APPENDIX
X [Amendment Number 6]
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Agency
Code 12000
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Contract
No. C020454
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Period
10/1/07-9/30/08
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Funding
Amount for Period Based on
approved capitation rates
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This
is an AGREEMENT between THE STATE OF NEW YORK, acting by and
through The New York
State Department of Health , having its principal
office at Corning Tower,
Room 2001, Empire State Plaza, Albany NY 12237 ,
(hereinafter referred to as the STATE), and WellCare of
New York,
Inc. , (hereinafter referred to as the CONTRACTOR), to
modify Contract Number
C020454 as set forth below. The effective date of these
modifications is October 1, 2007, unless otherwise noted
below.
1.
Amend Section
11.5 "Corrective and Remedial Actions" to read as
follows:
11.5 Corrective
and Remedial Actions
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a) |
If
the Contractor's Marketing activities do not comply with the
Marketing Guidelines set forth in Appendix D of this
Agreement or
the Contractor's approved
Marketing plan, the SDOH, in consultation with the LDSS, may take
any of the following actions as
it, in its sole discretion, deems necessary
to protect the interests of Enrollees and the integrity of the MMC
and FHPlus Programs.
The Contractor shall take the corrective and
remedial actions directed by the SDOH within the specified
timeframes.
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i) |
If
the Contractor or its representative commits a first time
infraction of the Marketing Guidelines and/or the Contractor's
approved Marketing plan, and the SDOH, in consultation with the
LDSS, deems the infraction to be minor or unintentional in nature,
the SDOH and/or the LDSS may issue a warning letter to the
Contractor.
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ii) |
If
the Contractor engages in Marketing activities that SDOH
determines, in it sole discretion, to be an intentional or serious
breach of the Marketing Guidelines or the Contractor's approved
Marketing plan, or a pattern of minor breaches, SDOH, in
consultation with the LDSS, may require the Contractor to, and the
Contractor shall, prepare and implement a corrective action plan
acceptable to SDOH within a specified timeframe. In addition, or
alternatively, SDOH may impose sanctions, including monetary
penalties, as permitted by law.
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iii) |
If
the Contractor commits further infractions, fails to pay monetary
penalties within the specified timeframe, fails to implement a
corrective action plan in a timely manner or commits an egregious
first-time infraction, the SDOH, in consultation with the LDSS, may
in addition to any other legal remedy available to SDOH in law or
equity:
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A) |
direct
the Contractor to suspend its Marketing activities for a period up
to the end of the Agreement period;
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B) |
suspend
new Enrollments, other than newborns, for a period up to the
remainder of the Agreement period; or
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C
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terminate
this Agreement pursuant to termination procedures described in
Section 2.7 of this Agreement.
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MMC/FHPlus
Contract Amendment
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b) |
The
corrective and remedial actions described in Section 11.5 a) apply
to violations of the reporting requirements in Section 18.5 a)
xiii).
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2.
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Amend Section 18.5 "Reporting Requirements" to read as
follows:
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18.5
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Reporting
Requirements
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a) |
The
Contractor shall submit the following reports to SDOH (unless
otherwise specified). The Contractor will certify
the data submitted pursuant to this section as required by SDOH.
The certification shall be in the manner and format established by
SDOH and must attest, based on best knowledge,
information, and belief to the accuracy, completeness
and truthfulness of the data being
submitted.
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i) |
Annual
Financial Statements:
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Contractor
shall submit Annual Financial Statements to SDOH. The due date for
annual statements shall be April 1 following the report closing
date.
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ii) |
Quarterly
Financial Statements:
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Contractor
shall submit Quarterly Financial Statements to SDOH. The due
date for quarterly reports shall be forty-five (45) days after
the end of the calendar quarter.
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iii) |
Other
Financial Reports:
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Contractor
shall submit financial reports, including certified annual
financial statements, and make available documents relevant to
its financial condition to SDOH and the State Insurance
Department (SID) in a timely manner as required by State laws
and regulations, including but not limited to PHL
§
§
4403-a, 4404 and 4409, Title 10 NYCRR Part 98; and when
applicable, SIL §
§
304, 305, 306, and 310. The SDOH may require the Contractor to
submit such relevant financial reports and documents related
to its financial condition to the LDSS.
The
Contractor shall prepare and submit encounter data on a
monthly basis to SDOH through SDOH's designated Fiscal Agent.
Each provider is required to have a unique identifier.
Submissions shall be comprised of encounter records or
adjustments to previously submitted records, which the
Contractor has received and processed from provider encounter
or claim records of all contracted services rendered to the
Enrollee in the current or any preceding months. Monthly
submissions must be received by the Fiscal Agent in accordance
with the time frames specified in the MEDS II data dictionary
on the HPN to assure the submission is included in the Fiscal
Agent's monthly production processing.
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v) |
Quality
of Care Performance Measures:
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The
Contractor shall prepare and submit reports to SDOH, as specified
in the Quality Assurance Reporting Requirements (QARR). The
Contractor must arrange for an NCQA-certified entity to audit the
QARR data prior to its submission to the SDOH unless this
requirement is specifically waived by the SDOH. The SDOH will
select the measures which will be audited.
MMC/FHPlus
Contract Amendment
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vi) |
Complaint
and Action Appeal Reports:
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A) |
The
Contractor must provide the SDOH on a quarterly basis, and within
fifteen (15) business days of the close of the quarter, a summary
of all Complaints and Action Appeals subject to PHL
§
4408-a received during the preceding quarter via the Summary
Complaint Form on the Health Provider Network. The Summary
Complaint Form has been developed by the SDOH to categorize the
type of Complaints and Action Appeals subject to PHL
§
4408-a received by the Contractor.
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B) |
The
Contractor agrees to provide on a quarterly basis, via Summary
Complaint Form on the HPN, the total number of Complaints and
Action Appeals subject to PHL §
4408-a that have been unresolved for more than forty-five (45)
days. The Contractor shall maintain records on these and other
Complaints, Complaint Appeals and Action Appeals pursuant to
Appendix F of this Agreement.
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C) |
Nothing
in this Section is intended to limit the right of the SDOH or its
designee to obtain information immediately from a Contractor
pursuant to investigating a particular Enrollee or provider
Complaint, Complaint Appeal or Action Appeal.
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vii) |
Fraud
and Abuse Reporting Requirements:
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A) |
The
Contractor must submit quarterly, via the HPN Complaint reporting
format, the number of Complaints of fraud or abuse made to the
Contractor that warrant preliminary investigation by the
Contractor.
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B) |
The
Contractor also must submit to the SDOH the following information
on an ongoing basis for each confirmed case of fraud and abuse it
identifies through Complaints, organizational monitoring,
contractors, subcontractors, providers, beneficiaries, Enrollees,
or any other source:
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I) |
The
name of the individual or entity that committed the fraud or
abuse;
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II) |
The
source that identified the fraud or abuse;
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III) |
The
type of provider, entity or organization that committed the fraud
or abuse;
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IV) |
A
description of the fraud or abuse;
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V) |
The
approximate dollar amount of the fraud or abuse;
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VI) |
The
legal and administrative disposition of the case, if available,
including actions taken by law enforcement officials to whom the
case has been referred; and
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VII) |
Other
data/information as prescribed by SDOH;
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C) |
Such
report shall be submitted when cases of fraud and abuse are
confirmed, and shall be reviewed and signed by an executive
officier of the Contractor.
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MMC/FHPlus
Contract Amendment
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viii) |
Participating
Provider Network Reports:
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The
Contractor shall submit electronically, the the HPN, an
updated provider network report on a quarterly basis. The
Contractor shall submit an annual notarized attestation that
the providers listed in each submission have executed an
agreement with the Contractor to serve Contractor's MMC and/or
FHPlus Enrollees, as applicable. The report submission must
comply with the Managed Care Provider Netw
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