Common use of Member Needs Relating to HIV Clause in Contracts

Member Needs Relating to HIV. HIV positive (+) persons will be permitted to enroll voluntarily into health plans at the start of this program, and plans must inform newly diagnosed HIV (+) Enrollees known to the plan of their enrollment options due to such exemption status. The Contractor agrees that anonymous testing may be furnished without prior approval by the Contractor and may be conducted at anonymous testing sites available to clients. Services provided for HIV treatment may only be obtained from the Contractor if the individual chooses to enroll and stay enrolled in the Contractor's plan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+) individuals who do enroll in managed care, the Contractor shall have in place all of the following: a) Methods for promoting HIV prevention to all Plan Enrollees. H IV prevention information, both primary (targeted to uninfected Enrollees ), as well as secondary (targeted to those Enrollees with HIV infection) should be tailored to the Enrollee's age, sex, and risk factor(s), including sexual orientation and injection drug use, and must be culturally and linguistically appropriate. All plan Enrollees should be informed of the availability of both in-plan HIV counseling and testing services, out-of-plan HIV counseling and testing services when performed as part of a family planning encounter, as well as HIV counseling and testing services available through SDOH, local health units and Anonymous Counseling and Testing Programs. b) Satisfactory methods for assuring the performance of 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 all women in prenatal care and their newborns. d) Satisfactory case management system linkages must be established with traditional HIV providers, including Designated AIDS Center Hospitals, HIV primary care providers, providers funded under the ▇▇▇▇ ▇▇▇▇▇ CARE Act and clinical education providers, as available. e) The Contractor shall assure that its Participating Providers shall report positive HIV results to the Local Public Health Agency and assist in contact investigation.

Member Needs Relating to HIV. Persons with HIV positive (+) persons infection an exempt from mandatory enrollment; however, they will be permitted to enroll voluntarily into health plans at the start of this program, and plans Managed Care Organizations. The Contractor must inform Enrollees newly diagnosed with HIV (+) Enrollees infection or AIDS, known to the plan Contractor, of their enrollment options due including the ability to return to fee-for-service or to disenroll from the Contractor's plan and to enroll into HIV Special Needs Plans (SNPs) as such exemption statusplans become available. 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 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 if during the individual chooses to enroll and stay period the Enrollee is enrolled in the Contractor's plan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of individuals with HIV positive (+) individuals infection who do enroll in managed care, the Contractor shall have in place all of the following: a) Methods for promoting HIV prevention to all Plan Enrollees. H IV HIV prevention information, both primary (targeted to uninfected Enrollees )primary, as well as secondary (targeted to those Enrollees with HIV infection) should be tailored to the Enrollee's age, sex, and risk factor(s), including sexual orientation and (e.g., injection drug useuse and sexual risk activities), and must 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 both HIV counseling, testing, referral and partner notification (CTRPN) services. b) Policies and procedures promoting the early identification of HIV infection in Enrollees. Such policies and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of in-plan HIV counseling and testing CTRPN services, out-of-cut of plan HIV counseling and testing CTRPN services when performed as part of a family planning encountervisit, as well as HIV counseling and testing anonymous CTRPN services available through SDOHfrom New York State, local health units New York City and Anonymous Counseling and Testing Programs. b) Satisfactory methods for assuring the performance of risk assessments, risk reduction counseling, diagnosis and early entry into treatmentLocal Public Health Agencies. c) The Contractor shall 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 testing, presented as a clinical recommendation, be provided to all women in prenatal care and their newborns. d) Satisfactory case management system linkages must be established . Consistent with traditional HIV providersthese requirements, including Designated AIDS Center Hospitals, HIV primary care providers, providers funded under the ▇▇▇▇ ▇▇▇▇▇ CARE Act and clinical education providers, as available. e) The Contractor shall assure ensure that its Participating Providers shall report positive refer such Enrollees determined to have HIV results to the Local Public Health Agency and assist in contact investigationinfection for clinically appropriate services.

Member Needs Relating to HIV. a) To adequately address the HIV positive (+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 have in place all of the following: i) persons will be permitted to enroll voluntarily into health plans at the start of this program, and plans must inform newly diagnosed HIV (+) Enrollees known to the plan of their enrollment options due to such exemption status. 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 sites available to clients. Services provided for HIV treatment may only be obtained from the Contractor if during the individual chooses to enroll and stay period the Enrollee is enrolled in the Contractor's plan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+) individuals who do enroll in managed care, the Contractor shall have in place all of the following:. aii) Methods for promoting HIV prevention to all Plan Enrollees. H IV HIV prevention information, both primary (targeted to uninfected Enrollees )primary, as well as secondary (targeted to those Enrollees with HIV infection) should be tailored to the Enrollee's age, sex, and risk factor(s), including sexual orientation and (e.g., injection drug useuse and sexual risk activities), and must 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 both in-plan HIV counseling, testing, referral and partner notification (CTRPN) services. iii) Policies and procedures promoting the early identification of HIV infection in Enrollees. Such policies and procedures shall include at a minimum: assessment methods for recognizing the early signs and symptoms of HIV disease; initial and routine screening for HIV risk factors through administration of sexual behavior and drug and alcohol use assessments; and the provision of information to all Enrollees regarding the availability of HIV CTRPN services from Participating Providers, or as part of a Family Planning and Reproductive Health services visit pursuant to Appendix C of this Agreement, and the availability of anonymous CTRPN services from New York State and the EPHA. iv) 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 services, outprovided shall be done in accordance with Article 27-of-plan F of the PHL. Such policies and procedures shall also direct Participating Providers to refer any HIV counseling and testing services when performed as part of a family planning encounter, as well as HIV counseling and testing services available through SDOH, local health units and Anonymous Counseling and Testing Programs. b) Satisfactory methods for assuring the performance of 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 all positive women in prenatal their care to clinically appropriate services for both the women and their newborns. dv) Satisfactory case management system linkages must A network of providers sufficient to meet the needs of its Enrollees with HIV. Satisfaction of the network requirement may be established 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 traditional HIV providers, including infection; inclusion of Designated AIDS Center Hospitals, Hospitals or other hospitals experienced in HIV primary care providers, in the Contractor's network; and contracts or linkages with providers funded under the ▇▇▇▇ ▇▇▇▇▇ CARE Act Act. The Contractor shall inform the providers in its network how to obtain information about the availability of Experienced HIV Providers and clinical education providersHIV Specialist PCPs vi) 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, as availableincluding in-plan case management, and/or, with appropriate consent of the Enrollee, COBRA Comprehensive Medicaid Case Management (CMCM) services and/or HIV community-based psychosocial case management services. evii) The Contractor shall assure that require its Participating Providers shall to report positive HIV test results and diagnoses and known contacts of such persons to the Local Public Health Agency New York State 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 assist in contact investigationupdate 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. HIV positive (+a) persons will be permitted to enroll voluntarily into health plans at If the start of this programContractor operates in a county that has implemented mandatory enrollment, and plans the Contractor must inform MMC Enrollees newly diagnosed with HIV (+) Enrollees infection or AIDS, who are known to the plan Contractor, of their enrollment options due 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 exemption statusplan 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 available to clientssites. Services provided for HIV treatment may only be obtained from the Contractor if during the individual chooses to enroll and stay period the Enrollee is enrolled in the Contractor's plan. To adequately address the HIV prevention needs of uninfected Enrollees, as well as the special needs of HIV positive (+MMC product. d) individuals who do enroll in managed care, the The Contractor shall have implement policies and procedures consistent with CDC recommendations as published in place all of the followingMMWR where consistent with New York State laws and SDOH Guidance for HIV Counseling & Testing: ai) Methods for promoting HIV prevention to all Plan Enrollees. H IV HIV prevention information, both primary (targeted to uninfected Enrollees ), as well as secondary (targeted to those Enrollees with HIV infection) secondary, should be tailored to the Enrollee's age, sex, and risk factor(s) (e.g., injection drug use and sexual risk activities), including sexual orientation and injection drug use, and must 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 both in-plan HIV counseling, testing, referral and partner notification (CTRPN) services. ii) Policies and procedures that promote HIV counseling and testing services, out-of-plan 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 counseling disease; initial and testing 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 when performed from Participating Providers or as part of a family planning encounterFamily Planning and Reproductive Health services visit pursuant to Appendix C of this Agreement, as well as HIV counseling and testing availability of anonymous CTRPN services available through SDOHfrom New York State, local health units New York City and Anonymous Counseling and Testing Programsthe LPHA. biii) Satisfactory methods 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 assuring the performance persons with HIV infection; inclusion of 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 all women in prenatal care and their newborns. d) Satisfactory case management system linkages must be established with traditional HIV providers, including Designated AIDS Center Hospitals, Hospitals or other hospitals experienced in HIV primary care providers, in the Contractor’s network; and contracts or linkages with providers funded under the ▇▇▇▇ ▇▇▇▇▇ CARE Act Act. The Contractor shall inform Participating Providers about how to obtain information about the availability of Experienced HIV Providers and clinical education providers, as availableHIV Specialist PCPs. eiv) 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 assure that require its Participating Providers shall to report positive HIV test results and diagnoses and known contacts of such persons to the Local Public Health Agency and assist in contact investigationNew 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.