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 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. 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 long term services and supports in Appendix A. The legal entity offering Health Plan is a separate legal entity under the servicessame 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 MAPpartial capitation MLTC plan: D-SNP WITH COMPANION PARTIAL CAPITATION MMC/HARP (MLTCIntegrated Benefit for Dually Eligible Enrollees Program -IB-PDual) 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 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 xxxxx://xxx.xxxxxx.xx.xxx/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv- snp_model_contract.pdf Health Plan operates an MLTCP with both Aligned and FFS enrollment into the D-SNP . Health Plan shall meet designation for is seeking HIDE SNP designation as defined in this agreement and outlined in the Appendix G link to the model contractagreement. The MLTCP plan coverage includes long term services and supports. Yes No CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Health Plan has received CMS approval for default enrollment for its MMC/HARP (IB-Dual) contract: Yes No Service Area- Check Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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 IB-Dual: QMB-Plus FBDE In Fee-For-Service (FFS): QMB QI QDWI QMB-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 long term services and supports. The legal entity offering Health Plan is a separate legal entity under the servicessame 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 MAP: partial capitation MLTC plan:____ D-SNP WITH COMPANION PARTIAL CAPITATION MMC/HARP (MLTCIntegrated Benefit for Dually Eligible Enrollees Program -IB-PDual) 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 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 xxxxx://xxx.xxxxxx.xx.xxx/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv- snp_model_contract.pdf Health Plan operates an MLTCP with both Aligned and FFS enrollment into the D-SNP . Health Plan shall meet designation for is seeking HIDE SNP designation as defined in this agreement and outlined in the Appendix G link to the model contractagreement. The MLTCP plan coverage includes long term services and supports. Yes __ _ No_ CMS Contract Code (H#): ___________________________ Contract Name: D-SNP Plan Benefit Package: Plan Name: _______ _ Health Plan has received CMS approval for default enrollment for its MMC/HARP (IB-Dual) contract: Yes ___ No____ Service Area- Check Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Seneca Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Xxxxxxxxx Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Xxxxxxxx Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Xxxxxxx Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Montgomery Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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 IB-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 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. (SMAC Requirements Matrix #4-6) Health Plan is seeking HIDE SNP designation as defined in this agreement. Yes No __ 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- 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 Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie Categories of Dual Eligible Beneficiaries Enrolled (SMAC 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: QMB QI QDWI QMB-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 Health Plan (D-SNP): ______ Full name of legal entity offering MAP: ______ _ D-SNP WITH COMPANION PARTIAL CAPITATION MEDICAID ADVANTAGE (MLTC-PMA) 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 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 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 ___________________________ DSNP Plan Benefit Package: _____________________ Plan Name: Name Service Area- Check Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Seneca Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Xxxxxxxxx Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Xxxxxxxx Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Xxxxxxx Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Montgomery Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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 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 Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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: QMB QI QDWI QMB-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 MAPIB-Dual: The legal entity offering Health Plan is the same legal entity offering the MAP plan IB-Dual program under which SDOH provides capitated payments for provision of the services in Appendix A. The legal entity offering Health Plan is a separate legal entity under the same parent organization from the legal entity offering the IB-Dual program under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering Health Plan (D-SNPDSNP): Full name of legal entity offering MAPIB-Dual: OTHER D-SNP WITH COMPANION PARTIAL CAPITATION (MLTC-P1) 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 Area – check all approved counties that apply. For counties awaiting DOH approval, check the county box and indicate as “pending”. : (Sec.5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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: QMB OTHER D-SNP (2) – CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Service Area – check all that apply: (Sec. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Hamilton 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 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:

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 MAPIB-Dual: The legal entity offering Health Plan is the same legal entity offering the MAP plan IB-Dual program under which SDOH provides capitated payments for provision of the services in Appendix A. The legal entity offering Health Plan is a separate legal entity under the same parent organization from the legal entity offering the IB-Dual program under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering Health Plan (D-SNPDSNP): Full name of legal entity offering MAPIB-Dual: OTHER D-SNP WITH COMPANION PARTIAL CAPITATION (MLTC-P1) 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 Area – check all approved counties that apply. For counties awaiting DOH approval, check the county box and indicate as “pending”. : (Sec.5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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: QMB OTHER D-SNP (2) – CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Service Area – check all that apply: (Sec. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Hamilton 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 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:

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 long term services and supports in Appendix A. The legal entity offering Health Plan is a separate legal entity under the servicessame 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 MAPpartial capitation MLTC plan: D-SNP WITH COMPANION PARTIAL CAPITATION MMC/HARP (MLTCIntegrated Benefit for Dually Eligible Enrollees Program -IB-PDual) 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 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 xxxxx://xxx.xxxxxx.xx.xxx/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv- snp_model_contract.pdf Health Plan operates an MLTCP with both Aligned and FFS enrollment into the D-SNP . Health Plan shall meet designation for is seeking HIDE SNP designation as defined in this agreement and outlined in the Appendix G link to the model contractagreement. The MLTCP plan coverage includes long term services and supports. Yes No CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Health Plan has received CMS approval for default enrollment for its MMC/HARP (IB-Dual) contract: Yes No Service Area- Check Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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 IB-Dual: QMB-Plus FBDE In Fee-For-Service (FFS): QMB QI QDWI QMB-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 Health Plan (D-SNPDSNP): ______ Full name of legal entity offering MAPMA: _____ _ 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 __ 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 Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Seneca Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Xxxxxxxxx Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Xxxxxxxx Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Xxxxxxx Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Montgomery Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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: 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 MAPIB-Dual: The legal entity offering Health Plan is the same legal entity offering the MAP plan IB-Dual program 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 from the legal entity offering the IB-Dual program under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering Health Plan (D-SNPDSNP): ______ __ Full name of legal entity offering MAPIB-Dual: ___ _ OTHER D-SNP (1) – CMS Contract Code (H#): ___________________________ Contract Name: D-SNP WITH COMPANION PARTIAL CAPITATION Plan Benefit Package: Plan Name: _______ _ Service Area – check all that apply: (MLTC-PSec.5.11.7) PLAN 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 shall complete all information below for each verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: QMB OTHER 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. (2) – CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: _______ _ Service Area- Check Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Seneca Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Orleans Xxxxxxxx Cayuga Herkimer Oswego Tioga Chautauqua Xxxxxxxxx Jefferson Otsego Xxxxxxxx Chemung Kings Xxxxxx Ulster Xxxxxxxx Chenango Xxxxx Queens Xxxxxx Xxxxxxx Xxxxxxxxxx Rensselaer Washington Columbia Xxxxxxx Madison Xxxxxxxx Xxxxx Xxxxxxxx Xxxxxx Rockland Westchester Delaware Montgomery Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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:

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 MAPIB-Dual: The legal entity offering Health Plan is the same legal entity offering the MAP plan IB-Dual program under which SDOH provides capitated payments for provision of the services in Appendix A. The legal entity offering Health Plan is a separate legal entity under the same parent organization from the legal entity offering the IB-Dual program under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering Health Plan (D-SNPDSNP): Full name of legal entity offering MAPIB-Dual: COORDINATION ONLY D-SNP WITH COMPANION PARTIAL CAPITATION (MLTC-P1) 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 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 SchoharieSchoharie Categories of Dual Eligible Beneficiaries Enrolled: Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: QMB QI QDWI QMB-Plus FBDE COORDINATION ONLY D-SNP (2) – CMS Contract Code (H#): Contract Name: D-SNP Plan Benefit Package: Plan Name: Service Area – check all approved counties that apply: 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 Categories of Dual Eligible Beneficiaries Enrolled: Health Plan verifies that only Dual Eligible Beneficiaries from the following categories, as defined in Attachment A, are enrolled in this D-SNP: QMB QI QDWI

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 MAPIB-Dual: The legal entity offering Health Plan is the same legal entity offering the MAP plan IB-Dual program under which SDOH provides capitated payments for provision of the services in Appendix A. The legal entity offering Health Plan is a separate legal entity under the same parent organization from the legal entity offering the IB-Dual program under which SDOH provides capitated payments for the provision of the services. Full name of legal entity offering Health Plan (D-SNPDSNP): ______ Full name of legal entity offering MAPIB-Dual: ___ _ COORDINATION ONLY D-SNP WITH COMPANION PARTIAL CAPITATION (MLTC-P1) 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 Area – check all approved counties that apply. For counties awaiting DOH approval, check the county box and indicate as “pending”. : (SMAC Req Matrix #7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie Categories of Dual Eligible Beneficiaries Enrolled (SMAC 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: QMB QI QDWI QMB-Plus FBDE COORDINATION ONLY D-SNP (2) – CMS Contract Code (H#): ___________________________ Contract Name: D-SNP Plan Benefit Package: Plan Name: _______ _ Service Area – check all approved counties that apply: (SMAC Req Matrix #7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Orange Suffolk Cattaraugus Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara Schoharie Categories of Dual Eligible Beneficiaries Enrolled (SMAC 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: QMB QI QDWI

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 Area – check all approved counties that apply: (Sec. For counties awaiting DOH approval, check the county box and indicate as “pending”. 5.11.7) Albany Franklin Xxxxxx Xxxxxxxx Allegany Xxxxxx Onondaga Xxxxxx Bronx Genesee Ontario Steuben Broome Xxxxxx Xxxxxx Orange Suffolk Cattaraugus Xxxxxxxx Hamilton 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 Xxxxxxxxxx St. Xxxxxxxx Wyoming Dutchess Nassau Saratoga Xxxxx Erie New York Schenectady Essex Niagara SchoharieSchoharie 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: QMB QI QDWI QMB-Plus FBDE