APPENDIX X
Exhibit
10.1
APPENDIX
X
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Agency
Code: 12000
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Contract
No.: C-014386
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Period:
October 1,1997 - December 31, 2006
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Funding
Amount for Period: No
Change
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This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department
of Health,
having
its principal office at Corning
Tower, Empire State Plaza, Albany, NY.
(hereinafter referred to as the STATE), and WellCare
of New York, Inc.
hereinafter referred to as the CONTRACTOR), for modification of Contract Number
C-014386 as reflected in the attached revisions to Appendix A-2.
All
other
provisions of said AGREEMENT shall remain in fall force and effect.
IN
WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates
appearing under their signatures.
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CONTRACTOR
SIGNATURE
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STATE
AGENCY SIGNATURE
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By:
/s/
Xxxx Xxxxx
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By:
/s/
Xxxxxx Xxxxxx
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Xxxx
X. Xxxxx
Printed
Name
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Xxxxxx
Xxxxxx
Printed
Name
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Title:
President and CEO
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Title:
Deputy Commissioner
Division
of Planning, Policy & Resource Development
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Date:
4/25/06
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Date:
4/28/06
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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
On
the 25
day of April 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
the
WellCare
of New York, Inc.,
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)
/s/
Xxxxxxx Xxxx
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STATE
COMPTROLLER SIGNATURE
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Title
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Date
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APPENDIX
A-2
PROGRAM
SPECIFIC CLAUSES
Section
N
is added as follows:
III.
CONTRACTOR'S
RESPONSIBILITES
N.
Marketing/Facilitated Enrollment Integrity
The
CONTRACTOR shall institute policies and procedures to prevent fraud and abuse
by
applicants and marketing/facilitated enrollment staff and take corrective action
in a timely fashion against employees engaged in fraud and abuse. The CONTRACTOR
shall implement the following:
1.
Quality Assurance
The
CONTRACTOR shall review all applications for Medicaid, Family Health Plus and
Child Health Plus A and B for completeness and logic. This includes those taken
by a health plan marketing representatives/facilitators, those submitted by
outside facilitators, and those mailed in by applicants. Specifically, the
CONTRACTOR'S quality assurance reviewers must confirm that:
•
All
sections of the application are complete and the application is
signed.
•
The
appropriate documents are included with the application.
•
The
signature on the application appears to match the signature on any supporting
documentation, if applicable. The applicant signature must not appear to match
the signature of the marketer/facilitator in the "For Office Use Only" section
of the application.
•
No
white out was used on any documents and that information pertinent to
eligibility was not changed in any way without being initialed by the applicant.
If pertinent information has been changed without being initialed by the
applicant, the CONTRACTOR shall verify the change with the applicant prior
to
enrollment. The CONTRACTOR may change and initial an applicant-initiated change
to the application provided they send the changed, initialed page to the
applicant and can document having done so. This requirement does not apply
to
applications received in the mail directly from the member.
•
For
CHPlus B applicants listed as undocumented immigrants, the CONTRACTOR must
review the application and supporting documentation for a Social Security
Number. If a Social Security Number for the applying child is found, the
CONTRACTOR shall verify the undocumented status with the applicant. If a Social
Security Number is listed, but the family confirms that the child is
undocumented, the CONTRACTOR may accept the family's word and note it on the
application. The CONTRACTOR shall refer any such case to the STATE for review
of
the Social Security Number.
•
The
individuals listed in Section B (Household Information) are consistent with
those listed in Section E (Household Income) to be certain that income was
not
overlooked. The CONTRACTOR must include an explanation on the application
(Section E) if a parent or caretaker relative listed in Section B does not
have
income listed in Section E. This requirement does not apply to applications
received in the mail directly from the member.
•
For
all
applications, including child only applications, the CONTRACTOR shall check
that
the household income is adequate to support the monthly housing payment listed
on the application. The question on monthly housing payments is now required
for
all applicants. The CONTRACTOR must, prior to processing applications that
indicate the monthly housing payment is more than 50 percent of the total
monthly income, further review the application to determine how the household
is
meeting its basic financial needs. This includes contacting the family for
an
explanation. The CONTRACTOR must include an explanation on a comment sheet
included with the application as to how the household is meeting its financial
obligations.
•
For
single parent households, the CONTRACTOR shall ensure that child support
payments are listed, or if not, that there is a notation in the unearned income
part of Section E that the custodial parent does not receive child support.
This
requirement does not apply to applications received in the mail directly from
the member.
If
any
item above is incomplete or suspect, the CONTRACTOR shall resolve the issue
as
described above prior to forwarding the application for eligibility
determination within the contractor's
plan,
another health plan or to an LDSS. If the application is signed, but the
applicant appears ineligible for any program, it must be forwarded to the
appropriate eligibility determining entity batched with the ineligible
applications.
For
applications received from other facilitated enrollment organizations (e.g.,
another plan, provider, or community-based organization), the quality assurance
review described above is the responsibility of the entity that assisted in
completing the application. In these cases, where the CONTRACTOR receives an
application from an entity that acted as a facilitator on behalf of a family,
the CONTRACTOR shall review the application for logic and completeness according
to the criteria above. However, any applications requiring verification with
the
family or an employer shall be returned to the originating facilitated
enrollment entity as an incomplete application.
The
CONTRACTOR shall attach to the application a quality assurance check list
developed by the STATE and signed by the CONTRACTOR as an attestation of
completing a quality assurance review process. The checklist shall be included
with all applications submitted to the LDSS or other health plans. The
CONTRACTOR shall maintain a copy of the checklist for their files. For CHPlus
B
enrollees, the check list should be included in the file which will be subject
to review at audit. Alternatively, for CHPlus B applications, the CONTRACTOR
may
utilize its own electronic quality assurance checklist that shall be available
for STATE review during an audit.
2.
Targeted Verification
The
CONTRACTOR shall verify the information taken by their marketers/facilitators
with the family or employer (if applicable), using a sample of applications,
which include the following four categories:
•
Applications with non-aipplying children or adults (if applicable) that impact
eligibility.
•
Applications with a self-declaration of income.
•
Applications with a declaration of no income/letter of support.
•
Applications with employer letters as income documentation. The income
information in these applications must be verified with the
employer.
CONTRACTORS
that do not take applications from applicants other than through the mail shall
not be required to conduct verification phone calls provided such applications
do not contain a high volume of the above four categories as determined by
the
STATE. The STATE will conduct special audits of the applications taken by these
plans through the mail to determine whether additional verification is
required.
The
CONTRACTOR shall conduct verification phone calls on a stratified sample of
applications to confirm the information provided by the applicant prior to
its
being submitted to the LDSS, another
health
plan, or enrolled in CHPlus B. The CONTRACTOR may develop its own process for
conducting the verification phone calls. The sample may be drawn monthly or
quarterly. For large plans (more than 300 applications completed by facilitators
per month) the sample shall be at least 10 percent of all applications in the
period (month or quarter). Smaller plans (less than 300 per month) will need
to
verify 30 applications in these categories, collectively, per period. The
CONTRACTOR is not required to track applications by the four categories above.
That is one option for drawing the sample. Another option is to take a random
sample of all applications at a percent believed to be high enough that the
sample captures applications from each of the four categories above. The
CONTRACTOR'S methodology for completing the verification phone calls shall
be
approved by the STATE prior to implementation and must be based on a projected
number of applications to be received within each category.
The
CONTRACTOR shall over sample in the categories to be verified to permit
replacement of those the plan is unable to reach. The CONTRACTOR may drop and
replace applicants they are unable to verify due to an inability to reach the
family after three attempts. There is no limit on the number that can be
replaced as long as the final sample meets the number agreed upon in the
CONTRACTOR'S plan approved by the STATE that shall be submitted pursuant to
this
agreement. The CONTRACTOR is required to provide information to the STATE on
the
dropped cases including the number dropped in a period, the reasons for
replacement (e.g., unable to contact, refused to cooperate). The CONTRACTOR
shall make at least three attempts to contact the family at different times
of
the day (e.g., morning, afternoon, evening) prior to dropping the case. The
replacement case shall fall within the same category as the sample case. For
example, if the dropped case includes non-applying people affecting eligibility,
the replacement case shall include non-applying people.
Applications
must be verified by the CONTRACTOR on a prospective basis, however, the
CONTRACTOR is prohibited from delaying enrollment in order to implement such
verification. The CONTRACTOR shall determine the sample and conduct the calls
on
an ongoing basis so as not to delay enrollment. The CONTRACTOR shall develop
a
methodology to conduct verification, based on the expected number of
applications in each category.
If
the
applicant concurs with all! the information on the application, the CONTRACTOR
is not required to take additional steps to verify the information. The
CONTRACTOR must still complete the checklist.
If
the
CONTRACTOR, through a verification phone call, finds that the application
includes inaccurate information or misrepresentation of the applicant's
circumstances, the CONTRACTOR must make best efforts to determine if the
inaccuracy was due to actions of the marketer/facilitator. The CONTRACTOR must
investigate if the marketer/facilitator acted with the intent to falsify the
application. The CONTRACTOR must not enroll the applicant if the new information
renders them ineligible.
If
the
CONTRACTOR finds that the marketer/facilitator's action did result in false
information on the application, the CONTRACTOR shall remove the employee as
a
facilitator immediately and follow the CONTRACTOR'S process for employee
disciplinary action. In addition, the CONTRACTOR shall review one month of
prior
applications taken by that marketer/facilitator. If evidence of fraud is found
on any one of those applications, the CONTRACTOR shall review an additional
two
months of prior applications taken by the marketer/facilitator.
If
the
intent is unclear or it is determined the marketer/facilitator made a mistake,
the CONTRACTOR shall re-train the employee immediately. The CONTRACTOR shall
review all subsequent applications submitted by the marketer/facilitator for
the
next month to ensure compliance. If continued mistakes are found on those
applications, the CONTRACTOR shall remove the employee as a facilitator
immediately and follow the CONTRACTOR'S employee disciplinary action procedures.
The review of individual marketer/facilitator applications shall encompass
all
applications for the period and does not need to be sorted into the four
categories above.
Verification
of a specific facilitator's applications cannot substitute for the CONTRACTOR'S
sample review required by this section of the AGREEMENT. The CONTRACTOR must
make the appropriate adjustments to claims for CHPlus B applications found
to be
ineligible and must report their findings to the STATE. If CHPlus A, Medicaid,
or FHPlus applicants appear ineligible for those programs, the CONTRACTOR shall
refer those cases to the appropriate LDSS for review and action.
The
CONTRACTOR shall protect applicants who have been subjected to facilitator
fraud. For those applications that are verified prior to enrollment the
CONTRACTOR shall:
•
Enroll
applicants or forward to the LDSS those applications in which the information
is
verified by the applicant.
•
Enroll
applicants or forward with corrections to the LDSS those applications in which
information was omitted by the facilitator, but the individual is still
eligible. The CONTRACTOR may obtain the corrected information over the phone,
initial the application, and send a copy of the updated information to the
applicant.
•
Forward
all signed Medicaid applications to LDSS batched according to whether applicants
appear eligible or ineligible.
For
cases
in which the CONTRACTOR retroactively reviewed the applications of a facilitator
found to have committed fraud, the CONTRACTOR shall:
•
Do
nothing with enrollees who confirm the information on the
application.
•
Inform
the LDSS of any Medicaid enrollees who may not be eligible based on the
retrospective review.
•
Allow
CHPlus B enrollees to reapply if it appears that they may still be eligible
for
coverage. Coverage for a CHPlus B enrollee may be continued for two months
while
the new application is completed and processed. During this time any CHPlus
B
applicant found to be eligible in a higher family contribution category will
be
permitted to remain enrolled provided they remit the appropriate family
contribution. A new code will be added to the KIDS system to permit the
CONTRACTOR to track these children.
•
Forward
all new CHPlus A, Medicaid, and FHPlus applications to the LDSS with an
explanation of the results of the verification.
If
during
the course of the verification process, the CONTRACTOR identifies cases of
fraud
committed by applicants and/or enrollees, those cases, with supporting evidence,
shall be submitted to the STATE.
3.
Field Monitoring
The
CONTRACTOR shall conduct field monitoring of their marketers/facilitators,
including announced and unannounced observed interviews between
marketers/facilitators and applicants. If the CONTRACTOR does not have field
marketers, it shall develop a process for observing the actions of their
marketers when assisting applicants (e.g., over the telephone). This process
must be reviewed and approved by the STATE.
The
CONTRACTOR shall conduct secret shopping of their marketers/facilitators to
ensure that marketers/facilitators are following the rules and do not coach
or
condone applicants to falsify information. The CONTRACTOR may use its employees
as secret shoppers or may contract with another entity for such services. If
all
application assistance by the CONTRACTOR is provided over the
telephone, the CONTRACTOR may meet the secret shopping requirement by recording
telephone conversations to ensure the accuracy of the information
provided.
The
CONTRACTOR must immediately remove from facilitated enrollment activities any
marketing representative or facilitator found to be coaching or condoning
applicants to falsify information. The CONTRACTOR must review all applications
of any employee found to be engaged in fraud for the prior three months, make
the appropriate adjustments to claims for applicants found to be ineligible,
and
report such findings to the STATE and the LDSS, if applicable.
The
CONTRACTOR shall submit its secret shopping plan to the STATE for approval
prior
to implementation.
4.
Training
All
facilitated enrollment staff hired by the CONTRACTOR after the date of this
amendment must attend the STATE sponsored training. If STATE training is not
available at that specific time, new employees may be trained by the CONTRACTOR
using the training materials developed by the STATE. New employees may begin
facilitated enrollment activities only after they are trained by the CONTRACTOR
or the STATE. Those who begin facilitated enrollment activities following
training by the CONTRACTOR shall attend the next scheduled STATE training.
The
CONTRACTOR shall continue to provide semi-annual refresher training.
Additionally, the CONTRACTOR'S facilitated enrollment staff must attend any
mandatory LDSS "Integrity Training" programs. The CONTRACTOR'S training must
include:
•
Classroom training
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Field
training
•
Refresher training
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Field
monitoring
•
Probationary period for new marketers/enrollers
•
Facilitator exam
The
CONTRACTOR shall require all marketers/facilitators to sign an attestation
that
they attended training and that they fully understand the rules before being
permitted to provide application assistance. This applies to new employees
as
well as marketers/facilitators who have been taking applications prior to the
effective date of this amendment. This attestation shall include rules about
program integrity (e.g., the facilitator knows all income must be reported
including any off the books income). The CONTRACTOR shall retain a copy of
this
form in the employee's employment records. The CONTRACTOR'S attestation form
shall be approved by the STATE.
5.
Reports
The
CONTRACTOR must submit quarterly reports on the results of these monitoring
activities. The report is due 30 days after the end of the quarter beginning
immediately after the STATE has approved the field monitoring programs.
Thereafter, each quarterly report shall be due within 30 days following the
end
of the quarter. The reports shall include:
•
The
outcome of the quality assurance activities (e.g., number of applications
requiring further review, number of applicants found ineligible upon further
review, improper marketing/facilitated enrollment activities).
•
The
number of applications in each of the four categories to be verified and the
outcome of the verification phone calls (i.e., those found eligible, those
that
appear ineligible based on current program rules, and those found eligible
in a
different subsidy category).
•
The
number of observed interviews and/or secret shopping encounters and the results
of those encounters.
•
The
number of facilitated enrollment employees terminated for fraud during the
period and the reason for each termination. This report must also include the
name and last known address of each terminated employee.
•
The
names and identification numbers of the enrollees that were identified as
problematic as a result of reviewing applications taken by a terminated
employee. Information shall include the name of the program the enrollee is
in,
the enrollee's county of residence and the effective date of enrollment.
.
This
report will be added to the current list of reports, via certified letter to
the
CONTRACTOR'S Chief Executive Officer, and subject to the 2 percent penalty
for
late reports.
6.
Effective Date
This
contract amendment shall be effective immediately. The CONTRACTOR has 30 days
from the date of this amendment to submit a plan to the STATE which outlines
how
they will meet the requirements of this section and the timeframe for
implementation. Failure to submit a plan in the required timeframe shall result
in the CONTRACTOR'S suspension of facilitated enrollment activities for all
programs. The CONTRACTOR shall be in full compliance no later than 90 days
after
the CONTRACTOR'S program has been approved by the STATE.
Quality
Assurance Checklist
This
checklist must be completed and signed by Quality Assurance Staffer the
Facilitator Supervisor.
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All
required sections of the application are
complete
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All
required documents are included with the application
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Signature
match review completed
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Information
pertinent to eligibility is not altered without applicant initials
or
facilitator initials and notice to the applicant, as
necessary
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Internal
consistency checks completed:
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Household
Composition/Reported Income review and verification
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Housing
expenses review and verification
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Child
support income review and verification
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Undocumented
immigrant review
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Signature
of Reviewer: ______________________________________
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Print
Name: ______________________________________________
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FE
Organization:___________________________________________
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Date:
___________________________________________________
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