MEDICAID ADVANTAGE CONTRACT ATTESTATION
Exhibit
10.1
I Xxxx
X. Xxxxx being
an
individual authorized to execute agreements on
behalf
of WellCare of New York, Inc. (hereafter "MCO"), hereby attest that
the Medicaid
Advantage contract submitted by MCO to the New York State Department of Health,
follows the latest model Medicaid Advantage contract provided to us by the
New
York State Department of Health. This executed contract contains no deviations
from the aforementioned model contract language.
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2/24/06
(Date)
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/s/
Xxxx X. Xxxxx
(Signature)
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Xxxx
X. Xxxxx
(Print
Name in Full)
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President
and CEO
(Title)
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/s/
Xxxxxxx XxXxxxx
(Notary
Seal and Signature)
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MISCELLANEOUS/CONSULTANT
SERVICES
(Non-Competitive
Award)
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STATE
AGENCY (Name and Address):
New
York State Department of Health Office of Managed Care Empire State
Plaza
Corning Tower, Room 0000
Xxxxxx,
XX 00000
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XXX
Comptroller's Number: C021236
Originating
Agency Code: 12000
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_________________________________
CONTRACTOR
(Name and Address):
WellCare
of New York, Inc.
00
Xxxx 00xx
Xxxxxx
Xxx
Xxxx, Xxx Xxxx 00000
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_________________________________
TYPE
OF PROGRAM:
Medicaid
Advantage
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CHARITIES
REGISTRATION NUMBER:
N/A
FEDERAL
TAX IDENTIFICATION NUMBER:
000000000
MUNICIPALITY
NUMBER (if applicable):
N/A
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CONTRACT
TERM
FROM:
April 1,2006
TO:
December 31,2006
FUNDING
AMOUNT FOR:
Based
on approved capitation rates
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____________________________
STATUS:
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__________________________________________
THIS
CONTRACT IS RENEWABLE FOR FOUR ADDITIONAL ONE YEAR PERIODS SUBJECT
TO THE
APPROVAL OF THE NYS DEPARTMENT OF HEALTH, THE DEPARTMENT OF HEALTH
AND
HUMAN SERVICES AND THE OFFICE OF THE STATE COMPTROLLER.
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CONTRACTOR
IS [ ] IS NOT [X] A SECTARIAN ENTITY
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CONTRACTOR
IS [ ] IS NOT [X] A NOT-FOR-PROFIT ORGANIZATION
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CONTRACTOR
IS [X] IS NOT [ ] ANY
STATE BUSINESS ENTERPRISE
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APPENDICES
TO THIS AGREEMENT AND INCORPORATED BY REFERENCE INTO THE
AGREEMENT
-X-
Appendix A.
New York
State Standard Contract Clauses
-X-
Appendix B.
Certification Regarding Lobbying
-X-
Appendix X-x.
Certification Regarding XxxXxxxx Fair Employment Principles
-X-
Appendix C.
New York
State Department of Health Requirements for Free Access to Family Planning
and
Reproductive Health Services
-X-
Appendix D.
New York
State Department of Health Medicaid Advantage Marketing Guidelines
-X-
Appendix
E. New
York State Department of Health Member Handbook Guidelines
-X-
Appendix F.
New York
State Department of Health Medicaid Advantage Action and Grievance System
Requirements
-X-
Appendix G.
RESERVED
-X-
Appendix H.
New York
State Department of Health Guidelines for the Processing of Medicaid Advantage
Enrollments and Disenrollments
-X-
Appendix I.
RESERVED
-X-
Appendix J.
New York
State Department of Health Guidelines for Contractor Compliance with the Federal
Americans with Disabilities Act
-X-
Appendix K.
Medicare
and Medicaid Advantage Products and Non-Covered Services
-X-
Appendix L.
Approved
Capitation Payment Rates
-X-
Appendix M.
Service
Area
-X-
Appendix N.
RESERVED
-X-
Appendix 0.
Requirements for Proof of Workers' Compensation and Disability Benefits
Coverage
-X-
Appendix P.
RESERVED
-X-
Appendix Q.
RESERVED
-X-
Appendix R.
Additional Specifications for the Medicaid Advantage Agreement
-X-
Appendix X.
Modification Agreement Form
IN
WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT
as
of the dates appearing under their signatures.
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CONTRACTOR
SIGNATURE
By:
/s/
Xxxx X. Xxxxx
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STATE
AGENCY SIGNATURE
By:
/s/
Xxxxx Xxxxxxxxxx
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Xxxx
X. Xxxxx
(print
name)
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Xxxxx
Xxxxxxxxxx
(print
name)
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Title:
President
and Chief Executive Officer
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Title:
Deputy Director, OMC
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Date:
2/24/06
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Date:
3/22/06
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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.
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STATE
OF FLORIDA )
COUNTY
OF HILLSBOROUGH )
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On
the 24
day of February
2006,
before me personally appeared Xxxx
X. Xxxxx ,
to
me known, who being by me duly sworn, did depose and say that he/she
resides at Tampa,
Florida ,
that he/she is the
President and CEO of
WellCare of New York , the
corporation described herein which executed the foregoing instrument;
and
that he/she signed his/her name thereto by order of the board of
directors
of said corporation.
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/s/
Xxxxxxx XxXxxxx
(Notary)
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| ATTORNEY GENERAL'S SIGNATURE |
STATE
COMPTROLLER’S SIGNATURE
___________________________________
|
|
Title:
|
Title
|
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Date
|
Date
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MEDICAID
ADVANTAGE
MODEL
CONTRACT
January
1, 2006
State
Model
Table
of Contents for Medicaid Advantage Model Contract
Recitals
Section
1 Definitions
Section
2
Agreement Term, Amendments, Extensions, and General Contract
Administration
Provisions
2.1 Term
2.2
Amendments
2.3
Approvals
2.4
Entire Agreement
2.5
Renegotiation
2.6
Assignment and Subcontracting
2.7
Termination
a.
SDOH
Initiated Termination
b.
Contractor and SDOH Initiated Termination
c.
Contractor Initiated Termination
d.
Termination Due to Loss of Funding
2.8
Close-Out Procedures
2.9
Rights and Remedies
2.10
Notices
2.11
Severability
Section
3
Compensation
3.1
Capitation Payments
3.2
Modification of Rates During Contract Period
3.3
Rate
Setting Methodology
3.4
Payment of Capitation
3.5
Denial of Capitation Payments
3.6
SDOH
Right to Recover Premiums
3.7
Third
Party Health Insurance Determination
3.8
Contractor Financial Liability
3.9
Tracking Services Provided by Indian Health Clinics
Section
4
Service Area
Section
5
Eligibility For Enrollment in Medicaid Advantage
5.1
Eligible to Enroll in the Medicaid Advantage Program
5.2
Not
Eligible to Enroll
in
the
Medicaid
Advantage Program
5.3
Change in Eligibility Status
Section
6
Enrollment
6.1
Enrollment Requirements
6.2
Equality of Access to Enrollment
6.3
Enrollment Decisions
6.4
Prohibition Against Conditions on Enrollment
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
1
Table
of Contents for Medicaid Advantage Model Contract
6.5
Effective Date of Enrollment
6.6
Contractor Liability
6.7
Roster
6.8
Automatic Re-Enrollment
6.9
Failure to Enroll in Contractor's Medicare Advantage Product
6.10
Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility
6.11
Newborn Enrollment
RESERVED
Disenrollment
8.1
Disenrollment Requirements
8.2
Disenrollment Prohibitions
8.3
Disenrollment Requests
a.
Routine Disenrollment Requests b. Non-Routine Disenrollment
Requests
8.4
Contractor Notification of Disenrollments
8.5
Contractor's Liability
8.6
Enrollee Initiated Disenrollment
8.7
Contractor Initiated Disenrollment
8.8LDSS
Initiated Disenrollment
Guaranteed
Eligibility
9.1
General Requirements
9.2
Right
to Guaranteed Eligibility
9.3
Covered Services During Guaranteed Eligibility
9.4
Disenrollment During Guaranteed Eligibility
Benefit
Package, Covered and Non-Covered Services
10.1
Contractor Responsibilities
10.2
SDOH
Responsibilities
10.3
Benefit Package and Non-Covered Services Descriptions
10.4
Adult Protective Services
10.5
Court-Ordered Services
10.6
Family Planning and Reproductive Health Services
10.7
Emergency and Post Stabilization Care Services
10.8
Medicaid Utilization Thresholds (MUTS)
10.9
Services for Which Enrollees Can Self-Refer
a.
Diagnosis and Treatment of Tuberculosis
b.
Family
Planning and Reproductive Health Services
c.
Article 28 Clinics Operated by Academic Dental Centers
10.10
Coordination with Local Public Health Agencies
10.11
Public Health Services
a.
Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
(TB/DOT)
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
2
Table
of Contents for Medicaid Advantage Model Contract
b.
Immunizations
c.
Prevention and Treatment of Sexually Transmitted Diseases
10.12
Adults with Chronic Illnesses and Physical or Developmental
Disabilities
10.13
Persons Requiring Ongoing Mental Health Services
10.14
Member Needs Relating to HI V
10.15
Persons Requiring Chemical Dependence Services
10.16
Native Americans
10.17
Urgently Needed Services
10.18
Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network
10.19
Coordination of Services
Section
11 Marketing
11.1
Marketing Requirements
Section
12 Member Services
12.1
General Functions
12.2
Translation and Oral Interpretation
12.3
Communicating with the Visually, Hearing and Cognitively Impaired
Section
13 Enrollee Notification
13.1
General Requirements
13.2
Member ID Cards
13.3
Member Handbooks
Section
14 Organization Determinations, Actions, and Grievance System
14.1
General Requirements
14.2
Filing and Modification of Medicaid Advantage Action and Grievance System
Procedures
14.3
Medicaid Advantage Action and Grievance System Additional
Provisions
14.4
Notification of Medicaid Advantage Action and Grievance System
Procedures
14.5
Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
Section
15 Access Requirements
Section
16 Quality Management and Performance Improvement
Section
17 Monitoring and Evaluation
17.1
Right To Monitor Contractor Performance
17.2
Cooperation During Monitoring And Evaluation
17.3
Cooperation During On-Site Reviews
17.4
Cooperation During Review of Services by External Review Agency
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
3
Table
of Contents for Medicaid Advantage Model Contract
Section
18 Contractor Reporting Requirements
18.1
General Requirements
18.2
Time
Frames for Report Submissions
18.3
SDOH
Instructions for Report Submissions
18.4
Liquidated Damages
18.5
Notification of Changes in Report Due Dates, Requirements or
Formats
18.6
Reporting Requirements
18.7
Ownership and Related Information Disclosure
18.8
Public Access to Reports
18.9
Certification Regarding Individuals Who Have Been Debarred or Suspended by
Federal, State or Local Government
18.10
Conflict of Interest Disclosure
18.11
Physician Incentive Plan Reporting
Section
19 Records Maintenance and Audit Rights
19.1
Maintenance of Contractor Performance Records
19.2
Maintenance of Financial Records and Statistical Data
19.3
Access to Contractor Records
19.4
Retention Periods
Section
20 Confidentiality
20.1
Confidentiality of Identifying Information about Enrollees, Eligible Persons
and
Prospective Enrollees
20.2
Confidentiality of Medical Records
20.3
Length of Confidentiality Requirements
Section
21 Participating Providers
21.1
General Requirements
21.2
Medicaid Advantage Network Requirements
21.3
SDOH
Exclusion or Termination of Providers
21.4
Payment in Full
21.5
Dental Networks
Section
22 Subcontracts and Provider Agreements for Medicaid Only Covered
Services
22.1
Written Subcontracts
22.2
Permissible Subcontracts
22.3
Provision of Services Through Provider Agreements
22.4
Approvals
22.5
Required Components
22.6
Timely Payment
22.7
Physician Incentive Plan
Section
23 Americans With Disabilities Act Compliance Plan
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
4
Table
of Contents for Medicaid Advantage Model Contract
Section
24 Fair Hearings
24.1
Enrollee Accessto
Fair
Hearing
Process
24.2
Enrollee Rights to a Fair Hearing
24.3
Contractor Notice to Enrollees
24.4
Aid
Continuing
24.5
Responsibilities of SDOH
24.6
Contractor's Obligations
Section
25 External Appeal
25.1
Basis for External Appeal
25.2
Eligibility for External Appeal
25.3
External Appeal Determination
25.4
Compliance with External Appeal Laws and Regulations
25.5
Member Handbook
Section
26 Intermediate Sanctions
26.1
General
26.2
Unacceptable Practices
26.3
Intermediate Sanctions
26.4
Enrollment Limitations
26.5
Due
Process
Section
27 Environmental Compliance
Section
28 Energy Conservation
Section
29 Independent Capacity of Contractor
Section
30 No Third Party Beneficiaries
Section
31 Indemnification
31.1
Indemnification by Contractor
31.2
Indemnification by SDOH
Section
32 Prohibition on Use of Federal Funds for Lobbying
32.1
Prohibition of Use of Federal Funds for Lobbying
32.2
Disclosure Form to Report Lobbying
32.3
Requirements of Subcontractors
Section
33 Non-Discrimination
33.1
Equal Access to Benefit Package
33.2
Non-Discrimination
33.3
Equal Employment Opportunity
33.4
Native Americans Access to Services From Tribal or Urban Indian Health
Facility
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
5
Table
of Contents for Medicaid Advantage Model Contract
Section
34 Compliance with Applicable Laws and Regulations
34.1
Contractor and SDOH Compliance with Applicable Laws
34.2
Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
34.3
Certificate of Authority Requirements
34.4
Notification of Changes in Certificate of Incorporation
34.5
Contractor's Financial Solvency Requirements
34.6
Non-Liability ofEnrollees for Contractor's Debts
34.7
SDOH
Compliance with Conflict of Interest Laws
34.8
Compliance Plan
Section
35 New York State Standard Contract Clauses
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
6
Table
of
Contents for Medicaid Advantage Model Contract
APPENDICES
A.
New
York State Standard Contract Clauses
B.
Certification Regarding Lobbying
X-x.
Certification Regarding XxxXxxxx Fair Employment Principles
C.
New
York State Department of Health Requirements for Provision of Free Access to
Family Planning and Reproductive Health Services
D.
New
York State Department of HealthMedicaid Advantage Marketing
Guidelines
E.
New
York State Department of Health Medicaid Advantage Model Member Handbook
Guidelines
F.
New
York State Department of Health Medicaid Advantage Action and Grievance Systems
Requirements
G.
RESERVED
H.
New
York State Department of Health Guidelines for the Processing of Medicaid
Advantage Enrollments and Disenrollments
I.
RESERVED
J.
New
York State Department of Health Guidelines of Federal Americans with
Disabilities Act
K.
Medicare and Medicaid Advantage Products and Non-Covered Services
L.
Approved Capitation Payment Rates
M.
Service Area
N.
RESERVED
0.
Requirements for Proof of Workers' Compensation and Disability Benefits
Coverage
P.
RESERVED
Q.
RESERVED
R.
Additional Specifications for the Medicaid Advantage Agreement
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
7
Table
of Contents for Medicaid AdvantageModel
Contract
X. Modification
Agreement Form
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
State
2006
8
This
AGREEMENT is hereby made by and between the New York State Department of Health
(SDOH) and WellCare
of New York, Inc.
(Contractor) located at: 00
Xxxx
00xx
Xxxxxx,
Xxx Xxxx, Xxx Xxxx 00000.
RECITALS
WHEREAS,
pursuant to Title XIX of the Federal Social Security Act, codified as 42 U.S.C.
Section 1396 et seq. (the Social Security Act), and Title 11 of Article 5 of
the
New York State Social Services Law (SSL), codified as SSL Section 363 et seq.,
a
comprehensive program of Medical Assistance for needy persons exists in the
State of New York (Medicaid); and
WHEREAS,
pursuant to Article 44 of the Public Health Law (PHL), the New York State
Department of Health (SDOH) is authorized to issue Certificates of Authority
to
establish Health Maintenance Organizations (HMOs), PHL Section 4400 et seq.,
and
Prepaid Health Services Plans (PHSPs), PHL Section 4403-a; and
WHEREAS,
the State Social Services Law defines Medicaid to include payment of part or
all
of the cost of care and services furnished by an HMO or a PHSP, identified
as
Managed Care Organizations (MCOs) in this Agreement, to Eligible Persons, as
defined in this Agreement, residing in the geographic area specified in Appendix
M (Service Area) when such care and services are furnished in accordance with
an
agreement approved by the SDOH that meets the requirements of federal law and
regulations; and
WHEREAS,
the Contractor is a corporation organized under the laws of New York State
and
is certified under Article 44 of the State Public Health Law or Article 43
of
the NYS Insurance Law; and
WHEREAS,
the Contractor has applied to participate in the Medicaid Managed Care Program
and the SDOH has determined that the Contractor meets the qualification criteria
established for participation; and
WHEREAS,
the Contractor is an entity which has been determined to be an eligible Medicare
Advantage Organization by the Administrator of the Centers for Medicare and
Medicaid Services (CMS) under 42 CFR 422.503; and has entered into a contract
with CMS pursuant to Sections 1851 through 1859 of the Social Security Act
to
operate a coordinated care plan, as described in its final Plan Benefit Package
(PBP) bid submission proposal approved by CMS, in compliance with 42 CFR Part
422 and other applicable Federal statutes, regulations and policies;
and
WHEREAS,
the Contractor is an entity that has amended its contract with CMS to include
an
agreement to offer qualified Medicare Part D coverage pursuant to sections
1860D-1 through 1860D-42 of the Social Security Act and Subpart K of 42 CFR
Part
422 or is a Specialized Medicare Advantage Plan for Special Needs Individuals
which includes qualified Medicare Part D prescription drug coverage;
and
Medicaid
Advantage Contract
RECITALS
State
2006
Page
1 of
2
WHEREAS,
the Contractor offers a comprehensive health services plan and represents that
it is able to make provision for furnishing the Medicare Plan Benefit Package
(Medicare Part C benefit), the Medicare Voluntary Prescription Drug Benefit
(Medicare Part D prescription drug benefit) and the Medicaid Advantage Product
as defined in this Agreement and has proposed to provide coverage of these
products to Eligible Persons as defined in this Agreement residing in the
geographic area specified in Appendix M.
NOW
THEREFORE,
the
parties agree as follows:
Medicaid
Advantage Contract
RECITALS
State
2006
Page
2 of
2
1.
DEFINITIONS
"Capitation
Rate"
means
the fixed monthly amount that the Contractor receives from the State for an
Enrollee to provide that Enrollee with the Medicaid Advantage Benefit
Package.
"Court-Ordered
Services" means those services that the Contractor is required to provide to
Enrollees pursuant to orders of courts of competent jurisdiction, provided
however, that such ordered services are within the Contractor's Medicare and
Medicaid Advantage Benefit Packages.
"Days"
means
calendar days except as otherwise stated.
"Department
of Health and Mental Hygiene" or "DOHMH"
means
the New York City Department of Health and Mental Hygiene.
"Disenrollment"
means
the process by which an Enrollee's membership in the Contractor's Medicaid
Advantage Product terminates.
"Dually
Eligible"
means
eligible for both Medicare and Medicaid.
"Effective
Date of Disenrollment"
means
the date on which an Enrollee is no longer a member of the Contractor's Medicaid
Advantage Product.
"Effective
Date of Enrollment"
means
the date on which an Enrollee is a member of the Contractor's Medicaid Advantage
Product.
"Eligible
Person"
means a
person whom the LDSS, state or federal government determines to be eligible
for
Medicaid and who meets all the other conditions for enrollment in the Medicaid
Advantage Program as set forth in Section 5.1 of this Agreement.
"eMedNY"
means
the electronic Medicaid system of New York State for eligibility verification
and Medicaid provider claim submission and payments.
"Emergency
Medical Condition"
means a
medical or behavioral condition, the onset of which is sudden, that manifests
itself by symptoms of sufficient severity, including severe pain, that a prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to result
in:
(i)
placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition, placing the health of the
person or others in serious jeopardy; or (ii) serious impairment to such
person's bodily functions; or (iii) serious dysfunction of any bodily organ
or
part of such person; or (iv) serious disfigurement of such person.
Medicaid
Advantage Contract
SECTION
1
(DEFINITIONS)
State
2006
1-1
"Emergency Services"
means
covered services that are needed to treat an Emergency Medical Condition.
Emergency services include health care procedures, treatments or services needed
to evaluate or stabilize an Emergency Medical Condition including psychiatric
stabilization and medical detoxification from drugs or alcohol.
"Enrollee"
means an
Eligible Person who, either personally or through an authorized representative,
has enrolled in the Contractor's Medicaid Advantage Product pursuant to Section
6 of this Agreement.
"Enrollment"
means
the process by which an Enrollee's membership in a Contractor's Medicaid
Advantage Product begins.
"Enrollment
Broker"
means
the state and/or county-contracted entity that provides enrollment, education,
and outreach services; effectuates Enrollments and Disenrollments in the
Medicaid Advantage Program; and provides other contracted services on behalf
of
the SDOH and the LDSS.
"Fiscal
Agent"
means
the entity that processes or pays vendor claims on behalf of the
Medicaid
state agency pursuant to an agreement between the entity and such
agency.
"Guaranteed
Eligibility"
means
the period beginning on the Enrollee's Effective Date of Enrollment in the
Contractor's Medicaid Advantage Product and ending six (6) months thereafter,
during which the Enrollee, who remains enrolled in the Contractor's Medicare
Advantage Product, may be entitled to continued enrollment in the Contractor's
Medicaid Advantage Product despite the loss of Medicaid eligibility as set
forth
in Section 9 of this Agreement.
"Health
Provider
Network"
or "HPN" means a closed communication network dedicated to secure data exchange
and distribution of health related information between various health facility
providers and the SDOH. HPN functions include: collection of Medicaid complaint
and disenrollment information; collection of Medicaid financial reports;
collection and reporting of managed care provider networks systems (PNS); and
the reporting of Medicaid encounter data systems (MEDS).
"Local
Department of Social Services"
or
"LDSS"
means a
city or county social services district as constituted by Section 61 of the
SSL.
"Local
Public Health
Agency"
or
"LPHA"
means
the city or county government agency responsible for monitoring the population's
health, promoting the health and safety of the public, delivering public health
services and intervening when necessary to protect the health and safety of
the
public.
"Managed
Care Organization"
or "MCO"
means a health maintenance organization ("HMO") or prepaid health service plan
("PHSP") certified under Article 44 of the New York State PHL.
Medicaid
Advantage Contract
SECTION
1
(DEFINITIONS)
State
2006
1-2
"Marketing"
means
activity of the Contractor, subcontractor or individuals or entities affiliated
with the Contractor, as described in AppendixD,
by which
information about the Contractor is made known to Eligible Persons for the
purpose of persuading such persons to enroll in the Contractor's Medicaid
Advantage Product.
"Marketing
Representative"
means
any individual or entity engaged by the Contractor to market on behalf of the
Contractor.
"Medicaid
Advantage Benefit Package"
means
the services and benefits described in Appendix K-2 of this Agreement, plus
the
CMS approved Medicare supplemental premium for the Medicare Part C benefits
described in Appendix K-l of this Agreement, if any, included in the Capitation
Rate paid to the MCO by the State.
"Medicaid
Advantage Program"
means
the program that the State has developed to enroll persons who are Dually
Eligible in Medicaid managed care pursuant 364-j of the Social Services
Law.
"Medicaid
Advantage Product"
means
the product offered by a qualified MCO to Eligible Persons under this Agreement
as described in Appendix
K--2
of this
Agreement.
"Medicaid
Only
Covered
Services" means those services included in the Medicaid Advantage Benefit
Package that are covered solely by Medicaid and which are not included in the
Contractor's plan Benefit Package Bid submission proposal as approved by
CMS.
"Medical
Record"
means a
complete record of care rendered by a provider documenting the care rendered
to
the Enrollee, including inpatient, outpatient, and emergency care, in accordance
with all applicable federal, state and local laws, rules and regulations. Such
record shall be signed by the medical professional rendering the
services.
"Medically
Necessary",
as
applicable to services that the Contractor determines are a Medicaid only
benefit and to services that the Contractor determines are a benefit under
both
Medicare and Medicaid, means health care and services that are necessary to
prevent, diagnose, manage or treat conditions in the person that cause acute
suffering, endanger life, result in illness or infirmity, interfere with such
person's capacity for normal activity, or threaten some significant
handicap.
"Medicare
Advantage Benefit Package"
means
all the health care services and supplies that are covered by the Contractor's
Medicare Advantage Product including Medicare Part C and qualified Part D
Benefits, on file with CMS, as described in Appendix K-l of this
Agreement.
"Medicare
Advantage Organization"
means a
public or private organization licensed by the State as a risk-bearing entity
that is under contract with CMS to provide the Medicare Advantage Benefit
Package as defined in this Agreement.
Medicaid
Advantage Contract
SECTION
1
(DEFINITIONS)
State
2006
1-3
"Medicare
Advantage Product"
means
the product offered by a qualified MCO to Eligible Persons under this Agreement
as described in Appendix K-l of this Agreement.
"Member
Handbook"
means
the publication prepared by the Contractor and issued to Enrollees to inform
them of their benefits and services, how to access health care services and
to
explain their rights and responsibilities as a Medicaid Advantage
Enrollee.
"Native
American"
means,
for purposes of this Agreement, a person identified in the Medicaid eligibility
system as a Native American.
"Nonconsensual
Enrollment"
means
Enrollment of an Eligible Person, in a Medicaid Advantage Product, without
the
consent of the Eligible Person or consent of a person with the legal authority
to act on behalf of the Eligible Person at the time of Enrollment.
"Non-Participating
Provider"
means a
provider of medical care and/or services with which the Contractor has no
Provider Agreement.
"Participating
Provider"
means a
provider of medical care and/or services that has a Provider Agreement with
the
Contractor.
"Permanent
Placement
Status"
means the status of an individual in a Residential Health Care Facility (RHCF)
when the LDSS determines that the individual is not expected to return home
based upon medical evidence affirming the individual's need for permanent RHCF
placement.
"Physician
Incentive Plan"
or "PIP"
means any compensation arrangement between the Contractor or one of its
contracting entities and a physician or physician group that may directly or
indirectly have the effect of reducing or limiting services furnished to the
Contractor's Enrollees.
"Post-stabilization
Care Services"
means
covered services, related to an Emergency Medical Condition, that are provided
after an Enrollee is stabilized in order to maintain the stabilized condition,
or to improve or resolve the Enrollee's condition.
"Prepaid
Capitation Plan Roster" or "Roster"
means
the enrollment list generated on a monthly basis by SDOH by which LDSS and
Contractor are informed of specifically which Eligible Persons the Contractor
will be serving in the Medicaid Advantage Program for the coming month, subject
to any revisions communicated in writing or electronically by SDOH, LDSS, or
the
Enrollment Broker.
"Prospective
Enrollee"
means
any Eligible Person as defined in this Agreement that has not yet enrolled
in
the Contractor's Medicaid Advantage Product.
Medicaid
Advantage Contract
SECTION
1
(DEFINITIONS)
State
2006
1-4
"Provider
Agreement" means any written contract between the Contractor and a Participating
Provider to provide medical care and/or services to the Contractor's
Enrollees.
"Tuberculosis
Directly Observed Therapy" or "TB/DOT"
means
the direct observation of ingestion of oral TB medications to assure patient
compliance with the physician's prescribed medication regimen.
"Urgently
Needed
Services" means covered services that are not Emergency Services as defined
in
this section, provided when an Enrollee is temporarily absent from the
Contractor's service area when the services are medically necessary and
immediately required: (1) as a result of an unforeseen illness, injury or
condition; and (2) it was not reasonable given the circumstances to obtain
the
services through the Contractor's Participating Providers.
Medicaid
Advantage Contract
SECTION
1
(DEFINITIONS)
State
2006
1-5
2.
AGREEMENT TERM, AMENDMENTS,
EXTENSIONS, AND GENERAL CONTRACT ADMINISTRATION PROVISIONS
2.1
Term
a)
This
Agreement is effective April 1, 2006 and shall remain in effect until December
31, 2006 or until the execution of an extension, renewal or successor Agreement
approved by the SDOH, the Office of the New York State Attorney General (OAG),
the New York State Office of the State Comptroller (OSC), and the US Department
of Health and Human Services (DHHS), and any other entities as required by
law
or regulation, whichever occurs first.
b)
This
Agreement shall not be automatically renewed at its expiration. The parties
to
the Agreement shall have the option to renew this Agreement for four additional
one (1) year terms, subject to the approval of the SDOH, OAG, OSC, DHHS, and
any
other entities as required by law or regulation.
c)
The
maximum duration of this Agreement is five (5) years; provided, however, that
an
extension to this Agreement beyond the five year maximum may be granted for
reasons including, but not limited to, the following:
i.
Negotiations for a successor agreement will not be completed by the expiration
date of the current Agreement; or
ii.
The
Contractor has submitted a termination notice and transition of Enrollees will
not be completed by the expiration date of the current Agreement.
d)
Notwithstanding the foregoing, this Agreement will automatically terminate
in
its entirety should federal financial participation for the Medicaid Advantage
program expire.
2.2
Amendments
a)
This
Agreement may only be modified in writing. Unless otherwise specified in this
Agreement, modifications must be signed by the parties and approved by the
OAG,
OSC and any other entities as required by law or regulation, and approved by
the
DHHS prior to the end of the quarter in which the amendment is to be
effective.
b)
SDOH
will make reasonable efforts to provide the Contractor with notice and
opportunity to comment with regard to proposed amendment of
this
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-1
Agreement
except when provision of advance notice would result in the SDOH being out
of
compliance with state or federal law.
c)
The
Contractor will return the signed amendment or notify the SDOH that it does
not
agree with the terms of the amendment within ten (10) business days of the
date
of the Contractor's receipt of the proposed amendment.
2.3
Approvals
This
Agreement and any amendments to this Agreement shall not be effective or binding
unless and until approved, in writing, by the OAG, OSC, DHHS and any other
entity as required in law or regulation. SDOH will provide a notice of such
approvals to the Contractor.
2.4
Entire Agreement
This
Agreement, including those attachments, schedules, appendices, exhibits, and
addenda that have been specifically incorporated herein and written plans
submitted by the Contractor and maintained on file by SDOH and/or LDSS pursuant
to this Agreement, contains all the terms and conditions agreed upon by the
parties, and no other Agreement, oral or otherwise, regarding the subject matter
of this Agreement shall be deemed to exist or to bind any of the parties or
vary
any of the terms contained in this Agreement. In the event of any inconsistency
or conflict among the document elements of this Agreement, such inconsistency
or
conflict shall be resolved by giving precedence to the document elements in
the
following order:
1)
Appendix A, Standard Clauses for all New York State Contracts;
2)
The
body of this Agreement;
3)
The
appendices attached to the body of this Agreement, other than Appendix
A;
4)
The
Contractor's approved:
i)
Medicaid Advantage Marketing Plan, if applicable, on file with SDOH and
LDSS
ii)
Action and Grievance System Procedures on file with SDOH iii) ADA Compliance
Plan on file with SDOH
2.5
Renegotiation
The
parties to this Agreement shall have the right to renegotiate the terms and
conditions of this Agreement in the event applicable local, state or federal
law, regulations or policy are altered from those existing at the time of this
Agreement in order to be in continuous compliance therewith. This Section shall
not limit the right of the parties to this Agreement from renegotiating or
amending other terms
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-2
and
conditions of this Agreement. Such changes shall only be made with the consent
of the parties and the prior approval of the OAG, OSC, and the
DHHS.
2.6
Assignment and Subcontracting
a)
The
Contractor shall not, without SDOH's prior written consent, assign, transfer,
convey, sublet, or otherwise dispose of this Agreement; of the Contractor's
right, title, interest, obligations, or duties under the Agreement;
of
the
Contractor's power to execute the Agreement; or, by power of attorney or
otherwise, of any of the Contractor's rights to receive monies due or to become
due under this Agreement. SDOH agrees that it will not unreasonably withhold
consent of the Contractor's assignment of this Agreement, in whole or in part,
to a parent, affiliate or subsidiary corporation, or to a transferee of all
or
substantially all of its assets. Any assignment, transfer, conveyance, sublease,
or other disposition without SDOH's consent shall be void.
b)
Contractor may not enter into any subcontracts related to the delivery of
Medicaid Only Covered services to Enrollees, except by written agreement, as
set
forth in Section 22 of this Agreement. The Contractor may subcontract for
provider services and management services. If such written agreement would
be
between Contractor and a provider of health care or ancillary health services
or
between Contractor and an independent practice association, the agreement must
be in a form previously approved by SDOH. If such subcontract is for management
services under 10 NYCRR Part 98, it must be approved by SDOH prior to becoming
effective. Any subcontract entered into by Contractor shall fulfill the
requirements of 42 CFR Parts 434 and 438 to the extent such regulations are
or
become effective that pertain to the service or activity delegated under such
subcontract. Contractor agrees that it shall remain legally responsible to
SDOH
for carrying out all activities under this Agreement and that no subcontract
shall limit or terminate Contractor's responsibility.
2.7
Termination
a)
SDOH
Initiated Termination
i)
SDOH
shall have the right to terminate this Agreement, in whole or in part if the
Contractor:
A)
takes
any action that threatens the health, safety, or welfare of its
Enrollees;
B)
has
engaged in an unacceptable practice under 18 NYCRR, Part 515, that affects
the
fiscal integrity of the Medicaid program or engaged in an unacceptable practice
pursuant to Section 26.2 of this Agreement;
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-3
C)
has
its Certificate of Authority suspended, limited or revoked by SDOH;
D)
materially breaches the Agreement or fails to comply with any term or condition
of this Agreement that is not cured within twenty (20) days, or to such longer
period as the parties may agree, ofSDOH's written request for
compliance;
E)
becomes insolvent;
F)
brings
a proceeding voluntarily, or has a proceeding brought against it involuntarily,
under Title 11 of the U.S. Code (the Bankruptcy Code);
G)
knowingly has a director, officer, partner or person owning or controlling
more
than five percent (5%) of the Contractor's equity, or has an employment,
consulting, or other agreement with such a person for the provision of items
and/or services that are significant to the Contractor's contractual obligation
who has been debarred or suspended by the federal, state or local government,
or
otherwise excluded from participating in procurement activities; or
H)
terminates or fails to renew its contract with CMS pursuant to Sections 1851
through 1859 of the Social Security Act to offer the Medicare Advantage Product,
including Medicare Part C benefits as defined in this Agreement and qualified
Medicare Part D benefits, to Eligible Persons residing in the service area
specified in Appendix M. In such instances, the Contractor shall notify the
SDOH
of the termination or failure to renew the contract with CMS immediately upon
knowledge of the impending termination or failure to renew.
ii)
The
SDOH will notify the Contractor of its intent to terminate this Agreement for
the Contractor's failure to meet the requirements of this Agreement and provide
Contractor with a hearing prior to the termination.
iii)
If
SDOH suspends, limits or revokes Contractor's Certificate of Authority under
PHL
§ 4404, and:
A.
If
such action results in the Contractor ceasing to have authority to serve the
entire contracted service area, as defined by Appendix M of this Agreement,
this
Agreement shall terminate on the date the Contractor ceases to have such
authority; or
B.
If
such action results in the Contractor retaining authority to serve some portion
of the contracted service area, the Contractor shall continue to offer its
Medicaid Advantage Product under this Agreement in any designated geographic
area not affected by such action, and shall terminate its Medicaid Advantage
Product in the geographic areas where the Contractor ceases to have authority
to
serve.
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-4
iv)
No
hearing will be required if this Agreement terminates due to SDOH suspension,
limitation or revocation of the Contractor's Certificate of
Authority.
v)
Prior
to the effective date of the termination the SDOH shall notify Enrollees of
the
termination, or delegate responsibility for such notification to the Contractor,
and such notice shall include a statement that Enrollees may disenroll
immediately from the Contractor's Medicaid Advantage Product.
b)
Contractor and SDOH Initiated Termination
i)
The
Contractor and the SDOH each shall have the right to terminate this Agreement
in
the event that SDOH and the Contractor fail to reach .agreement on the monthly
Capitation Rates.
ii)
The
Contractor and the SDOH shall each have the right to terminate this Agreement
in
the event the Contractor terminates or fails to renew its contract with CMS
to
offer the Medicare Advantage Product, as defined in this Agreement, to Eligible
Persons in the service area as specified in Appendix M.
iii)
In
such events, the party exercising its right shall give the other party written
notice specifying the reason for and the effective date of termination, which
shall not be less time than will permit an orderly disenrollment of Enrollees
from the Contractor's Medicaid Advantage Product. However, in the event that
this Agreement is terminated due to the Contractor's failure to renew its
contract with CMS to offer the Medicare Advantage Product, or that the
Contractor's Medicare Advantage contract with CMS otherwise expires or
terminates, this Agreement shall terminate on the effective date of the
termination of the Contractor's contract with CMS.
c)
Contractor Initiated Termination
i)
The
Contractor shall have the right to terminate this Agreement in the event that
SDOH materially breaches the Agreement or fails to comply with any term or
condition of this Agreement that is not cured within twenty (20) days, or to
such longer period as the parties may agree, of the Contractor's written request
for compliance. The Contractor shall give SDOH written notice specifying the
reason for and the effective date of the termination, which shall not be less
time than will permit an
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS, AND
GENERAL
CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-5
orderly
disenrollment of Enrollees from the Contractor's Medicaid Advantage
Product.
ii)
The
Contractor shall have the right to terminate this Agreement in the event that
its obligations are materially changed by modifications to this Agreement and
its Appendices by SDOH. In such event, Contractor shall give SDOH written notice
within thirty (30) days of notification of changes to the Agreement or
Appendices specifying the reason and the effective date of termination, which
shall not be less time than will permit an orderly disenrollment of Enrollees
from the Contractor's Medicaid Advantage Product.
iii)
The
Contractor shall have the right to terminate this Agreement in its entirety
or
in specified counties of the Contractor's service area if the Contractor is
unable to provide the Medicaid Advantage Benefit Package pursuant to this
Agreement because of a natural disaster and/or an act of God to such a degree
that Enrollees cannot obtain reasonable access to Medicaid Only Covered Services
within the Contractor's organization, and, after diligent efforts, the
Contractor cannot make other provisions for the delivery of such services.
The
Contractor shall give SDOH written notice of any such termination that
specifies:
A)
the
reason for the termination, with appropriate documentation of the circumstances
arising from a natural disaster and/or an act of God that preclude reasonable
access to services;
B)
the
Contractor's attempts to make other provision for the delivery of Medicaid
Only
Covered Services; and
C)
the
effective date of the termination, which shall not be less time than will permit
an orderly disenrollment of Enrollees from the Contractor's Medicaid Advantage
Product.
d)
Termination Due To Loss of Funding
In
the
event that State and/or Federal funding used to pay for services under this
Agreement is reduced so that payments cannot be made in full, this Agreement
shall automatically terminate, unless both parties agree to a modification
of
the obligations under this Agreement. The effective date of such termination
shall be ninety (90) days after the Contractor receives written notice of the
reduction in payment, unless available funds are insufficient to continue
payments in full during the ninety (90) day period, in which case SDOH shall
give the Contractor written notice of the earlier date upon which the Agreement
shall terminate. A reduction in State and/or Federal funding cannot reduce
monies due and owing to the Contractor on or before the effective date of the
termination of the Agreement.
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-6
2.8
Close-Out Procedures
a)
Upon
termination or expiration of this Agreement, in its entirety or in specific
counties in the Contractor's service area, and in the event that it is not
scheduled for renewal, the Contractor shall comply with close-out procedures
that the Contractor develops in conjunction with LDSS and that the LDSS, and
the
SDOH have approved. The close-out procedures shall include the
following:
i)
The
Contractor shall promptly account for and repay funds advanced by SDOH for
coverage of Enrollees for periods subsequent to the effective date of
termination;
ii)
The
Contractor shall give SDOH, and other authorized federal, state or local
agencies access to all books, records, and other documents and upon request,
portions of such books, records, or documents that may be required by such
agencies pursuant to the terms of this Agreement;
iii)
The
Contractor shall submit to SDOH, and other authorized federal, state or local
agencies, within ninety (90) days of termination, a final financial statement
and audit report relating to this Agreement, made by a certified public
accountant, unless the Contractor requests of SDOH and receives written approval
from SDOH and all other governmental agencies from which approval is required,
for an extension of time for this submission;
iv)
The
Contractor shall establish an appropriate plan acceptable to and prior approved
by the SDOH for the orderly disenrollment of Enrollees from the Contractor's
Medicaid Advantage Product;
v)
SDOH
shall promptly pay all claims and amounts owed to the Contractor.
b)
Any
termination of this Agreement by either the Contractor or SDOH shall be done
by
amendment to this Agreement, unless the Agreement is terminated by the SDOH
due
to conditions in Section 2.7 (a)(i) or Appendix A of this
Agreement.
2.9
Rights and Remedies
The
rights and remedies of SDOH and the Contractor provided expressly in this
Article shall not be exclusive and are in addition to all other rights and
remedies provided by law or under this Agreement.
Medicaid
Advantage Contract SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-7
2.10
Notices
All
notices to be given under this Agreement shall be in writing and shall be deemed
to have been given when mailed to, or, if personally delivered, when received
by
the Contractor and the SDOH at the following addresses:
For
SDOH:
New
York
State Department of Health Empire State Plaza Corning Tower, Rm. 0000 Xxxxxx,
XX
00000-0065
For
the
Contractor:
Chief
Executive Officer WellCare of New York, Inc. 00 Xxxx 00xx
Xxxxxx
Xxx Xxxx, Xxx Xxxx 00000
2.11 Severability
If
this
Agreement contains any unlawful provision that is not an essential part of
this
Agreement and that was not a controlling or material inducement to enter into
this Agreement, the provision shall have no effect and, upon notice by either
party, shall be deemed stricken from this Agreement without affecting the
binding force of the remainder of this Agreement.
Medicaid
Advantage Contract
SECTION
2
(AGREEMENT
TERM, AMENDMENTS, EXTENSIONS,
AND
GENERAL CONTRACT ADMINISTRATION PROVISIONS)
State
2006
2-8
3.
COMPENSATION
3.1
Capitation Payments
a)
Compensation to the Contractor shall consist of a monthly capitation payment
for
each Enrollee as described in this Section.
b)
The
monthly Capitation Rates are attached hereto as Appendix L and shall be deemed
incorporated into this Agreement without further action by the
parties.
c)
The
monthly capitation payments to the Contractor shall constitute full and complete
payments to the Contractor for all services that the Contractor provides
pursuant to this Agreement.
d)
Capitation Rates shall be effective for the entire contract period, except
as
described in Section 3.2.
3.2
Modification of Rates During Contract Period
Modification
to Capitation Rates during the term of this Agreement shall be subject to
approval by the New York State Division of the Budget (DOB) and shall be-
incorporated into this Agreement by written amendment mutually agreed upon
by
the SDOH and the Contractor, as specified in Section 2.2 of this
Agreement.
3.3
Rate
Setting Methodology
a)
Capitation Rates shall be determined prospectively and shall not be
retroactively adjusted to reflect actual fee-for-service data or plan experience
for the time period covered by the rates.
b)
Capitated rates in effect as of April 1, 2006 and thereafter, shall be certified
to be actuarially sound in accordance with 42 CFR § 438.6 (c ).
c)
Notwithstanding the provisions set forth in Section 3.3 (a) and (b) above,
the
SDOH reserves the right to terminate this Agreement in its entirety, or for
specified counties of the Contractor's service area, pursuant to Section 2.7
of
this Agreement, upon determination by SDOH that the aggregate monthly Capitation
Rates are not cost effective.
3.4
Payment of Capitation
a)
The
monthly capitation payments for each Enrollee are due to the Contractor from
the
Effective Date of Enrollment until the Effective Date of Disenrollment of the
Enrollee or termination of this Agreement, whichever occurs first. The
Contractor shall receive a full month's capitation payment
Medicaid
Advantage Contract
SECTION
3
(COMPENSATION)
State
2006
3-1
for
the
month in which Disenrollment occurs. The Roster generated by SDOH with any
modification communicated electronically or in writing by the LDSS or the
Enrollment Broker prior to the end of the month in which the Roster is
generated, shall be the Enrollment list for purposes of eMedNY premium billing
and payment, as discussed in Section 6.7 and Appendix H of this
Agreement.
b)
Upon
receipt by the Fiscal Agent of a properly completed claim for monthly capitation
payments submitted by the Contractor pursuant to this Agreement, the Fiscal
Agent will promptly process such claim for payment and use its best efforts
to
complete such processing within thirty (30) business days from date of receipt
of the claim by the Fiscal Agent. Processing of Contractor claims shall be
in
compliance with the requirements of 42 CFR 447.45. The Fiscal Agent will also
use its best efforts to resolve any billing problem relating to the Contractor's
claims as soon as possible. In accordance with Section 41 of the State Finance
Law, the State and LDSS shall have no liability under this Agreement to the
Contractor or anyone else beyond funds appropriated and available for this
Agreement.
3.5
Denial of Capitation Payments
If
the
Centers for Medicare and Medicaid Services (CMS) denies payment for new
Enrollees, as authorized by SSA § 1903(m)(5) and 42 CFR § 438.730 (e), or such
other applicable federal statutes or regulations, based upon a determination
that Contractor failed substantially to provide medically necessary items and
services, imposed premium amounts or charges in excess of permitted payments,
engaged in discriminatory practices as described in SSA § 1932(e)(l)(A)(iii),
misrepresented or falsified information submitted to CMS, SDOH, LDSS, the
Enrollment Broker, or an Enrollee, Prospective Enrollee, or health care
provider, or failed to comply with federal requirements (i.e. 42 CFR § 422.208
and 42 CFR § 438.6 (h)) relating to the Physician Incentive Plans, SDOH and LDSS
will deny capitation payments to the Contractor for the same Enrollees for
the
period of time for which CMS denies such payment.
3.6
SDOH
Right to Recover Premiums
The
parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month, to have been disenrolled
from the Contractor's Medicare Advantage Product; to have been in an
institution; to have been incarcerated; to have moved out of the Contractor's
service area subject to any time remaining in the Enrollee's Guaranteed
Eligibility period; or to have died. In any event, the State may only recover
premiums paid for Medicaid Enrollees listed on a Roster if it is determined
by
the SDOH that the Contractor was not at risk for provision of Benefit Package
services for any portion of the payment period.
Medicaid
Advantage Contract
SECTION
3
(COMPENSATION)
State
2006
3-2
3.7
Third
Party Health Insurance Determination
The
Contractor will make diligent efforts to determine whether Enrollees have third
party health insurance (TPHI). The LDSS is also responsible for making diligent
efforts to determine if Enrollees have TPHI and to maintain third party
information on the Welfare Management System (WMS)/eMedNY Third Party Resource
System. The Contractor shall make good faith efforts to coordinate benefits
with
and collect TPHI recoveries from other insurers, and must inform the LDSS of
any
known changes in status of TPHI insurance eligibility within thirty (30) days
of
learning of a change in TPHI. The Contractor may use the Roster as one method
to
determine TPHI information. The Contractor will be permitted to retain one
hundred percent (100%) of any reimbursement for Benefit Package services
obtained from TPHI. Capitation Rates are net of TPHI recoveries. In no instances
may an Enrollee be held responsible for disputes over these
recoveries.
3.8
Contractor Financial Liability
Contractor
shall not be financially liable for any services rendered to an Enrollee prior
to his or her Effective Date of Enrollment in the Contractor's Medicaid
Advantage Product.
3.9
Tracking Services Provided by Indian Health Clinics
The
SDOH
shall monitor all services provided by tribal or Indian health clinics or urban
Indian health facilities or centers to enrolled Native Americans, so that the
SDOH can reconcile payment made for those services, should it be deemed
necessary to do so.
Medicaid
Advantage Contract
SECTION
3
(COMPENSATION)
State
2006
3-3
4.
SERVICE AREA
The
Service Area described in Appendix M of this Agreement, which is hereby made
a
part of this Agreement as if set forth fully herein, is the specific geographic
area within which Eligible Persons must reside to enroll in the Contractor's
Medicaid Advantage Product.
Medicaid
Advantage Contract
SECTION
4
(SERVICE
AREA)
State
2006
4-1
5.
ELIGIBILITY FOR ENROLLMENT IN MEDICAID ADVANTAGE
5.1
Eligible to Enroll in the Medicaid Advantage Program
a)
Except
as specified in Section 5.2, persons meeting the following criteria shall be
eligible to enroll in the Contractor's Medicaid Advantage Product:
i)
Must
have full Medicaid coverage or full Medicaid coverage with Qualified Medicare
Beneficiary (QMB) eligibility;
ii)
Must
have evidence of Medicare Part A & B coverage; or be enrolled • in Medicare
Part C coverage;
iii)
Must
reside in the service area as defined in Appendix M of this
Agreement;
iv)
Must
be 21 years of age or older; and
v)
Must
enroll in the Contractor's Medicare Advantage Product as defined in Section
1
and Appendix K-l of this Agreement.
b)
Participation in the Medicaid Advantage Program and enrollment in the
Contractor's Medicaid Advantage Product shall be voluntary for all Eligible
Persons.
5.2
Not
Eligible to Enroll in the Medicaid Advantage Program
Persons
meeting the following criteria are not eligible to enroll in the Contractor's
Medicaid Advantage Product:
a)
Individuals who are medically determined to have End Stage Renal Disease (ESRD)
at the time of enrollment, unless such individuals meet the exceptions to
Medicare Advantage eligibility rules for persons who have ESRD as found in
Section 20.2.2 of the Medicare Managed Care Manual.
b)
Individuals who are only eligible for the Qualified Medicare Beneficiary (QMB),
Specified Low Income Medicare Beneficiary (SLIMB) or the Qualified Individual-1
(QI-1) and are not otherwise eligible for Medical Assistance.
c)
Individuals who become eligible for Medical Assistance only after spending
down
a portion of their income.
Medicaid
Advantage Contract
SECTION
5
(ELIGIBLE,
EXEMPT AND EXCLUDED POPULATIONS)
State
2006
5-1
d)
Individuals who are residents of State-operated psychiatric facilities or
residents of State-certified or voluntary treatment facilities for children
and
youth.
e)
Individuals who are residents of Residential Health Care Facilities ("RHCF")
at
the time of Enrollment, and Enrollees whose stay in a RHCF is classified as
permanent upon entry into the RHCF or is classified as permanent at a time
subsequent to entry.
f)
Individuals enrolled in managed long term care demonstrations authorized under
Article 4403-fofthe New York State PHL.
g)
Individuals with access to comprehensive private health care coverage, except
for Medicare, including those already enrolled in an MCO. Such health care
coverage purchased either partially or in full, by or on•behalf of the
individual, must be determined to be cost effective by the , local social
services district.
h)
Individuals expected to be eligible for Medicaid for less than six (6) "months,
except for pregnant women (e.g., seasonal agricultural•workers).
i)
Individuals in receipt of long-term care services through Long Term Home Health
Care programs (except ICF services for the ,Developmentally
Disabled).
j)
Individuals eligible for Medical Assistance benefits only with respect to TB
related services.
k)
Individuals placed in State Office of Mental Health licensed family care homes
pursuant to NYS Mental Hygiene Law, Section 31.03.
1)
Individuals enrolled in the Restricted Recipient Program.
m)
Individuals with a "County of Fiscal Responsibility" code of 99.
n)
Individuals admitted to a Hospice program prior to time of enrollment (if an
Enrollee enters a Hospice program while enrolled in the Contractor's plan,
he/she may remain enrolled in the Contractor's plan to maintain continuity
of
care with his/her PCP).
o)
Individuals with a "County of Fiscal Responsibility" code of 97 (OMH in
eMedNY).
Medicaid
Advantage Contract
SECTION
5
(ELIGIBLE,
EXEMPT AND EXCLUDED POPULATIONS)
State
2006
5-2
p)
Individuals with a "County of Fiscal Responsibility" code of 98 (OMRDD in
eMedNY) will be excluded until program features are approved by the State and
operational at the local district level to permit these individuals to
voluntarily enroll in Medicaid managed care.
q)
Individuals receiving family planning services pursuant to Section 366(l)(a)(ll)
of the Social Services Law who are not otherwise eligible for medical assistance
and whose net available income is 200% or less of the federal poverty
level.
r)
Individuals who are eligible for Medical Assistance pursuant to the "Medicaid
buy-in for the working disabled" (subparagraphs twelve or thirteen of paragraph
(a) of subdivision one of Section 366 of the Social Services Law), and who,
pursuant to subdivision 12 of Section 367-a of the Social Services Law, are
required to pay a premium.
s)
Individuals who are eligible for Medical Assistance pursuant to paragraph (v)
of
subdivision four of Section 366 of the Social Services Law (persons who are
under 65 years of age, have been screened for breast and/or cervical cancer
under the Centers for Disease Control and Prevention Breast and Cervical Cancer
Early Detection Program and need treatment for breast or cervical cancer, and
are not otherwise covered under creditable coverage as defined in the Federal
Public Health Service Act).
5.3
Change in Eligibility Status
a)
The
Contractor must report to the LDSS any change in status of its Enrollees, which
may impact the Enrollee's eligibility for Medicaid or Medicaid Advantage, within
five (5) business days of such information becoming known to the Contractor.
This information includes, but is not limited to: change of address;
incarceration; permanent placement in a nursing home or other residential
institution or program rendering the individual ineligible for enrollment in
Medicaid Advantage; death; and disenrollment from the Contractor's Medicare
Advantage Product as defined in this Agreement.
b)
To the
extent practicable, the LDSS will follow-up with Enrollees when the Contractor
provides documentation of any change in status which may affect the Enrollee's
Medicaid and/or Medicaid Advantage plan eligibility and enrollment.
Medicaid
Advantage Contract SECTION
5
(ELIGIBLE,
EXEMPT AND EXCLUDED POPULATIONS)
State
2006
5-3
6.
ENROLLMENT
6.1
Enrollment Requirements
The
LDSS
and the Contractor agree to conduct enrollment of Eligible Persons in accordance
with the policies and procedures set forth in Appendix H of this Agreement,
which is hereby made a part of this Agreement as if set forth fully
herein.
6.2
Equality of Access to Enrollment
The
Contractor shall accept Enrollments of Eligible Persons in the order in which
they are received without restriction and without regard to the Eligible
Person's age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services or to the Capitation Rate that the Contractor will
receive for such Eligible Person.
6.3
Enrollment Decisions
An
Eligible Person's decision to enroll in the Contractor's Medicaid Advantage
Product shall be voluntary. However, as a condition of eligibility for Medicaid
Advantage, individuals may only enroll in the Contractor's Medicaid Advantage
Product if they also enroll in the Contractor's Medicare Advantage Product
as
defined in this Agreement.
6.4
Prohibition Against Conditions on Enrollment
Unless
otherwise required by law or this Agreement, neither the Contractor nor LDSS
shall condition any Eligible Person's enrollment in the Medicaid Advantage
Program upon the performance of any act or suggest in any way that failure
to
enroll may result in a loss of Medicaid benefits.
6.5
Effective Date of Enrollment
a)
At the
time of Enrollment, the Contractor and the LDSS must notify the Enrollee of
the
expected Effective Date of Enrollment.
b)
To the
extent practicable, such notification must precede the Effective Date of
Enrollment.
c)
In the
event that the actual Effective Date of Enrollment changes, the Contractor
and
the LDSS must notify the Enrollee of the change.
Medicaid
Advantage Contract
SECTION
6
(ENROLLMENT)
State
2006
6-1
d)
An
Enrollee's Effective Date of Enrollment shall be the first day of the month
on
which the Enrollee's name appears on the Prepaid Capitation Plan Roster and
is
enrolled in the Contractor's Medicare Advantage Product for that
month.
6.6
Contractor Liability
As
of the
Effective Date of Enrollment, and until the Effective Date of Disenrollment
from
the Contractor's product, the Contractor shall be responsible for the provision
and cost of the Medicaid Advantage Benefit Package as described in Appendix
K-2
of this Agreement for Enrollees whose names appear on the Prepaid Capitation
Plan Roster.
6.7
Roster
a)
The
first and second monthly Rosters generated by SDOH in combination shall serve
as
the official Contractor enrollment list for purposes of eMedNY premium billing
and payment, subject to ongoing eligibility of the Enrollees as of the first
(1st)
day of
the Enrollment month. Modifications to the Roster may be made electronically
or
in writing by the LDSS or the Enrollment Broker. If the LDSS or Enrollment
Broker notifies the Contractor in writing or electronically of changes in the
Roster and provides supporting information as necessary prior to the effective
date of the Roster, the Contractor will accept that notification in the same
manner as the Roster.
b)
The
LDSS is responsible for making data on eligibility determinations available
to
the Contractor and SDOH to resolve discrepancies that may arise between the
Roster and the Contractor's enrollment files in accordance with the provisions
in Appendix H of this Agreement.
c)
All
Contractors must have the ability to receive these Rosters
electronically.
6.8
Automatic Re-Enrollment
An
Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product
due
to loss of Medicaid eligibility and who regains eligibility within a three
(3)
month period will be automatically prospectively re-enrolled in the Contractor's
Medicaid Advantage Product, provided that the individual remains enrolled in
the
Contractor's Medicare Advantage Product as defined in this Agreement
unless:
Medicaid
Advantage Contract
SECTION
6
(ENROLLMENT)
State
2006
6-2
i)
the
Contractor does not offer a Medicaid Advantage product in the Enrollee's county
of fiscal responsibility; or
ii)
the
Enrollee indicates in writing that he/she wishes to enroll in another MCO's
Medicaid and Medicare Advantage Products, or receive Medicaid coverage through
Medicaid fee-for-service.
6.9
Failure to Enroll in the Contractor's Medicare Advantage Product
If
an
Enrollee's enrollment in the Contractor's Medicare Advantage Product is rejected
by CMS, the Contractor must notify the local social services district within
five (5) business days of learning of CMS' rejection of the enrollment. In
such
instances, the LDSS shall delete the Enrollee's enrollment in the Contractor's
Medicaid Advantage Product retroactive to the Effective Date of
Enrollment.
6.10
Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility
Medicaid
managed care enrollees who will gain Medicare coverage may elect to transfer
to
the Contractor's Medicaid and Medicare Advantage Products or to enroll in
another MCO's Medicaid and Medicare Advantage Products for dually eligible
individuals. A new enrollment must be processed by the LDSS or the Enrollment
Broker to transfer a member of the Contractor's Medicaid managed care product
to
the Contractor's Medicaid Advantage Product. To the extent possible, such
enrollments shall be made effective the first day of the month that the
Enrollee's Medicare Advantage coverage is effective.
6.11
Newborn Enrollment
a)
A
pregnant Enrollee in the Contractor's Medicaid Advantage Product may choose
to
pre-enroll her unborn in any available Medicaid managed care health plan in
the
social services district in which she resides.
b)
The
Contractor shall notify the local district in writing of any enrollee that
is
pregnant within 30 days of knowledge of the pregnancy. Notification shall
include the pregnant woman's name, CIN, and expected date of
confinement.
c)
Upon
the newborn's birth, the Contractor must send identification of the infant's
demographic data to the LDSS within 5 days after knowledge of the birth. The
demographic data must include the mother's name and CIN, the newborn's name
and
CIN (if available), sex and the date of birth.
d)
The
SDOH and LDSS shall be responsible for ensuring that timely Medicaid eligibility
determination and Enrollment of the newborn is effected consistent
Medicaid
Advantage Contract
SECTION
6
(ENROLLMENT)
State
2006
6-3
with
state laws, regulations, and policy with the newborn Enrollment requirements
set
forth in Appendix H of this Agreement.
Medicaid
Advantage Contract
SECTION
6
(ENROLLMENT)
State
2006
6-4
7. RESERVED
Medicaid
Advantage Contract
SECTION
7
(LOCK-IN
PROVISIONS)
State
2006
7-1
8.
DISENROLLMENT
8.1
Disenrollment Requirements
a)
The
Contractor agrees to conduct Disenrollment of an Enrollee in accordance with
the
policies and procedures for Disenrollment set forth in Appendix H of this
Agreement.
b)
LDSSs
are responsible for making the final determination concerning Disenrollment
requests.
8.2
Disenrollment Prohibitions
Enrollees
shall not be disenrolled from the Contractor's Medicaid Advantage Product based
on any of the following reasons:
i)
an
existing condition or a change in the Enrollee's health which would necessitate
disenrollment pursuant to the terms of this Agreement, unless the change results
in the Enrollee becoming ineligible for Medicaid Advantage enrollment as
described in Section 5 of this Agreement;
ii)
any
of the factors listed in Section 33 (Non-Discrimination) of this Agreement;
or
iii)
the
Capitation Rate payable to the Contractor.
8.3
Disenrollment Requests
a)
Routine Disenrollment Requests
The
LDSS
or the Enrollment Broker is responsible for processing routine Disenrollment
requests to take effect on the first (1st)
day of
the next month, to the extent possible. In no event shall the Effective Date
of
Disenrollment be later than the first (1st)
day of
the second (2nd)
month
after the month in which an Enrollee requests a Disenrollment.
b)
Non-Routine Disenrollment Requests
i)
Enrollees with an urgent medical need to disenroll from the Contractor's
Medicaid Advantage Product may request an expedited Disenrollment by the LDSS.
Enrollees who have HIV, ESRD or SPMI/SED status are categorically eligible
for
expedited Disenrollment on the basis of urgent medical need.
ii)
Enrollees with a complaint of Non-consensual Enrollment may request an expedited
Disenrollment by the LDSS.
Medicaid
Advantage Contract
SECTION
8
(DISENROLLMENT)
State
2006
8-1
iii)
Homeless Enrollees residing in the shelter system may request an expedited
disenrollment by the LDSS.
iv)
An
expedited Disenrollment from the Contractor's Medicaid Advantage Product may
also be warranted in instances when the LDSS leams that an Enrollee is
disenrolling from the Contractor's Medicare Advantage Product. In such
instances, the LDSS will disenroll the individual effective concurrent with
the
Effective Date of Disenrollment from the Contractor's Medicare Advantage
Product.
v)
Retroactive Disenrollments from the Contractor's Medicaid Advantage Product
may
be warranted in rare instances and may be • requested of the LDSS as described
in Appendix H of this Agreement.
vi)
Substantiation of non-routine Disenrollment requests by the LDSS will result
in
Disenrollment in accordance with the timeframes as : set forth in Appendix
H of
this Agreement.
8.4
Contractor Notification of Disenrollments
a)
Notwithstanding anything herein to the contrary, the Roster, along with any
changes sent by the LDSS to the Contractor in writing or electronically, shall
serve as official notice to the Contractor of Disenrollment of an Enrollee.
In
cases of expedited and retroactive Disenrollment, the Contractor shall be
notified of the Enrollee's Effective Date of Disenrollment by the
LDSS.
b)
In the
event that the LDSS intends to retroactively disenroll an Enrollee on a date
prior to the first day of the month of the disenrollment request, the LDSS
shall
consult with the Contractor prior to Disenrollment. Such consultation shall
not
be required in cases where it is clear that the Contractor was not a risk for
the provision of the Medicaid Advantage Benefit Package for any portion of
the
retroactive period.
c)
In all
cases of retroactive Disenrollment, including Disenrollments effective the
first
day of the current month, the LDSS is responsible for notifying the Contractor
at the time of Disenrollment, of the Contractor's responsibility to submit
to
the SDOH's Fiscal Agent voided premium claims for any months of retroactive
Disenrollment where the Contractor was not at risk for the provision of the
Medicaid Advantage Benefit Package during the month.
8.5
Contractor's Liability
a)
The
Contractor is not responsible for providing the Medicaid Advantage Benefit
Package under this Agreement after the Effective Date of
Disenrollment.
Medicaid
Advantage Contract
SECTION
8
(DISENROLLMENT)
State
2006
8-2
8.6
Enrollee Initiated Disenrollment
An
Enrollee may disenroll from the Contractor's Medicaid Advantage Plan for any
reason. Disenrollments generally shall be effective on the first of the month
following receipt of the complete written Disenrollment request.
8.7
Contractor Initiated Disenrollment
a)
The
Contractor must notify the LDSS and initiate an Enrollee's Disenrollment from
the Contractor's Medicaid Advantage Product in the following cases:
i)
A
change in residence makes the Enrollee ineligible to be a member of the
plan;
ii)
The
Enrollee disenrolls from the Contractor's Medicare Advantage Product as defined
in this Agreement;
iii)
The
Enrollee dies;
iv)
The
Enrollee's status changes such that he/she is no longer eligible to participate
in Medicaid Advantage as described in Section 5 of this Agreement.
b)
The
Contractor may initiate an Enrollee's disenrollment from the Contractor's
Medicaid Advantage Product in the following cases:
i)
The
Enrollee engages in conduct or behavior that seriously impairs the Contractor's
ability to furnish services to either the Enrollee or other Enrollees, provided
that the Contractor has made and documented reasonable efforts to resolve the
problems presented by the Enrollee.
ii)
The
Enrollee provides fraudulent information on an enrollment form or the Enrollee
permits abuse of an enrollment card in the Medicaid Advantage Program except
when the Enrollee is no longer eligible for Medicaid and is in his/her
Guaranteed Eligibility period.
iii)
Consistent with 42 CFR 438.56 (b), the Contractor may not request Disenrollment
because of an adverse change in the Enrollee's health status, or because of
the
Enrollee's utilization of medical services, diminished mental capacity, or
uncooperative or disruptive behavior resulting from the Enrollee's special
needs
(except where continued enrollment in the Contractor's plan seriously impairs
the Contractor's ability to furnish services to either the Enrollee or other
Enrollees).
c)
Contractor-initiated Disenrollments must be carried out in accordance with
the
requirements and timeframes described in Appendix H of this
Agreement.
Medicaid
Advantage Contract
SECTION
8
(DISENROLLMENT)
State
2006
8-3
d)
Once
an Enrollee has been disenrolled at the Contractor's request, he/she will not
be
re-enrolled with the Contractor's plan unless the Contractor first agrees to
such re-enrollment.
8.8
LDSS
Initiated Disenrollment
a)
The
LDSS is responsible for promptly initiating Disenrollment from the Contractor's
Medicaid Advantage Product when:
i)
an
Enrollee fails to enroll or stay enrolled in the Contractor's Medicare Advantage
Product as specified in Sections 6.9 and 8.3(b)(iv) of this Agreement; or
ii)
an
Enrollee is no longer eligible for Medicaid or Medicaid Advantage; benefits;
or
iii)
the
Guaranteed Eligibility period ends (See Section 9) and an Enrollee, is no longer
eligible for any Medicaid benefits; or
iv)
an
Enrollee is no longer the financial responsibility of the LDSS; or
v)
an
Enrollee becomes ineligible for Enrollment pursuant to Section 5.2 of this
Agreement, as appropriate.
Medicaid
Advantage Contract
SECTION
8
(DISENROLLMENT)
State
2006
8-4
9.
GUARANTEED ELIGIBILITY
9.1
General Requirements
SDOH
and
the Contractor will follow the policies in this section subject to state and
federal laws and regulations.
9.2
Right
to Guaranteed Eligibility
a)
New
Enrollees, other than those identified in Section 9.2 who would otherwise lose
Medicaid eligibility during the first six (6) months of enrollment, will retain
the right to remain enrolled in the Contractor's Medicaid Advantage Product
under this Agreement for a period of six (6) months from their Effective Date
of
Enrollment as long as they also remain enrolled in the Contractor's Medicare
Advantage Product as defined in this Agreement.
b)
Guaranteed Eligibility is not available to the following Enrollees:
i)
Enrollees who lose eligibility due to death, moving out of State, or
incarceration;
ii)
Female enrollees with a net available income in excess of medically necessary
income but at or below two hundred percent (200%) of the federal poverty level
who are only eligible for Medicaid while pregnant and then through the end
of
the month in which the sixtieth (60th)
day
following the end of the pregnancy occurs.
c)
If,
during the first six (6) months of enrollment in the Contractor's Medicaid
Advantage Product, an Enrollee becomes eligible for Medicaid only as a
spend-down, the Enrollee will be eligible to remain enrolled in the Contractor's
Medicaid Advantage Product for the remainder of the six (6) month Guaranteed
Eligibility period as long as he/she also remains enrolled in the Contractor's
Medicare Advantage Product. During the six (6) month Guaranteed Eligibility
period, an Enrollee eligible for spend-down has the option of spending down
to
gain full Medicaid eligibility. If the Enrollee spends down to gain full
Medicaid eligibility, the Enrollee will no longer be in guarantee status and
the
LDSS will manually set coverage codes as appropriate.
d)
Enrollees who lose and regain Medicaid eligibility within a three (3) month
period will not be entitled to a new period of six (6) months Guaranteed
Eligibility in Medicaid Advantage.
Medicaid
Advantage Contract
SECTION
9
(GUARANTEED
ELIGIBILITY)
State
2006
9-1
9.3
Covered Services During Guaranteed Eligibility
The
services covered during the Guaranteed Eligibility period shall be those
contained in the Medicaid Advantage Benefit Package, as specified in Appendix
K-2, and free access to family planning and reproductive health services as
set
forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
period Enrollees are also eligible for pharmacy services not covered by the
Medicare Advantage Product (Part B and Part D pharmacy benefits) on a Medicaid
fee-for-service basis.
9.4
Disenrollment During Guaranteed Eligibility
a)
An
Enrollee-initiated disenrollment from the Contractor's Medicare or Medicaid
Advantage Product terminates the Enrollee's Guaranteed Eligibility
period.
b)
During
the guarantee period, an Enrollee may not change health plans. An Enrollee
may
choose to disenroll from the Contractor's Medicaid Advantage Product during
the
guarantee period but is not eligible to enroll in another MCO's Medicaid
Advantage Product because he/she has lost eligibility for Medicaid.
Medicaid
Advantage Contract
SECTION
9
(GUARANTEED
ELIGIBILITY)
State
2006
9-2
10.
BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES
10.1
Contractor Responsibilities
a)
The
Contractor agrees to provide the Medicare Advantage Benefit Package, as
described in Appendix K-l of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Product subject to any exclusions or limitations imposed
by
Federal or State law during the period of this Agreement. Such services and
supplies shall be provided in
compliance with the requirements of the Contractor's Medicare Advantage
Coordinated Care Plan contract with CMS and all applicable federal statutes,
regulations and policies.
b)
The
Contractor agrees to provide the Medicaid Advantage Benefit Package, as
described in Appendix K-2 of this Agreement, to Enrollees of the Contractor's
Medicaid Advantage Product subject to any exclusions or limitations imposed
by
Federal or State law during the period of this Agreement. Such services and
supplies, shall be provided in compliance with the requirements of this
Agreement, the State Medicaid Plan established pursuant to Section 363-a of
the
State Social Services Law, and all applicable federal and state statutes,
regulations and policies.
10.2
SDOH
Responsibilities
SDOH
shall assure that Medicaid services covered under the Medicaid fee-for-service
program as described in Appendix K-3 of this Agreement which are not covered
in
the Medicare or Medicaid Advantage Benefit Packages are available to, and
accessible by, Medicaid Advantage Enrollees.
10.3
Benefit Package and Non-Covered Services Descriptions
The
Medicare and Medicaid Advantage Benefit Packages and Non-Covered Services agreed
to by the Contractor and the SDOH are contained in Appendix K, which is hereby
made a part of this Agreement as if set forth fully herein.
10.4
Adult Protective Services
The
Contractor shall cooperate with LDSS in the implementation of 18 NYCRR Part
457
and any subsequent amendments thereto with regard to medically necessary health
and mental health services and all Court Ordered Services for adults to the
extent such services are included in the Contractor's Medicare and Medicaid
Advantage Benefit Packages as described in Appendix K of this Agreement. The
Contractor is responsible for payment of those services as covered by the
Medicare and Medicaid Advantage Benefit Packages, even when provided by
Non-Participating Providers. Non-Participating Providers will be reimbursed
at
the Medicaid fee schedule by the Contractor.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-1
10.5
Court-Ordered Services
a)
The
Contractor shall provide any Medicare and Medicaid Advantage Benefit Package
services to Enrollees as ordered by a court of competent jurisdiction,
regardless of whether such services are provided by a Participating Provider
or
by a Non-Participating Provider. Non-Participating Providers shall be reimbursed
by the Contractor at the Medicaid fee schedule. The Contractor is responsible
for court-ordered services to the extent that such court-ordered services are
included in the Contractor's Medicare and Medicaid Advantage Benefit Packages
as
described in Appendix K of this Agreement.
b)
Court
Ordered Services are those services ordered by the court performed by, or under
the supervision of a physician, dentist, or other provider qualified under
State
law to furnish medical, dental, behavioral health (including mental health
and/or chemical dependence services), or other Medicare and Medicaid Advantage
covered services. The Contractor is responsible for payment of those services
as
covered by the Contractor's Medicare and Medicaid Advantage Benefit Packages,
even when provided by Non-Participating Providers.
10.6
Family Planning and Reproductive Health Services
a)
Nothing in this Agreement shall restrict the right of Enrollees to receive
Family
Planning and Reproductive Health Services, as defined in Appendix C of
this
Agreement, which is hereby made a part of this Agreement as if set
forth
fully herein.
i)
Enrollees may receive such services from any qualified Medicaid provider,
regardless of whether the provider is a Participating Provider or a
Non-Participating Provider in the Contractor's Medicare Advantage Product,
without referral from the Enrollee's PCP and without approval from the
Contractor.
b)
The
Contractor shall permit Enrollees to exercise their right to obtain Family
Planning and Reproductive Health Services from either the Contractor, if Family
Planning and Reproductive Health Services are provided by the Contractor, or
from any appropriate Medicaid enrolled Non-Participating family planning
Provider, without a referral from the Enrollee's PCP and without approval by
the
Contractor.
c)
If
Contractor provides Family Planning and Reproductive Health Services to its
Enrollees, the Contractor shall comply with the requirements in Part C-2 of
Appendix C of this Agreement, including assuring that Enrollees are fully
informed of their rights.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-2
d)
If
Contractor does not provide Family Planning and Reproductive Health Services
to
its Enrollees, the Contractor shall comply with Part C.3 of Appendix C of this
Agreement, including assuring that Enrollees are fully informed of their
rights.
10.7
Emergency and Post Stabilization Care Services
a)
The
Contractor shall provide Emergency and Post Stabilization Care Services in
accordance with applicable federal and state requirements, including 42 CFR
§422.113.
b)
The
Contractor shall ensure that Enrollees are able to access Emergency Services
twenty four (24) hours per day, seven (7) days per week.
c)
The
Contractor agrees that it will not require prior authorization for services
in a
medical or behavioral health emergency. The Contractor agrees to inform its
Enrollees that access to Emergency Services is not restricted and that Emergency
Services may be obtained from a Non-Participating Provider without penalty.
Nothing herein precludes the Contractor from entering into contracts with
providers or facilities that require providers or facilities to provide
notification to the Contractor after Enrollees present for Emergency Services
and are subsequently stabilized. The Contractor must pay for services for
Emergency Medical Conditions whether provided by a Participating Provider or
a
Non-Participating Provider, and may not deny payments for failure of the
Emergency Services provider or Enrollee to give notice.
d)
The
Contractor shall advise its Enrollees how to obtain Emergency Services when
it
is not feasible for Enrollees to receive Emergency Services from or through
a
Participating Provider. The Contractor shall bear the cost of providing
Emergency Services through Non-Participating Providers.
e)
Triage
Fees: For emergency room services that do not meet the definition of Emergency
Medical Conditions and for which the Contractor denies the Medicare Benefit,
the
Contractor shall pay the hospital a triage fee of $40.00 in the absence of
a
negotiated rate. Non-participating emergency departments cannot be denied a
payment on the basis of non-notification.
10.8
Medicaid Utilization Thresholds (MUTS)
Enrollees
may be subject to MUTS for services which are billed to Medicaid fee-for-service
and for dental services provided without referral at Article 28 clinics operated
by academic dental centers as described in Section 10.18 of this Agreement.
Enrollees are not otherwise subject to MUTS for services included in the
Medicaid Advantage Benefit Package.
Medicaid
Advantage Contract
SECTION
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(BENEFIT
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2006
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10.9
Services for Which Enrollees Can Self-Refer
In
addition to those services for which Medicare Advantage Enrollees can
self-refer, Medicaid Advantage Enrollees may self-refer to:
a)
Public
health agency facilities for the diagnosis and/or treatment of TB as described
in Section 10.11 (a) (i) of this Agreement.
b)
Family
Planning and Reproductive Health services as described in Section 10.6 and
Appendix C of this Agreement.
c)
Article 28 clinics operated by academic dental centers to obtain covered dental
services as described in Section 10.18 of this Agreement.
10.10
Coordination with Local Public Health Agencies
The
Contractor will coordinate its public health-related activities with the Local
Public Health Agency (LPHA) consistent with the SDOH MCO and Public Health
Guidelines. Coordination mechanisms and operational protocols for addressing
public health issues will be negotiated with the LPHA and customized to reflect
local public health priorities. Negotiations must result in agreements regarding
required Contractor activities related to public health. The outcome of
negotiations may take the form of an informal agreement among the parties which
may include memos or a separate memorandum of understanding signed by the LPHA,
LDSS, and the Contractor.
10.11
Public Health Services
a)
Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
(TB\DOT):
i)
Consistent with New York State law, public health clinics are required to
provide or arrange for treatment to individuals presenting with tuberculosis,
regardless of the person's insurance or enrollment status.
ii)
It is
the State's preference that Enrollees receive TB diagnosis and treatment through
the Contractor's Medicare Advantage Product, to the extent that Participating
Providers experienced in this type of care are available.
iii)
The
SDOH will coordinate with the LPHA to evaluate the Contractor's protocols
against State and local guidelines and to review the tuberculosis treatment
protocols and networks of Participating Providers to verify their readiness
to
treat tuberculosis patients. SDOH and LPHAs will also be available to offer
technical assistance to the Contractor in establishing TB policies and
procedures.
iv)
The
Contractor shall inform participating providers of their responsibility to
report TB cases to the LPHA.
Medicaid
Advantage Contract
SECTION
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2006
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v)
Enrollees may self-refer to public health agency facilities for the diagnosis
and/or treatment ofTB.
A.
The
Contractor agrees to reimburse public health clinics when physician visit and
patient management or laboratory and radiology services are rendered to their
Enrollees, within the context of TB diagnosis and treatment.
B.
The
Contractor will make best efforts to negotiate fees for these services with
the
LPHA. If no agreement has been reached, the Contractor agrees to reimburse
the
public health clinics for these services at rates determined by
SDOH.
C.
The
LPHA is responsible for: 1) giving notification to the Contractor before
delivering TB-related services, if so required in the public health agreement
established pursuant to Section 10.10, unless these services are ordered by
a
court of competent jurisdiction; and 2) making reasonable efforts to verify
with
the Enrollee's PCP that he/she has not already provided TB care and treatment,
and 3) providing documentation of services rendered along with the
claim.
D.
Prior
authorization for inpatient hospital admissions may not be required by the
Contractor for an admission pursuant to a court order or an order of detention
issued by the local commissioner or director of public health.
E.
The
Contractor shall provide the LPHA with access to health care practitioners
on a
twenty-four (24) hour a day seven (7) day a week basis who can authorize
inpatient hospital admissions. The Contractor shall respond to the LPHA's
request for authorization within the same day.
F)
The
Contractor will not be financially liable for treatments rendered to Enrollees
who have been institutionalized as a result of a local health commissioner's
order due to non-compliance with TB care regimens.
vi)
The
Contractor will not be financially liable for Directly Observed Therapy (DOT)
costs. While all other clinical management of tuberculosis is covered by the
Contractor, TB/DOT, where applicable, may be billed to any SDOH approved
fee-for-service Medicaid provider. The Contractor agrees to make all reasonable
efforts to ensure coordination with DOT providers regarding clinical care and
services. Enrollees may use any Medicaid fee-for-service TB/DOT provider. vii)
HIV counseling and testing provided to a Medicaid Advantage Enrollee during
a TB
related visit at a public health clinic, directly operated by a LPHA will be
covered by Medicaid fee-for-service (FFS) at rates established by the
SDOH.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-5
b)
Immunizations
i)
The
Contractor agrees to reimburse the Local Public Health Agency when Enrollees
self-refer to Local Public Health Agencies for immunizations covered by
Contractor's Medicare Advantage Plan.
ii)
The
LPHA is responsible for making reasonable efforts to (1) determine the
Enrollee's managed care membership status; and (2) ascertain the Enrollee's
immunization status. Reasonable efforts shall consist of client interviews,
review of medical records, and, when available, access to the Immunization
Registry. When an Enrollee presents a membership card with a PCP's name, the
LPHA is responsible for calling the PCP. If the LPHA is unable to verify the
immunization status from the PCP or leams that immunization is needed, the
LPHA
is responsible for delivering the service as appropriate, and the Contractor
will reimburse the LPHA at the negotiated rate or in the absence of an
agreement, at rates determined by SDOH.
c)
Prevention and Treatment of Sexually Transmitted Diseases
The
Contractor will be responsible for ensuring that its Participating Providers
educate their Enrollees about the risk and prevention of sexually transmitted
disease (STD). The Contractor also will be responsible for ensuring that its
Participating Providers screen and treat Enrollees for STDs and report cases
of
STD to the LPHA and cooperate in contact investigation, in accordance with
existing state and local laws and regulations. HIV counseling and testing
provided to an Enrollee during a STD related visit at a public health clinic,
directly operated by a LPHA, will be covered by Medicaid fee-for-service at
rates established by SDOH.
10.12
Adults with Chronic Illnesses and Physical or Developmental
Disabilities
a)
The
Contractor will implement all of the following to meet the needs of its adult
Enrollees with chronic illnesses and physical or developmental
disabilities:
i)
Satisfactory methods for ensuring that the Contractor is in compliance with
the
ADA and Section 504 of the Rehabilitation Act of 1973. Program accessibility
for
persons with disabilities shall be in accordance with Section 23 of this
Agreement.
ii)
Clinical case management which uses satisfactory methods/guidelines for
identifying persons at risk of or having, chronic diseases and disabilities
and
determining their specific needs in terms of specialist physician referrals,
durable medical equipment, home health services, self-management education
and
training, etc. The Contractor shall:
A)
develop protocols describing the Contractor's case management services and
minimum qualification requirements for case management staff;
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-6
B)
develop and implement protocols for monitoring effectiveness of case management
based on patient outcomes;
C)
develop and implement protocols for monitoring service utilization including
emergency room visits and hospitalizations, with adjustment of severity of
patient conditions;
D)
provide regular information to Participating Providers on the case management
services available to the Contractor's Enrollees and the criteria for referring
Enrollees to the Contractor for case management services.
iii)
Satisfactory methods/guidelines for determining which patients are in need
of
case management services, including establishment of severity
thresholds,
and
methods
for identification of patients including monitoring of hospitalizations and
ER
visits, provider referrals, new Enrollee health screenings and self-referrals
by
Enrollees.
iv)
Guidelines for determining specific needs of Enrollees in case management,
including specialist physician referrals, durable medical equipment, home health
services, self management education and training, etc.
v)
Satisfactory systems for coordinating service delivery with Non-Participating
Providers, including behavioral health providers for all Enrollees.
10.13
Persons Requiring Ongoing Mental Health Services
a)
The
Contractor will implement all of the following for its Enrollees with chronic
or
ongoing mental health service needs:
i)
Satisfactory methods for identifying Enrollees requiring such services and
encouraging self-referral and early entry into treatment.
ii)
Satisfactory case management systems or satisfactory case
management.
iii)
Satisfactory systems for coordinating service delivery between physical health,
chemical dependence, and mental health providers, and coordinating services
with
other available services, including Social Services.
iv)
The
Contractor agrees to participate in the local planning process for serving
persons with mental health needs to the extent requested by the LDSS. At the
LDSS' discretion, the Contractor will develop linkages with local governmental
units on coordination, procedures and standards related to mental health
services and related activities.
10.14
Member Needs Relating to HIV
a)
To
adequately address the HIV 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)
Anonymous testing may be furnished to the Enrollee without prior approval by
the
Contractor and may be conducted at anonymous testing
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-7
sites
available to clients. Services provided for HIV treatment may only be obtained
from the Contractor during the period the Enrollee is enrolled in the
Contractor's plan.
ii)
Methods for promoting HIV prevention to all Plan Enrollees. HIV prevention
information, both primary, as well as secondary should be tailored to the
Enrollee's age, sex, and risk factor(s), (e.g., injection drug use and sexual
risk activities), and 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 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 provided shall be done in accordance with Article 27-F
of
the PHL. Such policies and procedures shall also direct Participating Providers
to refer any HIV positive women in their care to clinically appropriate services
for both the women and their newborns.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-8
v)
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 persons with HIV infection; inclusion
of Designated AIDS Center Hospitals or other hospitals experienced in HIV care
in the Contractor's network; and contracts or linkages with providers funded
under the Xxxx Xxxxx CARE Act. The Contractor shall inform the providers in
its
network how to obtain information about the availability of Experienced HIV
Providers and HIV 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, including 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.
vii)
The
Contractor shall require its Participating Providers to report positive HIV
test
results and diagnoses and known contacts of such persons to the 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 update 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.
10.15
Persons Requiring Chemical Dependence Services
a)
The
Contractor will have in place all of the following for its Enrollees requiring
Chemical Dependence Services:
i)
Satisfactory methods for identifying persons requiring such services and
encouraging self-referral and early entry into treatment and methods for
referring Enrollees to the New York Office of Alcohol and Substance Abused
Services (OASAS) for appropriate services beyond the Contractor's Benefit
Package (e.g., halfway houses).
ii)
Satisfactory systems of care including Participating Provider networks and
referral processes sufficient to ensure that emergency services, including
crisis services, can be provided in a timely manner.
iii)
Satisfactory case management systems.
iv)
Satisfactory systems for coordinating service delivery between physical health,
chemical dependence, and mental health providers, and coordinating
in-plan services with other services, including Social Services.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-9
v)
The
Contractor agrees to also participate in the local planning process for serving
persons with chemical dependence, to the extent requested by the LDSS. At the
LDSS's discretion, the Contractor will develop linkages with local governmental
units on coordination procedures and standards related to Chemical Dependence
Services and related activities.
10.16
Native Americans
If
an
Enrollee is a Native American and the Enrollee chooses to access primary care
or
other services through their tribal health center, the PCP authorized by the
Contractor to refer the Enrollee for Medicare or Medicaid Advantage Product
benefits must develop a relationship with the Enrollee's PCP at the tribal
health center to coordinate services for said Native American
Enrollee.
10.17
Urgently Needed Services
The
Contractor is financially responsible for Urgently Needed Services.
10.18
Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network
a)
Consistent with Chapter 697 of Laws of 2003 amending Section 364 (j) of the
Social Services Law, dental services provided by Article 28 clinics operated
by
academic dental centers may be accessed directly by Medicaid Advantage Enrollees
without prior approval and without regard to network participation.
b)
If
dental services are part of the Contractor's Medicaid Advantage Benefit Package,
the Contractor will reimburse non-participating Article 28 clinics operated
by
academic dental centers for covered dental services provided to Enrollees at
approved Article 28 Medicaid clinic rates in accordance with the protocols
issued by the SDOH.
10.19
Coordination of Services
a)
The
Contractor shall coordinate care for Enrollees with:
i)
the
court system (for court ordered evaluations and treatment);
ii)
specialized providers of health care for the homeless, and other providers
of
services for victims of domestic violence;
iii)
family planning clinics, community health centers, migrant health centers,
rural
health centers;
iv)
WIC;
v)
programs funded through the Xxxx Xxxxx CARE Act;
vi)
other
pertinent entities that provide services out of network;
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-10
vii)
Prenatal Care Assistance Program (PCAP) Providers;
viii)
local governmental units responsible for public health, mental health, mental
retardation or Chemical Dependence Services; and
ix)
specialized providers of long term care for people with developmental
disabilities.
b)
Coordination may involve contracts or linkage agreements (if entities are
willing to enter into such an agreement), or other mechanisms to ensure
coordinated care for Enrollees, such as protocols for reciprocal referral and
communication of data and clinical information on Enrollees.
Medicaid
Advantage Contract
SECTION
10
(BENEFIT
PACKAGE, COVERED AND NON-COVERED SERVICES)
State
2006
10-11
11. MARKETING
11.1
Marketing Requirements
a)
The
Contractor agrees to follow the Medicare Advantage Marketing Guidelines as
set
forth in Chapter 3 ofCMS's Medicare Managed Care Manual, as well as all
applicable statutes and regulations including and without limitation Section
1851 (h) of the Social Security Act and 42 CFR Sections 422.80, 422.111, and
423.50 when marketing to individuals entitled to enroll in Medicare
Advantage.
b)
In
developing marketing materials and conducting marketing activities for the
Medicaid Advantage Program, the Contractor shall comply with the Medicaid
Advantage Marketing Guidelines as defined in Appendix D of this document as
if
set forth mlly herein.
Medicaid
Advantage Contract
SECTION
11
(MARKETING)
State
2006
11-1
12.
MEMBER SERVICES
12.1
General Functions
a)
The
Contractor shall operate a Member Services function during regular business
hours, which must be accessible to Enrollees via a toll-free telephone line.
Personnel must also be available via a toll-free telephone line (which can
be
the member services toll-free line or separate toll-free lines) not less than
during regular business hours to address complaints and utilization review
inquiries. In addition, the Contractor must have a telephone system capable
of
accepting, recording or providing instruction in response to incoming calls
regarding complaints and utilization review during other than normal business
hours and measures in place to ensure a response to those calls the next
business day after the call was received.
b)
Member
Services staff must be responsible for the following:
i)
Explaining the benefits and covered services offered under the Medicare and
Medicaid Advantage Products, including applicable conditions and limitations,
and any conditions associated with the receipt or use of benefits.
ii)
Explaining the Contractor's rules for obtaining Medicare and Medicaid Advantage
Benefit Package services and additional services available to the Enrollee
through use of his/her Medicaid benefit card.
iii)
Providing information on: the providers from whom Enrollees may obtain Medicare
and Medicaid Advantage Benefit Package Services, any out-of-area coverage
provided by the plan, and coverage of emergency services and urgently needed
care.
iv)
Fielding and responding to Enrollee questions and complaints regarding the
Contractor's Medicare and Medicaid Advantage Products and benefits, and advising
Enrollees of the prerogative to complain at any time to the CMS regarding the
Medicare Advantage Product, and to the SDOH and LDSS, regarding the Medicaid
Advantage Product.
v)
Clarifying information in the member handbooks for Enrollees regarding the
Contractor's Medicare and Medicaid Advantage Products and benefits.
vi)
Advising Enrollees of the Contractor's applicable complaint and appeals
programs, utilization review processes, and the Enrollee's rights to a fair
hearing or external review.
vii)
Clarifying an Enrollee's Disenrollment rights and responsibilities under the
Contractor's Medicare and Medicaid Advantage Products.
Medicaid
Advantage Contract
SECTION
12
(MEMBER
SERVICES)
State
2006
12-1
12.2
Translation and Oral Interpretation
a)
The
Contractor must make available written marketing and other informational
materials (e.g., member handbooks) in a language other than English whenever
at
least five percent (5%) of the Prospective Enrollees of the Contractor in any
county of the service area speak that particular language and do not speak
English as a first language.
b)
In
addition, verbal interpretation services must be made available to Enrollees
who
speak a language other than English as a primary language. Interpreter services
must be offered in person where practical, but otherwise may be offered by
telephone.
c)
The
SDOH will determine the need for other than English translations based on
county-specific census data or other available measures.
12.3
Communicating with the Visually, Hearing and Cognitively Impaired
The
Contractor also must have in place appropriate alternative mechanisms for
communicating effectively with persons with visual, hearing, speech, physical
or
developmental disabilities. These alternative mechanisms include Braille or
audio tapes for the visually impaired, TTY access for those with certified
speech or hearing disabilities, and use of American Sign Language and/or
integrative technologies.
Medicaid
Advantage Contract
SECTION
12
(MEMBER
SERVICES)
State
2006
12-2
13.
ENROLLEE NOTIFICATION
13.1
General Requirements
a)
The
Contractor shall disclose required information to Prospective Enrollees and
Enrollees as prescribed by applicable federal and state law and regulations
found at 42 CFR 422.111, New York PHL 4408, SSL 364-j, and 42 CFR §438.10 (e),
(f) and (g), and any specific guidance issued by CMS and SDOH.
b)
The
Contractor must provide Enrollees with an annual notice that this information
is
available to them upon request.
c)
The
Contractor must inform Enrollees that oral interpretation service is available
for any language and that information is available in alternative formats and
how to access these formats.
d)
Medicaid Advantage post enrollment notices and materials shall include, but
not
be limited to the following:
Provider
Directories
Member
ID
Cards
Member
Handbooks
Notice
of
the Effective Date of Enrollment
Notice
of
the Effective Date of Benefit Package Changes
Notice
of
Termination, Service Area Changes and Network Changes
Summary
of Benefits
e)
Integrated post enrollment materials including member handbooks, member notices,
and summary of benefits targeted to Enrollees of the Contractor's Medicare
and
Medicaid Advantage Products must be prior approved by the CMS Regional Office;
in collaboration with SDOH.
13.2
Member ID Cards
The
Contractor must issue an identification card to the Enrollee that complies
with
CMS and SDOH specifications.
13.3
Member Handbooks
The
Contractor shall issue to a new Enrollee no later than fourteen (14) days
following the Effective Date of Enrollment a Medicaid Advantage Member Handbook,
which is approved by SDOH and consistent with the Medicaid Advantage Model
Handbook Guidelines in Appendix E, which is hereby made a part of this Agreement
as if set forth fully herein.
Medicaid
Advantage Contract
SECTION
13
(ENROLLEE
NOTIFICATION)
State
2006
13-1
13.4
Enrollee Rights
a)
The
Contractor shall,in
compliance with the requirements of 42 CFR § 438.6(i)(l) and 42 CFR Part 489
Subpart 1, maintain written policies and procedures regarding advance directives
and inform each Enrollee in writing at the time of enrollment of an individual's
rights under State law to formulate advance directives and of the Contractor's
policies regarding the implementation of such rights. The Contractor shall
include in such written notice to the Enrollee materials relating to advance
directives and health care proxies as specified in 10 NYCRR Part 98 and § 700.5.
The written information must reflect changes in State law as soon as possible,
but no later than ninety (90) days after the effective date of the
change.
b)
The
Contractor shall have policies and procedures that protect the Enrollee's right
to:
i)
receive information about the Contractor and managed care;
ii)
be
treated with respect and due consideration for his or her dignity and
privacy;
iii)
receive information on available treatment options and alternatives, presented
in a manner appropriate to the Enrollee's condition and ability to
understand;
iv)
participate in decisions regarding his or her health care, including the right
to refuse treatment;
v)
be
free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation, as specified in Federal regulations
on
the use of restraints and seclusion; and
vi)
If
the privacy rule, as set forth in 45 CFR Parts 160 and 164, Subparts A and
E,
applies, request and receive a copy of his or her medical records and request
that they be amended or corrected, as specified in 45 CFR §§ 164.524 and
164.526.
c)
The
Contractor's policies and procedures must require that neither the Contractor
nor its Participating Providers adversely regard an Enrollee who exercises
his/her rights in 13.4(b) above.
Medicaid
Advantage Contract
SECTION
13
(ENROLLEE
NOTIFICATION)
State
2006
13-2
14.
ORGANIZATION DETERMINATIONS, ACTIONS AND GRIEVANCE SYSTEM
14.1
General Requirements
a)
The
Contractor agrees to comply with, and shall establish and maintain written
Organization Determination and Action procedures and a comprehensive Grievance
system, as described in Appendix F, which is hereby made a part of this
Agreement as if set forth fully herein, that complies with:
i)
all
procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter 13
ofCMS's Medicare Managed Care Manual for services that the Contractor determines
are a Medicare only benefit.
ii)
all
procedures and requirements of 42 CFR Subpart M of Part 422 and Chapter 13
of
CMS's Medicare Managed Care Manual for services the Contractor determines to
be
a benefit covered under both Medicare and Medicaid, except that:
A)
the
Contractor will determine whether services are Medically Necessary as that
term
is defined in this Agreement; and
B)
when
the Contractor intends to reduce, suspend, or terminate a previously authorized
service within an authorization period, the notification provisions of paragraph
F.2(4)(a) of Appendix F of this Agreement shall apply.
iii)
all
procedures and requirements of the Medicaid Advantage Action and Medicaid
Advantage Grievance System requirements described in Appendix F of this
Agreement and 42 CFR Section 438.400 et. seq., for services that the Contractor
determines are a Medicaid only benefit. With respect to Medicaid-only services,
nothing herein shall release the Contractor from its responsibilities under
PHL
§ 4408-a or PHL Article 49 and 10 NYCRR Part 98 that are not otherwise expressly
established in Appendix F of this Agreement.
b)
For
services that the Contractor determines are a benefit under both Medicare and
Medicaid, the Contractor agrees to offer Enrollees the right to pursue either
the Medicare appeal procedures or the Medicaid Advantage Action Appeal and
Grievance System in the manner described and provided for in Appendix F of
this
Agreement.
14.2
Filing and Modification of Medicaid Advantage Action and Grievance Systems
Procedures
a)
The
Contractor's Action and Grievance System Procedures governing services
determined by the Contractor to be a Medicaid only benefit and
services
Medicaid
Advantage Contract
SECTION
4
(COMPLAINT
AND APPEAL PROCEDURE)
State
2006
14-1
determined
by the Contractor to be a benefit under both Medicare and Medicaid shall be,
approved by the SDOH, and kept on file with the Contractor and
SDOH.
b)
The
Contractor shall not modify its Action and Grievance System Procedures without
the prior written approval of SDOH, and shall provide SDOH with a copy of the
approved modifications within fifteen (15) days of its approval.
14.3
Medicaid Advantage Action and Grievance System Additional
Provisions
a)
The
Contractor must have in place effective mechanisms to ensure consistent
application of review criteria for Service Authorization Determinations and
consult with the requesting provider when appropriate.
b)
If the
Contractor subcontracts for Service Authorization Determinations and utilization
review, the Contractor must ensure that its subcontractors have in place and
follow written policies and procedures for delegated activities regarding
processing requests for initial and continuing authorization of services
consistent with Article 49 of the PHL, 10 NYCRR Part 98, 42 CFR Part 438,
Appendix F of this Agreement, and the Contractor's policies and
procedures.
c)
The
Contractor must ensure that compensation to individuals or entities that perform
Service Authorization Determination and utilization management activities is
not
structured to include incentives that would result in the denial, limiting,
or
discontinuance of Medically Necessary services to Enrollees.
d)
The
Contractor or its subcontractors may not arbitrarily deny or reduce the amount,
duration, or scope of a covered service solely because of the diagnosis, type
of
illness, or Enrollee's condition. The Contractor may place appropriate limits
on
a service on the basis of criteria such as Medical Necessity or utilization
control, provided that the services furnished can reasonably be expected to
achieve their purpose.
e)
The
Contractor shall ensure that its Medicaid Advantage Grievance System includes
methods for prompt internal adjudication of Enrollee Complaints, Complaint
Appeals and Action Appeals and provides for the maintenance of a written record
of all Complaints, Complaint Appeals and Action Appeals received and reviewed
and their disposition, as specified in Appendix F of this
Agreement.
f)
The
Contractor shall ensure that persons with authority to require corrective action
participate in the Medicaid Advantage Grievance System.
Medicaid
Advantage Contract
SECTION
14
(COMPLAINT
AND APPEAL PROCEDURE)
State
2006
14-2
14.4
Notification ofMedicaid Advantage Action and Grievance System
Procedures
a)
The
Contractor's specific Action and Grievance System Procedures for services
determined by the Contractor to be a Medicaid only benefit and services
determined by the Contractor to be a benefit under both Medicare and Medicaid
shall be described in the Contractor's Medicaid Advantage member handbook and
shall be made available to all Medicaid Advantage Enrollees.
b)
The
Contractor will advise Enrollees of their right to a fair hearing as appropriate
and comply with the procedures established by SDOH for the Contractor to
participate in the fair hearing process, as set forth in Section 24 of this
Agreement. Such procedures shall include the provision of a Medicaid notice
in
accordance with 42 CFR Sections 438.210 and 438.404.
c)
The
Contractor will also advise Enrollees of their right to an External Appeal,
related to services determined by the Contractor to be a Medicaid only benefit
or services determined by the Contractor to be a benefit under both Medicare
and
Medicaid, in accordance with Section 25 of this Agreement.
d)
The
Contractor will provide written notice to all Participating Providers, and
subcontractors to whom the Contractor has delegated utilization review and
Service Authorization Determination procedures, at the time they enter into
an
agreement with the Contractor, of the following Medicaid Advantage Complaint,
Complaint Appeal, Action Appeal and fair hearing procedures and when such
procedures may be applicable:
i)
the
Enrollee's right to a fair hearing, how to obtain a fair hearing, and
representation rules at a hearing;
ii)
the
Enrollee's right to file Complaints, Complaint Appeals and Action Appeals and
the process and timeframes for filing;
iii)
the
Enrollee's right to designate a representative to file Complaints, Complaint
Appeals and Action Appeals on his/her behalf;
iv)
the
availability of assistance from the Contractor for filing Complaints, Complaint
Appeals and Action Appeals;
v)
the
toll-free numbers to file oral Complaints, Complaint Appeals and Action
Appeals;
vi)
the
Enrollee's right to request continuation of benefits while an Action Appeal
or
state fair hearing is pending, and that if the Contractor's Action is upheld
in
a hearing, the Enrollee may be liable for the cost of any continued
benefits;
Medicaid
Advantage Contract
SECTION
14
(COMPLAINT
AND APPEAL PROCEDURE)
State
2006
14-3
vii)
the
right of the provider to reconsideration of an Adverse Determination pursuant
to
Section 4903(6) of the PHL; and
viii)
the
right of the provider to appeal a retrospective Adverse Determination pursuant
to Section 4904(1) of the PHL.
14.5
Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
The
Contractor must adhere to determinations resulting from Complaint, Complaint
Appeal and Action Appeal investigations conducted by SDOH.
Medicaid
Advantage Contract
SECTION
14
(COMPLAINT
AND APPEAL PROCEDURE)
State
2006
14-4
15. ACCESS
REQUIREMENTS
a)
The
Contractor agrees to provide Enrollees access to Medicare Advantage Benefit
Package and Medicaid Only Covered Services as described in Appendix K-l and
K-2
of this Agreement in a manner consistent with professionally recognized
standards of health care and access standards required by 42 CFR Section 422.112
and applicable state law, respectively.
b)
The
Contractor will establish and implement mechanisms to ensure that Participating
Providers comply with timely access requirements, monitor regularly to determine
compliance and take corrective action if there is a failure to
comply.
c)
The
Contractor will participate in the State's efforts to promote the delivery
of
services in a culturally competent manner to all Enrollees, including those
with
limited English proficiency and diverse cultural and ethnic
backgrounds.
Medicaid
Advantage Contract
SECTION
15
(EQUALITY
OF ACCESS AND TREATMENT)
State
2006
15-1
16.
QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT
16.1
The
Contractor agrees to operate an ongoing quality management and performance
improvement program in accordance with Section 1852 (e) of the SSA and 42 CFR
Section 422.152.
16.2
The
Contractor agrees to conduct a Chronic Care Improvement Program (CCIP) relevant
to its membership as directed by CMS and to submit the annual report on the
Contractor's CCIP to CMS and SDOH.
16.3
The
Contractor agrees to conduct performance improvement projects and to measure
performance using standard measures required by CMS, and to report results
to
CMS and SDOH. Standard Measures will include, but not be limited
to:
•
Health
Plan and Employer Data Information Set (HEDIS);
•
Consumer Assessment of Health Plan Satisfaction (CAHPS); and
•
Health
Outcomes Survey (HOS).
Medicaid
Advantage Contract
SECTION
16
(QUALITY
ASSURANCE)
State 2006
16-1
17.
MONITORING AND EVALUATION
17.1
Right to Monitor Contractor Performance
The
SDOH
and/or its designee and DHHS shall each have the right, during the Contractor's
normal operating hours, and at any other time a Contractor function or activity
is being conducted, to monitor and evaluate, through inspection or other means,
the Contractor's performance, including, but not limited to, the quality,
appropriateness, and timeliness of services provided under this
Agreement.
17.2
Cooperation During Monitoring and Evaluation
The
Contractor shall cooperate with and provide reasonable assistance to the SDOH
and/or its designee, and DHHS in the monitoring and evaluation of the services
provided under this Agreement.
17.3
Cooperation During On-Site Reviews
The
Contractor shall cooperate with SDOH and/or its designee and DHHS in any on-site
review of the Contractor's operations.
17.4
Cooperation During Review of Services by External Review Agency
The
Contractor shall comply with all requirements associated with any review of
the
quality of services rendered to its Enrollees to be performed by an external
review agent selected by the SDOH or DHHS.
Medicaid
Advantage Contract
SECTION
17
(MONITORING
AND EVALUATION)
State
2006
17-1
18.
CONTRACTOR REPORTING REQUIREMENTS
18.1
General Requirements
a)
The
Contractor must maintain a health information system that collects, analyzes,
integrates and reports data. The system must be sufficient to provide the data
necessary to comply with the requirements of this Agreement.
b)
The
Contractor must take steps to ensure that data entered into the system,
particularly that received from Participating Providers, is accurate and
complete.
c)
The
Contractor must make collected information available to CMS and SDOH, as
requested under this Agreement.
18.2
Time
Frames for Report Submissions
Except
as
otherwise specified herein, the Contractor shall prepare and submit to SDOH
the
reports required under this Section in an agreed media format within sixty
(60)
days of the close of the applicable semi-annual or annual reporting period,
and
within fifteen (15) business days of the close of the applicable quarterly
reporting period.
18.3
SDOH
Instructions for Report Submissions
SDOH
will
provide Contractor with instructions for submitting the reports required by
Section 18.6 (a) (i) through (x) of this Agreement, including time frames,
and
requisite formats. The instructions, time frames and formats may be modified
by
SDOH upon sixty (60) days written notice to the Contractor.
18.4
Liquidated Damages
The
Contractor shall pay liquidated damages of $2,500 to SDOH if any report required
pursuant to this Section is materially incomplete, contains material
misstatements or inaccurate information, or is not submitted in the requested
format. The Contractor shall pay liquidated damages of $2,500 to the SDOH if
its
monthly encounter data submission is not received by the Fiscal Agent by the
due
date specified in Section 18.6(a) (iv) of this Agreement. The Contractor shall
pay liquidated damages of $500 to SDOH for each day other reports required
by
this Section are late. The SDOH shall not impose liquidated damages for a first
time infraction by the Contractor unless the SDOH deems the infraction to be
a
material misrepresentation of fact or the Contractor fails to cure the first
infraction within a reasonable period of time upon notice from the SDOH.
Liquidated damages may be waived at the sole discretion of SDOH. Nothing in
this
Section shall limit other remedies or rights available to SDOH relating to
the
timeliness, completeness and/or accuracy of Contractor's reporting
submission.
Medicaid
Advantage Contract
SECTION
8
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-1
18.5
Notification of Changes in Report Due Dates, Requirements or
Formats
SDOH
may
extend due dates, or modify report requirements or formats upon a written
request by the Contractor to the SDOH, where the Contractor has demonstrated
a
good and compelling reason for the extension or modification. The determination
to grant a modification or extension of time shall be made by the
SDOH.
18.6
Reportin g Requirements
a)
The
Contractor shall submit the following reports to SDOH (unless otherwise
specified). The Contractor will certify the data submitted pursuant to this
section as required by SDOH. The certification shall be in the manner and format
established by SDOH and must attest, based on best knowledge, information,
and
belief to the accuracy, completeness and truthfulness of the data being
submitted.
i)
Annual
Financial Statements:
Contractor
shall submit Annual Financial Statements to SDOH. The due date for annual
statements shall be April 1 following the report closing date.
ii)
Quarterly Financial Statements:
Contractor
shall submit Quarterly Financial Statements to SDOH. The due date for quarterly
reports shall be forty-five (45) days after the end of the calendar
quarter.
iii)
Other Financial Reports:
Contractor
shall submit financial reports, including certified annual financial statements,
and make available documents relevant to its financial condition to SDOH and
the
State Insurance Department (SID) in a timely manner as required by State laws
and regulations including, but not limited to, PHL §§ 4403-a, 4404 and 4409,
Title 10 NYCRR Part 98 and when applicable, SIL §§ 304, 305, 306, and 310. The
SDOH may require the Contractor to submit such relevant financial reports and
documents related to its financial condition to the LDSS-
iv)
Encounter Data:
The
Contractor shall prepare and submit encounter data on a monthly basis to SDOH
through SDOH's designated Fiscal Agent. Each provider is required to have a
unique identifier. Submissions shall be comprised of encounter records, or
adjustments to previously submitted records, which
Medicaid
Advantage Contract
SECTION
18
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-2
the
Contractor has received and processed from provider encounter or claim records
of any contractedservices rendered to the Enrollee in the current or any
preceding months, including both Medicare and Medicaid covered services. Monthly
submissions must be received by the Fiscal Agent in accordance with the time
frames specified in the MEDS II data dictionary on the HPN to assure the
submission is included in the Fiscal Agent's monthly production
processing.
v)
Quality of Care Performance Measures:
The
Contractor shall prepare and submit reports to SDOH, as specified by CMS for
the
Medicare Advantage Program including Medicare HEDIS results and Medicare CAHPS.
Reports should be duplicative of reports submitted to CMS, and separate reports
for the dual eligible population are not required.
vi)
Complaint and Action Appeal Reports:
A)
The
Contractor must provide the SDOH on a quarterly basis, and within fifteen (15)
business days of the close of the quarter, a summary of all Complaints and
Action Appeals subject to PHL §4408-a received during the preceding quarter via
the Summary Complaint Form on the HPN related to Medicaid Only Covered Services
and services determined by the Contractor to be a benefit under both Medicare
and Medicaid.
B)
The
Contractor also agrees to provide on a quarterly basis, via the Summary
Complaint form on the HPN, the total number of Complaints and Action Appeals
subject to PHL §4408-a and related to Medicaid Only Covered Services and
services determined by the Contractor to be a benefit under both Medicare and
Medicaid that have been unresolved for more than forty-five (45) days. The
Contractor shall maintain records on these and other Complaints, Complaint
Appeals and Action Appeals pursuant to Appendix F of this
Agreement.
C)
Nothing in this Section is intended to limit the right of the SDOH or its
designee to obtain information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider Complaint, Complaint Appeal
or
Action Appeal.
vii)
Fraud and Abuse Reporting Requirements:
A)
The
Contractor must submit quarterly, via the HPN Complaint reporting format, the
number of Complaints of fraud or abuse made to the Contractor related to
Medicaid Only Covered Services that warrant preliminary investigation by the
Contractor.
Medicaid
Advantage Contract
SECTION
18
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-3
B)
The
Contractor must also submit to the SDOH the following on an ongoing basis for
each confirmed case of fraud or abuse it identifies through Complaints,
organizational monitoring, contractors, subcontractors, providers,
beneficiaries, Enrollees, etc related to Medicaid Only Covered
Services:
1)
The
name of the individual or entity that committed the fraud or abuse;
2)
The
source that identified the fraud or abuse;
3)
The
type of provider, entity or organization that committed the fraud or
abuse;
4)
A
description of the fraud or abuse;
5)
The
approximate dollar amount of the fraud or abuse;
6)
The
legal and administrative disposition of the case including actions taken by
law
enforcement officials to whom the case has been referred; and
7)
Other
data/information as prescribed by XXXX.
C)
Such
report shall be submitted when cases of fraud or abuse are confirmed, and shall
be reviewed and signed by an executive officer of the Contractor.
viii)
Participating Provider Network Reports:
The
Contractor shall submit electronically to the HPN, an updated provider network
report on a quarterly basis for providers of Medicaid Only Covered Services
as
defined in this Agreement and described in Appendix IC-2. The Contractor shall
submit an annual notarized attestation that the providers listed in each
submission have executed an agreement with the Contractor to serve Contractor's
Medicaid Enrollees. The report submission must comply with the Managed Care
Provider Network Data Dictionary. Networks must be reported separately for
each
county in which the Contractor operates.
ix)
Quality Assessment and Performance Improvement Projects
The
Contractor will submit reports to SDOH on all quality assessment and performance
improvement projects directed by CMS for the Medicare Advantage Program,
including the annual report on the Contractor's Chronic Care Improvement
Program. Reports should be duplicative of reports submitted to CMS, and separate
reports for the dual eligible population are not required.
x)
Additional Reports
Upon
request by the SDOH, the Contractor shall prepare and submit other operational
data reports. Such requests will be limited to situations in
Medicaid
Advantage Contract
SECTION
18
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-4
which
the
desired data is considered essential and cannot be obtained through existing
Contractor reports. Whenever possible, the Contractor will be provided with
ninety (90) days notice and the opportunity to discuss and comment on the
proposed requirements before work is begun. However, the SDOH reserves the
right
to give thirty (30) days notice in circumstances where time is of the
essence.
18.7
Ownership and Related Information Disclosure
The
Contractor shall report ownership and related information to SDOH, and upon
request to the Secretary of Health and Human Services and the Inspector General
of Health and Human Services, in accordance with 42 U.S.C. §§ 1320a-3 and
1396b(m)(4) (Sections 1124 and 1903(m)(4) of the SSA).
18.8
Public Access to Reports
Any
data,
information, or reports collected and prepared by the Contractor and submitted
to NYS authorities in the course of performing their duties and obligation
under
this program will be deemed to be a record of the SDOH subject to and consistent
with the requirements of Freedom of Information Law. This provision is made
in
consideration of the Contractor's participation in the Medicaid Advantage
Program for which the data and information is collected, reported, prepared
and
submitted.
18.9
Certification Regarding Individuals Who Have Been Debarred Or Suspended
By
Federal,
State, or Local Government
Contractor
will certify to the SDOH initially and immediately upon changed circumstances
from the last such certification that it does not knowingly have an individual
who has been debarred or suspended by the federal, state or local government,
or
otherwise excluded from participating in procurement activities:
a)
as a
director, officer, partner or person with beneficial ownership of more than
five
percent (5%) of the Contractor's equity; or
b)
as a
party to an employment, consulting or other agreement with the Contractor for
the provision of items and services that are significant and material to the
Contractor's obligations in the Medicaid managed care program, consistent with
requirements of SSA § 1932 (d)(l).
18.10
Conflict of Interest Disclosure
Contractor
shall report to SDOH, in a format specified by SDOH, documentation, including
but not limited to the identity of and financial statements of, person(s) or
corporation(s) with an ownership or contract interest in the managed care plan,
or with any subcontract(s) in which the managed care plan has a five percent
(5%)
Medicaid
Advantage Contract
SECTION
18
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-5
or
more
ownership interest, consistent with requirements of SSA § 1903 (m)(2)(a)(viii)
and 42 CFR §§ 455.100 - 455.104.
18.11
Physician Incentive Plan Reporting
The
Contractor shall submit to SDOH annual reports containing the information on
all
of its Physician Incentive Plan arrangements in accordance with 42 CFR § 438.6
(h) or, if no such arrangements are in place, attest to that. The contents
and
time frame of such reports shall comply with the requirements of 42 CFR §§
422.208 and 422.210 and be in a format provided by SDOH.
Medicaid
Advantage Contract
SECTION
18
(CONTRACTOR
REPORTING REQUIREMENTS)
State
2006
18-6
19.
RECORDS MAINTENANCE
AND AUDIT RIGHTS
19.1
Maintenance of Contractor Performance Records
a)
The
Contractor shall maintain and shall require its subcontractors, including its
Participating Providers, to maintain appropriate records relating to Contractor
performance under this Agreement, including:
i)
records related to services provided to Enrollees, including a separate Medical
Record for each Enrollee;
ii)
all
financial records and statistical data that SDOH and DHHS and any other
authorized governmental agency may require including books, accounts, journals,
ledgers, and all financial records relating to capitation payments, third party
health insurance recovery, and other revenue received and expenses incurred
under this Agreement;
iii)
appropriate financial records to document fiscal activities and expenditures,
including records relating to the sources and application of funds and to the
capacity of the Contractor or its subcontractors, including its Participating
Providers, if applicable, to bear the risk of potential financial
losses.
b)
The
record maintenance requirements of this Section shall survive the termination,
in whole or in part, of this Agreement.
19.2
Maintenance of Financial Records and Statistical Data
The
Contractor shall maintain all financial records and statistical data according
to generally accepted accounting principles.
19.3
Access to Contractor Records
The
Contractor shall provide SDOH, the Comptroller of the State of New York, DHHS,
the Comptroller General of the United States, and their authorized
representatives with access to all records relating to Contractor performance
under this Agreement for the purposes of examination, audit, and copying (at
reasonable cost to the requesting party) of such records. The Contractor shall
give access to such records on two (2) business days prior written notice,
during normal business hours, unless otherwise provided or permitted by
applicable laws, rules, or regulations.
19.4
Retention Periods
The
Contractor shall preserve and retain all records relating to Contractor
performance under this Agreement in readily accessible form during the term
of
Medicaid
Advantage Contract
SECTION
19
(RECORDS
MAINTENANCE AND AUDIT RIGHTS)
State
2006
19-1
this
Agreement and for a period of six (6) years thereafter except that the
Contractor shall retain Enrollees' medical records that are in the custody
of
the Contractor for six (6) years after the date of service rendered to the
Enrollee or cessation of Contractor operation, and in the case of a minor,
for
six (6) years after majority. The Contractor shall require and make reasonable
efforts to assure that Enrollees' medical records are retained by providers
for
six (6) years after the date of service rendered to the Enrollee or cessation
of
Contractor operation, and in the case of a minor, for six (6) years after
majority. All provisions of this Agreement relating to record maintenance and
audit access shall survive the termination of this Agreement and shall bind
the
Contractor until the expiration of a period of six (6) years commencing with
termination of this Agreement or if an audit is commenced, until the completion
of the audit, whichever occurs later. If the Contractor becomes aware of any
litigation, claim, financial management review or audit that is started before
the expiration of the six (6) year period, the records shall be retained until
all litigation, claims, financial management reviews or audit findings involved
in the record have been resolved and final action taken.
Medicaid
Advantage Contract
SECTION
19
(RECORDS
MAINTENANCE AND AUDIT RIGHTS)
State
2006
19-2
20.
CONFIDENTIALITY
20.1
Confidentiality of Identifying Information about Enrollees, Eligible Persons,
and Prospective Enrollees
All
information relating to services to Enrollees, Eligible Persons and Prospective
Enrollees which is obtained by the Contractor shall be confidential pursuant
to
the PHL including PHL Article 27-F, the provisions of Section 369(4) of the
SSL,
42 U.S.C. § 1396a (a)(7) (Section 1902(a)(7) of SSA), Section 33.13 of the
Mental Hygiene Law, and regulations promulgated under such laws including 42
CFR
§422.118 and 42 CFR Part 2 pertaining to Alcohol and Substance Abuse Services.
Such information including information relating to services provided to
Enrollees, Eligible Persons and Prospective Enrollees under this Agreement
shall
be used or disclosed by the Contractor only for a purpose directly connected
with performance of the Contractor's obligations. It shall be the responsibility
of the Contractor to inform its employees and contractors of the confidential
nature of Medicaid information.
20.2
Confidentiality of Medical Records
Medical
records of Enrollees pursuant to this Agreement shall be confidential and shall
be disclosed to and by other persons within the Contractor's organization
including Participating Providers, only as necessary to provide medical care,
to
conduct quality assurance functions and peer review functions, or as necessary
to respond to a complaint and appeal under the terms of this
Agreement.
20.3
Length of Confidentiality Requirements
The
provisions of this Section shall survive the termination of this Agreement
and
shall bind the Contractor so long as the Contractor maintains any individually
identifiable information relating to Enrollees, Eligible Persons and Prospective
Enrollees.
Medicaid
Advantage Contract
SECTION
20
(CONFIDENTIALITY)
State
2006
20-1
21.
PARTICIPATING PROVIDERS
21.1
General Requirements
a)
The
Contractor agrees to comply with all applicable requirements and standards
set
forth at 42 CFR Section 422.112, Subpart C; Part 422, Subpart E; Section
422.504(a)(6) and 422.504(i), Subpart K; Part 423, subpart C and other
applicable federal laws and regulations related to MCO relationships with
providers and with related entities, contractors and subcontractors for services
in the Contractor's Medicare Advantage Product.
b)
The
Contractor agrees to comply with all applicable requirements and standards
set
forth at PHL Article 44, 10 NYCRR Part 98, and other applicable federal and
state laws and regulations related to MCO relationships with providers and
with
related entities, contractors and subcontractors for services in the
Contractor's Medicaid Advantage Product.
21.2
Medicaid Advantage Network Requirements
a)
The
Contractor will establish and maintain a network of Participating Providers
that
is supported by written agreements and is sufficient to provide adequate access
to covered services to meet the needs ofEnrollees.
b)
In
establishing the network, the Contractor must consider the
following:
anticipated
Enrollment, expected utilization of Medicaid Only Covered Services by the
population to be enrolled, the number and types of providers necessary to
furnish the services in the Medicaid Advantage Benefit Package, the number
of
providers who are not accepting new patients, and the geographic location of
the
providers and Enrollees.
c)
The
Contractor's Medicaid Advantage Plan network must contain all of the provider
types necessary to furnish Medicaid Only Covered Services to Enrollees,
including inpatient mental health services beyond the 190-day lifetime limit;
non-Medicare covered home health services; private duty nursing services, and
dental health services and non-emergency transportation services when included
in the Contractor's Medicaid Advantage Product.
d)
To be
considered accessible, the network must contain a sufficient number and array
of
providers to meet the diverse needs of the Enrollee population. This includes
being geographically accessible (meeting time/distance standards) and being
accessible for the disabled.
e)
The
Contractor shall not include in its network any provider who has been sanctioned
or prohibited from participation in Federal health care programs under either
Section 1128 or Section 1128A of the SSA, or who has had his/her license
suspended by the New York State Education Department or the SDOH Office of
Professional Medical Conduct.
Medicaid
Advantage Contract
SECTION
21
(PROVIDER
NETWORK AND AGREEMENTS)
State
2006
21-1
21.3
SDOH
Exclusion or Termination of Providers
If
SDOH
excludes or terminates a provider from its Medicaid Program, the Contractor
shall, upon learning of such exclusion or termination, immediately terminate
the
provider agreement with the Participating Provider with respect to the
Contractor's Medicaid Advantage Product, and agrees to no longer utilize the
services of the subject provider, as applicable. The Contractor shall access
information pertaining to excluded Medicaid providers through the SDOH HPN.
Such
information available to the Contractor on the HPN shall be deemed to constitute
constructive notice. The HPN should not be the sole basis for identifying
current exclusions or termination of previously approved providers. Should
the
Contractor become aware, through the HPN or any other source, of an SDOH
exclusion or termination, the Contractor shall validate this information with
the Office of Medicaid Management, Bureau of Enforcement Activities and comply
with the provisions of this Section.
21.4
Payment in Full
Contractor
must limit participation to providers who agree that payment received from
the
Contractor for services included in the Medicare and Medicaid Advantage Benefit
Package is payment in full for services provided to Enrollees, except for the
collection of applicable co-payments from Enrollees as provided by
law.
21.5
Dental Networks
If
the
Contractor includes dental services in its Medicaid Advantage Benefit Package,
the Contractor's dental network shall include geographically accessible general
dentists sufficient to offer each Enrollee a choice of two (2) primary care
dentists in their Service Area and to achieve a ratio of at least one (1)
primary care dentist for each 2,000 Enrollees. Networks must also include at
least one (1) oral surgeon. Orthognathic surgery, temporal mandibular disorders
(TMD) and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists and
endodontists must also be available by referral. The network should include
dentists with expertise in serving special needs populations (e.g., HIV+ and
developmentally disabled patients).
Dental
surgery performed in an ambulatory or inpatient setting is covered by the
Contractor's Medicare Advantage Product.
Medicaid
Advantage Contract
SECTION
21
(PROVIDER
NETWORK AND AGREEMENTS)
State
2006
21-2
22.
SUBCONTRACTS AND PROVIDER AGREEMENTS FOR MEDICAID ONLY COVERED
SERVICES
22.1
Written Subcontracts
a)
Contractor may not enter into any subcontracts related to the delivery of
Medicaid Only Covered Services to Enrollees, except by a written
agreement.
b)
If the
Contractor enters into subcontracts for the performance of work pursuant to
this
Agreement, the Contractor shall retain full responsibility for performance
of
the subcontracted services. Nothing in this subcontract shall impair the rights
of the State under this Agreement. No sub-contractual relationship shall be
deemed to exist between the subcontractor and the SDOH or the
State.
c)
The
delegation by the Contractor of its responsibilities assumed by this Agreement
to any subcontractors will be limited to those specified in the
subcontracts.
22.2
Permissible Subcontracts
Contractor'may
subcontract for provider services as set forth in Section 2.6 and 21 of this
Agreement, for management services and for other services as are acceptable
to
the SDOH. The Contractor must evaluate the prospective subcontractor's ability
to perform the activities to be delegated.
22.3
Provision of Services through Provider Agreements
All
medical care and/or services covered under this Agreement, with the exception
of
Emergency Services, Family Planning and Reproductive Health Services, and
services for which Enrollees can self refer, shall be provided through Provider
Agreements with Participating Providers.
22.4
Approvals
a)
Provider Agreements related to Medicaid Only Covered Services shall require
the
approval of SDOH as set forth in PHL § 4402 and 10 NYCRR Part 98.
b)
If a
subcontract is for management services under 10 NYCRR Part 98, it must be
approved by SDOH prior to its becoming effective.
c)
The
Contractor shall notify SDOH of any material amendments to any such Provider
Agreement as set forth in 10 NYCRR Part 98.
Medicaid
Advantage Contract
SECTION
22
(PROVIDER
AGREEMENTS)
State
2006
22-1
22.5
Required Components
a)
All
subcontracts, including Provider Agreements entered into by the Contractor
to
provide program services under this Agreement shall contain provisions
specifying:
i)
the
activities and reporting responsibilities delegated to the subcontractor; and
provide for revoking the delegation, in whole or in part, and imposing other
sanctions if the subcontractor's performance does not satisfy standards set
forth in this Agreement, and an obligation for the provider to take corrective
action;
ii)
that
the work performed by the subcontractor must be in accordance with the terms
of
this Agreement; and
iii)
that
the subcontractor specifically agrees to be bound by the confidentiality
provisions set forth in this Agreement.
b)
The
Contractor shall impose obligations and duties on its subcontractors, including
its Participating Providers, that are consistent with this Agreement, and that
do not impair any rights accorded to LDSS, SDOH, or DHHS.
c)
No
subcontract, including any Provider Agreement shall limit or terminate the
Contractor's duties and obligations under this Agreement.
d)
Nothing contained in this Agreement shall create any contractual relationship
between any subcontractor of the Contractor, including its Participating
Providers, and the SDOH
e)
Any
subcontract entered into by the Contractor shall fulfill the requirements of
42
CFR Part 438 that are appropriate to the service or activity delegated under
such subcontract.
f)
The
Contractor shall also ensure that, in the event the Contractor fails to pay
any
subcontractor, including any Participating Provider in accordance with the
subcontract or Provider Agreement, the subcontractor or Participating Provider
will not seek payment from the SDOH, LDSS, the Enrollees, or persons acting
on
an Enrollee's behalf.
g)
The
Contractor shall include in every Provider Agreement a procedure for the
resolution of disputes between the Contractor and its Participating
Providers.
h)
The
Contractor must monitor the subcontractor's performance on an ongoing basis
and
subject it to formal review according to time frames established by the State,
consistent with State laws and regulations, and the terms of this
Agreement. When
deficiencies or areas for improvement are identified, the Contractor and
subcontractor must take corrective action.
Medicaid
Advantage Contract
SECTION
22
(PROVIDER
AGREEMENTS)
State
2006
22-2
22.6
Timely Payment
Contractor
shall make payments to health care providers for items and services included
in
the Contractor's Medicaid Advantage Product on a timely basis, consistent with
the claims payment procedures described in SIL § 3224-a.
22.7
Physician Incentive Plan
a)
If
Contractor elects to operate a Physician Incentive Plan, Contractor agrees
that
no specific payment will be made directly or indirectly under the plan to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an Enrollee. Contractor agrees to submit to
SDOH
annual reports containing the information on its physician incentive plan in
accordance with 42 CFR § 438.6 (h). The contents of such reports shall comply
with the requirements of 42 CFR §§ 422.208 and 422.210 and be in a format to be
provided by SDOH.
b)
The
Contractor must ensure that any agreements for contracted services covered
by
this Agreement, such as agreements between the Contractor and other entities
or
between the Contractor's subcontracted entities and their contractors, at all
levels including the physician level, include language requiring that the
physician incentive plan information be provided by the sub-contractor in an
accurate and timely manner to the Contractor, in the format requested by
SDOH.
c)
In the
event that the incentive arrangements place the physician or physician group
at
risk for services beyond those provided directly by the physician or physician
group for an amount beyond the risk threshold of twenty five percent (25%)
of
potential payments for covered services (substantial financial risk), the
Contractor must comply with all additional requirements listed in regulation,
such as: conduct enrollee/disenrollee satisfaction surveys; disclose the
requirements for the physician incentive plans to its beneficiaries upon
request; and ensure that all physicians and physician groups at substantial
financial risk have adequate stop-loss protection. Any of these additional
requirements that are passed on to the subcontractors must be clearly stated
in
their Agreement.
Medicaid
Advantage Contract
SECTION
22
(PROVIDER
AGREEMENTS)
State
2006
22-3
23.
AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN
Contractor
must comply with Title II of the ADA and Section 504 of the Rehabilitation
Act
of 1973 for program accessibility, and must develop an ADA Compliance Plan
consistent with the applicable SDOH Guidelines for Medicaid MCO Compliance
with
the ADA set forth in Appendix J, which is hereby made a part of this Agreement
as if set forth fully herein. Said plan must be approved by the SDOH, be filed
with the SDOH and be kept on file by the Contractor.
24.
FAIR HEARINGS
24.1
Enrollee Access to Fair Hearing Process
Enrollees
in the Contractor's Medicaid Advantage Product may access the fair hearing
process related to services determined by the Contractor to be a Medicaid only
benefit or services determined by the Contractor to be a benefit under both
Medicare and Medicaid in accordance with applicable federal and state laws
and
regulations. The Contractor must abide by and participate in New York State's
Fair Hearing Process and comply with determinations made by a fair hearing
officer.
24.2
Enrollee Rights to a Fair Hearing
Enrollees
in the Contractor's Medicaid Advantage Product may request a fair hearing
regarding adverse LDSS determinations concerning enrollment, disenrollment
and
eligibility, and regarding the denial, termination, suspension or reduction
of a
service determined by the Contractor to be a Medicaid only benefit or a benefit
under both Medicare and Medicaid. For issues related to disputed services,
Enrollees must have received an adverse determination from the Contractor or
its
approved utilization review agent either overriding a recommendation to provide
services by a Participating Provider or confirming the decision of a
Participating Provider to deny those services. An Enrollee may also seek a
fair
hearing for a failure by the Contractor to act with reasonable promptness with
respect to such services. Reasonable promptness shall mean compliance with
the
time frames established for review of grievances and utilization review in
Sections 44 and 49 of the Public Health Law, the grievance system requirements
of 42 CFR Part 438 and Appendix F of this Agreement.
24.3
Contractor Notice to Enrollees
a)
Contractor must issue a written Notice of Action and notice of a right to
request a fair hearing within applicable timeframes to any Enrollee when taking
an adverse Action and when making an Appeal determination as provided in
Appendix F of this Agreement.
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SECTION
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2006
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-
b)
Contractor agrees to serve notice on affected Enrollees by mail and must
maintain documentation of such.
24.4
Aid
Continuing
a)
Contractor shall be required to continue the provision of services determined
by
the Contractor to be a Medicaid only benefit or a benefit under both Medicare
and Medicaid that are the subject of the fair hearing to an Enrollee (hereafter
referred to as "aid continuing") if so ordered by the OAH under the following
circumstances:
i)
Contractor has or is seeking to reduce, suspend or terminate such service or
treatment currently being provided;
ii)
Enrollee has filed a timely request for a fair hearing with OAH;
and
iii)
There is a valid order for the service or treatment from a Participating
Provider.
b)
Contractor shall provide aid continuing until the matter has been resolved
to
the Enrollee's satisfaction or until the administrative process is completed
and
there is a determination from OAH that Enrollee is not entitled to receive
the
service, the Enrollee withdraws the request for aid continuing and/or the fair
hearing in writing, or the service or treatment originally ordered by the
provider has been completed, whichever occurs first.
c)
If the
services and/or benefits in dispute have been terminated, suspended or reduced
and the Enrollee requests a fair hearing in a timely manner, Contractor shall,
at the direction of either SDOH or LDSS, restore the disputed services and/or
benefits consistent with the provisions of Section 24.4 of this
Agreement.
24.5
Responsibilities of SDOH
SDOH
will
make every reasonable effort to ensure that the Contractor receives timely
notice in writing by fax, or e-mail, of all requests, schedules and directives
regarding fair hearings.
24.6
Contractor's Obligations
a)
Contractor shall appear at all scheduled fair hearings concerning its clinical
determinations and/or Contractor-initiated Disenrollments to present evidence
as
justification for its determination or submit written evidence as justification
for its determination regarding the disputed benefits and/or services. If
Contractor will not be making a personal appearance at the fair hearing, the
written material must be submitted to OAH and Enrollee or Enrollee's
representative at least three (3) business days prior to the scheduled hearing.
If the hearing is scheduled fewer than three (3) business days after the
request, Contractor must deliver the evidence to the hearing site no later
than
one (1)
Medicaid
Advantage Contract
SECTION
23 -SECTION 35
State
2006
-2-
business
day prior to the hearing, otherwise Contractor must appear in person.
Notwithstanding the above provisions. Contractor may be required to make a
personal appearance at the discretion of the hearing officer and/or
SDOH.
b)
Despite an Enrollee's request for a State fair hearing in any given dispute,
Contractor is required to maintain and operate in good faith its own internal
Complaint and Appeal processes for services determined by the Contractor to
be a
Medicaid only benefit or a benefit under both Medicare and Medicaid as required
under state and federal laws and by Section 14 and Appendix F of this Agreement.
Enrollees may seek redress of Adverse Determinations simultaneously through
Contractor's internal process and the State fair hearing process. If Contractor
has reversed its initial determination and provided the service to the Enrollee,
Contractor may request a waiver from appearing at the hearing and, in submitted
papers, explain that it has withdrawn its initial determination and is providing
the service or treatment formerly in dispute.
c)
Contractor shall comply with all determinations rendered by OAH at fair
hearings. Contractor shall cooperate with SDOH efforts to ensure that Contractor
is in compliance with fair hearing determinations. Failure by Contractor to
maintain such compliance shall constitute breach of this Agreement. Nothing
in
this Section shall limit the remedies available to SDOH, LDSS or the federal
government relating to any non-compliance by Contractor with a fair hearing
determination or Contractor's refusal to provide disputed services.
d)
If
SDOH investigates a Complaint that has as its basis the same dispute that is
the
subject of a pending fair hearing and, as a result of its investigation,
concludes that the disputed services and/or benefits should be provided to
the
Enrollee, Contractor shall comply with SDOH's directive to provide those
services and/or benefits and provide notice to OAH and Enrollee as required
by
Section 24.6(b) of this Agreement.
e)
If
SDOH, through its Complaint investigation process, or OAH, by a determination
after a fair hearing, directs Contractor to provide a service that was initially
denied by Contractor, Contractor may either directly provide the service,
arrange for the provision of that service or pay for the provision of that
service by a Non-Participating Provider. If the services were not furnished
during the period in which the fair hearing was pending, the Contractor must
authorize and furnish the disputed services promptly and as expeditiously as
the
Enrollee's health condition requires.
f)
Contractor agrees to abide by changes made to this Section of the Agreement
with
respect to the fair hearing, Service Authorization, Action, Action Appeal,
Complaint and Complaint Appeal processes by SDOH in order to comply with any
amendments to applicable state or federal statutes or regulations.
Medicaid
Advantage Contract
SECTION
23 -SECTION 35
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2006
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g)
Contractor agrees to identify a contact person within its organization who
will
serve as a liaison to SDOH for the purpose of receiving fair hearing requests,
scheduled fair hearing dates and adjourned fair hearing dates and compliance
with State directives. Such individual shall be accessible to the State by
e-mail; shall monitor e-mail for correspondence from the State at least once
every business day; and shall agree, on behalf of Contractor, to accept notices
to the Contractor transmitted via e-mail as legally valid.
h)
The
information describing fair hearing rights, aid continuing. Service
Authorization, Action Appeal, Complaint and Complaint Appeal procedures shall
be
included in all Medicaid Advantage member handbooks and shall comply with
Section 14, and Appendix F of this Agreement.
i)
Contractor shall bear the burden of proof at hearings regarding the reduction,
suspension or termination of ongoing services determined by the Contractor
to be
a Medicaid only benefit or a benefit under both Medicare and Medicaid. In the
event that Contractor's initial adverse determination is upheld as a result
of a
fair hearing, any aid continuing provided pursuant to that hearing request,
may
be recouped by Contractor.
25.
EXTERNAL APPEAL
25.1
Basis for External Appeal
Enrollees
in the Contractor's Medicaid Advantage Product are eligible to request an
External Appeal when one or more health care service determined by the
Contractor to be a Medicaid only benefit or a benefit under both Medicare and
Medicaid has been denied by the Contractor on the basis that the service(s)
is
not medically necessary or is experimental or investigational.
25.2
Eligibility for External Appeal
An
Enrollee is eligible for an External Appeal when the Enrollee has received
a
final adverse determination from the Contractor for an expedited internal Action
Appeal, has received a final adverse determination from the Contractor, or
both
the Enrollee and the Contractor have agreed to waive internal Action Appeal
procedures in accordance with PHL § 4914 (2) 2 (a). A provider is also eligible
for an External Appeal of retrospective denials.
25.3
External Appeal Determination
The
External Appeal determination is binding on the Contractor; however, a fair
hearing determination supercedes an external appeal determination for Medicaid
Advantage Enrollees.
Medicaid
Advantage Contract
SECTION
23 -SECTION 35
State
2006
-4-
25.4
Compliance with External Appeal Laws and Regulations
The
Contractor must comply with the provisions of Sections 4910-4914 of the PHL
and
10 NYCRR Part 98 regarding the External Appeal program with respect to services
determined by the Contractor to be a Medicaid only benefit or a benefit under
both the Medicare and Medicaid programs.
25.5
Member Handbook
The
Contractor shall describe its Action and utilization review policies and
procedures, including a notice of the right to an External Appeal together
with
a description of the External Appeal process and the timeframes for External
Appeal in the Medicaid Advantage Handbook;
26.
INTERMEDIATE SANCTIONS
26.1
General
Contractor
is subject to imposition of sanctions as authorized by 42 CFR 422, Subpart
0. In
addition, for the Medicaid Advantage Program, the Contractor is subject to
the
imposition of sanctions as authorized by State and Federal law and regulation,
including the SDOH's right to impose sanctions for unacceptable practices as
set
forth in 18 NYCRR Part 515 and civil and monetary penalties as set forth in
18
NYCRR Part 516 and 43 CFR § 438.700, and such other sanctions and penalties as
are authorized by local laws and ordinances and resultant administrative codes,
rules and regulations related to the Medical Assistance Program or to the
delivery of the contracted for services.
26.2
Unacceptable Practices
a)
Unacceptable practices for which the Contractor may be sanctioned include,
but
are not limited to:
i)
Failing to provide medically necessary services that the Contractor is required
to provide under its contract with the State. ii) Imposing premiums or charges
on Enrollees that are in excess of the premiums or charges permitted under
the
Medicaid Advantage Program;
iii)
Discriminating among Enrollees on the basis of their health status or need
for
health care services.
iv)
Misrepresenting or falsifying information that the Contractor furnishes to
an
Enrollee, Eligible Persons, Prospective Enrollees, health care providers, the
State or to CMS. v) Failing to comply with the requirements for Physician
Incentive Plans, as set forth in 42 CFR §§ 422.208 and 422.210.
vi)
Distributing directly or through any agent or independent contractor, marketing
materials that have not been approved by CMS and the State or that contain
false
or materially misleading information.
Medicaid
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SECTION
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vii)
Violating any other applicable requirements of SSA §§ 1903 (m) or 1932 and any
implementing regulations
viii)
Violating any other applicable requirements of 18 NYCRR or 10 NYCRR Part 98.
ix)
Failing to comply with the terms of this Agreement.
26.3
Intermediate Sanctions
a)
Intermediate Sanctions may include, but are not limited to:
i)
Civil
and monetary penalties.
ii)
Suspension of all new Enrollment, after the effective date of the
sanction.
iii)
Termination of the Agreement, pursuant to Section 2.7 of this
Agreement.
26.4
Enrollment Limitations
a)
The
SDOH shall have the right, upon notice to the LDSS, to limit, suspend, or
terminate Enrollment activities by the Contractor and/or enrollment into the
Contractor's Medicaid Advantage Product upon ten (10) days written notice to
the
Contractor. The written notice shall specify the action(s) contemplated and
the
reason(s) for such action(s) and shall provide the Contractor with an
opportunity to submit additional information that would support the conclusion
that limitation, suspension or termination of Enrollment activities or
Enrollment in the Contractor's plan is unnecessary. Nothing in this paragraph
limits other remedies available to the SDOH under this Agreement.
26.5
Due
Process
The
Contractor will be afforded due process pursuant to federal and state law and
regulations (42 CFR § 438.710,18 NYCRR Part 516, and Article 44 of the
PHL).
27.
ENVIRONMENTAL COMPLIANCE
The
Contractor shall comply with all applicable standards, orders, or requirements
issued under Section 306 of the Clean Air Act (42 U.S.C. § 1857(h)), Section 508
of the Federal Water Pollution Control Act as amended (33 U.S.C. § 1368),
Executive Order 11738, and the Environmental Protection Agency ("EPA")
regulations (40 CFR, Part 15) that prohibit the use of the facilities included
on the EPA List of Violating Facilities. The Contractor shall report violations
to SDOH and to the Assistant Administrator for Enforcement of the
EPA.
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Advantage Contract
SECTION
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28.
ENERGY CONSERVATION
The
Contractor shall comply with any applicable mandatory standards and policies
relating to energy efficiency that are contained in the State Energy
Conservation regulation issued in compliance with the Energy Policy and
Conservation Act of 1975 (Pub. L. 94-165) and any amendment to the
Act.
29.
INDEPENDENT CAPACITY OF CONTRACTOR
The
parties agree that the Contractor is an independent Contractor, and that the
Contractor, its agents, officers, and employees act in an independent capacity
and not as officers or employees of LDSS, DHHS or the SDOH.
30.
NO THIRD PARTY BENEFICIARIES
Only
the
parties to this Agreement and their successors in interest and assigns have
any
rights or remedies under or by reason of this Agreement.
31.
INDEMNIFICATION
31.1
Indemnification by Contractor
a)
The
Contractor shall indemnify, defend, and hold harmless the SDOH and LDSS, and
their officers, agents, and employees and the Enrollees and their eligible
dependents from
i)
any
and all claims and losses accruing or resulting to any and all
Contractors,
subcontractors, materialmen, laborers, and any other person, firm, or
corporation furnishing or supplying work, services, materials, or supplies
in
connection with the performance of this Agreement
ii)
any
and all claims and losses accruing or resulting to any person, firm, or
corporation that may be injured or damaged by the Contractor, its officers,
agents, employees, or subcontractors, including Participating Providers, in
connection with the performance of this Agreement;
iii)
any
liability, including costs and expenses, for violation of proprietary rights,
copyrights, or rights of privacy, arising out of the publication, translation,
reproduction, delivery, performance, use, or disposition of any data furnished
under this Agreement, or based on any libelous or otherwise unlawful matter
contained in such data.
b)
The
SDOH will provide the Contractor with prompt written notice of any claim made
against the SDOH, and the Contractor, at its sole option, shall defend or settle
said claim. The SDOH shall cooperate with the Contractor to the extent necessary
for the Contractor to discharge its obligation under Section 31.1.
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c)
The
Contractor shall have no obligation under this section with respect to any
claim
or cause of action for damages to persons or property solely caused by the
negligence of SDOH its employees, or agents.
31.2
Indemnification by SDOH
Subject
to the availability of lawful appropriations as required by State Finance Law
§
41, the SDOH agrees to indemnify and hold the Contractor harmless from any
liability, loss or damages, claim, suit or judgment, and all allowable costs
and
expenses of any kind or nature, as determined by the New York State Court of
Claims and arising out of the actions or the omissions of the SDOH, its
officers, agents or employees in connection with this Agreement. Provisions
concerning the SDOH's responsibility for any claims for liability as may arise
during the term of this Agreement are set forth in the New York State Court
of
Claims Act, and any damages arising for such liability shall issue from the
New
York State Court of Claims Fund or any applicable, annual appropriation of
the
Legislature for the State of New York.
32.
PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
32.1
Prohibition of Use of Federal Funds for Lobbying
The
Contractor agrees, pursuant to 31 U.S.C. § 1352 and 45 CFR Part 93, that no
Federally appropriated funds have been paid or will be paid to any person by
or
on behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection
with the award of any Federal contract, the making of any federal grant, the
making of any Federal loan, the entering into of any cooperative agreement,
or
the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement. The Contractor agrees to
complete and submit the "Certification Regarding Lobbying", Appendix B attached
hereto and incorporated herein, if this Agreement exceeds $100,000.
32.2
Disclosure Form to Report Lobbying
If
any
funds other than Federally appropriated funds have been paid or will be paid
to
any person for the purpose of influencing or attempting to influence an officer
or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with the award
of
any Federal contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds $100,000,
the
Contractor shall complete and submit Standard Form-LLL "Disclosure Form to
Report Lobbying," in accordance with its instructions.
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32.3
Requirements of Subcontractors
The
Contractor shall include the provisions of this section in its subcontracts,
including its Provider Agreements. For all subcontracts, including Provider
Agreements, that exceed $100,000, the Contractor shall require the
subcontractor, including any Participating Provider to certify and disclose
accordingly to the Contractor.
33.
NON-DISCRIMINATION
33.1
Equal Access to Benefit Package
Except
as
otherwise provided in applicable sections of this Agreement the Contractor
shall
provide the Medicaid Advantage Benefit Package to all Enrollees in the same
manner, in accordance with the same standards, and with the same priority as
Enrollees of the Contractor enrolled under any other contracts.
33.2
Non-Discrimination
The
Contractor shall not discriminate against Eligible Persons or Enrollees on
the
basis of age, sex, race, creed, physical or mental handicap/developmental
disability, national origin, sexual orientation, type of illness or condition,
need for health services, or Capitation Rate that the Contractor will receive
for such Eligible Persons or Enrollees.
33.3
Equal Employment Opportunity
Contractor
must comply with Executive Order 11246, entitled "Equal Employment Opportunity"
as amended by Executive Order 11375, and as supplemented in Department of Labor
regulations.
33.4
Native Americans Access to Services from Tribal or Urban Indian Health
Facility
The
Contractor shall not prohibit, restrict or discourage enrolled Native Americans
from receiving care from or accessing Medicaid reimbursed health services from
or through a tribal health or urban Indian health facility or
center.
34.
COMPLIANCE WITH APPLICABLE LAWS AND REGULATIONS
34.1
Contractor and SDOH Compliance with Applicable Laws
Notwithstanding
any inconsistent provisions in this Agreement, the Contractor and SDOH shall
comply with all applicable requirements of the State Public Health Law; the
State Insurance Law; the State Social Services Law; and state regulations
related to the aforementioned state statutes. Such state laws and
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regulations
shall not be deemed to be applicable to the extent that they are pre-empted
by
federal laws. The Contractor also shall comply with Titles XVIII and XIX of
the
Social Security Act and regulations promulgated thereunder, including but not
limited to 43 CFR Part 422 and Part 423; Title VI of the Civil Rights Act of
1964 and 45 C.F.R. Part 80, as amended; Section 504 of the Rehabilitation Act
of
1973 and 45 C.F.R. Part 84, as amended; Age Discrimination Act of 1975 and
45
C.F.R. Part 91, as amended; the ADA; Title XIII of the Federal Public Health
Services Act, 42 U.S.C. § 300e et seq., and the regulations promulgated there
under; the Health Insurance Portability and Accountability Act of 1996 (P.L.
104-191) and related regulations; and all other applicable legal and regulatory
requirements in effect at the time that this Agreement is signed and as adopted
or amended during the term of this Agreement. The parties agree that this
Agreement shall be interpreted according to the laws of the State of New
York.
34.2
Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
Should
any provision of this Agreement be declared or found to be illegal or
unenforceable, ineffective or void, then each party shall be relieved of any
obligation arising from such provision; the balance of this Agreement, if
capable of performance, shall remain in full force and effect.
34.3
Certificate of Authority Requirements
The
Contractor must satisfy conditions for issuance of a certificate of authority,
including proof of financial solvency, as specified in 10 NYCRR Part
98.
34.4
Notification of Changes in Certificate of Incorporation
The
Contractor shall notify SDOH of any amendment to its Certificate of
Incorporation or Articles of Organization pursuant to 10 NYCRR Part
98.
34.5
Contractor's Financial Solvency Requirements
The
Contractor, for the duration of this Agreement, shall remain in compliance
with
all applicable state requirements for financial solvency for MCOs participating
in the Medicaid Program. The Contractor shall continue to be financially
responsible as defined in PHL § 4403(1 )(c) and shall comply with the contingent
reserve fund and escrow deposit requirements of 10 NYCRR Part 98 and must meet
minimum net worth requirements established by SDOH and the State Insurance
Department. The Contractor shall make provision, satisfactory to SDOH, for
protections for SDOH, LDSS and the Enrollees in the event of HMO or
subcontractor insolvency, including but not limited to, hold harmless and
continuation of treatment provisions in all provider agreements which protect
SDOH, LDSSs and Enrollees from costs of treatment and assures continued access
to care for Enrollees.
Medicaid
Advantage Contract
SECTION
23 -SECTION 35
State
2006
-10-
34.6
Non-Liability ofEnrollees for Contractor's Debts
Contractor
agrees that in no event shall the Enrollee become liable for the Contractor's
debts as set forth in SSA § 1932(b)(6).
34.7
SDOH
Compliance with Conflict of Interest Laws
SDOH
and
its employees shall comply with Article 18 of the General Municipal Law and
all
other appropriate provisions of New York State law, local laws and ordinances
and all resultant codes, rules and regulations pertaining to conflicts of
interest.
34.8
Compliance Plan
The
Contractor agrees to implement a compliance plan in accordance with the
requirements of 42 CFR §422.503(b)(4)(vi) and 42 CFR § 438.608.
35.
NEW YORK STATE STANDARD CONTRACT CLAUSES
The
parties agree to be bound by the standard clauses for all New York State
contracts and standard clauses, if any, for local government contracts contained
in Appendix A, attached to and incorporated into this Agreement as if set forth
fully herein, and any amendment thereto.
Medicai
d
Advantage Contract
SECTION
23 -SECTION 35
State
2006
-11-
APPENDIX
A
New
York State Standard Contract Clauses
Medicaid
Advantage Contract
APPENDIX
A
State
2006
STANDARD
CLAUSES FOR NYS CONTRACTS
APPENDIX
A
STANDARD
CLAUSES FOR NYS CONTRACTS
The
parties to the attached contract, license, lease, amendment or other agreement
of any kind (hereinafter, "the contract" or "this contract") agree to be bound
by the following clauses which are hereby made a part of the contract (the
word
"Contractor" herein refers to any party other than the State, whether a
contractor, licenser, licensee, lessor, lessee or any other party):
1.
EXECUTORY CLAUSE.
In
accordance with Section 41 of the State Finance Law, the State shall have no
liability under this contract to the Contractor or to anyone else beyond funds
appropriated and available for this contract.
2.
NON-ASSIGNMENT
CLAUSE.
In
accordance with Section 138 of the State Finance Law, this contract may not
be
assigned by the Contractor or its right, title or interest therein assigned,
transferred, conveyed, sublet or otherwise disposed of without the previous
consent, in writing, of the State and any attempts to assign the contract
without the State's written consent are null and void. The Contractor may,
however, assign its right to receive payment without the State's prior written
consent unless this contract concerns Certificates of Participation pursuant
to
Article 5-A of the State Finance Law.
3.
COMPTROLLER'S
APPROVAL.
In
accordance with Section 112 of the State Finance Law (or, if this contract
is
with the State University or City University of New York, Section 355 or Section
6218 of the Education Law), if this contract exceeds $15,000 (or the minimum
thresholds agreed to by the Office of the State Comptroller for certain S.U.N.Y.
and C.U.N.Y. contracts), or if this is an amendment for any amount to a contract
which, as so amended, exceeds said statutory amount, or if, by this contract,
the State agrees to give something other than money when the value or reasonably
estimated value of such consideration exceeds $10,000, it shall not be valid,
effective or binding upon the State until it has been approved by the State
Comptroller and filed in his office. Comptroller's approval of contracts let
by
the Office of General Services is required when such contracts exceed $30,000
(State Finance Law Section 163.6.a).
4.
WORKERS'
COMPENSATION BENEFITS.
In
accordance with Section 142 of the State Finance Law, this contract shall be
void and of no force and effect unless the Contractor shall provide and maintain
coverage during the life of this contract for the benefit of such employees
as
are required to be covered by the provisions of the Workers' Compensation
Law,
5.
NON-DISCRIMINATION
REQUIREMENTS.
To the
extent required by Article 15 of the Executive Law (also known as the Human
Rights Law) and all other State and Federal statutory and constitutional
non-discrimination provisions, the Contractor will not discriminate against
any
employee or applicant for employment because of race, creed, color, sex,
national origin, sexual orientation, age, disability, genetic predisposition
or
carrier status, or marital status. Furthermore, in accordance with Section
220-e
of the Labor Law, if this is a contract for the construction, alteration or
repair of any public building or public work or for the manufacture, sale or
distribution of materials, equipment or supplies, and to the extent that this
contract shall be performed within the State of New York, Contractor agrees
that
neither it not its subcontractors shall, by reason of race, creed, color,
disability, sex, or national origin: (a) discriminate in hiring against any
New
York State citizen who is qualified and available to perform the work; or (b)
discriminate against or intimidate any employee hired for the performance of
work under this contract. If this is a building service contract as defined
in
Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
Contractor agrees that neither it nor its subcontractors shall by reason of
race, creed, color, national origin, age, sex or disability: (a) discriminate
in
hiring against any New York State citizen who is qualified and available to
perform die work; or (b) discriminate against or intimidate any employee hired
for the performance
of work under this contract. Contractor is subject to fines of $50.00 per person
per day for any violation of Section 220-e or Section 239 as well as possible
termination of this contract and forfeiture of all moneys due hereunder for
a
second or subsequent violation.
6.
WAGE
AND HOURS PROVISIONS.
If this
is a public work
contract
covered by Article 8 of the Labor Law or a building service contract covered
by
Article 9 thereof, neither Contractor's employees nor the employees of its
subcontractors may be required or permitted to work more than the number of
hours or days stated in said statutes, except as otherwise provided in the
Labor
Law and as set forth in prevailing wage and supplement schedules issued by
the
State Labor Department. Furthermore, Contractor and its subcontractors must
pay
at least the prevailing wage rate and pay or provide the prevailing supplements,
including the premium rates for overtime pay, as determined by the State Labor
Department in accordance with the Labor Law.
7.
NON-COLLUSIVE BIDDING CERTIFICATION.
In
accordance
with
Section 139-d of the State Finance Law, if this contract was awarded based
upon
the submission of bids. Contractor warrants, under penalty of perjury, that
its
bid was arrived at independently and without collusion aimed at restricting
competition. Contractor further warrants that, at the time Contractor submitted
its bid, an authorized and responsible person executed and delivered to the
State a non-collusive bidding certification on Contractor's behalf.
8.
INTERNATIONAL
BOYCOTT PROHIBITION.
In
accordance
with
Section 220-f of the Labor Law and Section 139-h of the State Finance Law,
if
this contract exceeds $5,000, the Contractor agrees, as a material condition
of
the contract, that neither the Contractor nor any substantially owned or
affiliated person, firm, partnership or corporation has participated, is
participating, or shall participate in an international boycott in violation
of
the federal Export Administration Act of 1979 (50 USC App. Sections 2401 et
seq.) or regulations thereunder. If such Contractor, or any of the aforesaid
affiliates of Contractor, is convicted or is otherwise found to have violated
said laws or regulations upon the final determination of the United States
Commerce Department or any other appropriate agency of the United States
subsequent to the contract's execution, such contract, amendment or modification
thereto shall be rendered forfeit and void. The Contractor shall so notify
the
State Comptroller within five (5) business days of such conviction,
determination or disposition of appeal (2NYCRR 105.4).
9.
SET-OFF
RIGHTS.
The
State shall have all of its common law, equitable and statutory rights of
set-off. These rights shall include, but not be limited to, the State's option
to withhold for the purposes of set-off any moneys due to the Contractor under
this contract up to any amounts due and owing to the State with regard to this
contract, any other contract with any State department or agency, including
any
contract for a term commencing prior to the term of this contract, plus any
amounts due and owing to the State for any other reason including, without
limitation, tax delinquencies, fee delinquencies or monetary penalties relative
thereto. The State shall exercise its set-off rights in accordance with normal
State practices including, in cases of set-off pursuant to an audit, the
finalization of such audit by the State agency, its representatives, or the
State Comptroller.
10.
RECORDS.
The
Contractor shall establish and maintain complete and
accurate books, records, documents, accounts and other evidence directly
pertinent to performance under this contract (hereinafter, collectively, "the
Records"). The Records must be kept for the balance of the calendar year in
which they were made and for six (6) additional years thereafter. The State
Comptroller, the Attorney General and any other person or entity authorized
to
conduct an examination, as well as the agency or agencies involved in this
contract, shall have access to the Records during normal business hours at
an
office of the Contractor
May,2003
STANDARD
CLAUSES FOR NYS CONTRACTS
APPENDIX
A
within
the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which
are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and
(ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.
11.
IDENTIFYING
INFORMATION AND PRIVACY NOTIFICATION,
(a)
FEDERAL EMPLOYER IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER.
All invoices or New York State standard vouchers submitted for payment for
the
sale of goods or services or the lease of real or personal property to a New
York State agency must include the payee's identification number, i.e., the
seller's or lessor's identification number. The number is either the payee's
Federal employer identification number or Federal social security number, or
both such numbers when the payee has both such numbers. Failure to include
this
number or numbers may delay payment. Where the payee does not have such number
or numbers, the payee, on its invoice or New York State standard voucher, must
give the reason or reasons why the payee does not have such number or
numbers.
(b)
PRIVACY NOTIFICATION. (1)
The
authority to request the above personal information from a seller of goods
or
services or a lessor of real or personal property, and the authority to maintain
such information, is found in Section 5 of the State Tax Law. Disclosure of
this
information by the seller or lessor to the State is mandatory. The principal
purpose for which the information is collected is to enable the State to
identify individuals, businesses and others who have been delinquent in filing
tax returns or may have understated their tax liabilities and to generally
identify persons affected by the taxes administered by the Commissioner of
Taxation and Finance. The information will be used for tax administration
purposes and for any other purpose authorized by law.
(2)
The
personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained in
New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, AESOB, Albany, New York 12236.
12.
EQUAL
EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN.
In
accordance with Section 312 of the Executive Law, if this contract is: (i)
a
written agreement or purchase order instrument, providing for a total
expenditure in excess of $25,000.00, whereby a contracting agency is committed
to expend or does expend funds in return for labor, services, supplies,
equipment, materials or any combination of the foregoing, to be performed for,
or rendered or furnished to the contracting agency; or (ii) a written agreement
in excess of $100,000.00 whereby a contracting agency is committed to expend
or
does expend funds for the acquisition, construction, demolition, replacement,
major repair or renovation of real property and improvements thereon; or (iii)
a
written agreement in excess of $100,000.00 whereby the owner of a State assisted
housing project is committed to expend or does expend funds for the acquisition,
construction, demolition, replacement, major repair or renovation of real
property and improvements thereon for such project, then:
(a)
The
Contractor will not discriminate against employees or applicants for employment
because of race, creed, color, national origin, sex, age, disability or marital
status, and will undertake or continue existing programs of affirmative action
to ensure that minority group members and women are afforded equal employment
opportunities without discrimination. Affirmative action shall mean recruitment,
employment,
job assignment, promotion, upgradings, demotion, transfer, layoff, or
termination and rates of pay or other forms of compensation;
(b)
at
the request of the contracting agency, the Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding, to
furnish a written statement that such employment agency, labor union or
representative will not discriminate on the basis of race, creed, color,
national origin, sex, age, disability or marital status and that such union
or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein; and
(c)
the
Contractor shall state, in all solicitations or advertisements for
employees,
that, in the performance of the State contract, all qualified applicants will
be
afforded equal employment opportunities without discrimination because of race,
creed, color, national origin, sex, age, disability or marital
status.
Contractor
will include the provisions of "a", "b", and "c" above, in every subcontract
over $25,000.00 for the construction, demolition, replacement, major repair,
renovation, planning or design of real property and improvements thereon (the
"Work") except where the Work is for the beneficial use of the Contractor.
Section 312 does not apply to: (i) work, goods or services unrelated to this
contract; or (ii) employment outside New York State; or (iii) banking services,
insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any federal
law concerning equal employment opportunity which effectuates the purpose of
this section. The contracting agency shall determine whether the imposition
of
the requirements of the provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful rules
and regulations of the Governor's Office of Minority and Women's Business
Development pertaining hereto.
13. CONFLICTING
TERMS.
In the
event of a conflict between the terms of the contract (including any and all
attachments thereto and amendments thereof) and the terms of this Appendix
A,
the terms of this Appendix A shall control.
14.
GOVERNING
LAW. This
contract shall be governed by the laws of the State of New York except where
the
Federal supremacy clause requires otherwise.
15. LATE
PAYMENT.
Timeliness of payment and any interest to be paid to Contractor for late payment
shall be governed by Article 11-A of the State Finance Law to the extent
required by law.
16.
NO
ARBITRATION.
Disputes
involving this contract, including
the
breach or alleged breach thereof, may not be submitted to binding arbitration
(except where statutorily authorized), but must, instead, be heard in a court
of
competent jurisdiction of the State of New York.
17.
SERVICE
OF PROCESS.
In
addition to the methods of service allowed by the State Civil Practice Law
&
Rules ("CPLR"), Contractor hereby consents to service of process upon it by
registered or certified mail, return receipt requested. Service hereunder shall
be complete upon Contractor's actual receipt of process or upon the State's
receipt of the return thereof by the United States Postal Service as refused
or
undeliverable. Contractor must promptly notify the State, in writing, of each
and every change of address to which service of process can be made. Service
by
the State to the last known address shall be sufficient. Contractor will have
thirty (30) calendar days after service hereunder is complete in which to
respond.
May,2003
STANDARD
CLAUSES FOR NYSCONTRACTS
APPENDIX
A
18.
PROHIBITION
ON PURCHASE OF TROPICAL HARDWOODS.
The
Contractor certifies and warrants that all wood products to be used under this
contract award will be in accordance with, but not limited to, the
specifications and provisions of State Finance Law §165. (Use of Tropical
Hardwoods) which prohibits purchase and use of tropical hardwoods, unless
specifically exempted, by the State or any governmental agency or political
subdivision or public benefit corporation. Qualification for an exemption under
this law will be the responsibility of the contractor to establish to meet
with
the approval of the State.
In
addition, when any portion of this contract involving the use of xxxxx, whether
supply or installation, is to be performed by any subcontractor, the prime
Contractor will indicate and certify in the submitted bid proposal that the
subcontractor has been informed and is in compliance with specifications and
provisions regarding use of tropical hardwoods as detailed in §165 State Finance
Law. Any such use must meet with the approval of the State; otherwise, the
bid
may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor to
meet
with the approval of the State.
19.
XXXXXXXX
FAIR EMPLOYMENT PRINCIPLES.
In
accordance
with the XxxXxxxx Fair Employment Principles (Chapter 807 of the Laws of 1992),
the Contractor hereby stipulates that the Contractor either (a) has no business
operations in Northern Ireland, or (b) shall take lawful steps in good faith
to
conduct any business operations in Northern Ireland in accordance with the
XxxXxxxx Fair Employment Principles (as described in Section 165 of the New
York
State Finance Law), and shall permit independent monitoring of compliance with
such principles.
20.
OMNIBUS
PROCUREMENT ACT OF 1992.
It is
the policy of New York State to maximize opportunities for the participation
of
New York State business enterprises, including minority and women-owned business
enterprises as bidders, subcontractors and suppliers on its procurement
contracts.
Information
on the availability of New York State subcontractors and suppliers is available
from:
NYS
Department of Economic Development
Division
for Small Business
00
Xxxxx
Xxxxx Xx - 0xx
Xxxxx
Albany,
New York 12245
Telephone:
000-000-0000
A
directory of certified minority and women-owned business enterprises is
available from:
NYS
Department of Economic Development
Division
of Minority and Women's Business Development
00
Xxxxx
Xxxxx Xx - 0xx Floor
Albany,
New York 12245
xxxx://xxx.xxxxxx.xxxxx.xx.xx
The
Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or
contract, as applicable, Contractors certify that whenever the total bid amount
is greater than $1 million:
(a)
The
Contractor has made reasonable efforts to encourage the participation of New
York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project, and
has retained the documentation of these efforts to be provided upon request
to
the State;
(b)
The
Contractor has complied with the Federal Equal Opportunity Act of 1972 (P.L.
92-261), as amended;
(c)
The
Contractor agrees to make reasonable efforts to provide notification to New
York
State residents of employment opportunities on this project through listing
any
such positions with the Job Service Division of the New York State Department
of
Labor, or providing such notification in such manner as is consistent with
existing collective bargaining contracts or agreements. The Contractor agrees
to
document these efforts and to provide said documentation to the State upon
request; and
(d)
The
Contractor acknowledges notice that the State may seek to obtain offset credits
from foreign countries as a result of this contract and agrees to cooperate
with
the State in these efforts.
21.
RECIPROCITY AND SANCTIONS PROVISIONS.
Bidders
are hereby notified that if their principal place of business is located in
a
country, nation, province, state or political subdivision that penalizes New
York State vendors, and if the goods or services they offer will be
substantially produced or performed outside New York State, the Omnibus
Procurement Act 1994 and 2000 amendments (Chapter 684 and Chapter 383,
respectively) require that they be denied contracts which they would otherwise
obtain. NOTE: As of May 15, 2002, the list of discriminatory jurisdictions
subject to this provision includes the states of South Carolina, Alaska, West
Virginia, Wyoming, Louisiana and Hawaii. Contact NYS Department of Economic
Development for a current list of jurisdictions subject to this
provision.
22.
PURCHASES
OF APPAREL.
In
accordance with State Finance
Law
162
(4-a), the State shall not purchase any apparel from any vendor unable or
unwilling to certify that: (i) such apparel was manufactured in compliance
with
all applicable labor and occupational safety laws, including, but not limited
to, child labor laws, wage and hours laws and workplace safety laws, and (ii)
vendor will supply, with its bid (or, if not a bid situation, prior to or at
the
time of signing a contract with the State), if known, the names and addresses
of
each subcontractor and a list of all manufacturing plants to be utilized by
the
bidder.
APPENDIX
B
Certification
Regarding Lobbying
Medicaid
Advantage Contract
APPENDIX
B
State
2006
X-x
APPENDIX
B CERTIFICATION REGARDING LOBBYING
The
undersigned certifies, to the best of his or her knowledge, that:
1.
No
Federal appropriated funds have been paid or will be paid to any person by
or on
behalf of the Contractor for the purpose of influencing or attempting to
influence an officer or employee of any agency, a Member of Congress, an officer
or employee of a Member of Congress in connection with the award of any Federal
loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement.
2.
If any
funds other than Federal appropriated funds have been paid or will be paid
to
any person for the purpose of influencing or attempting to influence an officer
or employee of any agency, a Member of Congress in connection with the award
of
any Federal contract, the making of any Federal grant, the making of any Federal
loan, the entering into of any cooperative agreement, or the extension,
continuation, renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds $100,000,
the
Contractor shall complete and submit Standard Form -LLL "Disclosure Form to
Report Lobbying", in accordance with its instructions.
3.
The
Contractor shall include the provisions of this section in all provider
Agreements under this Agreement and require all Participating providers whose
Provider Agreements exceed $ 100,000 to certify and disclose accordingly to
the
Contractor.
This
certification is a material representation of fact upon which reliance was
place
when this transaction was made or entered into. Submission of this certification
is a prerequisite for making or entering into this transaction pursuant to
U.S.C. Section 1352. The failure to file the required certification shall
subject the violator to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
DATE:
2/24/06
SIGNATURE:
/s/
Xxxx X. Xxxxx
TITLE: President
& CEO
ORGANIZATION:
WellCare
of New York. Inc.
Medicaid
Advantage Contract
APPENDIX
B
State
2006
B-2
APPENDIX
X-x
Certification
Regarding XxxXxxxx Fair Employment Principles
Medicaid
Advantage Contract
APPENDIX
B-1
State
2006
X-x
Page 1
APPENDIX
X-x
NONDISCRIMINATION
IN EMPLOYMENT IN NORTHERN IRELAND:
XxxXXXXX
FAIR EMPLOYMENT PRINCIPLES
Note:
Failure to stipulate to these principles may result in the contract being
awarded to another bidder. Governmental and non-profit organizations are
exempted from this stipulation requirement.
In
accordance with Chapter 807 of the Laws of 1992 (State Finance Law Section
174-b), the Contractor, by signing this Agreement, certifies that it or any
individual or legal entity in which the Contractor holds a 10% or greater
ownership interest, or any individual or legal entity that holds a 10% or
greater ownership interest in the Contractor, either:
•
has
business operations in Northern Ireland: Y__ N T
•
if
yes
to above, shall take lawful steps in good faith to conduct any business
operations they have in Northern Ireland in accordance with the XxxXxxxx Fair
Employment Principles relating to non-discrimination in employment and freedom
of workplace opportunity regarding such operations in Northern Ireland, and
shall permit independent monitoring of their compliance with such
Principles: Y___
N____
Medicaid
Advantage Contract
APPENDIX
B-1
State
2006
X-x
Page
2
Appendix
C
New
York
State Department of Health Requirements for the Provision of Free Access to
Family Planning and Reproductive Health Services
C.I
Definitions and General Requirements for the Provision of Family Planning and
Reproductive Health Services
C.2
Requirements for MCOs that Provide Family Planning and Reproductive Health
Services
C.3
Requirements for MCOs That Do Not Provide Family Planning and Reproductive
Health Services
Medicaid
Advantage Contract
APPENDIX
C
State
2006
C-l
C.I
Definitions
and General Requirements for the Provision of Family Planning and Reproductive
Health Services
1.
Family Planning and Reproductive Health Services
a)
Family
Planning and Reproductive Health Services mean the offering, arranging and
furnishing of those health services which enable Enrollees, including minors
who
may be sexually active, to prevent or reduce the incidence of unwanted
pregnancies.
i)
Family
Planning and Reproductive Health Services include the following
medically-necessary services, related drugs and supplies which are furnished
or
administered under the supervision of a physician, licensed midwife or certified
nurse practitioner during the course of a Family Planning and Reproductive
Health visit for the purposeof:
A)
contraception, including all FDA-approved birth control methods, devices such
as
insertion/removal of an intrauterine device (IUD)or insertion/removal of
contraceptive implants, and injection procedures involving Pharmaceuticals
such
as Depo-Provera;
B)
sterilization;
C)
emergency contraception and followup;
D)
screening, related diagnosis, and referral to a Participating Provider
for
pregnancy;
E)
medically-necessary induced abortions, which are procedures, either medical
or
surgical, that result in the termination of pregnancy. The determination of
medical necessity shall include positive evidence of pregnancy, with an estimate
of its duration.
ii)
Family Planning and Reproductive Health Services include those education and
counseling services necessary to render the services effective.
iii)
Family Planning and Reproductive Health Services include medically-necessary
ordered contraceptives and pharmaceuticals:
A)
The
Contractor is responsible for pharmaceuticals and medical supplies such as
IUDS
and Depo-Provera that must be furnished or administered under the supervision
of
a physician, licensed midwife, or certified nurse practitioner during the course
of a Family Planning and Reproductive Health visit and for
Medicaid
Advantage Contract
APPENDK
C
State
2006
C-2
prescription
drugs included in the Contractor's Medicare Part D Prescription Drug Benefit.
Over the counter drugs are not the responsibility of the Contractor and are
to
be obtained when covered on the New York State list of Medicaid reimbursable
drugs by the Enrollee from any appropriate eMedNY-enrolled health care provider
of the Enrollee's choice.
b)
When
clinically indicated, the following services may be provided as a part of a
Family Planning and Reproductive Health visit:
i)
Screening, related diagnosis, ambulatory treatment and referral as needed for
dysmenorrhea, cervical cancer, or other pelvic
abnormality/pathology.
ii)
Screening, related diagnosis and referral for anemia, cervical cancer,
glycosuria, proteinuria, hypertension and breast disease.
iii)
Screening and treatment for sexually transmissible disease.
iv)
HIV
blood testing and pre- and post-test counseling.
2.
Free Access to Services for Enrolles
a)
Free
Access means Enrolles may obtain Family Planning and Reproductive Health
Services, and HIV blood testing and pre-and post-test counseling when performed
as part of a Family Planning and Reproductive Health encounter, from either
the
Contractor, if it provides such services in its Medicare Advantage Benefit
Package, or from any appropriate eMedNY-enrolled health care provider of the
Enrollee's choice. No referral from the PCP
or
approval by the Contractor is required to access such services.
b)
The
Family Planning and Reproductive Health Services listed above are the only
services which are covered under the Free Access policy. Routine obstetric
and/or gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care are not covered under the Free Access policy, and are the
responsibility of the Contractor.
Medicaid
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APPENDIX
C
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2006
C-3
C.2
Requirements
for MCOs that Provide Family Planning and Reproductive Health
Services
1.
Notification to Enrollees
a)
If the
Contractor provides Family Planning and Reproductive Health Services, the
Contractor must notify all Enrollees of reproductive age at the time of
Enrollment about their right to obtain Family Planning and Reproductive Health
Services and supplies without referral or approval. The notification must
contain the following:
i)
Information about the Enrollee's right to obtain the full range of Family
Planning and Reproductive Health Services, including HIV counseling and testing
when performed as part of a Family Planning and Reproductive Health encounter,
from the Contractor's Participating Provider without referral, approval or
notification.
ii)
Enrollees must receive notification that they also have the right to obtain
Family Planning and Reproductive Health Services in accordance with the Medicaid
Free Access policy as defined in C.I of this Appendix.
iii)
A
current list of qualified Participating Family Planning Providers who provide
the full range of Family Planning and Reproductive Health Services within the
Enrollee's geographic area, including addresses and telephone numbers. The
Contractor may also provide Enrollees with a list of qualified Non-Participating
providers who accept Medicaid and who provide the full range of these
services.
iv)
Information that the cost of the Enrollee's Family Planning and Reproductive
Health care will be fully covered, including when an Enrollee obtains such
services in accordance with the Medicaid Free Access policy.
2.
Billing Policy
a)
The
Contractor must notify its Participating Providers that all claims for Family
Planning and Reproductive Health Services must be billed to the Contractor
and
not the Medicaid fee-for-service program.
b)
Non-Participating Providers will bill Medicaid fee-for-service.
3.
Consent and Confidentiality
a)
The
Contractor will comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure
Participating
Medicaid
Advantage Contract
APPENDIX
C
State
2006
C-4
Providers
comply with all of the requirements set forth in Sections 17 and 18 of the
PHL
and 10 NYCRR Section 751.9 and Part 753 relating to informed consent and
confidentiality.
b)
Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review
and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health services remains confidential and is not disclosed
to
family members or other unauthorized parties, without the Enrollee's consent
to
the disclosure.
4.
Informing and Standards
a)
The
Contractor will inform its Participating Providers and administrative personnel
about policies concerning Free Access as defined in C. 1 of this Appendix,
where
applicable; HIV counseling and testing; reimbursement for Family Planning and
Reproductive Health encounters; Enrollee Family Planning and Reproductive Health
education and confidentiality.
b)
The
Contractor will inform its Participating Providers that they must comply with
professional medical standards of practice, the Contractor's practice
guidelines, and all applicable federal, state, and local laws. These include
but
are not limited to, standards established by the American College of
Obstetricians and Gynecologists, the American Academy of Family Physicians,
the
U.S. Task Force on Preventive Services and the New York State Child/Teen Health
Program. These standards and laws recognize that Family Planning counseling
is
an integral part of primary and preventive care.
Medicaid
Advantage Contract
APPENDIX
C
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2006
C-5
C.3
Requirements
for MCOs That Do Not Provide Family Planning and Reproductive Health
Services
1.
Requirements
a)
The
Contractor agrees to comply with the policies and procedures stated in the
SDOH-approved statement described in Section 2 below.
b)
Within
ninety (90) days of signing this Agreement, the Contractor shall submit to
the
SDOH a policy and procedure statement that the Contractor will use to ensure
that its Enrollees are fully informed of their rights to access a full range
of
Family Planning and Reproductive Health Services, using the following
guidelines. The statement must be sent to the Director, Office of Managed Care,
NYS Department of Health, Coming Tower, Room 2001, Albany, NY
12237.
c)
SDOH
may waive the requirement in (b) above if such approved statement is already
on
file with SDOH and remains unchanged.
2.
Policy and Procedure Statement
a)
The
policy and procedure statement regarding Family Planning .and Reproductive
Health Services must contain the following:
i)
Enrollee Notification
A)
A
statement that the Contractor will inform Prospective Enrollees, new Enrollees
and current Enrollees that:
I)
Certain Family Planning and Reproductive Health Services (such as abortion,
sterilization and birth control) are not covered by the Contractor, but that
routine obstetric and/or gynecologic care, including hysterectomies, pre-natal,
delivery and post-partum care are covered by the Contractor;
II)
Such
Family Planning and Reproductive Health Services that are not covered by the
Contractor may be obtained through fee-for-service Medicaid providers for
Medicaid Advantage Enrollees;
III)
No
referral is needed for such services, and there will be no cost to the Enrollee
for such services;
Medicaid
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APPENDIX
C
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2006
C-6
IV)HIV
counseling and testing services are available through the Contractor and are
also available as part of a Family Planning and Reproductive Health encounter
when furnished by a fee-for-service Medicaid provider to Medicaid Advantage
Enrollees; and that anonymous counseling and testing services are available
from
SDOH, Local Public Health Agency clinics and other New York City or county
programs.
B)
A
statement that this information will be provided in the following
manner:
I)
Through the Contractor's written Marketing materials, including the Member
Handbook. The Member Handbook and Marketing materials will indicate that the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, and will explain the right of all Medicaid Advantage Enrollees
to secure such services through fee-for-service Medicaid from any
provider/clinic which offers these services and who accepts
Medicaid.
II)
Orally at the time of Enrollment and any time an inquiry is made regarding
Family Planning and Reproductive Health Services.
III)
By
inclusion on any web site of the Contractor which includes information
concerning its Medicaid Advantage product. Such information shall be prominently
displayed and easily navigated.
C)
A
description of the mechanisms to provide all new Medicaid Advantage Enrollees
with an SDOH approved letter explaining how to access Family Planning and
Reproductive Health Services and the SDOH approved list of Family Planning
providers. This material will be furnished by SDOH and mailed to the Enrollee
no
later than fourteen (14) days after the Effective Date of
Enrollment.
D)
A
statement that if an Enrollee or Prospective Enrollee requests information
about
these non-covered services, the Contractor's Marketing or Enrollment
representative or member services department will advise the Enrollee or
Prospective Enrollee as follows:
I)
Family
Planning and Reproductive Health Services such as abortion, sterilization and
birth control are not covered by the Contractor and that only routine obstetric
and/or gynecologic care, including hysterectomies, pre-natal, delivery and
post-partum care are the responsibility of the Contractor.
II)
Medicaid Advantage Enrollees can use their Medicaid card to receive these
non-covered services from any doctor or clinic that provides these services
and
accepts Medicaid.
Medicaid
Advantage Contract
APPENDIX
C
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2006
C-7
III)
Each
Medicaid Advantage Enrollee and Prospective Enrollee who calls will be mailed
a
copy of the SDOH approved letter explaining the Enrollee's right to receive
these non-covered services, and an SDOH approved list of Family Planning
Providers who participate in Medicaid in the Enrollee's community. These
materials will be mailed within two (2) business days of the
contact.
IV)Enrollees
can call the Contractor's member services number for further information about
how to obtain these non-covered services. Medicaid Advantage Enrollees can
also
call the New York State Growing-Up-Healthy Hotline (0-000-000-0000) to request
a
copy of the list of Medicaid Family Planning Providers.
E)
The
procedure for maintaining a manual log of all requests for such information,
including the date of the call, the Enrollee's client identification number
(CIN), and the date the SDOH approved letter and SDOH approved list were mailed,
where applicable. The Contractor will review this log monthly and upon request,
submit a copy to SDOH.
ii)
Participating Provider and Employee Notification
A)
A
statement that the Contractor will inform its Participating Providers and
administrative personnel about Family Planning and Reproductive Health policies
under Medicaid Advantage Free Access, as defined in C.I of this Appendix, H1V
counseling and testing; reimbursement for Family Planning and Reproductive
Health encounters; Enrollee Family Planning and Reproductive Health education
and confidentiality.
B)
A
statement that the Contractor will inform its Participating Providers that
they
must comply with professional medical standards of practice, the Contractor's
practice guidelines, and all applicable federal, state, and local laws. These
include but are not limited to, standards established by the American College
of
Obstetricians and Gynecologists, the American Academy of Family Physicians,
the
U.S. Task Force on Preventive Services. These standards and laws recognize
that
Family Planning counseling is an integral part of primary and preventive
care.
C)
The
procedure(s) for informing the Contractor's Participating primary care
providers, family practice physicians, obstetricians, and gynecologists that
the
Contractor has elected not to cover certain Family Planning and Reproductive
Health Services, but that routine obstetric and/or gynecologic care, including
hysterectomies, pre-natal, delivery and post-partum care are covered; and that
Participating Providers may provide, make referrals, or arrange for non-covered
services in accordance with Medicaid Advantage Free Access policy, as defined
in
C.I of this Appendix.
Medicaid
Advantage Contract
APPENDIX
C
State
2006
C-8
D)
A
description of the mechanisms to inform the Contractor's Participating Providers
that:
I)
if
they also participate in the fee-for-service Medicaid program and they render
non-covered Family Planning and Reproductive Health Services to Medicaid
Advantage Enrollees, they do so as a fee-for-service Medicaid practitioner,
independent of the Contractor.
E)
A
description of the mechanisms to inform Participating Providers that, if
requested by the Enrollee, or, if in the provider's best professional judgment,
certain Family Planning and Reproductive Health Services not offered through
the
Contractor are medically indicated in accordance with generally accepted
standards of professional practice, an appropriately trained professional should
so advise the Enrollee and either:
I)
offer
those services to Medicaid Advantage Enrollees on a fee-for-service basis as
an
eMedNY-enrolled provider, or
II)
provide Medicaid Advantage Enrollees with a copy of the SDOH approved list
of
Medicaid Family Planning Providers, or
III)
give
Enrollees the Contractor's member services number to call to obtain the list
of
Medicaid Family Planning Providers .
F)
A
statement that the Contractor acknowledges that the exchange of medical
information, when indicated in accordance with generally accepted standards
of
professional practice, is necessary for the overall coordination of Enrollees'
care and assist Primary Care Providers in providing the highest quality care
to
the Contractor's Enrollees. The Contractor must also acknowledge that medical
record information maintained by Participating Providers may include information
relating to Family Planning and Reproductive Health Services provided under
the
fee-for-service Medicaid program .
iii)
Quality Assurance Initiatives
A)
A
statement that the Contractor will submit any materials to be furnished to
Enrollees and providers relating to access to non-covered Family Planning and
Reproductive Health Services to SDOH, Office of Managed Care for its review
and
approval before issuance. Such materials include, but are not limited to, Member
Handbooks, provider manuals, and Marketing materials.
B)
A
description of monitoring mechanisms the Contractor will use to assess the
quality of the information provided to Enrollees.
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APPENDIX
C
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C-9
C)
A
statement that the Contractor will prepare a monthly list of Medicaid Advantage
Enrollees who have been sent a copy of the SDOH approved letter and the SDOH
approved list of Family Planning providers. This information will be available
to SDOH upon request.
D)
A
statement that the Contractor will provide all new employees with a copy of
these policies. A statement that the Contractor's orientation programs will
include a thorough discussion of all aspects of these policies and procedures
and that annual retraining programs for all employees will be conducted to
ensure continuing compliance with these policies.
3.
Consent and Confidentiality
a)
The
Contractor must comply with federal, state, and local laws, regulations and
policies regarding informed consent and confidentiality and ensure that
Participating Providers comply with all of the requirements set forth in
Sections 17 and 18 of the PHL and 10 NYCRR § 751.9 and Part 753 relating to
informed consent and confidentiality.
b)
Participating Providers may share patient information with appropriate
Contractor personnel for the purposes of claims payment, utilization review
and
quality assurance, unless the provider agreement with the Contractor provides
otherwise. The Contractor must ensure that an Enrollee's use of Family Planning
and Reproductive Health Services remains confidential and is not disclosed
to
family members or other unauthorized parties, without the Enrollee's consent
to
disclosure.
Medicaid
Advantage Contract
APPENDIX
C
State
2006
C-10
Appendix
D
New
York State Department of Health Medicaid Advantage Marketing
Guidelines
Medicaid
Advantage Contract
APPENDIX
D
State
2006
D-l
MEDICAID
ADVANTAGE MARKETING GUIDELINES
I.
Purpose
The
purpose of these guidelines is to provide an operational framework for the
Medicaid managed care organizations (MCOs) in the development of marketing
materials and the conduct of marketing activities for the Medicaid Advantage
Program. The marketing guidelines set forth in this Appendix do not replace
the
CMS marketing requirements for Medicare Advantage Plans;
they
supplement them.
II.
Marketing Materials
A.
Definitions
1.
Marketing materials generally include the concepts of advertising, public
service announcements, printed publications, and other broadcast or electronic
messages designed to increase awareness and interest in a Contractor's Medicaid
Advantage product. The target audience for these marketing materials is Eligible
Persons as defined in Section 5.1 of this Agreement living in the defined
service area.
2.
For
purposes of this Agreement, marketing materials include any information that
references the Contractor's Medicaid Advantage Product and which is intended
for
distribution to Dual Eligibles, and is produced in a variety of print,
broadcast, and direct marketing mediums. These generally include: radio,
television, billboards, newspapers, leaflets, informational brochures, videos,
telephone book yellow page ads, letters, and posters. Additional materials
requiring marketing approval include a listing of items to be provided as
nominal gifts or incentives.
B.
Marketing Material Requirements
In
addition to meeting CMS' Medicare Advantage marketing requirements and guidance
on marketing to individuals entitled to Medicare and Medicaid:
1.
Medicaid Advantage marketing materials must be written in prose that is
understood at a fourth-to sixth-grade reading level except when the Contractor
is using language required by CMS, and must be printed in at least twelve (12)
point font.
2.
The
Contractor must make available written marketing and other informational
materials (e.g., member handbooks) in a language other than English whenever
at
least five percent (5%) of the Prospective Enrollees of the Contractor in any
county of the service area speak that particular language and do not speak
English as a first language. SDOH will inform the LDSS and LDSS will inform
the
Contractor when the 5% threshold has been reached. Marketing materials to
be
Medicaid
Advantage Contract
APPENDIX
D
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2006
D-2
translated
include those key materials, such as informational brochures, that are produced
for routine distribution, and which are included within the MCO's marketing
plan. SDOH will determine the need for other than English translations based
on
county specific census data or other available measures.
3.
The
Contractor shall advise potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or have
an existing relationship with, that such medical services providers participate
in the selected managed care provider's network and are available to serve
the
participant.
C.
Prior
Approvals
1.
The
CMS and SDOH will jointly review and approve Medicaid Advantage marketing
videos, materials for broadcast (radio, television, or electronic), billboards,
mass transit (bus, subway or other livery) and statewide/regional print
advertising materialsin
accordance with CMS timeframes for review of marketing materials. These
materials must be submitted to the CMS Regional Office for review. CMS will
coordinate SDOH input in the review process just as SDOH will coordinate LDSS
input in the review process.
2.
CMS
and SDOH will jointly review and approve the following Medicaid Advantage
marketing materials:
a.
Scripts or outlines of presentations and materials used at health fairs and
other approved types of events and locations;
b.
All
pre-enrollment written marketing materials - written marketing materials include
brochures and leaflets, and presentation materials used by marketing
representatives;
c.
All
direct mailing from the Contractor specifically targeted to the Medicaid
market.
3.
The
Contractor shall electronically submit all materials related to marketing
Medicaid Advantage to Dually Eligible persons to the CMS Regional Office for
prior written approval. The CMS Medicare Regional Office Plan Manager will
be
responsible for obtaining SDOH input in the review and approval process in
accordance with CMS timeframes for the review of marketing materials. Similarly,
SDOH will be responsible for obtaining LDSS input in the review and approval
process.
4.
The
Contractor shall not distribute or use any Medicaid Advantage marketing
materials that the CMS Regional Office and the SDOH have not jointly approved,
prior to the expiration of the required review period.
Medicaid
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APPENDIX
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D-3
5.
Approved marketing materials shall be kept on file in the offices of the
Contractor, the LDSS, the SDOH, and CMS.
D.
Dissemination of Outreach Materials to LDSS
1.
Upon
request, the Contractor shall provide to the LDSS and/or Enrollment Broker,
sufficient quantities of approved Marketing materials or alternative
informational materials that describe coverage in the LDSS
jurisdiction.
2.
The
Contractor shall, upon request, submit to the LDSS or Enrollment Broker, a
current provider directory, together with information that describes how to
determine whether a provider is presently available.
III.
Marketing Activities
A.
General Requirements
1.
The
Contractor must follow the State's Medicaid marketing rules and the requirements
of 42 CFR 438.104 to the extent applicable when conducting marketing activities
that are primarily intended to sell a Medicaid managed care product (i.e.,
Medicaid Advantage). Marketing activities intended to sell a Medicaid managed
care product shall be defined as activities which are conducted pursuant to
a
Medicaid Advantage marketing program in which a dedicated staff of marketing
representatives employed by the Contractor, or by an entity with which the
Contractor has subcontracted, are engaged in marketing activities with the
primary purpose of enrolling recipients in the Contractor's Medicaid Advantage
product.
2.
Marketing activities that do not meet the above criteria shall not be construed
as having a primary purpose of intending to sell a Medicaid managed care product
and shall be conducted in accordance with Medicare Advantage marketing
requirements. Such activities include but are not limited to plan sponsored
events in which marketing representatives not dedicated to the marketing of
the
Medicaid Advantage product explain Medicare products offered by the Contractor
as well as the Contractor's Medicaid Advantage product.
B.
Marketing at LDSS Offices
With
prior LDSS approval, MCOs may distribute CMS/SDOH approved Medicaid Advantage
marketing materials in the local social services district offices and
facilities.
C.
Responsibility for Marketing Representatives
Individuals
employed by the Contractor as marketing representatives and employees of
marketing subcontractors must have successfully completed the Contractor's
training
Medicaid
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APPENDIX
D
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2006
D-4
program
including training related to an Enrollee's rights and responsibilities in
Medicaid Advantage. The Contractor shall be responsible for the activities
of
its marketing representatives and the activities of any subcontractor or
management entity.
D.
Medicaid Advantage Specific Marketing Requirements
The
requirements in Section D apply only if marketing activities for the Medicaid
Advantage Program are conducted pursuant to a Medicaid Advantage marketing
program in which a dedicated staff of marketing representatives employed by
the
Contractor or by an entity with which the Contractor has a subcontract are
engaged in marketing activities with the sole purpose of enrolling recipients
in
the Contractor's Medicaid Advantage product.
1.
Approved Marketing Plan
a.
The
Contractor must submit a plan of Medicaid Advantage Marketing activities that
meet the SDOH requirements to the SDOH.
b.
The
SDOH is responsible for the review and approval of Medicaid Advantage Marketing
plans, using a SDOH and CMS approved checklist.
c.
Approved Marketing plans will set forth the terms and conditions and proposed
activities of the Medicaid Advantage dedicated staff during the contract period.
The following must be included: description of materials to be used,
distribution methods; primary types of marketing locations and a listing of
the
kinds of community service events the Contractor anticipates sponsoring and/or
participating in during which it will provide information and/or distribute
Medicaid Advantage marketing materials.
d.
An
approved marketing plan must be on file with the SDOH and each LDSS in its
contracted service area prior to the Contractor engaging in the Medicaid
Advantage specific marketing activities.
e.
The
plan shall include stated marketing goal and strategies, marketing activities,
and the training, development and responsibilities of dedicated marketing
staff.
f.
The
Contractor must describe how it is able to meet the informational needs related
to marketing for the physical and cultural diversity of its potential
membership. This may include, but not be limited to, a description of the
Contractor's other than English language provisions, interpreter services,
alternate communication mechanisms including sign language. Braille, audio
tapes, and/or use of Telecommunications Devices for the Deaf (TTY)
services.
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APPENDIX
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D-5
g.
The
Contractor shall describe measures for monitoring and enforcing compliance
with
these guidelines by its Marketing representatives including the prohibition
of
door to door solicitation and cold-call telephoning; a description of the
development of pre-enrollee mailing lists that maintains client confidentiality
and honors the client's express request for direct contact by the Contractor;
the selection and distribution of pre-enrollment gifts and incentives to
prospective enrollees ; and a description of the training, compensation and
supervision of its Medicaid Advantage dedicated Marketing
representatives.
2.
Compensation for Dedicated Medicaid Advantage Marketing Staff
The
Contractor shall not offer compensation to Medicaid Advantage dedicated
Marketing Representatives, including salary increases or bonuses, based solely
on the number of individuals they enroll in Medicaid Advantage. However, the
Contractor may base compensation of these Marketing Representatives on periodic
performance evaluations which consider enrollment productivity as one of several
performance factors during a performance period, subject to the following
requirements:
a.
"Compensation" shall mean any remuneration required to be reported as income
or
compensation for federal tax purposes;
b.
The
Contractor may not pay a "commission" or fixed amount per
enrollment;
c.
The
Contractor may not award bonuses more frequently than quarterly, or for an
annual amount that exceeds ten percent (10%) of his/her total annual
compensation;
d.
The
Contractor shall keep written documentation, including performance evaluations
or other tools it uses as a basis for awarding bonuses or increasing the salary
of Marketing Representatives and employees involved in Marketing and make such
documentation available for inspection by SDOH or the LDSS;
3.
Prohibition of Cold Call Marketing Activities
Contractors
are prohibited from directly or indirectly, engaging in door to door,
telephone,
or other cold-call marketing activities.
4.
Marketing in Emergency Rooms or Other Patient Care Areas
Contractors
may not distribute materials or assist prospective Enrollees in completing
Medicaid Advantage application forms in hospital emergency rooms, in provider
offices, or other areas where health care is delivered unless requested by the
individual.
Medicaid
Advantage Contract
APPENDIX
D
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D-6
5.
Enrollment Incentives
Contractors
may not offer incentives of any kind to Medicaid recipients to join Medicaid
Advantage. Incentives are defined as any type of inducement whose receipt is
contingent upon the recipients joining the Contractor's Medicaid Advantage
product.
E.
General Marketing Restrictions
The
following restrictions apply anytime the Contractor markets its Medicaid
Advantage product:
1.
Contractors are prohibited from misrepresenting the Medicaid program, the
Medicaid Advantage Program or the policy requirements of the LDSS or
SDOH.
2.
Contractors are prohibited from purchasing or otherwise acquiring or using
mailing lists that specifically identify Medicaid recipients from third party
vendors, including providers and LDSS offices, unless otherwise permitted by
CMS. The Contractor may produce materials and cover their costs of mailing
to
Medicaid recipients if the mailing is carried out by the State or LDSS, without
sharing specific Medicaid information with the Contractor.
3.
Contractors may not discriminate against a potential Enrollee based on his/her
current health status or anticipated need for future health care. The Contractor
may not discriminate on the basis of disability or perceived disability of
any
Enrollee or their family member. Health assessments may not be performed by
the
Contractor prior to enrollment. The Contractor may inquire about existing
primary care relationships of the applicant and explain whether and how such
relationships may be maintained. Upon request, each potential Enrollee shall
be
provided with a listing of all participating providers and facilities in the
MCO's network. The Contractor may respond to a potential Enrollee's question
about whether a particular specialist is in the network. However, the Contractor
is prohibited from inquiring about the types of specialists utilized by the
potential Enrollee.
4.
Contractors may not require participating providers to distribute plan prepared
communications to their patients, including communications which compare the
benefits of different health plans, unless the materials have the concurrence
of
all MCOs involved, and have received prior approval by SDOH, and by CMS, if
Medicare Advantage is referenced.
5.
Contractors are responsible for ensuring that their Marketing representatives
engage in professional and courteous behavior in their interactions with LDSS
staff, staff from other health plans and Medicaid clients. Examples of
inappropriate behavior include interfering with other health plan presentations
or talking negatively about another health plan.
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APPENDIX
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IV.
Marketing Infractions
A.
Infractions ofMedicaid marketing guidelines, as found in Appendix D, Sections
III D and E, may result in the following actions being taken by the SDOH, in
consultation with the LDSS, to protect the interests of the program and its
clients. These actions shall be taken by the SDOH in collaboration with the
LDSS
and the CMS Regional Office.
1.
If the
Contractor or its representative commits a first time infraction of marketing
guidelines and the SDOH, in consultation with the LDSS, deems the infraction
to
be minor or unintentional in nature, the SDOH and/or the LDSS may issue a
warning letter to the Contractor.
2.
If the
Contractor engages in Marketing activities that the SDOH determines, in its
sole
discretion, to be an intentional or serious breach of the Medicaid Advantage
Marketing Guidelines or the Contractor's approved Medicaid Advantage Marketing
Plan, or a pattern of minor breaches, SDOH, in consultation with the LDSS,
may
require the Contractor to, and the Contractor shall prepare and implement a
corrective action plan acceptable to the SDOH within a specified timeframe.
In
addition, or alternatively, SDOH may impose sanctions, including monetary
penalties, as permitted by law.
3.
If the
Contractor commits further infractions, fails to pay monetary penalties within
the specified timeframe, fails to implement a corrective action plan in a timely
manner or commits an egregious first time infraction, the SDOH, in consultation
with the LDSS, may in addition to any other legal remedy available to the SDOH
in law or equity:
a)
direct
the Contractor to suspend its Medicaid Advantage Marketing activities for a
period up to the end of the Agreement period;
b)
suspend new Medicaid Advantage Enrollments, for a period up to the remainder
of
the Agreement period; or
c)
terminate this Agreement pursuant to termination procedures described in Section
2.7 of this Agreement.
Medicaid
Advantage Contract
APPENDIX
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D-8
Appendix
E
New
York State Department of Health Medicaid Advantage Model Member Handbook
Guidelines
Medicaid
Advantage Contract
APPENDIX
E
State
2006
E-l
Introduction
Managed
care organizations (MCOs) under contract to provide a Medicaid Advantage Product
to Dually Eligible beneficiaries must provide Enrollees with a Medicaid
Advantage member handbook which is consistent with the current model Medicaid
Advantage member handbook provided by SDOH and approved by the CMS Regional
Office and the SDOH. This model handbook is to be issued by the Contractor
to
Enrollees in addition to the handbook or Explanation of Coverage (EOC) required
by CMS for Medicare Advantage. The model member handbook may be revised based
on
changes in the law and the changing needs of the program. Handbooks must be
approved by the CMS Regional Office and the SDOH prior to printing and
distribution by the Contractor.
General
Format
Member
handbooks must be written in a style and reading level that will accommodate
the
reading skills of Medicaid recipients. In general the writing should not exceed
a fourth to sixth-grade reading level, taking into consideration the need to
incorporate and explain certain technical or unfamiliar terms to assure
accuracy. The text must be printed in at least twelve (12) point font. The
SDOH
reserves the right to require evidence that a handbook has been tested against
the sixth-grade reading-level standard. Member handbooks must be available
in
languages other than English whenever at least five percent (5%) of the
Prospective Enrollees in any county in the Contractor's service area speak
that
particular language and do not speak English as a first language.
Model
Medicaid Advantage Handbook
It
will
be the responsibility of the SDOH to provide a copy of the current model
Medicaid Advantage member handbook to the Contractor.
Medicaid
Advantage Contract
APPENDIX
E
State
2006
E-2
APPENDIX
F
New
York State Department of Health Medicaid Advantage Action and Grievance System
Requirements
F.I General
Requirements
F.2 Medicaid
Advantage Action Requirements
F.3 Medicaid
Advantage Grievance System Requirements
Medicaid
Advantage Contract APPENDIX F
State
2006
F-l
F.I
General
Requirements
1.
Organization Determinations
a)
Organization Determinations means any decision by or on behalf of a MCO
regarding payment or services to which an Enrollee believes he or she is
entitled. For the purposes of this Agreement, Organization Determinations are
synonymous with Action, as defined by this Appendix.
b)
Organization Determinations regarding services determined by the Contractor
to
be benefits covered solely by Medicare shall be conducted in accordance with
the
procedures and requirements of 42 CFR Subpart M of Part 422, and the Medicare
Managed Care Manual.
c)
Organization Determinations regarding services determined by the Contractor
to
be benefits covered by Medicare and Medicaid shall be conducted in accordance
with the procedures and requirements of 42 CFR Subpart M of Part 422 and the
Medicare Managed Care Manual, except that:
i)
the
Contractor will determine whether services are Medically Necessary as that
term
is defined in this Agreement; and
ii)
when
the Contractor intends to reduce, suspend, or terminate a previously authorized
service within an authorization period, the notification provisions of paragraph
F.2(4)(a) of this Appendix shall apply.
d)
Organization Determinations regarding services determined by the Contractor
to
be solely covered by Medicaid shall be conducted in accordance with Appendix
F.I
of this Agreement, and Articles 44 and 49 of the PHL, and 10 NYCRR Part 98,
not
otherwise expressly established herein.
2.
Notices, Action Appeals, Complaints and Complaint Appeals
a)
Services determined by the Contractor to be benefits solely covered by Medicare
are subject to the Medicare Advantage Complaint and Appeals Process. In these
cases, the Contractor will follow such procedures to notify Enrollees, and
providers as applicable, regarding Organization Determinations and offer the
Enrollee Medicare appeal rights.
b)
Services determined by the Contractor to be solely covered by Medicaid are
subject to the Medicaid Advantage Grievance System. In these cases, the
Contractor will follow such procedures to notify Enrollees and providers
regarding Organization Determinations and offer Action Appeal, Complaint, and
Complaint Appeals rights in accordance with Appendices F.2 and F.3 of this
Agreement and the requirements of Articles 44 and 49 of the PHL, and 10 NYCRR
Part 98, not otherwise expressly established herein.
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-2
c)
For
Organization Determinations regarding services determined by the Contractor
to
be a benefit under both Medicare and Medicaid, the Contractor must offer
Enrollees the right to pursue either the Medicare appeal procedures or the
Medicaid Advantage Action Appeals, Complaint, and Complaint Appeals
procedures.
i)
As
part of, or attached to, the appropriate Organization Determination notice,
the
Contractor must provide Enrollees with a notice that informs the Enrollee of
his
or her appeal rights under both the Medicare and Medicaid Advantage programs,
and of their right to select either the Medicare or Medicaid Advantage appeals
process, and instructions to make such selection. Such notice shall inform
the
Enrollee that:
A)
if he
or she chooses to pursue the Medicare appeal procedures to challenge a service
denial, suspension, reduction, or termination, the Enrollee may not pursue
a
Medicaid Advantage appeal and may not file a Fair Hearing request with the
state; and
B)
if he
or she chooses to pursue the Medicaid Advantage appeal procedures to challenge
a
service denial, suspension, reduction, or termination, the Enrollee has up
to 60
days from the day of the Contractor's notice of denial of coverage to pursue
a
Medicare appeal, regardless of the status of the Medicaid Advantage
appeal.
ii)
The
Contractor will enclose with the notice described in (i) above the notice of
Action and other attachments as may be required by Appendix F.2 (5)(a)(iii).
However, the notice of Action need not duplicate information provided in the
Organization Determination notice it is attached to.
iii)
If
the Enrollee files an appeal, but fails to select either the Medicare or
Medicaid Advantage procedure, the default procedure will be the Medicaid
Advantage procedure.
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-3
F.
2
Medicaid
Advantage Action Requirements
1. Definitions
a)
Service Authorization Request means a request by an Enrollee or a provider
on
the Enrollee's behalf, to the Contractor for the provision of a service,
including a request for a referral or for a non-covered service.
i)
Prior
Authorization Request is a Service Authorization Request by the Enrollee, or
a
provider on the Enrollee's behalf, for coverage of a new service, whether for
a
new authorization period or within an existing authorization period, before
such
service is provided to the Enrollee.
ii)
Concurrent Review Request is a Service Authorization Request by an Enrollee,
or
a provider on Enrollee's behalf, for continued, extended or more of an
authorized service than what is currently authorized by the
Contractor.
b)
Service Authorization Determination means the Contractor's approval or denial
of
a Service Authorization Request.
c)
Adverse Determination means a denial of a Service Authorization Request by
the
Contractor on the basis that the requested service is not Medically Necessary
or
an approval of a Service Authorization Request is in an amount, duration, or
scope that is less than requested.
d)
An
Action means an activity of a Contractor or its subcontractor that results
in:
i)
the
denial or limited authorization of a Service Authorization Request, including
the type or level of service;
ii)
the
reduction, suspension, or termination of a previously authorized
service;
iii)
the
denial, in whole or in part, of payment for a service;
iv)
failure to provide services in a timely manner as defined by applicable State
law and regulation and Section 15 of this Agreement; or
v)
failure of the Contractor to act within the timeframes for resolution and
notification of determinations regarding Complaints, Action Appeals and
Complaint Appeals provided in this Appendix.
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-4
2.
General Requirements
a)
The
Contractor's policies and procedures for Service Authorization Determinations
and utilization review determinations shall comply with 42 CFR Part 438 and
Article 49 of the PHL, including but not limited to the following:
i)
Expedited review of a Service Authorization Request must be conducted when
the
Contractor determines or the provider indicates that a delay would seriously
jeopardize the Enrollee's life or health or ability to attain, maintain, or
regain maximum function. The Enrollee may request expedited review of a Prior
Authorization Request or Concurrent Review Request. If the Contractor denies
the
Enrollee's request for expedited review, the Contractor must handle the request
under standard review timeframes.
ii)
Any
determination to deny a Service Authorization Request or to authorize a service
in an amount, duration, or scope that is less than requested, must be made
by a
licensed, certified, or registered health care professional. If such Adverse
Determination was based on medical necessity, the determination must be made
by
a clinical peer reviewer as defined by PHL §4900(2)(a).
iii)
The
Contractor is required to provide notice by phone and in writing to the Enrollee
and to the provider of Service Authorization Determinations, whether adverse
or
not, within the timeframe specified in Section 3 below. Notice to the provider
must contain the same information as the Notice of Action for the
Enrollee.
iv)
The
Contractor is required to provide the Enrollee written notice of any Action
other than a Service Authorization Determinations within the timeframe specified
in Section 4 below.
3.
Timeframes for Service Authorization Determinations
a)
For
Prior Authorization Requests, the Contractor must make a Service Authorization
Determination and notice the Enrollee of the determination by phone and in
writing as fast as the Enrollee's condition requires and no more
than:
i)
In the
case of an expedited review, three (3) business days after receipt of the
Service Authorization Request; or
ii)
In
all other cases, within three (3) business days of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization request.
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-5
b)
For
Concurrent Review Requests, the Contractor must make a Service Authorization
Determination and notice the Enrollee of the determination by phone and in
writing as fast as the Enrollee's condition requires and no more
than:
i)
In the
case of an expedited review, one (1) business day after receipt of necessary
information but no more than three (3) business days after receipt of the
Service Authorization Request; or
ii)
In
all other cases, within one (1) business day of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization Request.
c)
Timeframes for Service Authorization Determinations may be extended for up
to
fourteen (14) days if:
i)
the
Enrollee, the Enrollee's designee, or the Enrollee's provider requests an
extension orally or in writing; or
ii)
The
Contractor can demonstrate or substantiate that there is a need for additional
information and how the extension is in the Enrollee's interest. The Contractor
must send notice of the extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to demonstrate, upon SDOH's
request, that the extension was justified.
d)
If the
Contractor extended its review as provided in paragraph 3(c) above, the
Contractor must make a Service Authorization Determination and notice the
Enrollee by phone and in writing as fast as the Enrollee's condition requires
and within three (3) business days after receipt of necessary information for
Prior Authorization Requests or within one (1) business day after receipt of
necessary information for Concurrent Review Requests, but in no event later
than
the date the extension expires.
4.
Timeframes for Notices of Actions Other Than Service Authorizations
Determinations
a)
When
the Contractor intends to reduce, suspend, or terminate a previously authorized
service within an authorization period, it must provide the Enrollee with a
written notice at least ten (10) days prior to the intended Action,
except:
i)
the
period of advance notice is shortened to five (5) days in cases of confirmed
Enrollee fraud; or ii) the Contractor may mail notice not later than date of
the
Action for the following:
A)
the
death of the Enrollee;
B)
a
signed written statement from the Enrollee requesting service termination or
giving information requiring termination or reduction of services (where the
Enrollee understands that this must be the result of supplying the
information);
C)
the
Enrollee's admission to an institution where the Enrollee is ineligible for
further services;
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-6
D)
the
Enrollee's address is unknown and mail directed to the Enrollee is returned
stating that there is no forwarding address;
E)
the
Enrollee has been accepted for Medicaid services by another jurisdiction; or
F)
the
Enrollee's physician prescribes a change in the level of medical
care.
b)
The
Contractor must mail written notice to the Enrollee on the date of the Action
when the Action is denial of payment, in whole or in part, except as provided
in
paragraph F.2 6(b) below.
c)
When
the Contractor does not reach a determination within the Service Authorization
Determination timeframes described above, it is considered an Adverse
Determination, and the Contractor must send notice of Action to the Enrollee
on
the date the timeframes expire.
5.
Format and Content of Notices
a)
The
Contractor shall ensure that all notices are in writing, in easily understood
language and are accessible to non-English speaking and visually impaired
Enrollees. Notices shall include that oral interpretation and alternate formats
of written material for Enrollees with special needs are available and how
to
access the alternate formats.
i)
Notice
to the Enrollee that the Enrollee's request for an expedited review has been
denied shall include that the request will be reviewed under standard
timeframes, including a description of the timeframes.
ii)
Notice to the Enrollee regarding a Contractor-initiated extension shall
include:
A)
the
reason for the extension;
B)
an
explanation of how the delay is in the best interest of the
Enrollee;
C)
any
additional information the Contractor requires from any source to make its
determination;
D)
the
revised date by which the MCO will make its determination;
E)
the
right of the Enrollee to file a Complaint (as defined in Appendix F.3 of this
Agreement)regarding the extension;
F)
the
process for filing a Complaint with the Contractor and the timeframes within
which a Complaint determination must be made;
G)
the
right of an Enrollee to designate a representative to file a Complaint on behalf
of the Enrollee; and H) the right of the Enrollee to contact the New York State
Department of Health regarding his or her Complaint, including the SDOH's
toll-free number for Complaints.
iii)
Notice to the Enrollee of an Action shall include:
A)
the
description of the Action the Contractor has taken or intends to
take;
B)
the
reasons for the Action, including the clinical rationale, if any;
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-7
C)
the
Enrollee's right to file an Action Appeal (as defined in Appendix F.3 of this
Agreement) , including:
I)
The
fact that the Contractor will not retaliate or take any discriminatory action
against the Enrollee because he/she filed an Action Appeal.
II)
The
right of the Enrollee to designate a representative to file Action Appeals
on
his/her behalf;
D)
the
process and timeframe for filing an Action Appeal with the Contractor, including
an explanation that an expedited review of the Action Appeal can be requested
if
a delay would significantly increase the risk to an Enrollee's health, a
toll-free number for filing an oral Action Appeal and a form, if used by the
Contractor, for filing a written Action Appeal;
E)
a
description of what additional information, if any, must be obtained by the
Contractor from any source in order for the Contractor to make an Appeal
determination;
F)
the
timeframes within which the Action Appeal determination must be made;
G)
the
right of the Enrollee to contact the New York State Department of Health with
his or her Complaint, including the SDOH's toll-free number for Complaints;
and
H)
the
notice entitled "Managed Care Action Taken" for denial of benefits or for
termination or reduction in benefits, as applicable, containing the Enrollee's
fair hearing and aid continuing rights.
I)
For
Actions based on issues of Medical Necessity or an experimental or
investigational treatment, the notice of Action shall also include:
I)
a
clear statement that the notice constitutes the initial adverse determination
and specific use of the terms "medical necessity" or
"experimental/investigational;"
II)
a
statement that the specific clinical review criteria relied upon in making
the
determination is available upon request; and
III)
a
statement that the Enrollee may be eligible for, and the timeframes for filing
an External Appeal, including that if so eligible, the Enrollee may request
an
External Appeal after first filing an expedited Action Appeal with the
Contractor and receiving notice that the Contractor upholds its adverse
determination, or after filing a standard Action Appeal with the Contractor
and
receiving the Contractor's final adverse determination, or after the Contractor
and the Enrollee agree to waive the internal Action Appeal process.
6.
Contractor Obligation to Notice
a)
The
Contractor must provide written Notice of Action to Enrollees and providers
in
accordance with the requirements of this Appendix, including, but not limited
to, the following circumstances (except as provided for in paragraph 6(b)
below):
i)
the
Contractor makes a coverage determination or denies a request for a referral,
regardless of whether the Enrollee has received the benefit;
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-8
ii)
the
Contractor determines that a service does not have appropriate
authorization;
iii)
the
Contractor denies a claim for services provided by a Non-Participating Provider
for any reason;
iv)
the
Contractor denies a claim or service due to medical necessity;
v)
the
Contractor rejects a claim or denies payment due to a late claim
submission;
vi)
the
Contractor denies a claim because it has determined that the Enrollee was not
eligible for Medicaid Advantage coverage on the date of service;
vii)
the
Contractor denies a claim for service rendered by a Participating Provider
due
to lack of a referral;
viii)
the
Contractor denies a claim because it has determined it is not the appropriate
payor; or
ix)
the
Contractor denies a claim due to a Participating Provider billing for Benefit
Package services not included in the Provider Agreement between the Contractor
and the Participating Provider.
b)
The
Contractor is not required to provide written Notice of Action to Enrollees
in
the following circumstances:
i)
When
there is a prepaid capitation arrangement with a Participating Provider and
the
Participating Provider submits a fee-for-service claim to the Contractor for
a
service that falls within the capitation payment;
ii)
if a
Participating Provider of the Contractor itemizes or "unbundles" a claim for
services encompassed by a previously negotiated global fee
arrangement;
iii)
if a
duplicate claim is submitted by the Enrollee or a Participating Provider, no
notice is required, provided an initial notice has been issued;
iv)
if
the claim is for a service that is carved-out of the Benefit Package and is
provided to an Enrollee through Medicaid fee-for-service, however, the
Contractor should notify the provider to submit the claim to
Medicaid;
v)
if the
Contractor makes a coding adjustment to a claim (up-coding or down-coding)
and
its Provider Agreement with the Participating Provider includes a provision
allowing the Contractor to make such adjustments;
vi)
if
the Contractor has paid the negotiated amount reflected in the Provider
Agreement with a Participating Provider for the services provided to the
Enrollee and denies the Participating Provider's request for additional payment;
or
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-9
vii)
If
the Contractor has not yet adjudicated the claim. If the Contractor has pended
the claim while requesting additional information, a notice is not required
until the coverage determination has been made.
Medicaid
Advantage Contract
APPENDIX
F
State
2006
F-10
F.3
Medicaid
Advantage Grievance System Requirements
1.
Definitions
a)
A
Grievance System means the Contractor's Medicaid Advantage Complaint and Appeal
process, and includes a Complaint and Complaint Appeal process, a process to
appeal Actions, and access to the State's fair hearing system.
b)
For
the purposes of this Agreement, a Complaint means an Enrollee's expression
of
dissatisfaction with any aspect of his or her care other than an Action. A
"Complaint" means the same as a "grievance" as defined by 42 CFR §438.400
(b).
c)
An
Action Appeal means a request for a review of an Action.
d)
A
Complaint Appeal means a request for a review of a Complaint
determination.
e)
An
Inquiry means a written or verbal question or request for information posed
to
the Contractor with regard to such issues a.s benefits, contracts, and
organization rules. Neither Enrollee Complaints nor disagreements with
Contractor determinations are Inquiries.
2.
Grievance System - General Requirements
a)
The
Contractor shall describe its Grievance System in the Member Handbook, and
it
must be accessible to non-English speaking, visually, and hearing impaired
Enrollees. The handbook shall comply with The Member Handbook Guidelines
(Appendix E) of this Agreement.
b)
The
Contractor will provide Enrollees with any reasonable assistance in completing
forms and other procedural steps for filing a Complaint, Complaint Appeal or
Action Appeal, including, but not limited to, providing interpreter services
and
toll-free numbers with TTY/TDD and interpreter capability.
c)
The
Enrollee may designate a representative to file Complaints, Complaint Appeals
and Action Appeals on his/her behalf.
d)
The
Contractor will not retaliate or take any discriminatory action against the
Enrollee because he/she filed a Complaint, Complaint Appeal or Action
Appeal.
e)
The
Contractor's procedures for accepting Complaints, Complaint Appeals and Action
Appeals shall include:
i)
toll-free telephone number;
Medicaid
Advantage Contract
APPENDIX
F
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2006
F-ll
ii)
designated staff to receive calls;
iii)
"live" phone coverage at least 40 hours a week during normal business
hours;
iv)
a
mechanism to receive after hours calls, including either:
A)
a
telephone system available to take calls and a plan to respond to all such
calls
no later than on the next business day after the calls were recorded;
or
B)
a
mechanism to have available on a twenty-four (24) hour, seven (7) day a week
basis designated staff to accept telephone Complaints, whenever a delay would
significantly increase the risk to an Enrollee's health.
f)
The
Contractor must ensure that personnel making determinations regarding
Complaints, Complaint Appeals and Action Appeals were not involved in previous
levels of review or decision-making. If any of the following applies,
determinations must be made by qualified clinical personnel as specified in
this
Appendix:
i)
A
denial of an Action Appeal based on lack of medical necessity.
ii)
A
Complaint regarding denial of expedited resolution of an Action Appeal.
iii)
A
Complaint, Complaint Appeal, or Action Appeal that involves clinical issues.
3.
Action Appeals Process
a)
The
Contractor's Action Appeals process shall indicate the following regarding
resolution of Appeals of an Action:
i)
The
Enrollee, or his or her designee, will have no less than sixty (60) business
days and no more than 90 days from the date of the notice of Action to file
an
Action Appeal. An Enrollee filing an Action Appeal within ten (10) days of
the
notice of Action or by the intended date of an Action, whichever is later,
that
involves the reduction, suspension, or termination of previously approved
services may request "aid continuing" in accordance with Section 24.4 of this
Agreement.
ii)
The
Enrollee may file a written Action Appeal or an oral Action Appeal. Oral Action
Appeals must be followed by a written, signed, Action Appeal. The Contractor
may
provide a written summary of an oral Action Appeal to the Enrollee (with the
acknowledgement or separately) for the Enrollee to review, modify if needed,
sign and return to the Contractor. If the Enrollee or provider requests
expedited resolution of the Action Appeal, the oral Action Appeal does not
need
to be confirmed in writing. The date of the oral filing of the Action Appeal
will be the date of the Action Appeal for the purposes of the timeframes for
resolution of Action Appeals. Action Appeals resulting from a Concurrent Review
must be handled as an expedited Action Appeal.
Medicaid
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APPENDIX
F
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F-12
iii)
The
Contractor must send a written acknowledgement of the Action Appeal, including
the name, address and telephone number of the individual or department handling
the Action Appeal, within fifteen (15) days of receipt. If a determination
is
reached before the written acknowledgement is sent, the Contractor may include
the written acknowledgement with the notice of Action Appeal determination
(one
notice).
iv)
The
Contractor must provide the Enrollee reasonable opportunity to present evidence,
and allegations of fact or law, in person as well as in writing. The Contractor
must inform the Enrollee of the limited time to present such evidence in the
case of an expedited Action Appeal. The Contractor must allow the Enrollee
or
his or her designee, both before and during the Action Appeals process, to
examine the Enrollee's case file, including medical records and any other
documents and records considered during the Action Appeals process. The
Contractor will consider the Enrollee, his or her designee, or legal estate
representative of a deceased Enrollee a party to the Action Appeal.
v)
The
Contractor must have a process for handling expedited Action Appeals. Expedited
resolution of the Action Appeal must be conducted when the Contractor determines
or the provider indicates that a delay would seriously jeopardize the Enrollee's
life or health or ability to attain, maintain, or regain maximum function.
The
Enrollee may request an expedited review of an Action Appeal. If the Contractor
denies the Enrollee's request for an expedited review, the Contractor must
handle the request under standard Action Appeal resolution timeframes, make
reasonable efforts to provide prompt oral notice of the denial to the Enrollee
and send written notice of the denial within two (2) days of the denial
determination.
vi)
The
Contractor must ensure that punitive action is not taken against a provider
who
either requests an expedited resolution or supports an Enrollee's
Appeal.
vii)
Action Appeals of clinical matters must be decided by personnel qualified to
review the Action Appeal, including licensed, certified or registered health
care professionals who did not make the initial determination, at least one
of
whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a). Action
Appeals of non-clinical matters shall be determined by qualified personnel
at a
higher level than the personnel who made the original
determination.
4.
Timeframes for Resolution of Action Appeals
a)
The
Contractor's Action Appeals process shall indicate the following specific
timeframes regarding Action Appeal resolution:
i)
The
Contractor will resolve Action Appeals as fast as the Enrollee's condition
requires, and no later than thirty (30) days from the date of the receipt of
the
Action Appeal.
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APPENDIX
F
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ii)
The
Contractor will resolve expedited Action Appeals as fast as the Enrollee's
condition requires, within two (2) business days of receipt of necessary
information and no later than three (3) business days of the date of the receipt
of the Action Appeal.
iii)
Timeframes for Action Appeal resolution, in either (i) or (ii) above, may be
extended for up to fourteen (14) days if:
A)
the
Enrollee, his or her designee, or the provider requests an extension orally
or
in writing; or
B)
the
Contractor can demonstrate or substantiate that there is a need for additional
information and the extension is in the Enrollee's interest. The Contractor
must
send notice of the extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to demonstrate, upon SDOH's
request, that the extension was justified.
iv)
The
Contractor will make a reasonable effort to provide oral notice to the Enrollee,
his or her designee, and the provider where appropriate, for expedited Action
Appeals at the time the Action Appeal determination is made.
v)
The
Contractor must send written notice to the Enrollee, his or her designee, and
the provider where appropriate, within two (2) business days of the Action
Appeal determination.
5.
Action Appeal Notices
a)
The
Contractor shall ensure that all notices are in writing and in easily understood
language and are accessible to non-English speaking and visually impaired
Enrollees. Notices shall include that oral interpretation and alternate formats
of written material for Enrollees with special needs are available and how
to
access the alternate formats.
i)
Notice
to the Enrollee that the Enrollee's request for an expedited Action Appeal
has
been denied shall include that the request will be reviewed under standard
Action Appeal timeframes, including a description of the timeframes. This notice
may be combined with the acknowledgement.
ii)
Notice to the Enrollee regarding an Contractor-initiated extension shall
include:
A)
the
reason for the extension;
B)
an
explanation of how the delay is in the best interest of the
Enrollee;
C)
any
additional information the Contractor requires from any source to make its
determination;
D)
the
revised date by which the MCO will make its determination;
E)
the
right of the Enrollee to file a Complaint regarding the extension;
F)
the
process for filing a Complaint with the Contractor and the timeframes within
which a Complaint determination must be made;
Medicaid
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APPENDIX
F
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F-14
G)
the
right of an Enrollee to designate a representative to file a Complaint on behalf
of the Enrollee; and H) the right of the Enrollee to contact the New York State
Department of Health regarding his or her their Complaint, including the SDOH's
toll-free number for Complaints.
iii)
Notice to the Enrollee of Action Appeal Determination shall
include:
A)
Date
the Action Appeal was filed and a summary of the Action Appeal;
B)
Date
the Action Appeal process was completed;
C)
the
results and the reasons for the determination, including the clinical rationale,
if any;
D)
If the
determination was not in favor of the Enrollee, a description of Enrollee's
fair
hearing rights, if applicable;
E)
the
right of the Enrollee to contact the New York State Department of Health
regarding his or her Complaint, including the SDOH's toll-free number for
Complaints; and
F)
For
Action Appeals involving Medical Necessity or an experimental or investigational
treatment, the notice must also include:
I)
a
clear statement that the notice constitutes the final adverse determination
and
specifically use the terms "medical necessity" or
"experimental/investigational;"
II)
the
Enrollee's coverage type;
III)
the
procedure in question, and if available and applicable the name of the provider
and developer/manufacturer of the health care service;
IV)
statement that the Enrollee is eligible to file an External Appeal and the
timeframe for filing;
V)
a copy
of the "Standard Description and Instructions for Health Care Consumers to
Request an External Appeal" and the External Appeal application
form;
VI)
the
Contractor's contact person and telephone number;
VII)
the
contact person, telephone number, company name and full address of the
utilization review agent, if the determination was made by the agent;
and
VIII)
if
the Contractor has a second level internal review process, the notice shall
contain instructions on how to file a second level Action Appeal and a statement
in bold text that the timeframe for requesting an External Appeal begins upon
receipt of the final adverse determination of the first level Action Appeal,
regardless of whether or not a second level of Action Appeal is requested,
and
that by choosing to request a second level Action Appeal, the time may expire
for the Enrollee to request an External Appeal.
6.
Complaint Process
a)
The
Contractor' Complaint process shall include the following regarding the handling
of Enrollee Complaints:
Medicaid
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APPENDIX
F
State
2006
F-15
i)
The
Enrollee, or his or her designee, may file a Complaint regarding any dispute
with the Contractor orally or in writing. The Contractor may have requirements
for accepting written Complaints either by letter or Contractor supplied form.
The Contractor cannot require an Enrollee to file a Complaint in
writing.
ii)
The
Contractor must provide written acknowledgment of any Complaint not immediately
resolved, including the name, address and telephone number of the individual
or
department handling the Complaint, within fifteen (15) business days of receipt
of the Complaint. The acknowledgement must identify any additional information
required by the Contractor from any source to make a determination. If a
Complaint determination is made before the written acknowledgement is sent,
the
Contractor may include the acknowledgement with the notice of the determination
(one notice).
iii)
Complaints shall be reviewed by one or more qualified personnel.
iv)
Complaints pertaining to clinical matters shall be reviewed by one or more
licensed, certified or registered health care professionals in addition to
whichever non-clinical personnel the Contractor designates.
7.
Timeframes for Complaint Resolution by the Contractor
a)
The
Contractor's Complaint process shall indicate the following specific timeframes
regarding Complaint resolution:
i)
If the
Contractor immediately resolves an oral Complaint to the Enrollee's
satisfaction, that Complaint may be considered resolved without any additional
written notification to the Enrollee. Such Complaints must be logged by the
Contractor and included in the Contractor's quarterly HPN Complaint report
submitted to SDOH in accordance with Section 18 of this Agreement.
ii)
Whenever a delay would significantly increase the risk to an Enrollee's health,
Complaints shall be resolved within forty-eight (48) hours after receipt of
all
necessary information and no more than seven (7) days from the receipt of the
Complaint.
iii)
All
other Complaints shall be resolved within forty-five (45) days after the receipt
of all necessary information and no more than sixty (60) days from receipt
of
the Complaint. The Contractor shall maintain reports of Complaints unresolved
after forty-five (45) days in accordance with Section 18 of this
Agreement.
8.
Complaint Determination Notices
a)
The
Contractor's procedures regarding the resolution of Enrollee Complaints shall
include the following:
Medicaid
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APPENDIX
F
State
2006
F-16
i)
Complaint Determinations by the Contractor shall be made in writing to the
Enrollee or his/her designee and include:
A)
the
detailed reasons for the determination;
B)
in
cases where the determination has a clinical basis, the clinical rationale
for
the determination;
C)
the
procedures for the filing of an appeal of the determination, including a form,
if used by the Contractor, for the filing of such a Complaint Appeal; and notice
of the right of the Enrollee to contact the State Department of Health regarding
his or her Complaint, including SDOH's toll-free number for
Complaints.
ii)
If
the Contractor was unable to make a Complaint determination because insufficient
information was presented or available to reach a determination, the Contractor
will send a written statement that a determination could not be made to the
Enrollee on the date the allowable time to resolve the Complaint has
expired.
iii)
In
cases where delay would significantly increase the risk to an Enrollee's health,
the Contractor shall provide notice of a determination by telephone directly
to
the Enrollee or to the Enrollee's designee, or when no phone is available,
some
other method of communication, with written notice to follow within three (3)
business days.
9.
Complaint Appeals
a)
The
Contractor's procedures regarding Enrollee Complaint Appeals shall include
the
following:
i)
The
Enrollee or designee has no less than sixty (60) business days after receipt
of
the notice of the Complaint determination to file a written Complaint Appeal.
Complaint Appeals may be submitted by letter or by a form provided by the
Contractor.
ii)
Within fifteen (15) business days of receipt of the Complaint Appeal, the
Contractor shall provide written acknowledgment of the Complaint Appeal,
including the name, address and telephone number of the individual designated
to
respond to the Appeal. The Contractor shall indicate what additional
information, if any, must be provided for the Contractor to render a
determination.
iii)
Complaint Appeals of clinical matters must be decided by personnel qualified
to
review the Appeal, including licensed, certified or registered health care
professionals who did not make the initial determination, at least one of whom
must be a clinical peer reviewer, as defined by PHL §4900(2)(a).
iv)
Complaint Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original Complaint
determination.
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APPENDIX
F
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F-17
v)
Complaint Appeals shall be decided and notification provided to the Enrollee
no
more than:
A)
two
(2) business days after the receipt of all necessary information when a delay
would significantly increase the risk to an Enrollee's health; or
B)
thirty
(30) business days after the receipt of all necessary information in all other
instances.
vi)
The
notice of the Contractor's Complaint Appeal determination shall
include:
A)
the
detailed reasons for the determination;
B)
the
clinical rationale for
the
determination in cases where the determination has a clinical
basis;
C)
the
notice shall also inform the Enrollee of his/her option to also contact the
State Department of Health with his/her Complaint, including the SDOH's
toll-free number for Complaints;
D)
instructions for any further Appeal, if applicable.
10. Records
a)
The
Contractor shall maintain a file on each Complaint, Action Appeal and Complaint
Appeal. These records shall be readily available for review by the SDOH, upon
request. The file shall include:
i)
date
the Complaint was filed;
ii)
copy
of the Complaint, if written;
iii)
date
of receipt of and copy of the Enrollee's written confirmation, if
any;
iv)
log
of Complaint determination including the date of the determination and the
titles of the personnel and credentials of clinical personnel who reviewed
the
Complaint;
v)
date
and copy of the Enrollee's Action Appeal or Complaint Appeal;
vi)
Enrollee or provider requests for expedited Action Appeals and Complaint Appeals
and the Contractor's determination;
vii)
necessary documentation to support any extensions;
viii)
determination and date of determination of the Action Appeals and Complaint
Appeals;
ix)
the
titles and credentials of clinical staff who reviewed the Action Appeals and
Complaint Appeals; and
Medicaid
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APPENDIX
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F-18
x)
Complaints unresolved for greater than forty-five (45) days.
Medicaid
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APPENDIX
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F-19
APPENDIX
G
Reserved
Medicaid
Advantage Contract
APPENDIX
G
State
2006 G-l
APPENDIX
H
New
York State Department of Health Guidelines for the Processing of Medicaid
Advantage Enrollments and Disenrollments
Medicaid
Advantage Contract APPENDIX H
State
2006
H-l
Appendix
H
SDOH
Guidelines
For
the Processing of Medicaid Advantage Enrollments and
Disenrollments
1.
General
The
Contractor's Enrollment and Disenrollment procedures for Medicaid Advantage
shall be consistent with these requirements, except that to allow LDSS and
the
Contractor flexibility in developing processes that will meet the needs of
both
parties, the SDOH may allow modifications to timeframes and some procedures.
Where an Enrollment Broker exists, the Enrollment Broker may be responsible
for
some or all of the LDSS responsibilities.
2.
Enrollment
a)
SDOH Responsibilities.
i)
The
SDOH is responsible for monitoring Local District program activities and
providing technical assistance to the LDSS and the Contractor to ensure
compliance with the State's policies and procedures.
ii)
SDOH
reviews and approves proposed Enrollment materials prior to the Contractor
publishing and disseminating or otherwise using the materials.
b)
LDSS Responsibilities:
i)
The
LDSS has the primary responsibility for processing Medicaid Advantage
enrollments.
ii)
Each
LDSS determines Medicaid eligibility. To the extent practicable, the LDSS will
follow up with Enrollees when the Contractor provides documentation of any
change in status which may affect the Enrollee's Medicaid and/or Medicaid
Advantage eligibility.
iii)
LDSS
is responsible for providing pre-enrollment information on Medicaid Advantage
to
Dually Eligible beneficiaries, consistent with Social Services Law, Section
364-j(4)(e)(iv) and train persons providing enrollment counseling to Eligible
Persons.
iv)
The
LDSS is responsible for informing Eligible Persons of the availability of
Medicaid Advantage Products, the scope of services covered by each, and that
enrollment is voluntary.
Medicaid
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APPENDIX
H
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H-2
v)
The
LDSS is responsible for informing Eligible Persons of the right to confidential
face-to-face enrollment counseling and will make confidential face-to-face
sessions available upon request.
vi)
The
LDSS is responsible for instructing Eligible Persons, to verify with the medical
services providers they prefer, or have an existing relationship with, that
such
medical services providers are Participating Providers of the selected MCO
and
are available to serve the Enrollee. The LDSS includes such written instructions
to Eligible Persons in its written materials related to Enrollment.
vii)
For
Enrollments made during face-to-face counseling, if the Prospective Enrollee
has
a preference for particular medical services providers, Enrollment counselors
shall verify with the medical services providers that such medical services
providers whom the prospective Enrollee prefers are Participating Providers
of
the selected MCO and are available to serve the Prospective
Enrollee.
viii)
The
LDSS is responsible for the timely processing of Medicaid Advantage Enrollment
applications received from participating health plans.
ix)
The
LDSS is responsible for processing Enrollments in Medicaid Advantage without
edits for Medicare coverage in the Welfare Management System (WMS); however
the
LDSS is responsible for ensuring that WMS is updated with Medicare A and B
coverage status for new Enrollees upon review of documentation provided by
the
Contractor or the Enrollee.
x)
The
LDSS is responsible for determining the eligibility status of Medicaid Advantage
enrollment applications. Applications will be enrolled, pended or
denied.
xi)
The
LDSS is responsible for processing Medicaid Advantage enrollment applications
until the last day of the month preceding the Effective Date of Enrollment,
to
the extent possible.
xii)
The
LDSS is responsible for notifying the Contractor of plan-assisted enrollment
applications that are accepted, pended or denied.
xiii)
The
LDSS is responsible for entering individual enrollment form data and
transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem.
The transfer of enrollment information may be accomplished by any of the
following:
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APPENDIX
H
State
2006
H-3
A)
LDSS
directly enters data into PCP Subsystem; or
B)
LDSS
or Contractor submits a tape to the State, to be edited and entered into PCP
Subsystem; or
C)
LDSS
electronically transfers data via a dedicated line, from eMedNY to the PCP
Subsystem.
xiv)
Extensive use of the secondary roster will be utilized to coordinate the
Effective Dates of Enrollment for Medicaid and Medicare Advantage.
xv)
The
LDSS is responsible for prospectively re-enrolling an Enrollee who is
disenrolled from the Contractor's Medicaid Advantage Product due to loss of
Medicaid eligibility, who regains eligibility within three months, in the
Contractor's Medicaid Advantage Product, provided that the individual remains
enrolled in the Contractor's Medicare Advantage Product.
xvi)
The
LDSS is responsible for processing new Enrollment applications to transfer
a
member of the Contractor's Medicaid managed care product to the Contractor's
Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility,
wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent
possible, such Enrollments shall be made effective the first day of the month
that the Enrollee's Medicare Advantage Coverage is effective.
xvii)
The
LDSS is responsible for sending the following notices to Eligible
Persons:
A)
Enrollment Confirmation Notice: This notice indicates the Effective Date
of
Enrollment, the name of the Medicaid Advantage Product and the individual who
is
being enrolled. This notice must also include a statement advising the
individual that if his/her Medicare Advantage enrollment is denied by CMS,
the
individual's Medicaid Advantage Enrollment will be voided retroactively back
to
the Effective Date of Enrollment. In such instances, the individual may be
responsible for the cost of any Medicaid Advantage Benefit rendered during
the
retroactive period if the benefit was provided by a non-Medicaid participating
provider.
B)
Notice
of Denial of Enrollment: This notice is used when an individual has been
determined by LDSS to be ineligible for enrollment into a Medicaid Advantage
Product. This notice must include fair hearing rights.
Medicaid
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APPENDIX
H
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H-4
c)
Contractor Responsibilities:
i)
To the
extent permitted by law and regulation, the Contractor is responsible for
assisting Dually Eligible persons eligible for enrollment in Medicaid Advantage
to complete the Enrollment application. The Contractor will submit plan
Enrollments to the LDSS, within a maximum of five (5) business days from the
day
the Enrollment is received by the Contractor (unless otherwise agreed to by
SDOH
and LDSS).
ii)
The
Contractor is responsible for obtaining documentation of Medicare A and B
coverage prior to sending the Enrollment transaction to the LDSS for processing.
In all areas where Enrollments are not processed by the Enrollment Broker,
the
documentation must accompany the Enrollment form to the LDSS. Acceptable
documentation includes: a current Medicare card or other documentation
acceptable to CMS or received by the Contractor from interaction with CMS'
data
systems.
iii)
In
areas where Enrollments are submitted electronically to the Enrollment Broker,
the Contractor is responsible for forwarding the documentation of current
Medicare A and B coverage to the Enrollment Broker within five (5) business
days
of learning from the Enrollment Broker that evidence of Medicare A and B
coverage is not reflected in the WMS system.
iv)
The
Contractor must notify new Enrollees of their Effective Date of Enrollment.
To
the extent practicable, such notification must precede the Effective Date of
Enrollment. This notice must also include a statement advising the individual
that if his/her Medicare Advantage enrollment is denied by CMS, the individual's
Medicaid Advantage Enrollment will be voided retroactively back to the Effective
Date of Enrollment. In such instances, the individual may be responsible for
the
cost of any Medicaid Advantage Benefit rendered during the retroactive period
if
the benefit was provided by a non-Medicaid participating provider.
v)
The
Contractor must report any changes in status for its Enrollees to the LDSS
within five (5) business days of such information becoming known to the
Contractor. This includes, but is not limited to, factors that may impact
Medicaid or Medicaid Advantage eligibility such as address changes,
incarceration, third party insurance other than Medicare, Disenrollment from
the
Contractor's Medicare Advantage Product, etc.
vi)
If an
Enrollee's Enrollment in the Contractor's Medicare Advantage Product is rejected
by CMS, the Contractor must notify the LDSS within five (5) business days of
learning of CMS' rejection of the Enrollment.
Medicaid
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APPENDIX
H
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2006
H-5
In
such
instances, the LDSS shall delete the Enrollee's Enrollment in the Contractor's
Medicaid Advantage Plan.
vii)
The
Contractor shall advise potential Enrollees, in written materials related to
enrollment, to verify with the medical services providers they prefer, or have
an existing relationship with, that such medical services providers are
Participating Providers and are available to serve the Prospective
Enrollee.
viii)
The
Contractor shall accept all Enrollments as ordered by the Office of Temporary
and Disability Assistance's Office of Administrative Hearings due to fair
hearing requests or decisions.
3.
Newborn Enrollments:
a)
SDOH Responsibilities:
i)
The
SDOH will update WMS with information on the newborn received from hospitals
or
birthing centers, consistent with the requirements of Section 366-g of the
Social Services Law as amended by Chapter 412 of the Laws of 1999.
ii)
Upon
notification of the birth by the hospital or birthing center, the SDOH will
update WMS with the demographic data for the newborn generating appropriate
Medicaid coverage.
b)
LDSS Responsibilities:
i)
The
LDSS is responsible for granting Medicaid eligibility for newborns for one
(1)
year if born to a woman eligible for and receiving MA assistance on the date
of
birth.
(Social Services Law Section 366 (4) (1))
ii)
The
LDSS is responsible for adding eligible unborns to all WMS cases that include
a
pregnant woman as soon as the pregnancy is medically verified. (NYS
DSS Administrative Directive
85
ADM-33)
iii)
In
the event that the LDSS leams of an Enrollee's pregnancy prior to the
Contractor, the LDSS is responsible for establishing MA eligibility and
enrolling the unborn into Medicaid managed care in cases where an enrollment
form is received or other members of the family are enrolled in a mainstream
plan.
iv)
When
a newborn is enrolled in managed care, the LDSS is responsible for sending
an
Enrollment Confirmation Notice to inform the mother of
Medicaid
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APPENDIX
H
State
2006
H-6
the
Effective Date of Enrollment, which is the first (1st)
day of
the month of birth, and the plan in which the newborn is enrolled.
v)
The
LDSS may develop a transmittal form to be used for unborn/newborn notification
between the Contractor and the LDSS.
c)
Contractor Responsibilities:
i)
The
Contractor must notify the LDSS in writing of any Enrollee that is pregnant
within thirty (30) days of knowledge of the pregnancy. Notifications should
be
transmitted to the LDSS at least monthly. The notifications should contain
the
pregnant woman's name. Client ID Number (CIN), and the expected date of
confinement (EDC).
ii)
Upon
the newborn's birth, the Contractor must send verifications of infant's
demographic data to the LDSS, within five (5) days after knowledge of the birth.
The demographic data must include: the mother's name and CIN, the newborn's
name
and CIN (if newborn has a CIN), sex and the date of birth.
4.
Roster Reconciliation:
a)
All
Enrollments are effective the first of the month.
b)
SDOH Responsibilities:
i)
The
SDOH maintains both the PCP subsystem Enrollment files and the WMS eligibility
files, using data input by the LDSS. SDOH uses data contained in both these
files to generate the Roster.
ii)
SDOH
shall send monthly to the Contractor and LDSS (according to a schedule
established by SDOH) a complete list of all Enrollees for which the Contractor
is expected to assume medical risk beginning on the 1st
of the
following month (First Monthly Roster). Notification to the Contractor and
LDSS
will be accomplished via paper transmission, magnetic media, or the
HPN.
iii)
SDOH
shall send the Contractor and LDSS monthly, at the time of the first monthly
roster production, a Disenrollment Report listing those Enrollees from the
previous month's roster who were disenrolled, transferred to another MCO, or
whose Enrollments were deleted from the file. Notification to the Contractor
and
LDSSs will be accomplished via paper transmission, magnetic media, or the
HPN.
iv)
The
SDOH shall also forward an error report as necessary to the Contractor and
LDSS.
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APPENDIX
H
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H-7
v)
On the
first (1st)
weekend
after the first (1st)
day of
the month following the generation of the first (1st)
Roster,
SDOH shall send the Contractor and LDSS a second Roster which contains any
additional Enrollees that the LDSS has added for Enrollment for the current
month. The SDOH will also include any additions to the error report that have
occurred since the initial error report was generated.
c)
LDSS Responsibilities:
i)
The
LDSS is responsible for notifying the Contractor electronically or in writing
of
changes in the First Roster and error report, no later than the end of the
month. This includes, but is not limited to, new Enrollees whose Enrollments
in
Medicaid Advantage were processed subsequent to the pull-down date but prior
to
the Effective Date of Enrollment. (Note: To the extent practicable the date
specified must allow for timely notice to Enrollees regarding their Enrollment
status. The Contractor and the LDSS may develop protocols for the purpose of
resolving Roster discrepancies that remain unresolved beyond the end of the
month).
ii)
Enrollment and eligibility issues are reconciled by the LDSS to the extent
possible, through manual adjustments to the PCP subsystem Enrollment and WMS
eligibility files, if appropriate.
d)
Contractor Responsibilities:
i)
The
Contractor is at risk for providing Benefit Package services for those Enrollees
listed on the 1st
and
2nd
Rosters
for the month in which the 2nd
Roster
is generated. Contractor is not at risk for providing services to Enrollees
who
appear on the monthly Disenrollment report.
ii)
The
Contractor must submit claims to the State's Fiscal Agent for all Eligible
Persons that are on the 1st
and
2nd
Rosters
(see Appendix H, page 7), adjusted to add Eligible Persons enrolled by the
LDSS
after Roster production and to remove individuals disenrolled by LDSS after
Roster production (as notified to the Contractor). In the cases of retroactive
Disenrollments, the Contractor is responsible for submitting an adjustment
to
void any previously paid premiums for the period of retroactive Disenrollment,
where the Contractor was not at risk for the provision of Benefit Package
services. Payment of sub-capitation does not constitute "provision of Benefit
Package services."
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Advantage Contract
APPENDIX
H
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H-8
5.
Disenrollment:
a)
LDSS Responsibilities:
i)
Enrollees may request to disenroll from the Contractor's Medicaid Advantage
Product at any time for any reason. Disenrollment requests may be made by
Enrollees to the LDSS, the Enrollment Broker, or the Contractor.
ii)
Medicaid Advantage Plans, LDSSs, and the Enrollment Broker must utilize
State-approved Disenrollment forms.
iii)
The
LDSS will accept requests for Disenrollment directly from the Enrollee or from
the Contractor.
iv)
Enrollees may initiate a request for an expedited Disenrollment to the LDSS.
The
LDSS is responsible for expediting the Disenrollment process in those cases
where an Enrollee's request for Disenrollment involves concurrent Disenrollment
from the Contractor's Medicare Advantage Product, an urgent medical need, a
complaint of non-consensual enrollment or, in New York City, homeless
individuals in the shelter system. If approved, the LDSS will manually process
the Disenrollment through the PCP Subsystem. Enrollees who request to be
disenrolled from Medicaid Advantage based on their documented HIV, ESRD, or
SPMI/SED status are categorically eligible for an expedited Disenrollment on
the
basis of urgent medical need.
v)
The
LDSS is responsible for processing routine Disenrollment requests to take effect
on the first (1st)
day of
the following month to the extent possible. In no event shall the Effective
Date
of Disenrollment be later than the first (1st)
day of
the second month after the month in which an Enrollee requests a
Disenrollment.
vi)
The
LDSS is responsible for disenrolling Enrollees automatically upon death,
Disenrollment from the Contractor's Medicare Advantage Product, or loss of
Medicaid eligibility. All such Disenrollments will be effective at the end
of
the month in which the death. Effective Date of Disenrollment from the
Contractor's Medicare Advantage Product, or loss of eligibility occurs, or
at
the end of the last month of Guaranteed Eligibility, where
applicable.
vii)
The
LDSS is responsible for promptly disenrolling an Enrollee whose managed care
eligibility or status changes such that he/she is deemed by the LDSS to no
longer be eligible for Medicaid Advantage Enrollment. The LDSS is responsible
for providing Enrollees with a notice of their right to request a fair
hearing.
Medicaid
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APPENDIX
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H-9
viii)
The
LDSS is responsible for ensuring that Retroactive Disenrollments are used only
when absolutely necessary. Circumstances warranting a retroactive Disenrollment
are rare and include when an individual is deemed to have been non-consensually
enrolled in the Contractor's Medicaid Advantage Product, is enrolled when
ineligible for Enrollment, or when an Enrollee enters or resides in a
residential institution under circumstances which render the individual
ineligible; is incarcerated; is retroactively disenrolled from the Contractor's
Medicare Advantage Product, or dies - as long as the Contractor was not at
risk
for provision of Benefit Package services for any portion of the retroactive
period. Payment of subcapitation does not constitute "provision of Benefit
Package services." The LDSS is responsible for notifying the Contractor of
the
retroactive disenrollment prior to the action. The LDSS is responsible for
finding out if the Contractor has made payments to providers on behalf of the
Enrollee prior to Disenrollment. After this information is obtained, the LDSS
and Contractor will agree on a retroactive Disenrollment or prospective
Disenrollment date.
In
all
cases of retroactive Disenrollment, including Disenrollments effective the
first
day of the current month, the LDSS is responsible for sending notice to the
Contractor at the time of Disenrollment, of the Contractor's responsibility
to
submit to the SDOH's Fiscal Agent voided premium claims for any full months
of
retroactive Disenrollment where the Contractor was not at risk for the provision
of Benefit Package services during the month. However, failure by the LDSS
to so
notify the Contractor does not affect the right of the SDOH to recover the
premium payment as authorized by Section 3.6 of this Agreement.
ix)
Generally the effective dates of Disenrollment are prospective. Effective dates
for other than routine Disenrollments are described below:
Medicaid
Advantage Contract
APPENDIX
H
State
2006
H-10
|
Reason
for Disenrollment
|
Effective
Date of Disenrollment
|
|
•
Death of Enrollee
|
•
First day of the month after death
|
|
•
Incarceration
|
•
First day of the month of incarceration (note-Contractor is at risk
for
covered services only to the date of incarceration and is entitled
to the
capitation payment for the month of incarceration).
|
|
•
Enrollee entered or stayed in a residential institution under
circumstances which rendered the individual ineligible for enrollment
in
Medicaid Advantage or is in receipt ofwaivered services through the
Long
Term Home Health Care Program (LTHHCP), including when an Enrollee
is
admitted to a hospital that 1) is certified by Medicare as a long-term
care hospital and 2) has an average length of stay for all patients
greater than ninety-five (95) days as reported in the Statewide Planning
and Research Cooperative System (SPARCS) Annual Report
2002.
|
•
First day of the month of entry or first day of the month of
classification of the stay as permanent, subsequent to entry
(note-Contractor is at risk for covered services only to the date
of entry
or classification of the stay as permanent subsequent to entry, and
is
entitled to the capitation payment for the month of entry or
classification of the stay as permanent subsequent to
entry).
|
|
•
Individual enrolled while ineligible for enrollment
|
•
Effective Date of Enrollment in the Contractor's Plan.
|
|
•
Non-consensual Enrollment
|
•
Retroactive to the first day of the month of Enrollment
|
|
•
Enrollee moved outside of the District/County of Fiscal
Responsibility
|
•
First day of the month after the update of the system with the new
address*
|
|
•
Urgent medical need
|
•
First day of the next month after determination except where medical
need
requires an earlier Disenrollment
|
|
•
Homeless Enrollees in Medicaid Advantage residing in the shelter
system in
NYC
|
•
Retroactive to the first day of the month of
the
request
|
|
•
An Enrollee with more than one Client Identification Number (CIN)
is
enrolled in the Contractor's Medicaid Advantage Product under more
than
one of the CINs.
|
•
First day of the month the duplicate Enrollment
began.
|
*
In
counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor's plan. In
New
York City, Enrollees, not in guaranteed status, who move out of the
Contractor's
Medicaid
Advantage Contract
APPENDIX
H
State
2006
H-ll
Service
Area but not outside, of the City of New York (e.g., move from one borough
to
another), will not be involuntarily disenrolled, but must request a
Disenrollment or transfer. These Disenrollments will be performed on a routine
basis unless there is an urgent medical need to expedite the
Disenrollment.
x)
The
LDSS is responsible for informing Enrollees of their right to disenroll at
any
time for any reason.
xi)
The
LDSS will render a decision within five (5) days of the receipt of a fully
documented request for Disenrollment.
xii)
To
the extent possible, the LDSS is responsible for processing an expedited
disenrollment within two (2) business days of its determination that an
expedited Dissenrollment is warranted.
xiii)
The
LDSS is responsible for sending the following notices to Enrollees regarding
their Disenrollment status. Where practicable, the process will allow for timely
notification to Enrollees unless there is "good cause" to disenroll more
expeditiously.
A)
Notice
of Disenrollment: These notices will advise the Enrollee of the LDSS's
determination regarding an Enrollee-initiated, LDSS-initiated or
Contractor-initiated Disenrollment and will include the Effective Date of
Disenrollment. In cases where the Enrollee is being involuntarily disenrolled,
the notice must contain fair hearing rights.
B)
When
the LDSS denies any Enrollee's request for Disenrollment pursuant to Section
8
of this Agreement, the LDSS is responsible for informing the Enrollee in writing
explaining the reason for the denial, stating the facts upon which the denial
is
based, citing the statutory and regulatory authority and advising the Enrollee
of his/her right to a fair hearing pursuant to 18 NYCRR Part 358.
C)
Notice
of Change to "Guarantee Coverage": This notice will advise the Enrollee that
his
or her Medicaid coverage is ending and how this affects his or her enrollment
in
the Medicaid Advantage Product. This notice contains pertinent information
regarding "Guaranteed Eligibility" benefits and dates of coverage. If an
Enrollee is not eligible for guarantee, this notice is not
necessary.
xiv)
In
those instances where the LDSS approves the Contractor's request to disenroll
an
Enrollee, and the Enrollee requests a fair hearing, the Enrollee will remain
in
the Contractor's Medicaid Advantage Product until the disposition of the fair
hearing, if Aid to Continue is ordered by the New York State Office of
Administrative Hearings.
Medicaid
Advantage Contract
APPENDIX
H
State
2006
H-12
xv)
The
LDSS is responsible for reviewing each Contractor requested Disenrollment in
accordance with the provisions of Section 8.7 of this Agreement. Where
applicable, the LDSS may consult with local mental health and substance abuse
authorities in the district when making the determination to approve or
disapprove the request.
xvi)
The
LDSS is responsible for establishing procedures whereby the Contractor refers
cases which are appropriate for an LDSS-initiated Disenrollment and submits
supporting documentation to the LDSS.
xvii)
After the LDSS receives and, if appropriate, approves the request for
Disenrollment either from the Enrollee or the Contractor, the LDSS is
responsible for updating the PCP subsystem file with an end date. The Enrollee
is removed from the Contractor's Roster.
b)
Contractor Responsibilities:
i)
In
those instances where the Contractor directly receives Disenrollment forms,
the
Contractor will forward these Disenrollments to the LDSS for processing within
five (5) business days (or according to Section 5 of this Appendix). During
pull-down week, these forms may be faxed to the LDSS with the hard copy to
follow.
ii)
The
Contractor must accept and transmit all requests for voluntary Disenrollments
from its Enrollees to the LDSS, and shall not impose any barriers to
Disenrollment requests. The Contractor may require that a Disenrollment request
be in writing, contain the signature of the Enrollee, and state the Enrollee's
correct Contractor or Medicaid identification number.
iii)
Following LDSS procedures, the Contractor will refer cases which are appropriate
for an LDSS-initiated Disenrollment and will submit supporting documentation
to
the LDSS. This includes, but is not limited to, changes in status for its
enrolled members that may impact eligibility for Enrollment in an MCO such
as
address changes, incarceration, death, ineligibility for Medicaid Advantage
Enrollment, change in Medicare status, etc.
iv)
With
respect to Contractor-initiated Disenrollments:
A)
The
Contractor may initiate an involuntary Disenrollment if the
Enrollee:
i)
engages in conduct or behavior that seriously impairs the Contractor's ability
to furnish services to either the Enrollee or other Enrollee's, provided that
the Contractor has made
Medicaid
Advantage Contract
APPENDIX
H
State
2006
H-13
and
documented reasonable efforts to resolve the problems presented by the Enrollee;
or
ii)
provides fraudulent information on an enrollment form or permits abuse of an
enrollment card except when the Enrollee is no longer eligible for Medicaid
and
is in his/her Guaranteed Eligibility period.
B)
The
Contractor may not request Disenrollment because of an adverse change in the
Enrollee's health status, or because of the Enrollee's utilization of medical
services, diminished mental capacity, or uncooperative or disruptive behavior
resulting from the Enrollee's special needs (except where continued enrollment
in the Contractor's plan seriously impairs the Contractor's ability to furnish
services to either the Enrollee or other Enrollees).
C)
The
Contractor must make a reasonable effort to identify for the Enrollee, both
verbally and in writing, those actions of the Enrollee that have interfered
with
the effective provision of covered services as well as explain what actions
or
procedures are acceptable.
D)
The
Contractor shall give prior verbal and written notice to the Enrollee, with
a
copy to the LDSS, of its intent to request Disenrollment. The written notice
shall advise the Enrollee that the request has been forwarded to the LDSS for
review and approval. The written notice must include the mailing address and
telephone number of the LDSS.
E)
The
Contractor shall keep the LDSS informed of decisions related to all complaints
filed by an Enrollee as a result of, or subsequent to, the notice of intent
to
disenroll.
v)
The
Contractor will not consider an Enrollee disenrolled without confirmation from
the LDSS or the Roster (as described in Section 4 of this
Appendix).
Medicaid
Advantage Contract
APPENDIX
H
State
2006
H-14
APPENDIX
I
Reserved
Medicaid
Advantage Contract APPENDIX 1
State
2006
1-1
APPENDIX
J
New
York State Department of Health Guidelines of Federal Americans with
Disabilities Act
Medicaid
Advantage Contract
APPENDIX
J
State
2006
X-x
GUIDELINES
FOR MEDICAID MCO COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT
(ADA)
I.
OBJECTIVES
Title
II
of the Americans With Disabilities Act (ADA) and Section 504 of the
Rehabilitation Act of 1973 (Section 504) provides that no "qualified individual
with a disability shall, by reason of such disability, be excluded from
participation in or denied access to the benefits of services, programs or
activities of a public entity, or be subject to discrimination by such an
entity. Public entities include State and local government and ADA and Section
504 requirements extend to all programs and services provided by State and
local
government. Since Medicaid is a government program, health services provided
through Medicaid Managed Care, including Medicaid Advantage, must be accessible
to all who qualify for the program.
MCO
responsibilities for compliance with the ADA are imposed under Title II and
Section 504 when, as a contractor in a Medicaid program, a plan is providing
a
government service. If an individual provider under contract with the MCO is
not
accessible, it is the responsibility of the MCO to make arrangements to assure
that alternative services are provided. The MCO may determine it is expedient
to
make arrangements with other providers, or to describe reasonable alternative
means and methods to make these services accessible through its existing
contractors. The goals of compliance with ADA Title II requirements are to
offer
a level of services that allows people with disabilities access to the program
in its entirety, and the ability to achieve the same health care results as
any
program participant.
MCO
responsibilities for compliance with the ADA are also imposed under Title III
when the MCO functions as a public accommodation providing services to
individuals (e.g. program areas and sites such as marketing, education, member
services, orientation, complaints and appeals). The goals of compliance with
ADA
Title III requirements are to offer a level of services that allows people
with
disabilities full and equal enjoyment of the goods, services, facilities or
accommodations that the entity provides for its customers or clients. New and
altered areas and facilities must be as accessible as possible. Whenever MCOs
engage in new construction or renovation, compliance is also required with
accessible design and construction standards promulgated pursuant to the ADA
as
well as State and local laws. Title III also requires that public accommodations
undertake "readily achievable barrier removal" in existing facilities where
architectural and communications barriers can be removed easily and without
much
difficulty or expense.
The
state
uses Plan Qualification Standards to qualify MCOs for participation in the
Medicaid Managed Care Program. Pursuant to the state's responsibility to assure
program access to all recipients, the Plan Qualification Standards require
each
MCO to submit an ADA Compliance Plan that describes in detail how the MCO will
make services, programs and activities readily accessible and useable
by
Medicaid
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APPENDIX
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,2006
J-2
individuals
with disabilities. In the event that certain program sites are not readily
accessible, the MCO must describe reasonable alternative methods for making
the
services or activities accessible and usable.
The
objectives of these guidelines are threefold:
| · |
to
ensure that MCOs take appropriate steps to measure access and assure
program accessibility for persons with
disabilities;
|
| · |
to
provide a framework for managed care organizations (MCOs) as they
develop
a plan to assure compliance with the Americans with Disabilities
Act
(ADA); and
|
| · |
to
provide standards for the review of MCO Compliance
Plans.
|
These
guidelines include a general standard followed by a discussion of specific
considerations and suggestions of methods for assuring compliance Please be
advised that, although these guidelines and any subsequent reviews by State
and
local governments can give the contractor guidance, it is ultimately the
contractor's obligation to ensure that it complies with its contractual
obligations, as well as with the requirements of the ADA, Section 504, and
other
federal, state and local laws. Other federal, state and local statutes and
regulations also prohibit discrimination on the basis of disability and may
impose requirements in addition to those established under ADA. For example,
while the ADA covers those impairments that "substantially" limit one or more
of
the major life activities of an individual, New York City Human Rights Law
deletes the modifier "substantially".
II. Definitions
A.
"Auxiliary aids and services" may include qualified interpreters, note takers,
computer-aided transcription services, written materials, telephone handset
amplifiers, assistive listening systems, telephones compatible with hearing
aids, closed caption decoders, open and closed captioning, telecommunications
devices for enrollees who are deaf or hard of hearing (TTY/TDD), video test
displays, and other effective methods of making aurally delivered materials
available to individuals with hearing impairments; qualified readers, taped
texts, audio recordings, Brailed materials, large print materials, or other
effective methods of making visually delivered materials available to
individuals with visual impairments.
B.
"Disability" means a mental or physical impairment that substantially limits
one
or more of the major life activities of an individual; a record of such
impairment; or being regarded as having such an impairment.
Medicaid
Advantage Contract
APPENDIX
J
State
,2006
J-3
III. Scope
of MCO Compliance Plan
The
MCO
Compliance Plan must address accessibility to services at the MCO's program
sites, including both participating provider sites and MCO facilities intended
for use by enrollee.
IV. Program
Accessibility
Public
programs and services, when viewed in their entirety, must be readily accessible
to and useable by individuals with disabilities. This standard includes physical
access, non-discrimination in policies and procedures and communication.
Communications with individuals with disabilities are required to be as
effective as communications with others. The MCO Compliance Plan must include
a
detailed description of how MCO services, programs and activities are readily
accessible and usable by individuals with disabilities. In the event that full
physical accessibility is not readily available for people with disabilities,
the MCO Compliance Plan will describe the steps or actions the MCO will take
to
assure accessibility to services equivalent to those offered at the inaccessible
facilities.
IV.
Program Accessibility
A.
Pre-enrollment Marketing and Education
Standard
for Compliance:
Marketing
staff, activities and materials will be made available to persons with
disabilities. Marketing materials will be made available in alternative formats
(such as Braille, large print, audio tapes) so that they are readily usable
by
people with disabilities.
Suggested
Methods for Compliance
1.
Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as
necessary
2.
Materials available in alternative formats, such as Braille, large print, audio
tapes
3.
Staff
training which includes training and information regarding attitudinal barriers
related to disability
4.
Activities and fairs that include sign language interpreters or the distribution
of a written summary of the marketing script used by plan marketing
representatives
5.
Enrollee health promotion material/activities targeted specifically to persons
with disabilities (e.g. secondary infection prevention, decubitus prevention,
special exercise programs, etc.)
Medicaid
Advantage Contract
APPENDIX
J
State
,2006
J-4
6.
Policy
statement that marketing representatives will offer to read or summarize to
blind or vision impaired individuals any written material that is typically
distributed to all enrollees
7.
Staff/resources available to assist individuals with cognitive impairments
in
understanding materials
Compliance
Plan Submission
1.
A
description of methods to ensure that the MCO's marketing presentations
(materials and communications) are accessible to persons with auditory, visual
and cognitive impairments
2.
A
description of the MCO's policies and procedures, including marketing training,
to ensure that marketing representatives neither screen health status nor ask
questions about health status or prior health care services
IV. Program
Accessibility
B. Member
Services Department
Member
services functions include the provision to enrollees of information necessary
to make informed choices about treatment options, to effectively utilize the
health care resources, to assist enrollees in making appointments, and to field
questions and complaints, to assist enrollees with the complaint
process.
B1. Accessibility
Standard
for Compliance:
Member
Services sites and functions will be made accessible to, and usable by, people
with disabilities.
Suggested
Methods for Compliance
(include, but are not limited to those identified below)
1. Exterior
routes of travel, at least 36" wide, from parking areas or public transportation
stops into the MCO's facility
2. If
parking is provided, spaces reserved for people with disabilities, pedestrian
ramps at sidewalks, and dropoffs
3. Routes
of
travel into the facility are stable, slip-resistant, with all steps > '/2"
ramped, doorways with minimum 32" opening
4. Interior
halls and passageways providing a clear and unobstructed path or travel at
least
36" wide to bathrooms and other rooms commonly
used by enrollees
5. Waiting
rooms, restrooms, and other rooms used by enrollees are accessible to people
with disabilities
6. Sign
language interpreters and other auxiliary aids and services provided in
appropriate circumstances
Medicaid
Advantage Contract
APPENDIX
J
State,
2006
J-5
7.
Materials available in alternative formats, such as Braille, large print, audio
tapes
8.
Staff
training which includes sensitivity training related to disability issues
[Resources and technical assistance are available through the NYS Office of
Advocate for Persons with Disabilities - V/TTY (000) 000-0000; and the NYC
Mayor's Office for People with Disabilities-(212) 788-2830 or TTY
(000)000-0000]
9.
Availability of activities and educational materials tailored to specific
conditions/illnesses and secondary conditions that affect these populations
(e.g. secondary infection prevention, decubitus prevention, special exercise
programs, etc.) 10. MCO staff trained in the use of telecommunication devices
for enrollees who are deaf or hard of hearing (TTY/TDD) as well as in the use
of
NY Relay for phone communication 11 New enrollee orientation available in audio
or by interpreter services 12.
Policy
that when member services staff receive calls through the NY Relay, they will
offer to return the call utilizing a direct TTY/TDD connection
Compliance
Plan Submission
1.
A
description of accessibility to the member services department or reasonable
alternative means to access member services for enrollees using wheelchairs
(or
other mobility aids)
2.
A
description of the methods the member services department will use to
communicate with enrollees who have visual or hearing impairments, including
any
necessary auxiliary aid/services for enrollees who are deaf or hard of hearing,
and TTY/TDD technology or NY Relay Service available through a toll-free
telephone number
3.
A
description of the training provided to member services staff to assure that
staff adequately understands how to implement the requirements of the program,
and of these guidelines, and are sensitive to the needs of persons with
disabilities
IV.
PROGRAM ACCESSIBILITY
B2. Identification
of Enrollees with Disabilities
Standard
for Compliance:
MCOs
must
have in place satisfactory methods/guidelines for identifying persons at risk
of, or having, chronic diseases and disabilities and determining their specific
needs in terms of specialist physician referrals, durable medical equipment,
medical supplies, home health services etc. MCOs may not discriminate against
a
potential enrollee based on his/her current health status or anticipated need
for future health care. MCOs may not discriminate on the basis of disability,
or
perceived disability of an enrollee or their family member. Health assessment
forms may not be used by plans prior to enrollment. ( Once a plan has been
chosen, a health assessment form may be used to assess the person's health
care
needs.)
Medicaid
Advantage Contract
APPENDIX
J
State
,2006
J-6
Suggested
Methods for Compliance
1
Appropriate post enrollment health screening for each enrollee, using an
appropriate health screening tool
2
Patient
profiles by condition/disease for comparative analysis to national norms, with
appropriate outreach and education
3.
Process for follow-up of needs identified by initial screening; e.g. referrals,
assignment of case manager, assistance with scheduling/keeping
appointments
4
Enrolled population disability assessment survey
5.
Process for enrollees who acquire a disability subsequent to enrollment to
access appropriate services
Compliance
Plan Submission
1.
A
description of how the MCO will identify special health care, physical access
or
communication needs of enrollees on a timely basis, including but not limited
to
the health care needs of enrollees who:
| · |
are
blind or have visual impairments, including the type of auxiliary
aids and
services required by the enrollee
|
| · |
are
deaf or hard of hearing, including the type of auxiliary aids and
services
required by the enrollee
|
| · |
have
mobility impairments, including the extent, if any, to which they
can
ambulate
|
| · |
have
other physical or mental impairments or disabilities, including cognitive
impairments
|
| · |
have
conditions which may require more intensive case
management
|
IV.
PROGRAM ACCESSIBILITY
B3. New
Enrollee Orientation
Standard
for Compliance:
Enrollees
will be given information sufficient to ensure that they understand how to
access medical care through the plan. This information will be made accessible
to, and usable by, people with disabilities.
Suggested
Methods for Compliance\
1.
Activities held in physically accessible location, or staff at activities
available to meet with person in an accessible location as
necessary
2.
Materials available in alternative formats, such as Braille, large print, audio
tapes
3.
Staff
training which includes sensitivity training related to disability issues
[Resources and technical assistance are available
Medicaid
Advantage Contract
APPENDIX
J
State
,2006
J-7
Through
the NYS Office of Advocate for Persons with Disabilities - V/TTY (000) 000-0000;
and the NYC Major’s Office for People with Disabilities- (000) 000-0000 or TTY
(000)000-0000] .
4.
Activities and fairs that include sign language interpreters or the distribution
of a written summary of the marketing script used by plan marketing
representatives
5.
Include in written/audio materials available to enrollees information regarding
how and where people with disabilities can access help in getting services,
for
example help with making appointment or for arranging special transportation,
an
interpreter or assistive communication devices.
6.
Staff/resources available to assist individuals with cognitive impairments
in
understanding materials
Compliance
Plan Submission
1.
A
description of how the MCO will advise enrollees with disabilities, during
the
new enrollee orientation on how to access care
2.
A
description of how the MCO will assist new enrollees with disabilities (as
well
as current enrollees who acquire a disability) m selecting or arranging an
appointment with a Primary Care Practitioner (PCP)
| · |
This
should include a description of how the MCO will assure and provide
notice
to enrollees who are deal or hard o( hearing, blind or who have visual
impairments, of their right to obtain necessary auxiliary aids and
services during appointments and in scheduling appointments and follow-up
treatment with participating providers
|
| · |
In
the event that certain provider sites are not physically accessible
to
enrollees with mobility impairments, the MCO will assure that reasonable
alternative site and services are
available
|
3.
A
description of how the MCO will determine the specific needs of an enrollee
with
or at risk of having a disability/chronic disease, in terms of specialist
physician referrals, durable medical equipment (including assistive technology
and adaptive equipment), medical supplies and home health services and will
assure that such contractual services are provided
4.
A
description of how the MCO will identify if an enrollee with a disability
requires on-going mental health services and how MCO will encourage early entry
into treatment
5.
A
description of how the MCO will notify enrollees with disabilities as to how
to
access transportation, where applicable
IV.
PROGRAM ACCESSIBILITY
B4. Complaints
and Appeals
Standard
for Compliance:
The
MCO
will establish and maintain a procedure to protect the rights and interests
of
both enrollees and managed care plans by receiving, processing, and resolving
grievances and complaints in an expeditious manner, with the goal of ensuring
resolution of complaints and access to appropriate
Medicaid
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APPENDIX
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services
as rapidly as possible.
All
enrollees must be informed about the complaint process within their plan and
the
procedure for filing complaints. This information will be made available through
the member handbook, the SDOH toll-free complaint line [0-(000) 000-0000] and
the plan's complaint process annually as well as when the MCO denies a benefit
or referral. The MCO will inform enrollees of: the MCO's complaint procedure-
enrollees' right to contact the local district or SDOH with a complaint, and
to
file an appeal or request a fair hearing; the right to appoint a designee to
handle a complaint or appeal; the toll free complaint line. The MCO will
maintain designated staff to take and process complaints, and be responsible
for
assisting enrollees in complaint resolution.
The
MCO
will make all information regarding the complaint process available to and
usable by people with disabilities, and will assure that people with
disabilities have access to sites where enrollees typically file complaints
and
requests for appeals,
Suggested
Methods for Compliance
1. 800
complaint phone line with TDD/TTY capability
2. Staff
trained in complaint process, and able to provide interpretive or assistive
support to enrollee during the complaint process
3. Notification
materials and complaint forms in alternative formats for enrollees with visual
or hearing impairments
4. Availability
of physically accessible sites, e.g. member services department
sites
5. Assistance
for individuals with cognitive impairments
Compliance
Plan Submission
1.
A
description of how MCO's complaint and appeal procedures shall be accessible
for
persons with disabilities, including:
| · |
procedures
for complaints and appeals to be made in person at sites accessible
to
persons with mobility impairments
|
| · |
procedures
accessible to persons with sensory or other impairments who wish
to make
verbal complaints, and to communicate with such persons on an ongoing
basis as to the status or their complaints and rights to further
appeals
|
| · |
description
of methods to ensure notification material is available in alternative
formats for enrollees with vision and hearing
impairments
|
2.
A
description of how MCOs monitor complaints and grievances related to people
with
disabilities. Also, as part of the Compliance ____Plan, MCOs must submit a
summary report based on the MCO's most recent year's complaint
data.
Medicaid
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APPENDIX
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IV.
PROGRAM ACCESSIBILITY
C. Case
Management
Standard
for Compliance:
MCOs
must
have m place adequate case management systems to identify the service needs
of
all enrollees, including enrollees with chronic illness and enrollees with
disabilities, and ensure that medically necessary covered benefits are delivered
on a timely basis. These systems may include procedures for standing referrals,
specialists as PCPs, and referrals to specialty centers for enrollees who
require specialized medical care over a prolonged period of time (as determined
by a treatment plan approved by the MCO in consultation with the
primary care provider, the designated specialist and the enrollee or his/her
designee), out of plan referrals and continuation of existing treatment
relationships with out-of-plan providers (during transitional
period)
Suggested
Methods for Compliance
1.
Procedures for requesting specialist physicians to function as PCP
2.
Procedures for requesting standing referrals to specialists and/or specialty
centers, out of plan referrals, and continuation of existing
treatment relationships
3.
Procedures to meet enrollee needs for, durable medical equipment, medical
supplies, home visits as appropriate
4.
Appropriately trained MCO staff to function as case managers for special needs
populations, or sub-contract arrangements fur case management
5.
Procedures for informing enrollees about the availability of case management
services
Compliance
Plan Submission
1.
A
description of the MCO case management program for people with disabilities,
including case management functions, procedures for qualifying for and being
assigned a case manager , and description of case management staff
qualifications
2.
A
description of the MCO's model protocol to enable participating providers,
at
their point of service, to identify enrollees who require a case
manager
3.
A
description of the MCO's protocol for assignment of specialists as PCP, and
for
standing referrals to specialists and specialty centers, out-of-plan referrals
and continuing treatment relationships
4.
A
description of the MCO's notice procedures to enrollees regarding the
availability of case management services, specialists as ____PCPs, standing
referrals to specialists and specialty centers, out-of-plan referrals and
continuing treatment relationships
Medicaid
Advantage Contract
APPENDIX
J
January
1,2006
J-10
IV.
PROGRAM ACCESSIBILITY
Participating
Providers
Standard
for Compliance:
MCO
networks will include all the provider types necessary to finish the-benefit
package, to assure appropriate and timely health care to all enrollees,
including those with chronic illness and/or disabilities. Physical accessibility
is not limited to entry to a provider site, but also includes access to services
within the site, e.g. exam tables and medical equipment
Suggested
Methods for Compliance
1.
Process for MCO to evaluate provider network to ascertain the degree of provider
accessibility to persons with disabilities, to identify barriers to access
and
required modifications to policies/procedures
2.
Model
protocol to assist participating providers, at their point of service, to
identify enrollees who require case manager, audio, visual, mobility aids,
or
other accommodations
3.
Model
protocol for determining needs of enrollees with mental
disabilities
4.
Use of
Wheelchair Accessibility Certification Form (see attached)
5.
Submission of map of physically accessible sites
6.
Training for providers re: compliance with Title III of ADA, e.g. site access
requirements for door widths, wheelchair ramps, accessible diagnostic/treatment
rooms and equipment; communication issues; attitudinal barriers related to
disability, etc. [Resources and technical assistance are available through
the
NYS Office of Advocate for Persons with Disabilities -V/TTY (000) 000-0000;
and
the NYC Mayor's Office for People with Disabilities - (000) 000-0000 or TTY
(000)000-0000]
7.
Use of
ADA Checklist for Existing Facilities and NYC Addendum to OAPD ADA Accessibility
Checklist as guides for evaluating existing facilities and for new construction
and/or alteration.
Compliance
Plan Submission
1.
A
description of how MCO will ensure that its participating provider network
is
accessible to persons with disabilities. This includes the
following:
| · |
Policies
and procedures to prevent discrimination on the basis of disability
or
type of illness or condition
|
| · |
Identification
of participating provider sites which are accessible by people with
mobility impairments, including people using mobility devices. If
certain
provider sites are not physically accessible to persons with disabilities,
the MCO shall describe reasonable, alternative means that result
in making
the provider services readily
accessible.
|
| · |
Identification
of participating provider sites which do not have access to sign
language
interpreters or reasonable alternative means to communicate
|
Medicaid
Advantage Contract
APPENDIX
J
January
1,2006
J-11
with
enrollees who are deaf or hard of hearing; and for those sites describe
reasonable alternative methods to ensure that services will be made accessible
| · |
Identification
of participating providers which do not have adequate communication
systems for enrollees who are blind or have vision impairments (e.g.
raised symbol and lettering or visual signal appliances), and for
those
sites describe reasonable alternative methods to ensure that services
will
be made accessible
|
2
A
description of how the MCO's specialty network is sufficient to meet the needs
of enrollees with disabilities
3
A
description of methods to ensure the coordination of out-of-network providers
to
meet the needs of the enrollees with disabilities
| · |
This
may include the implementation of a referral system to ensure that
the
health care needs of enrollees with disabilities are met appropriately
|
| · |
MCO
shall describe policies and procedures to allow for the continuation
of
existing relationships with out-of-network providers, when in the
best
interest of the enrollee with a
disability
|
4
Submission of ADA Compliance Summary Report (see attached - county
specific/borough specific for NYC) or MCO statement that data submitted to
SDOH
on the Health Provider Network (HPN) files is an accurate reflection of each
network's physical accessibility
IV.
PROGRAM ACCESSIBILITY
E. Populations
Special Health Care Needs
Standard
for Compliance:
MCOs
will
have satisfactory methods for identifying persons at risk of, or having, chronic
disabilities and determining their specific needs in terms of specialist
physician referrals, durable medical equipment, medical supplies, home health
services, etc. MCOs will have satisfactory systems for coordinating service
delivery and, if necessary, procedures to allow continuation of existing
relationships witlh out-of-network provider for course of
treatment.
Suggested
Methods for Compliance
1.
Procedures for requesting standing referrals to specialists and/or specialty
centers, specialist physicians to function as PCP, out of plan referrals, and
continuation of existing relationships with out-of-network providers for course
of treatment
2.
Contracts with school-based health centers
3.
Linkages with preschool services, child protective agencies, early intervention
officials, behavioral health agencies, disability and advocacy organizations,
etc.
4.
Adequate network of providers and subspecialists (including pediatric providers
and sub-specialists) and contractual relationships with tertiary
institutions
Medicaid
Advantage Contract
APPENDIX
J
January
1,2006
J-12
5.
Procedures for assuring that these populations receive appropriate diagnostic
workups on a timely basis
6
Procedures for assuring that these populations receive appropriate access to
durable medical equipment on a timely basis
7.
Procedures for assuring that these populations receive appropriate allied health
professionals (Physical, Occupational and Speech Therapists, Audiologists)
on a
timely basis
8.
State
designation as a Well Qualified Plan to serve OMRDD population and
look-alikes
Compliance
Plan Submission
1.
a
description
of arrangements to ensure access to specialty care providers and centers in
and
out of New York State, standing referrals, specialist physicians to function
as
PCP, out of plan referrals, and continuation of existing relationships
(out-of-plan) diagnosis and treatment of rare disorders.
2
A
description of appropriate service delivery for children with disabilities.
This
may include a description of methods for interacting with school districts,
preschool services, child protective service agencies, early intervention
officials, behavioral health, and disability and advocacy organizations and
School Based Health Centers.
3.
A
description of the pediatric provider and sub-specialist network, including
contractual relationships with tertiary institutions to meet the health care
needs of children with disabilities.
V. ADDITIONAL
ADA RESPONSIBILITIES FOR PUBLIC ACCOMMODATIONS
Please
note that Title III of the ADA applies to all non-governmental providers of
health care. Title III of the Americans With Disabilities Act prohibits
discrimination on the basis of disability in the full and equal enjoyment of
goods, services, facilities, privileges, advantages or accommodations of any
place of public accommodation. A public accommodation is a private entity that
owns, leases or leases to, or operates a place of public accommodation. Places
of public accommodation identified by the ADA include, but are not limited
to,
stores (including pharmacies) offices (including doctors' offices), hospitals,
health care providers, and social service centers.
New
and
altered areas and facilities must be as accessible as possible. Barriers must
be
removed from existing facilities when it is readily achievable, defined by
the
ADA as easily accomplishable without much difficulty or expense. Factors to
be
considered when determining if barrier removal is readily achievable include
the
cost of the action, the financial resources of the site involved, and, if
applicable, the overall financial resources of any parent corporation or entity.
If barrier removal is not readily achievable, the ADA requires alternate methods
of making goods and services available. New facilities must be accessible unless
structurally impracticable.
Title
III
also requires places of public accommodation to provide any auxiliary aids
and
services that are needed to ensure equal access to the services it offers,
unless a fundamental alteration in the nature of services or an undue burden
would result. Auxiliary aids include but
Medicaid
Advantage Contract
APPENDIX
J
January
1,2006
J-13
are
not
limited to qualified sign interpreters, assistive listening systems, readers,
large print materials, etc. Undue burden is defined as "significant difficulty
or expense". The factors to be considered in determining "undue burden" include,
but are not limited to, the nature and cost of the action required and the
overall financial resources of the provider. "Undue burden" is a higher standard
than "readily achievable" in that it requires a greater level of effort on
the
part of the public accommodation.
Please
note also that the ADA is not the only law applicable for people with
disabilities. In some cases, State or local laws require more than the ADA.
For
example, New York City's Human Rights Law, which also prohibits discrimination
against people with disabilities, includes people whose impairments are not
as
"substantial" as the narrower ADA and uses the higher "undue burden"
("reasonable") standard where the ADA requires only that which is "readily
achievable". New York City's Building Code does not permit access waivers for
newly constructed facilities and requires incorporation of access features
as
existing facilities are renovated. Finally, the State Hospital code sets a
higher standard than the ADA for provision of communication (such as sign
language interpreters) for services provided at most hospitals, even on an
outpatient basis.icaid Advantage Contract
Medicaid
Advantage Contract
APPENDIX
J
January
1,2006
J-14
APPENDIX
K
Medicare
and Medicaid Advantage Products And Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
State
2006l
K
1
APPENDIX
K
Appendix
K is organized into three parts:
I.
Appendix K-l
Medicare
Advantage Product
II.
Appendix K-2
Medicaid
Advantage Product
Contractor/County
Election of Coverage for Optional Services
Description
of Medicaid Only Covered Services
III.
Appendix K-3
Non-Covered
Services
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-2
APPENDIX
K.1
MEDICARE
ADVANTAGE PRODUCT
|
Medicare
Advantage Benefit Package for Dual Eligibles - Upstate
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
Inpatient
Hospital Care Including Substance Abuse and Rehabilitation
Services
|
Up
to 365 Days per year (366 days for a leap year) $300 per stay
co-payment
|
|
Inpatient
Mental Health
Inpatient
Mental Health
|
Medically
necessary care. $300 per stay co-payment. 190-day lifetime limit
in a
psychiatric hospital
|
|
Skilled
Nursing Facility
|
Care
provided in a skilled nursing facility. Covered for 100 days each
benefit
period. No prior hospital stay required. No co-payment.
|
|
Home
Health
|
Medically
necessary intermittent skilled nursing care, home health aide services
and
rehabilitation services. $10 per visit co-payment.
|
|
PCP
Office Visits
|
Primary
care doctor office visits. Subject to $10 co-payment per
visit.
|
|
Specialist
Office Visits
|
Specialist
office visits. Subject to $20 co-payment for each specialist office
visit.
|
|
Chiropractic
|
Manual
manipulation of the spine to correct subluxation provided by chiropractors
or other qualified providers. Subject to $20 co-payment.
|
|
Podiatry
|
Medically
necessary foot care, including care for medical conditions affecting
lower
limbs, subject to $20 co-payment. Visits for routine foot care up
to 4
visits per year, not subject to co-payment.
|
|
Outpatient
Mental Health
|
Individual
and group therapy visits, subject to co-payment of $20 per individual
or
group visit. Enrollee must be able to self-refer for one assessment
from a
network provider in a twelve (12) month period.
|
|
Outpatient
Substance Abuse
|
Individual
and group visits subject to $20 co-payment per group or individual
visit.
Enrollee must be able to self-refer for one assessment from a network
provider in a twelve (12) month period
|
|
Outpatient
Surgery
|
Medically
necessary visits to an ambulatory surgery center or outpatient hospital
facility. $35 per visit to ambulatory surgery or outpatient
hospital.
|
|
Ambulance
|
Transportation
provided by an ambulance service, including air ambulance. Emergency
transportation if for the purpose of obtaining hospital service for
an
enrollee who suffers from severe, life-threatening or potentially
disabling conditions
|
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-3
|
Medicare
Advantage Benefit Package for Dual Eligibles - Upstate
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
which
require the provision of emergency services while the enrollee is
being
transported. Includes transportation to a hospital emergency room
generated by a "Dial 911." $50 co-payment.
|
|
|
Emergency
Room
|
Care
provided in an emergency room subject to prudent layperson standard.
$50
co-payment per visit. Co-payment waived if admitted to the hospital
within
24 hours for the same condition.
|
|
Urgent
Care
|
Urgently
needed care in most cases outside the plan's service area. Subject
to $20
co-payment.
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Occupational
therapy, physical therapy and speech and language therapy subject
to $20
co-payment.
|
|
Durable
Medical Equipment (DME)
|
Medicare
and Medicaid covered durable medical equipment, including devices
and
equipment other than medical/surgical supplies, enteral formula,
and
prosthetic or orthotic appliances having the following characteristics:
can withstand repeated use for a protracted period of time; are primarily
and customarily used for medical purposes; are generally not useful
to a
person in the absence of illness or injury and are usually fitted,
designed or fashioned for a particular individual's use. Must be
ordered
by a qualified practitioner. No homebound prerequisite and including
non-Medicare DME covered by Medicaid (e.g. tub stool; grab bars).
No
co-payment or coinsurance.
|
|
Prosthetics
|
Medicare
and Medicaid covered prosthetics, orthotics and orthopedic footwear.
No
diabetic or temporary impairment prerequisite for orthotics. Not
subject
to co-payment or coinsurance.
|
|
Diabetes
Monitoring
|
Diabetes
self-monitoring training and supplies including coverage for glucose
monitors, test strips, lancets and self-management training. No
co-payment.
|
|
Diagnostic
Testing
|
Diagnostic
tests, x-rays, lab services and radiation therapy. No
co-payment.
|
|
Bone
Mass Measurement
|
Bone
Mass Measurement for people at risk. No co-payment.
|
|
Colorectal
Screening
|
Colorectal
screening for people, age 50 and older. No co-payment.
|
|
Immunizations
|
Flu,
hepatitis B vaccine for people who are at risk. Pneumonia vaccine.
Vaccines/Toxoids. No co-payment.
|
|
Mammograms
|
Annual
screening for women age 40 and older. No referral necessary.
No co-payment.
|
|
Pap
Smear and Pelvic Exams
|
Pap
smears and Pelvic Exams for women. No co-payment.
|
|
Prostate
Cancer Screening
|
Prostate
Cancer Screening exams for men age 50 and older.
No
co-payment
|
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-4
|
Medicare
Advantage Benefit Package for Dual Eligibles -
Upstate Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
Outpatient
Drugs
|
Medicare
Part B covered prescription drugs and other drugs obtained by a provider
and administered in a physician office or clinic setting covered
by
Medicaid.
|
|
Hearing
Services
|
Medicaid
and Medicare hearing services and products when medically necessary
to
alleviate disability caused by the loss or impairment of hearing.
Services
include hearing aid selecting, fitting, and dispensing; hearing aid
checks
following dispensing, conformity evaluations and hearing aid repairs;
audiology services including examinations and testing, hearing aid
evaluations and hearing aid prescriptions; and hearing aid products
including hearing aids, ear-molds, special fittings and replacement
parts.
No co-payment or limitations.
|
|
Vision
Care Services
|
Services
of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate
lenses,
artificial eyes (stock or custom-made), low vision aids and low vision
services. Coverage includes the replacement of lost or destroyed
glasses.
Coverage also includes the repair or replacement of parts. Coverage
also
includes examinations for diagnosis and treatment for visual defects
and/or eye disease. Examinations for refraction are limited to every
two
(2) years unless otherwise justified as medically necessary. Eyeglasses
do
not require changing more frequently than every two (2) years unless
medically necessary or unless the glasses are lost, damaged or destroyed.
No prerequisite of cataract surgery. No co-payment.
|
|
Routine
Physical Exam 1/year
|
Up
to one routine physical per year. Subject to $10 co-payment per visit.
|
|
Health/Wellness
Education
|
Coverage
for the following: general health education classes, parenting classes,
smoking cessation classes, childbirth education and nutrition counseling,
plus additional benefits at plan option including but not limited
to items
such as newsletters, nutritional training, congestive heart program,
health club membership/fitness classes, nursing hotline, disease
management, other wellness services. No co-payments
|
|
Additional
Part C Benefits, if any
|
|
|
Medicare
Part D Prescription Drug Benefit as Approved by CMS
|
|
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-5
|
Medicare
Advantage Benefit Package for Dual Eligibles - NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
Inpatient
Hospital Care Including Substance Abuse and Rehabilitation
Services
|
Up
to 365 days per year (366 days for leap year) with no deductible
or
co-payment
|
|
Inpatient
Mental Health
|
Medically
necessary care with no deductible or co-payment. 190-day lifetime
limit in
a psychiatric hospital.
|
|
Skilled
Nursing Facility
|
Care
provided in a skilled nursing facility. Covered for 100 days each
benefit
period. No prior hospital stay required. No co-payment.
|
|
Home
Health
|
Medically
necessary intermittent skilled nursing care, home health aide services
and
rehabilitation services. No co-payment.
|
|
PCP
Office Visits
|
Primary
care doctor office visits. No co-payment.
|
|
Specialist
Office Visits
|
Specialist
office visits. Subject to $10 co-payment for each specialist office
visit.
|
|
Chiropractic
|
Manual
manipulation of the spine to correct subluxation provided by chiropractors
or other qualified providers. Subject to $10
co-payment.
|
|
Podiatry
|
Medically
necessary foot care, including care for medical conditions affecting
lower
limbs, subject to $10 co-payment. Visits for routine foot care up
to 4
visits per year, not subject to co-payment.
|
|
Outpatient
Mental Health
|
Individual
and group therapy visits, subject to co-payment of $20 per individual
or
group visit. Enrollee must be able to self-refer for one assessment
from a
network provider in a twelve (12) month period.
|
|
Outpatient
Substance Abuse
|
Individual
and group visits subject to $20 co-payment per group or individual
visit.
Enrollee must be able to self-refer for one assessment from a network
provider in a twelve (12) month period.
|
|
Outpatient
Surgery
|
Medically
necessary visits to an ambulatory surgery center or outpatient hospital
facility. No co-payment.
|
|
Ambulance
|
Transportation
provided by an ambulance service, including air ambulance. Emergency
transportation if for the purpose of obtaining hospital services
for an
enrollee who suffers from severe, life-threatening or potentially
disabling conditions which require the provision of emergency services
while the enrollee is being transported. Includes transportation
to a
hospital emergency room generated by a "Dial 911". No co-payment.
|
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-6
|
Medicare
Advantage Benefit Package for Dual Eligibles - NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
Emergency
Room
|
Care
provided in an emergency room subject to prudent layperson standard.
$50
co-payment per visit. Co-payment waived if admitted to the hospital
within
24 hours for the same condition.
|
|
Urgent
Care
|
Urgently
needed care in most cases outside the plan's service area. Subject
to $10
co-payment.
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Occupational
therapy, physical therapy and speech and language therapy subject
to $10
co-payment.
|
|
Durable
Medical Equipment (DME)
|
Medicare
and Medicaid covered durable medical equipment, including devices
and
equipment other than medical/surgical supplies, enteral formula,
and
prosthetic or orthotic appliances having the following characteristics:
can withstand repeated use for a protracted period of time; are primarily
and customarily used for medical purposes; are generally not useful
to a
person in the absence of illness or injury and are usually not fitted,
designed or fashioned for a particular individual's use. Must be
ordered
by a qualified practitioner. No homebound prerequisite and including
non-Medicare DME covered by Medicaid (e.g., tub stool; grab bar).
No
co-payment or coinsurance.
|
|
Prosthetics
|
Medicare
and Medicaid covered prosthetics, orthotics and orthopedic footwear.
No
diabetic prerequisite for orthotics. Not subject to co-payment or
coinsurance.
|
|
Diabetes
Monitoring
|
Diabetes
self-monitoring training and supplies including coverage for glucose
monitors, test strips, lancets and self-management training. No
co-payments.
|
|
Diagnostic
Testing
|
Diagnostic
tests, x-rays, lab services and radiation therapy. No co-payments.
|
|
Bone
Mass Measurement
|
Bone
Mass Measurement for people at risk. No co-payment
|
|
Colorectal
Screening
|
Colorectal
screening for people, age 50 and older. No co-payment.
|
|
Immunizations
|
Flu,
hepatitis B vaccine for people who are at risk. Pneumonia vaccine.
No
co-payment.
|
|
Mammograms
|
Annual
screening for women age 40 and older. No referral necessary.
No co-payment.
|
|
Pap
Smear and Pelvic Exams
|
Pap
smears and Pelvic Exams for women. No co-payment.
|
|
Prostate
Cancer Screening
|
Prostrate
Cancer Screening exams for men age 50 and older. No co-payment.
|
|
Outpatient
Drugs
|
Medicare
Part B covered prescription drugs and other drugs obtained by a provider
and administered in a physician office or clinic setting covered
by
Medicaid.
|
|
Hearing
Services
|
Medicare
and Medicaid hearing services and products when medically
necessary to alleviate disability caused by the loss or impairment
of
hearing. Services include hearing aid selecting, fitting, and dispensing;
hearing aid checks following dispensing, conformity evaluations and
hearing aid repairs; audiology services including examinations and
testing, hearing aid evaluations and hearing aid prescriptions; and
hearing aid products including hearing aids, earmolds, special fittings
and replacement parts. No co-payment or
limitations.
|
Medicaid
Advantage Contract
APPENDIX
K
January
1,2006
K-7
|
Medicare
Advantage Benefit Package for Dual Eligibles - NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
|
|
|
Vision
Care Services
|
Services
of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate
lenses,
artificial eyes (stock or custom-made), low vision aids and low vision
services. Coverage includes the replacement of lost or destroyed
glasses.
Coverage also includes the repair or replacement of parts. Coverage
also
includes examinations for diagnosis and treatment for visual defects
and/or eye disease. Examinations for refraction are limited to every
two
(2) years unless otherwise justified as medically necessary. Eyeglasses
do
not require changing more frequently than every two (2) years unless
medically necessary or unless the glasses are lost, damaged or destroyed.
No prerequisite of cataract services. No co-payment.
|
|
Routine
Physical Exam I/year
|
Up
to one routine physical per year. No co-payment.
|
|
Health/Wellness
Education
|
Coverage
for the following: general health education classes, parenting classes,
smoking cessation classes, childbirth education and nutrition counseling,
plus additional benefits at plan option including but not limited
to items
such as newsletters, nutritional training, congestive heart program,
health club membership/fitness classes, nursing hotline, disease
management, other wellness services. No co-payments.
|
|
Additional
Part C Benefits, if any
|
|
|
Medicare
Part D Prescription Drug Benefit as Approved by CMS
|
|
Medicaid
Advantage Contract
APPENDIX
K.
State,
2006
K-8
APPENDIX
K2
MEDICAID
ADVANTAGE PRODUCT
|
Medicaid
Advantage Benefit Package for Dual Eligibles - Upstate
Counties
|
|
|
Category of Service
|
Included
in Medicaid Capitation
|
|
Inpatient
Hospital Care Including Substance Abuse and Rehabilitation
Services
|
Elimination
of $300 per stay co-payment.
|
|
Inpatient
Mental Health
|
Elimination
of $300 per stay co-payment, plus days in excess of the 190-day lifetime
maximum.
|
|
Home
Health
|
Elimination
of $10 co-payment per Medicare covered visit, plus value of Medicare
non-covered visits including home health aid services with nursing
supervision to medically unstable individuals.
|
|
PCP
Office Visits
|
Elimination
of $10 co-payment
|
|
Specialist
Office Visits
|
Elimination
of $20 co-payment
|
|
Podiatry
|
Elimination
of $20 co-payment for medically necessary foot care
|
|
Outpatient
Mental Health
|
Elimination
of $20 co-payment
|
|
Outpatient
Substance Abuse
|
Elimination
of $20 co-payment
|
|
Outpatient
Surgery
|
Elimination
of $35 co-payment
|
|
Ambulance
|
Elimination
of $50 co-payment
|
|
Emergency
Room
|
Elimination
of $50 co-payment
|
|
Urgent
Care
|
Elimination
of $20 co-payment
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Elimination
of $20 co-payment
|
|
Dental
(Optional
benefit)
|
Medicaid
covered dental services including necessary preventive, prophylactic
and
other routine dental care, services and supplies and dental prosthetics
to
alleviate a serious health condition. Ambulatory or inpatient surgical
dental services subject to prior authorization.
|
|
Routine
Physical Exam I/year
|
Elimination
of $10 co-payment
|
|
Transportation
- Routine (Optional
benefit)
|
Transportation
essential for an enrollee to obtain necessary, medical care and services
under the plan's benefits or Medicaid fee-for-service. Includes ambulette,
invalid coach, taxicab, livery, public transportation, or other means
appropriate to the enrollee's medical condition and a transportation
attendant to accompany the enrollee, if necessary.
|
|
Private
Duty Nursing
|
Medically
necessary private duty nursing services in accordance with the ordering
physician, registered physician assistant or certified nurse
practitioner's written treatment plan.
|
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-9
|
Medicaid
Advantage Benefit Package for Dual Eligibles- NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
Category
of Service
|
Included
in Medicaid Capitation
|
|
Inpatient
Mental Health
|
Days
in excess of the 190-day lifetime maximum.
|
|
Home
Health
|
Non-Medicare
covered home health services, including home health aid services
and
nursing supervision to medically unstable individuals.
|
|
Specialist
Office Visits
|
Elimination
of $10 co-payment.
|
|
Podiatry
|
Elimination
of $10 co-payment for medically necessary footcare.
|
|
Outpatient
Mental Health
|
Elimination
of $20 co-payment.
|
|
Outpatient
Substance Abuse
|
Elimination
of $20 co-payment.
|
|
Emergency
Room
|
Elimination
of $50 co-payment
|
|
Urgent
Care
|
Elimination
of $10 co-payment.
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Elimination
of $10 co-payment.
|
|
Dental
(Optional
benefit outside of NYC )
|
Medicaid
covered dental services including necessary preventive, prophylactic
and
other routine dental care, services and supplies and dental prosthetics
to
alleviate a serious health condition. Ambulatory or inpatient surgical
dental services subject to prior authorization.
|
|
Transportation
- Routine (Optional
benefit outside of NYC)
|
Transportation
essential for an enrollee to obtain necessary medical care and services
under the plan's benefits or Medicaid fee-for-service. Includes ambulette,
invalid coach, taxicab, livery, public transportation, or other means
appropriate to the enrollee's medical condition and a transportation
attendant to accompany the enrollee, if necessary.
|
|
Private
Duty Nursing
|
Medically
necessary private duty nursing services in accordance with the ordering
physician, registered physician assistant or certified nurse
practitioner's written treatment
plan.
|
Medicaid
Advantage Contract
APPENDIX
K
January
1,2006
K-10
MCO
COVERAGE
OF
OPTIONAL SERVICES
MEDICAID
ADVANTAGE BENEFIT PACKAGE
MCO: WellCare
of New York. Inc.
|
Service
Area
|
Medicaid
Advantage Coverage Status
|
|
|
Dental
Services
|
Non-Emergency
Transporation
|
|
|
Albany
|
Not
Covered
|
Not
Covered
|
Medicaid
Advantage Contract
APPENDIX
K
January
1,2006
K-11
DESCRIPTION
OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE BENEFIT
PACKAGE:
Inpatient
Mental Health Over 190-Day Lifetime Limit
All
inpatient mental health services, including voluntary or involuntary admissions
for mental health services over the Medicare 190-Day Lifetime Limit. The
Contractor may provide the covered benefit for medically necessary mental health
impatient services through hospitals licensed pursuant to Article 28 of the
New
York State P.H.L.
Non-Medicare
Covered Home Health Services
Medicaid
covered home health services include the provision of skilled services not
covered by Medicare (e.g. physical therapist to supervise maintenance program
for patients who have reached their maximum restorative potential or nurse
to
pre-fill syringes for disabled individuals with diabetes) and /or home health
aide services as required by an approved plan of care developed by a certified
home health agency.
Private
Duty Nursing Services
Private
duty nursing services provided by a person possessing a license and current
registration from the NYS Education Department to practice as a registered
professional nurse or licensed practical nurse. Private duty nursing services
can be provided through an approved certified home health agency, a licensed
home care agency, or a private Practitioner. The location of nursing services
may be in the Enrollee's home or in the hospital.
Private
duty nursing services are covered when determined by the attending physician
to
be medically necessary. Nursing services may be intermittent, part-time or
continuous and provided in accordance with the ordering physician, registered
physician assistant or certified nurse practitioner's written treatment
plan.
Dental
Services (optional benefit outside of NYC)
Dental
care includes preventive, prophylactic and other routine dental care, services,
supplies and dental prosthetics required to alleviate a serious health
condition, including one which affects employability.
Dental
surgery performed in an ambulatory or inpatient setting is the responsibility
of
the Contractor whether dental services are a covered plan benefit, or not.
Inpatient claims and referred ambulatory claims for dental services provided
in
an inpatient or outpatient hospital setting for surgery, anesthesiology, x-rays,
etc. are the responsibility of the Contractor. In these situations, the
professional services of the dentist are covered by Medicaid fee-for-service.
The Contractor should set up procedures to prior approve dental services
provided in inpatient and ambulatory settings.
Medicaid
Advantage Contract
APPENDIX
K
State
2006
K-12
As
described in Sections 10.9 and 10.18 of this Agreement. Enrollees may self-refer
to Article 28 clinics operated by academic dental centers to obtain covered
dental services.
If
Contractor's Benefit Package excludes dental services:
i)
Enrollees may obtain routine exams, orthodontic services and appliances, dental
office surgery, fillings, prophylaxis, and other Medicaid covered dental
services from any qualified Medicaid provider who shall claim reimbursement
from
eMedNY; and
ii)
Inpatient and referred ambulatory claims for medical services provided in an
inpatient or outpatient hospital setting in conjunction with a dental procedure
(e.g. anesthesiology, x-rays), are the responsibility of the Contractor. In
these situations, the professional services of the dentist are covered Medicaid
fee-for-service.
Non-Emergency
Transportation (optional benefit outside of NYC)
Transportation
expenses arc covered when transportation is essential in order for an Enrollee
to obtain necessary medical care and services which are covered under the
Medicaid program (either as part of the Contractor's Benefit Package or by
fee-for-service Medicaid). Non-emergent transportation guidelines may be
developed in conjunction with the LDSS, based on the LDSS' approved
transportation plan.
Transportation
services means transportation by ambulance, ambulette, fixed wing or airplane
transport, invalid coach, taxicab, livery, public transportation, or other
means
appropriate to the Enrollee's medical condition; and a transportation attendant
to accompany the Enrollee, if necessary. Such services may include the
transportation attendant's transportation, meals, lodging and salary; however,
no salary will be paid to a transportation attendant who is a member of the
Enrollee's family.
When
the
Contractor is capitated for non-emergency transportation, the Contractor is
also
responsible for providing transportation to Medicaid covered services that
are
not part of the Contractor's Benefit Package.
For
Contractors that cover non-emergency transportation in the Medicaid Advantage
Benefit Package, transportation costs to MMTP services may be reimbursed by
Medicaid FFS in accordance with the LDSS transportation policies in local
districts where there is a systematic^ method to discretely identify and
reimburse such transportation costs.
For
Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-13
APPENDIX
K.3
NON
COVERED SERVICES
The
following services will not be the responsibility of the MCO under the
Medicare/Medicaid program:
Services
Covered by Direct Reimbursement from Original Medicare
•
Hospice
services provided to Medicare Advantage members
•
Other
services deemed to be covered by Original Medicare by CMS
Services
Covered by Medicaid Fee for Service
•
Out
of
network Family Planning services under the direct access provisions of the
waiver
•
Skilled
Nursing Facility (SNF) days not covered by Medicare
•
Personal Care Services
•
Medicaid-Covered Prescription and Non-Prescription (OTC) Drugs, Medical Supplies
and Enteral Formula not covered under Medicare Part B or the MCO's Medicare
Part
D Prescription Drug Benefit approved by CMS.
•
Methadone Maintenance Treatment Programs
•
Certain
Mental Health Services, including
o
Intensive Psychiatric Rehabilitation Treatment Programs
o
Day
Treatment
o
Continuing Day Treatment
o
Case
Management for Seriously and Persistently Mentally 111 (sponsored by state
or
local mental health units)
o
Partial
Hospitalizations
•
Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs
•
Office
of Mental Retardation and Developmental Disabilities (OMRDD)
Services
•
Comprehensive Medicaid Case Management
•
Directly
Observed Therapy for Tuberculosis Disease
•
AIDS
Adult Day Health Care
•
HIV
COBRA Case Management
•
Adult
Day Health Care
Medicaid
Advantage Program Optional Benefits
Optional
benefits will be covered Medicaid fee for service if the MCO elects not to
cover
these services in their Medicaid Advantage Product. Currently the only 2
optional benefits are:
•
Non-Emergency Transportation Services
•
Dental
Service
These
services are mandatory in NYC.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-14
DESCRIPTION
OF NON-COVERED SERVICES
The
following services are excluded from the Contractor's Medicare and Medicaid
Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
fee-for-service:
1.
Hospice Services
Provided to Medicaid Advantage EnroIIees
Hospice
services provided to Medicare Advantage EnroIIees by a Medicare approved hospice
providers are directly reimbursed by Medicare. Hospice is a coordinated program
of home and inpatient care that provides non-curative medical and support
services for persons certified by a physician to be terminally ill with a life
expectancy of six (6) months or less. Hospice programs provide patients and
families with palliative and supportive care to meet the special needs arising
out of physical, psychological, spiritual, social and economic stresses which
are experienced during the final stages of illness and during dying and
bereavement.
Hospices
are organizations which must be certified under Article 40 of the NYS P.H.L.
and
approved by Medicare. All services must be provided by qualified employees
and
volunteers of the hospice or by qualified staff through contractual arrangements
to the extent permitted by federal and state requirements. All services must
be
provided according to a written plan of care which reflects the changing needs
of the patient/family.
If
an
Enrollee in the Contractor's plan becomes terminally ill and receives Hospice
Program services he or she may remain enrolled and continue to access the
Contractor's Benefit Package while Hospice costs are paid for by Medicare
fee-for-service.
2.
Other Services Deemed to be Covered by Original Medicare by
CMS
3.
Personal Care Agency Services
Personal
care services (PCS) are the provision of some or total assistance with personal
hygiene, dressing and feeding; and nutritional and environmental support (meal
preparation and housekeeping). Such services must be essential to the
maintenance of the Enrollee's health and safety in his or her own home. The
service has to be ordered by a physician, and there has to be a medical need
for
the service. Licensed home care services agencies, as opposed to certified
home
health agencies, are the primary providers of PCS. EnroIIees receiving PCS
have
to have a v
stable
medical condition and are generally expected to be in receipt of such services
for an extended period of time (years).
Services
rendered by a personal care agency which are approved by the LDSS are not
covered under the Medicare or Medicaid Benefit Packages. Should it be medically
necessary for the PCP to order personal care agency services, the PCP (or the
Contractor on the physician's behalf) must first contact the Enrollee's LDSS
contact person for personal care. The district will determine the Enrollee's
need for personal care agency services and coordinate with the personal care
agency a plan of care.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-15
4.
Skilled Nursing Facility Days Not Covered by Medicare
Skilled
nursing facility days for Medicaid Advantage Enrollees in excess of the first
100 days in the benefit period are covered by Medicaid on a fee for service
basis.
5.
Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and
Enteral
Formula
Not Covered by Medicare Part B and the Medicare Advantage Organization's
Medicare Part D Prescription Drug Benefit approved by CMS
Coverage
for drugs dispensed by community pharmacies, over the counter drugs,
medical/surgical supplies and enteral formula covered by Medicaid and not
included in the Contractor's Medicare Advantage Benefit Package will be paid
for
by Medicaid fee-for-service. Medical/surgical supplies are items other than
drugs, prosthetic or orthotic appliances, or DME which have been ordered by
a
qualified practitioner in the treatment of a specific medical condition and
which are: consumable, non-reusable, disposable, or for a specific rather than
incidental purpose, and generally have no salvageable value (e.g. gauze pads,
bandages and diapers). Pharmaceuticals and medical supplies routinely furnished
or administered as part of a clinic or office visit are covered by the
Contractor.
6.
Out of Network Family Planning Services
As
described in Section 10.9 and 10.7 of this Agreement, out of network family
planning services provided by qualified Medicaid providers to plan enrollees
will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
schedule. Family Planning and Reproductive Health Care services means those
health services which enable Enrollees, including minors, who may be sexually
active to prevent or reduce the incidence of unwanted pregnancy. These include:
diagnosis and all medically necessary treatment, sterilization, screening and
treatment for sexually transmissible diseases and screening for disease and
pregnancy.
Also
included is HIV counseling and testing when provided as part of a family
planning visit. Additionally, reproductive health care includes coverage of
all
medically necessary abortions. Elective induced abortions must be covered for
New York City recipients. Fertility services are not covered.
7.
Dental (when
not in benefit package)
(see
description in Appendix K-2)
8.
Non-Emergency Transportation (when not in benefit package)
(see
description in Appendix K-2)
9.
Methadone Maintenance Treatment Program (MMTP)
Consists
of drug detoxification, drug dependence counseling, and rehabilitation services
which include chemical management of the patient with methadone. Facilities
that
provide methadone
Medicaid
Advantage Contract
APPENDIX
K.
State,
2006
K-16
maintenance
treatment do so as their principal mission and are certified by the Office
of
Alcohol and Substance Abuse Services (OASAS) under Title 14 NYCRR, Part
828.
10.
Certain Mental Health Services
Contractor
is not responsible for the provision and payment of the following services
which
are reimbursed through Medicaid fee-for-service.
a.
Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)
A
time
limited active psychiatric rehabilitation designed to assist a patient in
forming and achieving mutually agreed upon goals in living, learning, working
and social environments, to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified
by
OMH under 14 NYCRR, Part 587.
b.
Day
Treatment
A
combination of diagnostic, treatment, and rehabilitative procedures which,
through supervised and planned activities and extensive client-staff
interaction, provides the services of the clinic treatment program, as well
as
social training, task and skill training and socialization activities. Services
are expected to be of six (6) months duration. These services are certified
by
OMH under 14 NYCRR, Part 587.
c.
Continuing Day Treatment
Provides
treatment designed to maintain or enhance current levels of functioning and
skills, maintain community living, and develop self-awareness and self-esteem.
Includes: assessment and treatment planning; discharge planning; medication
therapy; medication education; case management; health screening and referral;
rehabilitative readiness development; psychiatric rehabilitative readiness
determination and referral; and symptom management. These services are certified
by OMH under 14 NYCRR, Part 587.
This
waiver is in select counties for children and adolescents who would otherwise
be
admitted to an institutional setting if waiver services were not provided.
The
services include individualized care coordination, respite, family support,
intensive in-home skill building, and crisis response
d.
Case
.Management for Seriously and Persistently Mentally 111 Sponsored by State
or
Local Mental Health Units
The
target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention
to
help them obtain those services which will permit functioning in the community
and either have symptom logy which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 506.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-17
Please
note: See generic definition of Comprehensive Medicaid Case Management (CMCM)
in
this section.
e.
Partial Hospitalization Not Covered by Medicare
Provides
active treatment designed to stabilize and ameliorate acute systems, serves
as
an alternative to inpatient hospitalization, or reduces the length of a hospital
stay within a medically supervised program by providing the following:
assessment and treatment planning; health screening and referral; symptom
management; medication therapy; medication education; verbal therapy; case
management; psychiatric rehabilitative readiness determination and referral
and
crisis intervention. These services are certified by OMH under NYCRR Part
587.
f
Assertive Community Treatment (ACT)
ACT
is a
mobile team-based approach to delivering comprehensive and flexible treatment,
rehabilitation, case management and support services to individuals in their
natural living setting. ACT programs deliver integrated services to recipients
and adjust services over time to meet the recipient's goals and changing needs;
are operated pursuant to approval or certification by OMH; and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 508.
g.
Personalized Recovery Oriented Services (PROS)
PROS,
licensed and reimbursed pursuant to 14 NYCCR Part 512, are designed to assist
individuals in recovery from the disabling effects of mental illness through
the
coordinated delivery of a customized array of rehabilitation, treatment, and
support services in traditional settings and in off-site locations. Specific
components of PROS include Community Rehabilitation and Support, Intensive
Rehabilitation, Ongoing Rehabilitation and Support and Clinical
Treatment.
11.
Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs, as
follows:
a.
OMH
Licensed CRs*
Rehabilitative
services in community residences are interventions, therapies and activities
which are medically therapeutic and remedial in nature, and are medically
necessary for the maximum reduction of functional and adaptive behavior defects
associated with the person's mental illness.
b.
Family-Based Treatment*
Rehabilitative
services in family-based treatment programs are intended to provide treatment
to
seriously emotionally disturbed children and youth to promote their successful
functioning and integration into the natural family, community, school or
independent living situations. Such services are provided in consideration
of a
child's developmental stage. Those children determined eligible for admission
are placed in surrogate family homes for care and treatment.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-18
*These
services are certified by OMH under 14 NYCRR Part 586.3, 594 and
595.
12.
Office of Mental Retardation and Developmental Disabilities (OMRDD)
Services
a.
Long
Term Therapy Services Provided by Article 16-Clinic Treatment Facilities or
Article 28 Facilities
These
services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate or
limit the disabling condition and to allow the person to remain in or move
to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under 14 NYCRR, Part 679 (or they are provided by Article
28
Diagnostic and Treatment Centers that are explicitly designated by the SDOH
as
serving primarily persons with developmental disabilities). If care of this
nature is provided in facilities other than Article 28 or Article 16 centers,
it
is a covered service.
b.
Day
Treatment
A
planned
combination of diagnostic, treatment and rehabilitation services provided to
developmentally disabled individuals in need of a broad range of services,
but
who do not need intensive twenty-four (24) hour care and medical supervision.
The services provided as identified in the comprehensive assessment may include
nutrition, recreation, self-care, independent living, therapies, nursing, and
transportation services. These services are generally provided in ICF or a
comparable setting. These services are certified by OMRDD under 14 NYCRR, Part
690.
c.
Medicaid Service Coordination (MSC)
Medicaid
Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
which assists persons with developmental disabilities and mental retardation
to
gain access to necessary services and supports appropriate to the needs of
the
needs of the individual. MSC is provided by qualified service coordinators
and
uses a person centered planning process in developing, implementing and
maintaining an Individualized Service Plan (ISP) with and for a person with
developmental disabilities and mental retardation. MSC promotes the concepts
of
a choice, individualized services and consumer satisfaction.
MSC
is
provided by authorized vendors who have a contract with OMRDD, and who are
paid
monthly pursuant to such contract. Persons who receive MSC must not permanently
reside in an ICF for persons with developmental disabilities, a developmental
center, a skilled nursing facility or any other hospital or Medical Assistance
institutional setting that provides service coordination. They must also not
concurrently be enrolled in any other comprehensive Medicaid long term service
coordination program/service including the Care at Home Waiver.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-19
Please
note: See generic definition of Comprehensive Medicaid Case Management (CMCM)
in
this section.
d.
Home
And Community Based Services Waivers (HCBS)
The
Home
and Community-Based Services Waiver serves persons with developmental
disabilities who would otherwise be admitted to an ICF/MR if waiver services
were not provided. HCBS waivers services include residential habilitation,
day
habilitation, prevocational, supported work, respite, adaptive devices,
consolidated supports and services, environmental modifications, family
education and training, live-in caregiver, and plan of care support services.
These services are authorized pursuant to a SSA Section 1915(c) waiver from
DHHS.
e.
Services Provided Through the Care At Home Program (OMRDD)
The
OMRDD
Care at Home 111, Care at Home IV, and Care at Home VI waivers, serve children
who would otherwise not be eligible for Medicaid because of their parents'
income and resources, and who would otherwise be eligible for an ICF/MR level
of
care. Care at Home waiver services include service coordination, respite and
assistive technologies. Care at Home waiver services are authorized pursuant
to
a SSA section 1915(c) waiver from DHHS.
13.
Comprehensive Medicaid Case Management (CMCM)
A
program
which provides "social work" case management referral services to a targeted
population (e.g.: teens, mentally ill). A CMCM case manager will assist a client
in accessing necessary services in accordance with goals contained in a written
case management plan. CMCM programs do not provide services directly, but refer
to a wide range of service Providers. Some of these services are: medical,
social, psycho-social, education, employment, financial, and mental health.
CMCM
referral to community service agencies and/or medical providers requires the
case manager to work out a mutually agreeable case coordination approach with
the agency/medical providers. Consequently, if an Enrollee of the Contractor
is
participating in a CMCM program, the Contractor should work collaboratively
with
the CMCM case manager to coordinate the provision of services covered by the
Contractor. CMCM programs will be instructed on how to identify a managed care
Enrollee on eMedNY and informed on the need to contact the Contractor to
coordinate service provision.
14.
Directly Observed Therapy for Tuberculosis Disease
Tuberculosis
directly observed therapy (TB/DOT) is the direct observation of oral ingestion
of TB medications to assure patient compliance with the physician's prescribed
medication regimen. While the clinical management of tuberculosis is covered
in
the Benefit Package, TB/DOT where applicable, can be billed directly to MM1S
by
any SDOH approved fee-for-service Medicaid TB/DOT Provider. The Contractor
remains responsible for communicating, cooperating and coordinating clinical
management of TB with the TB/DOT Provider.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-20
15.
AIDS Adult Day Health Care
Adult
Day
Health Care Programs (ADHCP) are programs designed to assist individuals with
HIV disease to live more independently in the community or eliminate the need
for residential health care services. Registrants in ADHCP require a greater
range of comprehensive health care services than can be provided in any single
setting, but do not require the level of services provided in a residential
health care setting. Regulations require that a person enrolled in an ADHCP
must
require at least three (3) hours of health care delivered on the basis of at
least one (1) visit per week. While health care services are broadly defined
in
this setting to include general medical care, nursing care, medication
management, nutritional services, rehabilitative services, and substance abuse
and mental health services, the latter two (2) cannot be the sole reason for
admission to the program. Admission criteria must include, at a minimum, the
need for general medical care and nursing services.
16.
HIV COBRA Case Management
The
HP/
COBRA (Community Follow-up Program) Case Management Program is a program that
provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service plan
development and implementation, monitoring, advocacy, crisis intervention,
exit
planning, and case specific supervisory case-review conferencing.
17.
Adult Day Health Care
Adult
Day Health
Care
means care and services provided to a registrant in a residential health care
facility or approved extension site under the medical direction of a physician
and which is provided by personnel of the adult day health care program in
accordance with a comprehensive assessment of care needs and individualized
health care plan, ongoing implementation and coordination of the health care
plan, and transportation.
Registrant
means a
person who is a nonresident of the residential health care facility who is
functionally impaired and not homebound and who requires certain preventive,
diagnostic, therapeutic, rehabilitative or palliative items or services provided
by a general hospital, or residential health care facility; and whose assessed
social and health care needs, in the professional judgment of the physician
of
record, nursing staff, Social Services and other professional personnel of
the
adult day health care program can be met in whole or in part satisfactorily
by
delivery of appropriate services in such program.
18.
Personal Emergency Response
Services (PERS)
Personal
Emergency Response Services (PERS) are not covered by the Benefit Package.
PERS
are covered on a fee-for-service basis through contracts between the LDSS and
PERS vendors.
Medicaid
Advantage Contract
APPENDIX
K
State,
2006
K-21
APPENDIX
L
Approved
Capitation Payment Rates
Medicaid
Advantage Contract
APPENDIX
L
State
2006
L-l
WellCare
of New York, Inc.
Dual
Eligible Medicaid Managed Care Rates
|
MMSI
ID#: 02645710 Effective Date: 01/01/06
Region:
Upstate
County:
Albany
|
|
RATE
CODE
|
PREMIUM
GROUP
|
RATE
AMOUNT
|
|
2370
|
DUALLY
ELIGIBLE SSI 21-64 MAKE/FEMALE
|
$83.79
|
|
2371
|
DUALLY
ELIGIBLE SSI 65+ MALE/FEMALE
|
$91.22
|
Optional
Benefits Offered:
£
Dental
£
Non-Emergent Transportation
Box
will
be checked if the optional benefit is covered by the plan
APPENDIX
M
Service
Area
Medicaid
Advantage Contract
APPENDIX
M
State
2006
M-l
The
Contractor's Medicaid Advantage service area is comprised of the following
Counties
in their entirety:
Albany
Medicaid
Advantage Contract
APPENDIX
M
State
2006
M-2
APPENDIX
N
Reserved
Medicaid
AdvantageContract
APPENDIX
N
State
2006
N-l
APPENDIX
0
Requirements
for Proof of Workers’ Compensation and Disability Benefits
Coverage
Medicaid
Advantage Contract
APPENDIX
0
State
2006
0-1
ReQuirements
for Proof of Coverage
Unless
the Contractor is a political sub-division of New York State, the Contractor
shall provide proof, completed by the Contractor's insurance carrier and/or
the
Workers' Compensation Board, of coverage for:
1.
Workers' Compensation,
for
which one of the following is incorporated into this Agreement herein as an
attachment to Appendix 0:
a)
Certificate of Workers' Compensation Insurance, on the Workers' Compensation
Board form C-105.2 (naming the NYS Department of Health, Coming Tower, Rm.
0000,
Xxxxxx, 00000-0000),
or
Certificate of Workers' Compensation Insurance, on the State Insurance Fund
form
U-26.3 (naming the NYS Department of Health, Corning Tower, Rm. 0000, Xxxxxx,
00000-0000); or
b)
Certificate of Workers Compensation Self-Insurance, form SI-12,
or
Certificate of Group Workers'Compensation Self-Insurance, form GSI-105.2;
or
c)
Affidavit for New York Entities And Any Out Of State Entities With No Employees,
That New York State Workers' Compensation And/Or Disability Benefits Coverage
Is
Not Required, form WC/DB-100, completed for Workers' Compensation;
or Affidavit
That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State Does Not
Require Specific New York State Workers' Compensation And/Or Disability Benefits
Insurance Coverage, form WC/DB-101, completed for Workers' Compensation;
[Affidavits must be notarized and stamped as received by the NYS Workers'
Compensation Board]; and
2.
Disability Benefits Coverage,
for
which one of the following is incorporated into this Agreement herein as an
attachment to Appendix 0:
a)
Certificate of Disability Benefits Insurance, form DB-120.1;
or Certificate/Cancellation
of Insurance, form DB-820/829; or
b)
Certificate of Disability Benefits Self-Insurance, form DB-155;
or
c)
Affidavit for New York Entities And Any Out Of State Entities With No Employees,
That New York State Workers' Compensation And/Or Disability Benefits Coverage
Is
Not Required, form WC/DB-100, completed for Disability Benefits;
or
Affidavit That An OUT-OF-STATE OR FOREIGN EMPLOYER Working In New York State
Does Not Require Specific New York State Workers' Compensation And/Or Disability
Benefits Insurance Coverage, form WC/DB-101, completed for Disability Benefits;
[Affidavits must be notarized and stamped as received by the NYS Workers'
Compensation Board].
NOTE:
XXXXX forms are NOT
acceptable proof of coverage.
Medicaid
Advantage Contract
APPENDIX
0
State
2006
0-2
APPENDIX
P
Reserved
Medicaid
Advantage Contract
APPENDIX
P
State
2006
P-l
APPENDIX
Q
Reserved
Medicaid
Advantage Contract
APPENDIX
Q
State
2006
Q-l
APPENDIX
R
Additional
Specifications for the Medicaid Advantage Agreement
Medicaid
Advantage Contract APPENDIX R
State
2006
X-x
Additional
Specifications for the Medicaid Advantage Agreement
Contractor
will give continuous attention to performance of its obligations herein for
the
duration of this Agreement and with the intent that the contracted services
shall be provided and reports submitted in a timely manner as SDOH may
prescribe.
Contractor
will possess, at no cost to the State, all qualifications, licenses and permits
to engage in the required business as may be required within the jurisdiction
where the work specified is to be performed. Workers to be employed in the
performance of this Agreement will possess the qualifications, training,
licenses and permits as may be required within such jurisdiction.
Work
for
Hire Contract
If
pursuant to this Agreement the Contractor will provide the SDOH with software
or
other copyrightable materials, this Agreement shall be considered a "Work for
Hire Contract." The SDOH will be the sole owner of all source code and any
software which is developed or included in the application software provided
to
the SDOH as a part of this Agreement.
Technology
Purchases Notification — The following provisions apply if this Agreement
procures only "Technology"
a)
For
the purposes of this policy, "technology" applies to all services and
commodities, voice/data/video and/or any related requirement, major software
acquisitions, systems modifications or upgrades, etc., that result in a
technical method of achieving a practical purpose or in improvements of
productivity. The purchase can be as simple as an order for new or replacement
personal computers, or for a consultant to design a new system, or as complex
as
a major systems improvement or innovation that changes how an agency conducts
its business practices.
b)
If
this Agreement is for procurement of software over $20,000, or other technology
over $50,000, or where the SDOH determines that the potential exists for
coordinating purchases among State agencies and/or the purchase may be of
interest to one or more other State agencies, PRIOR TO APPROVAL by OSC, this
Agreement is subject to review by the Governor's Task Force on Information
Resource Management.
c)
The
terms and conditions of this Agreement may be extended to any other State agency
in New York.
Subcontracting
The
Contractor agrees not to enter into any agreements with third party
organizations for the performance of its obligations, in whole or in part,
under
this Agreement without the State's prior written approyal of such third parties
and the scope of the work to be
Medicaid
Advantage Contract
APPENDIX
R
State
2006
R-2
performed
by them. The State's approval of the scope of work and the subcontractor does
not relieve the Contractor of its obligation to perform fully under this
Agreement.
6.
Sufficiency of Personnel and Equipment
If
SDOH
is of the opinion that the services required by the specifications cannot
satisfactorily be performed because of insufficiency of personnel, SDOH shall
have the authority to require the Contractor to use such additional personnel
to
take such steps necessary to perform the services satisfactorily at no
additional cost to the State.
7.
Provisions Upon Default
a)
The
services to be performed by the Contractor shall be at all times subject to
the
direction and control of the SDOH as to all matters arising in connection with
or relating to this Agreement.
b)
In the
event that the Contractor, through any cause, fails to perform any of the terms,
covenants or promises of this Agreement, the SDOH acting for and on behalf
of
the State, shall thereupon have the right to terminate this Agreement by giving
notice in writing of the fact and date of such termination to the Contractor,
pursuant to Section 2 of this Agreement.
c)
If, in
the judgment of the SDOH, the Contractor acts in such a way which is likely
to
or does impair or prejudice the interests of the State, the SDOH acting for
and
on behalf of the State, shall thereupon have the right to terminate this
Agreement by giving notice in writing of the fact and date of such termination
to the Contractor, pursuant to Section 2 of this Agreement.
8.
Minority And Women Owned Business Policy Statement
The
SDOH
recognizes the need to take affirmative action to ensure that Minority and
Women
Owned Business Enterprises are given the opportunity to participate in the
performance of the SDOH's contracting program. This opportunity for full
participation in our free enterprise system by traditionally socially and
economically disadvantaged persons is essential to obtain social and economic
equality and improve the functioning of the State economy.
It
is the
intention of the SDOH to provide Minority and Women Owned Business Enterprises
with equal opportunity to bid on contracts awarded by this agency in accordance
with the State Finance Law.
9.
Insurance Requirements
a)
The
Contractor must without expense to the State procure and maintain, until final
acceptance by the SDOH of the work covered by this Agreement, insurance of
the
kinds and in the amounts hereinafter provided, by insurance companies authorized
to
Medicaid
Advantage Contract
APPENDIX
R
State
2006
R-3
do
such
business in the State of New York covering all operations under this Agreement,
whether performed by it or by subcontractors. Before commencing the work, the
Contractor shall furnish to the SDOH a certificate or certificates, in a form
satisfactory to SDOH, showing that it has complied with the requirements of
this
section, which certificate or certificates shall state that the policies shall
not be changed or cancelled until thirty days written notice has been given
to
SDOH. The kinds and amounts of required insurance are:
i)
A
policy covering the obligations of the Contractor in accordance with the
provisions of Chapter 41, Laws of 1914, as amended, known as the Workers'
Compensation Law, and the Agreement shall be void and of no effect unless the
Contractor procures such policy and maintains it until acceptance of the
work.
ii)
Policies of Bodily Injury Liability and Property Damage Liability Insurance
of
the types hereinafter specified, each within limits of not less than $500,000
for all damages arising out of bodily injury, including death at any time
resulting therefrom sustained by one person in any one occurrence, and subject
to that limit for that person, not less than $1,000,000 for all damages arising
out of bodily injury, including death at any time resulting therefrom sustained
by two or more persons in any one occurrence, and not less than $500,000 for
damages arising out of damage to or destruction of property during any single
occurrence and not less than $1,000,000 aggregate for damages arising out of
damage to or destruction of property during the policy period.
A)
Contractor's Liability Insurance issued to and covering the liability of the
Contractor with respect to all work performed by it under this
Agreement.
B)
Automobile Liability Insurance issued to and covering the liability of the
People of the State of New York with respect to all operations under this
Agreement, by the Contractor or by its subcontractors, including omissions
and
supervisory acts of the State.
10.
Certification Regarding Debarment and Suspension
a)
Regulations of the U.S. Department of Health and Human Services, located at
Part
76 of Title 45 of the Code of Federal Regulations (CFR), implement Executive
Orders 12549 and 12689 concerning debarment and suspension of participants
in
Federal program and activities. Executive Order 12549 provides that, to the
extent permitted by law. Executive departments and agencies shall participate
in
a government wide system for non-procurement debarment and suspension. Executive
Order 12689 extends the debarment and suspension policy to procurement
activities of the Federal Government. A person who is debarred or suspended
by a
Federal agency is excluded from Federal financial and non-financial assistance
and benefits under Federal programs and activities, both directly (primary
covered transaction) and indirectly (lower tier covered transactions). Debarment
or suspension by one Federal agency has government wide effect.
Medicaid
Advantage Contract
APPENDIX
R
State
2006
R-4
b)
Pursuant to the above cited regulations, the SDOH (as a participant in a primary
covered transaction) may not knowingly do business with a person who is
debarred, suspended, proposed for debarment, or subject to other government
wide
exclusion (including an exclusion from Medicare and State health care program
participation on or after August 25, 1995), and the SDOH must require its
contractors, as lower tier participants, to provide the certification as set
forth below:
i)
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION-LOWER TIER COVERED TRANSACTIONS
Instructions
for Certification
A)
By
signing this Agreement, the Contractor, as a lower tier participant, is
providing the certification set out below.
B)
The
certification in this clause is a material representation of fact upon which
reliance was placed when this transaction was entered into. If it is later
determined that the lower tier participant knowingly rendered an erroneous
certification, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated
may
pursue available remedies, including suspension and/or debarment.
C)
The
lower tier participant shall provide immediate written notice to the SDOH if
at
any time the lower tier participant leams that its certification was erroneous
when submitted or had become erroneous by reason of changed
circumstances,
D)
The
terms covered transaction, debarred, suspended, ineligible, lower tier covered
transaction, participant, person, primary covered transaction, principal,
proposal, and voluntarily excluded, as used in this clause, have the meaning
set
out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. The Contractor may contact the SDOH for assistance in obtaining
a
copy of those regulations.
E)
The
lower tier participant agrees that it shall not knowingly enter into any lower
tier covered transaction with a person who is proposed for debarment under
48
CFR Subpart 9.4, debarred, suspended, declared ineligible, or voluntarily
excluded from participation in this covered transaction, unless authorized
by
the department or agency with which this transaction originated.
F)
The
lower tier participant farther agrees that it will include this clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion-Lower Tier Covered Transactions," without modification, in all lower
tier covered transactions.
Medicaid
Advantage Contract
APPENDIX
R
State
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R-5
G)
A
participant in a covered transaction may rely upon a certification of a
participant in a lower tier covered transaction that it is not proposed for
debarment under 48 CFR Subpart 9.4, debarred, suspended, ineligible, or
voluntarily excluded from covered transactions, unless it knows that the
certification is erroneous. A participant may decide the method and frequency
by
which it determines the eligibility of its principals. Each participant may,
but
is not required to, check the Excluded Parties List System.
H)
Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification
required by this clause. The knowledge and information of a participant is
not
required to exceed that which is normally possessed by a prudent person in
the
ordinary course of business dealings.
I)
Except
for transactions authorized under paragraph E of these instructions, if a
participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is proposed for debarment under 48 CFR Subpart
9.4, suspended, debarred, ineligible, or voluntarily excluded from participation
in this transaction, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated
may
pursue available remedies, including suspension and/or debarment.
ii)
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion - Lower Tier Covered Transactions
A)
The
lower tier participant certifies, by signing this Agreement, that neither it
nor
its principals is presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from participation in this
transaction by any Federal department agency.
B)
Where
the lower tier participant is unable to certify to any of the statements in
this
certification, such participant shall attach an explanation to this
Agreement.
11.
Reports and Publications
a)
Any
materials, articles, papers, etc., developed by the Contractor pertaining to
the
MMC Program or FHPlus Program must be reviewed and approved by the SDOH for
conformity with the policies and guidelines of the SDOH prior to dissemination
and/or publication. It is agreed that such review will be conducted in an
expeditious manner. Should the review result in any unresolved disagreements
regarding content, the Contractor shall be free to publish in scholarly journals
along with a disclaimer that the views within the Article or the policies
reflected are not necessarily those of the New York State Department of
Health.
Medicaid
Advantage Contract
APPENDIX
R
State
2006
R-6
b)
Any
publishable or otherwise reproducible material developed under or in the course
of performing this Agreement, dealing with any aspect of performance under
this
Agreement, or of the results and accomplishments attained in such performance,
shall be the sole and exclusive property of the State, and shall not be
published or otherwise disseminated by the Contractor to any other party unless
prior written approval is secured from the SDOH or under circumstances as
indicated in paragraph (a) above. Any and all net proceeds obtained by the
Contractor resulting from any such publication shall belong to and be paid
over
to the State. The State shall have a perpetual royalty-free, non-exclusive
and
irrevocable right to reproduce, publish or otherwise use, and to authorize
others to use, any such material for governmental purposes.
c)
No
report, document or other data produced in whole or in part with the funds
provided under this Agreement may be copyrighted by the Contractor or any of
its
employees, nor shall any notice of copyright be registered by the Contractor
or
any of its employees in connection with any report, document or other data
developed pursuant to this Agreement.
d)
All
reports, data sheets, documents, etc. generated under this Agreement shall
be
the sole and exclusive property of the SDOH. Upon completion or termination
of
this Agreement the Contractor shall deliver to the SDOH upon its demand all
copies of materials relating to or pertaining to this Agreement. The Contractor
shall have no right to disclose or use any of such material and documentation
for any purpose whatsoever, without the prior written approval of the SDOH
or
its authorized agents.
e)
The
Contractor, its officers, agents and employees and subcontractors shall treat
all information, which is obtained by it through its performance under this
Agreement, as confidential information to the extent required by the laws and
regulations of the United States and laws and regulations of the State of New
York.
12.
Provisions Related to New York State Executive Order Number 127
a)
If
applicable, the Contractor certifies that all information provided to the State
with respect to New York State Executive Order Number 127, signed by Governor
Xxxxxx on June 16,2003, is complete, true, and accurate.
b)
The
State reserves the right to terminate this Agreement in the event it is found
that the certification filed by the Contractor, in accordance with New York
State Executive Order Number 127, was intentionally false or intentionally
incomplete. Upon such finding, the State may exercise its termination right
by
providing written notification to the Contractor in accordance with the written
notification terms of this Agreement.
Medicaid
Advantage Contract
APPENDIX
R
State
2006
R-7
APPENDIX
X
Modification
Agreement Form
APPENDIX
X
State
2006
X-l
APPENDIX
X
|
Agency
Code
|
Contract
No.
|
|
Period
|
Funding
Amount for Period
|
This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through ____________________,
having its principal office at _____________ (hereinafter
referred to as the STATE), and
___________________
(hereinafter
referred to as the CONTRACTOR), for modification of Contract Number __ as
amended in attached Appendix(ices).
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
By:
____________________________________
Printed
Name
|
STATE
AGENCY SIGNATURE
By
__________________________________
Printed
Name
|
|
Title:
_______________________________________
|
Title:
_______________________________________
|
|
Date:
_______________________________________
|
Date:
_______________________________________
|
|
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
NEW YORK
County
of
__________________ )
On
the
_____________ day of _______________________ 20___, before me personally
appeared ______________________________________, to me known, who by me duly
sworn, did depose and say that he/she resides at
____________________________________________, that he/she is the
_________________________________ of _____________________________, the
corporation described herein which executed the foregoing instrument; and that
he/she signed his/her name thereto by order of the board of directors of said
corporation.
(Notary)
|
STATE
COMPTROLLER’S SIGNATURE
|
Title:
___________________________________
|
|
____________________________________
|
Date:
___________________________________
|
