APPENDIX X
Exhibit
10.2
APPENDIX
X
Agency
Code 12000 Contract
No. C017720
Period
9/1/05
- 9/30/05 Funding
Amount for Period Based
on approved capitation rates
This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
New York State Department of Health,
having
its principal office at Corning
Tower, Room 0000, Xxxxxx Xxxxx Xxxxx, Xxxxxx XX 00000,
(hereinafter referred to as the STATE), and Wellcare
of New York, Inc.,
(hereinafter referred to as the CONTRACTOR), to modify Contract Number
C017720
as set
forth below. The effective date of these modifications is September 1,
2005.
| 1. |
Paragraph
(b) of section 10.12 Services for Which Enrollees Can Self-Refer
is
amended to read as follows:
|
| b) |
Vision
Services
|
The
Contractor will allow its Enrollee to self-refer to any participating provider
of vision services (optometrist or ophthalmologist) for refractive vision
services as described in Appendix K of this Agreement.
| 2. |
Section
21.5 Payment in Full is amended to read as
follows:
|
Contractor
must limit participation to providers who agree that payment received from
the
Contractor for services included in the Benefit Package is payment in full
for
services provided to Enrollees, except for the collection of applicable
co-payments for Enrollees as provided by law.
| 3. |
The
definition of Covered Services in Appendix K New York State Department
of
Health Family Health Plus Prepaid Benefit Package Definitions of
Covered
and Non-covered Services is amended to read as
follows:
|
The
categories of services in the FHPlus Benefit Package, including optional covered
services, shall be provided by the Contractor to Enrollees when medically
necessary under the terms of this Agreement. The definitions of covered services
herein are in summary form; the full description and scope of each of the FHPlus
covered services are set forth in the applicable NYS Medicaid Provider Manual,
except for the Vision Care benefit for FHPlus Enrollees which is described
in
Appendix K herein.
| 4. |
The
definition of Vision Care in Appendix K New York State Department
of
Health Family Health Plus Prepaid Benefit Package Definitions of
Covered
and Non-covered Services is amended to read as
follows:
|
| A) |
Covered
Services include emergency vision care, and the following preventive
and
routine vision care provided once in any twenty-four (24) month
period:
|
| i) |
one
eye examination;
|
| ii) |
either:
one pair of prescription eyeglass lenses and a frame, or prescription
contact lenses when medically necessary;
and
|
| iii) |
one
pair of medically necessary occupational
eyeglasses.
|
| B) |
An
ophthalmic dispenser fills the prescription of an optometrist or
ophthalmologist and supplies eyeglasses or other vision aids upon
the
order of a qualified practitioner.
|
| C) |
FHPlus
Enrollees may self-refer to any Participating Provider of vision
services
(optometrist or ophthalmologist) for refractive vision services not
more
frequently than once every twenty-four (24)
months.
|
| D) |
If
the Contractor does not provide upgraded frames or additional features
that the Enrollee wants (such as scratch coating, progressive lenses
or
photo-gray lenses) as part of its covered vision benefit, the Contractor
cannot apply the cost of its covered eyeglass benefit to the total
cost of
the eyeglasses the Enrollee wants and bill only the difference to
the
Enrollee. The Enrollee can choose to purchase the upgraded frames
and/or
additional features by paying the entire cost of the eyeglasses as
a
private customer. For example, if the Contractor covers standard
bifocal
eyeglasses and the Enrollee wants no-line bifocal eyeglasses, the
Enrollee
must choose between taking the standard bifocal glasses or paying
the full
price for the no-line bifocal eyeglasses (not just the difference
between
the cost of bifocal lenses and no-line lenses). The Enrollee must
be
informed of this fact by the vision care provider at the time that
the
glasses are ordered.
|
| E) |
Contact
lenses are covered only when medically necessary. Contact lenses
shall not
be covered solely because the FHPlus Enrollee selects contact lenses
in
lieu of receiving eyeglasses.
|
| F) |
Coverage
does not include the replacement of lost, damaged or destroyed
eyeglasses.
|
| G) |
The
occupational vision benefit for FHPlus Enrollees covers the cost
of
job-related eyeglasses if that need is determined by a Participating
Provider through special testing done in conjunction with a regular
vision
examination. Such examination shall determine whether a special pair
of
eyeglasses would improve the performance of job-related activities.
Occupational eyeglasses can be provided in addition to regular glasses
but
are available only in conjunction with a regular vision benefit once
in
any twenty-four (24) month period. FHPlus Enrollees may purchase
an
upgraded frame or lenses for occupational eyeglasses by paying the
entire
cost as a private customer. Sun-sensitive and polarized lens options
are
not available for occupational
eyeglasses.
|
| 5. |
The
attached Appendix L Approved Capitation Rates for the FHPlus Program
is
substituted for the period beginning September 1,
2005.
|
All
other
provisions of said AGREEMENT shall remain in full force and effect.
IN
WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates
appearing under their signatures.
CONTRACTOR
SIGNATURE STATE
AGENCY SIGNATURE
By: /s/
Xxxx X. Xxxxx By: /s/
Xxxxx Xxxxxxxxxx
Xxxx
X. Xxxxx Xxxxx
Xxxxxxxxxx
Printed
Name Printed
Name
Title: President
& Chief Executive Officer Title: Deputy
Director, OMC
Date: 8/11/05 Title: 10/13/05
State
Agency Certification:
In
addition to the acceptance of this contract, I also certify that original copies
of this signature page will be attached to all other exact copies of this
contract.
STATE
OF
FLORIDA )
) SS.:
County
of
Hillsborough )
On
the
11th
day of
August
2005,
before
me personally appeared Xxxx
X. Xxxxx,
to me
known, who being by me duly sworn, did depose and say that he resides at
Tampa,
Florida,
that he
is the President
and CEO
of
Wellcare
of New York ,
the
corporation described herein which executed the foregoing instrument; and that
he signed his name thereto by order of the board of directors of said
corporation.
(Notary)
/s/
Xxxxxxxx X. Xxxxx
STATE
COMPTROLLER’S SIGNATURE Title:
Date:
Appendix
L
Family
Health Plus
Approved
Capitation Payment Rates
For
the
FHPlus Program
FHPlus
Appendix
L
September
1, 2005
WELLCARE
OF NEW YORK, INC.
Family
Health Plus Rates
Effective
September 1, 2005
|
Optional
benefits
covered
|
||||||
|
County
|
Adults
with
Children
19-64
|
Adults
without
Children
19-29
|
Adults
without
Children
30-64
|
Maternity
Kick
|
Family
Planning
|
Dental
|
|
Albany
|
$242.76
|
$301.45
|
$348.82
|
$4,661.82
|
Yes
|
Yes
|
|
Columbia
|
$268.10
|
$299.75
|
$414.05
|
$4,661.82
|
Yes
|
Yes
|
|
Dutchess
|
$217.45
|
$268.25
|
$325.09
|
$4,661.82
|
Yes
|
Yes
|
|
Xxxxxx
|
$268.10
|
$299.75
|
$414.05
|
$4,661.82
|
Yes
|
Yes
|
|
New
York City
|
$202.20
|
$196.86
|
$298.34
|
$4,834.20
|
Yes
|
Yes
|
|
Orange
|
$217.45
|
$268.25
|
$325.09
|
$4,661.82
|
Yes
|
Yes
|
|
Rensselaer
|
$242.76
|
$301.45
|
$348.82
|
$4,661.82
|
Yes
|
Yes
|
|
Rockland
|
$246.82
|
$298.20
|
$318.46
|
$4,661.82
|
Yes
|
Yes
|
|
Ulster
|
$217.45
|
$268.25
|
$325.09
|
$4,661.82
|
Yes
|
Yes
|
