MEDICAID MANAGED CARE MODEL CONTRACT
Exhibit
10.2
MEDICAID
MANAGED CARE MODEL CONTRACT
Contract
Amendment
Between
City
of New York
And
WellCare
of New York, Inc.
This
Amendment, effective April 1, 2006, amends the Medicaid Managed Care Model
Contract (hereinafter referred to as the "Agreement") made by and between
the
City of New York acting through the New York City Department of Health and
Mental Hygiene (hereinafter referred to as "DOHMH" or "LDSS") and WellCare
of
New York, Inc. (hereinafter referred to as "Contractor" or "MCO").
WHEREAS,
the
parties entered into an Agreement effective October 1, 2005, for the purpose
of
providing prepaid case managed health services to Medical Assistance recipients
residing in New York City; and
WHEREAS,
the
parties desire to amend said Agreement to modify certain provisions to reflect
current circumstances and intentions;
NOW
THEREFORE,
effective April 1, 2006, or such other date as indicated below, it is mutually
agreed by the parties to amend this Agreement as follows:
1.
Amend
Section 1, "Definitions," the definition for "Designated Third Party
Contractor," to read as follows:
"Designated
Third Party Contractor"
means a
MCO with which the SDOH has contracted to provide Family Planning and
Reproductive Health Services for FHPlus Enrollees of a MCO that does not
include
such services in its Benefit Package or, for the purpose of this Agreement,
the
New York State Medicaid fee-for-service program and its participating providers
and subcontractors.
2.
The
attached Appendix C, "New York State Department of Health Requirements for
the
Provision
of Family Planning and Reproductive Health," is substituted for the period
beginning April 1.2006.
3.
Effective
January 1, 2006, Item Number 10 in Section K.I, "Prepaid Benefit Package,"
of
Appendix K, "Prepaid Benefit Package Definitions of Covered and Non-Covered
Services," is amended to read as follows:
|
*
|
Covered
Services
|
MMC
Non-SSI
|
MMC
SSI
|
MFFS
|
FHPlus
**
|
|
10.
|
Prescription
and Non-Prescription
(OTC) Drugs,
Medical
Supplies, and Enteral Formula
|
Pharmaceuticals
and medical
supplies
routinely
furnished or administered
as part
of
a clinic or office visit,
except Risperdal
Consta [see Xxxxxxxx
X.0,0. b)
xi)
of this Agreement]
|
Pharmaceuticals
and medical
supplies
routinely
furnished or administered
as part of a
clinic or office visit, except
Xxxxxxxxx
Xxxxxx
[xxx Xxxxxxxx X.0,
0. b) xi) of this
Agreement]
|
Covered
outpatient
drugs
from
the list of Medicaid
reimbursable
prescription
drugs,
subject to any
applicable
co-payments
|
Covered,
may be
limited to
generic.
Vitamins
(except
to treat an
illness or condition),
OTCs,
and medical
supplies
are
not
covered
|
April
1,
2006 Amendment
1
4.
Effective January 1, 2006, Subsection xi) is added to Subsection 2.,
"Non-Covered Behavioral Health Services," b) "Mental Health Services." of
Section K.3, "Medicaid Managed Care Prepaid Benefit Package Definitions of
Non-Covered Services," in Appendix K, "Prepaid Benefit Package Definitions
of
Covered and Non-Covered Services," and reads as follows:
xi)
Risperdal Consta, an injectable mental health drug used for management of
patients with schizophrenia, furnished as part of a clinic or office
visit.
All
other
provisions of said AGREEMENT shall remain in full force and effect.
This
Agreement is effective April 1, 2006 and shall remain in effect until September
30, 2007 or until the execution of an extension, renewal or successor agreement
as provided for in the Agreement.
In
Witness Whereof, the parties have duly executed this Amendment to the Agreement
on the dates appearing below their respective signatures.
|
By:
/s/ Xxxx X. Xxxxx .
WellCare
of New York, Inc.
|
By:
/s/ Xxxxxx Xxxx
New
York City DOHMH
|
|
Xxxx
X. Xxxxx
Printed
Name
|
Xxxxxx
Xxxx
Printed
Name
|
|
Date:
5/25/06
|
Date:
7/13/06
|
April1,
2006
Amendment
0
XXXXX
XX
XXXXXXX
XX:
XXXXXX
XX
XXXXXXXXXXXX
Xx
this
25 day of May, 2006, Xxxx X. Xxxxx came before me, to me
known and known to be the President and CEO of WellCare of New York,
Inc., who is duly authorized to execute the foregoing instrument on behalf
of said corporation and s/he acknowledged to me that s/he executed the same
for
the purpose therein mentioned.
/s/
Xxxxxxx Xxxx
NOTARY
PUBLIC
STATE
OF
NEW YORK)
SS:
COUNTY
OF
NEW YORK
On
this 17 day of July , 2006,
Xxxxxx Xxxx came before
me, to me known and known to be the Deputy Commissioner in the
New York City Department of Health and Mental Hygiene, who is duly authorized
to
execute the foregoing instrument on behalf of the City and s/he acknowledged
to
me that s/he executed the same for the purpose therein mentioned.
/s/ Xxxxx Xxxx
NOTARY PUBLIC
APPENDIX
C
NEW
YORK STATE DEPARTMENT OF HEALTH
|
C.1
|
Definitions
and General Requirements for the Provision of Family
Planning and Reproductive Health Services
|
|
C.2
|
Requirements
for MCOs that Include Family Planning and Reproductive
Health Services in Their Benefit Package
|
|
C.3
|
Requirements
for MCOs That Do Not Include Family Planning Services and Reproductive
Health Services in Their Benefit
Package
|
APPENDIX
C
April
1,2006
C-l
C.1
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 purpose of:
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)
emergency contraception and follow up;
C)
sterilization;
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)
For
MMC Enrollees - 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. Other pharmacy prescriptions including
Appendix
C
April
1,2006
C-2
emergency
contraception, medical supplies, and 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)
For
FHPlus Enrollees - The Contractor, if it includes such services in its Benefit
Package is responsible for covering prescription contraceptives, including
emergency contraceptives, provided by a Participating pharmacy, consistent
with
the pharmacy benefit package as described in Appendix K. When the Contractor
does not provide Family Planning and Reproductive Health Services, the
Designated Third Party Contractor that covers such services for FHPlus Enrollees
is responsible for prescription contraceptives, including emergency
contraceptives, provided by a Participating pharmacy, consistent with the
pharmacy benefit package as described in Appendix K. The Contractor or the
Designated Third Party Contractor must cover at least one of every type of
the
following methods of contraception:
I)
Oral
II)
Oral,
emergency
III)
Injectable
IV)
Transdermal
V)
Intravaginal
VI)
Intravaginal, systemic
VII)
Implantable
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 testing
and
re- and post-test counseling.
2.
Free
Access to Services for MMC Enrollees
a)
Free
Access means MMC Enrollees may obtain Family Planning and Reproductive Health
services, and HIV 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 includes such services in its 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.
Appendix
C
April
1,
2006
C-3
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.
3.
Access to Services for FHPlus Enrollees
a)
FHPlus
Enrollees may obtain Family Planning and Reproductive Health services, and
HIV
testing and pre-and post-test counseling when performed as part of a Family
Planning and Reproductive Services encounter, from either the Contractor
or
through the Designated Third Party Contractor, as applicable. No referral
from
the PCP or approval by the Contractor is required to access such
services.
b)
The
Contractor is responsible for routine obstetric and/or gynecologic care,
including hysterectomies, pre-natal, delivery and post-partum care, regardless
of whether Family Planning and Reproductive Health services are included
in the
Contractor's Benefit Package.
Appendix
C
April
1,2006
C-4
C.2
Requirements
for MCOs that Include Family Planning and Reproductive
Health
Services in Their Benefit Package
1.
Notification to
Enrollees
a)
If the
Contractor includes Family Planning and Reproductive Health services in its
Benefit Package (as per Appendix M of this Agreement) the Contractor must
notify
all Enrollees of reproductive age, including minors who may be sexually active,
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)
MMC
Enrollees must receive notification that they also have the right to obtain
Family Planning and Reproductive Health services in accordance with MMC's
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 MMC 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
care will be fully covered, including when a MMC Enrollee obtains such services
in accordance with MMC's Free Access policy.
2.
Billing Policy
a)
The
Contractor must notify its Participating Providers that all claims for Family
Planning and Reproductive services must be billed to the Contractor and not
the
Medicaid fee-for-service program.
b)
The
Contractor will be charged for Family Planning and Reproductive Health services
furnished to MMC Enrollees by eMedNY-enrolled Non-Participating Providers
at the
applicable Medicaid rate or fee. In such instances, Non-Participating Providers
will xxxx Medicaid fee-for-service and the SDOH will issue a confidential
charge
back to the Contractor. Such charge back mechanism will comply with all
applicable patient confidentiality requirements.
Appendix
C
April
1,2006
C-5
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
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 any Enrollee's use including a
minor'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 MMC Free Access as defined in C.I 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.
Appendix
C
April
1,
2006
C-6
C.3
Requirements
for MCOs That Do Not
Include
Family Planning Services and Reproductive Health Services in Their Benefit
Package
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, Xxxxxxx Xxxxx, Xxxx 0000, Xxxxxx, XX
00000.
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
MMC
Enrollees and through the Designated Third Party Contractor for FHPlus
Enrollees;
III)
No
referral is needed for such services, and there will be no cost to the Enrollee
for such services.
Appendix
C
April
1,
2006
C-7
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 MMC Enrollees and
through the Designated Third Party Contractor to FHPlus Enrollees; and that
anonymous counseling and testing services are available from SDOH, Local
Public
Health Agency clinics and other 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 MMC Enrollees to secure
such
services through fee-for-service Medicaid from any provider/clinic which
offers
these services and who accepts Medicaid, and the right of all FHPlus Enrollees
to secure such services through the Designated Third Party
Contractor.
II)
Orally at the time of Enrollment and any time an inquiry is made regarding
Family Planning and Reproductive Health services.
Ill)
By
inclusion on any web site of the Contractor which includes information
concerning its MMC or FHPlus product(s). Such information shall be prominently
displayed and easily navigated.
C)
A
description of the mechanisms to provide all new MMC Enrollees and FHPlus
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.
Appendix
C
April
1,
2006
C-8
II)
MMC
Enrollees can use their Medicaid card to receive these non-covered services
from
any doctor or clinic that provides these services and accepts Medicaid. FHPlus
Enrollees can receive these non-covered services through the Designated Third
Party Contractor using either the Designated Third Party Contractor's
identification card or the Contractor's card which shall include the Enrollee's
Client Identification Number.
Ill)
Each
MMC Enrollee and Prospective MMC 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)
The
Contractor will provide the name and phone number of the Designated Third
Party
Contractor or such other organization designated by the SDOH to provide such
services to FHPlus Enrollees and Prospective FHPlus Enrollees. It is the
responsibility of the Designated Third Party Contractor or such other
organization designated by the .SDOH to mail to each FHPlus Enrollee or
Prospective FHPlus Enrollee who calls, a copy of the SDOH approved letter
explaining the Enrollee's right to receive such services, and an SDOH approved
list of Family Planning Providers from which the Enrollee may access family
planning services. The Designated Third Party Contractor or such other
organization designated by the SDOH is responsible for mailing these materials
within fourteen (14) days of notice by the Contractor of a new Enrollee in
the
Contractor's FHPlus product.
V)
Enrollees can call the Contractor's member services number for further
information about how to obtain these non-covered services. MMC Enrollees
can
also call the New York State Growing-Up-Healthy Hotline (1-800-522-5006)
to
request a copy of the list of Medicaid Family Planning Providers. FHPlus
Enrollees can also call the Designated Third Party Contractor or such other
organization designated by the SDOH for a list of 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 or LDSS 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
Appendix
C
April
1,
2006
C-9
A)
A
statement that the Contractor will inform its Participating Providers and
administrative personnel about Family Planning and Reproductive Health policies
under MMC Free Access, as defined in C. 1 of this Appendix, and/or the FHPlus
Designated Third Party Contractor for FHPlus Enrollees, HIV 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 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.
C)
The
procedure(s) for informing the Contractor's Participating primary care
providers, family practice physicians, obstetricians, gynecologists and
pediatricians 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 MMC's Free Access
policy,
as defined in C.I of this Appendix, and/or through the SDOH-contracted
Designated Third Party for FHPlus Enrollees.
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 MMC Enrollees,
they do so as a fee-for-service Medicaid practitioner, independent of the
Contractor.
II)
if
they also participate with the FHPlus Designated Third Party Contractor and
they
render non-covered Family Planning and Reproductive Health Services to FHPlus
Enrollees, they do so as a participating provider with the Designated Third
Party Contractor, 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:
Appendix
C
April
1,2006
C-10
I)
offer
those services to MMC Enrollees on a fee-for-service basis as an eMedNY-enrolled
provider, or to FHPlus Enrollees as a Participating Provider of the Designated
Third Party Contractor; or
II)
provide MMC Enrollees with a copy of the SDOH approved list of Medicaid Family
Planning Providers, and/or provide FHPlus Enrollees with the name and number
of
the Designated Third Party Contractor, or
III)
give
Enrollees the Contractor's member services number to call to obtain either
the
list of Medicaid Family Planning Providers or the name and number of the
Designated Third Party Contractor, as applicable.
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 or under the Designated Third Party contract
with SDOH.
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.
C)
A
statement that the Contractor will prepare a monthly list of MMC Enrollees
who
have been sent a copy of the SDOH approved letter and the SDOH approved list
of
Family Planning providers, and a list of FHPlus Enrollees who have been provided
with the name and telephone number of the Designated Third Party Contractor.
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.
Appendix
C
April
1,2006
C-ll
E)
A
description of the mechanisms to provide the Designated Third Party Contractor,
SDOH, or SDOH's subcontractor with a monthly listing of all FHPlus Enrollees
within seven (7) days of receipt of the Contractor's monthly Enrollment Roster
and any subsequent updates or adjustments. A copy of each file will also
be
provided simultaneously to the SDOH. A description of mechanisms to provide
SDOH
or SDOH's subcontractor with a list of prospective FHPlus Enrollees within
two
(2) business days of the prospective Enrollee encounter, and a list of Enrollees
who call to request information within two (2) business days of an Enrollee's
request.
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 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 and/or the Designated Third Party Contractor 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 any Enrollee's use including a minor'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.
APPENDIX
C
April
1,2006
C-12
