MEDICAID ADVANTAGE MODEL CONTRACT Amendment of Agreement Between The City of New York And WellCare of New York, Inc.
Back to Form 8-K
Amendment
of Agreement
Between
The
City of New York
And
WellCare
of New York, Inc.
This
Amendment, effective January 1, 2008, amends the Medicaid Advantage 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 "LDSS" or "DOHMH") and WellCare of
New York, Inc. (hereinafter referred to as "Contractor" or "MCO").
WHEREAS
the parties entered into an Agreement effective April 1, 2006 for the purpose of
providing Medicare and Medicaid Advantage Products to eligible recipients
residing in the Contractor's Medicaid Advantage Service Area; and
WHEREAS
the parties desire to amend said Agreement to modify certain provisions to
reflect current circumstances and intentions, and, as authorized in Section 2.1
of the Agreement, to extend the term of the Agreement until December 31,
2009;
NOW
THEREFORE, effective January 1, 2008, it is mutually agreed by the parties to
amend this Agreement as follows:
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1.
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Amend Section 19.1 of
the "Table of Contents for Model Contract," to read, "Section 19.1
Maintenance of
Contractor Performance Records, Records Evidencing Enrollment Fraud and
Documentation
Concerning Duplicate CINs."
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2.
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Amend Section 3.6,
"SDOH Right to Recover Premiums," to read as
follows:
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3.6
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SDOH
Right to Recover Premiums
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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. Notwithstanding the foregoing, the SDOH always has the
right to recover duplicate Medicaid Advantage premiums paid for persons
enrolled under more than one Client Identification Number (CIN) in the
Contractor's Medicaid Advantage product whether or not the Contractor has
made payments to providers.
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Medicaid
Advantage Contract Amendment
NYC
January 1, 2008
Page
1
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3.
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Amend Section 19.1,
"Maintenance of Contractor Performance Records," to read as
follows:
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19.1
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Maintenance
of Contractor Performance Records, Records Evidencing Enrollment Fraud and
Documentation Concerning Duplicate
CINs
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a)
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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:
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i)
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records
related to services provided to Enrollees, including a separate Medical
Record for each Enrollee;
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ii)
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all
financial records and statistical data that DOHMH, LDSS, SDOH, 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, any reserves related thereto and expenses incurred under
this Agreement;
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iii)
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all
documents concerning enrollment fraud or the fraudulent use of any
CIN;
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iv)
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all
documents concerning duplicate
CINs;
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v)
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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.
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b)
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The
record maintenance requirements of this Section shall survive the
termination, in whole or in part, of this
Agreement.
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4.
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Amend Section 19.3,
“Access to Contractor Records, “to read as
follows:
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19.3
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Access
to Contractor Records
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The
Contractor shall provide DOHMH, 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). 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.
Notwithstanding the foregoing, when records are sought in connection with
a "fraud" or "abuse" investigation, as defined respectively in 10 NYCRR
§98.1.21 (a) (1) and (a) (2), all costs associated with production and
reproduction shall be the responsibility of the
Contractor.
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5.
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Amend Section 22.7
"Recover of Over. payments to Providers" to read as
follows:
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22.7
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Recovery
of Overpayments to Providers
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Consistent
with the exception language in Section 3224-b of the Insurance Law, the
Contractor shall have and retain the right to audit participating
providers' claims for a six year period from the date the care, services
or supplies were provided or billed, whichever is later, and to recoup any
overpayments discovered as a result of the audit. This six year limitation
does not apply to situations in which fraud may be involved or in which
the provider or an agent of the provider prevents or obstructs the
Contractor's auditing.
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Medicaid
Advantage Contract Amendment
NYC
January 1, 2008
Page
2
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6.
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The
attached Appendix D, "New York State Department of Health Medicaid
Advantage Marketing Guidelines," is substituted for the period beginning
January 1, 2008.
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7.
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The
attached Appendix H, "New York State Department of Health Guidelines for
the Processing of Medicaid Advantage Enrollments and Disenrollments," is
substituted for the period beginning January 1,
2008.
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8.
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The
attached Appendix K, "Medicare and Medicaid Advantage Products and
Non-Covered Services," is substituted for the period beginning January 1,
2008.
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9.
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The
attached Appendix N "New York City Specific Contracting Requirements" is
substituted for the period beginning January 1,
2008.
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Medicaid
Advantage Contract Amendment
NYC
January 1, 2008
Page 3
This
Amendment is effective January 1, 2008 and the Agreement, including the
modifications made by this Amendment, shall remain in effect until December 31,
2009 or until an extension, renewal or successor Agreement is entered into as
provided for in Section 2.1 of the Agreement.
IN
WITNESS WHEREOF, the parties have duly executed this Amendment to the Agreement
on the dates appearing below their respective signatures.
CONTRACTOR
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CITY
OF NEW YORK
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By /s/ Xxxxx
Xxxxxxxxx
(Signature)
Xxxxx
Xxxxxxxxx
(Printed Name)
Title
President and
CEO
WellCare of New York,
Inc.
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By
/s/ Xxxxxx Xxxx
(Signature)
Xxxxxx
Xxxx
(Printed
Name)
Title
Chief Operating
Officer
(NYC DOHMH)
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Date 6/2/08
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Date 7/18/08
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Medicaid
Advantage Contract Amendment
NYC
January 1, 2008
Page 0
XXXXX XX
XXXXXXX
XXXXXX XX
XXXXXXXXXXXX
Xx this
6th day
of June,
2008, Xxxxx Xxxxxxxxx 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/ Xxxx
Xxxxx
NOTARY
PUBLIC
STATE OF
NEW YORK)
SS:
COUNTY OF
NEW YORK
On this
18th day of July, 2008, Xxxxxx
Xxxx came
before me, to me known and known to be the Chief Operating Officer 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
D
New
York State Department of Health
Medicaid
Advantage Marketing Guidelines
Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-1
MEDICAID
ADVANTAGE MEETING 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
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1.
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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.
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2.
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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.
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B. Marketing
Material Requirements
In
addition to meeting CMS' Medicare Advantage marketing requirements and guidance
on marketing to individuals entitled to Medicare and Medicaid:
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1.
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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.
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2.
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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 DOHMH and
the DOHMH will the Contractor when the 5% threshold has been reached.
Marketing materials tobe 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.
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D- 2
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3.
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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.
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C. Prior
Approvals
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1.
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The
CMS and SDOH will jointly review and approve Medicaid Advantage marketing
videos, materials fpr broadcast (radio, television, or electronic),
billboards, mass transit (bus, subway or other livery) and
statewide/regional print advertising materials in 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 DOHMH input in
the review process.
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2.
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CMS
and SDOH will jointly review and approve the following Medicaid Advantage
marketing materials:
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a.
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Scripts
or outlines of presentations and materials used at health fairs and other
approved types of events and
locations;
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b.
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All
pre-enrollment written marketing materials – written marketing materials
include brochures and leaflets, and presentation materials used by
marketing representatives;
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c.
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All
direct mailing from the Contractor specifically targeted to the Medicaid
market.
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3.
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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 DOHMH input
in the review and approval process.
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4.
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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.
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D- 3
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5.
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Approved
marketing materials shall be kept on file in the offices of the
Contractor, the DOHMH, the SDOH, and
CMS.
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D. Dissemination
of Outreach Materials to LDSS
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1.
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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.
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2.
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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.
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III. Marketing
Activities
A. General
Requirements
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1.
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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.
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2.
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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.
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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 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.
Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-4
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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.
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1.
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Approved
Marketing Plan
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a.
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The
Contractor must submit a plan of Medicaid Advantage Marketing activities
that meet the SDOH requirements to the
SDOH.
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b.
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The
SDOH, in consultation with DOHMH, is responsible for the review and
approval of Medicaid Advantage Marketing plans, using a SDOH and CMS
approved checklist.
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c.
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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.
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d.
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An
approved marketing plan must be on file with the SDOH and the DOHMH prior
to the Contractor engaging in the Medicaid Advantage specific marketing
activities.
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e.
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The
plan shall include stated marketing goal and strategies, marketing
activities, and the training, development and responsibilities of
dedicated marketing staff.
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f.
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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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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-5
g.
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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.
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2.
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Prohibition
of Cold Call Marketing Activities
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Contractors
are prohibited from directly or indirectly, engaging in door to door, telephone,
or other cold-call marketing activities.
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3.
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Marketing
in Emergency Rooms or Other Patient Care
Areas
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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.
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4.
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Enrollment
Incentives
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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:
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1.
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Contractors
are prohibited from misrepresenting the Medicaid program, the Medicaid
Advantage Program or the policy requirements of the LDSS or
SDOH.
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2.
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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.
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3.
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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.
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-6
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4.
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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.
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5.
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Contractors
are responsible for ensuring that their Marketing representatives engage
in professional and courteous behavior in their interactions with LDSS and
DOHMH 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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6.
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The
Contractor shall not market to enrollees of other health plans. If the
Contractor becomes aware during a marketing encounter that an individual
is enrolled in another health plan, the marketing encounter must be
promptly terminated, unless the individual voluntarily suggests
dissatisfaction with the health plan in which he or she is
enrolled.
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7.
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The
Contractor shall not offer compensation including salary increases or
bonuses, based solely on the number of individuals enrolled by Marketing
Representatives who are licensed to offer Medicare products only,
including Medicaid Advantage, and who also market Medicaid, Family Health
Plus and Child Health Plus. 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:
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a.
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"Compensation"
shall mean any remuneration required to be reported as income or
compensation for federal tax
purposes;
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b.
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The
Contractor may not pay a "commission" or fixed amount per
enrollment;
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c.
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The
Contractor may not award bonuses more frequently than quarterly, or for an
annual amount that exceeds ten percent (10%) of a Marketing
Representative's total annual compensation;
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-7
d.
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Sign
on bonuses for Marketing Representatives are
prohibited;
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e.
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Where
productivity is a factor in the bonus determination, bonuses must be
structured in such a way that productivity carries a weight of no more
than 30% of the total bonus and that application quality/accuracy must
carry a weight equal to or greater than the productivity
component;
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f.
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The
Contractor must limit salary adjustments for Marketing Representatives to
annual adjustments except where the adjustment occurs during the first
year of employment after a traditional trainee/probationary period or in
the event of a company wide
adjustment;
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g.
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The
Contractor is prohibited from reducing base salaries for Marketing
Representatives for failure to meet productivity
targets;
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h.
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The
Contractor is prohibited from offering non-monetary compensation such as
gifts and trips to Marketing
Representatives;
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i.
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The
Contractor shall have human resource policies and procedures for the
earning and payment of overtime and must be able to produce documentation
(such as time sheets) to support overtime compensation;
and
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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 DOHMH.
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IV. Marketing
Infractions
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A.
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Infractions
of Medicaid marketing guidelines, as found in Appendix D, Sections III D
and E, may result in the following actions being taken by the SDOH and/or
the DOHMH to protect the interests of the program and its clients. These
actions shall be taken by the SDOH and/or DOHMH in collaboration with the
CMS Regional Office.
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1.
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If
the Contractor or its representative commits a first time infraction of
marketing guidelines and the SDOH and/or the DOHMH deems the infraction to
be minor or unintentional in nature, the SDOH and/or the DOHMH may issue a
warning letter to the Contractor.
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2.
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If
the Contractor engages in Marketing activities that the SDOH and/or DOHMH
determines 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 and/or the
DOHMH may require the Contractor to, and the Contractor shall prepare and
implement a corrective action plan acceptable to the SDOH and/or DOHMH
within a specified timeframe. In addition, or alternatively, SDOH and the
DOHMH, in consultation with SDOH, may impose sanctions, including monetary
penalties, as permitted by law.
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 2008
D-8
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3.
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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 or the DOHMH, in consultation with the SDOH, may in
addition to any other legal remedy available to the SDOH and/or DOHMH in
law or equity:
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a)
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direct
the Contractor to suspend its Medicaid Advantage Marketing activities for
a period up to the end of the Agreement
period;
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b)
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suspend
new Medicaid Advantage Enrollments, for a period up to the remainder of
the Agreement period; or
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c)
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terminate
this Agreement pursuant to termination procedures described in Section 2.7
of this Agreement.
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Medicaid
Advantage Contract
APPENDIX
D
NYC
January 1, 0000
X-0
XXXXXXXX
X
Xxx
Xxxx Xxxxx Department of Health Guidelines for the
Processing
of Medicaid Advantage Enrollments and Disenrollments
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-1
Appendix
H
SDOH
Guidelines
For
the Processing of Medicaid Advantage Enrollments and
Disenrollments
1.
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General
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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, upon receipt of a written request from either the LDSS or the
Contractor, may allow modifications to timeframes and some procedures. Where an
Enrollment Broker exists, the Enrollment Broker will be responsible for some or
all of the LDSS responsibilities as set forth in the Enrollment Broker
Contract.
2.
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Enrollment
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a)
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SDOH
Responsibilities:
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i)
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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.
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ii)
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SDOH
reviews and approves proposed Enrollment materials prior to the Contractor
publishing and disseminating or otherwise using the
materials.
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b)
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LDSS
Responsibilities:
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i)
|
The
LDSS has the primary responsibility for processing Medicaid Advantage
enrollments.
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ii)
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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.
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iii)
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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.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-2
|
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.
|
|
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.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-3
|
The
transfer of enrollment information may be accomplished by any of the
following:
|
|
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
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
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 LDS
S).
|
|
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 that affect or may affect the Medicaid
or Medicaid Advantage eligibility status of 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, address changes,
incarceration, third party insurance other than Medicare, Disenrollment
from the Contractor's Medicare Advantage Product,
etc.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-5
|
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. In such
instances, the LDSS shall delete the Enrollee's Enrollment in the
Contractor's Medicaid Advantage
Plan.
|
|
vii)
|
The
Contractor, within five (5) business days of identifying cases where a
person may be enrolled in the Contractor's Medicaid Advantage product
under more than one MI, must convey that information in writing to the LDS
S .
|
|
viii)
|
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.
|
|
ix)
|
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)
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-6
|
iii)
|
In
the event that the LDSS learns of an Enrollee's pregnancy prior to the
Contractor, the LDSS is to establish MA eligibility and pre-enroll the
unborn into Medicaid managed care in cases where an enrollment form is
received.
|
|
iv)
|
When
a newborn is enrolled in managed care, the LDSS is responsible for sending
an Enrollment Confirmation Notice to inform the mother of 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.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-7
|
iv)
|
The
SDOH shall also forward an error report as necessary to the Contractor and
LDSS.
|
|
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
211d 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 2"d 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
theprovision of Benefit Package services. Payment of sub-capitation does
not constitute "provision of Benefit Package
services."
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
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 nonconsensual 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
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
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."
Notwithstanding the foregoing, the SDOH always has the right to recover
duplicate Medicaid Advantage premiums paid for persons enrolled under more
than one Client Identification Number (CIN) in the Contractor's Medicaid
Advantage product whether or not the Contractor has made payments to
providers.
|
|
ix)
|
The
SDOH may recover premiums paid for Medicaid Advantage Enrollees whose
eligibility for this program was based on false information, when such
false information was provided as a result of intentional actions or
failures to act on the part of an employee of the Contractor; and the
Contractor shall have no right of recourse against the Enrollee or a
provider of services for the cost of services provided to the Enrollee for
the period covered by such
premiums.
|
|
x)
|
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
within thirty (30) business days of notification from the LDSS for any
full months of retroactive Disenrollment where the Contractor was not at
risk for the provision
of
Benefit Package services during the month. Notwithstanding the foregoing,
the SDOH always has the right to recover duplicate Medicaid Advantage
premiums paid for persons enrolled under more than one Client
Identification Number (CIN) in the Contractor's Medicaid Advantage product
whether or notthe Contractor has made payments to providers. Failure by
the LDSS to 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
or for the State Attorney General to bring legal action to recover any
overpayment.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-10
|
xi)
|
Generally
the effective dates of Disenrollment are prospective. Effective dates for
other than routine Disenrollments are described
below:
|
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 of waivered services through the Long Tenn 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. |
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-11
*
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 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.
|
|
xii)
|
The
LDSS is responsible for informing Enrollees of their right to disenroll at
any time for any reason.
|
|
xiii)
|
The
LDSS will render a decision within five (5) days of the receipt of a fully
documented request for
Disenrollment.
|
|
xiv)
|
To
the extent possible, the LDSS is responsible for processing an expedited
disenrollment within two (2) business days of its determination that an
expedited Disenrollment is
warranted.
|
|
xv)
|
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, LDSSinitiated 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.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-12
|
xvi)
|
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.
|
|
xvii)
|
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.
|
|
xviii)
|
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.
|
|
xix)
|
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 fowls 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)
|
The
Contractor will make a good faith effort to identify cases which may be
appropriate for an LDSS-initiated Disenrollment. Within five, (5) business
days of identifying such cases and following LDSS procedures, the
Contractor will, in writing, 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, the apparent enrollment
of a member in the Contractor's Medicaid Advantage product under more than
one CIN, etc.
|
Medicaid
Advantage Contract
APPENDIX
H
NYC
January 1, 2008
H-13
|
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 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
NYC
January 1, 2008
H-14
APPENDIX K
Medicare
and Medicaid Advantage Products
And
Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-1
APPEDNIX
K
Appendix
K is organized into three parts:
I.
Appendix K-1
Medicare Advantage Product
II. Appendix
K-2
Medicaid Advantage Product
Description of Medicaid Only Covered Services
III. Appendix
K-3
Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-2
APPENDIX
K1
MEDICARE
ADVANTAGE PRODUCT
Medicare
Advantage Benefit Package for Dual Eligibles
|
|
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
NYC
January 1, 2008
K- 3
Medicare
Advantage Benefit Package for Dual Eligibles
|
|
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 and management training - and supplies including coverage
for glucose monitors, test strips, and lancets. None of which are subject
to co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol
swabs/pads, insulin syringes and needles are covered by Part
D.
|
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 xxxxx.Xx 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 xxxxx.Xx 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. |
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-4
Medicare
Advantage Benefit Package for Dual Eligibles
|
|
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 that are covered
by Medicaid. (No Part D).
|
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, eannolds, 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 aidsand low
visionservices. Coverage
includes the replacement of lost or destroyed glasses and 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 notrequirechanging 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 1/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
NYC
January 1, 2008
K-5
APPENDIX K2
MEDICAID
ADVANTAGE PRODUCT
Medicaid
Advantage Benefit Package for Dual Eligibles
|
|
Category
of Service
|
Included
in Medicaid Capitation
|
Inpatient
Mental Health
|
Days in excess
of the Medicare 190-day lifetime maximum.
|
Home
Health
|
Non-Medicare
covered home health services (e.g. home health aide services with 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
NYC
January 1, 2008
K-6
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 for 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.
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 must be provided in an Enrollee's home 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
services include, but shall not be limited to, 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 ancillary to
dental surgery provided in an inpatient or outpatient hospital setting 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
NYC
January 1, 2008
K-7
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 are 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 for an Enrollee to obtain 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 in which 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
NYC
January 1, 2008
K- 8
XXXXXXXX X0
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 provided under the direct access
provisions of the waiver
|
·
|
Skilled
Nursing Facility (SNF) days not covered by
Medicare
|
·
|
Personal
Care Services
|
·
|
Medicaid
Pharmacy Benefits allowed by State Law (select drug categories excluded
from the Medicare Part D benefit and certain medications included in the
Part D benefit when the Enrollee is unable to receive them from his/her
Medicare Advantage Plan), also certain Medical Supplies and Enteral
Formula when not covered by
Medicare.
|
·
|
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 Ill (sponsored by state
or local mental health units)
|
|
o
|
Partial
Hospitalizations
|
|
o
|
Assertive
Community Treatment (ACT)
|
|
o
|
Personalized
Recovery Oriented Services (PROS)
|
·
|
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
|
·
|
Personal
Emergency Response Services
(PERS)
|
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-9
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 two (2) optional benefits are:
●
Non-Emergency Transportation Services
●
Dental Service
|
Both of
these services, however, are mandatory in NYC.
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-10
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
Enrollees
Hospice
services provided to Medicare Advantage Enrollees by 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) involve 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
services must be ordered by a physician, and there has to be a medical need for
the services. Licensed home care services agencies, as opposed to certified home
health agencies, are the primary providers of PCS. Enrollees receiving PCS must
have a 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 a plan of care with the
personal care agency.
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-11
4.
|
Skilled
Nursing Facility Days Not Covered by
Medicare
|
Skilled
nursing facility days for Medicaid Advantage Enrollees in excess of the first
one hundred (100) days in the benefit period are covered by Medicaid on a fee
for service basis.
5.
|
Prescription
Drugs Permitted by State Law, Certain Medical Supplies and Enteral
Formulas Not Covered by Medicare
|
NYS
Medicaid continues to provide coverage for categories of drugs excluded from the
Medicare Part D benefit such as barbiturates, benzodiazepines, and some
prescription vitamins, and some non-prescription drugs. NYS also provides a wrap
around program which covers medications that are included in the Part D benefit
when the recipient is unable to receive them from his or her Part D plan.
Effective January 1, 2007, drugs which are covered through this Medicaid
wrap-around benefit will be limited to the following four categories of drugs:
1) atypical antipsychotics, 2) antidepressants, 3) antiretrovirals used in the
treatment of HIV/AIDS, and 4) anti-rejection drugs used in the treatment of
tissue and organ transplants, but only when 1) these drugs are not covered by
the specific plan, 2) the patient does not meet the plan's utilization
management requirements, or 3) there are quantity limits inconsistent with the
prescribed amount. Certain medical/surgical supplies and enteral formula covered
by Medicaid and not included in the Contractor's Medicare Advantage Benefit
Package also 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 Sections 10.6 and 10.9 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 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 are 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)
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-12
8.
Non-Emergency Transportation (when not in benefit package)
(See
description in Appendix K-2)
9.
Methadone Maintenance Treatment Program (MMTP)
MMTP
consists of drug detoxification, drug dependence counseling, and rehabilitation
services which include chemical management of the patient with methadone.
Facilities authorized to provide methadone maintenance treatment certified by
the Office of Alcohol and Substance Abuse Services (OASAS) under Part 828 of 14
NYCRR.
10. Certain
Mental Health Services
The
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)
|
IPRT is 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 and to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified by
OMH under Part 587 of 14 NYCRR.
b. Day
Treatment
Day
Treatment is 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. These services are certified by OMH under Part 587 of 14
NYCRR.
c.
Continuing Day Treatment
Continuing
Day Treatment is designed to maintain or enhance current levels of functioning
and skills, maintain community living, and develop self-awareness and
self-esteem. It 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 Part 587 of 14 NYCRR.
d.
|
Case
Management for Seriously and Persistently Mentally Ill 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 symptomology 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 Part 506 of 14 NYCRR.
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K-13
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 Part 587 of 14
NYCRR.
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.
They are operated pursuant to approval or certification by OMH; and receive
Medicaid reimbursement pursuant to Part 508 of 14 NYCRR.
g.
Personalized Recovery Oriented Services (PROS)
PROS,
licensed and reimbursed pursuant to Part 512 of 14 NYCRR, 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 a 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 family, community, school or independent
living situations. Such services are provided in consideration of a child's
developmental stage. Children detelllined eligible for admission are placed in
surrogate family homes for care and treatment. These services are certified by
OMH under Section 586.3, and Parts 594 and 595 of 14 NYCRR .
Medicaid
Advantage Contract
APPENDIX
K
NYC
January 1, 2008
K- 14
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 Part 679 of 14 NYCRR (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 an
Intermediate Care Facility (ICF) or a comparable setting. These services are
certified by OMRDD under Part 690 of 14 NYCRR.
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
NYC
January 1, 2008
K-15
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 waiver under Section 1915(c) of the
Social Security Act (SSA).
e. Services
Provided Through the Care At Home Program (OMRDD)
The OMRDD
Care at Home III, 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 waiver under Section 1915(c) of the (SSA).
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. The nature of these services include:
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 so that the program can contact the
Contractor or 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 MMIS by
any SDOH approved fee-forservice 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
NYC
January 1, 2008
K-16
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 HIV
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 an
individualized health care plan, and providing 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 satisfactorily in
whole or in part 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
NYC
January 1, 0000
X-00
Xxxxxxxx
X
Xxx Xxxx
City Specific Contracting Requirements
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 0000
X-0
Xxxxxxxx
X
Xxx
Xxxx Xxxx Specific Contracting Requirements
1.
General
|
a)
|
In
New York City, the Contractor will comply with all provisions of the main
body and other Appendices of this Agreement, except as otherwise expressly
established in this Appendix.
|
|
b)
|
This
Appendix sets forth New York City Specific Contracting Requirements and
contains the following sections:
|
|
N.1 |
Compensation
for Public Health Services
|
|
N.2 |
Coordination
with DOHMH on Public Health Initiatives
|
|
N.3 |
Benefits
|
|
N.4 |
Additional
Reporting Requirements
|
|
N.5 |
New
York City Additional Medicaid Advantage Marketing
Guidelines
|
|
N.6 |
Guidelines
for Processing Enrollments and Disenrollments in Xxx Xxxx
Xxxx
|
|
X.0 |
Xxx
Xxxx Xxxx Transportation Policy Guidelines
|
|
Schedule 1 |
DOHMH
Public Health Services Fee
Schedule
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-2
N.1
Compensation
for Public Health Services
1.
|
The
Contractor shall reimburse DOHMH at the rates contained in Schedule 1 of
this Appendix for Enrollees who receive the following services from DOHMH
facilities, except in those instances where DOHMH may xxxx Medicaid
fee-for-service.
|
a)
Diagnosis and/or treatment of TB
b) HIV
counseling and testing that is not part of an STD or TB visit
c)
Adult immunizations
d)
Dental services
e)
STD lab test (s)
2.
|
Notwithstanding
Sections 10.11 (a) (v) (C) and (b) (ii) of this Agreement, the following
requirements
concerning Contractor notification and documentation of services shall
apply in New York City:
|
|
a)
|
DOHMH
shall confirm the Enrollee's membership in the Contractor's Medicaid
Advantage product on the date of service through EMEDNY prior to billing
for these services.
|
|
b)
|
DOHMH
must submit claims for services provided to Enrollees no later than one
year from the date of service.
|
|
c)
|
The
Contractor shall not require pre-authorization, notification to the
Contractor or contacts with the PCP for the above mentioned
services.
|
|
d)
|
DOHMH
shall make reasonable efforts to notify the Contractor that it has
provided the above mentioned services to an
Enrollee.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-3
N.2
Coordination
with DOHMH on Public Health Initiatives
1. Coordination
with DOHMH
|
a)
|
The
Contractor shall provide the DOHMH with existing infoimation requested by
DOHMH to conduct epidemiological
investigations.
|
2. Provider
Reporting Obligations
|
a)
|
The
Contractor shall make reasonable efforts to assure timely and accurate
compliance by Participating Providers with public health reporting
requirements relating to communicable disease and conditions mandated in
the New York City Health Code pursuant to 24 RCNY §§ 11.03-11.07 and
Article 21 of the NYS Public Health
Law.
|
|
b)
|
"Reasonable
efforts" shall include:
|
|
i)
|
educating
Participating Providers on treatment guidelines and instructions for
reporting included in the NYC DOHMH Compendium of Public Health
Requirements and
Recommendations.
|
|
ii)
|
Including
reporting requirements in the Contractor's provider manual or other
written instructions or guidelines.
|
|
iii)
|
letters
from the Contractor to Participating Providers who generated claims that
suggest that an Enrollee may have a reportable disease or condition,
encouraging such providers to report and providing information on how to
report.
|
|
iv)
|
Other
methods for follow up with Participating Providers, subject to DOHMH
approval, may be employed.
|
3. Standing
Orders
The
Contractor shall encourage participating providers.who employ registered nurses
to implement standing orders for influenza and pneumococcal
vaccines.
4. Enrollee
Outreach/Education
|
a)
|
The
Contractor shall provide health education to Enrollees on an on-going
basis through methods such as distribution of Enrollee newsletters, health
education classes or individual counseling on preventive health and public
health topics. Each topic below shall be covered at least once every two
years.
|
|
i)
|
HIV/AIDS
|
A) Encourage Enrollee
counseling and testing
|
B)
|
Inform
Enrollees as to availability of sterile needles and
syringes
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-4
|
ii)
|
STDs
|
|
A)
|
Inform
Enrollees that confidential STD services are available at DOHMH facilities
for non-enrolled sexual and needle-sharing partners at no
charge
|
|
iii)
|
Injury
prevention, including guidance on preventing falls and poisoning, and
other age appropriate anticipatory
guidance
|
|
iv)
|
Domestic
violence
|
|
v)
|
Smoking
cessation
|
|
vi)
|
Asthma
|
|
vii)
|
Immunization-
influenza and pneumococcal
|
|
viii)
|
Mental
health services
|
|
ix)
|
Diabetes
|
|
x)
|
Screening
for Cancer
|
|
xi)
|
Chemical
Dependence
|
|
xii)
|
Physical
fitness and nutrition
|
|
xiii)
|
Cardiovascular
disease and hypertension
|
|
xiv)
|
Preserving
oral function and oral health
|
|
xv)
|
Stroke
recognition
|
5. Provider
Education
|
a)
|
DOHMH
shall prepare a public health compendium ("Compendium") with public health
guidelines, protocols, and recommendations which it shall make available
directly to Participating Providers and to the
Contractor.
|
|
b)
|
The
Contractor shall adapt public health guidance from the Compendium for its
internal protocols, practice manuals and
guidelines.
|
|
c)
|
The
Contractor will assist DOHMH in its efforts to disseminate electronic
materials to its Participating Providers by providing electronic addresses
if known by
|
-
|
|
Contractor
(fax and/or e-mail) for its Participating Providers, updated semi-
annually.
|
|
d)
|
The
Contractor shall promote the use of rapid HIV testing among its
Participating Providers.
|
6.
|
MCO
Staff Responsibilities and Training
|
a)
|
Domestic
Violence
|
|
i)
|
The
Contractor shall designate a domestic violence coordinator who
can:
|
|
A)
|
Provide
technical assistance to Participating Providers in documenting cases of
domestic violence;
|
|
B)
|
Provide
referrals to Enrollees or their Participating Providers, to obtain
protective, legal and or supportive social services;
and
|
|
C)
|
Provide
consultative assistance to other staff within the Contractor's
organization.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-5
|
ii)
|
The
Contractor shall distribute a directory of resources for victims of
domestic violence to appropriate staff, such as member services staff or
case managers.
|
7.
|
Medical
Directors
|
|
a)
|
The
Contractor's Medical Director shall participate in Medical Directors'
Meetings with the medical directors of the other MCOs participating in the
MMC Program in New York City and representatives of the New York City
Department of Health and Mental Hygiene. The purpose of the Medical
Directors' Meetings shall be to share public health information and data;
recommend that certain public health information be disseminated by the
MCOs to their Participating Providers; discuss public health strategies
and outreach efforts and potential collaborative projects; encourage the
development of MCO policies that support public health strategies; and
provide a vehicle for communication between the MCOs participating in the
MMC Program and the various bureaus and divisions of the NYC Department of
Health and Mental Hygiene.
|
|
b)
|
The
Contractor's Medical Director shall attend all periodic meetings, which
shall not exceed one every two months. In the event that the Medical
Director is unable to attend a particular meeting, the Contractor will
designate an appropriate substitute to attend the
meeting.
|
|
c)
|
DOHMH,
following consultation with the Medical Directors, may create workgroups
on particular public health topics. The Contractor's Medical Director may
participate. in any or all of the workgroups, but shall participate in at
least one of the designated
workgroups.
|
8.
|
Take
Care New York
|
a)
|
The
Contractor shall:
|
|
i)
|
Educate
Enrollees regarding prevention and treatment of diseases and conditions
included in the Take Care New York initiative
(TCNY);
|
|
ii)
|
Disseminate
TCNY health passports or materials containing similar content approved by
DOHMH to Enrollees;
|
|
iii)
|
Disseminate
reminders to obtain recommended health screenings at age appropriate
intervals to Enrollees; and
|
|
iv)
|
Educate
Participating Providers on recommended clinical guidelines regarding
prevention and treatment/management of diseases and conditions described
in the TCNY initiative.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-6
|
b)
|
The
Contractor shall, upon request by DOHMH, participate in one or more TCNY
workgroups or other activities sponsored by the
DOHMH.
|
9. Participation
in DOHMH public health detailing campaigns
|
a)
|
The
Contractor shall participate in a minimum of 1 DOHMH public health
detailing campaign (e.g. depression screening, colonoscopy or other
condition affecting the Medicaid Advantage population) in high-need
neighborhoods designated by DOHMH including the South Bronx, East and
Central Harlem, and North and Central Brooklyn by providing DOHMH with a
list of affiliated network providers that would benefit from such
detailing and a description of the criteria used to select these
providers.
|
|
b)
|
For
one detailing campaign selected by the Contractor, the Contractor shall
collaborate with the Department in an evaluation of the impact of that
detailing on provider practice in the detailed
neighborhood
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-7
N.3
Benefits
1. Transitional
Home Health Services Pending Placement in Personal Care Agency
Services
|
a)
|
Transitional
home health services are home health services as defined in Appendix K of
this Agreement provided by the Contractor to a Medicaid Advantage Enrollee
while the Human Resources Administration's determination regarding a
request for the provision of personal care agency services to the Enrollee
is pending. Transitional home health services are available to Medicaid
Advantage Enrollees in addition to the home health care services otherwise
covered under the Medicare and Medicaid Advantage Benefit Packages as
medically necessary.
|
|
b)
|
The
Contractor shall be responsible for providing transitional home health
services to Medicaid Advantage Enrollees for up to a thirty (30) day
period.
|
|
c)
|
For
Medicaid Advantage Enrollees discharged from a hospital or RHCF and for
whom personal care agency services have been requested by the
hospital/RHCF discharge planner, the thirty (30) day period shall commence
with the day following the Medicaid Advantage Enrollee's discharge from
the hospital or RHCF.
|
|
d)
|
For
Medicaid Advantage Enrollees who have been receiving home health care
services in the community and for whom personal care agency services have
been ordered by the Enrollee's physician, the thirty (30) day period shall
commence with the day following the last day that the Contractor approved
home health care services to be medically
necessary.
|
|
e)
|
Transitional
home health services shall not be available if the Medicaid Advantage
Enrollee was in receipt of personal care agency services prior to his/her
admission to a hospital or RHCF and both of the following circumstances
exist:
|
|
1)
|
The
Medicaid Advantage Enrollee was in a hospital and/or RHCF for a cumulative
total of fewer than thirty (30) consecutive days;
and
|
|
2)
|
The
Medicaid Advantage Enrollee requires the same level and hours of personal
care agency services upon
discharge.
|
|
f)
|
The
Contractor shall provide reasonable assistance as requested regarding the
completion of forms required by the Human Resources Administration to
initiate the review of a request for personal care agency services. Such
form, commonly referred to as the M11Q, requires physician orders, signed
by the licensed physician, to be received by HRA within thirty (30)
calendar days of the physician's
examination.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-8
N.4
Additional
Reporting Requirements
1.
|
DOHMH,
will provide Contractor with instructions for submitting the reports
required by paragraphs 4(c), below. These instructions shall include time
frames, and requisite formats. The instructions, time frames and formats
may be modified by DOHMH upon sixty (60) days written notice to the
Contractor.
|
2.
|
The
Contractor shall submit reports that are required to be submitted to DOHMH
by this Agreement electronically.
|
3.
|
The
Contractor shall pay liquidated damages of $500 to DOHMH for any report
required by paragraphs 4(c) below which is materially incomplete, contains
material misstatements or inaccurate information or is not submitted on
time in the requested format. The DOHMH shall not impose liquidated
damages for a first time infraction by the Contractor unless DOHMH 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 DOHMH. Liquidated damages may be waived at
the sole discretion of DOHMH.
|
4.
The Contractor shall submit the following reports
to DOHMH:
|
a)
|
The
Contractor shall provide DOHMH with all reports submitted to SDOH pursuant
to Sections 18.5(a)(i), (ii), (vi) and (vii) of this
Agreement.
|
|
b)
|
Upon
request by DOHMH, the Contractor shall submit to DOHMH reports submitted
to SDOH pursuant to Section 18.5(a) (iii) of this
Agreement.
|
|
c)
|
Upon
request by the DOHMH, the Contractor shall prepare and submit other
operational data reports. Such requests will be limited to situations in
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 DOHMH reserves the right to give thirty (30) days notice in
circumstances where time is of the
essence.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-9
N.5
New York City Additional
Medicaid Advantage Marketing Guidelines
1.
|
Contractor
may not market Medicaid Advantage within a two block perimeter of an HRA
facility.
Additionally, when a Medicaid community office is located in a hospital
facility, Contractor may not market Medicaid Advantage within 60 feet of
the Medicaid community
office.
|
2.
|
Contractor
shall not market in homeless
shelters.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-10
N.6
Guidelines
for Processing Enrollments and Disenrollments
in
New York City
1.
|
Notwithstanding
any contrary provisions in Appendix H, in New York City, Enrollment error
reports are generated by the Enrollment Broker to the Contractor generally
within 24-48 hours of Contractor Enrollment submissions and the Contractor
is able to resubmit corrections via the Enrollment Broker before Roster
pulldown. Changes in Enrollee eligibility or Enrollment status that occur
prior to production of the monthly Roster are reported by the State to the
Contractor with their rosters. Changes in Enrollee eligibility status that
occur subsequent to production of the monthly Roster shall be reported by
the Enrollment Broker by means of the electronic bulletin board. Reports
of Disenrollments processed by the Enrollment Broker shall be reported to
the Contractor as they occur by means of the electronic bulletin board.
Reports of Disenrollments processed by HRA shall be reported to the
Contractor manually as they occur or through the HPN. In the event that
the electronic bulletin board notification process is not available for
any reason, the Contractor shall use EMEDNY to verify loss of
eligibility.
|
2.
|
With
respect to Section 5 (a) (vi) of Appendix H of this Agreement, in the
event that an Enrollee loses Medicaid eligibility, the PCP Enrollment is
left on the system and removed thereafter by SDOH if no eligibility
reinstatement occurs.
|
3.
|
Section
3 (c ) (ii) of Appendix H of this Agreement is not applicable in New York
City. The Contractor shall not send verification of the infant's
demographic data to the HRA unless thirty days has expired since the date
of birth and the Contractor has not received confirmation via the HPN of a
successful Enrollment through the automated Enrollment system. When the
thirty days has expired the Contractor shall, within 10 days, send
verification of the infant's demographic data to the HRA including: the
mother's name and CIN; and the newborn's name, CIN, sex and date of birth.
Upon receipt of the data, if the Enrollment does not appear on the system,
HRA will process the retroactive
Enrollment.
|
4.
|
In
New York City, Enrollees may initiate a request for an expedited
Disenrollment to the HRA. The HRA will expedite the Disenrollment process
in those cases where: an Enrollee's request for Disenrollment involves an
urgent medical need; the Enrollee is a homeless individual residing in the
shelter system in New York City; the Enrollee has HIV, ESRD, or a SPMI/SED
condition; the request involves a complaint of nonconsenusal
Enrollment; or the Enrollee is certified blind or disabled and meets an
exemption criteria. If approved, the XXX will manually process the
Disenrollment.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-11
5.
|
Notwithstanding
Section 5 (a) (viii) of Appendix H of this Agreement, in New York City,
further notification by HRA is not required prior to retroactive
Disenrollment in the following
instances:
|
|
(a)
|
death
or incarceration of an Enrollee;
|
|
(b)
|
an
Enrollee has duplicate CINs and is enrolled in a Contractor's Medicaid
Advantage Product or FHPlus product under more than one of the CINs;
or
|
|
(c)
|
where
there has been communication between the Contractor and HRA or the
Enrollment Broker regarding the date of
disenrollment.
|
|
Consistent
with 5 (a) (viii) of Appendix H of this Agreement, the LDSS remains
responsible for sending a 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. Such notice shall be completed by the LDSS to
include: the Disenrollment Effective Date, the reason for the retroactive
Disenrollment, and the months for which premiums must be repaid. The
Contractor has 10 days to notify the LDSS should it refute the
Disenrollment Effective Date, based on a belief that the Contractor was at
risk for the provision of Benefit Package Services for any month for which
recoupment of premium has been requested. However failure by the LDSS to
so notify the Contractor does not affect the right of SDOH to recover
premium payment as authorized by Section 3.6 of this
Agreement.
|
6.
|
In
New York City, the LDSS will only accept Medicaid Advantage plan
Enrollments submitted
to the Enrollment Broker via the bulletin board with the exception of
consumers currently enrolled in a mainstream plan. For consumers enrolled
in a mainstream plan, Enrollment applications will only be accepted when
submitted to the Enrollment Broker via paper
application.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 0000
X-00
X.0
Xxx Xxxx Xxxx Transportation Policy
Guidelines
1.
|
The
Medicaid Managed Care Program contractual Benefit Package in New York City
includes non emergency transportation to all medical care and services
that are covered under the Medicare and Medicaid program, regardless of
whether the specific medical service is included in the Benefit Package or
paid for on a fee-for-service basis, except for transportation costs to
Methadone Maintenance Treatment Programs. The transportation obligation
includes the cost of meals and lodging incurred when going to and
returning from a provider of medical care and services when distance and
travel time require these costs.
|
2.
|
Generally,
the Contractor may provide transportation by giving or reimbursing the
Enrollee subway/bus tokens for the round trip for their medical care and
services, if public transportation is available for such care and
services. The Contractor is not required to provide transportation if the
distance to the medical appointment is so short that the Enrollee would
customarily walk to perform other routine errands. The Contractor may
adopt policies requiring a minimum distance between an Enrollee's
residence and the medical appointment, which may not be greater than ten
blocks; however, the policy must provide transportation for Enrollees
living a lesser distance upon a showing of special circumstances such as a
physical disability on a case-by-case
basis.
|
3.
|
If
the Enrollee has disabilities or medical conditions which prevent him or
her from utilizing
public transportation, the Contractor must provide accessible
transportation which is appropriate to the disability or condition such as
livery, ambulette, or taxi. The Contractor may require pre-authorization
of non-public transportation except for emergency
transportation.
|
|
a)
|
The
Contractor shall provide livery transportation under the following
circumstances, unless the Enrollee requires transportation by ambulette or
ambulance:
|
|
i)
|
The
Enrollee is able to travel independently but due to a debilitating
physical or mental condition, cannot use the mass transit
system.
|
|
ii)
|
The
Enrollee is traveling to and from a location that is inaccessible by mass
transit.
|
|
iii)
|
The
Enrollee cannot access the mass transit system due to temporary severe
weather, which prohibits use of the normal mode of
transportation.
|
|
b)
|
The
Contractor shall provide ambulette transportation under the following
circumstances, unless the Enrollee requires transportation by
ambulance:
|
|
i)
|
The
Enrollee requires personal assistance from the driver in entering/exiting
the Enrollee's residence, the ambulette and the medical
facility.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-13
|
ii)
|
The
Enrollee is wheelchair-bound (non-collapsible or requires a specially
configured vehicle).
|
|
iii)
|
The
Enrollee has a mental impairment and requires the personal assistance of
the ambulette driver.
|
|
iv)
|
The
Enrollee has a severe, debilitating weakness or is mentally disoriented as
a result of medical treatment and requires the personal assistance of the
ambulette driver.
|
|
v)
|
The
Enrollee has a disabling physical condition that requires the use of a
walker, cane, crutch or brace and is unable to use livery service or mass
transportation.
|
|
c)
|
The
Contractor shall provide non-emergency ambulance transportation when the
Enrollee must be transported on a stretcher and/or requires the
administration of life support equipment by trained medical personnel. The
use of non-emergency ambulance is indicated when the Enrollee's condition
would prohibit any other fowl of
transport.
|
4.
|
Emergency
transportation may only be provided by accessing 911 emergency ambulances.
Urgent care transportation may be provided by any mode of transportation
so long as such mode is appropriate for the medical condition or
disability experienced by the
Enrollee.
|
5.
|
If
an attendant is medically necessary to accompany the Enrollee to the
medical appointment, the Contractor is responsible for the transportation
of the attendant. A medically required attendant (authorized by the
attending physician) may include a family member, friend, legal guardian
or home health worker. When a child travels to medical care and services,
and an attendant is required, the parent or guardian of the child may act
as an attendant. In these situations, the costs of the transportation,
lodging and meals of the parent or guardian may be reimbursable, and
authorization of the attending physician is not
required.
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-14
Schedule
1 of Appendix N
SERVICE
|
FEE
|
TB
CLINIC
|
$125.00
|
IMMUNIZATION
|
|
Children
under 19 years
|
17.85
|
Adults
19 years and older
|
CDC
acquisition
cost
per dose
+
$2.00
Administration
fee
|
HIV
COUNSELING AND TESTING VISIT
|
$96.47
|
HIV
COUNSELING AND NO TESTING
|
$90.12
|
HIV
POST TEST COUNSELING
|
|
Visit
Positive Result
|
$90.12
|
LAB
TESTS
|
|
HIV-1/HIV-2
(Single Assay),
|
$15.17
|
HIV
Antibody, Confirmatory (Western Blot)
|
$26.75
|
GC/Chlamydia
Combo (GCT) Test
|
|
Chlamydia
Trachomatis, Amplified Probe
|
$21.43
|
Technique
|
|
Neisseria
Gonorrhoeae, Amplified Probe
|
$21.43
|
Technique
|
|
Culture
Bacterial (GC Cultures)
|
$8.15
|
DENTAL
SERVICES
|
$108.00
|
Medicaid
Advantage Contract
APPENDIX
N
NYC
January 1, 2008
N-15