Common use of Ownership and Affiliation Clause in Contracts

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 MAP: ______ _ Health Plan shall complete all information below for each D-SNP under this Agreement. 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/medicaid/redesign/mrt90/hlth_plans_prov_prof.htm CMS Contract Code (H#): Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAP: ______ _ 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 K 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 CMS Contract Code (H#): Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAPpartial capitation MLTC plan: The legal entity offering Health Plan is the same legal entity offering the MAP partial capitation MLTC plan under which SDOH provides capitated payments for provision of the services. Full name of long term services and supports in Appendix A. The legal entity offering MAP: ______ _ Health Plan shall complete all information below is a separate legal entity under the same parent organization offering the partial capitation MLTC plan under which SDOH provides capitated payments for each D-SNP under this Agreementthe provision of long term services and supports. 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/medicaid/redesign/mrt90/hlth_plans_prov_prof.htm Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes No Health Plan has received CMS Contract Code approval for default enrollment for its MMC/HARP (H#): IB-Dual) contract: Yes No Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid AdvantageIB-Dual: QMB-Plus FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAPpartial capitation MLTC plan: The legal entity offering Health Plan is the same legal entity offering the MAP partial capitation MLTC plan under which SDOH provides capitated payments for provision of the serviceslong term services and supports. Full name of The legal entity offering MAP: ______ _ Health Plan shall complete all information below is a separate legal entity under the same parent organization offering the partial capitation MLTC plan under which SDOH provides capitated payments for each D-SNP under this Agreementthe provision of long term services and supports. 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/medicaid/redesign/mrt90/hlth_plans_prov_prof.htm Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes __ _ No_ Plan Name: _______ _ Health Plan has received CMS Contract Code approval for default enrollment for its MMC/HARP (H#): IB-Dual) contract: Yes ___ No____ Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid AdvantageIB-Dual: QMB-Plus SLMB-Plus FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAPpartial capitation MLTC plan: The legal entity offering Health Plan is the same legal entity offering the MAP partial capitation MLTC plan under which SDOH provides capitated payments for provision of the services. Full name of long term services and supports in Appendix A. The legal entity offering MAP: ______ _ Health Plan shall complete all information below is a separate legal entity under the same parent organization offering the partial capitation MLTC plan under which SDOH provides capitated payments for each D-SNP under this Agreementthe provision of long term services and supports. 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/medicaid/redesign/mrt90/hlth_plans_prov_prof.htm Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes No Health Plan has received CMS Contract Code approval for default enrollment for its MMC/HARP (H#): IB-Dual) contract: Yes No Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid AdvantageIB-Dual: QMB-Plus FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAPMA: The legal entity offering Health Plan is the same legal entity offering the MAP MA plan under which SDOH provides capitated payments for provision of the services. The legal entity offering Health Plan is a separate legal entity under the same parent organization offering the MA plan under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering MAPMA: ______ _ 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 K 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 CMS Contract Code (H#): ):___________________________ Plan Name: _______ _ Service Area – check all that apply: (Sec. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAP: ______ _ Health Plan shall complete all information below for each D-SNP under this Agreement. (SMAC Requirements Matrix #4-6) Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes __ No_ Health Plan shall attach copy of Appendix K 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 CMS Contract Code (H#): 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. Plan Name: _______ _ Check all approved counties that apply. For counties awaiting approval, check the county box and indicate as “pending”. Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2SMAC Req Matrix #2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE

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 MAP: ______ _ 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 K 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 CMS Contract Code (H#): 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. 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 Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx Montgomery St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDESchoharie

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 MAP: ______ _ 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 K 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 CMS Contract Code (H#): Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Seneca Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Jefferson Xxxxxxxxx Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Chenango Xxxxxxxx Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Madison Xxxxxxx Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (Sec. 5.11.2): Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: In Medicaid Advantage: FBDE In Fee-For-Service (FFS): QMB SLMB QI QDWI QMB-Plus SLMB-Plus FBDE