Contractor provides documentation of any change in status
which may affect the Enrollee's Medicaid, FHPlus, or MMC
eligibility.
iii) The LDSS is responsible for coordinating the Medicaid and FHPlus
application and Enrollment processes.
iv) The LDSS is responsible for providing pre-enrollment information
to Eligible Persons, consistent with Sections 364-j(4)(e)(iv) and
369-ee of the SSL, and the training of persons providing
Enrollment counseling to Eligible Persons.
v) The LDSS is responsible for informing Eligible Persons of the
availability of MCOs and HIV SNPs offering MMC and/or FHPlus
products and the scope of services covered by each.
vi) The LDSS is responsible for informing Eligible Persons of the
right to confidential face-to-face Enrollment counseling and will
make confidential face-to-face sessions available upon request.
APPENDIX H
October 1, 2005
H-2
vii) The LDSS is responsible for instructing Eligible Persons to
verify with the medical services providers they prefer, or have
an existing relationship with, that such medical services
providers are Participating Providers of the selected MCO and are
available to serve the Enrollee. The LDSS includes such
instructions to Eligible Persons in its written materials related
to Enrollment.
viii) For Enrollments made during face-to-face counseling, if the
Prospective Enrollee has a preference for particular medical
services providers, Enrollment counselors shall verify with the
medical services providers that such medical services providers
whom the Prospective Enrollee prefers are Participating Providers
of the selected MCO and are available to serve the Prospective
Enrollee.
ix) The LDSS is responsible for the timely processing of managed care
Enrollment applications, Exemptions, and Exclusions.
x) The LDSS is responsible for determining the status of Enrollment
applications. Applications will be enrolled, pended or denied.
The LDSS will notify the Contractor of the denial of any
Enrollment applications that the Contractor assisted in
completing and submitting to the LDSS under the circumstances
described in 2(c)(i) of this Appendix.
xi) The LDSS is responsible for determining the Exemption and
Exclusion status of individuals determined to be eligible for
Medicaid under Title 11 of the SSL.
A) Exempt means an individual eligible for Medicaid under Title
11 of the SSL determined by the LDSS or the SDOH to be in a
category of persons, as specified in Section 364-j of the
SSL and/or New York State's Operational Protocol for the
Partnership Plan, that are not required to participate in
the MMC Program; however, individuals designated as Exempt
may elect to voluntarily enroll.
B) Excluded means an individual eligible for Medicaid under
Title 11 of the SSL determined by the LDSS or the SDOH to be
in a category of persons, as specified in Section 364-j of
the SSL and/or New York State's Operational Protocol for the
Partnership Plan, that are precluded from participating in
the MMC Program.
xii) Individuals eligible for Medicaid under Title 11 of the SSL in
the following categories will be eligible for Enrollment in the
Contractor's MMC product at the LDSS's option, as indicated in
Schedule 2 of Appendix M.
A) Foster care children in the direct care of LDSS;
B) Homeless persons living in shelters outside of New York
City.
APPENDIX H
October 1, 2005
H-3
xiii) The LDSS is responsible for entering individual Enrollment form
data and transmitting that data to the State's Prepaid Capitation
Plan (PCP) Subsystem. The transfer of Enrollment information may
be accomplished by any of the following:
A) LDSS directly enters data into PCP Subsystem; or
B) LDSS or Contractor submits a tape to the State, to be edited
and entered into PCP Subsystem; or
C) LDSS electronically transfers data, via a dedicated line or
Medicaid Eligibility Verification System (MEVS) to the PCP
Subsystem.
xiv) The LDSS is responsible for sending the following required
notices to Eligible Persons:
A) For mandatory MMC program only - Initial Notification
Letter: This letter informs Eligible Persons about the
mandatory MMC program and the timeframes for choosing a MCO
offering a MMC product. Included with the letter are managed
care brochures, an Enrollment form, and information on their
rights and responsibilities under this program, including
the option for HIV/AIDS infected individuals who are
categorically exempt from the mainstream MMC program to
enroll in an HIV SNP on a voluntary basis in LDSS
jurisdictions where HIV SNPs exist.
B) For mandatory MMC program only - Reminder Letter: A letter
to all Eligible Persons in a mandatory category who have not
responded by submitting a completed Enrollment form within
thirty (30) days of being sent or given an Enrollment
packet.
C) For MMC program - Enrollment Confirmation Notice for MMC
Enrollees: This notice indicates the Effective Date of
Enrollment, the name of the MCO and all individuals who are
being enrolled. This notice should also be used for case
additions and re-enrollments into the same MCO. There is no
requirement that an Enrollment Confirmation Notice be sent
to FHPlus Enrollees.
D) Notice of Denial of Enrollment: This notice is used when an
individual has been determined by LDSS to be ineligible for
Enrollment into the MMC or FHPlus program. This notice must
include fair hearing rights. This notice is not required
when Medicaid or FHPlus eligibility is being denied (or
closed).
E) For MMC program only - Exemption Request Forms: Exemption
forms are provided to MMC Eligible Persons upon request if
they wish to apply for an Exemption. Individuals pre-coded
on the system as meeting Exemption or Exclusion criteria do
not need to complete an Exemption request form. This notice
is required for mandatory MMC Eligible Persons.
APPENDIX H
October 1, 2005
H-4
F) For MMC program only - Exemption and Exclusion Request
Approval or Denial: This notice is designed to inform a
recipient who applied for an exemption or who failed to
provide documentation of exclusion criteria when requested
by the LDSS of the LDSS's disposition of the request,
including the right to a fair hearing if the request for
exemption or exclusion is denied. This notice is required
for voluntary and mandatory MMC Eligible Persons.
c) Contractor Responsibilities:
i) To the extent permitted by law and regulation, the Contractor may
accept Enrollment forms from Potential Enrollees for the MMC
program, provided that the appropriate education has been
provided to the Potential Enrollee by the LDSS pursuant to
Section 2(b) of this Appendix. In those instances, the Contractor
will submit resulting Enrollments to the LDSS, within a maximum
of five (5) business days from the day the Enrollment is received
by the Contractor (unless otherwise agreed to by SDOH and LDSS).
ii) The Contractor must notify new MMC and FHPlus Enrollees of their
Effective Date of Enrollment. In the event that the actual
Effective Date of Enrollment is different from that previously
given to the Enrollee, the Contractor must notify the Enrollee of
the actual date of Enrollment. This may be accomplished through a
Welcome Letter. To the extent practicable, such notification must
precede the Effective Date of Enrollment.
iii) The Contractor must report any changes in status for its enrolled
members to the LDSS within five (5) business days of such
information becoming known to the Contractor. This includes, but
is not limited to, factors that may impact Medicaid or FHPlus
eligibility such as address changes, verification of pregnancy,
incarceration, third party insurance, etc.
iv) The Contractor shall advise Prospective Enrollees, in written
materials related to Enrollment, to verify with the medical
services providers they prefer, or have an existing relationship
with, that such medical services providers are Participating
Providers of the selected MCO and are available to serve the
Prospective Enrollee.
v) The Contractor shall accept all Enrollments as ordered by the
Office of Temporary and Disability Assistance's Office of
Administrative Hearings due to fair hearing requests or
decisions.
3. NEWBORN ENROLLMENTS
a) The Contractor agrees to enroll and provide coverage for eligible
newborn children effective from the time of birth.
APPENDIX H
October 1, 2005
H-5
b) SDOH Responsibilities:
i) The SDOH will update WMS with information on the newborn received
from hospitals, consistent with the requirements of Section 366-g
of the SSL as amended by Chapter 412 of the Laws of 1999.
ii) Upon notification of the birth by the hospital or birthing
center, the SDOH will update WMS with the demographic data for
the newborn and enroll the newborn in the mother's MCO if the
newborn is not already enrolled, the mother's MCO offers a MMC
product, and the newborn is not identified as SSI or SSI-related
and therefore Excluded from the MMC Program pursuant to Section
2(b)(xi) of this Appendix. The newborn will be retroactively
enrolled back to the first (1st) day of the month of birth. Based
on the transaction date of the Enrollment of the newborn on the
PCP subsystem, the newborn will appear on either the next month's
Roster or the subsequent month's Roster. On Rosters for upstate
and NYC, the "PCP Effective From Date" will indicate the first
day of the month of birth, as described in 01 OMM/ADM 5
"Automatic Medicaid Enrollment for Newborns." If the newborn's
Enrollment is not completed by this process, the LDSS is
responsible for Enrollment (see (c)(iv) below).
c) LDSS Responsibilities:
i) Grant Medicaid eligibility for newborns for one (1) year if born
to a woman eligible for and receiving Medicaid or FHPlus on the
date of the newborn's birth.
ii) The LDSS is responsible for adding eligible unborns to all WMS
cases that include a pregnant woman as soon as the pregnancy is
medically verified.
iii) In the event that the LDSS learns of an Enrollee's pregnancy
prior to the Contractor, the LDSS is responsible for establishing
Medicaid eligibility and enrolling the unborn in the Contractor's
MMC product. If the Contractor does not offer a MMC product, the
pregnant woman will be asked to select a MCO offering a MMC
product for the unborn. If a MCO offering a MMC product is
unavailable, or if Enrollment is voluntary in the LDSS
jurisdiction and an MCO is not chosen by the mother, the newborn
will be eligible for Medicaid fee-for-service coverage, and such
information will be entered on the WMS.
iv) The LDSS is responsible for newborn Enrollment if enrollment is
not successfully completed under the "SDOH Responsibilities"
process as outlined in 2(b)(ii) above.
d) Contractor Responsibilities:
i) The Contractor must notify the LDSS in writing of any Enrollee
that is pregnant within thirty (30) days of knowledge of the
pregnancy. Notifications should be transmitted to the LDSS at
least monthly. The notifications should contain the
APPENDIX H
October 1, 2005
H-6
pregnant woman's name, Client ID Number (CIN), and the expected
date of confinement (EDC).
ii) The Contractor must send verifications of infant's demographic
data to the LDSS, within five (5) days after knowledge of the
birth. The demographic data must include: the mother's name and
CIN, the newborn's name and CIN (if newborn has a CIN), sex and
the date of birth.
iii) In districts that use an Enrollment Broker, the Contractor shall
not submit electronic Enrollments of newborns to the Enrollment
Broker, as this will interfere with the retroactive Enrollment of
the newborn back to the first (1st) day of the month of birth.
For newborns whose mothers are not enrolled in the Contractor's
MMC or FHPlus product and who were not pre-enrolled into the
Contractor's MMC product as unborns, the Contractor may submit
electronic Enrollment of the newborns to the Enrollment Broker.
In such cases, the Effective Date of Enrollment will be
prospective.
iv) In voluntary MMC counties, the Contractor will accept Enrollment
applications for unborns if that is the mothers' intent, even if
the mothers are not and/or will not be enrolled in the
Contractor's MMC or FHPlus product. In all counties, when a
mother is ineligible for Enrollment or chooses not to enroll, the
Contractor will accept Enrollment applications for pre-enrollment
of unborns who are eligible.
v) The Contractor is responsible for provision of services to a
newborn and payment of the hospital or birthing center bill if
the mother is an Enrollee at the time of the newborn's birth,
even if the newborn is not yet on the Roster, unless the
Contractor does not offer a MMC product in the mother's county of
fiscal responsibility or the newborn is Excluded from the MMC
Program pursuant to Section 2(b)(xi) of this Appendix.
vi) Within fourteen (14) days of the date on which the Contractor
becomes aware of the birth, the Contractor will issue a letter,
informing parent(s) about the newborn's Enrollment and how to
access care, or a member identification card.
vii) In those cases in which the Contractor is aware of the pregnancy,
the Contractor will ensure that enrolled pregnant women select a
PCP for their infants prior to birth.
viii) The Contractor will ensure that the newborn is linked with a PCP
prior to discharge from the hospital or birthing center, in those
instances in which the Contractor has received appropriate
notification of birth prior to discharge.
APPENDIX H
October 1, 2005
H-7
4. AUTO-ASSIGNMENT PROCESS (APPLIES TO MANDATORY MMC PROGRAM ONLY):
a) This section only applies to a LDSS where CMS has given approval and
the LDSS has begun mandatory Enrollment into the Medicaid Managed Care
Program. The details of the auto-assignment process are contained in
Section 12 of New York State's Operational Protocol for the
Partnership Plan.
b) SDOH Responsibilities:
i) The SDOH, LDSS or Enrollment Broker will assign MMC Eligible
Persons not pre-coded in WMS as Exempt or Excluded, who have not
chosen a MCO offering a MMC product in the required time period,
to a MCO offering a MMC product using an algorithm as specified
in Section 364-j(4)(d) of the SSL.
ii) SDOH will ensure the auto-assignment process automatically
updates the PCP Subsystem, and will notify MCOs offering MMC
products of auto-assigned individuals electronically.
iii) SDOH will notify the LDSS electronically on a daily basis of
those individuals for whom SDOH has selected a MCO offering a MMC
product through the Automated PCP Update Report. Note: This does
not apply in Local Districts that utilize an Enrollment Broker.
c) LDSS Responsibilities:
i) The LDSS is responsible for tracking an individual's choice
period.
ii) As with Eligible Persons who voluntarily choose a MCO's MMC
product, the LDSS is responsible for providing notification to
assigned individuals regarding their Enrollment status as
specified in Section 2 of this Appendix.
d) Contractor Responsibilities:
i) The Contractor is responsible for providing notification to
assigned individuals regarding their Enrollment status as
specified in Section 2 of this Appendix.
5. ROSTER RECONCILIATION:
a) All Enrollments are effective the first of the month.
b) SDOH Responsibilities:
i) The SDOH maintains both the PCP subsystem Enrollment files and
the WMS eligibility files, using data entered by the LDSS. SDOH
uses data contained in both these files to generate the Roster.
APPENDIX H
October 1, 2005
H-8
A) SDOH shall send the Contractor and LDSS monthly (according
to a schedule established by SDOH), a complete list of all
Enrollees for which the Contractor is expected to assume
medical risk beginning on the 1st of the following month
(First Monthly Roster). Notification to the Contractor and
LDSS will be accomplished via paper transmission, magnetic
media, or the HPN.
B) SDOH shall send the Contractor and LDSS monthly, at the time
of the first monthly roster production, a Disenrollment
Report listing those Enrollees from the previous month's
roster who were disenrolled, transferred to another MOO, or
whose Enrollments were deleted from the file. Notification
to the Contractor and LDSS will be accomplished via paper
transmission, magnetic media, or the HPN.
C) The SDOH shall also forward an error report as necessary to
the Contractor and LDSS.
D) On the first (1st) weekend after the first (1st) day of the
month following the generation of the first (1st) Roster,
SDOH shall send the Contractor and LDSS a second Roster
which contains any additional Enrollees that the LDSS has
added for Enrollment for the current month. The SDOH will
also include any additions to the error report that have
occurred since the initial error report was generated.
c) LDSS Responsibilities:
i) The LDSS is responsible for notifying the Contractor
electronically or in writing of changes in the Roster and error
report, no later than the end of the month. (Note: To the extent
practicable the date specified must allow for timely notice to
Enrollees regarding their Enrollment status. The Contractor and
the LDSS may develop protocols for the purpose of resolving
Roster discrepancies that remain unresolved beyond the end of the
month.)
ii) Enrollment and eligibility issues are reconciled by the LDSS to
the extent possible, through manual adjustments to the PCP
subsystem Enrollment and WMS eligibility files, if appropriate.
d) Contractor Responsibilities:
i) The Contractor is at risk for providing Benefit Package services
for those Enrollees listed on the 1st and 2nd Rosters for the
month in which the 2nd Roster is generated. Contractor is not at
risk for providing services to Enrollees who appear on the
monthly Disenrollment report.
ii) The Contractor must submit claims to the State's Fiscal Agent for
all Eligible Persons that are on the 1st and 2nd Rosters,
adjusted to add Eligible Persons enrolled by the LDSS after
Roster production and to remove individuals
APPENDIX H
October 1, 2005
H-9
disenrolled by LDSS after Roster production (as notified to the
Contractor). In the cases of retroactive Disenrollments, the
Contractor is responsible for submitting an adjustment to void
any previously paid premiums for the period of retroactive
Disenrollment, where the Contractor was not at risk for the
provision of Benefit Package services. Payment of subcapitation
does not constitute "provision of Benefit Package services."
6. DISENROLLMENT:
a) LDSS Responsibilities:
i) The LDSS is responsible for accepting requests for Disenrollment
directly from Enrollees and may not require Enrollees to approach
the Contractor for a Disenrollment form. Where an LDSS is
authorized to mandate Enrollment, all requests for Disenrollment
must be directed to the LDSS or the Enrollment Broker. The LDSS
and the Enrollment Broker must utilize the State-approved
Disenrollment forms.
ii) Enrollees may initiate a request for an expedited Disenrollment
to the LDSS. The LDSS will expedite the Disenrollment process in
those cases where an Enrollee's request for Disenrollment
involves an urgent medical need, a complaint of non-consensual
Enrollment or, in local districts where homeless individuals are
exempt, homeless individuals in the shelter system. If approved,
the LDSS will manually process the Disenrollment through the PCP
Subsystem. MMC Enrollees who request to be disenrolled from
managed care based on their documented HIV, ESRD, or SPMI/SED
status are categorically eligible for an expedited Disenrollment
on the basis of urgent medical need.
iii) The LDSS is responsible for processing routine Disenrollment
requests to take effect on the first (1st) day of the following
month if the request is made BEFORE the fifteenth (15th) day of
the month. In no event shall the Effective Date of Disenrollment
be later than the first (1st) day of the second month after the
month in which an Enrollee requests a Disenrollment.
iv) The LDSS is responsible for disenrolling Enrollees automatically
upon death or loss of Medicaid or FHPlus eligibility. All such
Disenrollments will be effective at the end of the month in which
the death or loss of eligibility occurs or at the end of the last
month of Guaranteed Eligibility, where applicable.
v) The LDSS is responsible for informing Enrollees of their right to
change Contractors if there is more than one available including
any applicable Lock-In restrictions. Enrollees subject to Lock-In
may disenroll after the grace period for Good Cause as defined
below. The LDSS is responsible for determining if the Enrollee
has Good Cause and processing the Disenrollment request in
accordance with the procedures outlined in this Appendix. The
LDSS is responsible for providing Enrollees with notice of their
right to request a fair hearing if their
APPENDIX H
October 1, 2005
H-10
Disenrollment request is denied Such notice must include the
reason(s) for the denial. An Enrollee has Good Cause to disenroll
if:
A) The Contractor has failed to furnish accessible and
appropriate medical care services or supplies to which the
Enrollee is entitled under the terms of the contract under
which the Contractor has agreed to provide services. This
includes, but is not limited to the failure to:
I) provide primary care services;
II) arrange for in-patient care, consultation with
specialists, or laboratory and radiological services
when reasonably necessary;
III) arrange for consultation appointments;
IV) coordinate and interpret any consultation findings with
emphasis on continuity of medical care;
V) arrange for services with qualified licensed or
certified providers;
VI) coordinate the Enrollee's overall medical care such as
periodic immunizations and diagnosis and treatment of
any illness or injury; or
B) The Contractor cannot make a Primary Care Provider available
to the Enrollee within the time and distance standards
prescribed by SDOH; or
C) The Contractor fails to adhere to the standards prescribed
by SDOH and such failure negatively and specifically impacts
the Enrollee; or
D) The Enrollee moves his/her residence out of the Contractor's
service area or to a county where the Contractor does not
offer the product the Enrollee is eligible for; or
E) The Enrollee meets the criteria for an Exemption or
Exclusion as set forth in 2(b)(xi) of this Appendix; or
F) It is determined by the LDSS, the SDOH, or its agent that
the Enrollment was not consensual; or
G) The Enrollee, the Contractor and the LDSS agree that a
change of MCOs would be in the best interest of the
Enrollee; or
H) The Contractor is a primary care partial capitation provider
that does not have a utilization review process in
accordance with Title I of Article 49 of the PHL and the
Enrollee requests Enrollment in an MCO that has such a
utilization review process; or
I) The Contractor has elected not to cover the Benefit Package
service that an Enrollee seeks and the service is offered by
one or more other MCOs in the Enrollee's county of fiscal
responsibility; or
APPENDIX H
October 1, 2005
H-11
J) The Enrollee's medical condition requires related services
to be performed at the same time but all such related
services cannot be arranged by the Contractor because the
Contractor has elected not to cover one of the services the
Enrollee seeks, and the Enrollee's Primary Care Provider or
another provider determines that receiving the services
separately would subject the Enrollee to unnecessary risk;
or
K) An FHPlus Enrollee is pregnant.
vi) An Enrollee subject to Lock-In may initiate Disenrollment for
Good Cause by filing an oral or written request with the LDSS.
vii) The LDSS is responsible for promptly disenrolling an MMC Enrollee
whose MMC eligibility or health status changes such that he/she
is deemed by the LDSS to meet the Exclusion criteria. The LDSS
will provide the MMC Enrollee with a notice of his or her right
to request a fair hearing.
viii) In instances where an MMC Enrollee requests Disenrollment due to
MMC Exclusion, the LDSS must notify the MMC Enrollee of the
approval or denial of exclusion/Disenrollment status, including
fair hearing rights if Disenrollment is denied.
ix) The LDSS is responsible for ensuring that retroactive
Disenrollments are used only when absolutely necessary.
Circumstances warranting a retroactive Disenrollment are rare and
include when an Enrollee is determined to have been
non-consensually enrolled in a MCO; he or she enters or resides
in a residential institution under circumstances which render the
individual Excluded from the MMC program; is incarcerated; is an
SSI infant less than six (6) months of age; is simultaneously in
receipt of comprehensive health care coverage from a MCO and is
Enrolled in either the MMC or FHPlus product of the same MCO; it
is determined that an Enrollee with more than one Client
Identification Number (CIN) is enrolled in a MCO's MMC or FHPlus
product under more than one of the CINs; or he or she died - as
long as the Contractor was not at risk for provision of Benefit
Package services for any portion of the retroactive period.
Payment of subcapitation does not constitute "provision of
Benefit Package services." The LDSS is responsible for notifying
the Contractor of the retroactive Disenrollment prior to the
action. The LDSS is responsible for finding out if the Contractor
has made payments to providers on behalf of the Enrollee prior to
Disenrollment. After this information is obtained, the LDSS and
Contractor will agree on a retroactive Disenrollment or
prospective Disenrollment date. In all cases of retroactive
Disenrollment, including Disenrollments effective the first day
of the current month, the LDSS is responsible for sending notice
to the Contractor at the time of Disenrollment, of the
Contractor's responsibility to submit to the SDOH's Fiscal Agent
voided premium claims for any full months of retroactive
Disenrollment where the Contractor was not at risk for the
provision of Benefit Package services during the month. However,
failure by the LDSS to so
APPENDIX H
October 1, 2005
H-12
notify the Contractor does not affect the right of the SDOH to
recover the premium payment as authorized by Section 3.6 of this
Agreement.
APPENDIX H
October 1, 2005
H-13
x) Generally the effective dates of Disenrollment are prospective.
Effective dates for other than routine Disenrollments are
described below:
REASON FOR DISENROLLMENT EFFECTIVE DATE OF DISENROLLMENT
------------------------ -------------------------------
A) Infants weighing less than 1200 grams at First Day of the month of birth or the month
birth and other infants under six (6) months of onset of disability, whichever is later
of age who meet the criteria for the SSI or
SSI related category
B) Death of Enrollee First day of the month after death
C) Incarceration First day of the month of incarceration
(note-Contractor is at risk for covered
services only to the date of incarceration and
is entitled to the capitation payment for the
month of incarceration)
D) Medicaid Managed Care Enrollee entered or First day of the month of entry or first day
stayed in a residential institution under of the month of classification of the stay as
circumstances which rendered the individual permanent subsequent to entry (note-Contractor
excluded from managed care, or is in receipt is at risk for covered services only to the
of waivered services through the Long Term date of entry or classification of the stay as
Home Health Care Program (LTHHCP), including permanent subsequent to entry, and is entitled
when an Enrollee is admitted to a hospital to the capitation payment for the month of
that 1) is certified by Medicare as a entry or classification of the stay as
long-term care hospital and 2) has an average permanent subsequent to entry)
length of stay for all patients greater than
ninety-five (95) days as reported in the
Statewide Planning and Research Cooperative
System (SPARCS) Annual Report 2002.
E) Individual's effective date of Enrollment or Effective Date of Enrollment in the
autoassignment into a MMC product occurred Contractor's Plan
while meeting institutional criteria in (D)
above
F) Non-consensual Enrollment Retroactive to the first day of the month of
Enrollment
G) Enrollee moved outside of the District/County First day of the month after the update of the
of Fiscal Responsibility system with the new address(1)
H) Urgent medical need First day of the next month after
determination except where medical need
requires an earlier Disenrollment
I) Homeless Enrollees in Medicaid Managed Care Retroactive to the first day of the month of
residing in the shelter system in NYC or in the request
other districts where homeless individuals
are exempt
J) Individual is simultaneously in receipt of First day of the month after simultaneous
comprehensive health care coverage from an coverage began
MCO and is Enrolled in either the MMC or
FHPlus product of the same MCO
K) An Enrollee with more than one Client First day of the month the duplicate
Identification Number (CIN) is enrolled in an Enrollment began
MCO's MMC or FHPlus product under more than
one of the CINs
(1) In counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor's MMC or
FHPlus product. In New York City, Enrollees, not in guaranteed status, who
move out of the Contractor's Service Area but not outside of the City of
New York (e.g., move from one borough to another), will not be
involuntarily disenrolled, but must request a Disenrollment or transfer.
These Disenrollments will be performed on a routine basis unless there is
an urgent medical need to expedite the Disenrollment.
APPENDIX H
October 1, 2005
H-14
xi) The LDSS is responsible for rendering a determination and
responding within thirty (30) days of the receipt of a fully
documented request for Disenrollment, except for
Contractor-initiated Disenrollments where the LDSS decision must
be made within fifteen (15) days. The LDSS, to the extent
possible, is responsible for processing an expedited
Disenrollment within two (2) business days of its determination
that an expedited Disenrollment is warranted.
xii) The Contractor must respond timely to LDSS inquiries regarding
Good Cause Disenrollment requests to enable the LDSS to make a
determination within thirty (30) days of the receipt of the
request from the Enrollee.
xiii) The LDSS is responsible for sending the following notices to
Enrollees regarding their Disenrollment status. Where
practicable, the process will allow for timely notification to
Enrollees unless there is Good Cause to disenroll more
expeditiously.
A) Notice of Disenrollment: This notice will advise the
Enrollee of the LDSS's determination regarding an
Enrollee-initiated, LDSS-initiated or Contractor- initiated
Disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being
involuntarily disenrolled, the notice must contain fair
hearing rights.
B) When the LDSS denies any Enrollee's request for
Disenrollment pursuant to Section 8 of this Agreement, the
LDSS is responsible for informing the Enrollee in writing,
explaining the reason for the denial, stating the facts upon
which the denial is based, citing the statutory and
regulatory authority and advising the Enrollee of his/her
right to a fair hearing pursuant to 18NYCRR Part 358.
C) End of Lock-In Notice: Where Lock-In provisions are
applicable, Enrollees must be notified sixty (60) days
before the end of their Lock-In Period. The SDOH or its
designee is responsible for notifying Enrollees of this
provision in applicable LDSS jurisdictions.
D) Notice of Change to Guarantee Coverage: This notice will
advise the Enrollee that his or her Medicaid or FHPlus
eligibility is ending and how this affects his or her
Enrollment in an MCO's MMC or FHPlus product. This notice
contains pertinent information regarding Guaranteed
Eligibility benefits and dates of coverage. If an Enrollee
is not eligible for Guarantee, this notice is not necessary.
xiv) The LDSS may require that a MMC Enrollee that has been
disenrolled at the request of the Contractor be returned to the
Medicaid fee-for-service program. In the FHPlus program, a FHPlus
Enrollee disenrolled at the request of the Contractor, may choose
another MCO offering a FHPlus product. If the FHPlus Enrollee
does not choose, or there is not another MCO offering FHPlus in
the LDSS jurisdiction, the case will be closed.
APPENDIX H
October 1, 2005
H-15
xv) In those instances where the LDSS approves the Contractor's
request to disenroll an Enrollee, and the Enrollee requests a
fair hearing, the Enrollee will remain enrolled in the
Contractor's MMC or FHPlus product until the disposition of the
fair hearing if Aid to Continue is ordered by the New York State
Office of Administrative Hearings.
xvi) The LDSS is responsible for reviewing each Contractor-requested
Disenrollment in accordance with the provisions of Section 8.7 of
this Agreement and this Appendix. Where applicable, the LDSS may
consult with local mental health and substance abuse authorities
in the district when making the determination to approve or
disapprove the request.
xvii) The LDSS is responsible for establishing procedures whereby the
Contractor refers cases which are appropriate for an
LDSS-initiated Disenrollment and submits supporting documentation
to the LDSS.
xviii) After the LDSS receives and, if appropriate, approves the
request for Disenrollment either from the Enrollee or the
Contractor, the LDSS is responsible for updating the PCP
subsystem file with an end date. The Enrollee is removed from the
Contractor's Roster.
b) Contractor Responsibilities:
i) In those instances where the Contractor directly receives
Disenrollment forms, the Contractor will forward these
Disenrollments to the LDSS for processing within five (5)
business days (or according to Section 6 of this Appendix).
During pulldown week, these forms may be faxed to the LDSS with
the hard copy to follow.
ii) The Contractor must accept and transmit all requests for
voluntary Disenrollments from its Enrollees to the LDSS, and
shall not impose any barriers to Disenrollment requests. The
Contractor may require that a Disenrollment request be in
writing, contain the signature of the Enrollee, and state the
Enrollee's correct Contractor or Medicaid identification number.
iii) Following LDSS procedures, the Contractor will refer cases which
are appropriate for an LDSS-initiated Disenrollment and will
submit supporting documentation to the LDSS. This includes, but
is not limited to, changes in status for its Enrollees that may
impact eligibility for Enrollment such as address changes,
incarceration, death, Exclusion from the MMC program, etc.
iv) Pursuant to Section 8.7 of this Agreement, the Contractor may
initiate an involuntary Disenrollment if the Enrollee engages in
conduct or behavior that seriously impairs the Contractor's
ability to furnish services to either the Enrollee or other
Enrollees, provided that the Contractor has made and
APPENDIX H
October 1, 2005
H-16
documented reasonable efforts to resolve the problems presented
by the Enrollee.
v) The Contractor may not request Disenrollment because of an
adverse change in the Enrollee's health status, or because of the
Enrollee's utilization of medical services, diminished mental
capacity, or uncooperative or disruptive behavior resulting from
the Enrollee's special needs (except where continued Enrollment
in the Contractor's MMC or FHPlus product seriously impairs the
Contractor's ability to furnish services to either the Enrollee
or other Enrollees).
vi) The Contractor must make a reasonable effort to identify for the
Enrollee, both verbally and in writing, those actions of the
Enrollee that have interfered with the effective provision of
covered services as well as explain what actions or procedures
are acceptable.
vii) The Contractor shall give prior verbal and written notice to the
Enrollee, with a copy to the LDSS, of its intent to request
Disenrollment. The written notice shall advise the Enrollee that
the request has been forwarded to the LDSS for review and
approval. The written notice must include the mailing address and
telephone number of the LDSS.
viii) The Contractor shall keep the LDSS informed of decisions related
to all complaints filed by an Enrollee as a result of, or
subsequent to, the notice of intent to disenroll.
ix) The Contractor will not consider an Enrollee disenrolled without
confirmation from the LDSS or the Roster (as described in Section
5 of this Appendix).
APPENDIX H
October 1, 2005
H-17
APPENDIX I
NEW YORK STATE DEPARTMENT OF HEALTH
GUIDELINES FOR USE OF MEDICAL RESIDENTS AND FELLOWS
APPENDIX I
October 1, 2005
I-1
MEDICAL RESIDENTS AND FELLOWS
1. MEDICAL RESIDENTS AND FELLOWS FOR PRIMARY CARE.
a) The Contractor may utilize medical residents and fellows as
participants (but not designated as 'primary care providers') in the
care of Enrollees as long as all of the following conditions are met:
i) Residents/fellows are a part of patient care teams headed by
fully licensed and Contractor credentialed attending physicians
serving patients in one or more training sites in an "up
weighted" or "designated priority" residency program.
Residents/fellows in a training program which was disapproved as
a designated priority program solely due to the outcome
measurement requirement for graduates may be eligible to
participate in such patient care teams.
ii) Only the attending physicians and certified nurse practitioners
on the training team, not residents/fellows, may be credentialed
to the Contractor and may be empanelled with Enrollees. Enrollees
must be assigned an attending physician or certified nurse
practitioner to act as their PCP, though residents/fellows on the
team may provide care during all or many of the visits to the
Enrollee as long as the majority of these visits are under the
direct supervision of the Enrollee's designated PCP. Enrollees
have the right to request and receive care by their PCP in
addition or instead of being seen by a resident or fellow.
iii) Residents/fellows may work with attending physicians and
certified nurse practitioners to provide continuity of care to
patients under the supervision of the patient's PCP. Patients
must be made aware of the resident/fellow and attending PCP
relationship and be informed of their rights to be cared for
directly by their PCP.
iv) Residents/fellows eligible to be involved in a continuity
relationship with patients must be available at least twenty
percent (20%) of the total training time in the continuity of
care setting and no less than ten percent (10%) of training time
in any training year must be in the continuity of care setting
and no fewer than nine (9) months a year must be spent in the
continuity of care setting.
v) Residents/fellows meeting these criteria provide increased
capacity for Enrollment to their team according to the formula
below. Only hours spent routinely scheduled for patient care in
the continuity of care training site may count as providing
capacity and are based on 1.0 FTE=40 hours.
PGY-1 300 per FTE
PGY-2 750 per FTE
PGY-3 1125 per FTE
PGY-4 and above 1500 per FTE
APPENDIX I
October 1, 2005
I-2
vi) In order for a resident/fellow to provide continuity of care to
an Enrollee, both the resident/fellow and the attending PCP must
have regular hours in the continuity site and must be scheduled
to be in the site together the majority of the time.
vii) A preceptor/attending is required to be present a minimum of
sixteen (16) hours of combined precepting and direct patient care
in the primary care setting to be counted as a team supervising
PCP and accept an increased number of Enrollees based upon the
residents/fellows working on his/her team. Time spent in patient
care activities at other clinical sites or in other activities
off-site is not counted towards this requirement.
viii) A sixteen (16) hour per week attending may have no more than
four (4) residents/fellows on their team. Attendings spending
twenty-four (24) hours per week in patient care/supervisory
activity at the continuity site may have six (6)
residents/fellows per team. Attendings spending thirty-two (32)
hours per week may have eight (8) residents/fellows on their
team. Two (2) or more attendings may join together to form a
larger team as long as the ratio of attending to
residents/fellows does not exceed 1:4 and all attendings comply
with the sixteen (16) hour minimum.
ix) Responsibility for the care of the Enrollee remains with the
attending physician. All attending and resident/fellow teams must
provide adequate continuity of care, twenty-four (24) hour a day,
seven (7) day a week coverage, and appointment and availability
access. Enrollees must be given the name of the responsible
primary care physician (attending) in writing and be told how he
or she may contact the attending physician or covering physician,
if needed.
x) Residents/fellows who do not qualify to act as continuity
providers as part of an attending and resident/fellow team may
still participate in the episodic care of Enrollees as long as
that care is under the supervision of an attending physician
credentialed to the Contractor. Such residents/fellows do not add
to the capacity of that attending to empanel Enrollees.
xi) Certified nurse practitioners and registered physician's
assistants may not act as attending preceptors for resident
physicians or fellows.
2. MEDICAL RESIDENTS AND FELLOWS AS SPECIALTY CARE PROVIDERS
a) Residents/fellows may participate in the specialty care of Enrollees
in all settings supervised by fully licensed and Contractor
credentialed specialty attending physicians.
b) Only the attending physicians, not residents or fellows, may be
credentialed by the Contractor. Each attending must be credentialed by
each MCO with which he or she will participate. Residents/fellows may
perform all or many of the clinical services for
APPENDIX I
October 1, 2005
I-3
the Enrollee as long as these clinical services are under the
supervision of an appropriately credentialed specialty physician. Even
when residents/fellows are credentialed by their program in particular
procedures, certifying their competence to perform and teach those
procedures, the overall care of each Enrollee remains the
responsibility of the supervising Contractor credentialed attending.
c) The Contractor agrees that although many Enrollees will identify a
resident or fellow as their specialty provider, the responsibility for
all clinical decision-making remains ultimately with the attending
physician of record.
d) Enrollees must be given the name of the responsible attending
physician in writing and be told how they may contact their attending
physician or covering physician, if needed. This allows Enrollees to
assist in the communication between their primary care provider and
specialty attending and enables them to reach the specialty attending
if an emergency arises in the course of their care. Enrollees must be
made aware of the resident/fellow and attending relationship and must
have a right to be cared for directly by the responsible attending
physician, if requested.
e) Enrollees requiring ongoing specialty care must be cared for in a
continuity of care setting. This requires the ability to make
follow-up appointments with a particular resident/fellow and attending
physician team, or if that provider team is not available, with a
member of the provider's coverage group in order to insure ongoing
responsibility for the patient by his/her Contractor credentialed
specialist. The responsible specialist and his/her specialty coverage
group must be identifiable to the patient as well as to the referring
primary care provider.
f) Attending specialists must be available for emergency consultation and
care during non-clinic hours. Emergency coverage may be provided by
residents/fellows under adequate supervision. The attending or a
member of the attending's coverage group must be available for
telephone and/or in-person consultation when necessary.
g) All training programs participating in the MMC or FHPlus Program must
be accredited by the appropriate academic accrediting agency.
h) All sites in which residents/fellows train must produce legible
(preferably typewritten) consultation reports. Reports must be
transmitted such that they are received in a time frame consistent
with the clinical condition of the patient, the urgency of the problem
and the need for follow-up by the primary care physician. At a
minimum, reports should be transmitted so that they are received no
later than two (2) weeks from the date of the specialty visit.
i) Written reports are required at the time of initial consultation and
again with the receipt of all major significant diagnostic information
or changes in therapy. In addition, specialists must promptly report
to the referring primary care physician any significant findings or
urgent changes in therapy which result from the specialty
consultation.
APPENDIX I
October 1, 2005
I-4
3. TRAINING SITES
All training sites must deliver the same standard of care to all patients
irrespective of payor. Training sites must integrate the care of Medicaid,
FHPlus, uninsured and private patients in the same settings.
APPENDIX I
October 1, 2005
1-5
APPENDIX J
NEW YORK STATE DEPARTMENT OF HEALTH GUIDELINES FOR CONTRACTOR
COMPLIANCE WITH THE FEDERAL AMERICANS WITH DISABILITIES ACT
APPENDIX J
October 1, 2005
J-l
I. OBJECTIVES
Title II of the Americans With Disabilities Act (ADA) and Section 504 of
the Rehabilitation Act of 1973 (Section 504) provides that no qualified
individual with a disability shall, by reason of such disability, be
excluded from participation in or denied access to the benefits of
services, programs or activities of a public entity, or be subject to
discrimination by such an entity. Public entities include State and local
government and ADA and Section 504 requirements extend to all programs and
services provided by State and local government. Since MMC and FHPlus are
government programs, health services provided through MMC and FHPlus
Programs must be accessible to all that qualify for them.
Contractor responsibilities for compliance with the ADA are imposed under
Title II and Section 504 when, as a Contractor in a MMC or FHPlus Program,
a Contractor is providing a government service. If an individual provider
under contract with the Contractor is not accessible, it is the
responsibility of the Contractor to make arrangements to assure that
alternative services are provided. The Contractor may determine it is
expedient to make arrangements with other providers, or to describe
reasonable alternative means and methods to make these services accessible
through its existing Participating Providers. The goals of compliance with
ADA Title II requirements are to offer a level of services that allows
people with disabilities access to the program in its entirety, and the
ability to achieve the same health care results as any Enrollee.
Contractor responsibilities for compliance with the ADA are also imposed
under Title III when the Contractor functions as a public accommodation
providing services to individuals (e.g. program areas and sites such as
Marketing, education, member services, orientation, Complaints and
Appeals). The goals of compliance with ADA Title III requirements are to
offer a level of services that allows people with disabilities full and
equal enjoyment of the goods, services, facilities or accommodations that
the entity provides for its customers or clients. New and altered areas and
facilities must be as accessible as possible. Whenever Contractors engage
in new construction or renovation, compliance is also required with
accessible design and construction standards promulgated pursuant to the
ADA as well as State and local laws. Title III also requires that public
accommodations undertake "readily achievable barrier removal" in existing
facilities where architectural and communications barriers can be removed
easily and without much difficulty or expense.
The State uses MCO Qualification Standards to qualify MCOs for
participation in the MMC and FHPlus Programs. Pursuant to the State's
responsibility to assure program access to all Enrollees, the Plan
Qualification Standards require each MCO to submit an ADA Compliance Plan
that describes in detail how the MCO will make services, programs and
activities readily accessible and useable by individuals with disabilities.
In the event that certain program sites are not readily accessible, the MCO
must describe reasonable alternative methods for making the services or
activities accessible and usable.
APPENDIX J
October 1, 2005
J-2
The objectives of these guidelines are threefold:
- To ensure that Contractors take appropriate steps to measure access
and assure program accessibility for persons with disabilities;
- To provide a framework for Contractors as they develop a plan to
assure compliance with the Americans with Disabilities Act (ADA); and
- To provide standards for the review of the Contractor Compliance
Plans.
These guidelines include a general standard followed by a discussion of
specific considerations and suggestions of methods for assuring compliance.
Please be advised that, although these guidelines and any subsequent
reviews by State and local governments can give the Contractor guidance, it
is ultimately the Contractor's obligation to ensure that it complies with
its Contractual obligations, as well as with the requirements of the ADA,
Section 504, and other federal, state and local laws. Other federal, state
and local statutes and regulations also prohibit discrimination on the
basis of disability and may impose requirements in addition to those
established under ADA. For example, while the ADA covers those impairments
that "substantially" limit one or more of the major life activities of an
individual, New York City Human Rights Law deletes the modifier
"substantially".
II. DEFINITIONS
A. "Auxiliary aids and services" may include qualified interpreters, note
takers, computer-aided transcription services, written materials,
telephone handset amplifiers, assistive listening systems, telephones
compatible with hearing aids, closed caption decoders, open and closed
captioning, telecommunications devices for Enrollees who are deaf or
hard of hearing (TTY/TDD), video test displays, and other effective
methods of making aurally delivered materials available to individuals
with hearing impairments; qualified readers, taped texts, audio
recordings, Braille materials, large print materials, or other
effective methods of making visually delivered materials available to
individuals with visual impairments.
B. "Disability" means a mental or physical impairment that substantially
limits one or more of the major life activities of an individual; a
record of such impairment; or being regarded as having such an
impairment.
III. SCOPE OF CONTRACTOR COMPLIANCE PLAN
The Contractor Compliance Plan must address accessibility to services at
Contractor's program sites, including both Participating Provider sites and
Contractor facilities intended for use by Enrollees.
APPENDIX J
October 1, 2005
J-3
IV. PROGRAM ACCESSIBILITY
Public programs and services, when viewed in their entirety must be readily
accessible to and useable by individuals with disabilities. This standard
includes physical access, non-discrimination in policies and procedures and
communication. Communications with individuals with disabilities are
required to be as effective as communications with others. The Contractor
Compliance Plan must include a detailed description of how Contractor
services, programs, and activities are readily accessible and usable by
individuals with disabilities. In the event that full physical
accessibility is not readily available for people with disabilities, the
Contractor Compliance Plan will describe the steps or actions the
Contractor will take to assure accessibility to services equivalent to
those offered at the inaccessible facilities.
A. PRE-ENROLLMENT MARKETING AND EDUCATION
STANDARD FOR COMPLIANCE
Marketing staff, activities and materials will be made available to
persons with disabilities. Marketing materials will be made available
in alternative formats (such as Braille, large print, and audiotapes)
so that they are readily usable by people with disabilities.
SUGGESTED METHODS FOR COMPLIANCE
1. Activities held in physically accessible location, or staff at
activities available to meet with person in an accessible
location as necessary
2. Materials available in alternative formats, such as Braille,
large print, audio tapes
3. Staff training which includes training and information regarding
attitudinal barriers related to disability
4. Activities and fairs that include sign language interpreters or
the distribution of a written summary of the marketing script
used by Contractor marketing representatives
5. Enrollee health promotion material/activities targeted
specifically to persons with disabilities (e.g. secondary
infection prevention, decubitus prevention, special exercise
programs, etc.)
6. Policy statement that Marketing Representatives will offer to
read or summarize to blind or vision impaired individuals any
written material that is typically distributed to all Enrollees
7. Staff/resources available to assist individuals with cognitive
impairments in understanding materials
APPENDIX J
October 1, 2005
J-4
COMPLIANCE PLAN SUBMISSION
1. A description of methods to ensure that the Contractor's
Marketing presentations (materials and communications) are
accessible to persons with auditory, visual and cognitive
impairments
2. A description of the Contractor's policies and procedures,
including Marketing training, to ensure that Marketing
Representatives neither screen health status nor ask questions
about health status or prior health care services
B. MEMBER SERVICES DEPARTMENT
Member services functions include the provision to Enrollees of
information necessary to make informed choices about treatment
options, to effectively utilize the health care resources, to assist
Enrollees in making appointments, and to field questions and
Complaints, to assist Enrollees with the Complaint process.
B1. ACCESSIBILITY
STANDARD FOR COMPLIANCE
Member Services sites and functions will be made accessible to and
usable by, people with disabilities.
SUGGESTED METHODS FOR COMPLIANCE (include, but are not limited to
those identified below):
1. Exterior routes of travel, at least 36" wide, from parking areas
or public transportation stops into the Contractor's facility
2. If parking is provided, spaces reserved for people with
disabilities, pedestrian ramps at sidewalks, and drop-offs
3. Routes of travel into the facility are stable, slip-resistant,
with all steps > 1/2" ramped, doorways with minimum 32" opening
4. Interior halls and passageways providing a clear and unobstructed
path or travel at least 36" wide to bathrooms and other rooms
commonly used by Enrollees
5. Waiting rooms, restrooms, and other rooms used by Enrollees are
accessible to people with disabilities
6. Sign language interpreters and other auxiliary aids and services
provided in appropriate circumstances
7. Materials available in alternative formats, such as Braille,
large print, audio tapes
APPENDIX J
October 1, 2005
J-5
8. Staff training which includes sensitivity training related to
disability issues (Resources and technical assistance are available
through the NYS Office of Advocate for Persons with Disabilities -
V/TTY (800) 522-4369; and the NYC Mayor's Office for People with
Disabilities - (212) 788-2830 or TTY (212)788-2838)
9. Availability of activities and educational materials tailored to
specific conditions/illnesses and secondary conditions that affect
these populations (e.g. secondary infection prevention, decubitus
prevention, special exercise programs, etc.)
10. Contractor staff trained in the use of telecommunication devices for
Enrollees who are deaf or hard of hearing (TTY/TDD) as well as in the
use of NY Relay for phone communication
11. New Enrollee orientation available in audio or by interpreter services
12. Policy that when member services staff receive calls through the NY
Relay, they will offer to return the call utilizing a direct TTY/TDD
connection
COMPLIANCE PLAN SUBMISSION
1. A description of accessibility to the Contractor's member services
department or reasonable alternative means to access member services
for Enrollees using wheelchairs (or other mobility aids)
2. A description of the methods the Contractor's member services
department will use to communicate with Enrollees who have visual or
hearing impairments, including any necessary auxiliary aid/services
for Enrollees who are deaf or hard of hearing, and TTY/TDD technology
or NY Relay service available through a toll-free telephone number
3. A description of the training provided to the Contractor's member
services staff to assure that staff adequately understands how to
implement the requirements of the program, and of these guidelines,
and are sensitive to the needs of persons with disabilities
B2. IDENTIFICATION OF ENROLLEES WITH DISABILITIES
STANDARD FOR COMPLIANCE
The Contractor must have in place satisfactory methods/guidelines for
identifying persons at risk of, or having, chronic diseases and
disabilities and determining their specific needs in terms of specialist
physician referrals, durable medical equipment, medical supplies, home
health services etc. The Contractor may not discriminate against a
Prospective Enrollee based on his/her current health status or anticipated
need for future health care. The Contractor may not discriminate on the
basis of disability, or perceived disability of an Enrollee or their family
member. Health assessment forms may not be used by the Contractor prior to
Enrollment. Once a MCO has been chosen, a health assessment form may be
used to assess the person's health care needs.
APPENDIX J
October 1, 2005
J-6
SUGGESTED METHODS FOR COMPLIANCE
1. Appropriate post Enrollment health screening for each Enrollee, using
an appropriate health screening tool
2. Patient profiles by condition/disease for comparative analysis to
national norms, with appropriate outreach and education
3. Process for follow-up of needs identified by initial screening; e.g.
referrals, assignment of case manager, assistance with
scheduling/keeping appointments
4. Enrolled population disability assessment survey
5. Process for Enrollees who acquire a disability subsequent to
Enrollment to access appropriate services
COMPLIANCE PLAN SUBMISSION
A description of how the Contractor will identify special health care,
physical access or communication needs of Enrollees on a timely basis,
including but not limited to the health care needs of Enrollees who:
- are blind or have visual impairments, including the type of auxiliary
aids and services required by the Enrollee
- are deaf or hard of hearing, including the type of auxiliary aids and
services required by the Enrollee
- have mobility impairments, including the extent, if any, to which they
can ambulate
- have other physical or mental impairments or disabilities, including
cognitive impairments
- have conditions which may require more intensive case management
B3. NEW ENROLLEE ORIENTATION
STANDARD FOR COMPLIANCE
Enrollees will be given information sufficient to ensure that they
understand how to access medical care through the Contractor. This
information will be made accessible to and usable by people with
disabilities.
SUGGESTED METHODS FOR COMPLIANCE
1. Activities held in physically accessible location, or staff at
activities available to meet with person in an accessible location as
necessary
2. Materials available in alternative formats, such as Braille, large
print, audio tapes
APPENDIX J
October 1, 2005
J-7
3. Staff training which includes sensitivity training related to
disability issues (Resources and technical assistance are available
through the NYS Office of Advocate for Persons with Disabilities -
V/TTY (800) 522-4369; and the NYC Mayor's Office for People with
Disabilities - (212) 788-2830 or TTY (212)788-2838)
4. Activities and fairs that include sign language interpreters or the
distribution of a written summary of the Marketing script used by
Contractor marketing representatives
5. Include in written/audio materials available to all Enrollees
information regarding how and where people with disabilities can
access help in getting services, for example help with making
appointments or for arranging special transportation, an interpreter
or assistive communication devices
6. Staff/resources available to assist individuals with cognitive
impairments in understanding materials
COMPLIANCE PLAN SUBMISSION
1. A description of how the Contractor will advise Enrollees with
disabilities, during the new Enrollee orientation on how to access
care
2. A description of how the Contractor will assist new Enrollees with
disabilities (as well as current Enrollees who acquire a disability)
in selecting or arranging an appointment with a Primary Care
Practitioner (PCP)
- This should include a description of how the Contractor will
assure and provide notice to Enrollees who are deaf or hard of
hearing, blind or who have visual impairments, of their right to
obtain necessary auxiliary aids and services during appointments
and in scheduling appointments and follow-up treatment with
Participating Providers
- In the event that certain provider sites are not physically
accessible to Enrollees with mobility impairments, the Contractor
will assure that reasonable alternative site and services are
available
3. A description of how the Contractor will determine the specific needs
of an Enrollee with or at risk of having a disability/chronic disease,
in terms of specialist physician referrals, durable medical equipment
(including assistive technology and adaptive equipment), medical
supplies and home health services and will assure that such
contractual services are provided
4. A description of how the Contractor will identify if an Enrollee with
a disability requires on-going mental health services and how the
Contractor will encourage early entry into treatment
5. A description of how the Contractor will notify Enrollees with
disabilities as to how to access transportation, where applicable
APPENDIX J
October 1, 2005
J-8
B4. COMPLAINTS, COMPLAINT APPEALS AND ACTION APPEALS
STANDARD FOR COMPLIANCE
The Contractor will establish and maintain a procedure to protect the
rights and interests of both Enrollees and the Contractor by receiving,
processing, and resolving Complaints, Complaint Appeals and Action Appeals
in an expeditious manner, with the goal of ensuring resolution of
Complaints, Complaint Appeals, and Action Appeals and access to appropriate
services as rapidly as possible.
All Enrollees must be informed about the Grievance System within their
Contractor and the procedure for filing Complaints, Complaint Appeals and
Action Appeals. This information will be made available through the Member
Handbook, SDOH toll-free Complaint line (l-(800) 206-8125) and the
Contractor's Complaint process annually, as well as when the Contractor
denies a benefit or referral. The Contractor will inform Enrollees of the
Contractor's Grievance System; Enrollees' right to contact the LDSS or SDOH
with a Complaint, and to file a Complaint Appeal, Action Appeal or request
a fair hearing; the right to appoint a designee to handle a Complaint,
Complaint Appeal or Action Appeal; and the toll free Complaint line. The
Contractor will maintain designated staff to take and process Complaints,
Complaint Appeals and Action Appeals, and be responsible for assisting
Enrollees in Complaint, Complaint Appeal or Action Appeal resolution.
The Contractor will make all information regarding the Grievance System
available to and usable by people with disabilities, and will assure that
people with disabilities have access to sites where Enrollees typically
file Complaints and requests for Complaint Appeals and Action Appeals.
SUGGESTED METHODS FOR COMPLIANCE
1. Toll-free Complaint phone line with TDD/TTY capability
2. Staff trained in Complaint process, and able to provide interpretive
or assistive support to Enrollee during the Complaint process
3. Notification materials and Complaint forms in alternative formats for
Enrollees with visual or hearing impairments
4. Availability of physically accessible sites, e.g. member services
department sites
5. Assistance for individuals with cognitive impairments
APPENDIX J
October 1, 2005
J-9
COMPLIANCE PLAN SUBMISSION
1. A description of how the Contractor's Complaint, Complaint Appeals and
Action Appeal procedures shall be accessible for persons with
disabilities, including:
- procedures for Complaints, Complaint Appeals and Action Appeals
to be made in person at sites accessible to persons with mobility
impairments
- procedures accessible to persons with sensory or other
impairments who wish to make verbal Complaints, Complaint Appeals
or Action Appeals, and to communicate with such persons on an
ongoing basis as to the status or their Complaints and rights to
further appeals
- description of methods to ensure notification material is
available in alternative formats for Enrollees with vision and
hearing impairments
2. A description of how the Contractor monitors Complaints, Complaint
Appeals and Action Appeals related to people with disabilities. Also,
as part of the Compliance Plan, the Contractor must submit a summary
report based on the Contractor's most recent year's Complaints,
Complaint Appeals and Action Appeals data.
C. CASE MANAGEMENT
STANDARD FOR COMPLIANCE
The Contractor must have in place adequate case management systems to
identify the service needs of all Enrollees, including Enrollees with
chronic illness and Enrollees with disabilities, and ensure that medically
necessary covered benefits are delivered on a timely basis. These systems
must include procedures for standing referrals, specialists as PCPs, and
referrals to specialty centers for Enrollees who require specialized
medical care over a prolonged period of time (as determined by a treatment
plan approved by the Contractor in consultation with the primary care
provider, the designated specialist and the Enrollee or his/her designee),
out-of-network referrals and continuation of existing treatment
relationships with out-of-network providers (during transitional period).
SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting specialist physicians to function as PCP
2. Procedures for requesting standing referrals to specialists and/or
specialty centers, out-of-network referrals, and continuation of
existing treatment relationships
3. Procedures to meet Enrollee needs for, durable medical equipment,
medical supplies, home visits as appropriate
APPENDIX J
October 1, 2005
J-10
4. Appropriately trained Contractor staff to function as case managers
for special needs populations, or sub-contract arrangements for case
management
5. Procedures for informing Enrollees about the availability of case
management services
COMPLIANCE PLAN SUBMISSION
1. A description of the Contractor case management program for people
with disabilities, including case management functions, procedures for
qualifying for and being assigned a case manager, and description of
case management staff qualifications
2. A description of the Contractor's model protocol to enable
Participating Providers, at their point of service, to identify
Enrollees who require a case manager
3. A description of the Contractor's protocol for assignment of
specialists as PCP, and for standing referrals to specialists and
specialty centers, out-of-network referrals and continuing treatment
relationships
4. A description of the Contractor's notice procedures to Enrollees
regarding the availability of case management services, specialists as
PCPs, standing referrals to specialists and specialty centers,
out-of-network referrals and continuing treatment relationships
D. PARTICIPATING PROVIDERS
STANDARD FOR COMPLIANCE
The Contractor's network will include all the provider types necessary to
furnish the Benefit Package, to assure appropriate and timely health care
to all Enrollees, including those with chronic illness and/or disabilities.
Physical accessibility is not limited to entry to a provider site, but also
includes access to services within the site, e.g., exam tables and medical
equipment.
SUGGESTED METHODS FOR COMPLIANCE
1. Process for the Contractor to evaluate provider network to ascertain
the degree of provider accessibility to persons with disabilities, to
identify barriers to access and required modifications to
policies/procedures
2. Model protocol to assist Participating Providers, at their point of
service, to identify Enrollees who require case manager, audio,
visual, mobility aids, or other accommodations
3. Model protocol for determining needs of Enrollees with mental
disabilities
4. Use of Wheelchair Accessibility Certification Form (see attached)
5. Submission of map of physically accessible sites
APPENDIX J
October 1, 2005
J-11
6. Training for providers re: compliance with Title III of ADA, e.g. site
access requirements for door widths, wheelchair ramps, accessible
diagnostic/treatment rooms and equipment; communication issues;
attitudinal barriers related to disability, etc. (Resources and
technical assistance are available through the NYS Office of Advocate
for Persons with Disabilities -V/TTY (800) 522-4369; and the NYC
Mayor's Office for People with Disabilities - (212) 788-2830 or TTY
(212) 788-2838).
7. Use of NYS Office of Persons with Disabilities (OAPD) ADA
Accessibility Checklist for Existing Facilities and NYC Addendum to
OAPD ADA Accessibility Checklist as guides for evaluating existing
facilities and for new construction and/or alteration.
COMPLIANCE PLAN SUBMISSION
1. A description of how the Contractor will ensure that its Participating
Provider network is accessible to persons with disabilities. This
includes the following:
- Policies and procedures to prevent discrimination on the basis of
disability or type of illness or condition
- Identification of Participating Provider sites which are
accessible by people with mobility impairments, including people
using mobility devices. If certain provider sites are not
physically accessible to persons with disabilities, the
Contractor shall describe reasonable, alternative means that
result in making the provider services readily accessible
- Identification of Participating Provider sites which do not have
access to sign language interpreters or reasonable alternative
means to communicate with Enrollees who are deaf or hard of
hearing; and for those sites, a description of reasonable
alternative methods to ensure that services will be made
accessible
- Identification of Participating Providers which do not have
adequate communication systems for Enrollees who are blind or
have vision impairments (e.g. raised symbol and lettering or
visual signal appliances), and for those sites, a description of
reasonable alternative methods to ensure that services will be
made accessible
2. A description of how the Contractor's specialty network is sufficient
to meet the needs of Enrollees with disabilities
3. A description of methods to ensure the coordination of out-of-network
providers to meet the needs of the Enrollees with disabilities
- This may include the implementation of a referral system to
ensure that the health care needs of Enrollees with disabilities
are met appropriately
- The Contractor shall describe policies and procedures to allow
for the continuation of existing relationships with
out-of-network providers, when in the best interest of the
Enrollee with a disability
APPENDIX J
October 1, 2005
J-12
4. Submission of the ADA Compliance Summary Report or Contractor
statement that data submitted to SDOH on the Health Provider Network
(HPN) files is an accurate reflection of each network's physical
accessibility.
E. POPULATIONS WITH SPECIAL HEALTH CARE NEEDS
STANDARD FOR COMPLIANCE
The Contractor will have satisfactory methods for identifying persons at
risk of, or having, chronic disabilities and determining their specific
needs in terms of specialist physician referrals, durable medical
equipment, medical supplies, home health services, etc. The Contractor will
have satisfactory systems for coordinating service delivery and, if
necessary, procedures to allow continuation of existing relationships with
out-of-network provider for course of treatment.
SUGGESTED METHODS FOR COMPLIANCE
1. Procedures for requesting standing referrals to specialists and/or
specialty centers, specialist physicians to function as PCP,
out-of-network referrals, and continuation of existing relationships
with out-of-network providers for course of treatment
2. Linkages with behavioral health agencies, disability and advocacy
organizations, etc.
3. Adequate network of providers and sub-specialists (including pediatric
providers and sub-specialists) and contractual relationships with
tertiary institutions
4. Procedures for assuring that these populations receive appropriate
diagnostic work-ups on a timely basis
5. Procedures for assuring that these populations receive appropriate
access to durable medical equipment on a timely basis
6. Procedures for assuring that these populations receive appropriate
allied health professionals (Physical, Occupational and Speech
Therapists, Audiologists) on a timely basis
7. State designation as a Well Qualified Plan to serve the OMRDD
population and look-alikes
COMPLIANCE PLAN SUBMISSION
1. A description of arrangements to ensure access to specialty care
providers and centers in and out of New York State, standing
referrals, specialist physicians to function as PCP, out-of-network
referrals, and continuation of existing relationships (out-of-network)
for diagnosis and treatment of rare disorders
2. A description of appropriate service delivery for children with
disabilities. This may include a description of methods for
interacting with school
APPENDIX J
October 1, 2005
J-13
districts, child protective service agencies, early intervention
officials, behavioral health, and disability and advocacy
organizations.
3. A description of the sub-specialist network, including contractual
relationships with tertiary institutions to meet the health care needs
of people with disabilities
F. ADDITIONAL ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS
Please note that Title III of the ADA applies to all non-governmental
providers of health care. Title III of the Americans with Disabilities Act
prohibits discrimination on the basis of disability in the full and equal
enjoyment of goods, services, facilities, privileges, advantages or
accommodations of any place of public accommodation. A public accommodation
is a private entity that owns, leases or leases to, or operates a place of
public accommodation. Places of public accommodation identified by the ADA
include, but are not limited to, stores (including pharmacies) offices
(including doctors' offices), hospitals, health care providers, and social
service centers.
New and altered areas and facilities must be as accessible as possible.
Barriers must be removed from existing facilities when it is readily
achievable, defined by the ADA as easily accomplishable without much
difficulty or expense. Factors to be considered when determining if barrier
removal is readily achievable include the cost of the action, the financial
resources of the site involved, and, if applicable, the overall financial
resources of any parent corporation or entity. If barrier removal is not
readily achievable, the ADA requires alternate methods of making goods and
services available. New facilities must be accessible unless structurally
impracticable.
Title III also requires places of public accommodation to provide any
auxiliary aids and services that are needed to ensure equal access to the
services it offers, unless a fundamental alteration in the nature of
services or an undue burden would result. Auxiliary aids include, but are
not limited to, qualified sign interpreters, assistive listening systems,
readers, large print materials, etc. Undue burden is defined as
"significant difficulty or expense". The factors to be considered in
determining "undue burden" include, but are not limited to, the nature and
cost of the action required and the overall financial resources of the
provider. "Undue burden" is a higher standard than "readily achievable" in
that it requires a greater level of effort on the part of the public
accommodation.
APPENDIX J
October 1, 2005
J-14
Please note also that the ADA is not the only law applicable for people
with disabilities. In some cases, State or local laws require more than the
ADA. For example, New York City's Human Rights Law, which also prohibits
discrimination against people with disabilities, includes people whose
impairments are not as "substantial" as the narrower ADA and uses the
higher "undue burden" ("reasonable") standard where the ADA requires only
that which is "readily achievable". New York City's Building Code does not
permit access waivers for newly constructed facilities and requires
incorporation of access features as existing facilities are renovated.
Finally, the State Hospital code sets a higher standard than the ADA for
provision of communication (such as sign language interpreters) for
services provided at most hospitals, even on an outpatient basis.
APPENDIX J
October 1, 2005
J-15
APPENDIX K
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND
NON-COVERED SERVICES
K.1 CHART OF PREPAID BENEFIT PACKAGE
- MEDICAID MANAGED CARE NON-SSI (MMC NON-SSI)
- MEDICAID MANAGED CARE SSI (MMC SSI)
- MEDICAID FEE-FOR-SERVICE (MFFS)
- FAMILY HEALTH PLUS (FHPLUS)
K.2 PREPAID BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES
K.3 MEDICAID MANAGED CARE DEFINITIONS OF NON-COVERED SERVICES
K.4 FAMILY HEALTH PLUS NON-COVERED SERVICES
APPENDIX K
October 1, 2005
K-l
APPENDIX K
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED AND NON-COVERED SERVICES
1. GENERAL
a) The categories of services in the Medicaid Managed Care and Family
Health Plus Benefit Packages, including optional-covered services
shall be provided by the Contractor to MMC Enrollees and FHPlus
Enrollees, respectively, when medically necessary under the terms of
this Agreement. The definitions of covered and non-covered services
herein are in summary form; the full description and scope of each
covered service as established by the New York Medical Assistance
Program are set forth in the applicable NYS Medicaid Provider Manual,
except for the Eye Care and Vision benefit for FHPlus Enrollees which
is described in Section 19 of Appendix K.2.
b) All care provided by the Contractor, pursuant to this Agreement, must
be provided, arranged, or authorized by the Contractor or its
Participating Providers with the exception of most behavioral health
services to SSI or SSI related beneficiaries, and emergency services,
emergency transportation, Family Planning and Reproductive Health
services, mental health and chemical dependence assessments (one (1)
of each per year), court ordered services, and services provided by
Local Public Health Agencies as described in Section 10 of this
Agreement.
c) This Appendix contains the following sections:
i) K.1 - "Chart of Prepaid Benefit Package" lists the services
provided by the Contractor to all Medicaid Managed Care Non-SSI
Enrollees, Medicaid Managed Care SSI Enrollees, Medicaid
fee-for-service coverage for carved out and wraparound benefits,
and Family Health Plus Enrollees.
ii) K.2 - "Prepaid Benefit Package Definitions Of Covered Services"
describes the covered services, as numbered in K.1. Each service
description applies to both MMC and FHPlus Benefit Package unless
otherwise noted.
iii) K.3 - "Medicaid Managed Care Definitions of Non-Covered Services"
describes services that are not covered by the MMC Benefit
Package. These services are covered by the Medicaid
fee-for-service program unless otherwise noted.
iv) K.4 - "Family Health Plus Non-Covered Services" lists the
services that are not covered by the FHPlus Benefit Package.
There is no Medicaid fee-for-service coverage available for any
service outside of the FHPlus Benefit Package.
APPENDIX K
October 1, 2005
K-2
K.1
PREPAID BENEFIT PACKAGE
* COVERED SERVICES MMC NON-SSI MMC SSI MFFS FHPLUS **
- --- ---------------- ----------- ------- ---- ---------
1. Inpatient Hospital Services Covered, unless Covered, unless Stay covered only Covered, unless
admit date precedes admit date precedes when admit date admit date precedes
Effective Date of Effective Date of precedes Effective Effective Date
Enrollment (see Enrollment (see Date of Enrollment of Enrollment (see
Section 6.8 of this Section 6.8 of this (see Section 6.8 Section 6.8 of this
Agreement) Agreement) of this Agreement) Agreement)
2. Inpatient Stay Pending Covered Covered Covered
Alternate Level of Medical
Care
3. Physician Services Covered Covered Covered
4. Nurse Practitioner Services Covered Covered Covered
5. Midwifery Services Covered Covered Covered
6. Preventive Health Services Covered Covered Covered
7. Second Medical/Surgical Covered Covered Covered
Opinion
8. Laboratory Services Covered Covered HIV phenotypic, Covered
virtual phenotypic
and genotypic drug
resistance tests
9. Radiology Services Covered Covered Covered
10. Prescription and Pharmaceuticals and Pharmaceuticals and Covered outpatient Covered, may be
Non-Prescription (OTC) medical supplies medical supplies drugs from the limited to generic.
Drugs, Medical Supplies, routinely furnished routinely furnished list of Medicaid Vitamins (except
and Enteral Formula or administered as or administered as reimbursable to treat an illness
part of a clinic or part of a clinic or prescription or condition), OTCs,
office visit office visit drugs, subject to and medical
any applicable supplies are not
co-payments covered
11. Smoking Cessation Products Covered Covered
12. Rehabilitation Services Covered Covered Covered for short
term inpatient, and
limited to 20
visits per calendar
year for outpatient
PT and OT
13. EPSDT Services/Child Teen Covered Covered Covered
Health Program (C/THP)
* See K_2 for Scope of Benefits
Note: If cell is blank, there is no coverage.
** No Medicaid fee-for service-wrap around is available. Subject to applicable
co-pays.
APPENDIX K
October 1, 2005
K-3
* COVERED SERVICES MMC NON-SSI MMC SSI MFFS FHPLUS **
- --- ---------------- ----------- ------- ---- ---------
14. Home Health Services Covered Covered Covered for 40
visits in lieu of a
skilled nursing
facility stay or
hospitalization,
plus 2 post partum
home visits for
high risk women
15 Private Duty Nursing Covered Covered Not covered
Services
16 Hospice Covered Covered
17. Emergency Services Covered Covered Covered
Post-Stabilization Care Covered Covered Covered
Services (see also Appendix
G of this Agreement)
18. Foot Care Services Covered Covered Covered
19. Eye Care and Low Vision Covered Covered Covered
Services
20. Durable Medical Equipment Covered Covered Covered
(DME)
21. Audiology, Hearing Aids Covered except for Covered except for Hearing aid Covered including
Services & Products hearing aid hearing aid batteries hearing aid
batteries batteries batteries
22. Family Planning and Covered if included Covered if included Covered pursuant Covered if included
Reproductive Health in Contractor's in Contractor's to Appendix C of in Contractor's
Services Benefit Package as Benefit Package as Agreement Benefit Package as
per Appendix M of per Appendix M of per Appendix M of
this Agreement this Agreement this Agreement or
through the DTP
Contractor
23. Non-Emergency Covered if included Covered if included Covered if not Not Covered, except
Transportation in Contractor's in Contractor's included in for transportation
Benefit Package as Benefit Package as Contractor's to C/THP services
per Appendix M of per Appendix M of Benefit Package for 19 and 20
this Agreement this Agreement year olds
24 Emergency Transportation Covered if included Covered if included Covered if not Covered
in Contractor's in Contractor's included in
Benefit Package as Benefit Package as Contractor's
per Appendix M of per Appendix M of Benefit Package
this Agreement this Agreement
* See K_2 for Scope of Benefits
Note: If cell is blank, there is no coverage.
** No Medicaid fee-for service-wrap around is available. Subject to applicable
co-pays.
APPENDIX K
October 1, 2005
K-4
* COVERED SERVICES MMC NON-SSI MMC SSI MFFS FHPLUS **
- --- ---------------- ----------- ------- ---- ---------
25. Dental Services Covered if included Covered if included Covered if not Covered, if included
in Contractor's in Contractor's included in the in Contractor's
Benefit Package as Benefit Package as Contractor's Benefit Package as
per Appendix M of per Appendix M of Benefit Package, per Appendix M of
this Agreement, this Agreement, Orthodonita in all this Agreement,
except orthodonita except orthodonita instances excluding orthodontia
26. Court-Ordered Services Covered, pursuant Covered, pursuant Covered, pursuant
to court order (see to court order (see to court order (see
also Section 10.9 also Section 10.9 also Section 10.9
of this Agreement) of this Agreement) of this Agreement)
27. Prosthetic/Orthotic Covered Covered Covered, except
Services/Orthopedic orthopedic shoes
Footwear
28. Mental Health Services Covered subject to Covered for SSI Covered subject to
stop loss Enrollees calendar year
benefit limit of 30
days inpatient, 60
visits outpatient,
combined with
chemical dependency
services
29. Detoxification Services Covered Covered Covered
30. Chemical Dependence Covered subject to Covered for SSI Covered subject to
Inpatient Rehabilitation stop loss recipients calendar year
and Treatment Services benefit limit 30
days combined with
mental health
services
31 Chemical Dependence Covered Covered subject to
Outpatient calendar year
benefit limits of
60 visits combined
with mental health
services
32. Experimental and/or Covered on a case Covered on a case Covered on a case
Investigational Treatment by case basis by case basis by case basis
33. Renal Dialysis Covered Covered Covered
34. Residential Health Care Coveredsubject to Coveredsubject to
Facility Services (RHCF) stop loss, except stop loss, except
for individuals in for individuals in
permanent placement permanent placement
* See K_2 for Scope of Benefits
Note: If cell is blank, there is no coverage.
** No Medicaid fee-for service-wrap around is available. Subject to applicable
co-pays.
APPENDIX K
October 1, 2005
K-5
K.2
PREPAID BENEFIT PACKAGE
DEFINITIONS OF COVERED SERVICES
SERVICE DEFINITIONS IN THIS SECTION PERTAIN TO BOTH MMC AND FHPLUS UNLESS
OTHERWISE INDICATED.
1. INPATIENT HOSPITAL SERVICES
Inpatient hospital services, as medically necessary, shall include, except
as otherwise specified, the care, treatment, maintenance and nursing
services as may be required, on an inpatient hospital basis, up to 365 days
per year (366 days in leap year). The Contractor will not be responsible
for hospital stays that commence prior to the Effective Date of Enrollment
(see Section 6.8 of this Agreement), but will be responsible for stays that
commence prior to the Effective Date of Disenrollment (see Section 8.5 of
this Agreement). Among other services, inpatient hospital services
encompass a full range of necessary diagnostic and therapeutic care
including medical, surgical, nursing, radiological, and rehabilitative
services. Services are provided under the direction of a physician,
certified nurse practitioner, or dentist.
2. INPATIENT STAY PENDING ALTERNATE LEVEL OF MEDICAL CARE
Inpatient stay pending alternate level of medical care, or continued care
in a hospital pending placement in an alternate lower medical level of
care, consistent with the provisions of 18 NYCRR Section 505.20 and 10
NYCRR Part 85.
3. PHYSICIAN SERVICES
a) "Physician services," whether furnished in the office, the Enrollee's
home, a hospital, a skilled nursing facility, or elsewhere, means
services furnished by a physician:
i) within the scope of practice of medicine as defined in law by the
New York State Education Department; and
ii) by or under the personal supervision of an individual licensed
and currently registered by the New York State Education
Department to practice medicine.
b) Physician services include the full range of preventive care services,
primary care medical services and physician specialty services that
fall within a physician's scope of practice under New York State law.
c) The following are also included without limitations:
i) pharmaceuticals and medical supplies routinely furnished or
administered as part of a clinic or office visit;
APPENDIX K
October 1, 2005
K-6
ii) physical examinations, including those which are necessary for
employment, school, and camp;
iii) physical and/or mental health, or chemical dependence
examinations of children and their parents as requested by the
LDSS to fulfill its statutory responsibilities for the protection
of children and adults and for children in foster care;
iv) health and mental health assessments for the purpose of making
recommendations regarding a Enrollee's disability status for
Federal SSI applications;
v) health assessments for the Infant/Child Assessment Program
(ICHAP);
vi) annual preventive health visits for adolescents;
vii) new admission exams for school children if required by the LDSS;
viii)health screening, assessment and treatment of refugees, including
completing SDOH/LDSS required forms;
ix) Child/Teen Health Program (C/THP) services which are
comprehensive primary health care services provided to persons
under twenty-one (21) years of age (see Section 10.4 of this
Agreement).
4. CERTIFIED NURSE PRACTITIONER SERVICES
a) Certified nurse practitioner services include preventive services, the
diagnosis of illness and physical conditions, and the performance of
therapeutic and corrective measures, within the scope of the certified
nurse practitioner's licensure and collaborative practice agreement
with a licensed physician in accordance with the requirements of the
NYS Education Department.
b) The following services are also included in the certified nurse
practitioner's scope of services, without limitation:
i) Child/Teen Health Program(C/THP) services which are comprehensive
primary health care services provided to persons under twenty-one
(21) (see Item 13 of this Appendix and Section 10.4 of this
Agreement);
ii) Physical examinations, including those which are necessary for
employment, school and camp.
APPENDIX K
October 1, 2005
K-7
5. MIDWIFERY SERVICES
SSA Section 1905 (a)(17), Education Law Section 6951(i).
Midwifery services include the management of normal pregnancy, childbirth
and postpartum care as well as primary preventive reproductive health care
to essentially healthy women as specified in a written practice agreement
and shall include newborn evaluation, resuscitation and referral for
infants. The care may be provided on an inpatient or outpatient basis,
including in a birthing center or in the Enrollee's home as appropriate.
The midwife must be licensed by the NYS Education Department.
6. PREVENTIVE HEALTH SERVICES
a) Preventive health services means care and services to avert
disease/illness and/or its consequences. There are three (3) levels of
preventive health services: 1) primary, such as immunizations, aimed
at preventing disease; 2) secondary, such as disease screening
programs aimed at early detection of disease; and 3) tertiary, such as
physical therapy, aimed at restoring function after the disease has
occurred. Commonly, the term "preventive care" is used to designate
prevention and early detection programs rather than restorative
programs.
b) The Contractor must offer the following preventive health services
essential for promoting and preventing illness:
i) General health education classes.
ii) Pneumonia and influenza immunizations for at risk populations.
iii) Smoking cessation classes, with targeted outreach for adolescents
and pregnant women.
iv) Childbirth education classes.
v) Parenting classes covering topics such as bathing, feeding,
injury prevention, sleeping, illness prevention, steps to follow
in an emergency, growth and development, discipline, signs of
illness, etc.
vi) Nutrition counseling, with targeted outreach for diabetics and
pregnant women.
vii) Extended care coordination, as needed, for pregnant women.
viii) HIV counseling and testing.
7. SECOND MEDICAL/SURGICAL OPINIONS
The Contractor will allow Enrollees to obtain second opinions for diagnosis
of a condition, treatment or surgical procedure by a qualified physician or
appropriate specialist, including one affiliated with a specialty care
center. In the event that the Contractor determines that it does not have a
Participating Provider in its network with appropriate training and
experience qualifying the Participating Provider to provide a second
opinion, the Contractor shall make a referral to an appropriate
Non-Participating Provider. The Contractor shall pay for the cost of the
services associated with obtaining a second opinion regarding medical or
surgical care, including diagnostic and evaluation services, provided by
the Non-Participating Provider.
APPENDIX K
October 1, 2005
K-8
8. LABORATORY SERVICES
18 NYCRR Section 505.7(a)
a) Laboratory services include medically necessary tests and
procedures ordered by a qualified medical professional and listed
in the Medicaid fee schedule for laboratory services.
b) All laboratory testing sites providing services under this
Agreement must have a permit issued by the New York State
Department of Health and a Clinical Laboratory Improvement Act
(CLIA) certificate of waiver, a physician performed microscopy
procedures (PPMP) certificate, or a certificate of registration
along with a CLIA identification number. Those laboratories with
certificates of waiver or a PPMP certificate may perform only
those specific tests permitted under the terms of their waiver.
Laboratories with certificates of registration may perform a full
range of laboratory tests for which they have been certified.
Physicians providing laboratory testing may perform only those
specific limited laboratory procedures identified in the
Physician's NYS Medicaid Provider Manual.
c) For MMC only: coverage for HIV phenotypic, HIV virtual phenotypic
and HIV genotypic drug resistance tests are covered by Medicaid
fee-for-service.
9. RADIOLOGY SERVICES
18 NYCRR Section 505.17(c)(7)(d)
Radiology services include medically necessary services provided by
qualified practitioners in the provision of diagnostic radiology,
diagnostic ultrasound, nuclear medicine, radiation oncology, and
magnetic resonance imaging (MRI). These services may only be performed
upon the order of a qualified practitioner.
10. PRESCRIPTION AND NON-PRESCRIPTION (OTC) DRUGS, MEDICAL SUPPLIES AND
ENTERAL FORMULAS
a) For Medicaid fee-for-service only: Medically necessary
prescription and non-prescription (OTC) drugs, medical supplies
and enteral formula are covered when ordered by a qualified
provider.
b) MMC Enrollees are covered for prescription drugs through the
Medicaid fee-for-service program. Pharmaceuticals and medical
supplies routinely furnished or administered as part of a clinic
or office visit are covered by the MMC Program. Self-administered
injectable drugs (including those administered by a family
member) and injectable drugs administered during a home care
visit are covered by Medicaid fee-for-service if the drug is on
the list of Medicaid reimbursable prescription drugs or covered
by the Contractor, subject to medical necessity, if the drug is
not on the list of Medicaid reimbursable prescription drugs.
APPENDIX K
October 1, 2005
K-9
c) For Family Health Plus only:
i) Prescription drugs are covered, but may be limited to
generic medications where medically acceptable. All
medications used for preventive and therapeutic purposes are
covered, as well as family planning or contraceptive
medications or devices.
ii) Coverage includes enteral formulas for home use for which a
physician or other provider authorized to prescribe has
issued a written order. Enteral formulas for the treatment
of specific diseases shall be distinguished from nutritional
supplements taken electively. Coverage for certain inherited
diseases of amino acid and organic acid metabolism shall
include modified solid food products that are low-protein or
which contain modified protein. Vitamins are not covered
except when necessary to treat a diagnosed illness or
condition.
iii) Experimental and/or investigational drugs are generally
excluded, except where approved in the course of
experimental/investigational treatment.
iv) Drugs prescribed for cosmetic purposes are excluded.
v) Over-the-counter items are excluded with the exception of
diabetic supplies, including insulin and smoking cessation
agents. Non-prescription (OTC) drugs and medical supplies
are not covered.
11. SMOKING CESSATION PRODUCTS
a) MMC Enrollees are covered for smoking cessation products through
the Medicaid fee-for-service program.
b) For Family Health Plus only: At least two courses of smoking
cessation therapy per person per year, as medically necessary are
covered. A course of therapy is defined as no more than a ninety
(90)day supply (an original prescription and two (2) refills,
even if less than a thirty (30)day supply is dispensed in any
fill). Duplicative use of one agent is not allowed (i.e., same
drug/same dosage form/same strength). Both prescription and
over-the-counter therapies/agents are covered; this includes
nicotine patches, inhalers, nasal sprays, gum, and Zyban
(bupropion).
12. REHABILITATION SERVICES
18 NYCRR Section 505.11
a) Rehabilitation services are provided for the maximum reduction of
physical or mental disability and restoration of the Enrollee to
his or her best functional level. Rehabilitation services include
care and services rendered by physical therapists,
speech-language pathologists and occupational therapists.
Rehabilitation services may be provided in an Article 28
inpatient or outpatient facility, in an Enrollee's home, in an
approved home health agency, in the office of a qualified private
practicing therapist or speech pathologist, or for a child in a
school, pre-school or
APPENDIX K
October 1, 2005
K-10
community setting, or in a Residential Health Care Facility
(RHCF) as long as the Enrollee's stay is classified as a
rehabilitative stay and meets the requirements for covered RHCF
services as defined herein. For the MMC Program, rehabilitation
services provided in Residential Health Care Facilities are
subject to the stop-loss provisions specified in Section 3.13 of
this Agreement. Rehabilitation services are covered as medically
necessary, when ordered by the Contractor's Participating
Provider.
b) For Family Health Plus only: Outpatient visits for physical and
occupational therapy is limited to twenty (20) visits per
calendar year. Coverage for speech therapy services is limited to
those required for a condition amenable to significant clinical
improvement within a two month period.
13. EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT)
SERVICES THROUGH THE CHILD TEEN HEALTH PROGRAM (C/THP) AND ADOLESCENT
PREVENTIVE SERVICES
18 NYCRR Section 508.8
Child/Teen Health Program (C/THP) is a package of early and periodic
screening, including inter-periodic screens and, diagnostic and
treatment services that New York State offers all Medicaid eligible
children under twenty-one (21) years of age. Care and services shall
be provided in accordance with the periodicity schedule and guidelines
developed by the New York State Department of Health. The care
includes necessary health care, diagnostic services, treatment and
other measures (described in Section 1905(a) of the Social Security
Act) to correct or ameliorate defects, and physical and mental
illnesses and conditions discovered by the screening services
(regardless of whether the service is otherwise included in the New
York State Medicaid Plan). The package of services includes
administrative services designed to assist families obtain services
for children including outreach, education, appointment scheduling,
administrative case management and transportation assistance.
14. HOME HEALTH SERVICES
18 NYCRR Section 505.23(a)(3)
a) Home health care services are provided to Enrollees in their
homes by a home health agency certified under Article 36 of the
PHL (Certified Home Health Agency - CHHA). Home health services
mean the following services when prescribed by a Provider and
provided to a Enrollee in his or her home:
i) nursing services provided on a part-time or intermittent
basis by a CHHA or, if there is no CHHA that services the
county/district, by a registered professional nurse or a
licensed practical nurse acting under the direction of the
Enrollee's PCP;
ii) physical therapy, occupational therapy, or speech pathology
and audiology services; and
APPENDIX K
October 1, 2005
K-11
iii) home health services provided by a person who meets the training
requirements of the SDOH, is assigned by a registered
professional nurse to provide home health aid services in
accordance with the Enrollee's plan of care, and is supervised by
a registered professional nurse from a CHHA or if the Contractor
has no CHHA available, a registered nurse, or therapist.
b) Personal care tasks performed by a home health aide incidental to a
certified home health care agency visit, and pursuant to an
established care plan, are covered.
c) Services include care rendered directly to the Enrollee and
instructions to his/her family or caretaker such as teacher or day
care provider in the procedures necessary for the Enrollee's treatment
or maintenance.
d) The Contractor must provide up to two (2) post partum home visits for
high risk infants and/or high risk mothers, as well as to women with
less than a forty-eight (48) hour hospital stay after a vaginal
delivery or less than a ninety-six (96) hour stay after a cesarean
delivery. Visits must be made by a qualified health professional
(minimum qualifications being an RN with maternal/child health
background), the first visit to occur within forty-eight (48) hours of
discharge.
e) For Family Health Plus only: coverage is limited to forty (40) home
health care visits per calendar year in lieu of a skilled nursing
facility stay or hospitalization. Post partum home visits apply only
to high risk mothers. For the purposes of this Section, visit is
defined as the delivery of a discreet service (e.g. nursing, OT, PT,
ST, audiology or home health aide). Four (4) hours of home health aide
services equals one visit.
15. PRIVATE DUTY NURSING SERVICES - FOR MMC PROGRAM ONLY
a) Private duty nursing services shall be provided by a person possessing
a license and current registration from the NYS Education Department
to practice as a registered professional nurse or licensed practical
nurse. Private duty nursing services can be provided through an
approved certified home health agency, a licensed home care agency, or
a private Practitioner. The location of nursing services may be in the
MMC Enrollee's home or in the hospital.
b) Private duty nursing services are covered only when determined by the
attending physician to be medically necessary. Nursing services may be
intermittent, part-time or continuous and provided in accordance with
the ordering physicians, or certified nurse practitioner's written
treatment plan.
16. HOSPICE SERVICES
a) Hospice Services means a coordinated hospice program of home and
inpatient services which provide non-curative medical and support
services for Enrollees certified by a physician to be terminally ill
with a life expectancy of six (6) months or less.
APPENDIX K
October 1, 2005
K-12
b) Hospice services include palliative and supportive care provided to an
Enrollee to meet the special needs arising out of physical,
psychological, spiritual, social and economic stress which are
experienced during the final stages of illness and during dying and
bereavement. Hospices must be certified under Article 40 of the New
York State Public Health Law. All services must be provided by
qualified employees and volunteers of the hospice or by qualified
staff through contractual arrangements to the extent permitted by
federal and state requirements. All services must be provided
according to a written plan of care which reflects the changing needs
of the Enrollee and the Enrollee's family. Family members are eligible
for up to five visits for bereavement counseling.
c) Medicaid Managed Care Enrollees receive coverage for hospice services
through the Medicaid fee-for-service program.
17. EMERGENCY SERVICES
a) Emergency conditions, medical or behavioral, the onset of which is
sudden, manifesting itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, possessing an average
knowledge of medicine and health, could reasonably expect the absence
of medical attention to result in (a) placing the health of the person
afflicted with such condition in serious jeopardy, or in the case of a
behavioral condition, placing the health of such person or others in
serious jeopardy; (b) serious impairment of such person's bodily
functions; (c) serious dysfunction of any bodily organ or part of such
person; or (d) serious disfigurement of such person are covered.
Emergency services include health care procedures, treatments or
services needed to evaluate or stabilize an Emergency Medical
Condition including psychiatric stabilization and medical
detoxification from drugs or alcohol. A medical assessment (triage) is
covered for non-emergent conditions. See also Appendix G of this
Agreement.
b) Post Stabilization Care Services means services related to an
emergency medical condition that are provided after an Enrollee is
stabilized in order to maintain the stabilized condition, or to
improve or resolve the Enrollee's condition. These services are
covered pursuant to Appendix G of this Agreement.
18. FOOT CARE SERVICES
a) Covered services must include routine foot care when the physical
condition of any Enrollee (regardless of age) poses a hazard due to
the presence of localized illness, injury or symptoms involving the
foot, or when performed as a necessary and integral part of otherwise
covered services such as the diagnosis and treatment of diabetes,
ulcers, and infections.
b) Services provided by a podiatrist for persons under twenty-one (21)
must be covered upon referral of a physician, registered physician
assistant, certified nurse practitioner or licensed midwife.
APPENDIX K
October 1, 2005
K-13
c) Routine hygienic care of the feet, the treatment of corns and
calluses, the trimming of nails, and other hygienic care such as
cleaning or soaking feet, is not covered in the absence of a
pathological condition.
APPENDIX K
October 1, 2005
K-14
19. EYE CARE AND LOW VISION SERVICES
18 NYCRR Section 505.6(b)(l-3)
SSL Section 369-ee(l)(e)(xii)
a) For Medicaid Managed Care only:
i) Emergency, preventive and routine eye care services are covered.
Eye care includes the services of ophthalmologists, optometrists
and ophthalmic dispensers, and includes eyeglasses, medically
necessary contact lenses and polycarbonate lenses, artificial
eyes (stock or custom-made), low vision aids and low vision
services. Eye care coverage includes the replacement of lost or
destroyed eyeglasses. The replacement of a complete pair of
eyeglasses must duplicate the original prescription and frames.
Coverage also includes the repair or replacement of parts in
situations where the damage is the result of causes other than
defective workmanship. Replacement parts must duplicate the
original prescription and frames. Repairs to, and replacements
of, frames and/or lenses must be rendered as needed.
ii) If the Contractor does not provide upgraded eyeglass frames or
additional features (such as scratch coating, progressive lenses
or photo-gray lenses) as part of its covered vision benefit, the
Contractor cannot apply the cost of its covered eyeglass benefit
to the total cost of the eyeglasses the Enrollee wants and bill
only the difference to the Enrollee. The Enrollee can choose to
purchase the upgraded frames and/or additional features by paying
the entire cost of the eyeglasses as a private customer. For
example, if the Contractor covers standard bifocal eyeglasses and
the Enrollee wants no-line bifocal eyeglasses, the Enrollee must
choose between taking the standard bifocal eyeglasses or paying
the full price of the no-line bifocal eyeglasses (not just the
difference between the cost of biofocal lenses and the no-line
lenses). The Enrollee must be informed of this fact by the vision
care provider at the time that the glasses are ordered.
iii) Examinations for diagnosis and treatment for visual defects
and/or eye disease are provided only as necessary and as required
by the Enrollee's particular condition. Examinations which
include refraction are limited to once every twenty four (24)
months unless otherwise justified as medically necessary.
iv) Eyeglasses do not require changing more frequently than once
every twenty four (24) months unless medically indicated, such as
a change in correction greater than 1/2 diopter, or unless the
glasses are lost, damaged, or destroyed.
v) An ophthalmic dispenser fills the prescription of an optometrist
or ophthalmologist and supplies eyeglasses or other vision aids
upon the order of a qualified practitioner.
vi) MMC Enrollees may self-refer to any Participating Provider of
vision services (optometrist or ophthalmologist) for refractive
vision services not more frequently than once every twenty four
(24) months, or if otherwise justified as
APPENDIX K
October 1, 2005
K-15
medically necessary or if eyeglasses are lost, damaged or
destroyed as described above.
b) For Family Health Plus only:
i) Covered Services include emergency vision care and the following
preventive and routine vision care provided once in any
twenty-four (24) month period:
A) one eye examination;
B) either: one pair of prescription eyeglass lenses and a
frame, or prescription contact lenses where medically
necessary; and
C) one pair of medically necessary occupational eyeglasses.
ii) An ophthalmic dispenser fills the prescription of an optometrist
or ophthalmologist and supplies eyeglasses or other vision aids
upon the order of a qualified practitioner.
iii) FHPlus Enrollees may self-refer to any Participating Provider of
vision services (optometrist or ophthalmologist) for refractive
vision services not more frequently than once every twenty four
(24) months.
iv) If the Contractor does not provide upgraded frames or additional
features that the Enrollee wants (such as scratch coating,
progressive lenses or photo-gray lenses) as part of its covered
vision benefit, the Contractor cannot apply the cost of its
covered eyeglass benefit to the total cost of the eyeglasses the
Enrollee wants and bill only the difference to the Enrollee. The
Enrollee can choose to purchase the upgraded frames and/or
additional features by paying the entire cost of the eyeglasses
as a private customer. For example, if the Contractor covers
standard bifocal eyeglasses and the Enrollee wants no-line
bifocal eyeglasses, the Enrollee must choose between taking the
standard bifocal glasses or paying the full price for the no-line
bifocal eyeglasses (not just the difference between the cost of
bifocal lenses and no-line lenses). The Enrollee must be informed
of this fact by the vision care provider at the time that the
glasses are ordered.
v) Contact lenses are covered only when medically necessary. Contact
lenses shall not be covered solely because the FHPlus Enrollee
selects contact lenses in lieu of receiving eyeglasses.
vi) Coverage does not include the replacement of lost, damaged or
destroyed eyeglasses.
vii) The occupational vision benefit for FHPlus Enrollees covers the
cost of job-related eyeglasses if that need is determined by a
Participating Provider through special testing done in
conjunction with a regular vision examination. Such examination
shall determine whether a special pair of eyeglasses would
improve the performance of job-related activities. Occupational
eyeglasses can be provided in addition to regular glasses but are
available only in conjunction with
APPENDIX K
October 1, 2005
K-16
a regular vision benefit once in any twenty-four (24) month
period. FHPlus Enrollees may purchase an upgraded frame or lenses
for occupational eyeglasses by paying the entire cost as a
private customer. Sun-sensitive and polarized lens options are
not available for occupational eyeglasses.
20. DURABLE MEDICAL EQUIPMENT (DME)
18 NYCRR Section 505.5(a)(l) and Section 4.4 of the NYS Medicaid DME,
Medical and Surgical Supplies and Prosthetic and Orthotic Appliances
Provider Manual
a) Durable Medical Equipment (DME) are devices and equipment, other than
medical/surgical supplies, enteral formula, and prosthetic or orthotic
appliances, and have the following characteristics:
i) can withstand repeated use for a protracted period of time;
ii) are primarily and customarily used for medical purposes;
iii) are generally not useful to a person in the absence of illness or
injury; and
iv) are usually not fitted, designed or fashioned for a particular
individual's use. Where equipment is intended for use by only one
(1) person, it may be either custom made or customized.
b) Coverage includes equipment servicing but excludes disposable medical
supplies.
21. AUDIOLOGY, HEARING AID SERVICES AND PRODUCTS
18 NYCRR Section 505.31 (a)(l)(2) and Section 4.7 of the NYS Medicaid
Hearing Aid Provider Manual
a) Hearing aid services and products are provided in compliance with
Article 37-A of the General Business Law when medically necessary to
alleviate disability caused by the loss or impairment of hearing.
Hearing aid services include: selecting, fitting and dispensing of
hearing aids, hearing aid checks following dispensing of hearing aids,
conformity evaluation, and hearing aid repairs.
b) Audiology services include audiometric examinations and testing,
hearing aid evaluations and hearing aid prescriptions or
recommendations, as medically indicated.
c) Hearing aid products include hearing aids, earmolds, special fittings,
and replacement parts.
d) Hearing aid batteries:
i) For Family Health Plus only: Hearing aid batteries are covered as
part of the prescription drug benefit.
ii) For Medicaid Managed Care only: Hearing aid batteries are covered
through the Medicaid fee-for-service program.
22. FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE
APPENDIX K
October 1, 2005
K-17
a) Family Planning and Reproductive Health Care services means the
offering, arranging and furnishing of those health services which
enable Enrollees, including minors who may be sexually active, to
prevent or reduce the incidence of unwanted pregnancy, as specified in
Appendix C of this Agreement.
b) HIV counseling and testing is included in coverage when provided as
part of a Family Planning and Reproductive Health visit.
c) All medically necessary abortions are covered, as specified in
Appendix C of this Agreement.
d) Fertility services are not covered.
e) If the Contractor excludes Family Planning and Reproductive Health
services from its Benefit Package, as specified in Appendix M of this
Agreement, the Contractor is required to comply with the requirements
of Appendix C.3 of this Agreement and still provide the following
services:
i) screening, related diagnosis, ambulatory treatment, and referral
to Participating Provider as needed for dysmenorrhea, cervical
cancer or other pelvic abnormality/pathology;
ii) screening, related diagnosis, and referral to Participating
Provider for anemia, cervical cancer, glycosuria, proteinuria,
hypertension, breast disease and pregnancy.
23. NON-EMERGENCY TRANSPORTATION
a) Transportation expenses are covered for MMC Enrollees when
transportation is essential in order for a MMC Enrollee to obtain
necessary medical care and services which are covered under the
Medicaid program (either as part of the Contractor's Benefit Package
or by Medicaid fee-for-service). Non-emergent transportation
guidelines may be developed in conjunction with the LDSS, based on the
LDSS' approved transportation plan.
b) Transportation services means transportation by ambulance, ambulette
fixed wing or airplane transport, invalid coach, taxicab, livery,
public transportation, or other means appropriate to the MMC
Enrollee's medical condition; and a transportation attendant to
accompany the MMC Enrollee, if necessary. Such services may include
the transportation attendant's transportation, meals, lodging and
salary; however, no salary will be paid to a transportation attendant
who is a member of the MMC Enrollee's family.
c) When the Contractor is capitated for non-emergency transportation, the
Contractor is also responsible for providing transportation to
Medicaid covered services that are not part of the Contractor's
Benefit Package.
APPENDIX K
October 1, 2005
K-18
d) Non-emergency transportation is covered for FHPlus Enrollees that are
nineteen (19) or twenty (20) years old and are receiving C/THP
services.
e) For MMC Enrollees with disabilities, the method of transportation must
reasonably accommodate their needs, taking into account the severity
and nature of the disability.
f) Non-emergency transportation is covered for FHPlus Enrollees that are
nineteen (19) or twenty (20) years old and are receiving C/THP
services.
24. EMERGENCY TRANSPORTATION
a) Emergency transportation can only be provided by an ambulance service,
including air ambulance service. Emergency ambulance transportation
means the provision of ambulance transportation for the purpose of
obtaining hospital services for an Enrollee who suffers from severe,
life-threatening or potentially disabling conditions which require the
provision of Emergency Services while the Enrollee is being
transported.
b) Emergency Services means the health care procedures, treatments or
services needed to evaluate or stabilize an Emergency Medical
Condition including, but not limited to, the treatment of trauma,
burns, respiratory, circulatory and obstetrical emergencies.
c) Emergency ambulance transportation is transportation to a hospital
emergency room generated by a "Dial 911" emergency system call or some
other request for an immediate response to a medical emergency.
Because of the urgency of the transportation request, insurance
coverage or other billing provisions are not addressed until after the
trip is completed. When the Contractor is capitated for this benefit,
emergency transportation via 911 or any other emergency call system is
a covered benefit and the Contractor is responsible for payment. The
Contractor shall reimburse the transportation provider for all
emergency ambulance services without regard for final diagnosis or
prudent layperson standard.
25. DENTAL SERVICES
a) Dental care includes preventive, prophylactic and other routine dental
care, services, supplies and dental prosthetics required to alleviate
a serious health condition, including one which affects employability.
Orthodontic services are not covered.
b) Dental surgery performed in an ambulatory or inpatient setting is the
responsibility of the Contractor, whether dental services are included
in the Benefit Package or not. Inpatient claims and referred
ambulatory claims for dental services provided in an inpatient or
outpatient hospital setting for surgery, anesthesiology, X-rays, etc.
are the responsibility of the Contractor. The Contractor shall set up
procedures to prior approve dental services provided in inpatient and
ambulatory settings.
c) For Medicaid Managed Care only:
APPENDIX K
October 1, 2005
K-19
i) As described in Sections 10.15 and 10.27 of this Agreement,
Enrollees may self-refer to Article 28 clinics operated by
academic dental centers to obtain covered dental services if
dental services are included in the Benefit Package.
ii) Professional services of a dentist for dental surgery performed
in an ambulatory or inpatient setting are billed Medicaid
fee-for-service if the Contractor does not include dental
services in the benefit package.
d) For Family Health Plus only: professional services of a dentist for
dental surgery performed in an ambulatory or inpatient setting are not
covered.
26. COURT ORDERED SERVICES
Court ordered services are those services ordered by a court of competent
jurisdiction which are performed by or under the supervision of a
physician, dentist, or other provider qualified under State law to furnish
medical, dental, behavioral health (including treatment for mental health
and/or chemical dependence), or other covered services. The Contractor is
responsible for payment of those services included in the benefit package.
27. PROSTHETIC/ORTHOTIC ORTHOPEDIC FOOTWEAR
Section 4.5, 4.6 and 4.7 of the NYS Medicaid DME, Medical and Surgical
Supplies and Prosthetic and Orthotic Appliances Provider Manual
a) Prosthetics are those appliances or devices which replace or perform
the function of any missing part of the body. Artificial eyes are
covered as part of the eye care benefit.
b) Orthotics are those appliances or devices which are used for the
purpose of supporting a weak or deformed body part or to restrict or
eliminate motion in a diseased or injured part of the body.
c) Medicaid Managed Care: Orthopedic Footwear means shoes, shoe
modifications, or shoe additions which are used to correct,
accommodate or prevent a physical deformity or range of motion
malfunction in a diseased or injured part of the ankle or foot; to
support a weak or deformed structure of the ankle or foot, or to form
an integral part of a brace.
28. MENTAL HEALTH SERVICES
a) Inpatient Services
All inpatient mental health services, including voluntary or
involuntary admissions for mental health services. The Contractor may
provide the covered benefit for medically necessary mental health
inpatient services through hospitals licensed pursuant to Article 28
of the PHL.
b) Outpatient Services
APPENDIX K
October 1, 2005
K-20
Outpatient services including but not limited to: assessment,
stabilization, treatment planning, discharge planning, verbal
therapies, education, symptom management, case management services,
crisis intervention and outreach services, chlozapine monitoring and
collateral services as certified by the New York State Office of
Mental Health (OMH). Services may be provided in-home, in an office or
in the community. Services may be provided by licensed OMH providers
or by other providers of mental health services, including clinical
psychologists and physicians.
c) Family Health Plus Enrollees have a combined mental health/chemical
dependency benefit limit of thirty (30) days inpatient and sixty (60)
outpatient visits per calendar year.
d) MMC SSI Enrollees obtain all mental health services through the
Medicaid fee-for-service program.
29. DETOXIFICATION SERVICES
a) Medically Managed Inpatient Detoxification
These programs provide medically directed twenty-four (24) hour care
on an inpatient basis to individuals who are at risk of severe alcohol
or substance abuse withdrawal, incapacitated, a risk to self or
others, or diagnosed with an acute physical or mental co-morbidity.
Specific services include, but are not limited to: medical management,
bio-psychosocial assessments, stabilization of medical psychiatric /
psychological problems, individual and group counseling, level of care
determinations and referral and linkages to other services as
necessary. Medically Managed Detoxification Services are provided by
facilities licensed by OASAS under Title 14 NYCRR Section 816.6 and
the Department of Health as a general hospital pursuant to Article 28
of the Public Health Law or by the Department of Health as a general
hospital pursuant to Article 28 of the Public Health Law.
b) Medically Supervised Withdrawal
i) Medically Supervised Inpatient Withdrawal
These programs offer treatment for moderate withdrawal on an
inpatient basis. Services must include medical supervision and
direction under the care of a physician in the treatment for
moderate withdrawal. Specific services must include, but are not
limited to: medical assessment within twenty four (24) hours of
admission; medical supervision of intoxication and withdrawal
conditions; bio-psychosocial assessments; individual and group
counseling and linkages to other services as necessary.
Maintenance on methadone while a patient is being treated for
withdrawal from other substances may be provided where the
provider is appropriately authorized. Medically Supervised
Inpatient Withdrawal services are provided by facilities licensed
under Title 14 NYCRR Section 816.7.
ii) Medically Supervised Outpatient Withdrawal
APPENDIX K
October 1, 2005
K-21
These programs offer treatment for moderate withdrawal on an
outpatient basis. Required services include, but are not limited
to: medical supervision of intoxication and withdrawal
conditions; bio-psychosocial assessments; individual and group
counseling; level of care determinations; discharge planning; and
referrals to appropriate services. Maintenance on methadone while
a patient is being treated for withdrawal from other substances
may be provided where the provider is appropriately authorized.
Medically Supervised Outpatient Withdrawal services are provided
by facilities licensed under Title 14 NYCRR Section 816.7.
c) For Medicaid Managed Care only; all detoxification and withdrawal
services are a covered benefit for all Enrollees, including those
categorized as SSI or SSI-related. Detoxification Services in Article
28 inpatient hospital facilities are subject to the inpatient hospital
stop-loss provisions specified in Section 3.11 of this Agreement.
APPENDIX K
October 1, 2005
K-22
30. CHEMICAL DEPENDENCE INPATIENT REHABILITATION AND TREATMENT SERVICES
a) Services provided include intensive management of chemical dependence
symptoms and medical management of physical or mental complications
from chemical dependence to clients who cannot be effectively served
on an outpatient basis and who are not in need of medical
detoxification or acute care. These services can be provided in a
hospital or free-standing facility. Specific services can include, but
are not limited to: comprehensive admission evaluation and treatment
planning; individual group, and family counseling; awareness and
relapse prevention; education about self-help groups; assessment and
referral services; vocational and educational assessment; medical and
psychiatric consultation; food and housing; and HIV and AIDS
education. These services may be provided by facilities licensed by
the New York State Office of Alcoholism and Substance Abuse Services
(OASAS) to provide Chemical Dependence Inpatient Rehabilitation and
Treatment Services under Title 14 NYCRR Part 818. Maintenance on
methadone while a patient is being treated for withdrawal from other
substances may be provided where the provider is appropriately
authorized.
b) Family Health Plus Enrollees have a combined mental health/chemical
dependency benefit limit of thirty (30) days inpatient and sixty (60)
outpatient visits per calendar year.
31. OUTPATIENT CHEMICAL DEPENDENCY SERVICES
a) Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs
Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs are licensed under Title 14 NYCRR Part 822 and provide
chemical dependence outpatient treatment to individuals who suffer
from chemical abuse or dependence and their family members or
significant others.
b) Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs
Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs provide full or half-day services to meet the needs of a
specific target population of chronic alcoholic persons who need a
range of services which are different from those typically provided in
an alcoholism outpatient clinic. Programs are licensed by as Chemical
Dependence Outpatient Rehabilitation Programs under Title 14 NYCRR
Section 822.9.
c) Outpatient Chemical Dependence for Youth Programs
Outpatient Chemical Dependence for Youth Programs (OCDY) are licensed
under Title 14 NYCRR Part 823. OCDY programs offer discrete,
ambulatory clinic services to chemically-dependent youth in a
treatment setting that supports abstinence from chemical dependence
(including alcohol and substance abuse) services.
APPENDIX K
October 1, 2005
K-23
d) Medicaid Managed Care Enrollees access outpatient chemical dependency
services through the Medicaid fee-for-service program.
32. EXPERIMENTAL AND/OR INVESTIGATIONAL TREATMENT
a) Experimental and/or investigational treatment are covered on a case by
case basis.
b) Experimental and/or investigational treatment for life-threatening
and/or disabling illnesses may also be considered for coverage under
the external appeal process pursuant to the requirements of Section
4910 of the PHL under the following conditions:
i) The Enrollee has had coverage of a health care service denied on
the basis that such service is experimental and/or
investigational, and
ii) The Enrollee's attending physician has certified that the
Enrollee has a life-threatening or disabling condition or
disease:
A) for which standard health services or procedures have been
ineffective or would be medically inappropriate, or
B) for which there does not exist a more beneficial standard
health service or procedure covered by the Contractor, or
C) for which there exists a clinical trial, and
iii) The Enrollee's provider, who must be a licensed, board-certified
or board-eligible physician, qualified to practice in the area of
practice appropriate to treat the Enrollee's life-threatening or
disabling condition or disease, must have recommended either:
A) a health service or procedure that, based on two (2)
documents from the available medical and scientific
evidence, is likely to be more beneficial to the Enrollee
than any covered standard health service or procedure; or
B) a clinical trial for which the Enrollee is eligible; and
iv) The specific health service or procedure recommended by the
attending physician would otherwise be covered except for the
Contractor's determination that the health service or procedure
is experimental and/or investigational.
33. RENAL DIALYSIS
Renal dialysis may be provided in an inpatient hospital setting, in an
ambulatory care facility, or in the home on recommendation from a renal
dialysis center.
34. RESIDENTIAL HEALTH CARE FACILITY (RHCF) SERVICES - FOR MMC PROGRAM ONLY
APPENDIX K
October 1, 2005
K-24
a) Residential Health Care Facility (RHCF) Services means inpatient
nursing home services provided by facilities licensed under Article 28
of the New York State Public Health Law, including AIDS nursing
facilities. Covered services includes the following health care
services: medical supervision, twenty-four (24) hour per day nursing
care, assistance with the activities of daily living, physical
therapy, occupational therapy, and speech/language pathology services
and other services as specified in the New York State Health Law and
Regulations for residential health care facilities and AIDS nursing
facilities. These services should be provided to an MMC Enrollee:
i) Who is diagnosed by a physician as having one or more clinically
determined illnesses or conditions that cause the MMC Enrollee to
be so incapacitated, sick, invalid, infirm, disabled, or
convalescent as to require at least medical and nursing care; and
ii) Whose assessed health care needs, in the professional judgment of
the MMC Enrollee's physician or a medical team:
A) do not require care or active treatment of the MMC Enrollee
in a general or special hospital;
B) cannot be met satisfactorily in the MMC Enrollee's own home
or home substitute through provision of such home health
services, including medical and other health and
health-related services as are available in or near his or
her community; and
C) cannot be met satisfactorily in the physician's office, a
hospital clinic, or other ambulatory care setting because of
the unavailability of medical or other health and
health-related services for the MMC Enrollee in such setting
in or near his or her community.
b) The Contractor is also responsible for respite days and bed hold days
authorized by the Contractor.
c) The Contractor is responsible for all medically necessary and
clinically appropriate inpatient Residential Health Care Facility
services authorized by the Contractor up to a sixty (60) day calendar
year stop-loss for MMC Enrollees who are not in Permanent Placement
Status as determined by LDSS.
APPENDIX K
October 1, 2005
K-25
K.3
MEDICAID MANAGED CARE PREPAID BENEFIT PACKAGE
DEFINITIONS OF NON-COVERED SERVICES
The following services are excluded from the Contractor's Benefit Package, but
are covered, in most instances, by Medicaid fee-for-service:
1. MEDICAL NON-COVERED SERVICES
a) Personal Care Agency Services
i) Personal care services (PCS) are the provision of some or total
assistance with personal hygiene, dressing and feeding; and
nutritional and environmental support (meal preparation and
housekeeping). Such services must be essential to the maintenance
of the Enrollee's health and safety in his or her own home. The
service has to be ordered by a physician, and there has to be a
medical need for the service. Licensed home care services
agencies, as opposed to certified home health agencies, are the
primary providers of PCS. Enrollees receiving PCS have to have a
stable medical condition and are generally expected to be in
receipt of such services for an extended period of time (years).
ii) Services rendered by a personal care agency which are approved by
the LDSS are not covered under the Benefit Package. Should it be
medically necessary for the PCP to order personal care agency
services, the PCP (or the Contractor on the physician's behalf)
must first contact the Enrollee's LDSS contact person for
personal care. The district will determine the Enrollee's need
for personal care agency services and coordinate with the
personal care agency to develop a plan of care.
b) Residential Health Care Facilities (RHCF)
Services provided in a Residential Health Care Facility (RHCF) to an
individual who is determined by the LDSS to be in Permanent Status are
not covered.
c) Hospice Program
i) Hospice is a coordinated program of home and inpatient care that
provides non-curative medical and support services for persons
certified by a physician to be terminally ill with a life
expectancy of six (6) months or less. Hospice programs provide
patients and families with palliative and supportive care to meet
the special needs arising out of physical, psychological,
spiritual, social and economic stresses which are experienced
during the final stages of illness and during dying and
bereavement.
ii) Hospices are organizations which must be certified under Article
40 of the PHL. All services must be provided by qualified
employees and volunteers of the
APPENDIX K
October 1, 2005
K-26
hospice or by qualified staff through contractual arrangements to
the extent permitted by federal and state requirements. All
services must be provided according to a written plan of care
which reflects the changing needs of the patient/family.
iii) If an Enrollee becomes terminally ill and receives Hospice
Program services, he or she may remain enrolled and continue to
access the Contractor's Benefit Package while Hospice costs are
paid for by Medicaid fee-for-service.
d) Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and
Enteral Formula
Coverage for drugs dispensed by community pharmacies, over the counter
drugs, medical/surgical supplies and enteral formula are not included
in the Benefit Package and will be paid for by Medicaid
fee-for-service. Medical/surgical supplies are items other than drugs,
prosthetic or orthotic appliances, or DME which have been ordered by a
qualified practitioner in the treatment of a specific medical
condition and which are: consumable, non-reusable, disposable, or for
a specific rather than incidental purpose, and generally have no
salvageable value (e.g. gauze pads, bandages and diapers).
Pharmaceuticals and medical supplies routinely furnished or
administered as part of a clinic or office visit are covered.
2. NON-COVERED BEHAVIORAL HEALTH SERVICES
a) Chemical Dependence Services
i) Outpatient Rehabilitation and Treatment Services
A) Methadone Maintenance Treatment Program (MMTP)
Consists of drug detoxification, drug dependence counseling,
and rehabilitation services which include chemical
management of the patient with methadone. Facilities that
provide methadone maintenance treatment do so as their
principal mission and are certified by OASAS under 14 NYCRR
Part 828.
B) Medically Supervised Ambulatory Chemical Dependence
Outpatient Clinic Programs
Medically Supervised Ambulatory Chemical Dependence
Outpatient Clinic Programs are licensed under Title 14 NYCRR
Part 822 and provide chemical dependence outpatient
treatment to individuals who suffer from chemical abuse or
dependence and their family members or significant others.
APPENDIX K
October 1, 2005
K-27
C) Medically Supervised Chemical Dependence Outpatient
Rehabilitation Programs
Medically Supervised Chemical Dependence Outpatient
Rehabilitation Programs provide full or half-day services to
meet the needs of a specific target population of chronic
alcoholic persons who need a range of services which are
different from those typically provided in an alcoholism
outpatient clinic. Programs are licensed by as Chemical
Dependence Outpatient Rehabilitation Programs under Title 14
NYCRR Section 822.9.
D) Outpatient Chemical Dependence for Youth Programs
Outpatient Chemical Dependence for Youth Programs (OCDY)
licensed under Title 14 NYCRR Part 823, establish programs
and service regulations for OCDY programs. OCDY programs
offer discrete, ambulatory clinic services to
chemically-dependent youth in a treatment setting that
supports abstinence from chemical dependence (including
alcohol and substance abuse) services.
ii) Chemical Dependence Services Ordered by the LDSS
A) The Contractor is not responsible for the provision and
payment of Chemical Dependence Inpatient Rehabilitation and
Treatment Services ordered by the LDSS and provided to
Enrollees who have:
I) been assessed as unable to work by the LDSS and are
mandated to receive Chemical Dependence Inpatient
Rehabilitation and Treatment Services as a condition of
eligibility for Public Assistance or Medicaid, or
II) have been determined to be able to work with
limitations (work limited) and are simultaneously
mandated by the LDSS into Chemical Dependence Inpatient
Rehabilitation and Treatment Services (including
alcohol and substance abuse treatment services)
pursuant to work activity requirements.
B) The Contractor is not responsible for the provision and
payment of Medically Supervised Inpatient and Outpatient
Withdrawal Services ordered by the LDSS under Welfare Reform
(as indicated by Code 83).
C) The Contractor is responsible for the provision and payment
of Medically Managed Detoxification Services in this
Agreement.
D) If the Contractor is already providing an Enrollee with
Chemical Dependence Inpatient Rehabilitation and Treatment
Services and Detoxification Services and the LDSS is
satisfied with the level of care and services, then the
Contractor will continue to be responsible for the provision
and payment of these services.
APPENDIX K
October 1, 2005
K-28
b) Mental Health Services
i) Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)
Time limited, active psychiatric rehabilitation designed to
assist a patient in forming and achieving mutually agreed upon
goals in living, learning, working and social environments, to
intervene with psychiatric rehabilitative technologies to
overcome functional disabilities. IPRT services are certified by
OMH under 14 NYCRR Part 587.
ii) Day Treatment
A combination of diagnostic, treatment, and rehabilitative
procedures which, through supervised and planned activities and
extensive client-staff interaction, provides the services of the
clinic treatment program, as well as social training, task and
skill training and socialization activities. Services are
expected to be of six (6) months duration. These services are
certified by OMH under 14 NYCRR Part 587.
iii) Continuing Day Treatment
Provides treatment designed to maintain or enhance current levels
of functioning and skills, maintain community living, and develop
self-awareness and self-esteem. Includes: assessment and
treatment planning; discharge planning; medication therapy;
medication education; case management; health screening and
referral; rehabilitative readiness development; psychiatric
rehabilitative readiness determination and referral; and symptom
management. These services are certified by OMH under 14 NYCRR
Part 587.
iv) Day Treatment Programs Serving Children
Day treatment programs are characterized by a blend of mental
health and special education services provided in a fully
integrated program. Typically these programs include: special
education in small classes with an emphasis on individualized
instruction, individual and group counseling, family services
such as family counseling, support and education, crisis
intervention, interpersonal skill development, behavior
modification, art and music therapy.
v) Home and Community Based Services Waiver for Seriously
Emotionally Disturbed Children
This waiver is in select counties for children and adolescents
who would otherwise be admitted to an institutional setting if
waiver services were not provided. The services include
individualized care coordination, respite, family support,
intensive in-home skill building, and crisis response.
APPENDIX K
October 1, 2005
K-29
vi) Case Management
The target population consists of individuals who are seriously
and persistently mentally ill (SPMI), require intensive, personal
and proactive intervention to help them obtain those services
which will permit functioning in the community and either have
symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the
existing mental health care system. Three case management models
are currently operated pursuant to an agreement with OMH or a
local governmental unit, and receive Medicaid reimbursement
pursuant to 14 NYCRR Part 506. Please note: See generic
definition of Comprehensive Medicaid Case Management (CMCM) under
Item 3 - "Other Non-Covered Services."
vii) Partial Hospitalization
Provides active treatment designed to stabilize and ameliorate
acute systems, serves as an alternative to inpatient
hospitalization, or reduces the length of a hospital stay within
a medically supervised program by providing the following:
assessment and treatment planning; health screening and referral;
symptom management; medication therapy; medication education;
verbal therapy; case management; psychiatric rehabilitative
readiness determination and referral and crisis intervention.
These services are certified by OMH under NYCRR Part 587.
viii)Services Provided Through OMH Designated Clinics for Children
With A Diagnosis of Serious Emotional Disturbance (SED)
These are services provided by designated OMH clinics to children
and adolescents with a clinical diagnosis of SED.
ix) Assertive Community Treatment (ACT)
ACT is a mobile team-based approach to delivering comprehensive
and flexible treatment, rehabilitation, case management and
support services to individuals in their natural living setting.
ACT programs deliver integrated services to recipients and adjust
services over time to meet the recipient's goals and changing
needs; are operated pursuant to approval or certification by OMH;
and receive Medicaid reimbursement pursuant to 14 NYCRR Part 508.
x) Personalized Recovery Oriented Services (PROS)
PROS, licensed and reimbursed pursuant to 14 NYCRR Part 512, are
designed to assist individuals in recovery from the disabling
effects of mental illness through the coordinated delivery of a
customized array of rehabilitation, treatment, and support
services in traditional settings and in off-site locations.
Specific components of PROS include Community Rehabilitation and
Support, Intensive Rehabilitation, Ongoing Rehabilitation and
Support and Clinical Treatment.
APPENDIX K
October 1, 2005
K-30
c) Rehabilitation Services Provided to Residents of OMH Licensed
Community Residences (CRs) and Family Based Treatment Programs, as
follows:
i) OMH Licensed CRs*
Rehabilitative services in community residences are
interventions, therapies and activities which are medically
therapeutic and remedial in nature, and are medically necessary
for the maximum reduction of functional and adaptive behavior
defects associated with the person's mental illness.
ii) Family-Based Treatment*
Rehabilitative services in family-based treatment programs are
intended to provide treatment to seriously emotionally disturbed
children and youth to promote their successful functioning and
integration into the natural family, community, school or
independent living situations. Such services are provided in
consideration of a child's developmental stage. Those children
determined eligible for admission are placed in surrogate family
homes for care and treatment.
* These services are certified by OMH under 14 NYCRR Section
586.3 and Parts 594 and 595.
d) Office of Mental Retardation and Developmental Disabilities (OMRDD)
Services
i) Long Term Therapy Services Provided by Article 16-Clinic
Treatment Facilities or Article 28 Facilities
These services are provided to persons with developmental
disabilities including medical or remedial services recommended
by a physician or other licensed practitioner of the healing arts
for a maximum reduction of the effects of physical or mental
disability and restoration of the person to his or her best
possible functional level. It also includes the fitting,
training, and modification of assistive devices by licensed
practitioners or trained others under their direct supervision.
Such services are designed to ameliorate or limit the disabling
condition and to allow the person to remain in or move to, the
least restrictive residential and/or day setting. These services
are certified by OMRDD under 14 NYCRR Part 679 (or they are
provided by Article 28 Diagnostic and Treatment Centers that are
explicitly designated by the SDOH as serving primarily persons
with developmental disabilities). If care of this nature is
provided in facilities other than Article 28 or Article 16
centers, it is a covered service.
ii) Day Treatment
A planned combination of diagnostic, treatment and rehabilitation
services provided to developmentally disabled individuals in need
of a broad range of services, but who do not need intensive
twenty-four (24) hour care and medical supervision. The services
provided as identified in the comprehensive assessment
APPENDIX K
October 1, 2005
K-31
may include nutrition, recreation, self-care, independent living,
therapies, nursing, and transportation services. These services
are generally provided in an ICF or a comparable setting. These
services are certified by OMRDD under 14 NYCRR Part 690.
iii) Medicaid Service Coordination (MSC)
Medicaid Service Coordination (MSC) is a Medicaid State Plan
service provided by OMRDD which assists persons with
developmental disabilities and mental retardation to gain access
to necessary services and supports appropriate to the needs of
the needs of the individual. MSC is provided by qualified service
coordinators and uses a person centered planning process in
developing, implementing and maintaining an Individualized
Service Plan (ISP) with and for a person with developmental
disabilities and mental retardation. MSC promotes the concepts of
a choice, individualized services and consumer satisfaction. MSC
is provided by authorized vendors who have a contract with OMRDD,
and who are paid monthly pursuant to such contract. Persons who
receive MSC must not permanently reside in an ICF for persons
with developmental disabilities, a developmental center, a
skilled nursing facility or any other hospital or Medical
Assistance institutional setting that provides service
coordination. They must also not concurrently be enrolled in any
other comprehensive Medicaid long term service coordination
program/service including the Care at Home Waiver. Please note:
See generic definition of Comprehensive Medicaid Case Management
(CMCM) under Item 3 "Other Non-Covered Services."
iv) Home And Community Based Services Waivers (HCBS)
The Home and Community-Based Services Waiver serves persons with
developmental disabilities who would otherwise be admitted to an
ICF/MR if waiver services were not provided. HCBS waivers
services include residential habilitation, day habilitation,
prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications,
family education and training, live-in caregiver, and plan of
care support services. These services are authorized pursuant to
a SSA Section 1915(c) waiver from DHHS.
v) Services Provided Through the Care At Home Program (OMRDD)
The OMRDD Care at Home III, Care at Home IV, and Care at Home VI
waivers, serve children who would otherwise not be eligible for
Medicaid because of their parents' income and resources, and who
would otherwise be eligible for an ICF/MR level of care. Care at
Home waiver services include service coordination, respite and
assistive technologies. Care at Home waiver services are
authorized pursuant to a SSA Section 1915(c) waiver from DHHS.
APPENDIX K
October 1, 2005
K-32
3. OTHER NON-COVERED SERVICES
a) The Early Intervention Program (EIP) - Children Birth to Two (2) Years
of Age
i) This program provides early intervention services to certain
children, from birth through two (2) years of age, who have a
developmental delay or a diagnosed physical or mental condition
that has a high probability of resulting in developmental delay.
All managed care providers MUST refer infants and toddlers
suspected of having a delay to the local designated Early
Intervention agency in their area. (In most municipalities, the
County Health Department is the designated agency, except: New
York City - the Department of Health and Mental Hygiene; Erie
County - The Department of Youth Services; Jefferson County - the
Office of Community Services; and Ulster County - the Department
of Social Services).
ii) Early intervention services provided to this eligible population
are categorized as Non-Covered. These services, which are
designed to meet the developmental needs of the child and the
needs of the family related to enhancing the child's development,
will be identified on eMedNY by unique rate codes by which only
the designated early intervention agency can claim reimbursement.
Contractor covered and authorized services will continue to be
provided by the Contractor. Consequently, the Contractor, through
its Participating Providers, will be expected to refer any
enrolled child suspected of having a developmental delay to the
locally designated early intervention agency in their area and
participate in the development of the Child's Individualized
Family Services Plan (IFSP). Contractor's participation in the
development of the IFSP is necessary in order to coordinate the
provision of early intervention services and services covered by
the Contractor.
iii) SDOH will instruct the locally designated early intervention
agencies on how to identify an Enrollee and the need to contact
the Contractor or the Participating Provider to coordinate
service provision.
b) Preschool Supportive Health Services-Children Three (3) Through Four
(4) Years of Age
i) The Preschool Supportive Health Services Program (PSHSP) enables
counties and New York City to obtain Medicaid reimbursement for
certain educationally related medical services provided by
approved preschool special education programs for young children
with disabilities. The Committee on Preschool Special Education
in each school district is responsible for the development of an
Individualized Education Program (IEP) for each child evaluated
in need of special education and medically related health
services.
ii) PSHSP services rendered to children three (3) through four (4)
years of age in conjunction with an approved IEP are categorized
as Non-Covered.
APPENDIX K
October 1, 2005
K-33
iii) The PSHSP services will be identified on eMedNY by unique rate
codes through which only counties and New York City can claim
reimbursement. In addition, a limited number of Article 28
clinics associated with approved pre-school programs are allowed
to directly bill Medicaid fee-for-service for these services.
Contractor covered and authorized services will continue to be
provided by the Contractor.
c) School Supportive Health Services-Children Five (5) Through Twenty-One
(21) Years of Age
i) The School Supportive Health Services Program (SSHSP) enables
school districts to obtain Medicaid reimbursement for certain
educationally related medical services provided by approved
special education programs for children with disabilities. The
Committee on Special Education in each school district is
responsible for the development of an Individualized Education
Program (IEP) for each child evaluated in need of special
education and medically related services.
ii) SSHSP services rendered to children five (5) through twenty-one
(21) years of age in conjunction with an approved IEP are
categorized as Non-Covered.
iii) The SSHSP services are identified on eMedNY by unique rate codes
through which only school districts can claim Medicaid
reimbursement. Contractor covered and authorized services will
continue to be provided by the Contractor.
d) Comprehensive Medicaid Case Management (CMCM)
A program which provides "social work" case management referral
services to a targeted population (e.g.: pregnant teens, mentally
ill). A CMCM case manager will assist a client in accessing necessary
services in accordance with goals contained in a written case
management plan. CMCM programs do not provide services directly, but
refer to a wide range of service Providers. Some of these services
are: medical, social, psycho-social, education, employment, financial,
and mental health. CMCM referral to community service agencies and/or
medical providers requires the case manager to work out a mutually
agreeable case coordination approach with the agency/medical
providers. Consequently, if an Enrollee of the Contractor is
participating in a CMCM program, the Contractor must work
collaboratively with the CMCM case manager to coordinate the provision
of services covered by the Contractor. CMCM programs will be
instructed on how to identify a managed care Enrollee and informed on
the need to contact the Contractor to coordinate service provision.
e) Directly Observed Therapy for Tuberculosis Disease
Tuberculosis directly observed therapy (TB/DOT) is the direct
observation of oral ingestion of TB medications to assure patient
compliance with the physician's prescribed medication regimen. While
the clinical management of tuberculosis is included in the Benefit
Package, TB/DOT where applicable, can be billed directly to eMedNY by
any SDOH approved Medicaid fee-for-service TB/DOT Provider. The
APPENDIX K
October 1, 2005
K-34
Contractor remains responsible for communicating, cooperating and
coordinating clinical management of TB with the TB/DOT Provider.
f) AIDS Adult Day Health Care
Adult Day Health Care Programs (ADHCP) are programs designed to assist
individuals with HIV disease to live more independently in the
community or eliminate the need for residential health care services.
Registrants in ADHCP require a greater range of comprehensive health
care services than can be provided in any single setting, but do not
require the level of services provided in a residential health care
setting. Regulations require that a person enrolled in an ADHCP must
require at least three (3) hours of health care delivered on the basis
of at least one (1) visit per week. While health care services are
broadly defined in this setting to include general medical care,
nursing care, medication management, nutritional services,
rehabilitative services, and substance abuse and mental health
services, the latter two (2) cannot be the sole reason for admission
to the program. Admission criteria must include, at a minimum, the
need for general medical care and nursing services.
g) HIV COBRA Case Management
The HIV COBRA (Community Follow-up Program) Case Management Program is
a program that provides intensive, family-centered case management and
community follow-up activities by case managers, case management
technicians, and community follow-up workers. Reimbursement is through
an hourly rate billable to Medicaid. Reimbursable activities include
intake, assessment, reassessment, service plan development and
implementation, monitoring, advocacy, crisis intervention, exit
planning, and case specific supervisory case-review conferencing.
h) Adult Day Health Care
i) Adult Day Health Care means care and services provided to a
registrant in a residential health care facility or approved
extension site under the medical direction of a physician and
which is provided by personnel of the adult day health care
program in accordance with a comprehensive assessment of care
needs and individualized health care plan, ongoing implementation
and coordination of the health care plan, and transportation.
ii) Registrant means a person who is a nonresident of the residential
health care facility who is functionally impaired and not
homebound and who requires certain preventive, diagnostic,
therapeutic, rehabilitative or palliative items or services
provided by a general hospital, or residential health care
facility; and whose assessed social and health care needs, in the
professional judgment of the physician of record, nursing staff,
Social Services and other professional personnel of the adult day
health care program can be met in whole or in part satisfactorily
by delivery of appropriate services in such program.
APPENDIX K
October 1, 2005
K-35
i) Personal Emergency Response Services (PERS)
Personal Emergency Response Services (PERS) are not included in
the Benefit Package. PERS are covered on a fee-for-service basis
through contracts between the LDSS and PERS vendors.
j) School-Based Health Centers
A School-Based Health Center (SBHC) is an Article 28 extension
clinic that is located in a school and provides students with
primary and preventive physical and mental health care services,
acute or first contact care, chronic care, and referral as
needed. SBHC services include comprehensive physical and mental
health histories and assessments, diagnosis and treatment of
acute and chronic illnesses, screenings (e.g., vision, hearing,
dental, nutrition, TB), routine management of chronic diseases
(e.g., asthma, diabetes), health education, mental health
counseling and/or referral, immunizations and physicals for
working papers and sports.
APPENDIX K
October 1, 2005
K-36
K.4
FAMILY HEALTH PLUS
NON-COVERED SERVICES
1. Non-Emergent Transportation Services (except for 19 and 20 year olds
receiving C/THP Services)
2. Personal Care Agency Services
3. Private Duty Nursing Services
4. Long Term Care - Residential Health Care Facility Services
5. Non-Prescription (OTC) Drugs and Medical Supplies
6. Alcohol and Substance Abuse (ASA) Services Ordered by the LDSS
7. Office of Mental Health/ Office of Mental Retardation and Developmental
Disabilities Services
8. School Supportive Health Services
9. Comprehensive Medicaid Case Management (CMCM)
10. Directly Observed Therapy for Tuberculosis Disease
11. AIDS Adult Day Health Care
12. HIV COBRA Case Management
13. Home and Community Based Services Waiver
14. Methadone Maintenance Treatment Program
15. Day Treatment
16. IPRT
17. Infertility Services
18. Adult Day Health Care
19. School Based Health Care Services
20. Personal Emergency Response Systems
APPENDIX K
October 1, 2005
K-37
APPENDIX L
APPROVED CAPITATION PAYMENT RATES
APPENDIX L
October 1, 2005
L-l
CAREPLUS, LLC
Medicaid Managed Care Rates
MMIS ID#: 01617894 Effective Date: 10/01/05
Approved by DOB: Yes Region: NYC
DOH HMO #: 05-035 County: NEW YORK CITY
Reinsurance: No Status: Mandatory
PREMIUM GROUP RATE AMOUNT
- -------------- -----------
TANF/SN <6MO M/F $ 263.45
TANF/SN 6MO-14 F $ 90.96
TANF/SN 15-20 F $ 113.53
TANF/SN 6mo-20 M $ 101.28
TANF 21+ M/F $ 184.98
SN 21-29 M/F $ 180.98
SN 30+ M/F $ 237.58
SSI 6MO-20 M/F $ 187.76
SSI 21-64 M/F $ 493.90
SSI 65+ M/F $ 386.60
MATERNITY KICK PAYMENT $4,700.66
NEWBORN KICK PAYMENT $2,795.63
OPTIONAL BENEFITS OFFERED:
[X] Emergency Transportation [X] Dental
[X] Non-Emergent Transportation [X] Fami1y Planning
BOX WILL BE CHECKED IF THE OPTIONAL BENEFIT IS COVERED BY THE PLAN
APPENDIX M
SERVICE AREA, BENEFIT OPTIONS, AND ENROLLMENT ELECTIONS
APPENDIX M
October 1, 2005
M-l
SCHEDULE 1 OF APPENDIX M
SERVICE AREA, PROGRAM PARTICIPATION AND
PREPAID BENEFIT PACKAGE OPTIONAL COVERED SERVICES
1. SERVICE AREA
The Contractor's service area is comprised of the counties listed in Column
A of this schedule in their entirety.
2. PROGRAM PARTICIPATION AND OPTIONAL BENEFIT PACKAGE COVERED SERVICES
a) For each county listed in Column A below, an entry of "yes" in the
subsections of Columns B and C means the Contractor offers the MMC
and/or FHPlus product and/or includes the optional service indicated
in its Benefit Package.
b) For each county listed in Column A below, an entry of "no" in the
subsections of Columns B and C means the Contractor does not offer the
MMC and/or FHPlus product and/or does not include the optional service
indicated in its Benefit Package.
c) In the schedule below, an entry of "N/A" means not applicable for the
purposes of this Agreement.
3. EFFECTIVE DATE
The effective date of this Schedule is October 1, 2005.
CONTRACTOR: CarePlus, LLC
COLUMN B MEDICAID MANAGED CARE COLUMN C FHPLUS
------------------------------------------------------------------ ---------------------------------------
COLUMN A Contractor Family Non-Emergency Emergency Contractor
COUNTY Participates Dental Planning Transportation Transportation Participates Dental Family Planning
- -------- ------------ ------ -------- -------------- -------------- ------------ ------ ---------------
Kings Yes Yes Yes Yes Yes N/A N/A N/A
New York Yes Yes Yes Yes Yes N/A N/A N/A
Queens Yes Yes Yes Yes Yes N/A N/A N/A
Richmond Yes Yes Yes Yes Yes N/A N/A N/A
APPENDIX M
October 1, 2005
M-2
SCHEDULE 2 OF APPENDIX M
LDSS ELECTION OF ENROLLMENT IN MEDICAID MANAGED CARE
FOR FOSTER CARE CHILDREN AND HOMELESS PERSONS
1. Effective October 1, 2005, in the Contractor's service area, Medicaid
Eligible Persons in the following categories will be eligible for
Enrollment in the Contractor's Medicaid Managed Care product at the LDSS's
option as described in (a) and (b) as follows, and indicated by an "X" in
the chart below:
a) Options for foster care children in the direct care of LDSS:
i) Children in LDSS direct care are mandatorily enrolled in MMC
(mandatory counties only);
ii) Children in LDSS direct care are enrolled in on a case by case
basis in MMC (mandatory or voluntary counties);
iii) All foster care children are Excluded from Enrollment in MMC
(mandatory or voluntary counties).
b) Options for homeless persons living in shelters outside of New York
City:
i) Homeless persons are mandatorily enrolled in MMC (mandatory
counties only);
ii) Homeless persons are enrolled in on a case by case basis in MMC
(mandatory or voluntary counties);
iii) All homeless persons are Excluded from Enrollment in MMC
(mandatory or voluntary counties).
c) In the schedule below, an entry of "N/A" means not applicable for the
purposes of this Agreement.
CONTRACTOR: CarePlus, LLC
- -------------------------------------------------------------------------------------------
FOSTER CARE CHILDREN HOMELESS PERSONS
--------------------------------------- --------------------------------------
Enrolled on Excluded Enrolled on Excluded
Mandatorily Case by Case from Mandatorily Case by from
COUNTY Enrolled Basis Enrollment Enrolled Case Basis Enrollment
- ------ ----------- ------------ ---------- ----------- ----------- ----------
Kings X N/A N/A N/A
New York X N/A N/A N/A
Queens X N/A N/A N/A
Richmond X N/A N/A N/A
APPENDIX M
October 1, 2005
M-3
APPENDIX N
NEW YORK CITY SPECIFIC CONTRACTING REQUIREMENTS
APPENDIX N
October 1, 2005
N-l
APPENDIX N
NEW YORK CITY SPECIFIC CONTRACTING REQUIREMENTS
1. GENERAL
a) In New York City, the Contractor will comply with all provisions of
the main body and other Appendices of this Agreement, except as
otherwise expressly established in this Appendix.
b) This Appendix sets forth New York City Specific Contracting
Requirements and contains the following sections:
N.1 Compensation for Public Health Services
N.2 Coordination with DOHMH on Public Health Initiatives
N.3 Benefits
N.4 Additional Reporting Requirements
N.5 Quality Management
N.6 New York City Additional Marketing Guidelines
N.7 Guidelines for Processing Enrollments and Disenrollments in New York City
N.8 New York City Transportation Policy Guidelines
Schedule 1 DOHMH Public Health Services Fee Schedule
APPENDIX N
October 1, 2005
N-2
N.1
COMPENSATION FOR PUBLIC HEALTH SERVICES
1. The Contractor shall reimburse DOHMH at the rates contained in Schedule 1
of this Appendix for Enrollees who receive the following services from
DOHMH facilities, except in those instances where DOHMH may bill Medicaid
fee-for-service.
a) Diagnosis and/or treatment of TB
b) HIV counseling and testing that is not part of an STD or TB visit
c) Adult and child immunizations
d) Lead poison screening
e) Dental services
2. Notwithstanding Sections 10.18 (a) (ii) (C) and (b) (ii)(C) of this
Agreement, the following requirements concerning Contractor notification
and documentation of services shall apply in New York City:
a) DOHMH shall confirm the Enrollee's membership in the Contractor's MMC
product on the date of service through EMEDNY prior to billing for
these services.
b) DOHMH must submit claims for services provided to Enrollees no later
than one year from the date of service.
c) The Contractor shall not require pre-authorization, notification to
the Contractor or contacts with the PCP for the above mentioned
services.
d) DOHMH shall make reasonable efforts to notify the Contractor that it
has provided the above mentioned services to an Enrollee.
APPENDIX N
October 1, 2005
N-3
N.2
COORDINATION WITH DOHMH ON PUBLIC HEALTH INITIATIVES
1. COORDINATION WITH DOHMH
a) The Contractor shall provide the DOHMH with existing information
requested by DOHMH to conduct epidemiological investigations.
2. PROVIDER REPORTING OBLIGATIONS
a) The Contractor shall make reasonable efforts to assure timely and
accurate compliance by Participating Providers with public health
reporting requirements relating to communicable disease and conditions
mandated in the New York City Health Code pursuant to 24 RCNY Sections
1103-1107 and Title 21, Article 3 of the NYS Public Health Law.
b) The Contractor shall make reasonable efforts to assure timely and
accurate compliance by Participating Providers with other mandated
reporting requirements, including the following:
i) Infants and toddlers suspected of having a developmental delay or
disability;
ii) Suspected instances of child abuse;
iii) Immunization (reporting to immunization registry); and
iv) Additional reporting requirements adopted by the New York City
Health Code
c) "Reasonable efforts" shall include:
i) For mandated reporting requirements described in paragraphs
(2)(a) and (2)(b) above:
A) Educating Participating Providers on treatment guidelines
and instructions for reporting included in the NYC DOHMH
Compendium of Public Health Requirements and
Recommendations.
B) Including reporting requirements in the Contractor's
provider manual or other written instructions or guidelines
ii) For mandated reporting requirements described in paragraph (2)(a)
above:
A) Letters from the Contractor to Participating Providers who
generated claims that suggest that an Enrollee may have a
reportable disease or condition, encouraging such providers
to report and providing information on how to report.
B) Other methods for follow up with Participating Providers,
subject to DOHMH approval, may be employed.
3. MATCHING TO REGISTRIES
APPENDIX N
October 1, 2005
N-4
a) The Contactor shall participate in matches of its Enrollees to the
DOHMH immunization and lead registries through submission of files in
formats specified by DOHMH Immunization and Lead Poisoning Prevention
Programs.
i) Matches to the Citywide Immunization Registry shall occur, at a
minimum, twice a year, in March and October, but may occur more
frequently at the Contractor's discretion. The file matches which
occur in March and October will include all children aged 18
through 30 months who are enrolled in the Contractor's MMC
Product at the time of the match, regardless of the children's
length of Enrollment in the Contractor's MMC Product. Additional
file matches, done at the discretion of the Contractor, may
include any group of children currently enrolled in the
Contractor's MMC Product at the time of the match and may be done
at any time of year.
ii) Matches to the City Lead Registry shall occur at least twice a
year, but may occur more frequently as agreed by both the
Contractor and the DOHMH Lead Poisoning Prevention Program. Files
for these matches shall be submitted in March and October, and
will include all children up to 36 months of age who are enrolled
in the Contractor's MMC Product at the time of the match,
regardless of the children's length of Enrollment in the
Contractor's MMC Product.
b) Formats for reports from the DOHMH to the Contractor based on these
matches will be developed through discussion between the Contractor
and DOHMH programs.
c) The Contractor will follow up with Participating Providers of
Enrollees who have not been appropriately immunized or screened for
lead poisoning to facilitate provision of appropriate services.
d) The following provisions regarding confidentiality shall apply:
i) Consistent with the New York City Health Code Section 11.07 (c)
and (d), the Contractor and DOHMH shall keep confidential all
identifying information provided by the DOHMH and not further
disclose to any other person or entity such identifying
information unless compelled by law to disclose such identifying
information, except as provided in provided in paragraph 3(c)
above.
ii) The Contractor shall notify the DOHMH Office of General Counsel
for Health in writing, of the receipt of any document seeking
disclosure of identifying information that is not accompanied by
a written consent from the parent or guardian of an Enrollee
authorizing the disclosure of such identifying information as
follows:
A) Such notice shall be given not later than five days prior to
the date on which a disclosure is required by a subpoena,
court order or other document, and shall attach a copy of
the document requesting identifying information.
APPENDIX N
October 1, 2005
N-5
B) If a subpoena, court order or other document requests
disclosure to be made within five days or less after its
receipt by the Contractor, the Contractor shall provide
DOHMH with such notice as far in advance of the disclosure
date as possible, but in no circumstance shall the
Contractor make such disclosure without prior notice to the
DOHMH.
C) The Contractor acknowledges that DOHMH may elect to seek a
court order prohibiting the disclosure of identifying
information when it deems it appropriate to do so, and
consents to DOHMH's intervention in any proceeding,
including, but not limited to any judicial proceeding, that
seeks the disclosure of identifying information.
4. ENROLLEE OUTREACH/EDUCATION
a) The Contractor shall provide health education to Enrollees on an
on-going basis through methods such as distribution of Enrollee
newsletters, health education classes or individual counseling on
preventive health and public health topics. Each topic below shall be
covered at least once every two years.
i) HIV/AIDS
A) Encourage Enrollee counseling and testing
B) Inform Enrollees as to availability of sterile needles and
syringes
ii) STDs
A) Inform Enrollees that confidential STD services are
available at DOHMH facilities for non-enrolled sexual and
needle-sharing partners at no charge
iii) Lead poisoning prevention
iv) Maternal and child health, including importance of developmental
screening for children
v) Injury prevention, including age appropriate anticipatory
guidance
vi) Domestic violence
vii) Smoking cessation
viii) Asthma
ix) Immunization
x) Mental health services
xi) Diabetes
xii) Family planning
xiii) Screening for Cancer
xiv) Chemical Dependence
xv) Physical fitness and nutrition
xvi) Cardiovascular disease and hypertension
5. PROVIDER EDUCATION
a) DOHMH shall prepare a public health compendium ("Compendium") with
public health guidelines, protocols, and recommendations which it
shall make available directly to Participating Providers and to the
Contractor.
APPENDIX N
October 1, 2005
N-6
b) The Contractor shall adapt public health guidance from the Compendium
for its internal protocols, practice manuals and guidelines.
c) The Contractor will assist DOHMH in its efforts to disseminate
electronic materials to its Participating Providers by providing
electronic addresses if known by Contractor (fax and/or e-mail) for
its Participating Providers, updated semi-annually.
d) The Contractor shall promote the use of rapid HIV testing among its
Participating Providers.
6. MCO STAFF RESPONSIBILITIES AND TRAINING
a) Early Intervention Services
i) The Contractor shall ensure that appropriate MCO staff, such as
member services staff and case managers are knowledgeable about
early intervention services and provide technical assistance and
consultation to Enrollees concerning early intervention services
(including eligibility, referral process and coordination of
services).
b) Domestic Violence
i) The Contractor shall designate a domestic violence coordinator
who can:
A) Provide technical assistance to Participating Providers in
documenting cases of domestic violence;
B) Provide referrals to Enrollees or their Participating
Providers, to obtain protective, legal and or supportive
social services; and
C) Provide consultative assistance to other staff within the
Contractor's organization.
ii) The Contractor shall distribute a directory of resources for
victims of domestic violence to appropriate staff, such as member
services staff or case managers.
7. MEDICAL DIRECTORS
a) The Contractor's Medical Director shall participate in Medical
Directors' Meetings with the medical directors of the other MCOs
participating in the MMC Program in New York City and representatives
of the New York City Department of Health and Mental Hygiene. The
purpose of the Medical Directors' Meetings shall be to share public
health information and data; recommend that certain public health
information be disseminated by the MCOs to their Participating
Providers; discuss public health strategies and outreach efforts and
potential collaborative projects; encourage the development of MCO
policies that support public health strategies; and provide a vehicle
for communication between the MCOs participating in the MMC Program
and the various bureaus and divisions of the NYC Department of Health
and Mental Hygiene.
APPENDIX N
October 1, 2005
N-7
b) The Contractor's Medical Director shall attend all periodic meetings,
which shall not exceed one every two months. In the event that the
Medical Director is unable to attend a particular meeting, the
Contractor will designate an appropriate substitute to attend the
meeting.
c) DOHMH, following consultation with the Medical Directors, may create
workgroups on particular public health topics. The Contractor's
Medical Director may participate in any or all of the workgroups, but
shall participate in at least one of the designated workgroups.
8. TAKE CARE NEW YORK
a) The Contractor shall:
i) Educate Enrollees regarding prevention and treatment of diseases
and conditions included in the Take Care New York initiative
(TCNY);
ii) Disseminate TCNY health passports or materials containing similar
content approved by DOHMH to Enrollees;
iii) Disseminate reminders to obtain recommended health screenings at
age appropriate intervals to Enrollees; and
iv) Educate Participating Providers on recommended clinical
guidelines regarding prevention and treatment/management of
diseases and conditions described in the TCNY initiative.
b) The Contractor shall select one condition annually from the TCNY
initiative and perform the following:
i) Identify Enrollees with the condition using information from
multiple sources (e.g., utilization data, including
hospitalizations and ER visits; provider referrals; new Enrollee
screenings; self-referrals by Enrollees) and maintain such
information in a patient registry; and
ii) Develop and submit to DOHMH for approval a proposal to evaluate
the effectiveness of Contractor interventions for this condition
by tracking service utilization and assessing health outcomes.
c) The Contractor shall, upon request by DOHMH, participate in one or
more TCNY workgroups or other activities sponsored by the DOHMH.
APPENDIX N
October 1, 2005
N-8
N.3
BENEFITS
1. Transitional Home Health Services Pending Placement in Personal Care Agency
Services
a) Transitional home health services are home health services as defined
in Appendix K of this Agreement provided by the Contractor to an MMC
Enrollee while the Human Resources Administration's determination
regarding a request for the provision of personal care agency services
to the Enrollee is pending. Transitional home health services are
available to MMC Enrollees in addition to the home health care
services otherwise covered under the Benefit Package as medically
necessary.
b) The Contractor shall be responsible for providing transitional home
health services to MMC Enrollees for up to a thirty (30) day period as
follows:
i) For MMC enrollees discharged from a hospital or RHCF and for whom
personal care agency services have been requested by the
hospital/RHCF discharge planner, the thirty (30) day period shall
commence with the day following the MMC Enrollee's discharge from
the hospital or RHCF. Transitional home health services shall not
be available if the MMC Enrollee: was hospitalized less than
thirty (30) days, was in receipt of personal care agency services
prior to his/her admission to the hospital or RHCF, and requires
the same level and hours of personal care agency services upon
discharge.
ii) For MMC Enrollees who have been receiving home health care
services in the community and for whom personal care agency
services have been ordered by the Enrollee's physician, the
thirty (30) day period shall commence with the day following the
last day that the Contractor approved home health care services
to be medically necessary.
c) The Contractor shall provide reasonable assistance as requested
regarding the completion of forms required by the Human Resources
Administration to initiate the review of a request for personal care
agency services. Such form, commonly referred to as the M11Q, requires
physician orders, signed by the licensed physician, to be received by
HRA within thirty (30) calendar days of the physician's examination.
APPENDIX N
October 1, 2005
N-9
N.4
ADDITIONAL REPORTING REQUIREMENTS
1. DOHMH, will provide Contractor with instructions for submitting the reports
required by paragraphs 4(c), (d) and (e) below. These instructions shall
include time frames, and requisite formats. The instructions, time frames
and formats may be modified by DOHMH upon sixty (60) days written notice to
the Contractor.
2. The Contractor shall submit reports that are required to be submitted to
DOHMH by this Agreement electronically.
3. The Contractor shall pay liquidated damages of $500 to DOHMH for any report
required by paragraphs 4(c), (d) and (e) below which is materially
incomplete, contains material misstatements or inaccurate information or is
not submitted on time in the requested format. The DOHMH shall not impose
liquidated damages for a first time infraction by the Contractor unless
DOHMH deems the infraction to be a material misrepresentation of fact or
the Contractor fails to cure the first infraction within a reasonable
period of time upon notice from the DOHMH. Liquidated damages may be waived
at the sole discretion of DOHMH.
4. The Contractor shall submit the following reports to DOHMH:
a) The Contractor shall provide DOHMH with all reports submitted to SDOH
pursuant to Sections 18.6(a)(i), (ii), (vi), (vii), and (xii) of this
Agreement.
b) Upon request by DOHMH, the Contractor shall submit to DOHMH reports
submitted to SDOH pursuant to Section 18.6(a)(iii); and Section
18.6(xi) and/or Section 23.2 of this Agreement.
c) To meet the appointment availability review requirements of Section
18.6(a)(ix), the Contractor shall conduct a service area specific
review of appointment availability for two specialist types, to be
determined by DOHMH, semi-annually. Reports on the results of such
surveys must be kept on file by the Contractor and be readily
available for review by SDOH and DOHMH, and submitted to the DOHMH.
d) The Contractor shall conduct annual Enrollee satisfaction surveys of
its Medicaid Enrollees in New York City and report to DOHMH on the
results of these surveys. The Contractor shall not be required to
conduct a separate survey during those calendar years during which an
Enrollee satisfaction survey is conducted by SDOH or its designee.
DOHMH, in its sole discretion, may waive this requirement in a
particular year and/or limit the survey to a targeted sub-population.
APPENDIX N
October 1, 2005
N-10
i) The surveys shall follow guidelines established by DOHMH and the
methodology must be approved by DOHMH. Surveys should exclude
data from non-NYC counties, but sample all boroughs within the
Contractor's service area.
e) Upon request by the DOHMH, the Contractor shall prepare and submit
other operational data reports. Such requests will be limited to
situations in which the desired data is considered essential and
cannot be obtained through existing Contractor reports. Whenever
possible, the Contractor will be provided with ninety (90) days notice
and the opportunity to discuss and comment on the proposed
requirements before work is begun. However, the DOHMH reserves the
right to give thirty (30) days notice in circumstances where time is
of the essence.
APPENDIX N
October 1, 2005
N-11
N.5
QUALITY MANAGEMENT
1. The Contractor's quality management program, as approved by SDOH, must be
kept on file with the DOHMH. The Contractor shall notify the DOHMH when it
modifies its quality management program.
APPENDIX N
October 1, 2005
N-12
N.6
NEW YORK CITY ADDITIONAL MARKETING GUIDELINES
1. PRIOR APPROVALS
a) In addition to the Marketing submission and approval requirements of
Section 11 and Appendix D of this Agreement, the Contractor shall
submit to DOHMH for review and prior approval, in consultation with
SDOH, the following:
i) The Contractor's Marketing plan;
A) The Contractor must have on file with DOHMH an approved
Marketing plan prior to the contract award date or before
Marketing and Enrollment begin whichever is sooner.
Subsequent changes to the Marketing plan must be submitted
to the SDOH and DOHMH for approval at least 60 days before
implementation.
B) The Marketing plan shall include a copy of the training
curriculum for the Contractor's Marketing Representatives
and a description of the minimum qualifications for the
Contractor's Marketing staff.
ii) A copy of all Contractor written policies and procedures related
to Marketing to Prospective Enrollees in New York City.
iii) A copy of all Marketing material and scripts for Marketing
presentations in New York City;
A) Marketing materials sent by Participating Providers to their
patients must be pre-approved by DOHMH.
iv) Advertising that is targeted solely to New York City including
videos, broadcast material (radio, television, or electronic),
billboards, mass transit and print advertising material.
2. MARKETING SCHEDULES
a) Contractor shall submit to the DOHMH, a bi-weekly schedule of all
Marketing activities in accordance with instructions for submitting
the schedule and requisite formats provided by DOHMH. The
instructions, time frames and formats may be modified by DOHMH with
thirty days prior notice to the Contractor.
b) Contractor shall submit electronically a schedule of all intended
marketing activities within HRA sites to both HRA and DOHMH.
c) DOHMH may, in its sole discretion, waive the reporting of certain
activities.
APPENDIX N
October 1, 2005
N-13
3. MARKETING MATERIALS
a) The Contractor shall ensure that Marketing brochures or similar
materials that describe Contractor services, benefits and enrollment
shall contain the following information:
i) Contractor's name and toll free telephone number and TTY
ii) A contact telephone number for New York Medicaid CHOICE
iii) The Potential Enrollee has a choice among several alternative
MCOs in his or her neighborhood
iv) The Potential Enrollee will have a choice among at least three
Primary Care Providers
v) Upon Enrollment in an MCO's MMC Product, the Enrollee will be
required to use his or her Primary Care Provider and other MCO
Participating Providers exclusively for medical care, except in
certain limited circumstances
vi) Upon Enrollment in an MCO's MMC Product, the Enrollee will have
90 days to disenroll without cause, and thereafter will not be
allowed to disenroll or transfer without good cause for the next
nine months
vii) Newborns will automatically be enrolled in the mother's MCO's MMC
Product
viii) Language advising Prospective Enrollees to verify with the
provider of their choice that the provider participates in the
Contractor's network and is available to serve the Enrollee
ix) If the Contractor does not include Family Planning and
Reproductive Health services in its Benefit Package, the
Marketing brochure must tell Prospective Enrollees that:
A) Certain Family Planning and Reproductive Health services
(such as abortion, sterilization and birth control) are not
covered by the Contractor;
B) Such services may be obtained through fee-for-service
Medicaid from any provider who accepts Medicaid; and
C) No referral is needed for such services and that there will
be no cost to the Enrollee for such services.
b) Foreign language translations of Marketing materials need not be
independently reviewed by DOHMH if the Contractor submits a letter by
the translation service attesting that it has used its best efforts to
accurately translate the Marketing material into the specified
languages. At a minimum, the translation service must perform a
reverse translation, (translate the foreign language version back into
English and compare to original document). Translated materials must
meet the readability standards described in Section 13.8 of this
Agreement.
4. MARKETING ENCOUNTERS
a) Marketing encounters must clearly inform Potential Enrollees of the
Partnership Plan policies described in paragraphs (3)(a)(iii) through
(ix) above, in addition to meeting any other information requirements
of Section 11.1 and Appendix D of this Agreement.
APPENDIX N
October 1, 2005
N-14
b) Marketing Representatives shall ask Prospective Enrollees whether they
are currently enrolled in another MCO's MMC Product, and shall not
market to persons who are enrolled in another MCO's MMC Product.
c) Marketing Representatives must give a copy of the document, "What
Managed Care Plans are Available in My Neighborhood" to Prospective
Enrollees at each Marketing encounter.
d) Marketing Representatives shall ask Prospective Enrollees whether they
currently have a provider whom they would like to continue to see, and
shall assist him or her in making sure that this provider participates
in the Contractor's network.
e) Marketing Representatives shall give a business card, identifying the
name of the representative, the name of the Contractor, and a
telephone contact number (which may be the Contractor's member
services number) to each Prospective Enrollee so that he or she may
ask follow-up questions. In the alternative, the Marketing
Representative may have this information printed or stamped on the
Contractor's Marketing flyers or brochures that are distributed to
each Prospective Enrollee.
f) Marketing Representatives shall inform Prospective Enrollees that upon
Enrollment they shall receive either a phone call or a welcome package
from the Contractor to assess their health care needs and explain how
to access Contractor services.
5. MARKETING IN HRA FACILITIES
a) Contractor may conduct Marketing activities within HRA facilities with
the prior approval of NYC HRA and must adhere to HRA procedures. HRA
shall give Contractor an allotted number of allowable Marketing
Representatives at each HRA facility, and Contractor shall not exceed
this allotment. No other Marketing Representatives for Contractor may
market within a two block perimeter of an HRA facility. Additionally,
when a Medicaid community office is located in a hospital facility,
Contractor may not market within 60 feet of the Medicaid community
office. The Contractor is required to adhere to all HRA Marketing
guidelines when marketing in HRA facilities. HRA has the right to
suspend Marketing privileges within their facilities for failure to
adhere to these guidelines.
6. MARKETING SITES
a) The Contractor may not market at sites that were not reported on its
Marketing schedule to DOHMH.
b) The Contractor shall not market in homeless shelters.
c) The Contractor shall not market in low income housing projects unless
permission is requested by the Contractor for a special event in the
public areas of the project, and
APPENDIX N
October 1, 2005
N-15
approval is received in writing from the facility, and a copy sent to
DOHMH with the Marketing schedule.
d) The Contractor shall not market within a two block perimeter of an HRA
facility (except as authorized by paragraph 5(a) of these guidelines).
e) The Contractor may not market in the same room or immediate proximity
of New York Medicaid CHOICE presentations.
7. MARKETING CONDUCT
a) All Marketing activities shall be conducted in an orderly,
non-disruptive manner and shall not interfere with the privacy of
Prospective Enrollees or the general community.
8. MARKETING REPRESENTATIVES
a) The Contractor's Marketing Representatives must attend Marketing
training sessions provided by DOHMH, upon request from DOHMH.
b) Marketing Representatives must wear visible badges with the name of
the Contractor and the Marketing Representative's name during all
Marketing activities.
c) Marketing Representatives may not wear any additional identification
badge from a Participating Provider or facility that is likely to
confuse Enrollees or lead them to believe that the Marketing
Representative is an employee of such organization. The Contractor
shall obtain prior approval from DOHMH to wear identification badges
bearing the name of any other organization.
d) Marketing Representatives employed by a subcontractor of the
Contractor or affiliated with a community based organization which
performs outreach, education and Enrollment on behalf of the
Contractor, shall attend a training session conducted by the
Contractor consistent with the training curriculum approved by DOHMH.
9. MARKETING INFRACTIONS
a) In addition to the corrective and remedial actions specified in
Section 11.5 of this Agreement, if the Contractor or its
representative commits a repeat violation or an infraction which is
not minor or unintentional, DOHMH may, following consultation with
SDOH, impose liquidated damages of $2000.00 for each such infraction.
Imposition of liquidated damages shall be taken at the sole discretion
of the DOHMH except that DOHMH shall not impose liquidated damages for
any infraction of the Contractor where SDOH has imposed a monetary
sanction.
APPENDIX N
October 1, 2005
N-16
N.7
GUIDELINES FOR THE PROCESSING OF ENROLLMENTS AND DISENROLLMENTS
IN NEW YORK CITY
1. Notwithstanding any contrary provisions in Appendix H, in New York City,
Enrollment error reports are generated by the Enrollment Broker to the
Contractor generally within 24-48 hours of Contractor Enrollment
submissions and the Contractor is able to resubmit corrections via the
Enrollment Broker before Roster pulldown. Changes in Enrollee eligibility
or Enrollment status that occur prior to production of the monthly Roster
are reported by the State to the Contractor with their rosters. Changes in
Enrollee eligibility status that occur subsequent to production of the
monthly Roster shall be reported by the Enrollment Broker by means of the
electronic bulletin board. Reports of Disenrollments processed by the
Enrollment Broker shall be reported to the Contractor as they occur by
means of the electronic bulletin board. Reports of Disenrollments processed
by HRA shall be reported to the Contractor manually as they occur or
through the HPN. In the event that the electronic bulletin board
notification process is not available for any reason, the Contractor shall
use EMEDNY to verify loss of eligibility.
2. Paragraph 6(a)(iv) of Appendix H of this Agreement (LDSS responsibilities)
is not applicable in New York City. In the event that an Enrollee loses
Medicaid eligibility, the PCP Enrollment is left on the system and removed
thereafter by SDOH if no eligibility reinstatement occurs.
3. Paragraph 3(d)(ii) of Appendix H of this Agreement is not applicable in New
York City. The Contractor shall not send verification of the infant's
demographic data to the HRA unless thirty days has expired since the date
of birth and the Contractor has not received confirmation via the HPN of a
successful Enrollment through the automated Enrollment system. When the
thirty days has expired the Contractor shall, within 10 days, send
verification of the infant's demographic data to the HRA including: the
mother's name and CIN; and the newborn's name, CIN, sex and date of birth.
Upon receipt of the data, if the Enrollment does not appear on the system,
HRA will process the retroactive Enrollment.
4. In New York City, Enrollees may initiate a request for an expedited
Disenrollment to the HRA. The HRA will expedite the Disenrollment process
in those cases where: an Enrollee's request for Disenrollment involves an
urgent medical need; the Enrollee is a homeless individual residing in the
shelter system in New York City; the Enrollee has HIV, ESRD, or a SPMI/SED
condition; the request involves a complaint of non-consenusal Enrollment;
or the Enrollee is certified blind or disabled and meets an exemption
criteria. If approved, the HRA will manually process the Disenrollment.
5. Notwithstanding paragraph (6)(a)(ix) of Appendix H of this Agreement, in
New York City, further notification by HRA is not required prior to
retroactive Disenrollment in the following instances:
APPENDIX N
October 1, 2005
N-17
(a) death or incarceration of an Enrollee;
(b) an Enrollee has duplicate CINs and is enrolled in an MCO's MMC or
FHPlus product under more than one of the CINS; or
(c) where there has been communication between the Contractor and HRA or
the Enrollment Broker regarding the date of disenrollment.
Consistent with paragraph 6(a)(ix) of Appendix H of this Agreement, the LDSS
remains responsible for sending a notice to the Contractor at the time of
Disenrollment of the Contractor's responsibility to submit to the SDOH's Fiscal
Agent voided premium claims for any full months of retroactive Disenrollment
where the Contractor was not at risk for the provision of Benefit Package
Services. Such notice shall be completed by the LDSS to include: the
Disenrollment Effective Date, the reason for the retroactive Disenrollment, and
the months for which premiums must be repayed. The Contractor has 10 days to
notify the LDSS should it refute the Disenrollment Effective Date, based on a
belief that the Contractor was at risk for the provision of Benefit Package
Services for any month for which recoupment of premium has been requested.
However failure by the LDSS to so notify the Contractor does not affect the
right of SDOH to recover premium payment as authorized by Section 3.6 of this
Agreement.
APPENDIX N
October 1, 2005
N-18
N.8
NEW YORK CITY TRANSPORTATION POLICY GUIDELINES
1. The Medicaid Managed Care Program contractual Benefit Package in New York
City includes transportation to all medical care and services that are
covered under the Medicaid program, regardless of whether the specific
medical service is included in the Benefit Package or paid for on a
fee-for-service basis, except for transportation costs to Methadone
Maintenance Treatment Programs. The transportation obligation includes the
cost of meals and lodging incurred when going to and returning from a
provider of medical care and services when distance and travel time require
these costs.
2. Generally, the Contractor may provide transportation by giving or
reimbursing the Enrollee subway/bus tokens for the round trip for their
medical care and services, if public transportation is available for such
care and services. The Contractor is not required to provide transportation
if the distance to the medical appointment is so short that the Enrollee
would customarily walk to perform other routine errands. The Contractor may
adopt policies requiring a minimum distance between an Enrollee's residence
and the medical appointment, which may not be greater than ten blocks;
however, the policy must provide transportation for Enrollees living a
lesser distance upon a showing of special circumstances such as a physical
disability on a case-by-case basis.
3. If the Enrollee has disabilities or medical conditions which prevent him or
her from utilizing public transportation, the MCO must provide accessible
transportation which is appropriate to the disability or condition such as
livery, ambulette, or taxi. The MCO may require pre-authorization of
non-public transportation except for emergency transportation.
a) The MCO shall provide livery transportation under the following
circumstances, unless the Enrollee requires transportation by
ambulette or ambulance:
i) The Enrollee is able to travel independently but due to a
debilitating physical or mental condition, cannot use the mass
transit system.
ii) The Enrollee is traveling to and from a location that is
inaccessible by mass transit.
iii) The Enrollee cannot access the mass transit system due to
temporary severe weather, which prohibits use of the normal mode
of transportation.
b) The MCO shall provide ambulette transportation under the following
circumstances, unless the Enrollee requires transportation by
ambulance:
i) The Enrollee requires personal assistance from the driver in
entering/exiting the Enrollee's residence, the ambulette and the
medical facility.
APPENDIX N
October 1, 2005
N-19
ii) The Enrollee is wheelchair-bound (non-collapsible or requires a
specially configured vehicle).
iii) The Enrollee has a mental impairment and requires the personal
assistance of the ambulette driver.
iv) The Enrollee has a severe, debilitating weakness or is mentally
disoriented as a result of medical treatment and requires the
personal assistance of the ambulette driver.
v) The Enrollee has a disabling physical condition that requires the
use of a walker, cane, crutch or brace and is unable to use
livery service or mass transportation.
c) The MCO shall provide non-emergency ambulance transportation when the
Enrollee must be transported on a stretcher and/or requires the
administration of life support equipment by trained medical personnel.
The use of non-emergency ambulance is indicated when the Enrollee's
condition would prohibit any other form of transport.
4. Emergency transportation may only be provided by accessing 911 emergency
ambulances. Urgent care transportation may be provided by any mode of
transportation so long as such mode is appropriate for the medical
condition or disability experienced by the Enrollee.
5. If an attendant is Medically Necessary to accompany the Enrollee to the
medical appointment, the Contractor is responsible for the transportation
of the attendant. A medically required attendant (authorized by the
attending physician) may include a family member, friend, legal guardian or
home health worker. When a child travels to medical care and services, and
an attendant is required, the parent or guardian of the child may act as an
attendant. In these situations, the costs of the transportation, lodging
and meals of the parent or guardian may be reimbursable, and authorization
of the attending physician is not required.
APPENDIX N
October 1, 2005
N-20
SCHEDULE 1 OF APPENDIX N
DOHMH PUBLIC HEALTH SERVICES FEE SCHEDULE
SERVICE FEE
------- -------
TB CLINIC $125.00
IMMUNIZATION $ 50.00
LEAD POISONING SCREENING $ 15.00
HIV COUNSELING AND TESTING VISIT $ 96.47
HIV COUNSELING AND NO TESTING $ 90.12
HIV POST TEST COUNSELING
Visit Negative Result $ 72.54
Visit Positive Result $ 90.12
LAB TESTS
HIV 1 (ELISA Test) $ 12.27
HIV Antibody, Confirmatory (Western Blot) $ 26.75
DENTAL SERVICES $108.00
APPENDIX N
October 1, 2005
N-21
APPENDIX O
REQUIREMENTS FOR PROOF OF WORKERS' COMPENSATION
AND DISABILITY BENEFITS COVERAGE
Appendix O
October 1, 2005
O-l
REQUIREMENTS FOR PROOF OF COVERAGE
Unless the Contractor is a political sub-division of New York State, the
Contractor shall provide proof, completed by the Contractor's insurance carrier
and/or the Workers' Compensation Board, of coverage for:
1. WORKERS' COMPENSATION, for which one of the following is incorporated into
this Agreement herein as an attachment to Appendix O:
a) Certificate of Workers' Compensation Insurance, on the Workers'
Compensation Board form C-105.2 (naming the NYS Department of Health,
Corning Tower, Rm. 1325, Albany, 12237-0016), OR Certificate of
Workers' Compensation Insurance, on the State Insurance Fund form
U-26.3 (naming the NYS Department of Health, Corning Tower, Rm. 1325,
Albany, 12237-0016); OR
b) Certificate of Workers Compensation Self-Insurance, form SI-12, OR
Certificate of Group Workers' Compensation Self-Insurance, form
GSI-105.2; OR
c) Affidavit for New York Entities And Any Out Of State Entities With No
Employees, That New York State Workers' Compensation And/Or Disability
Benefits Coverage Is Not Required, form WC/DB-100, completed for
Workers' Compensation; OR Affidavit That An OUT-OF-STATE OR FOREIGN
EMPLOYER Working In New York State Does Not Require Specific New York
State Workers' Compensation And/Or Disability Benefits Insurance
Coverage, form WC/DB-101, completed for Workers' Compensation;
[Affidavits must be notarized and stamped as received by the NYS
Workers' Compensation Board]; and
2. DISABILITY BENEFITS COVERAGE, for which one of the following is
incorporated into this Agreement herein as an attachment to Appendix O:
a) Certificate of Disability Benefits Insurance, form DB-120.1; OR
Certificate/Cancellation of Insurance, form DB-820/829; OR
b) Certificate of Disability Benefits Self-Insurance, form DB-155; OR
c) Affidavit for New York Entities And Any Out Of State Entities With No
Employees, That New York State Workers' Compensation And/Or Disability
Benefits Coverage Is Not Required, form WC/DB-100, completed for
Disability Benefits; OR Affidavit That An OUT-OF-STATE OR FOREIGN
EMPLOYER Working In New York State Does Not Require Specific New York
State Workers' Compensation And/Or Disability Benefits Insurance
Coverage, form WC/DB-101, completed for Disability Benefits;
[Affidavits must be notarized and stamped as received by the NYS
Workers' Compensation Board].
NOTE: ACORD FORMS ARE NOT ACCEPTABLE PROOF OF COVERAGE.
Appendix O
October 1, 2005
O-2
APPENDIX P
Reserved
APPENDIX P
October 1, 2005
P-1
APPENDIX Q
Reserved
APPENDIX Q
October 1, 2005
Q-1
APPENDIX R
NEW YORK CITY STANDARD LOCAL CLAUSES
R.1 GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND
TECHNICAL SERVICES (NOT-FOR-PROFIT ENTITIES)
R.2 GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS, PROFESSIONAL AND
TECHNICAL SERVICES (FOR-PROFIT ENTITIES)
APPENDIX R
October 1, 2005
R-1
APPENDIX R 1
GENERAL PROVISIONS GOVERNING CONTRACTS FOR
CONSULTANTS, PROFESSIONAL AND TECHNICAL SERVICES (Not-For-Profit entities)
CONTENTS PAGE
- -------- ----
ARTICLE 1. DEFINITIONS................................................... 2
ARTICLE 2. REPRESENTATIONS AND WARRANTIES................................ 2
2.1 Procurement of Agreement....................................... 2
2.2 Conflict of Interest........................................... 2
2.3 Fair Practices................................................. 2
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY.............................. 3
ARTICLE 4. COVENANTS OF THE CONTRACTOR................................... 3
4.1 Employees...................................................... 3
4.2 Independent Contractor Status.................................. 4
4.3 Insurance...................................................... 4
4.4 Protection of City Property.................................... 6
4.5 Confidentiality................................................ 6
4.6 Books and Records.............................................. 6
4.7 Retention of Records........................................... 6
4.8 Compliance with Law............................................ 6
4.9 Investigation Clause........................................... 6
4.10 Assignment..................................................... 8
4.11 Subcontracting................................................. 8
4.12 Publicity...................................................... 9
4.13 Participation in an International Boycott...................... 9
4.14 Inventions, Patents and Copyrights............................. 9
4.15 Infringements.................................................. 9
4.16 Anti-trust..................................................... 10
ARTICLE 5. TERMINATION................................................... 10
5.1 Termination of Agreement....................................... 10
ARTICLE 6. MISCELLANEOUS................................................. 11
6.1 Conflict of Laws............................................... 11
6.2 General Release................................................ 11
6.3 Claims and Actions Thereon..................................... 11
6.4 No Claim Against Officers, Agents or Employees................. 11
6.5 Waiver......................................................... 12
6.6 Notice......................................................... 12
6.7 All Legal Provisions Deemed Included........................... 12
6.8 Severability................................................... 12
6.9 Political Activity............................................. 12
6.10 Modification................................................... 12
6.11 Paragraph Headings............................................. 13
6.12 No Removal of Records from Premises............................ 13
6.13 Inspection at Site............................................. 13
6.14 Pricing........................................................ 13
ARTICLE 7. MERGER........................................................ 13
ARTICLE 8. CONDITIONS PRECEDENT.......................................... 13
ARTICLE 9. PPB RULES..................................................... 14
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE................. 14
ARTICLE 11. FORUM PROVISION.............................................. 15
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY ................................ 15
ARTICLE 13. NO DAMAGE FOR DELAY.......................................... 16
ARTICLE 14. CONSULTANT REPORT INFORMATION................................ 16
ARTICLE 15. RESOLUTION OF DISPUTES....................................... 17
15.4 Presentation of Dispute to Agency Head......................... 17
15.5 Presentation of Dispute to the Comptroller..................... 18
15.6 Contract Dispute Resolution Board.............................. 19
15.7 Petition to Contract Dispute Resolution Board.................. 19
ARTICLE 16. PROMPT PAYMENT............................................... 20
NFP.W/P.L.
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ARTICLE 1. DEFINITIONS
As used throughout this Agreement, the following terms shall have the meaning
set forth below:
a. "CITY" shall mean the City of New York, its departments and
political subdivisions.
b. "COMPTROLLER" shall mean the Comptroller of the City of New York.
c. "DEPARTMENT" or "AGENCY" shall mean the DEPARTMENT OF HEALTH. AND
MENTAL HYGIENE
d. "COMMISSIONER" OR "ADMINISTRATOR" shall mean the COMMISSIONER OF
HEALTH AND MENTAL HYGIENE or his duly authorized representative.
The term "duly authorized representative" shall include any
person or persons acting within the limits of his or her
authority.
e. "LAW" or "LAWS" shall include but not be limited to the New York
City Charter, the New York City AdministrativeCode, a local law
of the City of New York, and any ordinance, rule or regulation
having the force of law.
f. "CONTRACTOR"or"CONSULTANT" shall mean VENDOR
ARTICLE 2. REPRESENTATIONS AND WARRANTIES
2.1 PROCUREMENT OF AGREEMENT
A. The Contractor represents and warrants that no person or selling agency has
been employed or retained to solicit or secure this Agreement upon an
agreement or understanding for a commission, percentage, brokerage fee,
contingent fee or any other compensation. The Contractor further represents
and warrants that no payment, gift or thing of value has been made, given
or promised to obtain this or any other agreement between the parties. The
Contractor makes such representations and warranties to induce the City to
enter into this Agreement and the City relies upon such representations and
warranties in the execution hereof.
B. For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without
liability, entitling the City to recover all monies paid hereunder and the
Contractor shall not make claim for, or be entitled to recover, any sum or
sums due under this Agreement. This remedy, if effected, shall not
constitute the sole remedy afforded the City for the falsity or breach, nor
shall it constitute a waiver of the City's right to claim damages or refuse
payment or to take any other action provided for by law or pursuant to this
Agreement.
2.2 CONFLICT OF INTEREST
The Contractor represents and warrants that neither it nor any of its
directors, officers, members, partners or employees, has any interest nor
shall they acquire any interest, directly or indirectly, which would or may
conflict in any manner or degree with the performance or rendering of the
services herein provided. The Contractor further represents and warrants
that in the performance of this Agreement no person having such interest or
possible interest shall be employed by it. No elected official or other
officer or employee of the City or Department, nor any person whose salary
is payable, in whole or in part, from the City Treasury, shall participate
in any decision relating to this Agreement which affects his or her
personal interest or the interest of any corporation, partnership or
association in which he or she is, directly or indirectly, interested; nor
shall any such person have any interest, direct or indirect, in this
Agreement or in the proceeds thereof.
2.3 FAIR PRACTICES
The Contractor and each person signing on behalf of any contractor
represents and warrants and certifies, under penalty of perjury, that to
the best of its knowledge and belief:
A. The prices in this contract have been arrived at independently without
collusion, consultation, communication, or agreement, for the purpose
of restricting competition, as to any matter relating to such prices
with any other bidder or with any competitor;
B. Unless otherwise required by law, the prices which have been quoted in
this contract and on the proposal submitted by the Contractor have not
been knowingly disclosed by the Contractor prior to the proposal
opening, directly or indirectly, to any other bidder or to any
competitor; and
C. No attempt has been made or will be made by the Contractor to induce
any other person, partnership or corporation to submit or not to
submit a proposal for the purpose of restricting competition. The fact
that the Contractor (a) has published price lists, rates, or tariffs
covering items being procured, (b) has informed prospective customers
of proposed
NFP.W/P.L.
- -2-
or pending publication of new or revised price lists for such items, or (C)
has sold the same items to other customers at the same prices being bid,
does not constitute, without more, a disclosure within the meaning of the
above.
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY
3.1 All vouchers or invoices presented for payment to be made hereunder, and
the books, records and accounts upon which said vouchers or invoices are
based are subject to audit by the Department and by the Comptroller of the
City of New York pursuant to the powers and responsibilities as conferred
upon said Department and said Comptroller by the New York City Charter and
Administrative Code of the City of New York, as well as all orders and
regulations promulgated pursuant thereto.
3.2 The Contractor shall submit any and all documentation and justification in
support of expenditures or fees under this Agreement as may be required by
said Department and said Comptroller so that they may evaluate the
reasonableness of the charges and shall make its records available to the
Department and to the Comptroller as they consider necessary.
3.3 All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by
the State of New York, Federal Government and other persons duly authorized
by the City. Such audit may include examination and review of the source
and application of all funds whether from the City, any State, the Federal
Government, private sources or otherwise.
3.4 The contractor shall not be entitled to final payment under the Agreement
until all requirements have been satisfactorily met.
ARTICLE 4. COVENANTS OF THE CONTRACTOR
4.1 EMPLOYEES
A. All experts or consultants or employees of the Contractor who are employed
by the Contractor to perform work under this contract are neither employees
of the City nor under contract to the City and the Contractor alone is
responsible for their work, direction, compensation and personal conduct
while engaged under this Agreement. Nothing in this contract shall impose
any liability or duty on the City for the acts, omissions, liabilities or
obligations of the Contractor any person, firm company, agency,
association, expert, consultant, independent contractor, specialist,
trainee, employee, servant, or agent, or for taxes of any nature including
but not limited to unemployment insurance, workmen's compensation,
disability benefits and social security, or, except as specifically stated
in this contract, to any person, firm or corporation.
B. The Contractor shall be solely responsible for all physical injuries or
death to its agents, servants, or employees or to any other person or
damage to any property sustained during its operations and work on the
project under this agreement resulting from any act of omission or
commission or error in judgment of any of its officers, trustees,
employees, agents, servants, or independent contractors, and shall hold
harmless and indemnify the City from liability upon any and all claims for
damages on account of such injuries or death to any such person or damages
to property on account of any neglect, fault or default of the Contractor,
its officers, trustees, employees, agents, servants, or independent
contractors. The Contractor shall be solely responsible for the safety and
protection of all of its employees whether due to the negligence, fault or
default of the Contractor or not.
C. Workmen's Compensation and Disability Benefits
If this Agreement be of such a character that the employees engaged thereon
are required to be insured by the provision of Chapter 615 of the Laws of
1922, known as the "Workmen's Compensation Law" and acts amendatory
thereto, the Agreement shall be void and of no effect unless the Contractor
shall secure compensation for the benefit of, and keep insured during the
life of this Agreement such employees in compliance with the provisions of
said law, inclusive of Disability Benefits,; and, shall furnish the
Department with two (2) certificates of these insurance coverages.
D. Unemployment Insurance
Unemployment Insurance coverage shall be obtained and provided by the
Contractor for its employees.
NFP.W/P.L.
- -3-
E. Minimum Wage
Except for those employees whose minimum wage is required to be fixed
pursuant to Section 220 of the Labor Law of the State of New York, all
persons employed by the Contractor in the performance of this Agreement
shall be paid, without subsequent deduction or rebate, unless expressly
authorized by law, not less than the minimum wage as prescribed by law. Any
breach or violation of the foregoing shall be deemed a breach or violation
of a material provision of this Agreement.
4.2 INDEPENDENT CONTRACTOR STATUS
The Contractor and the Department agree that the Contractor is an
independent contractor, and not an employee of the Department or the City
of New York, and that in accordance with such status as independent
contractor, the Contractor covenants and agrees that neither it nor its
employees or agents will hold themselves out as, nor claim to be, officers
or employees of the City of New York, or of any department, agency or unit
thereof, by reason hereof, and that they will not, by reason hereof, make
any claim, demand or application to or for any right or privilege
applicable to an officer or employee of the City of New York, including,
but not limited to, Workmen's Compensation coverage, Unemployment Insurance
Benefits, Social Security coverage or employee retirement membership or
credit.
4.3 INSURANCE
A. INSURANCE REQUIREMENTS FOR CONTRACTORS
Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property
which may arise from or in connection with the performance of the work
hereunder by the Contractor, his agents, representatives, employees or
subcontractors. All required insurance policies shall be maintained with
companies that may lawfully issue the required policy and have an A.M. Best
rating of at least A-7 or a Standard and Poor's rating of at least AA,
unless prior written approval is obtained from the Mayor's Office of
Operations. The cost of such insurance shall be included in the
Contractor's bid.
a. Minimum Scope of Insurance
Coverage shall be at least as broad as:
1. Insurance Services Office form number GL 0002 (1/73) covering
Comprehensive General Liability and Insurance Services Office
form number GL 0404 covering Broad Form Comprehensive General
Liability; or Insurance Services Office Commercial General
Liability coverage ("occurrence" form CG 0001).(ED 11/85).
2. Insurance Services Office form number CA 0001 (Ed. 1/78) covering
Automobile Liability, code 1 "any auto" and endorsements CA 2232
and CA 0112.
3. Workers' Compensation insurance as required by Labor Code of the
State of New York and Employers Liability insurance.
b. Minimum Limits of Insurance
Contractor shall maintain limits no less than:
1. Comprehensive General Liability: $1,000,000.00 combined single
limit per accident for bodily injury and property damage.
2. Professional liability: 1 Million Dollars per occurrence; Three
Million Dollars Aggregate.
3. Workers' Compensation and Employers Liability: Workers'
Compensation limits as required by the Labor Code of the State of
New York Employers Liability limits of $1,000,000.00 per
accident. Pursuant to Section 57 of the NYS Workers' Compensation
Law, the vendor has submitted proof of workers' compensation and
disability benefits coverage to the agency.
NFP.W/P.L.
- -4-
c. Deductibles and Self-Insured Retentions
Any deductibles and self-insured retentions must be declared to and
approved by the Agency. At the option of the Agency, either: the
insurer shall reduce or eliminate such deductibles or self-insured
retentions as respects and Agency, its officers, officials and
employees; or the Contractor shall procure a bond guaranteeing payment
of losses and related investigations, claim administration and defense
expenses.
1. General Liability and Automobile Liability Coverages
a. The City, its officers, officials and employees are to be
covered as insured as respects: liability arising out of
activities performed by or on behalf of the Contractor;
products and completed operations of the Contractor;
premises owned, leases or used by the Contractor; or
automobiles owned, leased, hired or borrowed by the
Contractor. The coverage shall contain no special
limitations on the scope of protection afforded to the City,
its officers, officials and employees.
b. The Contractor's insurance coverage shall be primary
insurance as respect the City, its officers, officials, and
employees. Any other insurance or self-insurance maintained
by the Agency, its officers, officials and employees shall
be excess of and not contribute with the Contractor's
insurance.
c. Any failure to comply with reporting provisions of the
policies shall not affect coverage provided to the Agency,
its officers, officials, and employees.
d. The Contractor's insurance shall apply separately to each
insured against whom claim is made or suit is brought,
except with respect to the limits of the insurers liability.
2. Workers' Compensation and Employers Liability Coverage
The insurer shall agree to waive all rights of subrogation
against the Agency, its officers, officials, and employees for
losses arising from work performed by the Contractor for Agency.
3. All Coverages
Each insurance policy required by this clause shall be endorsed
to state that coverage shall not be suspended, voided, cancelled
by either party, reduced in coverage or in limits except after
sixty (60) days prior written notice by certified mail, return
receipt requested, has been given to the City.
d. Acceptability of Insurers
Insurance is to be placed with insurers with an A.M. Best rating of at
least A-7 or a Standard and Poor's rating of at least AA, unless prior
written approval is obtained from the Mayor's Office of Operations.
e. Verification of Coverage
Contractor shall furnish the City with Certificates of Insurance
effecting coverage required by this clause. The Certificates for each
insurance policy are to be signed by a person authorized by that
insurer to bind coverage on its behalf. The Certificates are to be on
forms provided by the Agency and are to be received and approved by
the Agency before work commences. The Agency reserves the right to
obtain complete, certified copies of all required insurance policies,
at any time.
f. Subcontractors
Contractor shall include all subcontractors as insured under its
policies or shall furnish separate Certificates for each
subcontractor. All coverages for subcontractors shall be subject to
all of the requirements stated herein.
B. In the event that any claim is made or any action is brought against the
City arising out of negligent or careless acts of an employee of the
Contractor, either within or without the scope of his employment, or
arising out of Contractor's negligent performance of this Agreement, then
the City shall have the right to withhold further payments hereunder for
the purpose of set-off in sufficient sums to cover the said claim or
action. The rights and remedies of the City provided
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for in this clause shall not be exclusive and are in addition to any other
rights and remedies provided by law or this Agreement.
4.4 PROTECTION OF CITY PROPERTY
A. The Contractor assumes the risk of, and shall be responsible for, any loss
or damage to City property, including property and equipment leased by the
City, used in the performance of this Agreement; and caused, either
directly or indirectly by the acts, conduct, omissions or lack of good
faith of the Contractor, its officers, managerial personnel and employees,
or any person, firm, company, agent or others engaged by the Contractor as
expert, consultant, specialist or subcontractor hereunder.
B. In the event that any such City property is lost or damaged, except for
normal wear and tear, then the City shall have the right to withhold
further payments hereunder for the purpose of set-off, in sufficient sums
to cover such loss or damage.
C. The Contractor agrees to indemnify the City and hold it harmless from any
and all liability or claim for damages due to any such loss or damage to
any such City property described in subsection A above.
D. The rights and remedies of the City provided herein shall not be exclusive
and are in addition to any other rights and remedies provided by law or by
this Agreement.
4.5 CONFIDENTIALITY
All of the reports, information or data, furnished to or prepared,
assembled or used by the Contractor under this Agreement are to be held
confidential, and prior to publication, the Contractor agrees that the same
shall not be made available to any individual or organization without the
prior written approval of the Department.
4.6 BOOKS AND RECORDS
The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any
nature expended in the performance of this Agreement.
4.7 RETENTION OF RECORDS
The Contractor agrees to retain all books, records, and other documents
relevant to this Agreement for six years after the final payment or
termination of this Agreement, whichever is later. City, State and Federal
auditors and any other persons duly authorized by the Department shall have
full access to and the right to examine any of said materials during said
period.
4.8 COMPLIANCE WITH LAW
Contractor shall render all services under this Agreement in accordance
with the applicable provisions of federal, state and local laws, rules and
regulations as are in effect at the time such services are rendered.
4.9 INVESTIGATION CLAUSE
1. The parties to this agreement agree to cooperate fully and faithfully
with any investigation, audit or inquiry conducted by a State of New
York (State) or City of New York (City) governmental agency or
authority that is empowered directly or by designation to compel the
attendance of witnesses and to examine witnesses under oath, or
conducted by the Inspector General of a governmental agency that is a
party in interest to the transaction, submitted bid, submitted
proposal, contract, lease, permit, or license that is the subject of
the investigation, audit or inquiry.
2(a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her
in any subsequent criminal proceeding refuses to testify before a
grand jury or other governmental agency or authority empowered
directly or by designation to compel the attendance of witnesses and
to examine witnesses under oath concerning the award of or performance
under any transaction,
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agreement, lease, permit, contract, or license entered into with the
City, the State, or any political subdivision or public authority
thereof, or the Port Authority of New York and New Jersey, or any
local development corporation within the City, or any public benefit
corporation organized under the laws of the State of New York, or;
(b) If any person refuses to testify for a reason other than the assertion
of his or her privilege against self-incrimination in an
investigation, audit or inquiry conducted by a City or State
governmental agency or authority empowered directly or by designation
to compel the attendance of witnesses and to take testimony under
oath, or by the Inspector General of the governmental agency that is a
party in interest in, and is seeking testimony concerning the award
of, or performance under, any transaction, agreement, lease, permit,
contract, or license entered into with the City, the State, or any
political subdivision thereof or any local development corporation
within the City, then;
3(a) The commissioner or agency head whose agency is a party in interest to
the transaction, submitted bid, submitted proposal, contract, lease,
permit, or license shall convene a hearing, upon not less than five
(5) days written notice to the parties involved, to determine if any
penalties should attach for the failure of a person to testify.
3(b) If any non-governmental party to the hearing requests an adjournment,
the commissioner or agency head who convened the hearing may, upon
granting the adjournment, suspend any contract, lease, permit, or
license pending the final determination pursuant to paragraph 5 below
without the City incurring any penalty or damages for delay or
otherwise.
4. The penalties which may attach after a final determination by the
commissioner or agency head may include but shall not exceed:
(a) The disqualification for a period not to exceed five (5) years from
the date of an adverse determination for any person, or any entity of
which such person was a member at the time the testimony was sought,
from submitting bids for, or transacting business with, or entering
into or obtaining any contract, lease, permit or license with or from
the City; and/or
(b) The cancellation or termination of any and all such existing City
contracts, leases, permits or licenses that the refusal to testify
concerns and that have not been assigned as permitted under this
agreement, nor the proceeds of which pledged, to an unaffiliated and
unrelated institutional lender for fair value prior to the issuance of
the notice scheduling the hearing, without the City incurring any
penalty or damages on account of such cancellation or termination;
monies lawfully due for goods delivered, work done, rentals, or fees
accrued prior to the cancellation or termination shall be paid by the
City.
5. The commissioner or agency head shall consider and address in reaching
his or her determination and in assessing an appropriate penalty the
factors in paragraphs (a) and (b) below. He or she may also consider,
if relevant and appropriate, the criteria established in paragraphs
(c) and (d) below in addition to any other information which may be
relevant and appropriate:
(a) The party's good faith endeavors or lack thereof to cooperate fully
and faithfully with any governmental investigation or audit, including
but not limited to the discipline, discharge, or disassociation of any
person failing to testify, the production of accurate and complete
books and records, and the forthcoming testimony of all other members,
agents, assignees or fiduciaries whose testimony is sought.
(b) The relationship of the person who refused to testify to any entity
that is a party to the hearing, including, but not limited to, whether
the person whose testimony is sought has an ownership interest in the
entity and/or the degree of authority and responsibility the person
has within the entity.
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(c) The nexus of the testimony sought to the subject entity and its
contracts, leases, permits or licenses with the City.
(d) The effect a penalty may have on an unaffiliated and unrelated party
or entity that has a significant interest in an entity subject to
penalties under 4 above, provided that the party or entity has given
actual notice to the commissioner or agency head upon the acquisition
of the interest, or at the hearing called for in 3(a) above gives
notice and proves that such interest was previously acquired. Under
either circumstance the party or entity must present evidence at the
hearing demonstrating the potential adverse impact a penalty will have
on such person or entity.
6. The term "license" or "permit" as used herein shall be defined as a
license, permit, franchise or concession not granted as a matter of
right.
(a) The term "person" as used herein shall be defined as any natural
person doing business alone or associated with another person or
entity as a partner, director, officer, principal or employee.
(b) The term "entity" as used herein shall be defined as any firm,
partnership, corporation, association, or person that receives monies,
benefits, licenses, leases, or permits from or through the City or
otherwise transacts business with the City.
(c) The term "member" as used herein shall be defined as any person
associated with another person or entity as a partner, director,
officer, principal or employee.
7. In addition to and notwithstanding any other provision of this
agreement the Commissioner or agency head may in his or her sole
discretion terminate this agreement upon not less than three (3) days
written notice in the event contractor fails to promptly report in
writing to the Commissioner of Investigation of the City of New York
any solicitation of money, goods, requests for future employment or
other benefit or thing of value, by or on behalf of any employee of
the City or other person, firm, corporation or entity for any purpose
which may be related to the procurement or obtaining of this agreement
by the contractor, or affecting the performance of this contract.
4.10 ASSIGNMENT
A. The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor's rights, obligations, duties, in whole or
in part, or of its right to execute it, or its right, title or interest in
it or any part thereof, or assign, by power of attorney or otherwise, any
of the notices due or to become due under this contract, unless the prior
written consent of the Administrator shall be obtained. Any such
assignment, transfer, conveyance or other disposition without such consent
shall be void.
B. Failure of the Contractor to obtain any required consent to any assignment,
shall be cause for termination for cause, at the option of the
Administrator; and if so terminated, the City shall thereupon be relieved
and discharged from any further liability and obligation to the Contractor,
its assignees or transferees, and all monies that may become due under the
contract shall be forfeited to the City except so much thereof as may be
necessary to pay the Contractor's employees.
C. The provisions of this clause shall not hinder, prevent, or affect an
assignment by the Contractor for the benefit of its creditors made pursuant
to the laws of the State of New York.
D. This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.
4.11 SUBCONTRACTING
A. The Contractor agrees not to enter into any subcontracts for the
performance of its obligations, in whole or in part, under this Agreement
without the prior written approval of the Department. Two copies of each
such proposed subcontract
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shall be submitted to the Department with the Contractor's written request
for approval. All such subcontracts shall contain provisions specifying:
1. that the work performed by the subcontractor must be in accordance
with the terms of the Agreement between the Department and the
Contractor,
2. that nothing contained in such agreement shall impair the rights of
the Department,
3. that nothing contained herein, or under the Agreement between the
Department and the Contractor, shall create any contractual relation
between the subcontractor and the Department, and
4. that the subcontractor specifically agrees to be bound by the
confidentiality provision set forth in this Agreement between the
Department and the Contractor.
B. The Contractor agrees that it is fully responsible to the Department for
the acts and omissions of the subcontractors and of persons either directly
or indirectly employed by them as it is for the acts and omissions of
persons directly employed by it.
C. The aforesaid approval is required in all cases other than individual
employer-employee contracts.
D. The Contractor shall not in any way be relieved of any responsibility under
this Contract by any subcontract.
4.12 PUBLICITY
A. The prior written approval of the Department is required before the
Contractor or any of its employees, servants, agents, or independent
contractors may, at any time, either during or after completion or
termination of this Agreement, make any statement to the press or issue any
material for publication through any media of communication bearing on the
work performed or data collected under this Agreement.
B. If the Contractor publishes a work dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in
such performance, the Department shall have a royalty free, non-exclusive
and irrevocable license to reproduce, publish or otherwise use and to
authorize others to use the publication.
4.13 PARTICIPATION IN AN INTERNATIONAL BOYCOTT
A. The Contractor agrees that neither the Contractor nor any
substantially-owned affiliated company is participating or shall
participate in an international boycott in violation of the provisions of
the Export Administration Act of 1979, as amended, or the regulations of
the United States Department of Commerce promulgated thereunder.
B. Upon the final determination by the Commerce Department or any other agency
of the United States as to, or conviction of the Contractor or a
substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of 1979, as amended, or the regulations promulgated
thereunder, the Comptroller may, at his option, render forfeit and void
this contract.
C. The Contractor shall comply in all respects, with the provisions of Section
6-114 of the Administrative Code of the City of New York and the rules and
regulations issued by the Comptroller thereunder.
4.14 INVENTIONS, PATENTS AND COPYRIGHTS
A. Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds,
shall be promptly and fully reported to the Federal Government for
determination as to whether patent protection on such invention shall be
sought and how the rights in the invention or discovery, including rights
under any patent issued thereon, shall be disposed of and administered in
order to protect the public interest.
B. No report, document or other data produced in whole or in part with
contract funds shall be copyrighted by the Contractor nor shall any notice
of copyright be registered by the Contractor in connection with any report,
document or other data developed for the contract.
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C. In no case shall subsections A and B of this section apply to, or prevent
the Contractor from asserting or protecting its rights in any report,
document or other data, or any invention which existed prior to or was
developed or discovered independently from the activities directly related
to this Agreement.
4.15 INFRINGEMENTS
The Contractor shall be liable to the Department and hereby agrees to
indemnify and hold the Department harmless for any damage or loss or
expense sustained by the Department from any infringement by the Contractor
of any copyright, trademark or patent rights of design, systems, drawings,
graphs, charts, specifications or printed matter furnished or used by the
Contractor in the performance of this Agreement.
4.16 ANTI-TRUST
The Contractor hereby assigns, sells, and transfers to the City all right,
title and interest in and to any claims and causes of action arising under
the anti-trust laws of the State of New York or of the United States
relating to the particular goods or services purchased or procured by the
City under this Agreement.
ARTICLE 5. TERMINATION
5.1 TERMINATION OF AGREEMENT
A. The Department and/or City shall have the right to terminate this
Agreement, in whole or in part:
1. Under any right to terminate as specified in any section of this
Agreement.
2. Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.
3. Upon the Contractor's becoming insolvent.
4. Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily.
5. Upon the Commissioner's determination, termination is in the best
interest of the City.
B. The Department or City shall give the Contractor written notice of any
termination of this Agreement specifying therein the applicable provisions
of subsection A of this section and the effective date thereof which shall
not be less than ten (10) days from the date the notice is received.
C. The Contractor shall be entitled to apply to the Department to have this
Agreement terminated by said Department by reason of any failure in the
performance of this Agreement (including any failure by the Contractor to
make progress in the prosecution of work hereunder which endangers such
performance), if such failure arises out of causes beyond the control and
without the fault or negligence of the Contractor. Such causes may include,
but are not restricted to: acts of God or of the public enemy; acts of the
Government in either its sovereign or contractual capacity; fires; floods;
epidemics; quarantine restrictions; strikes; freight embargoes; or any
other cause beyond the reasonable control of the Contractor. The
determination that such failure arises out of causes beyond the control and
without the fault or negligence of the Contractor shall be made by the
Department which agrees to exercise reasonable judgment therein. If such a
determination is made and the Agreement terminated by the Department
pursuant to such application by the Contractor, such termination shall be
deemed to be without cause.
D. Upon termination of this Agreement the Contractor shall comply with the
Department or City close-out procedures, including but not limited to:
1. Accounting for and refund to the Department or City, within thirty
(30) days, any unexpended funds which have been paid to the Contractor
pursuant to this agreement.
2. Furnishing within thirty (30) days an inventory to the Department or
City of all equipment, appurtenances and property purchased through or
provided under this Agreement carrying out any Department or City
directive concerning the disposition thereof.
3. Not incurring or paying any further obligation pursuant to this
Agreement beyond the termination date. Any obligation necessarily
incurred by the Contractor on account of this Agreement prior to
receipt of notice of termination and falling due after such date shall
be paid by the Department or City in accordance with the terms
NFP.W/P.L.
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of this Agreement. In no event shall the word "obligation," as used
herein, be construed as including any lease agreement, oral or
written, entered into between the Contractor and its landlord.
4. Turn over to the Department or City or its designees all books,
records, documents and material specifically relating to this
Agreement.
5. Submit, within ninety (90) days, a final statement and report relating
to this Agreement. The report shall be made by a certified public
accountant or a licensed public accountant.
E. In the event the Department or City shall terminate this Agreement, in
whole or in part, as provided in paragraphs 1, 2, 3, or 4 of subsection A
of this section, the Department or City may procure, upon such terms and in
such manner as deemed appropriate, services similar to those so terminated,
and the Contractor shall continue the performance of this Agreement to the
extent not terminated hereby.
F. Not withstanding any other provisions of this contract, the Contractor
shall not be relieved of liability to the City for damages sustained by the
City by virtue of Contractor's breach of the contract, and the City may
withhold payments to the Contractor for the purpose of set-off until such
time as the exact amount of damages due to the City from the Contractor is
determined.
G. The provisions of the Agreement regarding confidentiality of information
shall remain in full force and effect following any termination.
H. The rights and remedies of the City provided in this section shall not be
exclusive and are in addition to all other rights and remedies provided by
law or under this Agreement.
ARTICLE 6. MISCELLANEOUS
6.1 CONFLICT OF LAWS
All disputes arising out of this Agreement shall be interpreted and decided
in accordance with the laws of the State of New York.
6.2 GENERAL RELEASE
The acceptance by the Contractor or its assignees of the final payment
under this contract, whether by voucher, judgment of any court of
competent jurisdiction or any other administrative means, shall constitute
and operate as a general release to the City from any and all claims of and
liability to the Contractor arising out of the performance of this
contract.
6.3 CLAIMS AND ACTIONS THEREON
A. No action at law or proceeding in equity against the City or Department
shall lie or be maintained upon any claim based upon this Agreement or
arising out of this Agreement or in any way connected with this Agreement
unless the Contractor shall have strictly complied with all requirements
relating to the giving of notice and of information with respect to such
claims, all as herein provided.
B. No action shall lie or be maintained against the City by Contractor upon
any claims based upon this Agreement unless such action shall be commenced
within six (6) months after the date of filing in the Office of the
Comptroller of the City of the certificate for the final payment hereunder,
or within six (6) months of the termination or conclusion of this
Agreement, or within six (6) months after the accrual of the Cause of
Action, whichever first occurs.
C. In the event any claim is made or any action brought in any way relating to
the Agreement herein, the Contractor shall diligently render to the
Department and/or the City of New York without additional compensation any
and all assistance which the Department and/or the City of New York may
require of the Contractor.
D. The Contractor shall report to the Department in writing within three (3)
working days of the initiation by or against the Contractor of any legal
action or proceeding in connection with or relating to this Agreement.
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6.4 NO CLAIM AGAINST OFFICERS, AGENTS OR EMPLOYEES
No claim whatsoever shall be made by the Contractor against any officer,
agent or employee of the City for, or on account of, anything done or
omitted in connection with this contract.
6.5 WAIVER
Waiver by the Department of a breach of any provision of this Agreement
shall not be deemed to be a waiver of any other or subsequent breach and
shall not be construed to be a modification of the terms of the Agreement
unless and until the same shall be agreed to in writing by the Department
or City as required and attached to the original Agreement.
6.6 NOTICE
The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered,
or to which they shall be mailed. Actual delivery of any such notice,
direction or communication to a party at the aforesaid place, or delivery
by certified mail shall be conclusive and deemed to be sufficient service
thereof upon such party as of the date such notice, direction or
communication is received by the party. Such address may be changed at any
time by an instrument in writing executed and acknowledged by the party
making such change and delivered to the other party in the manner as
specified above. Nothing in this section shall be deemed to serve as a
waiver of any requirements for the service of notice or process in the
institution of an action or proceeding as provided by law, including the
Civil Practice Law and Rules.
6.7 ALL LEGAL PROVISIONS DEEMED INCLUDED
It is the intent and understanding of the parties to this Agreement that
each and every provision of law required to be inserted in this Agreement
shall be and is inserted herein. Furthermore, it is hereby stipulated that
every such provision is to be deemed to be inserted herein, and if, through
mistake or otherwise, any such provision is not inserted, or is not
inserted in correct form, then this Agreement shall forthwith upon the
application of either party be amended by such insertion so as to comply
strictly with the law and without prejudice to the rights of either party
hereunder.
6.8 SEVERABILITY
If this Agreement contains any unlawful provision not an essential part of
the Agreement and which shall not appear to have been a controlling or
material inducement to the making thereof, the same shall be deemed of no
effect and shall upon notice by either party, be deemed stricken from the
Agreement without affecting the binding force of the remainder.
6.9 POLITICAL ACTIVITY
There shall be no partisan political activity or any activity to further
the election or defeat of any candidate for public, political or party
office as part of or in connection with this Agreement, nor shall any of
the funds provided under this Agreement be used for such purposes.
6.10 MODIFICATION
This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof. It may not be altered or
modified orally.
A. CONTRACT CHANGES
Changes may be made to this contract only as duly authorized by the Agency
Chief Contracting Officer of his or her designee. Vendors deviating from
the requirements of an original purchase order or contract without a duly
authorized change order document, or written contract modification or
amendment, do so at their own risk. All such duly authorized changes,
modifications and amendments will be reflected in a written change order
and become a part of the original contract. Contract changes will be made
only for work necessary to complete the work included in the original scope
of the contract, and for non-material changes to the scope of the contract.
Changes are not permitted for any material alteration in the scope of the
work. Changes may include any one or more of the following:
- Specification changes to account for design errors or omissions;
NFP.W/P.L.
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- changes in contract amount due to authorized additional or
omitted work. Any such changes require appropriate price and cost
analysis to determine reasonableness. In addition, except for
non-construction requirements contracts, all changes that
cumulatively exceed the greater of ten percent of the original
contract amount or $100,000 shall be approved by the City Chief
Procurement Officer.
- Extensions of a contract term for good and sufficient cause for a
cumulative period not to exceed one year from the date of
expiration of this current contract. Requirements contracts shall
be subject to this limitation;
- Changes in delivery location;
- Changes in shipment method; and
- Any other change not inconsistent with Section 4-02 of the P.P.B.
Rules (ed. 9/00), or any successor Rule.
The Contractor may be entitled to a price adjustment for extra work
performed pursuant to a written change order. If any part of the contract
work is necessarily delayed by a change order, the Contractor may be
entitled to an extension of time for performance. Adjustments to price
shall be validated for reasonableness by using appropriate price and cost
analysis.
6.11 PARAGRAPH HEADINGS
Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of
this contract and in no way affect this contract.
6.12 NO REMOVAL OF RECORDS FROM PREMISES
Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department's
designated official.
6.13 INSPECTION AT SITE
The Department shall have the right to have representatives of the
Department or of the City or of the State or Federal governments present at
the site of the engagement to observe the work being performed.
6.14 PRICING
A. The Contractor shall when ever required during the contract, including but
not limited to the time of bidding, submit cost or pricing data and
formally certify that, to the best of its knowledge and belief, the cost or
pricing date submitted was accurate, complete, and current as of a
specified date. The Contractor shall be required to keep its submission of
cost and pricing date current until the contract has been completed.
B. The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any significant
sums by which the City finds that such price was based on cost or price
data furnished by the supplier which was inaccurate, incomplete, or not
current as of the date agreed upon between the parties.
C. Time for Certification. The Contractor must certify that the cost or
pricing data submitted are accurate, complete and current as of a mutually
determined date.
D. Refusal to Submit Data. When any contractor refuses to submit the required
data to support a price, the Contracting Officer shall not allow the price.
E. Certificate of Current Cost or Pricing Data. Form of Certificate. In those
cases when cost or pricing data is required, certification shall be made
using a certificate substantially similar to the one contained in Chapter 4
of the PPB rules and such certification shall be retained in the agency
contract file.
ARTICLE 7. MERGER
This written Agreement contains all the terms and conditions agreed upon by the
parties hereto, and no other agreement, oral or otherwise, regarding the subject
matter of this Agreement shall be deemed to exist or to bind any of the parties
hereto, or to vary any of the terms contained herein.
NFP.W/P.L.
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ARTICLE 8. CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:
A. Approved by the Mayor pursuant to the provisions of Executive Order No. 42,
dated October 9, 1975, in the event the Executive Order requires such
approval; and
B. Certified by the Mayor (Mayor's Fiscal Committee created pursuant to
Executive Order No. 43, dated October 14, 1975) that performance thereof
will be in accordance with the City's financial plan; and
C. Approved by the New York State Financial Control Board (Board) pursuant to
the New York State Financial Emergency Act for the City of New York, as
amended, (the "Act"), in the event regulations of the Board pursuant to the
Act require such approval.
D. It has been authorized by the Mayor and the Comptroller shall have endorsed
his certificate that there remains unexpended and unapplied a balance of
the appropriation of funds applicable thereto sufficient to pay the
estimated expense of carrying out this Agreement. The requirements of this
section of the contract shall be in addition to, and not in lieu of, any
approval or authorization otherwise required for this contract to be
effective and for the expenditure of City funds.
ARTICLE 9. PPB RULES
This contract is subject to the Rules of the Procurement Policy Board of the
City of New York effective August 1, 1990, as amended. In the event of a
conflict between said Rules and a provision of this contract, the Rules shall
take precedence.
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
1. As required by New York State Labor Law Section 220-e:
a. That in the hiring of employees for the performance of work under
this contract or any subcontract hereunder, neither the
Contractor, Subcontractor, nor any person acting on behalf of
such Contractor or Subcontractor, shall by reason of race, creed,
color, sex or national origin discriminate against any citizen of
the State of New York who is qualified and available to perform
the work to which the employment relates;
b. That neither the Contractor, subcontractor, nor any person on his
behalf shall, in any manner, discriminate against or intimidate
any employee hired for the performance of work under this
contract on account of race, creed, color, sex or national
origin;
c. That there may be deducted from the amount payable to the
Contractor by the City under this contract a penalty of five
dollars for each person for each calendar day during which such
person was discriminated against or intimidated in violation of
the provisions of this contract; and
d. That this contract may be canceled or terminated by the City and
all monies due or to become due hereunder may be forfeited, for a
second or any subsequent violation of the terms or conditions of
this section of the contract.
e. The aforesaid provisions of this section covering every contract
for or on behalf of the State or a municipality for the
manufacture, sale or distribution of materials, equipment or
supplies shall be limited to operations performed within the
territorial limits of the State of New York.
2. As required by New York City Administrative Code Section 6-108:
a. It shall be unlawful for any person engaged in the construction,
alteration or repair of buildings or engaged in the construction
or repair of streets or highways pursuant to a contract with the
City or engaged in the manufacture, sale or distribution of
materials, equipment or supplies pursuant to a contract with the
City to refuse to employ or to refuse to continue in any
employment any person on account of the race, color or creed of
such person.
b. It shall be unlawful for any person or any servant, agent or
employee of any person, described in subdivision (a) above, to
ask, indicate or transmit, orally or in writing, directly or
indirectly, the race, color, creed or religious affiliation of
any person employed or seeking employment from such person, firm
or corporation.
c. Disobedience of the foregoing provisions shall be deemed a
violation of a material provision of this contract.
d Any person, or the employee, manager or owner of or officer of
such firm or corporation who shall violate any of the provisions
of this section shall, upon conviction thereof, be punished by a
fine of not more than one hundred dollars or by imprisonment for
not more than thirty days, or both.
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ARTICLE 11. FORUM PROVISION CHOICE OF LAW, CONSENT TO JURISDICTION AND VENUE
This Contract shall be deemed to be executed in the City of New York, State of
New York, regardless of the domicile of the Contractor, and shall be governed by
and construed in accordance with the laws of the State of New York. The parties
agree that any and all claims asserted by or against the City arising under this
Contract or related thereto shall be heard and determined either in the courts
of the United States located in New York City ("Federal Courts") or in the
courts of the State of New York ("New York State Courts") located in the City
and County of New York. To effect this Agreement and intent, the Contractor
agrees:
a. If the City initiates any action against the Contractor in
Federal Court or in New York State Court, service of process may
be made on the Contractor either in person, wherever such
Contractor may be found, or by registered mail addressed to the
Contractor at its address as set forth in this Contract, or to
such other address as the Contractor may provide to the City in
writing; and
b. With respect to any action between the City and the Contractor in
New York State Court, the Contractor hereby expressly waives and
relinquishes any rights it might otherwise have (I) to move to
dismiss on grounds of forum non conveniens; (ii) to remove to
Federal Court; and (iii) to move for a change of venue to a New
York State Court outside New York County.
c. With respect to any action between the City and the Contractor in
Federal Court located in New York City, the Contractor expressly
waives and relinquishes any right it might otherwise have to move
to transfer the action to a United States Court outside the City
of New York.
d. If the Contractor commences any action against the City in a
court located other than in the City and State of New York, upon
request of the City, the Contractor shall either consent to a
transfer of the action to a court of competent jurisdiction
located in the City and State of New York or, if the court where
the action is initially brought will not or cannot transfer the
action, the Contractor shall consent to dismiss such action
without prejudice and may thereafter reinstitute the action in a
court of competent jurisdiction in New York City. If any
provision(s) of this Article is held unenforceable for any
reason, each and all other provision(s) shall nevertheless remain
in full force and effect.
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY
This contract is subject to the requirements of Executive Order No. 50 (1980) as
revised ("E.O. 50") and the Rules and Regulations promulgated thereunder. No
contract will be awarded unless and until these requirements have been complied
with in their entirety. By signing this contract, the contractor agrees that it:
1. will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national
origin, sex age, disability, marital status or sexual orientation with
respect to all employment decisions including, but not limited to,
recruitment, hiring, upgrading, demotion, downgrading, transfer,
training, rates of pay or other forms of compensation, layoff,
termination, and all other terms and conditions of employment;
2. the contractor agrees that when it subcontracts it will not engage in
any unlawful discrimination in the selection of subcontractors on the
basis of the owner's race, color, creed, national origin, sex, age,
disability, marital status or sexual orientation;
3. will state in all solicitations or advertisements for employees placed
by or on behalf of the contractor that all qualified applicants will
receive consideration for employment without unlawful discrimination
based on race, creed, color, national origin, sex, age, disability,
marital status or sexual orientation, or that it is an equal
employment opportunity employer;
4. will send to each labor organization or representative of workers with
which it has a collective bargaining agreement or other contract or
memorandum of understanding, written notification of its equal
employment opportunity commitments under E. O. 50 and the rules and
regulations promulgated thereunder; and
5. will furnish all information and reports including an Employment
Report before the award of the contract which are required by E. O.
50, the rules and regulations promulgated thereunder, and orders of
the Director of the Bureau of Labor Services ("Bureau"), and will
permit access to its books, records and accounts by the Bureau for the
purposes of investigation to ascertain compliance with such rules,
regulations, and orders. The contractor understands that in the event
of its noncompliance with nondiscrimination clauses of this contract
or with any of such rules, regulations, or orders, such noncompliance
shall constitute a material breach of the contract and noncompliance
with the E. O. 50 and the rules and regulations promulgated
thereunder. After a hearing held pursuant to the rules of the Bureau,
the Director may direct the imposition by the contracting agency held
of any or all of the following sanctions:
(i) disapproval of the contractor;
NFP.W/P.L.
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(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or
(iv) in lieu of any of the foregoing sanctions, the Director may
impose an employment program. The Director of the Bureau may
recommend to the contracting agency head that a Board of
Responsibility be convened for purposes of declaring a
contractor who has repeatedly failed to comply with E.O. 50
and the rule and regulations promulgated thereunder to be
nonresponsible. The contractor agrees to include the
provisions of the foregoing paragraphs in every subcontract
or purchase order in excess of $50,000 to which it becomes a
party unless exempted by E.O. 50 and the rules and
regulations promulgated thereunder, so that such provisions
will be binding upon each subcontractor or vendor. The
contractor will take such action with respect to any
subcontract or purchase order as may be directed by the
Director of the Bureau of Labor Services as a means of
enforcing such provisions, including sanctions for
noncompliance. The contractor further agrees that it will
refrain from entering into any contract or contract
modification subject to E.O. 50 and the rules and
regulations promulgated thereunder with a subcontractor who
is not in compliance with the requirements of E.O. 50 and
the rules and regulations promulgated thereunder.
ARTICLE 13. NO DAMAGE FOR DELAY
The Contractor agrees to make no claim for damages for delay in the performance
of this Contract occasioned by any act or omission to act of the City or any of
its representatives, and agrees that any such claim shall be fully compensated
for by an extension of time to complete performance of the work as provided
herein.
ARTICLE 14. CONSULTANT REPORT INFORMATION
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or representative of a City department,
agency, commission or body or to any corporation, association or entity whose
expenses are paid in whole or in part from the City treasury shall be furnished
to the Commissioner of the department to which such report was submitted or, if
not a City department, then to the chief controlling officer or officers of such
other office or entity. A copy of such report shall also be furnished to the
Director of the Mayor's Office of Construction for matters related to
construction or to the Director of the Mayor's Office of Operations for all
other matters.
ARTICLE 15. RESOLUTION OF DISPUTES
15.1 All disputes between the City and the Contractor of the kind delineated in
this section that arise under, or by virtue of, this Contract shall be finally
resolved in accordance with the provisions of this section and Section 4-09 of
the Rules of the Procurement Policy Board ("PPB Rules"), and any successor Rule.
The procedure for resolving all disputes of the kind delineated herein shall be
the exclusive means of resolving any such disputes.
a. This section shall not apply to disputes concerning matters dealt
with in other sections of the PPB Rules or to disputes involving
patents, copyrights, trademarks, or trade secrets (as interpreted
by the courts of New York State) relating to proprietary rights
in computer software.
b. For construction and construction-related services this section
shall apply only to disputes about the scope of work delineated
by the Contract, the interpretation of Contract Documents, the
amount to be paid for extra work or disputed work performed in
connection with the Contract, the conformity of the Contractor's
work to the Contract, and the acceptability and quality of the
Contractor's work; such disputes arise when the Engineer makes a
determination with which the Contractor disagrees.
15.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on the
information and evidence presented to the party making the determination.
Failure to make such determination within the time period required by this
section shall be deemed a non-determination without prejudice that will allow
appeal to the next level.
15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with the
Contract and as directed by the Agency Chief Contracting Officer or Engineer.
Failure of the Contractor to continue the work as directed shall constitute a
waiver by the Contractor of any and all claims being presented pursuant to this
section and a material breach of Contract.
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15.4 Presentation of Dispute to Agency Head.
(A) Notice of Dispute and Agency Response. The Contractor shall present its
dispute in writing ("Notice of Dispute") to the Agency Head within the time
specified herein or, if no time is specified, within thirty (30) days of
receiving notice of the determination or action that is the subject of the
dispute. This notice requirement shall not be read to replace any other notice
requirements contained in the Contract. The Notice of Dispute shall include all
the facts, evidence, documents, or other basis upon which the Contractor relies
in support of its position, as well as a detailed computation demonstrating how
any amount of money claimed by the Contractor in the dispute was arrived at.
Within thirty (30) days after receipt of the detailed written submission, the
Agency Chief Contracting Officer or, in the case of construction or
construction-related services, the Engineer shall submit to the Agency Head all
materials he or she deems pertinent to the dispute. Following initial
submissions to the Agency Head, either party may demand of the other the
production of any document or other material the demanding party believes may be
relevant to the dispute. The requested party shall produce all relevant
materials that are not otherwise protected by a legal privilege recognized by
the courts of New York State. Any question of relevancy shall be determined by
the Agency Head whose decision shall be final. Wilful failure of the Contractor
to produce any requested material whose relevancy the Contractor has not
disputed, or whose relevancy has been affirmatively determined, shall constitute
a waiver by the Contractor of its claim.
(B) Agency Head Inquiry. The Agency Head shall examine the material and
may, in his or her discretion, convene an informal conference with the
Contractor and the Agency Chief Contracting Officer and, in the case of
construction or construction-related services, the Engineer to resolve the issue
by mutual consent prior to reaching a determination. The Agency Head may seek
such technical or other expertise as he or she shall deem appropriate, including
the use of neutral mediators, and require any such additional material from
either or both parties as he or she deems fit. The Agency Head's ability to
render, and the effect of, a decision hereunder shall not be impaired by any
negotiations in connection with the dispute presented, whether or not the Agency
Head participated therein. The Agency Head may or, at the request of any party
to the dispute, shall compel the participation of any other contractor with a
contract related to the work of this Contract, and that contractor shall be
bound by the decision of the Agency Head. Any contractor thus brought into the
dispute resolution proceeding shall have the same rights to make presentations
and to seek review as the Contractor initiating the dispute.
(C) Agency Head Determination. Within thirty (30) days after the receipt of
all materials and information, or such longer time as may be agreed to by the
parties, the Agency Head shall make his or her determination and shall deliver
or send a copy of such determination to the Contractor and Agency Chief
Contracting Officer and, in the case of construction or construction-related
services, the Engineer, together with a statement concerning how the decision
may be appealed.
(D) Finality of Agency Head Decision. The Agency Head's decision shall be
final and binding on all parties, unless presented to the Contract Dispute
Resolution Board pursuant to this section. The City may not take a petition to
the Contract Dispute Resolution Board. However, should the Contractor take such
a petition, the City may seek, and the Board may render, a determination less
favorable to the Contractor and more favorable to the City than the decision of
the Agency Head.
15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.
(A) Time, Form, and Content of Notice. Within thirty (30) days of its
receipt of a decision by the Agency Head, the Contractor shall submit to the
Comptroller and to the Agency Head a Notice of Claim regarding its dispute with
the Agency. The Notice of Claim shall consist of (i) a brief written statement
of the substance of the dispute, the amount of money, if any, claimed and the
reason(s) the Contractor contends the dispute was wrongly decided by the Agency
Head; (ii) a copy of the written decision of the Agency Head, and (iii) a copy
of all materials submitted by the Contractor to the Agency, including the Notice
of Dispute. The Contractor may not present to the Comptroller any material not
presented to the Agency Head, except at~the request of the Comptroller.
(B) Agency Response. Within thirty (30) days of receipt of the Notice of
Claim, the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.
NFP.W/P.L.
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(C) Comptroller Investigation. The Comptroller may investigate the claim in
dispute and, in the course of such investigation, may exercise all powers
provided in sections 7-201 and 7-203 of the New York City Administrative Code.
In addition, the Comptroller may demand of either party, and such party shall
provide, whatever additional material the Comptroller deems pertinent to the
claim, including original business records of the Contractor. Wilful failure of
the Contractor to produce within fifteen (15) days any material requested by the
Comptroller shall constitute a waiver by the Contractor of its claim. The
Comptroller may also schedule an informal conference to be attended by the
Contractor, Agency representatives, and any other personnel desired by the
Comptroller.
(D) Opportunity of Comptroller to Compromise or Adjust Claim. The
Comptroller shall have forty-five (45) days from his or her receipt of all
materials referred to in 5. (C) to investigate the disputed claim. The period
for investigation and compromise may be further extended by agreement between
the Contractor and the Comptroller, to a maximum of ninety (90) days from the
Comptroller's receipt of all the materials. The Contractor may not present its
petition to the Contract Dispute Resolution Board until the period for
investigation and compromise delineated in this paragraph has expired. In
compromising or adjusting any claim hereunder, the Comptroller may not revise or
disregard the terms of the Contract between the parties.
15.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed of:
A. the chief administrative law judge of the Office of Administrative
Trials and Hearings ("OATH") or his/her designated OATH administrative
law judge, who shall act as chairperson, and may adopt operational
procedures and issue such orders consistent with this section as may
be necessary in the execution of the Contract Dispute Resolution
Board's functions, including, but not limited to, granting extensions
of time to present or respond to submissions;
B. the City Chief Procurement Officer or a designee; or in the case of
disputes involving construction, the Director of the Office of
Construction or his/her designee; any designee shall have the
requisite background to consider and resolve the merits of the dispute
and shall not have participated personally and substantially in the
particular matter that is the subject of the dispute or report to
anyone who so participated, and
C. a neutral person with appropriate expertise. This person shall be
selected by the presiding administrative law judge from a prequalified
panel of individuals, established and administered by OATH, with
appropriate background to act as decision-makers in a dispute. Such
individuals may not have a contract or dispute with the City or be an
officer or employee of any company or organization that does, or
regularly represents persons, companies, or organizations having
disputes with the City.
15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided in
this section, the Contractor, within thirty (30) days thereafter, may petition
the Contract Dispute Resolution Board to review the Agency Head determination.
(A) Form and Content of Petition by Contractor. The Contractor shall
present its dispute to the Contract Dispute Resolution Board in the form of a
Petition, which shall include (i) a brief written statement of the substance of
the dispute, the amount of money, if any, claimed and the reason(s) the
Contractor contends that the dispute was wrongly decided by the Agency Head;
(ii) a copy of the written decision of the Agency Head; (iii) copies of all
materials submitted by the Contractor to the Agency; (iv) a copy of the written
decision of the Comptroller, if any, and (v) copies of all correspondence with,
or written material submitted by the Contractor to, the Comptroller's Office.
The Contractor shall concurrently submit four complete sets of the Petition: one
to the Corporation Counsel (Attn: Commercial and Real Estate Litigation
Division), and three to the Contract Dispute Resolution Board at OATH's offices
with proof of service on the Corporation Counsel. In addition, the supplier
shall submit a copy of the statement of the substance of the dispute, cited in
(i) above to both the Agency Head and the Comptroller.
(B) Agency Response. Within thirty (30) days of its receipt of the Petition
by the Corporation Counsel, the Agency shall respond to the brief written
statement of the Contractor and make available to the Board at OATH's offices
and one to the Contractor, all material it submitted to the Agency Head and
Comptroller. Extensions of time for submittal of the agency response shall be
given as necessary upon a showing of good cause or, upon the consent of the
parties, for an initial period of up to thirty (30) days.
(C) Further Proceedings. The Board shall permit the Contractor to present
its case by
NFP.W/P.L.
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the submission of memoranda, briefs, and oral argument. The Board shall also
permit the Agency to present its case in response to the Contractor by the
submission of memoranda, briefs, and oral argument. If requested by the
Corporation Counsel, the Comptroller shall provide reasonable assistance in the
preparation of the Agency's case. Neither the Contractor nor the Agency may
support its case with any documentation or other material that was not
considered by the Comptroller, unless requested by the Board. The Board, at its
discretion, may seek such technical or other expertise as it shall deem
appropriate and may seek, on its own or upon application of a party, any such
additional material from any party as it deems fit. The Board, in its
discretion, may combine more than one dispute between the parties of concurrent
resolution.
(D) Contract Dispute Resolution Board Determination. Within forty-five (45)
days of the conclusion of all written submissions and oral arguments, the Board
shall render a written decision resolving the dispute. In an unusually complex
case, the Board may render its decision in a longer period of time, not to
exceed ninety (90) days, and shall so advise the parties at the commencement of
this period. The Board's decision must be consistent with the terms of the
Contract. In reaching its decision, the Board shall accord no precedential
significance to prior decisions of the Board involving other non-related
contracts.
(E) Notification of Contract Dispute Resolution Board Decision. The Board
shall send a copy of its decision to the Contractor, the Agency Chief
Contracting Officer, the Corporation Counsel, the Comptroller, and in the case
of construction or construction-related services, the Engineer. A decision in
favor of the Contractor shall be subject to the prompt payment provisions of the
PPB Rules. The Required Payment Day shall be thirty (30) days after the date the
parties are formally notified of the Board's decision.
(F) Finality of Contract Dispute Resolution Board Decision. The Board's
decision shall be final and binding on all parties. Any party may seek review of
the Board's decision solely in the form of a challenge, made within four (4)
months of the date of the Board's decision, in a court of competent jurisdiction
of the State of New York, County of New York, pursuant to Article 78 of the
Civil Practice Law and Rules. Such review by the court shall be limited to the
question of whether or not the Board's decision was made in violation of lawful
procedure, was affected by an error of law, or was arbitrary and capricious or
an abuse of discretion. No evidence or information shall be introduced or relied
upon in such proceeding that was not presented to the Board in accordance with
Section 4-09 of the PPB Rules.
15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall not
affect or impair the ability of the Agency Head or Contract Dispute Resolution
Board to make a binding and final decision pursuant to this section.
ARTICLE 16. PROMPT PAYMENT
The Prompt Payment provisions set forth in Chapter 4, Section 4-06 of the
Procurement Policy Board Rules in effect at the time for this solicitation will
be applicable to payments made under this contract. The provisions require the
payment to the contractors of interest on payments made after the required
payment date except as set forth in Section 4-06 of the Rules.
The contractor must submit a proper invoice to receive payment, except where the
contract provides that the contractor will be paid at predetermined intervals
without having to submit an invoice for each scheduled payment.
Determinations of interest due will be made in accordance with the provisions of
the Procurement Policy Board Rules and General Municipal Law Section 3-a.
NFP.W/P.L.
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APPENDIX R 2
GENERAL PROVISIONS GOVERNING CONTRACTS FOR CONSULTANTS,
PROFESSIONAL AND TECHNICAL SERVICES (For-Profit Entities)
CONTENTS PAGE
- -------- ----
ARTICLE 1. DEFINITIONS 1
ARTICLE 2. REPRESENTATIONS AND WARRANTIES 1
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY 2
ARTICLE 4. COVENANTS OF THE CONTRACTOR 3
ARTICLE 5. TERMINATION 10
ARTICLE 6. MISCELLANEOUS 12
ARTICLE 7. MERGER 15
ARTICLE 8. CONDITIONS PRECEDENT 15
ARTICLE 9. PPB RULES 15
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE 15
ARTICLE 11. FORUM PROVISION 16
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY 17
ARTICLE 13. NO DAMAGE FOR DELAY 18
ARTICLE 14. CONSULTANT REPORT INFORMATION 18
ARTICLE 15. RESOLUTION OF DISPUTES 18
ARTICLE 16. PROMPT PAYMENT 22
ARTICLE 17. MACBRIDE PRINCIPLES 22
ARTICLE 1. DEFINITIONS
As used throughout this Agreement, the following terms shall have the
meaning set forth below:
a. "CITY" shall mean the City of New York, its departments and political
subdivisions.
b. "COMPTROLLER" shall mean the Comptroller of the City of New York.
c. "DEPARTMENT" or "Agency" shall mean the DEPARTMENT OF HEALTH AND
MENTAL HYGIENE.
d. "COMMISSIONER" or "ADMINISTRATOR" shall mean the COMMISSIONER OF
HEALTH AND MENTAL HYGIENE or his duly authorized representative. The
term "duly authorized representative" shall include any person or
persons acting within the limits of his or her authority.
e. "LAW" or "LAWS" shall include but not be limited to the New York City
Charter, the New York City Administrative Code, a local law of the
City of New York, and any ordinance, rule or regulation having the
force of law.
f. "CONTRACTOR" or "CONSULTANT" shall mean CarePlus, L.L.C.
ARTICLE 2. REPRESENTATIONS AND WARRANTIES
2.1 PROCUREMENT OF AGREEMENT
A. The Contractor represents and warrants that no person or selling agency has
been employed or retained to solicit or secure this Agreement upon an
agreement or understanding for a commission, percentage, brokerage fee,
contingent fee or any other compensation. The Contractor further represents
and warrants that no payment, gift or thing of value has been made, given
or promised to obtain this or any other agreement between the parties. The
Contractor makes such representations and warranties to induce the City to
enter
Profit.w/P.L.
- -1-
into this Agreement and the City relies upon such representations and
warranties in the execution hereof.
? For a breach or violation of such representations or warranties, the
Administrator shall have the right to annul this Agreement without
liability, entitling the City to recover all monies paid hereunder and the
Contractor shall not make claim for, or be entitled to recover, any sum or
sums due under this Agreement. This remedy, if effected, shall not
constitute the sole remedy afforded the City for the falsity or breach, nor
shall it constitute a waiver of the City's right to claim damages or refuse
payment or to take any other action provided for by law or pursuant to this
Agreement.
2.2 CONFLICT OF INTEREST
The Contractor represents and warrants that neither it nor any of its
directors, officers, members, partners or employees, has any interest nor
shall they acquire any interest, directly or indirectly, which would or may
conflict in any manner or degree with the performance or rendering of the
services herein provided. The Contractor further represents and warrants
that in the performance of this Agreement no person having such interest or
possible interest shall be employed by it. No elected official or other
officer or employee of the City or Department, nor any person whose salary
is payable, in whole or in part, from the City Treasury, shall participate
in any decision relating to this Agreement which affects his or her
personal interest or the interest of any corporation, partnership or
association in which he or she is, directly or indirectly, interested; nor
shall any such person have any interest, direct or indirect, in this
Agreement or in the proceeds thereof.
2.3 FAIR PRACTICES
The Contractor and each person signing on behalf of any contractor
represents and warrants and certifies, under penalty of perjury, that to
the best of its knowledge and belief:
A. The prices in this contract have been arrived at independently without
collusion, consultation, communication, or agreement, for the purpose
of restricting competition, as to any matter relating to such prices
with any other bidder or with any competitor;
B. Unless otherwise required by law, the prices which have been quoted in
this contract and on the proposal submitted by the Contractor have not
been knowingly disclosed by the Contractor prior to the proposal
opening, directly or indirectly, to any other bidder or to any
competitor; and
C. No attempt has been made or will be made by the Contractor to induce
any other person, partnership or corporation to submit or not to
submit a proposal for the purpose of restricting competition.
The fact that the Contractor (a) has published price lists, rates, or
tariffs covering items being procured, (b) has informed prospective
customers of proposed or pending publication of new or revised price lists
for such items, or (c) has sold the same items to other customers at the
same prices being bid, does not constitute, without more, a disclosure
within the meaning of the above.
ARTICLE 3. AUDIT BY THE DEPARTMENT AND CITY
3.1 All vouchers or invoices presented for payment to be made hereunder, and
the books, records and accounts upon which said vouchers or invoices are
based are subject to audit by the Department and by the Comptroller of the
City of New York pursuant to the powers and responsibilities as conferred
upon said Department and said Comptroller by the New York City Charter and
Administrative Code of the City of New York, as well as all orders and
regulations promulgated pursuant thereto.
3.2 The Contractor shall submit any and all documentation and justification in
support of expenditures or fees under this
Profit.w/P.L.
- -2-
Agreement as may be required by said Department and said Comptroller so
that they may evaluate the reasonableness of the charges and shall make its
records available to the Department and to the Comptroller as they consider
necessary.
3.3 All books, vouchers, records, reports, canceled checks and any and all
similar material may be subject to periodic inspection, review and audit by
the State of New York, Federal Government and other persons duly authorized
by the City. Such audit may include examination and review of the source
and application of all funds whether from the City, any State, the Federal
Government, private sources or otherwise.
3.4 The contractor shall not be entitled to final payment under the Agreement
until all requirements have been satisfactorily met.
ARTICLE 4. COVENANTS OF THE CONTRACTOR
?.1 EMPLOYEES
? All experts or consultants or employees of the Contractor who are employed
by the Contractor to perform work under this contract are neither employees
of the City nor under contract to the City and the Contractor alone is
responsible for their work, direction, compensation and personal conduct
while engaged under this Agreement. Nothing in this contract shall impose
any liability or duty on the City for the acts, omissions, liabilities or
obligations of the Contractor any person, firm company, agency,
association, expert, consultant, independent contractor, specialist,
trainee, employee, servant, or agent, or for taxes of any nature including
but not limited to unemployment insurance, workmen's compensation,
disability benefits and social security, or, except as specifically stated
in this contract, to any person, firm or corporation.
?. The Contractor shall be solely responsible for all physical injuries or
death to its agents, servants, or employees or to any other person or
damage to any property sustained during its operations and work on the
project under this agreement resulting from any act of omission or
commission or error in judgment of any of its officers, trustees,
employees, agents, servants, or independent contractors, and shall hold
harmless and indemnify the City from liability upon any and all claims for
damages on account of such injuries or death to any such person or damages
to property on account of any neglect, fault or default of the Contractor,
its officers, trustees, employees, agents, servants, or independent
contractors. The Contractor shall be solely responsible for the safety and
protection of all of its employees whether due to the negligence, fault or
default of the Contractor or not.
C. Workmen's Compensation and Disability Benefits
If this Agreement be of such a character that the employees engaged thereon
are required to be insured by the provision of Chapter 615 of the Laws of
1922, known as the "Workmen's Compensation Law" and acts amendatory
thereto, the Agreement shall be void and of no effect unless the Contractor
shall secure compensation for the benefit of, and keep insured during the
life of this Agreement such employees in compliance with the provisions of
said law, inclusive of Disability Benefits,; and, shall furnish the
Department with two (2) certificates of these insurance coverages.
D. Unemployment Insurance
Unemployment Insurance coverage shall be obtained and provided by the
Contractor for its employees.
E. Minimum Wage
Except for those employees whose minimum wage is required to be fixed
pursuant to Section 220 of the Labor Law of the State of New York, all
persons employed by the Contractor in the performance of this Agreement
shall be paid, without subsequent deduction or rebate, unless expressly
authorized by law, not less than the minimum wage as prescribed by law. Any
breach or violation of the foregoing shall be deemed a breach or violation
of a material provision of this Agreement.
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?.2 INDEPENDENT CONTRACTOR STATUS
The Contractor and the Department agree that the Contractor is an
independent contractor, and not an employee of the Department or the City
of New York, and that in accordance with such status as independent
contractor, the Contractor covenants and agrees that neither it nor its
employees or agents will hold themselves out as, nor claim to be, officers
or employees of the City of New York, or of any department, agency or unit
thereof, by reason hereof, and that they will not, by reason hereof, make
any claim, demand or application to or for any right or privilege
applicable to an officer or employee of the City of New York, including,
but not limited to, Workmen's Compensation coverage, Unemployment Insurance
Benefits, Social Security coverage or employee retirement membership or
credit.
?.3 INSURANCE
?. Insurance Requirements for Contractors
Contractors shall procure and maintain for the duration of the contract
insurance against claims for injuries to persons or damages to property
which may arise from or in connection with the performance of the work
hereunder by the Contractor, his agents, representatives, employees or
subcontractors. All required insurance policies shall be maintained with
companies that may lawfully issue the required policy and have an A.M. Best
rating of at least A-7 or a Standard and Poor's rating of at least AA,
unless prior written approval is obtained from the Mayor's Office of
Operations. The cost of such insurance shall be included in the
Contractor's bid.
a. Minimum Scope of Insurance
Coverage shall be at least as broad as:
1. Insurance Services Office form number GL 0002 (1/73) covering
Comprehensive General Liability and Insurance Services Office form
number GL 0404 covering Broad Form Commercial General Liability
Insurance General Liability; or Insurance Services Office Commercial
General Liability coverage ("occurrence" form CG 0001).(ED 11/85).
2. Insurance Services Office form number CA 0001 (Ed. 1/78) covering
Automobile Liability, code 1 "any auto" and endorsements CA 2232 and
CA 0112.
3. Workers' Compensation insurance as required by Labor Code of the State
of New York and Employers Liability insurance.
b. Minimum Limits of Insurance
Contractor shall maintain limits no less than:
1. Comprehensive General Liability: $1,000,000.00 combined single limit
per accident for bodily injury and property damage.
2. Professional liability: 1 Million Dollars per occurrence; Three
Million Dollars Aggregate.
3. Workers' Compensation and Employers Liability: Workers' Compensation
limits as required by the Labor Code of the State of New York
Employers Liability limits of $1,000,000.00 per accident. Pursuant to
Section 57 of the NYS Workers' Compensation Law, the vendor has
submitted proof of workers' compensation and disability benefits
coverage to the agency.
c. Deductibles and Self-Insured Retentions
Any deductibles and self-insured retentions must be declared to and
approved by the Agency. At the option of the Agency, either: the
insurer shall reduce or eliminate such deductibles or self-insured
retentions as respects the Agency, its officers, officials and
employees; or the Contractor shall procure a bond guaranteeing payment
of losses and related investigations, claim administration and defense
expenses.
1. General Liability and Automobile Liability Coverages
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a. The City, its officers, officials and employees are to be covered as
insured as respects: liability arising out of activities performed by or on
behalf of the Contractor; products and completed operations of the
Contractor; premises owned, leases or used by the Contractor; or
automobiles owned, leased, hired or borrowed by the Contractor. The
coverage shall contain no special limitations on the scope of protection
afforded to the City, its officers, officials and employees.
b. The Contractor's insurance coverage shall be primary insurance as respect
the City, its officers, officials, and employees. Any other insurance or
self-insurance maintained by the Agency, its officers, officials and
employees shall be excess of and not contribute with the Contractor's
insurance.
c. Any failure to comply with reporting provisions of the policies shall not
affect coverage provided to the Agency, its officers, officials, and
employees.
d. The Contractor's insurance shall apply separately to each insured against
whom claim is made or suit is brought, except with respect to the limits of
the insurers liability.
2. Workers Compensation and Employers Liability Coverage
The insurer shall agree to waive all rights of subrogation against the
Agency, its officers, officials, and employees for losses/rising from work
performed by the Contractor for Agency.
3. All Coverages
Each insurance policy required by this clause shall be endorsed to state
that coverage shall not be suspended, voided, cancelled by either party,
reduced in coverage or in limits except after sixty (60) days prior written
notice by certified mail, return receipt requested, has been given to the
City.
d. Acceptability of Insurers
Insurance is to be placed with insurers with a Best's rating of no less
than A.M. Best rating of at least A-7 or a Standard and Poor's rating of at
least AA, unless prior written approval is obtained from the Mayor's Office
of Operations.
e. Verification of Coverage
Contractor shall furnish the City with Certificates of Insurance effecting
coverage required by this clause. The Certificates for each insurance
policy are to be signed by a person authorized by that insurer to bind
coverage on its behalf. The Certificates are to be on forms provided by the
Agency and are to be received and approved by the Agency before work
commences. The Agency reserves the right to obtain complete, certified
copies of all required insurance policies, at any time.
f. Subcontractors
Contractor shall include all subcontractors as insured under its policies
or shall furnish separate Certificates for each subcontractor. All
coverages for subcontractors shall be subject to all of the requirements
stated herein.
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?.? In the event that any claim is made or any action is brought against the
City arising out of negligent or careless acts of an employee of the
Contractor, either within or without the scope of his employment, or
arising out of Contractor's negligent performance of this Agreement, then
the City shall have the right to withhold further payments hereunder for
the purpose of set-off in sufficient sums to cover the said claim or
action. The rights and remedies of the City provided for in this clause
shall not be exclusive and are in addition to any other rights and remedies
provided by law or this Agreement.
4.4 PROTECTION OF CITY PROPERTY
A. The Contractor assumes the risk of, and shall be responsible for, any
loss or damage to City property, including property and equipment
leased by the City, used in the performance of this Agreement; and
caused, either directly or indirectly by the acts, conduct, omissions
or lack of good faith of the Contractor, its officers, managerial
personnel and employees, or any person, firm, company, agent or others
engaged by the Contractor as expert, consultant, specialist or
subcontractor hereunder.
B. In the event that any such City property is lost or damaged, except
for normal wear and tear, then the City shall have the right to
withhold further payments hereunder for the purpose of set-off, in
sufficient sums to cover such loss or damage.
C. The Contractor agrees to indemnify the City and hold it harmless from
any and all liability or claim for damages due to any such loss or
damage to any such City property described in subsection A above.
D. The rights and remedies of the City provided herein shall not be
exclusive and are in addition to any other rights and remedies
provided by law or by this Agreement.
?.5 CONFIDENTIALITY
All of the reports, information or data, furnished to or prepared,
assembled or used by the Contractor under this Agreement are to be held
confidential, and prior to publication, the Contractor agrees that the same
shall not be made available to any individual or organization without the
prior written approval of the Department.
4.6 BOOKS AND RECORDS
The Contractor agrees to maintain separate and accurate books, records,
documents and other evidence and accounting procedures and practices which
sufficiently and properly reflect all direct and indirect costs of any
nature expended in the performance of this Agreement.
4.7 RETENTION OF RECORDS
The Contractor agrees to retain all books, records, and other documents
relevant to this Agreement for six years after the final payment or
termination of this Agreement, whichever is later. City, State and Federal
auditors and any other persons duly authorized by the Department shall have
full access to and the right to examine any of said materials during said
period.
4.8 COMPLIANCE WITH LAW
Contractor shall render all services under this Agreement in accordance
with the applicable provisions of federal, state and local laws, rules and
regulations as are in effect at the time such services are rendered.
4.9 INVESTIGATION CLAUSE
1. The parties to this agreement agree to cooperate fully and faithfully with
any investigation, audit or inquiry conducted by a State of New York
(State) or City of New York (City) governmental agency or authority that is
empowered directly or by designation to compel the attendance of witnesses
and to examine witnesses under oath, or conducted by the Inspector General
of a governmental agency that is a party in interest to the transaction,
submitted bid, submitted proposal, contract, lease, permit, or license that
is the subject of the investigation, audit or inquiry.
2.
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?a) If any person who has been advised that his or her statement, and any
information from such statement, will not be used against him or her in any
subsequent criminal proceeding refuses to testify before a grand jury or
other governmental agency or authority empowered directly or by designation
to compel the attendance of witnesses and to examine witnesses under oath
concerning the award of or performance under any transaction, agreement,
lease, permit, contract, or license entered into with the City, the State,
or any political subdivision or public authority thereof, or the Port
Authority of New York and New Jersey, or any local development corporation
within the City, or any public benefit corporation organized under the laws
of the State of New York, or;
?b) If any person refuses to testify for a reason other than the assertion of
his or her privilege against self-incrimination in an investigation, audit
or inquiry conducted by a City or State governmental agency or authority
empowered directly or by designation to compel the attendance of witnesses
and to take testimony under oath, or by the Inspector General of the
governmental agency that is a party in interest in, and is seeking
testimony concerning the award of, or performance under, any transaction,
agreement, lease, permit, contract, or license entered into with the City,
the State, or any political subdivision thereof or any local development
corporation within the City, then;
?a) The commissioner or agency head whose agency is a party in interest to the
transaction, submitted bid, submitted proposal, contract, lease, permit, or
license shall convene a hearing, upon not less than five (5) days written
notice to the parties involved, to determine if any penalties should attach
for the failure of a person to testify.
?3.
(b) If any non-governmental party to the hearing requests an adjournment, the
commissioner or agency head who convened the hearing may, upon granting the
adjournment, suspend any contract, lease, permit, or license pending the
final determination pursuant to paragraph 5 below without the City
incurring any penalty or damages for delay or otherwise.
4. The penalties which may attach after a final determination by the
commissioner or agency head may include but shall not exceed:
(a) The disqualification for a period not to exceed five (5) years from the
date of an adverse determination for any person, or any entity of which
such person was a member at the time the testimony was sought, from
submitting bids for, or transacting business with, or entering into or
obtaining any contract, lease, permit or license with or from the City;
and/or
(b) The cancellation or termination of any and all such existing City
contracts, leases, permits or licenses that the refusal to testify concerns
and that have not been assigned as permitted under this agreement, nor the
proceeds of which pledged, to an unaffiliated and unrelated institutional
lender for fair value prior to the issuance of the notice scheduling the
hearing, without the City incurring any penalty or damages on account of
such cancellation or termination; monies lawfully due for goods delivered,
work done, rentals, or fees accrued prior to the cancellation or
termination shall be paid by the City.
5. The commissioner or agency head shall consider and address in reaching his
or her determination and in assessing an appropriate penalty the factors in
paragraphs (a) and (b) below. He or she may also consider, if relevant and
appropriate, the criteria established in paragraphs (c) and (d) below in
addition to any other information which may be relevant and appropriate:
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(a) The party's good faith endeavors or lack thereof to cooperate fully and
faithfully with any governmental investigation or audit, including but not
limited to the discipline, discharge, or disassociation of any person
failing to testify, the production of accurate and complete books and
records, and the forthcoming testimony of all other members, agents,
assignees or fiduciaries whose testimony is sought.
(b) The relationship of the person who refused to testify to any entity that is
a party to the hearing, including, but not limited to, whether the person
whose testimony is sought has an ownership interest in the entity and/or
the degree of authority and responsibility the person has within the
entity.
(c) The nexus of the testimony sought to the subject entity and its contracts,
leases, permits or licenses with the City.
(d) The effect a penalty may have on an unaffiliated and unrelated party or
entity that has a significant interest in an entity subject to penalties
under 4 above, provided that the party or entity has given actual notice to
the commissioner or agency head upon the acquisition of the interest, or at
the hearing called for in 3(a) above gives notice and proves that such
interest was previously acquired. Under either circumstance the party or
entity must present evidence at the hearing demonstrating the potential
adverse impact a penalty will have on such person or entity.
(a) The term "license" or "permit" as used herein shall be defined as a
license, permit, franchise or concession not granted as a matter of right.
(b) The term "person" as used herein shall be defined as any natural person
doing business alone or associated with another person or entity as a
partner, director, officer, principal or employee.
(c) The term "entity" as used herein shall be defined as any firm, partnership,
corporation, association, or person that receives monies, benefits,
licenses, leases, or permits from or through the City or otherwise
transacts business with the City.
(d) The term "member" as used herein shall be defined as any person associated
with another person or entity as a partner, director, officer, principal or
employee.
7. In addition to and notwithstanding any other provision of this agreement
the Commissioner or agency head may in his or her sole discretion terminate
this agreement upon not less than three (3) days written notice in the
event contractor fails to promptly report in writing to the Commissioner of
Investigation of the City of New York any solicitation of money, goods,
requests for future employment or other benefit or thing of value, by or on
behalf of any employee of the City or other person, firm, corporation or
entity for any purpose which may be related to the procurement or obtaining
of this agreement by the contractor, or affecting the performance of this
contract.
4.10 ASSIGNMENT
A. The Contractor shall not assign, transfer, convey or otherwise dispose of
this Agreement or of Contractor's rights, obligations, duties, in whole or
in part, or of its right to execute it, or its right, title or interest in
it or any part thereof, or assign, by power of attorney or otherwise, any
of the notices due or to become due under this contract, unless the prior
written consent of the Administrator shall be obtained. Any such
assignment, transfer, conveyance or other disposition without such consent
shall be void.
B. Failure of the Contractor to obtain any required consent to any assignment,
shall be cause for termination for cause, at the option of the
Administrator; and if so terminated, the City shall thereupon be relieved
and discharged from any further liability and obligation to the Contractor,
its assignees or transferees, and all monies that may become due under the
contract shall be forfeited to the City
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except so much thereof as may be necessary to pay the Contractor's
employees.
C. The provisions of this clause shall not hinder, prevent, or affect an
assignment by the Contractor for the benefit of its creditors made pursuant
to the laws of the State of New York.
D. This Agreement may be assigned by the City to any corporation, agency or
instrumentality having authority to accept such assignment.
4.11 SUBCONTRACTING
A. The Contractor agrees not to enter into any subcontracts for the
performance of its obligations, in whole or in part, under this Agreement
without the prior written approval of the Department. Two copies of each
such proposed subcontract shall be submitted to the Department with the
Contractor's written request for approval. All such subcontracts shall
contain provisions specifying:
1. that the work performed by the subcontractor must be in accordance with the
terms of the Agreement between the Department and the Contractor,
2. that nothing contained in such agreement shall impair the rights of the
Department,
3. that nothing contained herein, or under the Agreement between the
Department and the Contractor, shall create any contractual relation
between the subcontractor and the Department, and
4. that the subcontractor specifically agrees to be bound by the
confidentiality provision set forth in this Agreement between the
Department and the Contractor.
B. The Contractor agrees that it is fully responsible to the Department for
the acts and omissions of the subcontractors and of persons either directly
or indirectly employed by them as it is for the acts and omissions of
persons directly employed by it.
C. The aforesaid approval is required in all cases other than individual
employer-employee contracts.
D. The Contractor shall not in any way be relieved of any responsibility under
this Contract by any subcontract.
4.12 PUBLICITY
A. The prior written approval of the Department is required before the
Contractor or any of its employees, servants, agents, or independent
contractors may, at any time, either during or after completion or
termination of this Agreement, make any statement to the press or issue any
material for publication through any media of communication bearing on the
work performed or data collected under this Agreement.
B. If the Contractor publishes a work dealing with any aspect of performance
under this Agreement, or of the results and accomplishments attained in
such performance, the Department shall have a royalty free, non-exclusive
and irrevocable license to reproduce, publish or otherwise use and to
authorize others to use the publication.
4.13 PARTICIPATION IN AN INTERNATIONAL BOYCOTT
A. The Contractor agrees that neither the Contractor nor any
substantially-owned affiliated company is participating or shall
participate in an international boycott in violation of the provisions of
the Export Administration Act of 1979, as amended, or the regulations of
the United States Department of Commerce promulgated thereunder.
B. Upon the final determination by the Commerce Department or any other agency
of the United States as to, or conviction of the Contractor or a
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substantially-owned affiliated company thereof, participation in an
international boycott in violation of the provisions of the Export
Administration Act of ?79, as amended, or the regulations promulgated
hereunder, the Comptroller may, at his option, render forfeit and void
this contract.
C. The Contractor shall comply in all respects, with the provisions of Section
6-114 of the Administrative Code of the City of New York and the rules and
regulations issued by the Comptroller thereunder.
4.14 INVENTIONS, PATENTS AND COPYRIGHTS
A. Any discovery or invention arising out of or developed in the course of
performance of this Agreement shall be promptly and fully reported to the
Department, and if this work is supported by a federal grant of funds,
shall be promptly and fully reported to the Federal Government for
determination as to whether patent protection on such invention shall be
sought and how the rights in the invention or discovery, including rights
under any patent issued thereon, shall be disposed of and administered in
order to protect the public interest.
B. No report, document or other data produced in whole or in part with
contract funds shall be copyrighted by the Contractor nor shall any notice
of copyright be registered by the Contractor in connection with any report,
document or other data developed for the contract.
C. In no case shall subsections A and B of this section apply to, or prevent
the Contractor from asserting or protecting its rights in any report,
document or other data, or any invention which existed prior to or was
developed or discovered independently from the activities directly related
to this Agreement
4.15 INFRINGEMENTS
The Contractor shall be liable to the Department and hereby agrees to
indemnify and hold the Department harmless for any damage or loss or
expense sustained by the Department from any infringement by the Contractor
of any copyright, trademark or patent rights of design, systems, drawings,
graphs, charts, specifications or printed matter furnished or used by the
Contractor in the performance of this Agreement.
4.16 ANTI-TRUST
The Contractor hereby assigns, sells, and transfers to the City all right,
title and interest in and to any claims and causes of action arising under
the anti-trust laws of the State of New York or of the United States
relating to the particular goods or services purchased or procured by the
City under this Agreement.
ARTICLE 5. TERMINATION
5.1 TERMINATION OF AGREEMENT
A. The Department and/or City shall have the right to terminate this
Agreement, in whole or in part:
1. Under any right to terminate as specified in any section of this Agreement.
2. Upon the failure of the Contractor to comply with any of the terms and
conditions of this Agreement.
3. Upon the Contractor's becoming insolvent.
4. Upon the commencement under the Bankruptcy Act of any proceeding by or
against the Contractor, either voluntarily or involuntarily.
5. Upon the Commissioner's determination, termination is in the best interest
of the City.
B. The Department or City shall give the Contractor written notice of any
termination of this Agreement specifying therein the applicable provisions
of subsection A of this section and the effective date thereof which shall
not be
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less than ten (10) days from the date the notice is received.
C. The Contractor shall be entitled to apply to the Department to have this
Agreement terminated by said Department by reason of any failure in the
performance of this Agreement (including any failure by the Contractor to
make progress in the prosecution of work hereunder which endangers such
performance), if such failure arises out of causes beyond the control and
without the fault or negligence of the Contractor. Such causes may include,
but are not restricted to: acts of God or of the public enemy; acts of the
Government in either its sovereign or contractual capacity; fires; floods;
epidemics; quarantine restrictions; strikes; freight embargoes; or any
other cause beyond the reasonable control of the Contractor. The
determination that such failure arises out of causes beyond the control and
without the fault or negligence of the Contractor shall be made by the
Department which agrees to exercise reasonable judgment therein. If such a
determination is made and the Agreement terminated by the Department
pursuant to such application by the Contractor, such termination shall be
deemed to be without cause.
D. Upon termination of this Agreement the Contractor shall comply with the
Department or City close-out procedures, including but not limited to:
1. Accounting for and refund to the Department or City, within thirty (30)
days, any unexpended funds which have been paid to the Contractor pursuant
to this agreement.
2. Furnishing within thirty (30) days an inventory to the Department or City
of all equipment, appurtenances and property purchased through or provided
under this Agreement carrying out any Department or City directive
concerning the disposition thereof.
3. Not incurring or paying any further obligation pursuant to this Agreement
beyond the termination date. Any obligation necessarily incurred by the
Contractor on account of this Agreement prior to receipt of notice of
termination and falling due after such date shall be paid by the Department
or City in accordance with the terms of this Agreement. In no event shall
the word "obligation," as used herein, be construed as including any lease
agreement, oral or written, entered into between the Contractor and its
landlord.
4. Turn over to the Department or City or its designees all books, records,
documents and material specifically relating to this Agreement.
5. Submit, within ninety (90) days, a final statement and report relating to
this Agreement. The report shall be made by a certified public accountant
or a licensed public accountant.
E. In the event the Department or City shall terminate this Agreement, in
whole or in part, as provided in paragraphs 1, 2, 3, or 4 of subsection A
of this section, the Department or City may procure, upon such terms and in
such manner as deemed appropriate, services similar to those so terminated,
and the Contractor shall continue the performance of this Agreement to the
extent not terminated hereby.
F. Not withstanding any other provisions of this contract, the Contractor
shall not be relieved of liability to the City for damages sustained by the
City by virtue of Contractor's breach of the contract, and the City may
withhold payments to the Contractor for the purpose of set-off until
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?uch time as the exact amount of damages due to the ?ity from the
Contractor is determined.
G. The provisions of the Agreement regarding confidentiality of
information shall remain in full force and effect following any
termination.
H. The rights and remedies of the City provided in this section shall not
be exclusive and are in addition to all other rights and remedies
provided by law or under this Agreement.
ARTICLE 6. MISCELLANEOUS
?.1 CONFLICT OF LAWS
All disputes arising out of this Agreement shall be interpreted and decided
in accordance with the laws of the State of New York.
?.2 GENERAL RELEASE
The acceptance by the Contractor or its assignees of the final payment
under this contract, whether by voucher, judgment of any court of competent
jurisdiction or any other administrative means, shall constitute and
operate as a general release to the City from any and all claims of and
liability to the Contractor arising out of the performance of this
contract.
?.3 CLAIMS AND ACTIONS THEREON
A. No action at law or proceeding in equity against the City or
Department shall lie or be maintained upon any claim based upon this
Agreement or arising out of this Agreement or in any way connected
with this Agreement unless the Contractor shall have strictly complied
with all requirements relating to the giving of notice and of
information with respect to such claims, all as herein provided.
B. No action shall lie or be maintained against the City by Contractor
upon any claims based upon this Agreement unless such action shall be
commenced within six (6) months after the date of filing in the Office
of the Comptroller of the City of the certificate for the final
payment hereunder, or within six (6) months of the termination or
conclusion of this Agreement, or within six (6) months after the
accrual of the Cause of Action, whichever first occurs.
C. In the event any claim is made or any action brought in any way
relating to the Agreement herein, the Contractor shall diligently
render to the Department and/or the City of New York without
additional compensation any and all assistance which the Department
and/or the City of New York may require of the Contractor.
D. The Contractor shall report to the Department in writing within three
(3) working days of the initiation by or against the Contractor of any
legal action or proceeding in connection with or relating to this
Agreement.
6.4 NO CLAIM AGAINST OFFICERS, AGENTS OR EMPLOYEES
No claim whatsoever shall be made by the Contractor against any officer,
agent or employee of the City for, or on account of, anything done or
omitted in connection with this contract.
6.5 WAIVER
Waiver by the Department of a breach of any provision of this Agreement
shall not be deemed to be a waiver of any other or subsequent breach and
shall not be construed to be a modification of the terms of the Agreement
unless and until the same shall be agreed to in writing by the Department
or City as required and attached to the original Agreement.
6.6 NOTICE
The Contractor and the Department hereby designate the business addresses
hereinabove specified as the places where all notices, directions or
communications from one such party to the other party shall be delivered,
or to which they shall be mailed. Actual delivery of any such notice,
direction or communication to a party at the
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aforesaid place, or delivery by certified mail shall be conclusive and
deemed to be sufficient service thereof upon such party as of the date such
notice, direction or communication is received by the party. Such address
may be changed at any time by an instrument in writing executed and
acknowledged by the party making such change and delivered to the other
party in the manner as specified above. Nothing in this section shall be
deemed to serve as a waiver of any requirements for the service of notice
or process in the institution of an action or proceeding as provided by
law, including the Civil Practice Law and Rules.
?.7 ALL LEGAL PROVISIONS DEEMED INCLUDED
It is the intent and understanding of the parties to this Agreement that
each and every provision of law required to be inserted in this Agreement
shall be and is inserted herein. Furthermore, it is hereby stipulated that
every such provision is to be deemed to be inserted herein, and if, through
mistake or otherwise, any such provision is not inserted, or is not
inserted in correct form, then this Agreement shall forthwith upon the
application of either party be amended by such insertion so as to comply
strictly with the law and without prejudice to the rights of either party
hereunder.
?.8 SEVERABILITY
If this Agreement contains any unlawful provision not an essential part of
the Agreement and which shall not appear to have been a controlling or
material inducement to the making thereof, the same shall be deemed of no
effect and shall upon notice by either party, be deemed stricken from the
Agreement without affecting the binding force of the remainder.
?.9 POLITICAL ACTIVITY
There shall be no partisan political activity or any activity to further
the election or defeat of any candidate for public, political or party
office as part of or in connection with this Agreement, nor shall any of
the funds provided under this Agreement be used for such purposes.
?.10 MODIFICATION
This Agreement may be modified by the parties in writing in a manner not
materially affecting the substance hereof. It may not be altered or
modified orally.
A. CONTRACT CHANGES
Changes may be made to this contract only as duly authorized by the Agency
Chief Contracting Officer of his or her designee. Vendors deviating from
the requirements of an original purchase order or contract without a duly
authorized change order document, or written contract modification or
amendment, do so at their own risk. All such duly authorized changes,
modifications and amendments will be reflected in a written change order
and become a part of the original contract. Contract changes will be made
only for work necessary to complete the work included in the original scope
of the contract, and for non-material changes to the scope of the contract.
Changes are not permitted for any material alteration in the scope of the
work. Changes may include any one or more of the following:
- Specification changes to account for design errors or omissions;
- changes in contract amount due to authorized additional or omitted
work. Any such changes require appropriate price and cost analysis to
determine reasonableness. In addition, except for non-construction
requirements contracts, all changes that cumulatively exceed the greater of
ten percent of the original contract amount or $100,000 shall be approved
by the City Chief Procurement Officer;
- Extensions of a contract term for good and sufficient cause for a
cumulative period not to exceed one year from the date of expiration of
this current contract. Requirements contracts shall be subject to this
limitation;
- Changes in delivery location;
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- Changes in shipment method; and
- Any other change not inconsistent with Section 5-02 of the P.P.B.
Rules (ed. 9/99), or any successor Rule.
The Contractor may be entitled to a price adjustment for extra work performed
pursuant to a written change order. If any part of the contract work is
necessarily delayed by a change order, the Contractor may be entitled to an
extension of time for performance. Adjustments to price shall be validated for
reasonableness by using appropriate price and cost analysis.
6.11 PARAGRAPH HEADINGS
Paragraph headings are inserted only as a matter of convenience and for
reference and in no way define, limit or describe the scope or intent of this
contract and in no way affect this contract.
6.12 NO REMOVAL OF RECORDS FROM PREMISES
Where performance of this Agreement involves use by the Contractor of
Departmental papers, files, data or records at Departmental facilities or
offices, the Contractor shall not remove any such papers, files, data or
records, therefrom without the prior approval of the Department's designated
official.
6.13 INSPECTION AT SITE
The Department shall have the right to have representatives of the Department or
of the City or of the State or Federal governments present at the site of the
engagement to observe the work being performed.
6.14 PRICING
A. The Contractor shall when ever required during the contract, including
but not limited to the time of bidding, submit cost or pricing data
and formally certify that, to the best of its knowledge and belief,
the cost or pricing date submitted was accurate, complete, and current
as of a specified date. The Contractor shall be required to keep its
submission of cost and pricing date current until the contract has
been completed.
B. The price of any change order or contract modification subject to the
conditions of paragraph A, shall be adjusted to exclude any
significant sums by which the City finds that such price was based on
cost or price data furnished by the supplier which was inaccurate,
incomplete, or not current as of the date agreed upon between the
parties.
C. Time for Certification. The Contractor must certify that the cost or
pricing data submitted are accurate, complete and current as of a
mutually determined date.
D. Refusal to Submit Data. When any contractor refuses to submit the
required data to support a price, the Contracting Officer shall not
allow the price.
E. Certificate of Current Cost or Pricing Data. Form of Certificate. In
those cases when cost or pricing data is required, certification shall
be made using a certificate substantially similar to the one contained
in Chapter 4 of the PPB rules and such certification shall be retained
in the agency contract file.
ARTICLE 7. MERGER
This written Agreement contains all the terms and conditions agreed upon by
the parties hereto, and no other agreement, oral or otherwise, regarding the
subject matter of this Agreement shall be deemed to exist or to bind any of the
parties hereto, or to vary any of the terms contained herein.
ARTICLE 8. CONDITIONS PRECEDENT
This contract shall neither be binding nor effective unless:
A. Approved by the Mayor pursuant to the provisions of Executive Order
No. 42, dated October 9, 1975, in the event the
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Executive Order requires such approval; and
B. Certified by the Mayor (Mayor's Fiscal Committee created pursuant to
Executive Order No. 43, dated October 14, 1975) that performance
thereof will be in accordance with the City's financial plan; and
C. Approved by the New York State Financial Control Board (Board)
pursuant to the New York State Financial Emergency Act for the City of
New York, as amended, (the "Act"), in the event regulations of the
Board pursuant to the Act require such approval.
D. It has been authorized by the Mayor and the Comptroller shall have
endorsed his certificate that there remains unexpended and unapplied a
balance of the appropriation of funds applicable thereto sufficient to
pay the estimated expense of carrying out this Agreement.
The requirements of this section of the contract shall be in addition to, and
not in lieu of, any approval or authorization otherwise required for this
contract to be effective and for the expenditure of City funds.
ARTICLE 9. PPB RULES
This contract is subject to the Rules of the Procurement Policy Board of
the City of New York effective August 1, 1990, as amended. In the event of
conflict between said Rules and a provision of this contract, the Rules shall
take precedence.
ARTICLE 10. STATE LABOR LAW AND CITY ADMINISTRATIVE CODE
? As required by New York State Labor Law Section 220-e:
a. That in the hiring of employees for the performance of work under this
contract or any subcontract hereunder, neither the Contractor,
Subcontractor, nor any person acting on behalf of such Contractor or
Subcontractor, shall by reason of race, creed, color, sex or national
origin discriminate against any citizen of the State of New York who is
qualified and available to perform the work to which the employment
relates;
b. That neither the Contractor, subcontractor, nor any person on his behalf
shall, in any manner, discriminate against or intimidate any employee hired
for the performance of work under this contract on account of race, creed,
color, sex or national origin;
c. That there may be deducted from the amount payable to the Contractor by the
City under this contract a penalty of five dollars for each person for each
calendar day during which such person was discriminated against or
intimidated in violation of the provisions of this contract; and
d. That this contract may be canceled or terminated by the City and all monies
due or to become due hereunder may be forfeited, for a second or any
subsequent violation of the terms or conditions of this section of the
contract.
e. The aforesaid provisions of this section covering every contract for or on
behalf of the State or a municipality for the manufacture, sale or
distribution of materials, equipment or supplies shall be limited to
operations performed within the territorial limits of the State of New
York.
2. As required by New York City Administrative Code Section 6-108:
a. It shall be unlawful for any person engaged in the construction, alteration
or repair of buildings or engaged in the construction or repair of streets
or highways pursuant to a contract with the City or engaged in the
manufacture, sale or distribution of materials, equipment or supplies
pursuant to a contract with the City to refuse to employ or to refuse to
continue in any employment any person on account of the race, color or
creed of such person.
b. It shall be unlawful for any person or any servant, agent or employee of
any person, described in subdivision (a) above, to ask, indicate or
transmit, orally or in writing, directly or indirectly, the race, color,
creed or religious affiliation of any person employed or seeking employment
from such
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person, firm or corporation.
c. Disobedience of the foregoing provisions shall be deemed a violation of a
material provision of this contract.
d. Any person, or the employee, manager or owner of or officer of such firm or
corporation who shall violate any of the provisions of this section shall,
upon conviction thereof, be punished by a fine of not more than one hundred
dollars or by imprisonment for not more than thirty days, or both.
ARTICLE 11. FORUM PROVISION
Choice of Law. Consent to Jurisdiction and Venue ?his Contract shall be
deemed to be executed in the City of New York, State of New York, regardless of
?e domicile of the Contractor, and shall be governed by and construed in
accordance with the laws of the State of New York.
The parties agree that any and all claims asserted by ?r against the City
arising under this Contract or related thereto shall be heard and determined
either in the courts of the United States located in New York City ("Federal
Courts") or in the courts of the State of New York ("New York State Courts")
located in the City and County of New York. To effect this agreement and intent,
the Contractor agrees:
a. If the City initiates any action against the Contractor in Federal Court or
in New York State Court, service of process may be made on the Contractor
either in person, wherever such Contractor may be found, or by registered
mail addressed to the Contractor at its address as set forth in this
Contract, or to such other address as the Contractor may provide to the
City in writing; and
b. With respect to any action between the City and the Contractor in New York
State Court, the Contractor hereby expressly waives and relinquishes any
rights it might otherwise have (I) to move to dismiss on grounds of forum
non conveniens; (ii) to remove to Federal Court; and (iii) to move for a
change of venue to a New York State Court outside New York County.
c. With respect to any action between the City and the Contractor in Federal
Court located in New York City, the Contractor expressly waives and
relinquishes any right it might otherwise have to move to transfer the
action to a United States Court outside the City of New York.
d. If the Contractor commences any action against the City in a court located
other than in the City and State of New York, upon request of the City, the
Contractor shall either consent to a transfer of the action to a court of
competent jurisdiction located in the City and State of New York or, if the
court where the action is initially brought will not or cannot transfer the
action, the Contractor shall consent to dismiss such action without
prejudice and may thereafter reinstitute the action in a court of competent
jurisdiction in New York City. If any provision(s) of this Article is held
unenforceable for any reason, each and all other provision(s) shall
nevertheless remain in full force and effect.
ARTICLE 12. EQUAL EMPLOYMENT OPPORTUNITY
This contract is subject to the requirements of Executive Order No. 50
(1980) as revised ("E.O. 50") and the Rules and Regulations promulgated
thereunder. No contract will be awarded unless and until these requirements have
been complied with in their entirety. By signing this contract, the contractor
agrees that it:
1. will not engage in any unlawful discrimination against any employee or
applicant for employment because of race, creed, color, national origin,
sex age, disability, marital status or sexual orientation with respect to
all employment decisions including, but not limited to, recruitment,
hiring, upgrading, demotion, downgrading, transfer, training, rates of pay
or other forms of compensation, layoff, termination, and all other terms
and conditions of employment;
2. the contractor agrees that when it subcontracts it
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will not engage in any unlawful discrimination in the ?lection of
subcontractors on the basis of the owner's ?ce, color, creed, national
origin, sex, age, disability, ?arital status or sexual orientation;
? will state in all solicitations or advertisements for employees placed by
or on behalf of the contractor that all qualified applicants will receive
consideration for employment without unlawful discrimination based on race,
creed, color, national origin, sex, age, disability, marital status or
sexual orientation, or that it is an equal employment opportunity employer;
? will send to each labor organization or representative of workers with
which it has a collective bargaining agreement or other contract or
memorandum of understanding, written notification of its equal employment
opportunity commitments under E. O. 50 and the rules and regulations
promulgated thereunder; and
? will furnish all information and reports including an Employment Report
before the award of the contract which are required by E. O. 50, the rules
and regulations promulgated thereunder, and orders of the Director of the
Bureau of Labor Services ("Bureau"), and will permit access to its books,
records and accounts by the Bureau for the purposes of investigation to
ascertain compliance with such rules, regulations, and orders.
The contractor understands that in the even of its noncompliance with
nondiscrimination clauses of this contract or with any of such rules,
regulations, or orders, such noncompliance shall constitute a material
breach of the contract and noncompliance with the E. O. 50 and the rules
and regulations promulgated thereunder. After a hearing held pursuant to
the rules of the Bureau, the Director may direct the imposition by the
contracting agency held of any or all of the following sanctions:
(i) disapproval of the contractor;
(ii) suspension or termination of the contract;
(iii) declaring the contractor in default; or
(iv) in lieu of any of the foregoing sanctions, the Director may impose an
employment program.
The Director of the Bureau may recommend to the contracting agency head
that a Board of Responsibility be convened for purposes of declaring a
contractor who has repeatedly failed to comply with E.O. 50 and the rule
and regulations promulgated thereunder to be nonresponsible.
The contractor agrees to include the provisions of the foregoing paragraphs
in every subcontract or purchase order in excess of $50,000 to which it
becomes a party unless exempted by E.O. 50 and the rules and regulations
promulgated thereunder, so that such provisions will be binding upon each
subcontractor or vendor. The contractor will take such action with respect
to any subcontract or purchase order as may be directed by the Director of
the Bureau of Labor Services as a means of enforcing such provisions,
including sanctions for noncompliance.
The contractor further agrees that it will refrain from entering into any
contract or contract modification subject to E.O. 50 and the rules and
regulations promulgated thereunder with a subcontractor who is not in
compliance with the requirements of E.O. 50 and the rules and regulations
promulgated thereunder.
ARTICLE 13. NO DAMAGE FOR DELAY
The Contractor agrees to make no claim for damages for delay in the performance
of this Contract occasioned by any act or omission to act of the City or any of
its representatives, and agrees that any such claim shall be fully compensated
for by an extension of time to complete performance of the work as provided
herein.
ARTICLE 14. CONSULTANT REPORT INFORMATION
A copy of each consultant report submitted by a consultant to any City official
or to any officer, employee, agent or representative of a City
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?epartment, agency, commission or body or to any corporation, association or
entity whose expenses are ?aid in whole or in part from the City treasury shall
be ?rnished to the Commissioner of the department to ?hich such report was
submitted or, if not a City ?epartment, then to the chief controlling officer or
?fficers of such other office or entity. A copy of such ?port shall also be
furnished to the Director of the ?ayor's Office of ?onstruction for matters
related to construction or to the Director of the Mayor's Office ?f Operations
for all other matters.
ARTICLE 15. RESOLUTION OF DISPUTES
?5.1 All disputes between the City and the ?ontractor of the kind delineated in
this section that ?rise under, or by virtue of, this Contract shall be
finally ?esolved in accordance with the provisions of this ?ection and
Section 5-11 of the Rules of the ?rocurement Policy Board ("PPB Rules").
The ?rocedure for resolving all disputes of the kind ?elineated herein
shall be the exclusive means of ?esolving any such disputes.
a. This section shall not apply to disputes ?oncerning matters dealt with
in other sections of the ?PB Rules or to disputes involving patents,
copyrights, ?rademarks, or trade secrets (as interpreted by the courts
?f New York State) relating to proprietary rights in computer
software.
b. For construction and construction-related services ?his section shall
apply only to ?isputes about the scope of work delineated by the
Contract, the interpretation of Contract Documents, the ?mount to be
paid for extra work or disputed work ?erformed in connection with the
Contract, the ?onformity of the Contractor's work to the Contract, and
?he acceptability and quality of the Contractor's work; ?uch disputes
arise when the Engineer makes a ?etermination with which the
Contractor disagrees.
15.2 All determinations required by this section shall be made in writing,
clearly stated, with a reasoned explanation for the determination based on
the information and evidence presented to the party making the
determination. Failure to make such determination within the time period
required by this section shall be deemed a non-determination without
prejudice that will allow appeal to the next level.
15.3 During such time as any dispute is being presented, heard, and considered
pursuant to this section, the contract terms shall remain in full force and
effect and the Contractor shall continue to perform work in accordance with
the Contract and as directed by the Agency Chief Contracting Officer or
Engineer. Failure of the Contractor to continue the work as directed shall
constitute a waiver by the Contractor of any and all claims being presented
pursuant to this section and a material breach of Contract.
15.4 Presentation of Dispute to Agency Head.
(A) Notice of Dispute and Agency Response. The Contractor shall present its
dispute in writing ("Notice of Dispute") to the Agency Head within the time
specified herein or, if no time is specified, within thirty (30) days of
receiving notice of the determination or action that is the subject of the
dispute. This notice requirement shall not be read to replace any other notice
requirements contained in the Contract. The Notice of Dispute shall include all
the facts, evidence, documents, or other basis upon which the Contractor relies
in support of its position, as well as a detailed computation demonstrating how
any amount of money claimed by the Contractor in the dispute was arrived at.
Within thirty (30) days after receipt of the detailed written submission, the
Agency Chief Contracting Officer or, in the case of construction or
construction-related services, the Engineer shall submit to the Agency Head all
materials he or she deems pertinent to the dispute. Following initial
submissions to the Agency Head, either party may demand of the other the
production of any document or other material the demanding party believes may be
relevant to the dispute.
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?he requested party shall produce all relevant materials ?at are not otherwise
protected by a legal privilege ?cognized by the courts of New York State. Any
?estion of relevancy shall be determined by the ?gency Head whose decision shall
be final. Wilful ?ilure of the Contractor to produce any requested ?aterial
whose relevancy the Contractor has not ?sputed, or whose relevancy has been
affirmatively ?etermined, shall constitute a waiver by the Contractor ?f its
claim.
(B) Agency Head Inquiry. The Agency Head shall ?xamine the material and
may, in his or her discretion, ?onvene an informal conference with the
Contractor and ?he Agency Chief Contracting Officer and, in the case of
?onstruction or construction-related services, the ?ngineer to resolve the issue
by mutual consent prior to ?eaching a determination. The Agency Head may seek
?uch technical or other expertise as he or she shall deem ?ppropriate, including
the use of neutral mediators, and ?equire any such additional material from
either or both ?arties as he or she deems fit. The Agency Head's ability ?o
render, and the effect of, a decision hereunder shall ?ot be impaired by any
negotiations in connection with ?he dispute presented, whether or not the Agency
Head ?articipated therein. The Agency Head may or, at the ?equest of any party
to the dispute, shall compel the participation of any other contractor with a
contract ?elated to the work of this Contract, and that contractor ?hall be
bound by the decision of the Agency Head. Any ?ontractor thus brought into the
dispute resolution ?roceeding shall have the same rights to make ?resentations
and to seek review as the Contractor ?nitiating the dispute.
(C) Agency Head Determination. Within thirty (30) ?ays after the receipt of
all materials and information, or ?uch longer time as may be agreed to by the
parties, the Agency Head shall make his or her determination and shall ?eliver
or send a copy of such determination to the Contractor and Agency Chief
Contracting Officer and, in the case of construction or construction-related
services, the Engineer, together with a statement concerning how the decision
may be appealed.
(D) Finality of Agency Head Decision. The Agency Head's decision shall be
final and binding on all parties, unless presented to the Contract Dispute
Resolution Board pursuant to this section. The City may not take a petition to
the Contract Dispute Resolution Board. However, should the Contractor take such
a petition, the City may seek, and the Board may render, a determination less
favorable to the Contractor and more favorable to the City than the decision of
the Agency Head.
15.5 Presentation of Dispute to the Comptroller. Before any dispute may be
brought by the Contractor to the Contract Dispute Resolution Board, the
Contractor must first present its claim to the comptroller for his or her
review, investigation, and possible adjustment.
(A) Time, Form, and Content of Notice. Within thirty (30) days of its
receipt of a decision by the Agency Head, the Contractor shall submit to the
Comptroller and to the Agency Head a Notice of Claim regarding its dispute with
the Agency. The Notice of Claim shall consist of (i) a brief written statement
of the substance of the dispute, the amount of money, if any, claimed and the
reason(s) the Contractor contends the dispute was wrongly decided by the Agency
Head; (ii) a copy of the written decision of the Agency Head, and (iii) a copy
of all materials submitted by the Contractor to the Agency, including the Notice
of Dispute. The Contractor may not present to the Comptroller any material not
presented to the Agency Head, except at~the request of the Comptroller.
(B) Agency Response. Within thirty (30) days of receipt of the Notice of
Claim, the Agency shall make available to the Comptroller a copy of all material
submitted by the Agency to the Agency Head in connection with the dispute. The
Agency may not present to the Comptroller any material not presented to the
Agency Head except at the request of the Comptroller.
(C) Comptroller Investigation. The Comptroller may
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?vestigate the claim in dispute and, in the course of ?ch investigation,
may exercise all powers provided in ?ctions 7-201 and 7-203 of the New York
City administrative Code. In addition, the Comptroller may ?mand of either
party, and such party shall provide, ?hatever additional material the
Comptroller deems ?rtinent to the claim, including original business ?cords
of the Contractor. Wilful failure of the ?ontractor to produce within
fifteen (15) days any ?aterial requested by the Comptroller shall
constitute a ?aiver by the Contractor of its claim. The Comptroller ?ay
also schedule an informal conference to be ?tended by the Contractor,
Agency representatives, and ?y other personnel desired by the Comptroller.
(D) Opportunity of Comptroller to Compromise or ?djust Claim. The Comptroller
shall have forty-five ?5) days from his or her receipt of all materials
referred ? in 5. (C) to investigate the disputed claim. The period ?
investigation and compromise may be further ?xtended by agreement between
the Contractor and the ?omptroller, to a maximum of ninety (90) days from
?e Comptroller's receipt of all the materials. The ?ontractor may not
present its petition to the Contract ?ispute Resolution Board until the
period for ?vestigation and compromise delineated in this ?aragraph has
expired. In compromising or adjusting ?ny claim hereunder, the Comptroller
may not revise or isregard the terms of the Contract between the parties.
5.6 Contract Dispute Resolution Board. There shall be a Contract Dispute
Resolution Board composed ?f:
(a) the chief administrative law judge of the Office of Administrative Trials
and Hearings ("OATH") or his/her designated OATH administrative law judge,
who shall act as chairperson, and may adopt operational procedures and
issue such orders consistent with this ?ection as may be necessary in the
execution of the Contract Dispute Resolution Board's functions, including,
but not limited to, granting extensions of ?ime to present or respond to
submissions;
(b) the City Chief Procurement Officer or a designee; or in the case of
disputes involving construction, the Director of the Office of Construction
or his/her designee; any designee shall have the requisite background to
consider and resolve the merits of the dispute and shall not have
participated personally and substantially in the particular matter that is
the subject of the dispute or report to anyone who so participated, and
(c) a neutral person with appropriate expertise. This person shall be selected
by the presiding administrative law judge from a prequalified panel of
individuals, established and administered by OATH, with appropriate
background to act as decision-makers in a dispute. Such individuals may not
have a contract or dispute with the City or be an officer or employee of
any company or organization that does, or regularly represents persons,
companies, or organizations having disputes with the City.
15.7 Petition to Contract Dispute Resolution Board. In the event the claim has
not been settled or adjusted by the Comptroller within the period provided
in this section, the Contractor, within thirty (30) days thereafter, may
petition the Contract Dispute Resolution Board to review the Agency Head
determination.
(A) Form and Content of Petition by Contractor. The Contractor shall present
its dispute to the Contract Dispute Resolution Board in the form of a
Petition, which shall include (i) a brief written statement of the
substance of the dispute, the amount of money, if any, claimed and the
reason(s) the Contractor contends that the dispute was wrongly decided by
the Agency Head; (ii) a copy of the written decision of the Agency Head;
(iii) copies of all materials submitted by the Contractor to the Agency;
(iv) a copy of the written decision of the Comptroller, if any, and (v)
copies of all correspondence with, or written material submitted by the
Contractor to, the Comptroller's Office. The Contractor shall concurrently
submit four complete sets of the Petition: one to the Corporation Counsel
(Attn: Commercial and
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?eal Estate Litigation Division), and three to the contract Dispute Resolution
Board at OATH's offices ?ith proof of service on the Corporation Counsel. In
?idition, the supplier shall submit a copy of the ?atement of the substance of
the dispute, cited in (i) ?ove to both the Agency Head and the Comptroller.
(B) Agency Response. Within thirty (30) days of its ?ceipt of the Petition by
the Corporation Counsel, the agency shall respond to the brief written
statement of ?e Contractor and make available to the Board at ?ATH's
offices and one to the Contractor, all material submitted to the Agency
Head and Comptroller, ?xtensions of time for submittal of the agency
response shall be given as necessary upon a showing of good ?ause or, upon
the consent of the parties, for an initial period of up to thirty (30)
days.
(C) Further Proceedings. The Board shall permit the Contractor to present its
case by ?e submission of memoranda, briefs, and oral ?rgument. The Board
shall also permit the Agency to ?resent its case in response to the
Contractor by the submission of memoranda, briefs, and oral argument. If
?quested by the Corporation Counsel, the Comptroller shall provide
reasonable assistance in the preparation of ?e Agency's case. Neither the
Contractor nor the ?gency may support its case with any documentation or
?ther material that was not considered by the Comptroller, unless requested
by the Board. The Board, ?t its discretion, may seek such technical or
other ?xpertise as it shall deem appropriate and may seek, on its own or
upon application of a party, any such additional material from any party as
it deems fit. The ?oard, in its discretion, may combine more than one
?ispute between the parties of concurrent resolution.
(D) Contract Dispute Resolution Board ?etermination. Within forty-five (45)
days of the conclusion of all written submissions and oral ?rguments, the
Board shall render a written decision resolving the dispute. In an
unusually complex case, the Board may render its decision in a longer
period of time, not to exceed ninety (90) days, and shall so advise the
parties at the commencement of this period. The Board's decision must be
consistent with the terms of the Contract. In reaching its decision, the
Board shall accord no precedential significance to prior decisions of the
Board involving other non-related contracts.
(E) Notification of Contract Dispute Resolution Board Decision. The Board shall
send a copy of its decision to the Contractor, the Agency Chief Contracting
Officer, the Corporation Counsel, the Comptroller, and in the case of
construction or construction-related services, the Engineer. A decision in
favor of the Contractor shall be subject to the prompt payment provisions
of the PPB Rules. The Required Payment Day shall be thirty (30) days after
the date the parties are formally notified of the Board's decision.
(F) Finality of Contract Dispute Resolution Board Decision. The Board's
decision shall be final and binding on all parties. Any party may seek
review of the Board's decision solely in the form of a challenge, made
within four (4) months of the date of the Board's decision, in a court of
competent jurisdiction of the State of New York, County of New York,
pursuant to Article 78 of the Civil Practice Law and Rules. Such review by
the court shall be limited to the question of whether or not the Board's
decision was made in violation of lawful procedure, was affected by an
error of law, or was arbitrary and capricious or an abuse of discretion. No
evidence or information shall be introduced or relied upon in such
proceeding that was not presented to the Board in accordance with Section
5-11 of the PPB Rules.
15.8 Any termination, cancellation, or alleged breach of the Contract prior to
or during the pendency of any proceedings pursuant to this section shall
not affect or impair the ability of the Agency Head or Contract Dispute
Resolution Board to make a binding and final decision pursuant to this
section.
ARTICLE 16. PROMPT PAYMENT
The Prompt Payment provisions set forth in Chapter 5,
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?ection 5-07 of the Procurement Policy Board Rules in ?ffect at the time for
this solicitation will be applicable ? payments made under this contract. The
provisions ?cquire the payments to the contractors of interest on payments made
after the required payment date except ? set forth in subdivisions c(3) and
d(2), (3), (4) and (5) ?f Section 5-07 of the Rules.
?he contractor must submit a proper invoice to receive ?ayment, except where the
contract provides that the ?ntractor will be paid at predetermined intervals
?ithout having to submit an invoice for each scheduled ?ayment.
?eterminations of interest due will be made in such ?ccordance with the
provisions of the Procurement ?olicy Board Rules and General Municipal Law
Section ?-a.
ARTICLE 17.
MACBRIDE PRINCIPLES PROVISIONS FOR NEW YORK CITY CONTRACTORS
ARTICLE I. MACBRIDE PRINCIPLES NOTICE TO ALL PROSPECTIVE ?ONTRACTORS
Local Law No. 34 of 1991 became effective on September 10, 1991 and added
section 6-115.1 to the ?dministrative Code of the City of New York. The ?cal law
provides for certain restrictions on City ?ontracts to express the opposition of
the people of the City of New York to employment discrimination ?ractices in
Northern Ireland and to encourage ?ompanies doing business in Northern Ireland
to ?romote freedom of workplace opportunity.
Pursuant to Section 6-115.1, prospective contractors or contracts to
provide goods or services involving an expenditure of an amount greater than ten
thousand dollars, or for construction involving an amount greater than fifteen
thousand dollars, are asked to sign a rider in which they covenant and
represent, as a material ?ondition of their contract, that any business in
Northern ?reland operations conducted by the contractor and any individual or
legal entity in which the contractor holds a ten percent or greater ownership
interest and any individual or legal entity that holds a ten percent or greater
ownership interest in the contractor will be conducted in accordance with the
MacBride Principles of nondiscrimination in employment.
Prospective contractors are not required to agree to these conditions.
However, in the case of contracts let by competitive sealed bidding, whenever
the lowest responsible bidder has not agreed to stipulate to the conditions set
forth in this notice and another bidder who has agreed to stipulate to such
conditions has submitted a bid within five percent of the lowest responsible bid
for a contract to supply goods, services or construction of comparable quality,
the contracting entity shall refer such bids to the Mayor, the Speaker or other
officials, as appropriate, who may determine, in accordance with applicable law
and rules, that it is in the best interest of the city that the contract be
awarded to other than the lowest responsible bidder pursuant to Section
313(b)(2) of the City Charter.
In the case of contracts let by other than competitive sealed bidding, if a
prospective contractor does not agree to these conditions, no agency, elected
official or the Council shall award the contract to that bidder unless the
entity seeking to use the goods, services or construction certifies in writing
that the contract is necessary for entity to perform its functions and there is
no other responsible contractor who will supply goods, services or construction
of comparable quality at a comparable price.
PART A
In accordance with section 6-115.1 of the Administrative Code of the City
of New York, the contractor stipulates that such contractor and any individual
or legal entity in which the contractor holds a ten percent or greater ownership
interest and any individual or legal entity that holds a ten percent or greater
ownership interest in the contractor either (a) have no business operations in
Northern Ireland, or (b) shall take lawful steps in good faith to conduct any
business operations they have in Northern Ireland in accordance with the
MacBride Principles, and shall
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?ermit independent monitoring of their compliance with ?ch principles.
PART B
?or purposes of this section, the following terms shall ?ave the following
meanings:
1. "MacBride Principles" shall mean those ?rinciples relating to
nondiscrimination in employment ?nd freedom of workplace opportunity which
require ?mployers doing business in Northern Ireland to:
(1) increase the representation of individuals from under represented
religious groups in the work force, including managerial, supervisory,
administrative, clerical and technical jobs;
(2) take steps to promote adequate security for the protection of employees
from under represented religious groups both at the workplace and while
traveling to and from work;
(3) ban provocative religious or political emblems from the workplace;
(4) publicly advertise all job openings and make special recruitment
efforts to attract applicants from under represented religious groups;
(5) establish layoff, recall and termination procedures which do not in
practice favor a particular religious group;
(6) abolish all job reservations, apprenticeship restrictions and different
employment criteria which discriminate on the basis of religion;
(7) develop training programs that will prepare substantial numbers of
current employees from under represented religious groups for skilled jobs,
including the expansion of existing programs and the creation of new
programs to train, upgrade and improve the skills of workers from under
represented religious groups;
(8) establish procedures to assess, identify and actively recruit employees
from under represented religious groups with potential for further
advancement; and
(9) appoint a senior management staff member to oversee affirmative action
efforts and develop a timetable to ensure their full implementation.
ARTICLE II. ENFORCEMENT OF ARTICLE I.
The contractor agrees that the covenants and representation in Article I above
are material conditions to this contract. In the event the contracting entity
receives information that the contractor who made the stipulation required by
this section is in violation thereof, the contracting entity shall review such
information and give the contractor an opportunity to respond. If the
contracting entity finds that a violation has occurred, the entity shall have
the right to declare the contractor in default and/or terminate this contract
for cause and procure the supplies, services or work from another source in any
manner the entity deems proper. In the event of such termination, the contractor
shall pay to the entity, or the entity in its sole discretion may withhold from
any amounts otherwise payable to the contractor, the difference between the
contract price for the uncompleted portion of this contract and the cost to the
contracting entity of completing performance of this contract either itself or
by engaging another contractor or contractors. In the case of a requirements
contract, the contractor shall be liable for such difference in price for the
entire amount of supplies required by the contracting entity for the uncompleted
term of its contract. In the case of a construction contract, the contracting
entity shall also have the right to hold the contractor in partial or total
default in accordance with the default provisions of this contract, and/or may
seek debarment or suspension of the contractor. The rights and remedies of the
entity hereunder shall be in addition to, and not in lieu of, any rights and
remedies the entity has pursuant to this contract or by operation of law.
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