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Exhibit 10.1
APPENDIX X
[Amendment Number 3]
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Agency
Code 12000
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Contract
Number CO21236
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Period
1/1/08 —
12/31/09
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Funding
Amount for Period Based on
approved capitation rates
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This
is an AGREEMENT between THE STATE OF NEW YORK, acting by and
through The New York
State Department of Health, having its principal office
at Corning Tower, Room 2001, Empire State
Plaza, Albany NY 12237, (hereinafter referred to as the
STATE), and WellCare of
New York,
Inc., (hereinafter referred to as the CONTRACTOR), to
modify Contract Number
CO21236 as set forth below as set forth below and to
extend the contract period through December 31, 2009. The
effective date of these modifications is January 1,
2008.
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1.
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Amend Section 19.1 of the "Table of Contents for Model Contract,"
to read, "Section 19.1 Maintenance of Contractor
Performance Records, Records Evidencing Enrollment Fraud and
Documentation
Concerning Duplicate CINs."
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2.
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Amend Section 3.6, "SDOH Right to Recover Premiums," to read as
follows:
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3.6
SDOH Right to Recover Premiums
The
parties acknowledge and accept that the SDOH has a right to
recover premiums paid to the Contractor for Enrollees listed
on the monthly Roster who are later determined for the entire
applicable payment month to have been disenrolled from the
Contractor's Medicare Advantage Product; to have been in an
institution; to have been incarcerated; to have moved out of
the Contractor's service area subject to any time remaining in
the Enrollee's Guaranteed Eligibility period; or to have died.
In any event, the State may only recover premiums paid for
Medicaid Enrollees listed on a Roster if it is determined by
the SDOH that the Contractor was not at risk for provision of
Benefit Package services for any portion of the payment
period. Notwithstanding the foregoing, the SDOH always has the
right to recover duplicate Medicaid Advantage premiums paid
for persons enrolled under more than one Client Identification
Number (ON) in the Contractor's Medicaid Advantage product
whether or not the Contractor has made payments to
providers.
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3.
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Amend Section 19.1, "Maintenance of Contractor Performance
Records," to read as follows:
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19.1
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Maintenance of Contractor Performance Records, Records Evidencing
Enrollment Fraud and Documentation Concerning Duplicate
ClNs
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a)
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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:
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i)
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records
related to services provided to Enrollees, including a separate
Medical Record for each Enrollee; |
Appendix
X
Medicaid
Advantage Contract Amendment
J anuary
1, 2008
Page
1
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ii)
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all
financial records and statistical data that SDOH and DHHS 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, any reserves related thereto and expenses
incurred under this Agreement;
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iii)
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all
documents concerning enrollment fraud or the fraudulent use of any
CIN;
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iv)
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all
documents concerning duplicate CINs;
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v)
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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.
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b)
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The record maintenance requirements of this Section shall survive
the termination, in whole or in part, of this
Agreement.
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4.
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Amend Section 19.3, "Access to Contractor Records," to read as
follows:
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19.3
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Access to Contractor Records
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The
Contractor shall provide SDOH, the Comptroller of the State of New
York, DHHS, the Comptroller General of the United States, and their
authorized representatives with access to all records relating to
Contractor performance under this Agreement for the purposes of
examination, audit, and copying (at reasonable cost to the
requesting party). 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. Notwithstanding the
foregoing, when records are sought in connection with a "fraud" or
"abuse" investigation, as defined respectively in 10 NYCRR
§98.1.21 (a) (1) and (a) (2), all costs associated with
production and reproduction shall be the responsibility of the
Contractor. |
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5. |
Amend
Section 22.7 "Recovery of Overpayments to Providers" to read as
follows: |
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22.7 |
Recovery
of Overpayments to Providers |
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Consistent
with the exception language in Section 3224-b of the Insurance Law,
the Contractor shall have and retain the right to audit
participating providers' claims for a six year period from the date
the care, services or supplies were provided or billed, whichever
is later, and to recoup any overpayments discovered as a result of
the audit. This six year limitation does not apply to situations in
which fraud may be involved or in which the provider or an agent of
the provider prevents or obstructs the Contractor's
auditing. |
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Appendix
X
Medicaid
Advantage Contract Amendment
J anuary
1, 2008
Page
2
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6. |
Amend
Section 31.2 "Indemnification by SDOH" to read as
follows: |
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31.2 |
Indemnification
by SDOH |
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Subject
to the availability of lawful appropriations as required by State
Finance Law § 41 and consistent with § 8 of the State
Court of Claims Act, SDOH shall hold the Contractor harmless from
and indemnify it for any final judgment of a court of competent
jurisdiction to the extent attributable to the negligence of SDOH
or its officers or employees when acting within the course and
scope of their employment. Provisions concerning the SDOH's
responsibility for any claims for liability as may arise during the
term of this Agreement are set forth in the New York State Court of
Claims Act, and any damages arising for such liability shall issue
from the New York State Court of Claims Fund or any applicable,
annual appropriation of the Legislature for the State of New
York. |
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7.
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The attached Appendix D, "New York State Department of Health
Medicaid Advantage
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Marketing
Guidelines," is substituted for the period beginning January 1,
2008.
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8.
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The attached Appendix H, "New York State Department of Health
Guidelines for the Processing of Medicaid Advantage
Enrollments and Disenrollments" is substituted for the .period
beginning January 1,
2008.
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9.
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The attached Appendix K, "Medicare and Medicaid Advantage Products
and Non-Covered Services," is
substituted for the period beginning January 1,
2008.
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10.
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The attached Appendix L, "Approved Capitation Payment Rates," is
substituted for the period beginning January 1,
2008.
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All
other provisions of said AGREEMENT shall remain in full force
and effect.
Appendix
X
Medicaid
Advantage Contract Amendment
J
anuary
1, 2008
Page
3
IN
WITNESS WHEREOF, the parties hereto have executed or approved
this AGREEMENT as of the dates appearing under their
signatures.
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CONTRACTOR
SIGNATURE
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STATE
AGENCY SIGNATURE
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By:
/s/
Heath
Schiesser
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By:
/s/ Vallencia
Lloyd
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Heath
Schiesser
(Print name)
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Vallencia
Lloyd___
(Print name)
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Title:
President and
CEO
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Title:
Deputy Director,
DMC
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Date:
5/12/08
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Date:
6/3/08
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State
Agency Certification:
In
addition to the acceptance of this contract, I also certify
that original copies of this signature page will be attached
to all other exact copies of this contract.
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STATE
OF FLORIDA
County
of Hillsborough
On
the 12 th
day of May 20008, before me personally appeared Heath
Schiesser, to me known, who being by me duly sworn, did depose
and say that he resides at Tampa, Florida, that he is the
President & CEO o WellCare of New York, Inc., the
corporation described herein which executed the foregoing
instrument; and that he/she signed his/her name thereto by
order of the board of the directors of said
corporation.
/s/ Sara
Gallo
(Notary)
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Approved:
/ s/ Lorraine
Remo
ATTORNEY
GENERAL
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Approved:
/s/ name
illegible
Thomas
P. DiNapoli
STATE
COMPTROLLER
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Title:
Associate Attorney
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Title:
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Date:
June 10, 2009
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Date:
June 17, 2008
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Appendix
X
Medicaid
Advantage Contract Amendment
January
1, 2008
Page
4
Appendix
D
New
York State Department of Health
Medicaid
Advantage Marketing Guidelines
Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-1
MEDICAID ADVANTAGE MARKETING GUIDELINES
I.
Purpose
The
purpose of these guidelines is to provide an operational
framework for the Medicaid managed care organizations (MCOs)
in the development of marketing materials and the conduct of
marketing activities for the Medicaid Advantage Program. The
marketing guidelines set forth in this Appendix do not replace
the CMS marketing requirements for Medicare Advantage Plans;
they supplement them.
II. Marketing
Materials
A.
Definitions
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1.
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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
a Contractor's Medicaid Advantage product. The target audience for
these marketing materials is Eligible Persons as defined in Section
5.1 of this Agreement living in the defined service
area.
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2.
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For
purposes of this Agreement, marketing materials include any
information that references the Contractor's Medicaid Advantage
Product and which is intended for distribution to Dual Eligibles,
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.
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B.
Marketing Material Requirements
In
addition to meeting CMS' Medicare Advantage marketing
requirements and guidance on marketing to individuals entitled
to Medicare and Medicaid:
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1.
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Medicaid
Advantage marketing materials must be written in prose that is
understood at a fourth-to sixth-grade reading level except when the
Contractor is using language required by CMS, and must be printed
in at least twelve (12) point font.
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2.
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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. SDOFI will inform the LDSS and LDSS
will inform the Contractor when the 5% threshold has been reached.
Marketing materials to be translated include those key materials,
such as informational brochures, that are produced for routine
distribution, and which are included within the MCO's marketing
plan. SDOH will determine the need for other than English
translations based on county specific census data or other
available measures.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-2
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3.
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The
Contractor shall advise potential Enrollees, in written materials
related to enrollment, to verify with the medical services
providers they prefer, or have an existing relationship with, that
such medical services providers participate in the selected managed
care provider's network and are available to serve the
participant.
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C. Prior Approvals
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1.
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The
CMS and SDOH will jointly review and approve Medicaid Advantage
marketing videos, materials for broadcast (radio, television, or
electronic), billboards, mass transit (bus, subway or other livery)
and statewide/regional print advertising materials in accordance
with CMS timeframes for review of marketing materials. These
materials must be submitted to the CMS Regional Office for review.
CMS will coordinate SDOH input in the review process just as SDOH
will coordinate LDSS input in the review process.
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2.
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CMS
and SDOH will jointly review and approve the following Medicaid
Advantage marketing materials:
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a.
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Scripts
or outlines of presentations and materials used at health fairs and
other approved types of events and locations;
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b.
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All
pre-enrollment written marketing materials – written
marketing materials include brochures and leaflets, and
presentation materials used by marketing
representatives;
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c.
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All
direct mailing from the Contractor specifically targeted to the
Medicaid market.
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3.
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The
Contractor shall electronically submit all materials related to
marketing Medicaid Advantage to Dually Eligible persons to the CMS
Regional Office for prior written approval. The CMS Medicare
Regional Office Plan Manager will be responsible for obtaining SDOH
input in the review and approval process in accordance with CMS
timeframes for the review of marketing materials. Similarly, SDOH
will be responsible for obtaining LDSS input in the review and
approval process.
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4.
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The
Contractor shall not distribute or use any Medicaid Advantage
marketing materials that the CMS Regional Office and the SDOH have
not jointly approved, prior to the expiration of the required
review period.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-3
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5.
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Approved
marketing materials shall be kept on file in the offices of the
Contractor, the LDSS, the SDOH, and CMS.
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D. Dissemination of Outreach Materials to
LDSS
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1.
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Upon
request, the Contractor shall provide to the LDSS and/or Enrollment
Broker, sufficient quantities of approved Marketing materials or
alternative informational materials that describe coverage in the
LDSS jurisdiction.
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2.
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The
Contractor shall, upon request, submit to the LDSS or Enrollment
Broker, a current provider directory, together with information
that describes how to determine whether a provider is
presently available.
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III. Marketing
Activities
A. General Requirements
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1.
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The
Contractor must follow the State's Medicaid marketing rules and the
requirements of 42 CFR 438.104 to the extent applicable when
conducting marketing activities that are primarily intended to sell
a Medicaid managed care product (i.e., Medicaid Advantage).
Marketing activities intended to sell a Medicaid managed care
product shall be defined as activities which are conducted pursuant
to a Medicaid Advantage marketing program in which a dedicated
staff of marketing representatives employed by the Contractor, or
by an entity with which the Contractor has subcontracted, are
engaged in marketing activities with the primary purpose of
enrolling recipients in the Contractor's Medicaid Advantage
product.
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2.
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Marketing
activities that do not meet the above criteria shall not be
construed as having a primary purpose of intending to sell a
Medicaid managed care product and shall be conducted in accordance
with Medicare Advantage marketing requirements. Such activities
include but are not limited to plan sponsored events in which
marketing representatives not dedicated to the marketing of the
Medicaid Advantage product explain Medicare products offered by the
Contractor as well as the Contractor's Medicaid Advantage
product.
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B. Marketing at LDSS
Offices
With prior LDSS approval, MCOs may distribute
CMS/SDOH approved Medicaid Advantage marketing materials in
the local social services district offices and
facilities.
C. Responsibility for
Marketing Representatives
Individuals employed by the Contractor as marketing
representatives and employees of marketing subcontractors must
have successfully completed the Contractor's
training
program including training related to an Enrollee's
rights and responsibilities in Medicaid Advantage. The
Contractor shall be responsible for the activities of its
marketing
representatives and the activities of any subcontractor or
management entity.
Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-4
D. Medicaid Advantage Specific Marketing
Requirements
The requirements in Section D apply only if marketing
activities for the Medicaid Advantage Program are conducted
pursuant to a Medicaid Advantage marketing program
in
which a dedicated staff of marketing representatives
employed by the Contractor or by an entity with which the
Contractor has a subcontract are engaged in
marketing
activities with the sole purpose of enrolling recipients in
the Contractor's Medicaid Advantage product.
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1.
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Approved
Marketing Plan
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a.
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The
Contractor must submit a plan of Medicaid Advantage Marketing
activities that meet the SDOH requirements to the
SDOH.
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b.
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The
SDOH is responsible for the review and approval of Medicaid
Advantage Marketing plans, using a SDOH and CMS approved
checklist.
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c.
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Approved
Marketing plans will set forth the terms and conditions and
proposed activities of the Medicaid Advantage dedicated staff
during the contract period. The following must be included:
description of materials to be used, distribution methods; primary
types of marketing locations and a listing of the kinds of
community service events the Contractor anticipates sponsoring
and/or participating in during which it will provide information
and/or distribute Medicaid Advantage marketing
materials.
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d.
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An
approved marketing plan must be on file with the SDOH and each LDSS
in its contracted service area prior to the Contractor engaging in
the Medicaid Advantage specific marketing activities.
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e.
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The
plan shall include stated marketing goal and strategies, marketing
activities, and the training, development and responsibilities of
dedicated marketing staff.
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f.
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The
Contractor must describe how it is able to meet the informational
needs related to marketing for the physical and cultural diversity
of its potential membership. This may include, but not be limited
to, a description of the Contractor's other than English language
provisions, interpreter services, alternate communication
mechanisms including sign language, Braille, audio tapes, and/or
use of Telecommunications Devices for the Deaf (TTY)
services.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-5
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g.
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The
Contractor shall describe measures for monitoring and enforcing
compliance with these guidelines by its Marketing representatives
including the prohibition of door to door solicitation and
cold-call telephoning; a description of the development of
pre-enrollee mailing lists that maintains client confidentiality
and honors the client's express request for direct contact by the
Contractor; the selection and distribution of pre-enrollment gifts
and incentives to prospective enrollees ; and a description of the
training, compensation and supervision of its Medicaid Advantage
dedicated Marketing representatives.
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2.
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Prohibition
of Cold Call Marketing Activities
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Contractors
are prohibited from directly or indirectly, engaging in door to
door, telephone, or other cold-call marketing
activities. |
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3. |
Marketing
in Emergency Rooms or Other Patient Care Areas |
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Contractors
may not distribute materials or assist prospective Enrollees in
completing Medicaid Advantage application forms in hospital
emergency rooms, in provider offices, or other areas where health
care is delivered unless requested by the individual. |
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4. |
Enrollment
Incentives |
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Contractors
may not offer incentives of any kind to Medicaid recipients to join
Medicaid Advantage. Incentives are defined as any type of
inducement whose receipt is contingent upon the recipients joining
the Contractor's Medicaid Advantage product. |
E. General Marketing
Restrictions
The following restrictions apply anytime the Contractor
markets its Medicaid Advantage product:
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1. |
Contractors
are prohibited from misrepresenting the Medicaid program, the
Medicaid Advantage Program or the policy requirements of the LDSS
or SDOH. |
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2. |
Contractors
are prohibited from purchasing or otherwise acquiring or using
mailing lists that specifically identify Medicaid recipients from
third party vendors, including providers and LDSS offices, unless
otherwise permitted by CMS. The Contractor may produce materials
and cover their costs of mailing to Medicaid recipients if the
mailing is carried out by the State or LDSS, without sharing
specific Medicaid information with the
Contractor. |
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3.
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Contractors
may not discriminate against a potential 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 any Enrollee or their family member. 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 potential
Enrollee shall be provided with a listing of all participating
providers and facilities in the MCO's network. The Contractor may
respond to a potential Enrollee's question about whether a
particular specialist is in the network. However, the Contractor is
prohibited from inquiring about the types of specialists utilized
by the potential Enrollee.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-6
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4. |
Contractors may not require participating providers to distribute
plan prepared communications to their patients, including
communications which compare the benefits of different health
plans, unless the materials have the concurrence of all MCOs
involved, and have received prior approval by SDOH, and by CMS, if
Medicare Advantage is referenced. |
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5. |
Contractors are responsible for ensuring that their Marketing
representatives engage in professional and courteous behavior in
their interactions with LDSS staff, staff from other health plans
and Medicaid clients. Examples of inappropriate behavior include
interfering with other health plan presentations or talking
negatively about another health plan. |
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6. |
The Contractor shall not market to enrollees of other health plans.
If the Contractor becomes aware during a marketing encounter that
an individual is enrolled in another health plan, the marketing
encounter must be promptly terminated, unless the individual
voluntarily suggests dissatisfaction with the health plan in which
he or she is enrolled. |
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7. |
The Contractor shall not offer compensation including salary
increases or bonuses, based solely on the number of individuals
enrolled by Marketing Representatives who are licensed to offer
Medicare products only, including Medicaid Advantage, and who also
market Medicaid, Family Health Plus and Child Health Plus. However,
the Contractor may base compensation of these 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: |
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a.
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"Compensation"
shall mean any remuneration required to be reported as income or
compensation for federal tax purposes;
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b.
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The
Contractor may not pay a "commission" or fixed amount per
enrollment;
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c.
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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;
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-7
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d.
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Sign
on bonuses for Marketing Representatives are
prohibited;
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e.
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Where
productivity is a factor in the bonus determination, bonuses must
be structured in such a way that productivity carries a weight of
no more than 30% of the total bonus and that application
quality/accuracy must carry a weight equal to or greater than the
productivity component;
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f.
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The
Contractor must limit salary adjustments for Marketing
Representatives to annual adjustments except where the adjustment
occurs during the first year of employment after a traditional
trainee/probationary period or in the event of a company wide
adjustment;
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g.
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The
Contractor is prohibited from reducing base salaries for Marketing
Representatives for failure to meet productivity
targets;
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h.
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The
Contractor is prohibited from offering non-monetary compensation
such as gifts and trips to Marketing Representatives;
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i.
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The
Contractor shall have human resource policies and procedures for
the earning and payment of overtime and must be able to produce
documentation (such as time sheets) to support overtime
compensation; and
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j.
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The
Contractor shall keep written documentation, including performance
evaluations or other tools it uses as a basis 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 LDSS.
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IV.
Marketing Infractions
A. Infractions of Medicaid marketing guidelines,
as found in Appendix D, Sections III D and E, may result in the
following actions being taken by the SDOH, in
consultation
with the LDSS, to protect the interests of the program
and its clients. These actions shall be taken by the SDOH in
collaboration with the LDSS and the CMS Regional
Office.
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1.
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If
the Contractor or its representative commits a first time
infraction of marketing guidelines and the SDOH, in consultation
with the LDSS, deems the infraction to be minor or unintentional in
nature, the SDOH and/or the LDSS may issue a warning letter to the
Contractor.
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2.
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If
the Contractor engages in Marketing activities that the SDOH
determines, in its sole discretion, to be an intentional or serious
breach of the Medicaid Advantage Marketing Guidelines or the
Contractor's approved Medicaid Advantage Marketing Plan, or a
pattern of minor breaches, SDOH, in consultation with the LDSS, may
require the Contractor to, and the Contractor shall prepare and
implement a corrective action plan acceptable to the SDOH within a
specified timeframe. In addition, or alternatively, SDOH may impose
sanctions, including monetary penalties, as permitted by
law.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-8
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3.
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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, in consultation with the LDSS, may
in addition to any other legal remedy available to the SDOH in law
or equity:
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a)
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direct
the Contractor to suspend its Medicaid Advantage .
Marketing activities for a period up to the end of the Agreement
period;
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b)
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suspend
new Medicaid Advantage Enrollments, for a period up to the
remainder of the Agreement period; or
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c)
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terminate
this Agreement pursuant to termination procedures described in
Section 2.7 of this Agreement.
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Medicaid
Advantage Contract Amendment
Appendix
D
State J
anuary
1, 2008
D-9
APPENDIX H
New York State Department of Health Guidelines for the
Processing of Medicaid Advantage Enrollments and
Disenrollments
Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-
1
Appendix H
SDOH Guidelines
For the Processing of Medicaid Advantage Enrollments
and
Disenroliments
1. General
The
Contractor's Enrollment and Disenrollment procedures for
Medicaid Advantage 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, the SDOH, upon receipt of a written request
from either the LDSS or the Contractor, may allow
modifications to timeframes and some procedures. Where an
Enrollment Broker exists, the Enrollment Broker will be
responsible for some or all of the LDSS responsibilities as
set forth in the Enrollment Broker Contract.
2. Enrollment
a) SDOH Responsibilities:
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i)
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The
SDOH is responsible for monitoring Local District program
activities and providing technical assistance to the LDSS and the
Contractor to ensure compliance with the State's policies and
procedures.
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ii)
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SDOH reviews and approves proposed Enrollment materials
prior to the Contractor publishing and disseminating or otherwise
using the materials.
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b) LDSS Responsibilities:
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i)
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The
LDSS has the primary responsibility for processing Medicaid
Advantage enrollments.
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ii)
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Each
LDSS determines Medicaid 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 and/or Medicaid Advantage
eligibility.
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iii)
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LDSS
is responsible for providing pre-enrollment information on Medicaid
Advantage to Dually Eligible beneficiaries, consistent with Social
Services Law, Section 364-j (4)(e)(iv) and train persons providing
enrollment counseling to Eligible Persons.
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Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-2
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iv)
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The
LDSS is responsible for informing Eligible Persons of the
availability of Medicaid Advantage Products, the scope of services
covered by each, and that enrollment is voluntary.
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v)
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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.
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vi)
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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 written instructions
to Eligible Persons in its written materials related to
Enrollment.
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vii)
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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.
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viii)
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The
LDSS is responsible for the timely processing of Medicaid Advantage
Enrollment applications received from participating health
plans.
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ix)
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The
LDSS is responsible for processing Enrollments in Medicaid
Advantage without edits for Medicare coverage in the Welfare
Management System (WMS); however the LDSS is responsible for
ensuring that WMS is updated with Medicare A and B coverage status
for new Enrollees upon review of documentation provided by the
Contractor or the Enrollee.
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x)
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The
LDSS is responsible for determining the eligibility status of
Medicaid Advantage enrollment applications. Applications will be
enrolled, pended or denied.
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xi)
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The
LDSS is responsible for processing Medicaid Advantage enrollment
applications until the last day of the month preceding the
Effective Date of Enrollment, to the extent possible.
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xii)
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The
LDSS is responsible for notifying the Contractor of plan-assisted
enrollment applications that are accepted, pended or
denied.
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xiii)
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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:
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Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-3
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A)
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LDSS
directly enters data into PCP Subsystem; or
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B)
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LDSS
or Contractor submits a tape to the State, to be edited and entered
into PCP Subsystem; or
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C)
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LDSS
electronically transfers data via a dedicated line, from eMedNY to
the PCP Subsystem.
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xiv)
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Extensive
use of the secondary roster will be utilized to coordinate the
Effective Dates of Enrollment for Medicaid and Medicare
Advantage.
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xv)
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The
LDSS is responsible for prospectively re-enrolling an Enrollee who
is disenrolled from the Contractor's Medicaid Advantage Product due
to loss of Medicaid eligibility, who regains eligibility within
three months, in the Contractor's Medicaid Advantage Product,
provided that the individual remains enrolled in the Contractor's
Medicare Advantage Product.
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xvi)
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The
LDSS is responsible for processing new Enrollment applications to
transfer a member of the Contractor's Medicaid managed care product
to the Contractor's Medicaid Advantage Product if the Enrollee,
upon gaining Medicare eligibility, wishes to enroll in the
Contractor's Medicaid Advantage Product. To the extent possible,
such Enrollments shall be made effective the first day of the month
that the Enrollee's Medicare Advantage Coverage is
effective.
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xvii)
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The
LDSS is responsible for sending the following notices to Eligible
Persons:
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A)
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Enrollment
Confirmation Notice: This notice indicates the Effective Date of
Enrollment, the name of the Medicaid Advantage Product and the
individual who is being enrolled. This notice must also include a
statement advising the individual that if his/her Medicare
Advantage enrollment is denied by CMS, the individual's Medicaid
Advantage Enrollment will be voided retroactively back to the
Effective Date of Enrollment. In such instances, the individual may
be responsible for the cost of any Medicaid Advantage Benefit
rendered during the retroactive period if the benefit was provided
by a non-Medicaid participating provider.
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B)
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Notice
of Denial of Enrollment: This notice is used when an individual has
been determined by LDSS to be ineligible for enrollment into a
Medicaid Advantage Product. This notice must include fair hearing
rights.
|
Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-4
c) Contractor Responsibilities:
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i)
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To
the extent permitted by law and regulation, the Contractor is
responsible for assisting Dually Eligible persons eligible for
enrollment in Medicaid Advantage to complete the Enrollment
application. The Contractor will submit plan Enrollments to the
LDSS, within a maximum of five (5) business days from the day the
Enrollment is received by the Contractor (unless otherwise agreed
to by SDOH and LDS S).
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ii)
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The
Contractor is responsible for obtaining documentation of Medicare A
and B coverage prior to sending the Enrollment transaction to the
LDSS for processing. In all areas where Enrollments are not
processed by the Enrollment Broker, the documentation must
accompany the Enrollment form to the LDSS. Acceptable documentation
includes: a current Medicare card or other documentation acceptable
to CMS or received by the Contractor from interaction with CMS'
data systems.
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iii)
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In
areas where Enrollments are submitted electronically to the
Enrollment Broker, the Contractor is responsible for forwarding the
documentation of current Medicare A and B coverage to the
Enrollment Broker within five (5) business days of learning from
the Enrollment Broker that evidence of Medicare A and B coverage is
not reflected in the WMS system.
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iv)
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The
Contractor must notify new Enrollees of their Effective Date of
Enrollment. To the extent practicable, such notification must
precede the Effective Date of Enrollment. This notice must also
include a statement advising the individual that if his/her
Medicare Advantage enrollment is denied by CMS, the individual's
Medicaid Advantage Enrollment will be voided retroactively back to
the Effective Date of Enrollment. In such instances, the individual
may be responsible for the cost of any Medicaid Advantage Benefit
rendered during the retroactive period if the benefit was provided
by a non-Medicaid participating provider.
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v)
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The
Contractor must report any changes that affect or may affect the
Medicaid or Medicaid Advantage eligibility status of its Enrollees
to the LDSS within five (5) business days of such information
becoming known to the Contractor. This includes, but is not limited
to, address changes, incarceration, third party insurance other
than Medicare, Disenrollment from the Contractor's Medicare
Advantage Product, etc.
|
Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-5
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vi)
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If
an Enrollee's Enrollment in the Contractor's Medicare Advantage
Product is rejected by CMS, the Contractor must notify the LDSS
within five (5) business days of learning of CMS' rejection of the
Enrollment. In such instances, the LDSS shall delete the Enrollee's
Enrollment in the Contractor's Medicaid Advantage
Plan.
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vii)
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The
Contractor, within five (5) business days of identifying cases
where a person may be enrolled in the Contractor's Medicaid
Advantage product under more than one CIN, must convey that
information in writing to the LDSS.
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viii)
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The
Contractor shall advise potential Enrollees, in written materials
related to enrollment, to verify with the medical services
providers they prefer, or have an existing relationship with, that
such medical services providers are Participating Providers and are
available to serve the Prospective Enrollee.
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ix)
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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.
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3. Newborn Enrollments:
a) SDOH Responsibilities:
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i)
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The
SDOH will update WMS with information on the newborn received from
hospitals or birthing centers, consistent with the requirements of
Section 366-g of the Social Services Law as amended by Chapter 412
of the Laws of 1999.
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ii)
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Upon
notification of the birth by the hospital or birthing center, the
SDOH will update WMS with the demographic data for the newborn
generating appropriate Medicaid coverage.
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b) LDSS Responsibilities:
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i)
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The
LDSS is responsible for granting Medicaid eligibility for newborns
for one (1) year if born to a woman eligible for and receiving MA
assistance on the date of birth. (Social Services Law Section
366 (4)
(1 ))
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ii)
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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. (NYS DSS
Administrative Directive 85 ADM-33)
|
Medicaid
Advantage Contract
APPENDIX
H
State
January 1, 2008
H-6
|
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iii)
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In
the event that the LDSS learns of an Enrollee's pregnancy prior to
the Contractor, the LDSS is to establish MA eligibility and
pre-enroll the unborn into Medicaid managed care in cases where an
enrollment form is received.
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iv)
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When
a newborn is enrolled in managed care, the LDSS is responsible for
sending an Enrollment Confirmation Notice to inform the mother of
the Effective Date of Enrollment, which is the first (1
st )
day of the month of birth, and the plan in which the newborn is
enrolled.
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v)
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The
LDSS may develop a transmittal form to be us
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