fully executed Contract Extension of Agreement

nyc.gov/health December 22, 2004

Ms. Karin Ajmani
Executive Director
CarePlus, L.L.C.
360 West 31st Street, Fifth Floor New York, NY 10001

Dear Ms. Ajmani:

Enclosed please find, for your files, one (1) fully executed Contract Extension of Agreement between the City of New York and CarePlus, L.L.C.

If you have any questions you may reach me at (212) 788-5533 or contact Liane Daniels at (212) 788-5657.

Sincerely,

Vivian Toan, Counsel
NYCDOHMH-Health Care Access & Improvement

Enclosure

1

MEDICAID MANAGED CARE

MODEL CONTRACT

2

October 1, 2004
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,

New York City Department of Health and Mental Hygiene [“DOHMH”]

Located at

161 William Street, 5 ^th floor

New York, NY 10038

And

CarePlus, L.L.C

Located At

360 West 31 ^St Street, Fifth Floor

New York, NY 10001
RECITALS
October 1, 2004
Page 1 of 2
RECITALS

Pursuant to Title XIX of the Federal Social Security Act, codified as 42 U.S.C. Section 1396 et seq. (the “Social Security Act”), and Title 11 of Article 5 of the New York State Social Services Law (“SSL”), codified as N.Y.S.S.L. Section 363 et seq., a comprehensive program of Medical Assistance for needy persons exists in the State of New York (“Medicaid”).

Pursuant to Article 44 of the Public Health Law (“PHL”), the New York State Department of Health (“SDOH”) is authorized to issue Certificates of Authority to establish Health Maintenance Organizations (“HMOs”), PHL Section 4400 et seq., and Prepaid Health Services Plans (“PHSPs”), PHL Section 4403-a.

The State Social Services Law defines Medicaid to include payment of part or all of the cost of care. and services furnished by an HMO or a PHSP, identified as Managed Care Organizations (“MCOs”) in this Agreement, to Eligible Persons, as defined in this Agreement, residing in the geographic area specified in Appendix M (Service Area) when such care and services are furnished in accordance with an agreement approved by the SDOH that meets the requirements of federal law and regulations.

The Contractor is a corporation organized under the laws of New York State and is certified under Article 44 of the State Public Health Law or Article 43 of the NYS Insurance Law.

The Contractor offers a comprehensive health services plan and represents that it is able to make provision for furnishing medical and health service benefits and has proposed to New York City Department of Health and Mental Hygiene to provide these services to Eligible Persons; and

The Contractor has applied to participate in the Medicaid Managed Care Program and the SDOH and City of New York have determined that the Contractor meets the qualification criteria established for participation.

NOW THEREFORE, the parties agree as follows:

RECITALS
October 1, 2004
Page 2 of 2

3

Table of Contents for Model Contract

Recitals

Section 1 Definitions

Section 2 Agreement Term, Amendments, Extensions, and General Contract Administration Provisions

a. LDSS Initiated Termination of Contract
b. Contractor and LDSS Initiated Termination
c. Contractor Initiated Termination
d. Termination Due to Loss of Funding

2.8 Close-Out Procedures
2.9 Rights and Remedies 2.10 Notices

3.9 Supplemental Maternity Capitation Payment 3.10 Contractor Financial Liability
3.11 Inpatient Hospital Stop-Loss Insurance
3.12 Mental Health and Chemical Dependence Stop-Loss 3.13 Enrollment Limitations
3.14 Tracking Visits Provided by Indian Health Clinics

TABLE OF CONTENTS

October 1, 2004 1

a. Routine Disenrollment
b. Expedited Disenrollment
c. Retroactive Disenrollment

a. Disenrollment for Good Cause

 

10.4

Provision of Services Through Participating and Non-Participating Providers

10.5 Child Teen Health Program / Adolescent Preventive Services 10.6 Foster Care Children
10.7 Child Protective Services
10.8 Welfare Reform

TABLE OF CONTENTS

October 1, 2004 2

a. Mental Health and Chemical Dependence Services
b. Vision Services
c. Diagnosis and Treatment of Tuberculosis
d. Family Planning and Reproductive Health Services
e. Article 28 Clinics Operated by Academic Dental Centers

10.17 Second Opinions for Medical or Surgical Care
10.18 Coordination with Local Public Health Agencies
10.19 Public Health Services

a.

Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy (TB/DOT)

b. Immunizations
c. Prevention and Treatment of Sexually Transmitted Diseases
d. Lead Poisoning

10.20 Adults with Chronic Illnesses and Physical or Developmental Disabilities 10.21 Children with Special Health Care Needs

13.9 Contractor Responsibility to Notify Enrollee of Expected Effective Date of Enrollment

TABLE OF CONTENTS

October 1, 2004

4

3
Table of Contents for Model Contract

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

a. Primary Care
b. Other Providers

15.5 Service Continuation

a. New Enrollees
b. Enrollees Whose Health Care Provider Leaves Network

a. Annual Financial Statements
b. Quarterly Financial Statements
c. Other Financial Reports
d. Encounter Data
e. Quality of Care Performance Measures
f. Complaint Reports
g. Fraud and Abuse Reporting Requirements
h. Participating Provider Network Reports
i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys
j. Clinical Studies
k. Independent Audits
l. New Enrollee Health Screening Completion Report
m. Additional Reports
n. LDSS Specific Reports

TABLE OF CONTENTS

October 1, 2004 4

 

TABLE OF CONTENTS

October I. 2004 5

5

Table of Contents for Model Contract

a. General Requirements
b. Medical Residents

21.14 Hospitals

a. Tertiary Services
b. Emergency Services

TABLE OF CONTENTS

October 1, 2004
6

6

Table of Contents for Model Contract

34.4 Native Americans Access to Services From Tribal or Urban Indian Health Facility

35.2 Nullification of Illegal, Unenforceable, Ineffective or Void Contract Provisions

Signature Page

TABLE OF CONTENTS
October I. 2004
7

Table of Contents for Model Contract APPENDICES

A. New York State Standard Clauses and Local Standard Clauses, if applicable
B. Certification Regarding Lobbying

C.

New York State Department of Health Guidelines for the Provision of Family Planning and Reproductive Health Services

D. New York State Department of Health Marketing Guidelines
E. New York State Department of Health Member Handbook Guidelines

F.

New York State Department of Health Medicaid Managed Care Complaint and Appeals Requirements

 

G.

New York State Department of Health Guidelines for the Provision of Emergency Care and Services

 

H.

New York State Department of Health Guidelines for the Processing of Enrollments and Disenrollments

I. New York State Department of Health Guidelines for Use of Medical Residents

J. New York State Department of Health Guidelines of Federal Americans with Disabilities Act

K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services
L. Approved Capitation Payment Rates
M. Service Area

N. Contractor-County Specific Agreements

TABLE OF CONTENTS
October 1, 2004
8

7

“Auto-assignment” means a process by which an Eligible Person, who is mandated to enroll in managed care, but who has not chosen to enroll within sixty (60) days of receipt of the mandatory notice, is assigned to a MCO contracted with the LDSS as a Medicaid Managed Care Provider in accordance with the auto-assignment algorithm determined by the SDOH.

“Behavioral Health Services” means services to address mental health disorders and/or chemical dependence.

“Benefit Package” means the covered services described in Appendix K of this Agreement to be provided to the Enrollee, as Enrollee is hereinafter defined, by or through the Contractor.

“Capitation Rate” means the fixed monthly amount that the Contractor receives for an Enrollee to provide that Enrollee with the Benefit Package.

“Chemical Dependence Services” means examination, diagnosis, level of care determination, treatment, rehabilitation, or habilitation of persons suffering from chemical abuse or dependence, and includes the provision of alcohol and/or substance abuse services.

“Child/Teen Health Program” or “C/THP” means the program of early and periodic screening, including inter-periodic, diagnostic and treatment services (EPSDT) that New York State offers all Medicaid eligible children under twenty-one (21) years of age. Care and services are provided in accordance with the periodicity schedule and guidelines developed by the New York State Department of Health. The services include administrative services designed to help families obtain services for children including outreach, information, appointment scheduling, administrative case management and transportation assistance, to the extent that transportation is included in the Benefit Package.

“Comprehensive HIV Special Needs Plan, or HIV SNP” means a Managed Care Organization certified pursuant to Section forty-four hundred three-c (4403-c) of Article 44 of the Public Health Law (Article 44) which, in addition to providing or arranging for the provision of comprehensive health services on a capitated basis, including those for which Medical Assistance payment is authorized pursuant to Section three hundred sixtyfive-a (365-a) of the Social Services Law, also provides or arranges for the provision of comprehensive and specialized HIV care to HIV positive persons eligible to receive benefits under Title XIX of the federal Social Security Act or other public programs.

“Court-Ordered Services” means those services that the Contractor is required to provide to Enrollees pursuant to orders of courts of competent jurisdiction, provided however, that such ordered services are within the Contractor’s Medicaid managed care Benefit Package and reimbursable under Title XIX of the Federal Social Security Act (SSL 364-j(4)(r)).

“Days” means calendar days except as otherwise stated.
“Detoxification Services” means Medically Managed Detoxification Services; and Medically Supervised Inpatient and Outpatient Withdrawal Services as defined in Appendix K.

“Disenrollment” means the process by which an Enrollee’s membership in the Contractor’s plan terminates.

“Effective Date of Disenrollment” means the date on which an Enrollee may no longer receive services from the Contractor, pursuant to Section 8.6 and Appendix H of this Agreement.

“Effective Date of Enrollment” means the date on which an Enrollee may receive services from the Contractor, pursuant to Section 6.8(b) and Appendix H of this Agreement.

“Eligible Person” means a person whom the LDSS, state or federal government determines to be eligible for Medicaid and who meets all the other conditions for enrollment in Medicaid managed care as set forth in this Agreement.

SECTION 1

(DEFINITIONS)

October 1, 2004

1-1

8

“Emergency Medical Condition” means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person or others in serious jeopardy; or (ii) serious impairment to such person’s bodily functions; or (iii) serious dysfunction of any bodily organ or part of such person; or (iv) serious disfigurement of such person.

“Emergency Services” means covered medical services that are required to treat an Emergency Medical Condition.

“Enrollee” means an Eligible Person who, either personally or through an authorized representative, has enrolled (or who has been auto-assigned) in the Contractor’s plan pursuant to Section 6 of this Agreement.

“Enrollment” means the process by which an Enrollee’s membership in a Contractor’s Plan begins.

“Enrollment Broker” means the state and/or county-contracted entity that provides enrollment, education, and outreach services; effectuates enrollments and disenrollments in Medicaid managed care; and provides other contracted services on behalf of the SDOH and the LDSS.

“Experienced HIV Provider” means an entity grant-funded by the SDOH AIDS Institute to provide clinical and/or supportive services or an entity licensed or certified by the SDOH to provide HIV/AIDS services.

“Family” means a mother and child(ren), a father and child(ren), a father and mother and child(ren), or a husband and wife residing in the same household or persons included in the same case for purposes of family enrollment in mandatory counties.

“Fiscal Agent” means the entity that processes or pays vendor claims on behalf of the Medicaid state agency pursuant to an agreement between the entity and such agency.

“Guaranteed Eligibility” means the period beginning on the Enrollee’s Effective Date of Enrollment with the Contractor and ending six (6) months thereafter, during which the Enrollee may be entitled to continued enrollment in the Contractor’s plan despite the loss of Medicaid eligibility as set forth in Section 9 of this Agreement.

“Health Provider Network” or “HPN” means a closed communication network dedicated to secure data exchange and distribution of health related information between various health facility providers ^. and the SDOH. HPN functions include: collection of Medicaid complaint and disenrollment information; collection of Medicaid financial reports; collection and reporting of managed care provider networks systems (PNS); and the reporting of Medicaid encounter data systems (MEDS).

“HIV Specialist PCP” means a Primary Care Provider that meets the following criteria:

• Direct clinical management of persons with HIV as part of a postgraduate program, clinic, hospital-based or private practice during the last two years. Primary ambulatory care of HIV-infected patients should include the management of, patients receiving antiretroviral therapy over an extended period of time. This experience should equal twenty patient- years experience, and

• Ten hours annually of Continuing Medical Education (CME) that includes information on the use of antiretroviral therapy in the ambulatory care setting.

“Inpatient Stay Pending Alternate Level of Medical Care” means continued care in a hospital pending placement in an alternate lower medical level of care, consistent with the provisions of 18 NYCRR 505.20 and 10 NYCRR, Part 85.

“Institution for Mental Disease” or “IMD” means a hospital, nursing facility, or other institution of more than sixteen (16) beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an Institution for Mental Disease is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for the mentally retarded is not an Institution for Mental Diseases.

SECTION 1 (DEFINITIONS) October 1, 2004

1-2 .

9

“Local Public Health Agency” means The New York City Department of Health and Mental Hygiene or its successor.

“Lock-In Period” means the period of time during which the Enrollee may not disenroll from the Contractor’s plan, unless the Enrollee becomes eligible for an exclusion or an exemption or can demonstrate good cause as established in state law and in 18 NYCRR § 360-10.13.

“Managed Care Organization” or “MCO ^” means a health maintenance organization (“HMO”) or prepaid health service plan (“PHSP”) certified under Article 44 of the New York State PHL.

“Marketing” means any activity of the Contractor, subcontractor or individuals or entities affiliated with the Contractor by which information about the Contractor is made known to Eligible Persons for the purpose of persuading such persons to enroll with the Contractor.

“Marketing Representative” means any individual or entity engaged by the Contractor to market on behalf of the Contractor.

“Medicaid Management Information System” or “MMIS” means the Medical Assistance Information and Payment System of the SDOH.

“Medical Record” means a complete record of care rendered by a provider documenting the care rendered to the Enrollee, including inpatient, outpatient, and emergency care, in accordance with all applicable federal, state and local laws, rules and regulations. Such record shall be signed by the medical professional rendering the services.

“Medically Necessary” means health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap.

“Native American” means, for purposes of this contract, a person identified in the Medicaid eligibility system as a Native American.

“Nonconsensual Enrollment” means Enrollment of an Eligible Person, other than through Auto-assignment, newborn enrollment or case addition, in a Managed Care Organization without the consent of the Eligible Person or consent of a person with the legal authority to act on behalf of the Eligible Person at the time of Enrollment.

“Non-Participating Provider” means a provider of medical care and/or services with which the Contractor has no Provider Agreement.

“Participating Provider” means a provider of medical care and/or services that has a Provider Agreement with the Contractor.

“Physician Incentive Plan” or “PIP” means any compensation arrangement between the Contractor or one of its contracting entities and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services furnished to Medicaid recipients enrolled by the MCO.

^“ Prepaid Capitation Plan Roster ^” or “Roster” means the enrollment list generated on a monthly basis by SDOH by which LDSS and Contractor are informed of specifically which recipients the Contractor will be serving for the coming month, subject to any revisions communicated in writing or electronically by SDOH, LDSS, or the Enrollment Broker.

“Presumptive Eligibility Provider” means a provider designated by the SDOH as qualified to determine the presumptive eligibility for pregnant women to allow them to receive prenatal services immediately. Such providers assist recipients with the completion of the full application for Medicaid and they may be comprehensive Prenatal Care Programs, Local Public Health Agencies, Certified Home Health Agencies, Public Health Nursing Services, Article 28 facilities, and individually licensed physicians and certified nurse practitioners.

“Preventive Care” means the care or services rendered to avert disease/illness and/or its consequences. There are three levels of preventive care: primary, such as immunizations, aimed at preventing disease; secondary, such as disease screening programs aimed at early detection of disease; and tertiary, such as physical. therapy, aimed at restoring function after the disease has occurred. Commonly, the term “preventive care” is used to designate prevention and early detection programs rather than treatment programs.

SECTION 1

(DEFINITIONS)

October 1, 2004

1-3

“Primary Care Provider” or “PCP” means a qualified physician, or certified nurse practitioner or team of no more than four (4) qualified physicians/nurse practitioners which provides all required primary care services contained in the Benefit Package to Enrollees.

“Provider Agreement” means any written contract between the Contractor and participating Providers to provide medical care and/or services to Contractor’s Enrollees.

“School Based Health Centers” or “SBHC” are SDOH approved centers which provide comprehensive primary and mental health services including health assessments, diagnosis and treatment of acute illnesses, screenings and immunizations, routine management of chronic diseases, health education, mental health counseling and treatment on-site in schools. Services are offered by multi-disciplinary staff from sponsoring Article 28 licensed hospitals and community health centers.

“Seriously Emotionally Disturbed” or “SED” means, a child through seventeen (17) years of age who has utilized the following during the twelve (12) month period prior to scheduled enrollment:

•

ten (10) or more encounters, including visits to a mental health clinic, psychiatrist or psychologist, and inpatient hospital days relating to a psychiatric diagnosis; or

 

•

one (1) or more specialty mental health visits (i.e., psychiatric rehabilitation treatment program; day treatment; continuing day treatment; comprehensive case management; partial hospitalization; rehabilitation services provided to residents of Office of Mental Health (OMH) licensed community residences and family-based treatment; and mental health clinics for seriously emotionally disturbed children).

^“ Seriously and Persistently Mentally Ill ^” or ^“ SMPI ^” means an adult eighteen (18) years or older who has utilized the following during the twelve (12) month period prior to scheduled enrollment:

• ten (10) or more encounters, including visits to a mental health clinic, psychiatrist or psychologist, and inpatient hospital days relating to a psychiatric diagnosis; or

• one (1) or more specialty mental health visits (i.e., psychiatric rehabilitation treatment program; day treatment; continuing day treatment; comprehensive case management; partial hospitalization; rehabilitation services provided to residents of OMH licensed community residences and family-based treatment; and mental health clinics for seriously emotionally disturbed children).

“Supplemental Maternity Capitation Payment” means the fixed amount paid to the Contractor for the prenatal and postpartum physician care and hospital or birthing center. delivery costs, limited to those cases in which the plan has paid the hospital or birthing center for the maternity stay, and can produce evidence of such payment.

“Supplemental Newborn Capitation Payment” means the fixed amount paid to the Contractor for the inpatient birthing costs for a newborn enrolled in the plan, limited to those cases in which the plan has paid the hospital or birthing center for the newborn stay, and can produce evidence of such payment.

“Tuberculosis Directly Observed Therapy” or “TB/DOT” means the direct observation of ingestion of oral TB medications to assure patient compliance with the physician’s prescribed medication regimen.

“Urgently Needed Services” means covered services that are not Emergency Services as defined in this Section, provided when an Enrollee is temporarily absent from the Contractor’s service area, when the services are medically necessary and immediately required: (1) as a result of an unforeseen illness, injury, or condition; and (2) it was not reasonable given the circumstances to obtain the services through the Contractor’s plan.

SECTION I

(DEFINITIONS)

October 1, 2004

1

10

2. AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION PROVISIONS

2.1 Term

a) This Agreement is effective October 1, 2004 and shall remain in effect until September 30, 2005; or until the execution of an extension, renewal or successor Agreement approved by the SDOH and the Department of Health and Human Services (DHHS); or until the effective date of an executed agreement between the Contractor and SDOH for Contractor’s participation in the Medicaid managed care program; whichever occurs first.

b) The. parties to the Agreement shall have the option to renew this Agreement for additional two (2) year and or one (1) year terms, subject to the approval of the LDSS, SDOH, DHHS and any other entities as required by law or regulation.

c) However, in no event, shall the maximum duration of this Agreement exceed five (5) years.

2.2 Amendments and Extensions

a)

This Agreement may only be modified in writing. Unless otherwise specified in this Agreement, modifications must be signed by the parties and approved by the SDOH, DHHS, and any other entities as required by law or regulation, prior to the end of the quarter in which the amendment is to be effective.

 

b)

This Agreement shall not be automatically renewed at its expiration. This Agreement may be extended by written amendment, in accordance with the procedures set forth in this Section.

c) An extension to this Agreement may be granted for reasons including, but not limited, to the following:

i) Negotiations for a successor Agreement will not be completed by the expiration date of the current contract; or

ii) The Contractor has submitted a termination notice and transition of Enrollees will not be completed by the expiration date of the current contract.

d) The parties will submit, to the extent practicable, the proposed signed and dated extensions, including all necessary local government approvals, to SDOH prior to the scheduled expiration date of this Agreement.

2.3 Approvals

This Agreement and any amendments to this Agreement shall not be effective or binding unless and until approved, in writing, by the DHHS, the SDOH and any other entity as required in law and regulation. SDOH will provide a notice of each such approval to the Contractor and the LDSS upon such approval.

2.4 Entire Agreement

This Agreement shall supersede all prior Agreements between the Contractor and the LDSS. This Agreement, including those attachments, schedules, appendices, exhibits, and addenda that have been specifically incorporated herein and written plans submitted by the Contractor and maintained on file by SDOH and/or LDSS pursuant to this Agreement, contains all the terms and conditions agreed upon by the parties, and no other Agreement, oral. or otherwise, regarding the subject matter of this Agreement shall be deemed to exist or to bind any of the parties or vary any of the terms contained in this Agreement. In the event of any inconsistency or conflict among the document elements of this Agreement, such inconsistency or conflict shall be resolved by giving precedence to the document elements in the following order:

SECTION 2

(AGREEMENT TERM, AMENDMENTS. EXTENSIONS.

AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)

October 1, 2004

2-l

11

1) Appendix A, Standard Clauses for all New York State Contracts;
2) Local Standard Clauses, if any;
3) The body of this Agreement;
4) The appendices attached to the body of this Agreement, other than Appendix A;
5) The Contractor’s approved:
i) Marketing Plan on file with SDOH and LDSS

v) Fraud and Abuse Prevention Plan on file with SDOH and LDSS.

2.5 Renegotiation

The parties to this Agreement shall have the right to renegotiate the terms and conditions of this Agreement in the event applicable local, state or federal law, regulations or policy are altered from those existing at the time of this Agreement in order to be in continuous compliance therewith. This Section shall not limit the right of the parties to this Agreement from renegotiating or amending other terms and conditions of this agreement. Such changes shall only be made with the consent of the parties and the prior approval of the SDOH and the DHHS.

2.6 Assignment and Subcontracting

a)

The Contractor shall not, without LDSS and SDOH’s prior written consent, assign, transfer, convey, sublet, or otherwise dispose of this Agreement; of the Contractor’s right, title, interest, obligations, or duties under the Agreement; of the Contractor’s power to execute the Agreement; or, by power of attorney or otherwise, of any of the Contractor’s rights to receive monies due or to become due under this Agreement. Any assignment, transfer, conveyance, sublease, or other disposition without LDSS and SDOH’s consent shall be void.

b) Contractor may not enter into any subcontracts related to the delivery of services to Enrollees, except by written agreement, as set forth in Section 22 of this Agreement. The Contractor may subcontract for provider services and management services. If such written agreement would be between Contractor and a provider of health care or ancillary health services or between Contractor and an independent practice association, the agreement must be in a form previously approved by SDOH. If such subcontract is for management services under 10 NYCRR § 98-1.11, it must be approved by SDOH prior to its becoming effective. Any subcontract entered into by Contractor shall fulfill the requirements of 42 CFR Parts 434 and 438 that are appropriate to the service or activity delegated under such subcontract. Contractor agrees that it shall remain legally responsible to LDSS for carrying out all activities under this Agreement and that no subcontract shall limit or terminate Contractor’s responsibility.

2.7 Termination

a) LDSS Initiated Termination of Contract

i) LDSS shall have the right to terminate this Agreement, in whole or in part if the Contractor:

A)

takes any action that threatens the health, safety, or welfare of its Enrollees;

B) has engaged in an unacceptable practice under 18 NYCRR, Part 515, that affects the

fiscal integrity of the Medicaid program;

C) has its Certificate of Authority suspended, limited or revoked by SDOH;

D) materially breaches the Agreement or fails to comply with any term or condition of this Agreement that is not cured within twenty (20) days, or to such longer period as the parties may agree, of LDSS’s written request for compliance;

E) becomes insolvent;

SECTION 2
(AGREEMENT TERM. AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October I, 2004
2-2

12

F)

brings a proceeding voluntarily, or has a proceeding brought against it involuntarily, under Title 11 of the U.S. Code (the Bankruptcy Code); or

G) knowingly has a director, officer, partner or person owning or controlling more than five percent (5%) of the. Contractor’s equity, or has an employment, consulting, or other agreement with such a person for the provision of items and/or services that are significant to the Contractor’s contractual obligation who has been debarred or suspended by the federal, state or local government, or otherwise excluded from participating in procurement activities.

ii) The LDSS will notify the Contractor of its intent to terminate this Agreement for the Contractor’s failure to meet the requirements of this Agreement and provide Contractor with a hearing prior to the termination.

iii) If SDOH suspends, limits or revokes Contractor’s Certificate of Authority under PHL § 4404, this Agreement shall expire on the date the Contractor ceases to have authority to serve the geographic area of the LDSS. No hearing will be required if the contract expires due to SDOH suspension, limitation or revocation of the Contractor’s Certificate of Authority.

iv) Prior to the effective date of the termination the LDSS shall notify Enrollees of the termination, or delegate responsibility for such notification to the Contractor, and such notice shall include a statement that Enrollees may disenroll immediately without cause.

b) Contractor and LDSS Initiated Termination

The Contractor and the LDSS each shall have the right to terminate this Agreement in the event that SDOH and the Contractor fail to reach agreement on the monthly Capitation Rates. In such event, the party exercising its right shall give the other party, LDSS, and SDOH written notice specifying the reason for and the effective date of termination, which shall not be less time than will permit an orderly disenrollment of Enrollees to the Medicaid fee-for-service payment mechanism or transfer to another MCO, as determined by LDSS, but no more than ninety (90) days.

c) Contractor Initiated Termination

i) The Contractor shall have the right to terminate this Agreement in the event that LDSS materially breaches the Agreement or fails to comply with any term or condition of this Agreement that is not cured within twenty (20) days, or to such longer period as the parties may agree, of the Contractor’s written request for compliance. The Contractor shall give LDSS written notice specifying the reason for and the effective date of the termination, which shall not be less time than will permit an orderly disenrollment of Enrollees to the Medicaid fee-for- service payment mechanism or transfer to another managed care program, as determined by LDSS, but no more than ninety (90) days.

ii) The Contractor shall have the right to terminate this Agreement in the event that its obligations are materially changed by modifications to this Agreement and its Appendices by SDOH or LDSS. In such event, Contractor shall give LDSS and SDOH written notice within thirty (30). days of notification of changes to the Agreement or Appendices specifying the reason and the effective date of termination, which shall not be less time .than will permit an orderly disenrollment of Enrollees to the Medicaid fee-for-service program or transfer to another MCO, as determined by the LDSS, but no more than ninety (90) days.

SECTION 2
(AGREEMENT TERM. AMENDMENTS. EXTENSIONS.
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October I , 2004
2-3

13

iii) The Contractor shall also have the right to terminate this Agreement if the Contractor is unable to provide services pursuant to this Agreement because of a natural disaster and/or an act of God to such a degree that Enrollees cannot obtain reasonable access to services within the Contractor’s organization, and, after diligent efforts, the Contractor cannot make other provisions for the delivery of such services. The Contractor shall give LDSS written notice of any such termination that specifies:

A)

the reason for the termination, with appropriate documentation of the circumstances arising from a natural disaster and/or an act of God that preclude reasonable access to services;

 

B)

the Contractor’s attempts to make other provision for the delivery of services; and

 

C)

the effective date of the termination, which shall not be less time than will permit an orderly disenrollment of Enrollees to the Medicaid fee-for-service payment mechanism or transfer to another MCO, as determined by LDSS, but no more than ninety (90) days.

d) Termination Due To Loss of Funding

In the event that State and/or Federal funding used to pay for services under this Agreement is reduced so that payments cannot be made in full, this Agreement shall automatically terminate, unless both parties agree to a modification of the obligations under this Agreement. The effective date of such termination shall be ninety (90) days after the Contractor receives written notice of the reduction in payment, unless available funds are insufficient to continue payments in full during the ninety (90) day period, in which case LDSS shall give the Contractor written notice of the earlier date upon which the Agreement shall terminate. A reduction in State and/or Federal funding cannot reduce monies due and owing to the Contractor on or before the effective date of the termination of the Agreement.

2.8 Close-Out Procedures

Upon termination or expiration of this Agreement and in the event that it is not scheduled for renewal, the Contractor shall comply with close-out procedures that the Contractor develops in conjunction with LDSS and that the LDSS, and the SDOH have approved. The close-out procedures shall include the following:

a)

The Contractor shall promptly account for and repay funds advanced by SDOH for coverage of Enrollees for periods subsequent to the effective date of termination;

 

b)

The Contractor shall give LDSS, SDOH, and other authorized federal, state or local agencies access to all books, records, and other documents and upon request, portions of such books, records, or documents that may be required by such agencies pursuant to the terms of this Agreement;

 

c)

The Contractor shall submit to LDSS, SDOH, and other authorized federal, state or local agencies, within ninety (90) days of termination, a final financial statement and audit report relating to this Agreement, made by a certified public accountant or a licensed public accountant, unless the Contractor requests of LDSS and receives written approval from LDSS, SDOH and all other governmental agencies from which approval is required, for an extension of time for this submission;

 

d)

The Contractor shall furnish to SDOH immediately upon receipt all information related to any request for reimbursement of any medical claims that result from services delivered after the date of termination of this Agreement;

SECTION 2

(AGREEMENT TERM. AMENDMENTS, EXTENSIONS,

AND GENERAL CONTRACTADMINLSTRATION PROVISIONS)

October 1, 2004

2-4

14

e)

The Contractor shall establish an appropriate plan acceptable to and prior approved by the LDSS and SDOH for the orderly disenrollment of Enrollees to the Medicaid fee-for-service program or enrollment into another MCO. This plan shall include the provision of pertinent information to identified Enrollees who are: pregnant; currently receiving treatment for a chronic or life threatening condition; prior approved for services or surgery; or whose care is being monitored by a case manager to assist them in making decisions which will promote continuity of care.

f) SDOH shall promptly pay all claims and amounts owed to the Contractor;

g)

Any termination of this Agreement by either the Contractor or LDSS shall be done by amendment to this Agreement, unless the contract is terminated by the LDSS due to conditions in Section 2.7 a.(i) or Appendix A of this Agreement.

2.9 Rights and Remedies

The rights and remedies of LDSS and the Contractor provided expressly in this Article shall not be exclusive and are in addition to all other rights and remedies provided by law or under this Agreement.

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
Coming Tower, Rm. 2074
Albany, NY 12237-0065

For the Contractor:

Executive Director
CarePlus, L.L.C.
360 West 31 ^St Street, Fifth Floor New York, NY 10001

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 I, 2004
2-5

15

3. COMPENSATION

3.1 Capitation Payments

Compensation to the Contractor shall consist of a monthly capitation payment for each Enrollee and the Supplemental Capitation Payments as described in Sections 3.1 (c) and 3.1 (d), where applicable.

a)

In no event shall monthly capitation payments to the Contractor for the Benefit Package exceed the cost of providing the Benefit Package on a fee-for-service basis to an actuarially equivalent, non-enrolled population group Upper Payment Limit (UPL) as determined by SDOH.

 

b)

The monthly Capitation Rates are attached hereto as Appendix L and shall be deemed incorporated into this Agreement without further action by the parties.

 

c)

The monthly capitation payments and the Supplemental Newborn Capitation Payment and the Supplemental Maternity Capitation Payment to the Contractor shall constitute full and complete payments to ‘the. Contractor for all services .that the Contractor provides pursuant to this Agreement subject to stop-loss provisions set forth in . Section 3.11 and 3.12 of this Agreement.

 

d)

Capitation Rates shall be effective for the entire contract period, except as described in Section 3.2.

3.2 Modification of Rates During Contract Period

a)

Any technical modification to Capitation Rates during the term of the Agreement as agreed to by the Contractor, including but not limited to, changes in reinsurance or the Benefit Package, shall be deemed incorporated into this Agreement without further action by the parties, upon approval by SDOH, and upon written notice by SDOH to the LDSS.

 

b)

Any other modification to Capitation Rates, as agreed to by SDOH and the Contractor, during the term of the Agreement shall be deemed incorporated into this Agreement without further action by the parties upon approval of such modifications by the SDOH and the State Division of the Budget, and upon written notice by SDOH to the LDSS.

 

c)

In the event that SDOH and the Contractor fail to reach agreement on modifications to the monthly Capitation Rates, the SDOH will provide formal written notice to the Contractor and LDSS of the amount and effective date of the modified Capitation Rates approved by the State Division of the Budget. The Contractor shall have the option of terminating this Agreement if such approved modified Capitation Rates are not acceptable. In such case, the Contractor shall give written notice to the SDOH and the LDSS within thirty (30) days of the date of the formal written notice of the modified Capitation Rates from SDOH specifying the reasons for and effective date of termination. The effective date of termination shall be ninety (90) days from the date of the Contractor’s written notice, unless the SDOH determines that an orderly disenrollment to Medicaid fee-for-service or transfer to another MCO can be accomplished in fewer days. During the period commencing with the effective date of the SDOH modified Capitation Rates through the effective date of termination of the Agreement, the Contractor shall have the option of continuing to receive capitation payments at the expired Capitation Rates or at the modified Capitation Rates approved by SDOH and State Division of the Budget for the rate period.

If the Contractor fails to exercise its right to terminate in accordance with this Section, then the modified Capitation Rates approved by SDOH and the State Division of the Budget shall be deemed incorporated into this Agreement without further action by the parties as of the effective date of the modified Capitation Rates as established by SDOH and approved by State Division of the Budget.

SECTION 3

(COMPENSATION)

October I, 2004

3-1

16

3.3 Rate Setting Methodology

Capitation Rates are determined using a prospective methodology whereby cost, utilization and other rate-setting data available for the time period prior to the time period covered by the rates are used to establish premiums. Capitation rates will not be retroactively adjusted to reflect actual fee-for-service data or plan experience for the time period covered by the rates.

3.4 Payment of Capitation

a)

The monthly capitation payments for each Enrollee are due to the Contractor from the Effective Date of Enrollment until the Effective Date of Disenrollment of the Enrollee or termination of this Agreement, whichever occurs first. The Contractor shall receive a full month’s capitation payment for the month in which disenrollment occurs. The Roster generated by SDOH with any modification communicated electronically or in writing by the LDSS or the Enrollment Broker prior to the end of the month in which the Roster is generated, shall be the enrollment list for purposes of MMIS premium billing and payment, as discussed in Section 6.9 and Appendix H.

 

b)

Upon receipt by the Fiscal Agent of a properly completed claim for monthly capitation payments submitted by the Contractor pursuant to this Agreement, the Fiscal Agent will promptly process such claim for payment through MMIS and use its best efforts to complete such processing within thirty (30) business days from date of receipt of the claim by the Fiscal Agent. Processing of Contractor claims shall be in compliance with the requirements of 42 CFR 447.45. The Fiscal Agent will also use its best efforts to resolve any billing problem relating to the Contractor’s claims as soon as possible. In accordance with Section 41 of the State Finance Law; the State and LDSS shall have no liability under this Agreement to the Contractor or anyone else beyond funds appropriated and available for payment of Medical Assistance care, services and supplies.

3.5 Denial of Capitation Payments

If the Centers for Medicare and Medicaid Services denies payment for new Enrollees, as authorized by Social Security Act (SSA) § 1903(m)(5) and 42 CFR § 434.67, or such other applicable federal statutes or regulations, based upon a determination that Contractor failed substantially to provide medically necessary items and services, imposed premium amounts or charges in excess of permitted payments, engaged in discriminatory practices as described in SSA § 1932(e)(l)(A)(iii), misrepresented or falsified information submitted to CMS, SDOH, LDSS, the Enrollment Broker, or an Enrollee, potential Enrollee, or health care provider, or failed to comply with federal requirements (i.e. 42 CFR § 417.479 and 42 CFR § 434.70) relating to the Physician Incentive Plans, SDOH and LDSS will deny capitation payments to the Contractor for the same Enrollees for the period of time-for which CMS denies such payment.

3.6 SDOH Right to Recover Premiums

The parties acknowledge and accept that the SDOH has a right to recover premiums paid to the Contractor for Enrollees listed on the monthly Roster who are later determined for the entire applicable payment month, to have been in an institution; to have been incarcerated; to have moved out of the Contractor’s service area subject to any time remaining in the Enrollee’s Guaranteed Eligibility period; or to have died. In any event, the State may only recover premiums paid for Medicaid Enrollees listed on a Roster if it is determined by the SDOH that the Contractor was not at risk for provision of Benefit Package services for any portion of the payment period.

3.7 Third Party Health Insurance Determination

The Contractor and the LDSS will make diligent efforts to determine whether Enrollees have third party health insurance (TPHI). The LDSS shall use its best efforts to maintain third party information on the WMS/MMIS Third Party Resource System. The Contractor shall make good faith efforts to coordinate benefits with and collect TPHI recoveries from other insurers, and must inform the LDSS of any known changes in status of TPHI insurance eligibility within thirty (30) days of learning of a change in TPHI. The Contractor may use the Roster as one method to determine TPHI information. The Contractor will be permitted to retain 100 percent of any reimbursement for Benefit Package services obtained

SECTION 3
(COMPENSATION)
October 1, 2004
3-3

17

from TPHI. Capitation Rates are net of TPHI recoveries. In no instances may an Enrollee be held responsible for disputes over these recoveries.

3.8 Payment For Newborns

a)

The Contractor shall be responsible for all costs and services included in the Benefit Package associated with the Enrollee’s newborn, unless the child is excluded from Medicaid Managed Care.

 

b)

The Contractor shall receive a capitation payment from the first day of the newborn’s month of birth and, in instances where the plan pays the hospital or birthing center for the newborn stay, a Supplemental Newborn Capitation Payment.

 

c)

Capitation Rate and Supplemental Newborn Capitation Payment for a newborn will begin the month following certification of the newborn’s eligibility and enrollment, retroactive to the first day of the month in which the child was born:

 

d)

The Contractor cannot bill for a Supplemental Newborn Capitation Payment unless the newborn hospital or birthing center payment has been paid by the Contractor. The Contractor must maintain on file evidence of payment to the hospital or birthing center of the claim for the newborn stay. Failure to have supporting records may, upon an audit, result in recoupment of the Supplemental Newborn Capitation Payment by SDOH.

3.9 Supplemental Maternity Capitation Payment

a)

The Contractor shall be responsible for all costs and services included in the Benefit Package associated with the maternity care of an Enrollee.

 

b)

In instances where the Enrollee is enrolled in the Contractor’s plan on the date of the delivery of a child, the Contractor shall be entitled to receive a Supplemental Maternity Capitation Payment. The Supplemental Maternity Capitation Payment reimburses the Contractor for the inpatient and outpatient costs of services normally provided as part of maternity care including antepartum care, delivery and post-partum care. The Supplemental Maternity Capitation Payment is in addition to the monthly Capitation Rate paid by the SDOH to the Contractor for the Enrollee.

 

c)

In instances where the Enrollee was enrolled in the Contractor’s plan for only part of the pregnancy, but was enrolled on the date of the delivery of the child, the plan shall be entitled to receive the entire Supplemental Maternity Capitation Payment. The Supplemental Capitation payment shall not be pro-rated to reflect that the Enrollee was not a member of the Contractor’s plan for the entire duration of the pregnancy.

 

d)

In instances where the Enrollee was enrolled in the Contractor’s plan for part of the pregnancy, but was not enrolled on the date of the delivery of the child, the Contractor shall not be entitled to receive the Supplemental Maternity Capitation Payment, or any portion thereof.

 

e)

Costs of inpatient and outpatient care associated with maternity cases that end in termination or miscarriage shall be reimbursed to the Contractor through the monthly Capitation Rate for the Enrollee and the Contractor shall not receive the Supplemental Maternity Capitation Payment.

SECTION 3

(COMPENSATION)

October I, 2004

3-4

18

f)

The Contractor may not bill a Supplemental Maternity Capitation Payment until the hospital inpatient or birthing center delivery is paid by the Contractor, and the Contractor must maintain on file evidence of payment of the delivery, plus any other inpatient and outpatient services for the maternity care of the Enrollee to be eligible to receive a Supplemental Maternity Capitation Payment. Failure to have supporting records may, upon audit, result in recoupment of the Supplemental Maternity Capitation Payment by the SDOH.

3.10 Contractor Financial Liability

Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her Effective Date of Enrollment in the Contractor’s plan.

3.11 Inpatient Hospital Stop-Loss Insurance

The Contractor must obtain stop-loss coverage for inpatient hospital services. A Contractor may elect to purchase stop-loss coverage from New York State. In such cases, the Capitation Rates paid to the Contractor shall be adjusted to reflect the cost of such stop-loss coverage. The cost of such coverage shall be determined by SDOH.

Under NYS stop-loss coverage, if the hospital inpatient expenses incurred by the Contractor for an individual Enrollee during any calendar year reaches $50,000, the Contractor shall be compensated for 80% of the cost of hospital inpatient services in excess of this amount up to a maximum of $250,000. Above that amount, the Contractor will be compensated for 100% of cost. All compensation shall be based on the lower of the Contractor’s negotiated hospital rate or Medicaid rates of payment.
• The Contractor has elected to have NYS provide stop-loss reinsurance.
OR
x Contractor has not elected to have NYS provide stop-loss reinsurance.

3.12 Mental Health and Chemical Dependence Stop-Loss

a)

The Contractor will be compensated for medically necessary and clinically appropriate Medicaid reimbursable mental health treatment outpatient visits in excess of twenty (20) visits during any calendar year at rates set forth in contracted fee schedules. Any Court Ordered Services for mental health treatment outpatient visits which specify the use of Non-Participating Providers shall be compensated at the Medicaid rate of payment.

 

b)

The Contractor will be compensated for medically necessary and clinically appropriate inpatient mental health services and/or Chemical Dependence Inpatient Rehabilitation and Treatment Services as defined in Appendix K in excess of a combined total of thirty (30) days during a calendar year at the lower of the Contractor’s negotiated inpatient rate or Medicaid rate of payment.

 

c)

Detoxification Services in Article 28 inpatient hospital facilities are subject to the stop-loss provisions specified in Section 3.11 of this. Agreement.

SECTION 3

(COMPENSATION)

October 1, 2004

3-5

19

3.12 Mental Health and Chemical Dependence Stop-Loss

a)

The Contractor will be compensated for medically necessary and clinically appropriate Medicaid reimbursable mental health treatment outpatient visits in excess of twenty (20) visits during any calendar year at rates set forth in contracted fee schedules. Any Court Ordered Services for mental health treatment outpatient visits which specify the use of Non-Participating Providers shall be compensated at the Medicaid rate of payment.

 

b)

The Contractor will be compensated for medically necessary and clinically appropriate inpatient mental health services and/or Chemical Dependence Inpatient Rehabilitation and Treatment Services as defined in Appendix K in excess of a combined total of thirty (30) days during a calendar year at the lower of the Contractor’s negotiated inpatient rate or Medicaid rate of payment.

 

c)

Detoxification Services in Article 28 inpatient hospital facilities are subject to the stop-loss provisions specified in Section 3.11 of this. Agreement.

3.13 Enrollment Limitations

a)

The Contractor may enroll up to the county specific provider network capacity limits determined by SDOH, provided that the Contractor’s statewide enrollment does not exceed the MCO’s financial capacity as determined annually by SDOH, or more frequently as deemed necessary by SDOH.

 

b)

LDSS shall have the right, upon consultation with and notice to the SDOH, to limit, suspend, or terminate enrollment activities by the Contractor and/or enrollment into the Contractor’s plan upon ten (10) days written notice to the Contractor. The written notice shall specify the actions contemplated and the reason(s) for such action(s) and shall provide the Contractor with an opportunity to submit additional information that would support the conclusion that limitation, suspension or termination of enrollment activities or enrollment in the Contractor’s plan is unnecessary. Nothing in this paragraph limits other remedies available to the LDSS under this Agreement.

 

c)

The SDOH shall have the right, upon notice to the LDSS, to limit, suspend or terminate enrollment activities by the Contractor and/or enrollment into the Contractor’s plan upon ten (10) days written notice to the Contractor. The written notice shall specify the action(s) contemplated and the reason(s) for such action(s) and shall provide the Contractor with an opportunity to submit additional information that would support the conclusion that limitation, suspension or termination of enrollment activities or enrollment in the Contractor’s plan is unnecessary. Nothing in this paragraph limits other remedies available to the SDOH or the LDSS under this Agreement.

3.14 Tracking Visits Provided by Indian Health Clinics

The SDOH shall monitor all visits provided by tribal or Indian health clinics or urban Indian health facilities or centers to enrolled Native Americans, so that the SDOH can reconcile payment made for those services, should it be deemed necessary to do so.

SECTION 3

(COMPENSATION)

October I. 2004

20

3-6

The Service Area described in Appendix M of this Agreement, which is hereby made a part of this Agreement as if set forth fully herein, is the specific geographic area within which Eligible Persons must reside to enroll in the Contractor’s plan.

SECTION 4
(SERVICE AREA)
October 1, 2004
4-1

21

5.

ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS

5.1 Eligible Populations

a)

Except as specified in Section 5.1(b) and 5.3 below, all persons in the following Medicaid-eligible beneficiary categories who reside in the service area shall be eligible for enrollment in the Contractor’s plan:

i) Singles/Childless Couples — Cash and Medicaid only
ii) Low Income Families with Children — Cash and Medicaid only
iii) Aid to Families with Dependent Children — Medicaid only

iv)

Pregnant women whose net available income is at or below two hundred percent (200%) of the federal poverty level for the applicable household size.

 

v)

Children aged one (1) year or below whose family’s net available income is at or below two hundred percent (200%) of the federal poverty level for the applicable household size.

 

vi)

Children between ages one (1) and five (5), whose family’s net available income is at or below one hundred and thirty-three percent (133%) of the federal poverty level for the applicable household size.

 

vii)

Children age six (6) up to age nineteen (19), whose family’s net available income is at or below one hundred and thirty-three percent (133%) of the federal poverty level for the applicable household size.

viii) Transitional Medical Assistance Beneficiaries

ix)

Supplemental Security Income (cash) and Supplemental Security Income Related (Medicaid only).

Medicaid eligible individuals in the following categories may be eligible for enrollment in the Contractor’s plan at the LDSS’ option, as indicated by an X below.

i) Foster care children in the direct care of LDSS.

      Mandatory county — children in LDSS direct care are mandatorily enrolled.
      Mandatory OR voluntary county — children in LDS S direct care are enrolled on a case-by-case basis.

_X      Mandatory OR voluntary county — all foster care children are excluded from managed care.

ii) Homeless persons living in shelters outside of New York City may be eligible for

enrollment if so determined by the LDSS.

Mandatory county — homeless persons are mandatorily enrolled.
Mandatory OR voluntary county — homeless persons are enrolled on a case-by- case basis.

Mandatory OR voluntary county — all homeless persons are excluded from managed care.

5.2 Exempt Populations

The following populations are exempt from mandatory enrollment in Medicaid managed care, but may enroll on a voluntary basis, if otherwise eligible.

a) Individuals who are HIV+ or have AIDS.

b)

Individuals who are Seriously and Persistently Mentally Ill or Seriously Emotionally Disturbed.

SECTION 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 2004
5-1

22

c)

Individuals for whom a Managed Care Provider is not geographically accessible so as to reasonably provide services: To qualify for this exemption, an individual must demonstrate that no participating .MCO has a provider located within thirty (30) minutes travel time/thirty (30) miles travel distance from the individual’s home, who is accepting new patients, and that there is a fee-for-service Medicaid provider available within the thirty (30) minutes travel time/thirty (30) miles travel distance.

 

d)

Pregnant women who are already receiving prenatal care from a provider authorized to provide such care not participating in any Medicaid managed care plan. This status will last through a woman’s pregnancy, extend through the sixty (60) day post-partum period and end at the end of the month in which the sixtieth (60 th ) day occurs.

Individuals with a chronic medical condition who, for at least six (6) months, have been under active treatment with a non-participating sub-specialist physician who is not a network provider for any MCO participating in the Medicaid managed care program service area. This status will last as long as the individual’s chronic medical condition exists or until the physician joins a participating MCO’s network. The SDOH’s Office of Managed Care, Medical Director will, upon the request of an individual or his/her guardian or legally authorized representative (health care agent authorized through a health care proxy), review cases of individuals with unusually severe chronic care needs for a possible exemption from mandatory enrollment in managed care if such individuals are not otherwise eligible for an exemption (i.e., meet one of the seventeen (17) criteria listed here). The SDOH’s 01N/1C Medical Director may also authorize a plan disenrollment for such individuals. Disenrollment requests should be made in a manner consistent with the overall disenrollment request process for “good cause” disenrollment.

f) Individuals with End Stage Renal Disease (ESRD).

g)

Individuals who are residents of Intermediate Care Facilities for the Mentally Retarded (“ICF/MR”).

 

h)

Individuals with characteristics and needs similar to those who are residents of — ICF/MRs based on criteria cooperatively established by the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and the SDOH.

 

i)

Individuals already scheduled for a major surgical. procedure (within thirty (30) days of scheduled enrollment) with a provider who is not a participant in the network of a Medicaid MCO under contract with the LDSS. This exemption will only apply until such time as the individual’s course of treatment is complete.

 

j)

Individuals with a developmental or physical disability who receive services through a Medicaid Home-and-Community-Based Services Waiver or Medicaid Model ‘Waiver (care-at-home) through a Section 1915c waiver, or individuals having characteristics and needs similar to such individuals (including individuals on the waiting list), based on criteria cooperatively established by OMRDD and SDOH.

 

k)

Individuals who are residents of Alcohol and Substance Abuse or Chemical Dependence Long Term Residential Treatment Programs.

 

l)

In New York City, all homeless individuals are exempt. In areas outside of NYC, exemption of homeless individuals residing in the shelter system is at the discretion of the local district. — See Section 5.1 (b).

m) Native Americans

n)

Individuals who cannot be served by a managed care provider due to a language barrier which exists when the individual is not capable of effectively communicating his or her medical needs in English or in a secondary language for which PCPs are available within the Medicaid managed care program. Individuals with a language barrier will be deemed able to be served if they have a choice, within time and distance standards, of three (3) PCPs who are able to communicate in the primary language of the eligible individual or who have a person on his/her staff capable of translating medical terminology. Individuals will be eligible for an exemption when:

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October 1.2004

5-2

23

i)

The individual has a relationship with a Medicaid fee-for-service Primary Care Provider who:

A) has the language capability to serve the individual;

B)

does not participate in any of the Medicaid managed care plans contracted for a service area which includes the individual’s residence;

 

C)

is located within a thirty (30) minute /thirty (30) mile radius of the eligible individual’s residence;

AND

D) there are fewer than three (3) participating PCPs available within the thirty

(30) minute/thirty (30) mile radius who arc able to communicate in the
primary language of the eligible individual or who have a person on
his/her staff capable of translating medical terminology.

OR

ii)

The individual has a relationship with a Medicaid fee-for-service Primary Care Provider who:

A) has the language capability to service the individual;

B)

does not participate in any of the Medicaid managed care plans contracted for a service area which includes the individual’s residence;

 

C)

is located outside a thirty (30) minute/thirty (30) mile radius of the eligible individual’s residence;

AND

D)

there are fewer than three (3) participating PCPs available within or outside the thirty (30) minute/thirty (30) mile radius who are able to communicate in the primary language .of the eligible individual or who have a person on his/her staff capable of translating medical terminology.

 

•

) Individuals temporarily residing out of district, (e.g., college students) will be exempt until the last day of the month in which the purpose of the absence is accomplished. The definition of temporary absence is set forth in Social Services regulations 18 NYCRR §360-1.4(p).

 

p)

SSI and SSI-related beneficiaries are considered exempt and may enroll on a voluntary basis.

 

q)

Individuals with a “County of Fiscal Responsibility” code of 98 (OMRDD in MMIS) are exempt in counties where program features are approved by the State and operational at the local district level to permit these individuals to voluntarily enroll in Medicaid managed care.

 

•

State-approved program features are in place and operational at the local district level to permit individuals with a “County of Fiscal Responsibility” code of 98 to voluntarily enroll in Medicaid managed care.

OR

x State-approved program features are not in place and operational at the local district level, therefore individuals with a “County of Fiscal Responsibility” code of 98 are excluded from enrollment in Medicaid managed care.

r) Individuals who are eligible for Medical Assistance pursuant to the “Medicaid buy-in for the working disabled” (subparagraphs twelve or thirteen of paragraph (a) of subdivision one of Section 366 of the Social Services Law), and who, pursuant to subdivision 12 of Section 367-a of the Social Services Law, are not required to pay a premium.

SECTION 5

(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)

October I. 2004

5-3

24

5.3 Excluded Populations

The following populations are ineligible for enrollment in Medicaid managed care.

a) Individuals who are Dually Eligible for Medicare/Medicaid.

b)

Individuals who become eligible for Medicaid only after spending down a portion of their income (Spend-down).

 

c)

Individuals who are residents of State-operated psychiatric facilities or residents of State-certified or voluntary treatment facilities for children and youth.

 

d)

Individuals who are residents of Residential Health Care Facilities (“RHCF”) at the time of Enrollment,:an4 Enrollees whose stay in a RHCF is classified as permanent upon entry into the RHCF or is classified as permanent at a time subsequent to entry.

 

e)

Individuals enrolled in managed long term care demonstrations authorized under Article 4403-f of the New York State PHL.

f) Medicaid-eligible infants living with incarcerated mothers.

g)

Infants weighing less than 1200 grams at birth and other infants under six (6) months of age who meet the criteria for the SSI or SSI related category (shall not be enrolled or shall be disenrolled retroactive to date of birth).

 

h)

Individuals with access to comprehensive private health care coverage including those already enrolled in an MCO. Such health care coverage, purchased either partially or in full, by or on behalf of the individual, must be determined to be cost effective by the local social services district.

i) Foster children in the placement of a voluntary agency.

j)

Certified blind or disabled children living or expected to be living separate and apart from the parent for thirty (30) days or more.

 

k)

Individuals expected to be eligible for Medicaid for less than six (6) months, except for pregnant women (e.g., seasonal agricultural workers).

 

l)

Foster children in direct care (unless LDSS opts to enroll them see Section 5.1(b)).

 

m)

Youths in the care and custody of the Commissioner of the NYS Office of Children and Family Services.

 

m)

Individuals in receipt of long-term care services through Long Term Home Health Care programs, or Child Care Facilities (except ICF services for the Developmentally Disabled).

 

n)

Individuals eligible for Medical assistance benefits only with respect to TB related services.

 

•

) Individuals placed in State Office of Mental Health licensed family care homes pursuant to NYS Mental Hygiene Law, Section 3-1.03.

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October 1, 2004
5-4

25

p)

Individuals enrolled in the Restricted Recipient Program.

r) Individuals with a “County of Fiscal Responsibility” code of 99.

s)

Individuals admitted to a Hospice program prior to time of enrollment (if an Enrollee enters a Hospice program while enrolled in the Contractor’s plan, he/she may remain enrolled in the Contractor’s plan to maintain continuity of care with his/her PCP). Hospice services are accessed through the fee-for-service Medicaid Program.

t) Individuals with a “County of Fiscal Responsibility” code of 97 (OMH in MMIS).

u)

Individuals with a “County of Fiscal Responsibility” code of 98 (OMRDD in MMIS) will be excluded until program features are approved by the State and operational at the local district level to permit these individuals to voluntarily enroll in Medicaid managed care.

 

v)

Individuals receiving family planning services pursuant to Section 366(1)(a)(11) of the Social Services Law who are not otherwise eli g ible for medical assistance and whose net available income is 200% or less of the federal poverty level.

 

w)

Individuals who are eligible for Medical Assistance pursuant to the `”Medicaid buy-in for the working disabled” (subparagraphs twelve or thirteen of paragraph (a) of subdivision one of Section 366 of the Social Services Law), and who, pursuant to subdivision 12 of Section 367-a of the Social Services Law, are required to pay a premium.

 

x)

Individuals who are eligible for Medical Assistance pursuant to paragraph (v) of subdivision four of Section 366 of the Social Services Law (persons who are under 65 years of age, have been screened for breast and/or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable coverage as defined in the Federal Public Health Service Act).

5.4 Family Health Plus

Individuals eligible for Medicaid (Family Health Plus) pursuant to Title 11-D of the Social Services Law are not eligible for enrollment in Medicaid managed care under this Agreement.

5.5 Family Enrollment

In local social service districts where enrollment in. managed care is mandatory, the Contractor agrees that members of the same family (defined as mother and her child(ren), father and his child(ren), a husband, wife and child(ren) or a husband and wife residing in the same household, or persons included in the same case) will be required to enroll in the same health plan, in accordance with Section 6.6 of this Agreement.

SECTION 5

(ELIGIBLE. EXEMPT AND EXCLUDED POPULATIONS)

October I , 2004

5-5

26

6.1 Enrollment Guidelines

a)

The LDSS may employ a variety of methods and programs for enrollment of Eligible Persons including, but not limited to enrollment assisted by the Contractor, enrollment assisted by an Enrollment Broker, enrollment by LDSS, or a combination of such. The policies and procedural guidelines which will be used for enrollment are set forth in Appendix H, which is hereby made a part of this Agreement as if set forth fully herein.

 

b)

The LDSS and the Contractor agree to . conduct enrollment of eligible individuals in accordance with the guidelines set forth in Appendix H.

 

c)

The SDOH and LDSS, upon mutual agreement, may make modifications to the guidelines set forth in Appendix H. The parties further acknowledge that such modifications shall be effective and made a part of this Agreement without further action by the parties upon sixty (60) days written notice to the LDSS and the Contractor.

6.2 Equality of Access to Enrollment

Eligible Person’s shall be enrolled in the Contractor’s plan, in accordance with the requirements set forth in Appendix H, Section A. In those instances in which the Contractor is directly involved in enrolling eligible recipients, the Contractor shall accept enrollments in the order they are received without regard to the Eligible Person’s age, sex, race, creed, physical or mental handicap/developmental disability, national origin, sexual orientation, type of illness or condition, need for health services or to the Capitation Rate that the Contractor will receive for such Eligible Person.

6.3 Enrollment Decisions

An Eligible Person’s decision to enroll in the Contractor’s plan shall be voluntary except as otherwise provided in Section 6.4 of the Agreement.

6.4 Auto Assignment

An Eligible Person whose enrollment in a MCO is mandatory and who fails to select a MCO within sixty (60) days of receipt of notice of mandatory enrollment may be assigned by the LDSS to the Contractor’s plan pursuant to NYS Social Services Law § 364-j and in accordance with Appendix H.

6.5 Prohibition Against Conditions on Enrollment

Unless otherwise required by law or this Agreement, neither the Contractor nor LDSS shall condition any Eligible Person’s enrollment upon the performance of any act or suggest in any way that failure to enroll may result in a loss of Medicaid benefits.

6.6 Family Enrollment

a)

In local social service districts where enrollment in managed care is mandatory, all eligible members of the Eligible Person’s Family shall be enrolled into the same plan.

 

b)

In local social service districts where enrollment in managed care is mandatory, the LDSS must inform Enrollees who have Family members enrolled in other MCOs that if anyone in the Family wishes to change plans, all members of the Family must enroll together in the newly-selected plan. The LDSS shall also notify the Enrollee that all members of the Family will be required to enroll together in a single MCO at the time of their next recertification for Medicaid eligibility unless waiver of this requirement is approved by the LDSS.

SECTION 6
(ENROLLMENT)
October 1, 2004
6-1

27

c) Notwithstanding the foregoing,

i)

the LDSS may, on a case-by-case basis, waive the same family rule specified in Sections 6.6 (a) and (b) to preserve continuity of care:

 

1)

if one or more members of the Family are receiving prenatal care and/or continuing care for a complex chronic medical condition from Non-Participating Providers; or

if one or more members of the Family transition from one government-sponsored insurance program to another.

ii)

the LDSS must allow HIV SNP-eligible individuals within a family to enroll in an HIV SNP, in Service Areas in which an HIV SNP exists.

6.7 Newborn Enrollment

i)

All newborn children not in an excluded category shall be enrolled in the MCO of the mother, effective from the first day of the child’s month of birth.

 

ii)

b) In addition to the responsibilities set forth in Appendix H, the Contractor is responsible for doing all of the following with respect to newborns:

i) Coordinating with the LDSS the efforts to ensure that all newborns are

enrolled in the managed care plan;

ii)

Issuing a letter informing parent(s) about newborn child’s enrollment or a member identification card within 14 days of the date on which the Contractor becomes aware of the birth;

 

iii)

Assuring that enrolled pregnant women select a PCP for an infant prior to birth and the mother to make an appointment with the PCP immediately upon birth; and

 

iv)

Ensuring that the newborn is linked with a PCP prior to discharge from the hospital, in those instances in which the Contractor has received appropriate notification of the birth prior to discharge.

 

c)

The LDSS shall be responsible for ensuring that timely Medicaid Eligibility determination and enrollment of the newborns is effected consistent with state laws, regulations, and policy and with the newborn enrollment guidelines set forth in Appendix H, Section B of this Agreement.

6.8 Effective Date of Enrollment

a)

The Contractor and the LDSS must notify the Enrollee of the expected Effective Date of Enrollment. This may be accomplished through a “Welcome Letter”. To the extent practicable, such notification must precede the Effective Date of Enrollment. In the event that the actual Effective Date of Enrollment changes, the Contractor and the LDSS must notify the Enrollee of the change.

 

b)

As of the Effective Date of Enrollment, and until the Effective Date of Disenrollment from the Contractor’s plan, the Contractor shall be responsible for the provision and cost of all care and services covered by the Benefit Package and provided to Enrollees whose names appear on the Prepaid Capitation Plan Roster, except as hereinafter provided.

SECTION 6

(ENROLLMENT)
October 1.2004
6-2

28

i)

Contractor shall not be liable for the cost of any services rendered to an Enrollee prior to his or her Effective Date of Enrollment.

 

ii)

Contractor shall not be liable for any part of the cost of a hospital stay for an Enrollee who is admitted to the hospital prior to the Effective Date of Enrollment in the Contractor’s plan and who remains hospitalized on the Effective Date of Enrollment; except when the Enrollee, on or after the Effective Date of Enrollment, 1) is transferred from one hospital to another; or 2) is discharged from one unit in the hospital to another unit in the same facility and under Medicaid fee for service payment rules, the method of payment changes from: a) DRG

case-based rate of payment per discharge to a per diem rate of payment exempt from DRG case-based payment rates, or b) from a per diem payment rate exempt from DRG case-based payment rates either to another per diem rate, or a DRG case-based payment rate. In such instances, the Contractor shall be liable for the cost of the consecutive stay.

iii)

Except for newborns, an Enrollee’s Effective Date of Enrollment shall be the first day of the month on which the Enrollee’s name appears on the PCP roster for that month.

6.9 Roster

a)

The first and second monthly Rosters generated by SDOH in combination shall serve as the official Contractor enrollment list for purposes of MMIS premium billing and payment, subject to ongoing eligibility of the Enrollees as of the first (I”) day of the enrollment month. Modifications to the first (1”) Roster may be made electronically or in writing by the LDSS or the Enrollment Broker prior to the end of the month in which the Roster is generated.

 

b)

The LDSS shall make data on eligibility determinations available to the Contractor and SDOH to resolve discrepancies that may arise between the Roster and the Contractor’s enrollment files in accordance with the provisions in Appendix H, Section D.

 

c)

If LDSS or Enrollment Broker notifies the Contractor in writing or electronically of changes in the first (1st) Roster and provides supporting information as necessary prior to the effective date of the Roster, the Contractor will accept that notification in the same manner as the Roster.

d) All Contractors must have the ability to receive these Rosters electronically.

6.10 Automatic Re-Enrollment

The Contractor agrees that Eligible Persons who are disenrolled from the Contractor’s plan due to loss of Medicaid eligibility and who regain eligibility within three (3) months will automatically be prospectively re-enrolled with the Contractor’s plan, subject to availability of enrollment capacity in the plan.

SECTION 6

(ENROLLMENT)

October t. 2004

6-3

29

7. LOCK-IN PROVISIONS

7.1 Lock-In Provisions in Voluntary Counties

All Enrollees in local social service districts where enrollment in managed care is voluntary shall be subject to a Lock-In Period under this Agreement if so required by the LDSS as indicated by an x below:

•

Enrollees are subject to a twelve (12) month Lock-In Period following the Effective Date of Enrollment in the Contractor’s plan with an initial ninety (90) day grace period to disenroll from the Contractor’s plan without cause.

• Enrollees are not subject to a Lock-In Period.

7.2 Lock-In Provisions in Mandatory Counties and New ^. York City

All Enrollees in local social service districts where enrollment in managed care is mandatory and in New York City are subject to a twelve (12) month Lock-In period following the Effective Date of Enrollment in the Contractor’s plan, with an initial ninety (90) day grace period in which to disenroll from the Contractor’s plan without cause, .regardless of whether the- Enrollee selected or was auto-assigned to the Contractor’s plan.

7.3 Disenrollment During Lock-In Period

An Enrollee, subject to Lock-In, may disenroll from the Contractor’s plan during the Lock-In period for “good cause” as established in 18 NYCRR Subpart 360-10 or, if the Enrollee becomes eligible for an exemption or exclusion from Medicaid managed care as set forth in Sections 5.2 and 5.3 of this Agreement.

7.4 Notification Regarding Lock-In and End of Lock-in Period

LDSS, either directly or through the Enrollment Broker, shall notify Enrollees of their right to change MCOs in the enrollment confirmation notice sent to individuals after they have selected a MCO or been auto-assigned (the latter being applicable to areas where the mandatory program is in effect). LDSS and the Enrollment Broker will be responsible for providing a notice of end of Lock-In and the right to change MCOs at least sixty (60) days prior to the first plan enrollment anniversary date.

SECTION 7
(LOCK-IN PROVISIONS)
October 1.2004

30

8. DISENROLLMENT

8.1 Disenrollment Guidelines

a)

Disenrollment of an Enrollee from the Contractor’s Plan may be initiated by the Enrollee, LDSS or the Contractor under the conditions specified in Sections 8.4, 8.7, 8.8 and 8.9 and as detailed in Appendix H, Section E and F of this Agreement.

The LDSS and the Contractor agree to conduct disenrollment in accordance with the guidelines set forth in Appendix H, Section E and F of this Agreement.

The SDOH and LDSS, upon mutual agreement, may modify Appendix H of this Agreement upon sixty (60) days prior written notice to the Contractor and such modifications shall become binding and incorporated into this Agreement without further action by the parties.

d) LDSS shall make the final determination concerning disenrollment.

8.2 Disenrollment Prohibitions

Disenrollment shall not be based in whole or in part on any of the following reasons:

a)

an existing condition or a change in the Enrollee’s health which would necessitate disenrollment pursuant to the terms of this Agreement, unless the change

 

i)

results in the Enrollee being reclassified into an excluded category for Medicaid — managed care as listed in Section 5.3 of this Agreement;

 

ii)

results in the Enrollee being reclassified into an exempt category as listed in Section 5.2 of this Agreement and the Enrollee wants to disenroll from managed care.

b) any of the factors listed in Section 34 — Non-Discrimination of this Agreement; or
c) on the Capitation Rate payable to the Contractor related to the Enrollee’s participation with

the Contractor.

8.3 Reasons for Voluntary Disenrollment

The LDSS or the Contractor, as agreed upon between the LDSS and Contractor, shall provide Enrollees who disenroll voluntarily with an opportunity to identify, in writing, their reason(s) for disenrollment.

8.4 Processing of Disenrollment Requests

a) Routine Disenrollment

Unless otherwise specified in Appendix H, Section F disenrollment requests will be processed to take effect on the first (1 ^st ) day of the next month if the request is made before the date specified in Appendix H. In no event shall the Effective Date of Disenrollment be later than the first (l ^st ) day of the second (2 ^nd ) month after the month in which an Enrollee requests a disenrollment.

SECTION K

(DISENROLLMENT)

October 1, 2004

8-1

b) Expedited Disenrollment

i)

Enrollees with an urgent medical need to disenroll from the Contractor’s plan may request an expedited disenrollment by the LDSS. Substantiation of the request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H. Individuals who are to be disenrolled from managed care based on their HIV, ESRD or SPMI/SED status are categorically eligible for an expedited disenrollment on the basis of urgent medical need.

 

ii)

Enrollees may request an expedited disenrollment by the LDSS based on a complaint of Non-consensual Enrollment. Substantiation of such a request by the LDSS shall result in an expedited disenrollment retroactive to the first day of the month of enrollment.

 

iii)

In New York City and other districts where homeless individuals are exempt, homeless Enrollees residing in the shelter system may request an expedited disenrollment by the LDSS. Substantiation of such a request by the LDSS will result in an expedited disenrollment in accordance with the guidelines and timeframes as set forth in Appendix H.

c) Retroactive Disenrollment

i)

Retroactive disenrollments may be warranted in rare instances and include when an individual is enrolled or autoassigned while meeting exlusion criteria or when an Enrollee enters or stays in a residential institution under circumstances which render the individual excluded from managed care; is incarcerated; is an SSI infant less than six months of age; or dies — as long as the Contractor was not at risk for provision of Benefit Package services for any portion of the retroactive period.

8.5 Contractor Notification of Disenrollments

a)

Notwithstanding anything herein to the contrary, the Roster, along with any changes sent by the LDSS to the Contractor in writing or electronically, shall serve as official notice to the Contractor of disenrollment of an Enrollee. In cases of expedited and retroactive disenrollment, the Contractor shall be notified of the Enrollee’s effective date of disenrollment by the LDSS.

 

b)

In the event that the LDSS intends to retroactively disenroll an Enrollee on a date prior to the first day of the month of the disenrollment request, the LDSS shall consult with the Contractor prior to disenrollment. Such consultation shall not be required for the retroactive disenrollment of SSE infants or in cases where it is clear that the Contractor was not a risk for the provision of Benefit Package services for any portion of the retroactive period.

In all cases of retroactive disenrollment, including disenrollments effective the first day of the current month, the LDSS must notice the plan at the time of disenrollment, of the Contractor’s responsibility to submit to the SDOH’s Fiscal Agent voided premium claims for any months of retroactive disenrollment where the Contract was not at risk for the provision of Benefit Package services during the month.

8.6 Contractor’s Liability

a)

The Contractor is not responsible for providing the Benefit Package under this Agreement after the Effective Date of Disenrollment except as hereinafter provided:

SECTION
(DISENROLLMENT)
October 1, 2004
8-2

i)

The Contractor shall be liable for any part of the cost of a hospital stay for an Enrollee who is admitted to the hospital prior to the Effective Date of Disenrollment in the Contractor’s plan and who remains hospitalized on the Effective Date of Disenrollment; except when the Enrollee, on or after the Effective Date of Disenrollment, 1) is transferred from one hospital to another; or 2) is discharged from one unit in the hospital to another unit in the same facility and under Medicaid fee for service payment rules, the method of payment changes from: a) DRG case-based rate of payment per discharge to a per diem rate of payment exempt from DRG case-based payment rates, or b) from a per diem payment rate exempt from DRG case-based payment rates to either another per diem rate, or a DRG case-based payment rate. In such instances, the Contractor shall not be liable for the cost of the consecutive stay. For the purposes of this Section, “hospital stay” does not include a stay in a hospital that is a) certified by Medicare as a long-term care hospital and b) has an average length of stay for all patients greater than ninety-five (95) days as reported in the Statewide Planning and Research Cooperative System (SPARCS) Annual Report 2002; in such instances, Contractor liability will cease on the Effective Date of Disenrollment.

 

b)

The Contractor shall notify the LDSS that the Enrollee remains in the hospital and provide the LDSS with information regarding his or her medical status. The Contractor is required to cooperate with the Enrollee and the new MCO (if applicable) on a timely basis to ensure a smooth transition and continuity of care.

8.7 Enrollee Initiated Disenrollment

a) Disenrollment For Good Cause

ii)

An Enrollee subject to Lock-In may initiate disenrollment from the Contractor’s plan for “good cause” as defined in 18 NYCRR § 360-10 at any time during the Lock-In period and may disenroll for any reason at any time after the twelfth (12 th ) month following the Effective Date of Enrollment.

 

iii)

An Enrollee subject to Lock-In may initiate disenrollment for “good cause” by filing a written request with the LDSS or the Contractor. The Contractor must notify the LDSS of the request. The LDSS must respond with a determination within thirty (30) days after receipt of the request. The Contractor must respond timely to LDSS inquiries regarding “good cause” disenrollment requests to enable the LDSS to make a determination within 30 days of the receipt of the request from the Enrollee.

 

iv)

Enrollees granted disenrollment for “good cause” in a voluntary county may join another plan, if one is available, or participate in Medicaid fee-for-service program. In mandatory counties, unless the Enrollee becomes exempt or excluded, he/she may be required to enroll with another MCO.

 

v)

In the event that the LDSS denies an Enrollee’s request for disenrollment for “good cause”, the LDSS must inform the Enrollee of the denial of the request with a written notice which explains the reason for the denial, states the facts upon which denial is based, cites the statutory and regulatory authority and advises the recipient of his or her right to a fair hearing pursuant to 18 NYCRR Part 358. In the event that the Enrollee’s request to disenroll is approved, the notice must state the Effective Date of Disenrollment.

vi) Once the Lock-In Period has expired, an Enrollee may disenroll from

the Contractor’s plan at any time, for any reason.

SECTION 8

(DISENROLLMENT)

October 1, 2004

8-3

31 8.8 Contractor Initiated Disenrollment

a)

The Contractor may initiate an involuntary disenrollment if the Enrollee engages in conduct or behavior that seriously impairs the Contractor’s ability to furnish services to either the Enrollee or other Enrollees, provided that the Contractor has made and documented reasonable efforts to resolve the problems presented by the Enrollee.

 

b)

Consistent with 42 CFR 438.56 (b), the Contractor may not request disenrollment because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s . utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the Enrollee’s special needs (except where continued enrollment in the Contractor’s plan seriously impairs the Contractor’s ability to furnish services to either the Enrollee or other Enrollees).

 

c)

The Contractor must make a reasonable effort to identify for the Enrollee, both ‘verbally and in. writing, those actions of the Enrollee that have interfered with the effective provision of covered services as well as explain what actions or procedures are acceptable.

 

d)

The Contractor shall give prior verbal and written notice to the Enrollee, with a copy to the LDSS, of its intent to request disenrollment. The written notice shall advise the Enrollee that the request has been forwarded to the LDSS for review and approval. The written notice must include the mailing address and telephone number of the LDSS.

 

e)

The Contractor shall keep the LDSS informed of decisions related to all complaints filed by an Enrollee as a result of, or subsequent to, the notice of intent to disenroll.

 

f)

LDSS will review each Contractor initiated disenrollment request in accordance with the provisions of this Section. 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 a Contractor initiated disenrollment request.

The LDSS will render a decision within fifteen (15) days of receipt of the fully documented request for disenrollment. Final written determination will be provided to the Enrollee and the Contractor. If the LDSS determination upholds the Contractor’s request to disenroll, the LDSS’s written determination must inform the Enrollee of the Effective Date of Disenrollment and include a notice of rights to a fair hearing. Should an Enrollee request a fair hearing as a result of the LDSS determination, the LDSS shall inform the Contractor of the fair hearing request and the Enrollee will remain enrolled in the Contractor’s plan until disposition of the fair hearing.

h)

Once an Enrollee has been disenrolled at the Contractor’s request, he/she will not be re-enrolled with the Contractor’s plan unless the Contractor first agrees to such re-enrollment.

8.9 LDSS Initiated Disenrollment

a) LDSS will promptly initiate disenrollment when:

i) an Enrollee is no longer eligible for any Medicaid benefits; or

ii)

the Guaranteed Eligibility period ends (See Section 9) and an Enrollee is no longer eligible for any Medicaid benefits; or

iii) an Enrollee is no longer the financial responsibility of the LDSS; or

iv)

an Enrollee becomes ineligible for enrollment pursuant to Section 5.3 of this Agreement, as appropriate; or

 

v)

an Enrollee resides outside the Service Area covered by this Agreement, unless Contractor can demonstrate that the. Enrollee has made an informed choice to continue enrollment with Contractor and that Enrollee will have sufficient access to Contractor’s provider network.

SECTION 8

(DISENROLLMENT)

October 1, 2004

8-4

32

9. GUARANTEED ELIGIBILITY

Except as may otherwise be required by law:

9.1

New Enrollees, other than those identified in Sections 9.2 who would otherwise lose Medicaid eligibility during the first six (6) months of enrollment will retain the right to remain enrolled in the Contractor’s plan under this Agreement for a period of six (6) months from their Effective Date of Enrollment.

 

9.2

Guaranteed eligibility is not available to Enrollees who lose Medicaid eligibility for one of the following reasons:

a) death, moving out of State, or incarceration;

b)

being a woman with a net available income in excess of medically necessary income but at or below 200% of the federal poverty level who is only eligible for Medicaid while she is pregnant and then through the end of the month in which the sixtieth (60 th ) day following the end of the pregnancy occurs.

 

9.3

If, during the first six (6) months of enrollment in the Contractor’s plan, an Enrollee becomes eligible for Medicaid only as a spend-down, the Enrollee will be eligible to remain enrolled in the Contractor’s plan for the remainder of the six (6) month guarantee period. During the six (6) month guarantee period, an Enrollee eligible for spend-down and in need of wraparound services has the option of spending down to gain full Medicaid eligibility for the wraparound services. In this situation, the LDSS will monitor the Enrollee’s need for wrap around services and manually set coverage codes as appropriate.

 

9.4

The services covered during the Guaranteed Eligibility period shall be those contained in the Benefit Package, as specified in Appendix K, including free access to family planning services as set forth in Section 10.12 of this Agreement. During the Guaranteed Eligibility period Enrollees are also eligible for pharmacy services on a Medicaid fee-for-service basis.

 

9.5

An Enrollee-initiated disenrollment from the Contractor’s plan terminates the Guaranteed Eligibility period.

 

9.6

Enrollees who lose and regain Medicaid eligibility within a three (3) month period will not be entitled to a new period of six (6) months Guaranteed Eligibility.

 

9.7

During the guarantee period, an Enrollee may not change health plans. An Enrollee may choose to disenroll from the Contractor’s Plan during the guarantee period but is not eligible to enroll in any other MCO because he/she has lost eligibility for Medicaid.

SECTION 9

(GUARANTEED ELIGIBILITY)

October 1, 2004

9-1

33

10.

BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES

10.1 Contractor Responsibilities

Contractor must provide all services set forth in the Benefit Package (Appendix K) that are covered under the Medicaid fee for service program except for services specifically excluded by the contract, or enacted or affected by Federal or State Law during the period of this agreement. SDOH and LDSS shall assure the continued availability and accessibility of Medicaid services not covered in the Benefit Package.

10.2 Compliance with State Medicaid Plan and Applicable Laws

Benefit Package services provided by the Contractor under this Agreement shall comply with all standards of the State Medicaid Plan established pursuant to Section 363-a of the State Social Services Law and shall satisfy all applicable requirements of the State Public Health and Social Services Laws.

10.3 Definitions

Benefit Package and Non-Covered Service definitions agreed to by the Contractor and the LDSS are contained in Appendix K, which is hereby made a part of this contract as if set forth fully herein.

10.4 Provision of Services Through Participating and Non-Participating Providers

With the exception of Emergency services described in Section 10.14 of this Agreement, Family Planning Services described in Section 10.11 of this Agreement, and services for which Enrollees can self refer as described in Section 10.16 of this Agreement, the Benefit Package must be provided and authorized by the Contractor through Provider Agreements with Participating Providers, as specified in Section 22 of this Agreement. A plan may also arrange for specialty or other services for Enrollees with Non-Participating Providers, in accordance with Section 21.1(b) of this Agreement.

10.5 Child Teen Health Program/Adolescent Preventive Services

a)

The Contractor and its Participating Providers are required to provide the Child Teen Health Program C/THP services outlined in Appendix K (Benefit Package) and comply with applicable EPSDT requirements specified in 42 CFR, Part 441, sub-part B, 18NYCRR, Part 508 and the New York State Department of Health C/THP manual. The Contractor and its Participating Providers are required to provide C/THP services to Medicaid Enrollees under 21 years of age when:

i) The care or services are essential to prevent, diagnose, prevent the worsening of, alleviate or ameliorate the effects of an illness, injury, disability, disorder or condition.

ii) The care or services are essential to the overall physical, cognitive and mental growth and developmental needs of the child.

iii) The care or service will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

The Contractor shall base its determination on medical and other relevant information provided by the Enrollee’s PCP, other health care providers, school, local social services, and/or local public health officials that have evaluated the child.

b)

The Contractor and its Participating Providers must comply with the C/THP program standards and must do at least the following with respect to all Enrollees under age 21:

SECTION 10

(BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES)

October 1, 2004

I 0-1

34

i)

Educate pregnant women and families with under age 21 Enrollees about the program and its importance to a child’s or adolescent’s health.

 

ii)

Educate network providers about the program and their responsibilities under it.

 

iii)

Conduct outreach, including by mail, telephone, and through home visits (where appropriate), to ensure children are kept current with respect to their periodicity schedules.

 

iv)

Schedule appointments for children and adolescents pursuant to the periodicity schedule, assist with referrals, and conduct follow-up with children and adolescents who miss or cancel appointments.

 

v)

Ensure that all appropriate diagnostic and treatment services, including specialist referrals, are furnished pursuant to findings from a C/THP screen.

 

vi)

Achieve and maintain an acceptable compliance rate for screening schedules during the contract period.

 

c)

In addition to C/THP requirements, the Contractor and its Participating Providers are required to comply with the American Medical Association’s Guidelines for Adolescent Preventive Services which require annual well adolescent preventive visits which focus on health guidance, immunizations, and screening for physical, emotional, and behavioral conditions.

10.6 Foster Care Children

The Contractor shall comply with the health requirements for foster children specified in 18 NYCRR Section 441.22 and Part 507 and any subsequent amendments thereto. These requirements include thirty (30) day obligations for a comprehensive physical and behavioral health assessment and assessment of the risk that the child may be HIV+ and should be tested.

10.7 Child Protective Services

The Contractor shall comply with the requirements specified for child protective examinations, provision of medical information to the child protective services investigation and court ordered services as specified in 18 NYCRR Section 432, and any subsequent amendments thereto. Medically necessary services, whether provided in or out of plan, must be provided. Out of plan providers will be reimbursed at the Medicaid fee schedule by the Contractor.

10.8 Welfare Reform

a)

The LDSS must determine whether each public assistance or combined public assistance/Medicaid applicant is incapacitated or can participate in work activities. As part of this work determination process, the LDSS may require medical documentation and/or an initial mental and/or physical examination to determine whether an individual has a mental or physical impairment that limits his/her ability to engage in work (12 NYCRR § 1300.2(d)(13)(i)). The LDSS may not require the Contractor to provide the initial district mandated or requested medical examination necessary for an Enrollee to meet welfare reform work participation requirements.

 

b)

The Contractor shall require that its Participating Providers, upon Enrollee consent, provide medical documentation and health, mental health and chemical dependence assessments as follows:

 

i)

Within ten (10) days of a request of an Enrollee or a former Enrollee, currently receiving public assistance or who is applying for public assistance, the Enrollee’s or former Enrollee’s PCP or specialist provider, as appropriate, shall provide medical documentation concerning the Enrollee or former Enrollee’s health or mental health status to the LDSS or to the LDSS’ designee. Medical documentation includes but is not limited to drug prescriptions and reports from the Enrollee’s PCP or specialist provider. The Contractor shall include the foregoing as a responsibility of the PCP and specialist provider in its provider contracts or in their provider manuals.

SECTION 10

(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)

October 1.2004

10-2

ii)

Within ten (10) days of a request of an Enrollee, who has already undergone, or is scheduled to undergo, an initial LDSS required mental and/or physical examination, the Enrollee’s PCP shall provide a health, or mental health and/or chemical dependence assessment, examination or other services as appropriate to identify or quantify an Enrollee’s level of incapacitation. Such assessment must contain a specific diagnosis resulting from any medically appropriate tests and specify any work limitations. The LDSS, may, upon written notice to the Contractor, specify the format and instructions for such an assessment.

 

c)

The Contractor shall designate a Welfare Reform liaison who shall work with the LDSS or its designee to (1) ensure that Enrollees receive timely access to assessments and services specified in this Agreement and (2) ensure completion of reports containing medical documentation required by the LDSS:

 

d)

The Contractor will continue to be responsible for the provision and payment of Chemical Dependence Services in the Benefit Package for Enrollees mandated by the LDSS under Welfare Reform if such services are already underway and the LDSS is satisfied with the level of care and services.

 

e)

The Contractor is not responsible for the provision and payment of Chemical Dependence Inpatient Rehabilitation and Treatment Services for Enrollees mandated by the LDSS as a condition of eligibility for Public Assistance or Medicaid under Welfare Reform (as indicated by Code 83) unless such services are already under way as described in (c) above.

 

f)

The Contractor is not responsible for the-provision and payment of Medically Supervised Inpatient and Outpatient Withdrawal Services for Enrollees mandated by the LDSS under Welfare Reform (as indicated by Code 83) unless such services are already under way as described in (c) above.

 

g)

The Contractor is responsible for the provision and payment of Medically Managed Detoxification Services ordered by the LDSS under Welfare Reform.

 

h)

The Contractor is responsible for the provisions of Sections 10.10, 10.16 (a) and 10.24 of this Agreement for Enrollees requiring LDSS mandated Chemical Dependence Services.

10.9 Adult Protective Services

The Contractor shall cooperate with LDSS in the implementation of 18 NYCRR Part 457 and any subsequent amendments thereto with regard to medically necessary health and mental health services and all Court Ordered Services for adults. These services are to be provided in or out of plan. Out of plan providers will be reimbursed at the Medicaid fee schedule.

10.10 Court-Ordered Services

a)

The Contractor shall provide any Benefit Package services to Enrollees as ordered by a court of competent jurisdiction, regardless of whether such services are provided by Participating Providers within the plan or by a Non-Participating Provider in compliance with such court order. The Non-Participating Provider shall be reimbursed by the Contractor at the Medicaid fee schedule. The Contractor is responsible for court-ordered services to the extent that such court-ordered services are covered by and reimbursable by Medicaid.

SECTION 10

(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)

October 1, 2004

10-3

35

b)

Court Ordered Services are those services ordered by the court performed by, or under the supervision of a physician, dentist, or other provider qualified under State Law to furnish medical, dental, behavioral health (including mental health and/or Chemical Dependence), or other Medicaid covered services. The Contractor is responsible for payment of those Medicaid services as covered by the Benefit Package, even when the providers are not in the Contractor’s provider network.

10.11 Family Planning and Reproductive Health Services

a)

Nothing in this Agreement shall restrict the right of Enrollees to receive Family Planning and Reproductive Health Services from any qualified Medicaid provider, regardless of whether the provider is a participating provider or a non-participating provider, without referral from the Enrollee’s PCP and without approval from the Contractor.

 

b)

The Contractor agrees to permit Enrollees to exercise their right to obtain Family Planning and Reproductive Health Services as defined in Part C-I of Appendix C, which is hereby made a part of this contract as if set forth fully herein, from either the Contractor, if family planning is a part of the Contractor’s Benefit Package, or from any appropriate Medicaid enrolled Non-Participating Family Planning Provider without a referral from the Enrollee’s PCP and without approval by the Contractor.

 

c)

The Contractor agrees to permit Enrollees to obtain pre and post-test HIV counseling and blood testing when performed as part of a Family Planning encounter from the Contractor, if Family Planning is a part of the Contractor’s Benefit Package, or from any appropriate Medicaid enrolled Non-Participating family planning Provider without a referral from the Enrollee’s PCP and without approval by the Contractor.

 

d)

The Contractor will inform Enrollees about the availability of in-plan HIV counseling and testing services, out-of-plan HIV counseling and testing services when performed as part of a Family Planning encounter and anonymous counseling and testing services available from SDOH, Local Public Health Agency clinics and other county programs. Counseling and testing rendered outside of a Family Planning encounter, as well as services provided as the result of an HIV+ diagnosis, will be furnished by the Contractor in accordance with standards of care.

 

e)

Contractor must comply with federal, state, and local laws, regulations and policies regarding informed consent and confidentiality. Providers who are employed by the Contractor may share patient information with appropriate Contractor personnel for the purposes of claims payment, utilization review and quality assurance. Providers who have a contract with the Contractor, with an appropriate consent, may share patient information with the Contractor for purposes of claims payment, utilization review and quality assurance. Contractor must ensure that an individual’s use of family planning services remains confidential and is not disclosed to family members or other unauthorized parties.

 

f)

Contractor must inform its practitioners and administrative personnel about policies concerning free access to family planning services, HIV counseling and testing, reimbursement, enrollee education and confidentiality. Contractor must inform its providers that they must comply with professional medical standards of practice, the Contractor’s practice guidelines, and all applicable federal, state, and local laws. These include but are not limited to, standards established by the American College of Obstetricians and Gynecologists, the American Academy of Family Physician, the U.S. Task Force on Preventive Services and the New York State Child/Teen Health Program: These standards and laws indicate that family planning counseling is an integral part of primary and preventive care.

SECTION 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1.2004
10-4

g) The Contractor agrees that if Family Planning is part of the Contractor’s Benefit Package, the Contractor will be charged for the services of out of network providers at the applicable Medicaid rate or fee. In such instances, out of network providers will bill Medicaid and the SDOH will issue a confidential charge back to the Contractor. Such charge back mechanism will comply with all applicable patient confidentiality requirements.

h) If Contractor includes family planning and reproductive health services in its benefits package, the Contractor shall comply with the requirements for informing Enrollees about family planning and reproductive health services set forth in Part C-2 of Appendix C, which is hereby made a part of this contract as if set forth herein.

i) If Contractor does not include family planning and reproductive health services in its Benefit Package, within ninety (90) days of signing this Agreement, Contractor must submit to the SDOH and LDSS a statement of the policy and procedure that the Contractor will use to ensure that its Enrollees are fully informed of their rights to access a full range of family planning and reproductive health services. Refer to Part C-3 of Appendix C for the SDOH Guidelines for Plans That Do Not Provide Family Planning Services in their Capitation. Contractor shall ensure that prospective Enrollees and Enrollees are advised of the family planning services which are not provided by the Contractor and of their right of access to such services in accordance with the provisions of Part C-3 of Appendix C, which is hereby made a part of this contract as if set forth fully herein.

j) SDOH with DHHS approval may issue modifications to Appendix (C) consistent with relevant provisions of federal and state statutes and regulations. Once issued and upon sixty (60) days notice to the LDSS and Contractor, such modifications shall be deemed incorporated into this Agreement without further action by the parties.

10.12. Prenatal Care

The Contractor is responsible for arranging for the provision of comprehensive Prenatal Care Services to all pregnant Enrollees including all services enumerated in Subdivision 1, Section 2522 of the Public Health Law in accordance with 10 NYCRR Part 85.40 (Prenatal Care Assistance Program).

10.13 Direct Access

The Contractor shall offer female Enrollees direct access to primary and preventive obstetrics and gynecology services, follow-up care as a result of a primary and preventive visit, and any care related to pregnancy from the Contractor’s network providers without referral from the PCP as set forth in Public Health Law Section 4406-b(1).

10.14 Emergency Services

a)

The Contractor shall maintain coverage utilizing a toll free telephone number twenty-four (24) hours per day seven (7) days per week, answered by a live voice, to advise Enrollees of procedures for accessing services for Emergency Medical Conditions and for accessing Urgently Needed Services. Emergency mental health calls must be triaged via telephone by a trained mental health professional.

 

b)

The Contractor agrees that it will not require prior authorization for services in a medical or behavioral health emergency. The Contractor agrees to inform its Enrollees that access to Emergency Services is not restricted and Emergency Services may be obtained from a Non-Participating Provider without penalty. The Contractor may require Enrollees to notify the plan or their PCP within a specified time frame after receiving emergency care and to obtain prior authorization for any follow-up care delivered pursuant to the emergency, as stated in Appendix G. Nothing herein precludes the Contractor from entering into contracts with providers or facilities that require providers or facilities to provide notification to the Contractor after Enrollees present for Emergency Services and are subsequently stabilized. Except as otherwise

SECTION 10

(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)

October I, 2004

10-5

36

otherwise provided by contractual agreement between the Contractor and a Participating Provider, the Contractor must pay for services for Emergency Medical Conditions whether provided by a Participating Provider or a Non-Participating Provider, and may not deny payments if notification is not timely.

c)

Emergency Services rendered by Non-Participating Providers: The Contractor shall advise its Enrollees how to obtain Emergency Services when it is not feasible for Enrollees to receive Emergency Services from or through a Participating Provider. The Contractor shall bear the cost of providing Emergency Services through Non-Participating Providers.

 

d)

The Contractor agrees to abide by guidelines for the provision and payment of Emergency Care and Services which are specified in Appendix G, which is hereby made a part of this contract as if set forth fully herein.

 

e)

When emergency transportation is included in the Contractor’s Benefit Package, the Contractor shall reimburse for all emergency ambulance services without regard to final diagnosis or prudent layperson standards.

10.15 Medicaid Utilization Thresholds (MUTS)

Enrollees may be subject to MUTS for outpatient pharmacy services which are billed Medicaid fee-for-service and for dental services provided without referral at Article 28 clinics operated by academic dental centers as described in Section 10.28 of this Agreement. Enrollees are not otherwise subject to MUTS for services included in the Benefit Package.

10.16 Services for Which Enrollees Can Self-Refer

a) Mental Health and Chemical Dependence Services

The Contractor will allow Enrollees or LDSS officials on the Enrollee’s behalf to make self referral or referral for one mental health assessment from a Participating Provider and one chemical dependence assessment from a Detoxification or Chemical Dependence Inpatient Rehabilitation and Treatment Participating Provider in any calendar year period without requiring preauthorization or referral from the Enrollee’s Primary Care Provider. In the case of children, such self-referrals may originate at the request of a school guidance counselor (with parental or guardian consent, or pursuant to procedures set forth in Section 33.21 of the Mental Hygiene Law), LDSS Official, Judicial Official, Probation Officer, parent or similar source.

i)

The Contractor shall make available to all Enrollees a complete listing of their participating mental health and Chemical Dependence Services providers. The listing should specify which provider groups or practitioners specialize in children’s mental health services.

 

ii)

The Contractor will also ensure that its Participating Providers have available and use formal assessment instruments to identify Enrollees requiring mental health and Chemical Dependence Services, and to determine the types of services that should be furnished.

 

iii)

The Contractor will implement policies and procedures to ensure that Enrollees receive follow-up Benefit Package services from appropriate providers based on the findings of their mental health and/or Detoxification or Chemical Dependence Inpatient Rehabilitation and Treatment assessment(s).

 

iv)

The Contractor will implement policies and procedures to ensure that Enrollees are referred to appropriate Chemical Dependence outpatient rehabilitation and treatment providers based on the findings of the Chemical Dependence assessment by the Contractor’s Participating Provider.

SECTION 10

(BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES)

October I, 2004

10-6

37

b) Vision Services

The Contractor will allow its Enrollees to self-refer to any participating provider of vision- services (optometrist, or ophthalmologist) for refractive: vision services. (See Appendix K).

c) Diagnosis and Treatment of Tuberculosis

Enrollees may self-refer to public health agency facilities for the diagnosis and/or treatment of TB as described in Section 10.19 (a)(i) of this Agreement.

d) Family Planning and Reproductive Health Services.

Enrollees may self-refer to family planning and reproductive health services as described in Section 10.11 and Appendix C of this Agreement.

e) Article 28 Clinics Operated by Academic Dental Centers

Enrollees may self-refer to Article 28 clinics operated by academic dental centers to obtain covered dental services as described in Section 10.28 of this Agreement.

10.17 Second Opinions for Medical or Surgical Care

The Contractor will allow Enrollees to obtain a second opinion within the Contractor’s network of providers for diagnosis of a condition, treatment or surgical procedure.

10.18 Coordination with Local Public Health Agencies

The Contractor will coordinate its public health-related activities with the Local Public Health Agency. Coordination mechanisms and operational protocols for addressing public health issues will be negotiated with the Local Public Health and Social Services Departments and be customized to reflect County public health priorities. Negotiations must result in agreements regarding required health plan activities related to public health. The outcome of negotiations may take the form of an informal agreement among the parties which may include memos; a separate memorandum of understanding signed by the Local Public Health Agency, LDSS, and the Contractor; or an appendix to the contract between the LDSS and the Contractor which shall be included in Appendix N as if set forth fully herein.

10.19 Public Health Services

	a)		Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy(TB DOT):

 

i)

Consistent with New York State law, public health clinics are required to provide or arrange for treatment to individuals presenting with tuberculosis, regardless of the person’s insurance or enrollment status. It is the State’s preference that the Contractor’s Enrollees receive TB diagnosis and treatment through the Contractor’s plan, to the extent that providers experienced in this type of care are available in the Contractor’s network of Participating Providers, although Enrollees may self-refer to public health agency facilities for the diagnosis and/or treatment of TB. The Contractor agrees to reimburse public health clinics when physician visit and patient management or laboratory and radiology services are rendered to their Enrollees, within the context of TB diagnosis and treatment.

 

ii)

The Contractor’s Participating Providers must report TB cases to the Local Public Health Agency. The LDSS will have the Local Public Health Agency review the tuberculosis treatment protocols and networks of Participating Providers of the Contractor, to verify their readiness to treat Tuberculosis patients. The Contractor’s protocols will be evaluated against State and local guidelines. State and local departments of health also will be available to offer technical assistance to the Contractor in establishing TB policies and procedures.

SECTION 10
(BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES)
October 1, 2004
10-7

iii)

The Contractor may require the Local Public Health Agency to give notification before delivering services, unless these services are ordered by a court of competent jurisdiction. The Local Public Health Agency will: 1) make reasonable efforts to verify with the Enrollee’s PCP that he/she has not already provided TB care and treatment, and 2) provide documentation of services rendered along with the claim.

 

iv)

The Contractor may use locally negotiated fees. In addition, SDOH will establish fee schedules for these services, which the Contractor may use in the absence of locally negotiated fees.

 

v)

Contractors may require prior authorization for non-emergency inpatient hospital admissions, except that prior authorization will not be required for an admission pursuant to a court order or an order of detention issued by the local commissioner or director of public health.

 

vi)

The Contractor shall provide the Local Public Health Agency with access to health care practitioners on a twenty-four (24) hour a day, seven (7) day a week basis who can authorize inpatient hospital admissions. The Contractor shall respond to the Local Public Health Agency’s request for authorization within the same day.

 

vii)

The Contractor will not be capitated or financially liable for Directly Observed Therapy (DOT) costs. The Contractor agrees to make all reasonable efforts to ensure coordination with DOT providers regarding clinical care and services. HIV counseling and testing during a TB related visit at a public health clinic, directly operated by a county health department or the New York City Department of Health and Mental Hygiene, will be covered by Medicaid fee-for-service (FFS) at rates established by the State. The Contractor also will not be financially liable for treatments rendered to Enrollees who have been: institutionalized as a result of a local health commissioner’s order due to non-compliance with TB care regimens.

viii) While all other clinical management of tuberculosis is covered by the Contractor, TB/DOT where applicable, can be billed directly to Medicaid by any SDOH approved fee-for-service Medicaid TB/DOT provider. The Contractor remains responsible for communicating, cooperating, and coordinating clinical management of TB with the TB/DOT provider. The Enrollee reserves the right to use any fee-for-service DOT provider because TB/DOT is a non-covered benefit.

b) Immunizations

i)

Immunizations for adults and administration of immunizations for children will be included in the Benefit Package and the Contractor will be required to reimburse the Local Public Health Agency when Enrollees self-refer.

 

ii)

In order to be eligible for reimbursement, a Local Public Health Agency must make reasonable efforts to (1) determine the Enrollee’s managed care membership status; and (2) ascertain the Enrollee’s immunization status. Such efforts shall consist of client interviews and, when available, access to the Immunization Registry. When an Enrollee presents a membership card with a PCP’s name, the Local Public Health Agency shall call the PCP. If the agency is unable to verify the immunization status from the PCP or learns that immunization is needed, the agency shall proceed to deliver the service as appropriate, and the Contractor will reimburse the Local Public Health Agency at the negotiated rate or at a fee schedule to be used in the absence of a negotiated rate. Upon implementation of the immunization registry, the Local Public Health Agency shall not be required to contact the PCP.

 

iii)

If the immunization is administered by the PCP, immunization materials for children should be obtained free of charge from the “Vaccine For Children Program”. The Contractor will be reimbursed only for administering the vaccine to children.

SECTION 10
(BENEFIT PACKAGE. COVERED AND NON-COVERED SERVICES)
October I. 2004

10-8

38 c) Prevention and Treatment of Sexually Transmitted Diseases

The Contractor will be responsible for ensuring that its Participating Providers educate their Enrollees about the risk and prevention of sexually transmitted disease (STD). The Contractor also will be responsible for ensuring that its Participating Providers screen and treat Enrollees for STDs and report cases of STD to the Local Public Health Agency and cooperate in contact investigation, in accordance with existing state and local laws and regulations. HIV counseling and testing provided during a STD related visit at a public health clinic, directly operated by a county health department or the New York City Department of Health and Mental Hygiene, will be covered by Medicaid FFS at rates established by the State.

d) Lead Poisoning

The Contractor will be responsible for carrying out and ensuring that its Participating Providers comply with lead poisoning screening and follow-up as specified in 10 NYCRR, Sub-part 67.1. The Contractor shall coordinate the care of such children with Local Public Health Agencies to assure appropriate follow-up in terms of environmental investigation, risk management and reporting requirements.

10.20 Adults with Chronic Illnesses and Physical or Developmental Disabilities

The Contractor will implement all of the following to meet the needs of their adult Enrollees with chronic illnesses and physical or developmental disabilities: