Ownership and Affiliation. Check the applicable box to describe the ownership and affiliation between the legal entity offering Health Plan and the legal entity offering the companion MAP: The legal entity offering Health Plan is the same legal entity offering the MAP plan under which SDOH provides capitated payments for provision of the services. Full name of legal entity offering Health Plan (D-SNP): Full name of legal entity offering MAP: D-SNP WITH COMPANION PARTIAL CAPITATION (MLTC-P) PLAN Health Plan shall complete all information below for each D-SNP under this Agreement. Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes No Health Plan shall attach copy of Appendix G of the model contract in its entirety when submitting to CMS. See the link below. xxxxx://xxx.xxxxxx.xx.xxx/health_care/medicaid/redesign/mrt90/hlth_plans_prov_prof.htm Health Plan operates an MLTCP with both Aligned and FFS enrollment into the D-SNP . Health Plan shall meet designation for HIDE SNP as defined in this agreement and outlined in the Appendix G link to the model contract. The MLTCP plan coverage includes long term services and supports. CMS Contract Code H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Service Area- Check all approved counties that apply. For counties awaiting DOH approval, check the county box and indicate as “pending”. Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Montgomery St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie
Ownership and Affiliation. Neither of Parent and Merger Sub is, nor at any time during the last three years has either of them been, an “interested stockholder” (as defined in Section 203 of the DGCL) of the Company. None of Parent, Merger Sub, and to Parent’s knowledge, the other Affiliates of Parent, beneficially owns any shares of Company Common Stock. Neither Parent nor Merger Sub has entered into any contract with any officer or director of the Company in connection with the Transactions.
Ownership and Affiliation. Check the applicable box to describe the ownership and affiliation between the legal entity offering Health Plan and the legal entity offering the companion partial capitation MLTC plan: The legal entity offering Health Plan is the same legal entity offering the partial capitation MLTC plan under which SDOH provides capitated payments for provision of long term services and supports in Appendix A. The legal entity offering Health Plan is a separate legal entity under the same parent organization offering the partial capitation MLTC plan under which SDOH provides capitated payments for the provision of long term services and supports. Full name of legal entity offering Health Plan (D-SNP): Full name of legal entity offering partial capitation MLTC plan: D-SNP WITH COMPANION MMC/HARP (Integrated Benefit for Dually Eligible Enrollees Program -IB-Dual) – Health Plan shall attach copy of Appendix K of the model contract in its entirety when submitting to CMS. See the link below. xxxxx://xxx.xxxxxx.xx.xxx/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv- snp_model_contract.pdf Health Plan that operates an IB-Dual with both Aligned and FFS dual eligible enrollees into the D-SNP. Health Plan shall meet designation for HIDE SNP as defined in this agreement and outlined in the Appendix K link to the model contract. The IB-Dual coverage includes behavioral health and/or long term services and supports. Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes No CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Health Plan has received SDOH approval to offer IB-Dual in all counties indicated below: Yes No If the answer is “no” to the above, please identify which counties are awaiting SDOH approval. Health Plan has received CMS approval for default enrollment for its MMC/HARP (IB-Dual) contract: Yes No
