Common use of Member Needs Relating to HIV Clause in Contracts

Member Needs Relating to HIV. a) If the Contractor operates in a county that has implemented mandatory enrollment, the Contractor must inform MMC Enrollees newly diagnosed with HIV infection or AIDS, who are known to the Contractor, of their enrollment options including the ability to return to the Medicaid fee-for-service program or to disenroll from the Contractor’s MMC product and to enroll into HIV Special Needs Plans (SNPs), if such plan is available. b) The Contractor will inform Enrollees about HIV counseling and testing services available through the Contractor’s Participating Provider network; HIV counseling and testing services available when performed as part of a Family Planning and Reproductive Health encounter; and anonymous counseling and testing services available from SDOH, Local Public Health Agency clinics and other county programs. Counseling and testing rendered outside of a Family Planning and Reproductive Health encounter, as well as services provided as the result of an HIV+ diagnosis, will be furnished by the Contractor in accordance with standards of care. c) The Contractor agrees that anonymous testing may be furnished to the Enrollee without prior approval by the Contractor and may be conducted at anonymous testing sites. Services provided for HIV treatment may only be obtained from the Contractor during the period the Enrollee is enrolled in the Contractor's MMC product. d) The Contractor shall implement policies and procedures consistent with CDC recommendations as published in the MMWR where consistent with New York State laws and SDOH Guidance for HIV Counseling & Testing: i) Methods for promoting HIV prevention to all Enrollees. HIV prevention information, both primary as well as secondary, should be tailored to the Enrollee's age, sex, and risk factor(s) (e.g., injection drug use and sexual risk activities), and should be culturally and linguistically appropriate. HIV primary prevention means the reduction or control of causative factors for HIV, including the reduction of risk factors. HIV Primary prevention includes strategies to help prevent uninfected Enrollees from acquiring HIV, i.e., behavior counseling for HIV negative Enrollees with risk behavior. Primary prevention also includes strategies to help prevent infected Enrollees from transmitting HIV infection, i.e., behavior counseling with an HIV infected Enrollee to reduce risky sexual behavior or providing antiviral therapy to a pregnant, HIV infected female to prevent transmission of HIV infection to a newborn. HIV Secondary Prevention means promotion of early detection and treatment of HIV disease in an asymptomatic Enrollee to prevent the development of symptomatic disease. This includes: regular medical assessments; routine immunization for preventable infections; prophylaxis for opportunistic infections; regular dental, optical, dermatological and gynecological care; optimal diet/nutritional supplementation; and partner notification services which lead to the early detection and treatment of other infected persons. All Enrollees should be informed of the availability of HIV counseling, testing, referral and partner notification (CTRPN) services. ii) Policies and procedures that promote HIV counseling and testing as a routine part of medical care. Such policies and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of HIV CTRPN services from Participating Providers or as part of a Family Planning and Reproductive Health services visit pursuant to Appendix C of this Agreement, and availability of anonymous CTRPN services from New York State, New York City and the LPHA. iii) A network of providers sufficient to meet the needs of its Enrollees with HIV. Satisfaction of the network requirement may be accomplished by inclusion of HIV specialists within the network or the provision of HIV specialist consultation to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion of Designated AIDS Center Hospitals or other hospitals experienced in HIV care in the Contractor’s network; and contracts or linkages with providers funded under the Xxxx Xxxxx CARE Act. The Contractor shall inform Participating Providers about how to obtain information about the availability of Experienced HIV Providers and HIV Specialist PCPs. iv) Case Management Assessment for Enrollees with HIV Infection. The Contractor shall establish policies and procedures to ensure that Enrollees who have been identified as having HIV infection are assessed for case management services. The Contractor shall arrange for any Enrollee identified as having HIV infection and needing case management services to be referred to an appropriate case management services provider, and/or, with appropriate consent of the Enrollee, HIV community-based psychosocial case management services and/or COBRA Comprehensive Medicaid Case Management (CMCM) services for MMC Enrollees. v) The Contractor shall require its Participating Providers to report positive HIV test results and diagnoses and known contacts of such persons to the New York State Commissioner of Health. In New York City, these shall be reported to the New York City Commissioner of Health. Access to partner notification services must be consistent with 10 NYCRR Part 63.

Member Needs Relating to HIV. a) If the Contractor operates in a county that has implemented Persons with HIV infection an exempt from mandatory enrollment; however, the they will be permitted to enroll voluntarily into Managed Care Organizations. The Contractor must inform MMC Enrollees newly diagnosed with HIV infection or AIDS, who are known to the Contractor, of their enrollment options including the ability to return to the Medicaid fee-for-service program or to disenroll from the Contractor’s MMC product 's plan and to enroll into HIV Special Needs Plans (SNPs), if ) as such plan is plans become available. b) The Contractor will inform Enrollees about HIV counseling and testing services available through the Contractor’s Participating Provider network; HIV counseling and testing services available when performed as part of a Family Planning and Reproductive Health encounter; and anonymous counseling and testing services available from SDOH, Local Public Health Agency clinics and other county programs. Counseling and testing rendered outside of a Family Planning and Reproductive Health encounter, as well as services provided as the result of an HIV+ diagnosis, will be furnished by the Contractor in accordance with standards of care. c) The Contractor agrees that anonymous testing may be furnished to the Enrollee without prior approval by the Contractor and may be conducted at anonymous testing sitessites available to clients. Services provided for HIV treatment may only SECTION 10 (BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES) October 1, 2004 10-14 be obtained from the Contractor during the period the Enrollee is enrolled in the Contractor's MMC product. d) The plan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of individuals with HIV infection who do enroll in managed care, the Contractor shall implement policies and procedures consistent with CDC recommendations as published have in place all of the MMWR where consistent with New York State laws and SDOH Guidance for HIV Counseling & Testingfollowing: ia) Methods for promoting HIV prevention to all Plan Enrollees. HIV prevention information, both primary primary, as well as secondary, secondary should be tailored to the Enrollee's age, sex, and risk factor(s) ), (e.g., injection drug use and sexual risk activities), and should be culturally and linguistically appropriate. HIV primary prevention means the reduction or control of causative factors for HIV, including the reduction of risk factors. HIV Primary prevention includes strategies to help prevent uninfected Enrollees from acquiring HIV, i.e., behavior counseling for HIV negative Enrollees with risk behavior. Primary prevention also includes strategies to help prevent infected Enrollees from transmitting HIV infection, i.e., behavior counseling with an HIV infected Enrollee to reduce risky sexual behavior or providing antiviral therapy to a pregnant, HIV infected female to prevent transmission of HIV infection to a newborn. HIV Secondary Prevention means promotion of early detection and treatment of HIV disease in an asymptomatic Enrollee to prevent the development of symptomatic disease. This includes: regular medical assessments; routine immunization for preventable infections; prophylaxis for opportunistic infections; regular dental, optical, dermatological and gynecological care; optimal diet/nutritional supplementation; and partner notification services which lead to the early detection and treatment of other infected persons. All plan Enrollees should be informed of the availability of HIV counseling, testing, referral and partner notification (CTRPN) services. iib) Policies and procedures that promote promoting the early identification of HIV counseling and testing as a routine part of medical careinfection in Enrollees. Such policies and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of in-plan HIV CTRPN services, cut of plan CTRPN services from Participating Providers or as part of a Family Planning and Reproductive Health services visit pursuant to Appendix C of this Agreementfamily planning visit, and availability of anonymous CTRPN services from New York State, New York City and the LPHALocal Public Health Agencies. iii) A network of providers sufficient to meet the needs of its Enrollees with HIV. Satisfaction of the network requirement may be accomplished by inclusion of HIV specialists within the network or the provision of HIV specialist consultation to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion of Designated AIDS Center Hospitals or other hospitals experienced in HIV care in the Contractor’s network; and contracts or linkages with providers funded under the Xxxx Xxxxx CARE Act. The Contractor shall inform Participating Providers about how to obtain information about the availability of Experienced HIV Providers and HIV Specialist PCPs. iv) Case Management Assessment for Enrollees with HIV Infection. The Contractor shall establish policies and procedures to ensure that Enrollees who have been identified as having HIV infection are assessed for case management services. The Contractor shall arrange for any Enrollee identified as having HIV infection and needing case management services to be referred to an appropriate case management services provider, and/or, with appropriate consent of the Enrollee, HIV community-based psychosocial case management services and/or COBRA Comprehensive Medicaid Case Management (CMCM) services for MMC Enrollees. vc) The Contractor shall require its comply with the requirements set forth in Title 10 NYCRR (including Part 98 and in Subpart 69-1) which mandate that HIV counseling with testing, presented as a clinical recommendation, be provided to all women in prenatal care and their newborns. Consistent with these requirements, the Contractor shall ensure that Participating Providers refer such Enrollees determined to report positive have HIV test results and diagnoses and known contacts of such persons to the New York State Commissioner of Health. In New York City, these shall be reported to the New York City Commissioner of Health. Access to partner notification services must be consistent with 10 NYCRR Part 63infection for clinically appropriate services.

Member Needs Relating to HIV. a) If To adequately address the Contractor operates in a county that has implemented mandatory enrollment, the Contractor must inform MMC Enrollees newly diagnosed with HIV infection or AIDS, who are known to the Contractor, prevention needs of their enrollment options including the ability to return to the Medicaid fee-for-service program or to disenroll from the Contractor’s MMC product and to enroll into HIV Special Needs Plans (SNPs), if such plan is available. b) The Contractor will inform Enrollees about HIV counseling and testing services available through the Contractor’s Participating Provider network; HIV counseling and testing services available when performed as part of a Family Planning and Reproductive Health encounter; and anonymous counseling and testing services available from SDOH, Local Public Health Agency clinics and other county programs. Counseling and testing rendered outside of a Family Planning and Reproductive Health encounteruninfected Enrollees, as well as services provided as the result special needs of an HIV+ diagnosisindividuals with HIV infection who do enroll in managed care, will be furnished by the Contractor shall have in accordance with standards place all of care.the following: ci) The Contractor agrees that anonymous Anonymous testing may be furnished to the Enrollee without prior approval by the Contractor and may be conducted at anonymous testing sitessites available to clients. Services provided for HIV treatment may only be obtained from the Contractor during the period the Enrollee is enrolled in the Contractor's MMC productplan. d) The Contractor shall implement policies and procedures consistent with CDC recommendations as published in the MMWR where consistent with New York State laws and SDOH Guidance for HIV Counseling & Testing: iii) Methods for promoting HIV prevention to all Plan Enrollees. HIV prevention information, both primary primary, as well as secondary, secondary should be tailored to the Enrollee's age, sex, and risk factor(s) ), (e.g., injection drug use and sexual risk activities), and should be culturally and linguistically appropriate. HIV primary prevention means the reduction or control of causative factors for HIV, including the reduction of risk factors. HIV Primary prevention includes strategies to help prevent uninfected Enrollees from acquiring HIV, i.e., behavior counseling for HIV negative Enrollees with risk behavior. Primary prevention also includes strategies to help prevent infected Enrollees from transmitting HIV infection, i.e., behavior counseling with an HIV infected Enrollee to reduce risky sexual behavior or providing antiviral therapy to a pregnant, HIV infected female to prevent transmission of HIV infection to a newborn. HIV Secondary Prevention means promotion of early detection and treatment of HIV disease in an asymptomatic Enrollee to prevent the development of symptomatic disease. This includes: regular medical assessments; routine immunization for preventable infections; prophylaxis for opportunistic infections; regular dental, optical, dermatological and gynecological care; optimal diet/nutritional supplementation; and partner notification services which lead to the early detection and treatment of other infected persons. All plan Enrollees should be informed of the availability of HIV counseling, testing, referral and partner notification (CTRPN) services. iiiii) Policies and procedures that promote promoting the early identification of HIV counseling and testing as a routine part of medical careinfection in Enrollees. Such policies and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of HIV CTRPN services from Participating Providers Providers, or as part of a Family Planning and Reproductive Health services visit pursuant to Appendix C of this Agreement, and the availability of anonymous CTRPN services from New York State, New York City State and the LPHAEPHA. iiiiv) Policies and procedures that require Participating Providers to provide HIV counseling and recommend HIV testing to pregnant women in their care. The HIV counseling and testing provided shall be done in accordance with Article 27-F of the PHL. Such policies and procedures shall also direct Participating Providers to refer any HIV positive women in their care to clinically appropriate services for both the women and their newborns. v) A network of providers sufficient to meet the needs of its Enrollees with HIV. Satisfaction of the network requirement may be accomplished by inclusion of HIV specialists within the network or the provision of HIV specialist consultation to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion of Designated AIDS Center Hospitals or other hospitals experienced in HIV care in the Contractor’s 's network; and contracts or linkages with providers funded under the Xxxx Xxxxx CARE Act. The Contractor shall inform Participating Providers about the providers in its network how to obtain information about the availability of Experienced HIV Providers and HIV Specialist PCPs. ivvi) Case Management Assessment for Enrollees with HIV Infection. The Contractor shall establish policies and procedures to ensure that Enrollees who have been identified as having HIV infection are assessed for case management services. The Contractor shall arrange for any Enrollee identified as having HIV infection and needing case management services to be referred to an appropriate case management services provider, including in-plan case management, and/or, with appropriate consent of the Enrollee, HIV community-based psychosocial case management services and/or COBRA Comprehensive Medicaid Case Management (CMCM) services for MMC Enrolleesand/or HIV community-based psychosocial case management services. vvii) The Contractor shall require its Participating Providers to report positive HIV test results and diagnoses and known contacts of such persons to the New York State Commissioner of Health. In New York City, these shall be reported to the New York City Commissioner of Health. Access to partner notification services must be consistent with 10 NYCRR Part 63. viii) The Contractor's Medical Director shall review Contractor's HIV practice guidelines at least annually and update them as necessary for compliance with recommended SDOH AIDS Institute and federal government clinical standards. The Contractor will disseminate the HIV Practice Guidelines or revised guidelines to Participating Providers at least annually, or more frequently as appropriate.

Member Needs Relating to HIV. aHIV positive (+) If persons will be permitted to enroll voluntarily into health plans at the Contractor operates in a county that has implemented mandatory enrollmentstart of this program, the Contractor and plans must inform MMC Enrollees newly diagnosed with HIV infection or AIDS, who are (+) Enrollees known to the Contractor, plan of their enrollment options including the ability due to return to the Medicaid fee-for-service program or to disenroll from the Contractor’s MMC product and to enroll into HIV Special Needs Plans (SNPs), if such plan is available. b) The Contractor will inform Enrollees about HIV counseling and testing services available through the Contractor’s Participating Provider network; HIV counseling and testing services available when performed as part of a Family Planning and Reproductive Health encounter; and anonymous counseling and testing services available from SDOH, Local Public Health Agency clinics and other county programsexemption status. Counseling and testing rendered outside of a Family Planning and Reproductive Health encounter, as well as services provided as the result of an HIV+ diagnosis, will be furnished by the Contractor in accordance with standards of care. c) The Contractor agrees that anonymous testing may be furnished to the Enrollee without prior approval by the Contractor and may be conducted at anonymous testing sitessites available to clients. Services provided for HIV treatment may only be obtained from the Contractor during if the period the Enrollee is individual chooses to enroll and stay enrolled in the Contractor's MMC product. dplan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+) The individuals who do enroll in managed care, the Contractor shall implement policies and procedures consistent with CDC recommendations as published have in place all of the MMWR where consistent with New York State laws and SDOH Guidance for HIV Counseling & Testingfollowing: ia) Methods for promoting HIV prevention to all Plan Enrollees. HIV H IV prevention information, both primary (targeted to uninfected Enrollees ), as well as secondary, secondary (targeted to those Enrollees with HIV infection) should be tailored to the Enrollee's age, sex, and risk factor(s) (e.g.), including sexual orientation and injection drug use and sexual risk activities)use, and should must be culturally and linguistically appropriate. HIV primary prevention means the reduction or control of causative factors for HIV, including the reduction of risk factors. HIV Primary prevention includes strategies to help prevent uninfected Enrollees from acquiring HIV, i.e., behavior counseling for HIV negative Enrollees with risk behavior. Primary prevention also includes strategies to help prevent infected Enrollees from transmitting HIV infection, i.e., behavior counseling with an HIV infected Enrollee to reduce risky sexual behavior or providing antiviral therapy to a pregnant, HIV infected female to prevent transmission of HIV infection to a newborn. HIV Secondary Prevention means promotion of early detection and treatment of HIV disease in an asymptomatic Enrollee to prevent the development of symptomatic disease. This includes: regular medical assessments; routine immunization for preventable infections; prophylaxis for opportunistic infections; regular dental, optical, dermatological and gynecological care; optimal diet/nutritional supplementation; and partner notification services which lead to the early detection and treatment of other infected persons. All plan Enrollees should be informed of the availability of HIV counseling, testing, referral and partner notification (CTRPN) services. ii) Policies and procedures that promote both in-plan HIV counseling and testing as a routine part of medical care. Such policies services, out-of-plan HIV counseling and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of HIV CTRPN testing services from Participating Providers or when performed as part of a Family Planning family planning encounter, as well as HIV counseling and Reproductive Health testing services visit pursuant to Appendix C of this Agreementavailable through SDOH, local health units and availability of anonymous CTRPN services from New York State, New York City Anonymous Counseling and the LPHATesting Programs. iiib) A network Satisfactory methods for assuring the performance of providers sufficient risk assessments, risk reduction counseling, diagnosis and early entry into treatment. c) The Contractor shall comply with the requirements in Title 10 NYCRR which mandate that HIV counseling with testing , presented as a clinical recommendation, be provided to meet the needs of its Enrollees all women in prenatal care and their newborns. d) Satisfactory case management system linkages must be established with HIV. Satisfaction of the network requirement may be accomplished by inclusion of traditional HIV specialists within the network or the provision of HIV specialist consultation to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion of providers, including Designated AIDS Center Hospitals or other hospitals experienced in Hospitals, HIV primary care in the Contractor’s network; and contracts or linkages with providers, providers funded under the Xxxx Xxxxx CARE Act. The Contractor shall inform Participating Providers about how to obtain information about the availability of Experienced HIV Providers Act and HIV Specialist PCPsclinical education providers, as available. iv) Case Management Assessment for Enrollees with HIV Infection. The Contractor shall establish policies and procedures to ensure that Enrollees who have been identified as having HIV infection are assessed for case management services. The Contractor shall arrange for any Enrollee identified as having HIV infection and needing case management services to be referred to an appropriate case management services provider, and/or, with appropriate consent of the Enrollee, HIV community-based psychosocial case management services and/or COBRA Comprehensive Medicaid Case Management (CMCM) services for MMC Enrollees. ve) The Contractor shall require assure that its Participating Providers to shall report positive HIV test results and diagnoses and known contacts of such persons to the New York State Commissioner of Health. In New York City, these shall be reported to the New York City Commissioner of Health. Access to partner notification services must be consistent with 10 NYCRR Part 63Local Public Health Agency and assist in contact investigation.