APPENDIX X [Amendment Number 3]
Exhibit
10.1
APPENDIX
X
[Amendment
Number 3]
Agency
Code 12000
|
Contract
Number CO21236
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Period
1/1/08 —
12/31/09
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Funding
Amount for Period Based on approved
capitation rates
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This is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York State
Department of Health, having its principal office at Corning Tower, Room
0000, Xxxxxx Xxxxx
Xxxxx, Xxxxxx XX 00000, (hereinafter referred to as the STATE), and WellCare of New York, Inc.,
(hereinafter referred to as the CONTRACTOR), to modify Contract Number CO21236
as set forth below as set forth below and to extend the contract period
through December 31, 2009. The effective date of these modifications is January
1, 2008.
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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
SDOH Right to Recover Premiums
The
parties acknowledge and accept that the SDOH has a right to recover premiums
paid to the Contractor for Enrollees listed on the monthly Roster who are later
determined for the entire applicable payment month to have been disenrolled from
the Contractor's Medicare Advantage Product; to have been in an institution; to
have been incarcerated; to have moved out of the Contractor's service area
subject to any time remaining in the Enrollee's Guaranteed Eligibility period;
or to have died. In any event, the State may only recover premiums paid for
Medicaid Enrollees listed on a Roster if it is determined by the SDOH that the
Contractor was not at risk for provision of Benefit Package services for any
portion of the payment period. 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 (ON) in the
Contractor's Medicaid Advantage product whether or not the Contractor has made
payments to providers.
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
ClNs
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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)
|
records related to services provided to Enrollees, including a separate Medical Record for each Enrollee; |
Appendix
X
Medicaid
Advantage Contract Amendment
January 1,
2008
Page
1
|
ii)
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all
financial records and statistical data that SDOH and DHHS and any other
authorized governmental agency may require, including books, accounts,
journals, ledgers, and all financial records relating to capitation
payments, third party health insurance recovery, and other revenue
received, 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 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. |
5. | Amend Section 22.7 "Recovery of Overpayments to Providers" to read as follows: |
22.7 | Recovery of Overpayments to Providers | |
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. |
Appendix
X
Medicaid
Advantage Contract Amendment
January
1, 2008
Page
2
|
6. | Amend Section 31.2 "Indemnification by SDOH" to read as follows: |
31.2 | Indemnification by SDOH | |
Subject to the availability of lawful appropriations as required by State Finance Law § 41 and consistent with § 8 of the State Court of Claims Act, SDOH shall hold the Contractor harmless from and indemnify it for any final judgment of a court of competent jurisdiction to the extent attributable to the negligence of SDOH or its officers or employees when acting within the course and scope of their employment. Provisions concerning the SDOH's responsibility for any claims for liability as may arise during the term of this Agreement are set forth in the New York State Court of Claims Act, and any damages arising for such liability shall issue from the New York State Court of Claims Fund or any applicable, annual appropriation of the Legislature for the State of New York. |
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7.
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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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8.
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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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9.
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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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10.
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The attached Appendix
L, "Approved Capitation Payment Rates," is substituted for the period
beginning
January 1, 2008.
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All other
provisions of said AGREEMENT shall remain in full force and
effect.
Appendix
X
Medicaid
Advantage Contract Amendment
January 1,
2008
Page
3
IN
WITNESS WHEREOF, the parties hereto have executed or approved this AGREEMENT as
of the dates appearing under their signatures.
CONTRACTOR
SIGNATURE
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STATE
AGENCY SIGNATURE
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By: /s/ Xxxxx
Xxxxxxxxx
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By:
/s/ Xxxxxxxxx
Xxxxx
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Xxxxx
Xxxxxxxxx
(Print name)
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Xxxxxxxxx
Xxxxx___
(Print name)
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Title: President and
CEO
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Title:
Deputy Director,
DMC
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Date:
5/12/08
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Date:
6/3/08
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State
Agency Certification:
In
addition to the acceptance of this contract, I also certify that original
copies of this signature page will be attached to all other exact copies
of this contract.
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STATE OF
FLORIDA
County of
Hillsborough
On the
12th
day of May 20008, before me personally appeared Xxxxx Xxxxxxxxx, to me known,
who being by me duly sworn, did depose and say that he resides at Tampa,
Florida, that he is the President & CEO o WellCare of New York, Inc., the
corporation described herein which executed the foregoing instrument; and that
he/she signed his/her name thereto by order of the board of the directors of
said corporation.
/s/ Xxxx
Xxxxx
(Notary)
Approved:
/s/ Xxxxxxxx
Xxxx
ATTORNEY
GENERAL
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Approved:
/s/ name
illegible
Xxxxxx
X. XxXxxxxx
STATE
COMPTROLLER
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Title:
Associate Attorney
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Title:
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Date:
June 10, 2009
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Date:
June 17, 2008
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Appendix
X
Medicaid
Advantage Contract Amendment
January 1,
2008
Page
4
Appendix D
New York
State Department of Health
Medicaid
Advantage Marketing Guidelines
Medicaid
Advantage Contract Amendment
Appendix D
State January 1,
2008
D-1
MEDICAID
ADVANTAGE MARKETING GUIDELINES
I.
Purpose
The
purpose of these guidelines is to provide an operational framework for the
Medicaid managed care organizations (MCOs) in the development of marketing
materials and the conduct of marketing activities for the Medicaid Advantage
Program. The marketing guidelines set forth in this Appendix do not replace the
CMS marketing requirements for Medicare Advantage Plans; they supplement
them.
II. Marketing
Materials
A.
Definitions
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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:
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. SDOFI will inform
the LDSS and LDSS will inform the Contractor when the 5% threshold has
been reached. Marketing materials to be 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 Amendment
Appendix D
State January 1,
2008
D-2
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 for 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 LDSS 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 LDSS 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 Amendment
Appendix D
State January 1,
2008
D-3
5.
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Approved
marketing materials shall be kept on file in the offices of the
Contractor, the LDSS, 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 Amendment
Appendix D
State January 1,
2008
D-4
D. Medicaid Advantage Specific Marketing
Requirements
The requirements in Section D apply only if marketing activities for the
Medicaid Advantage Program are conducted pursuant to a Medicaid Advantage
marketing program in
which a dedicated staff of marketing representatives employed by the
Contractor or by an entity with which the Contractor has a subcontract are
engaged in marketing
activities with the sole purpose of enrolling recipients in the Contractor's
Medicaid Advantage product.
1.
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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 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 each LDSS in its
contracted service area 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.
|
Medicaid
Advantage Contract Amendment
Appendix D
State 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.
|
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. | ||
3. | Marketing in Emergency Rooms or Other Patient Care Areas | |
Contractors may not distribute materials or assist prospective Enrollees in completing Medicaid Advantage application forms in hospital emergency rooms, in provider offices, or other areas where health care is delivered unless requested by the individual. | ||
4. | Enrollment Incentives | |
Contractors may not offer incentives of any kind to Medicaid recipients to join Medicaid Advantage. Incentives are defined as any type of inducement whose receipt is contingent upon the recipients joining the Contractor's Medicaid Advantage product. |
E. General Marketing Restrictions
The following restrictions apply anytime the Contractor markets its Medicaid
Advantage product:
1. | Contractors are prohibited from misrepresenting the Medicaid program, the Medicaid Advantage Program or the policy requirements of the LDSS or SDOH. | |
2. | Contractors are prohibited from purchasing or otherwise acquiring or using mailing lists that specifically identify Medicaid recipients from third party vendors, including providers and LDSS offices, unless otherwise permitted by CMS. The Contractor may produce materials and cover their costs of mailing to Medicaid recipients if the mailing is carried out by the State or LDSS, without sharing specific Medicaid information with the Contractor. | |
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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 Amendment
Appendix D
State January 1,
2008
D-6
4. | Contractors may not require participating providers to distribute plan prepared communications to their patients, including communications which compare the benefits of different health plans, unless the materials have the concurrence of all MCOs involved, and have received prior approval by SDOH, and by CMS, if Medicare Advantage is referenced. | |
5. | Contractors are responsible for ensuring that their Marketing representatives engage in professional and courteous behavior in their interactions with LDSS staff, staff from other health plans and Medicaid clients. Examples of inappropriate behavior include interfering with other health plan presentations or talking negatively about another health plan. | |
6. | 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. | |
7. | 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.
|
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 Amendment
Appendix D
State January 1,
2008
D-7
|
d.
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Sign
on bonuses for Marketing Representatives are
prohibited;
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e.
|
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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j.
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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 LDSS.
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IV.
Marketing Infractions
A. 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, in consultation
with the LDSS, to protect the interests of the program and its
clients. These actions shall be taken by the SDOH in collaboration with the LDSS
and the CMS Regional
Office.
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1.
|
If
the Contractor or its representative commits a first time infraction of
marketing guidelines and the SDOH, in consultation with the LDSS, deems
the infraction to be minor or unintentional in nature, the SDOH and/or the
LDSS may issue a warning letter to the
Contractor.
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2.
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If
the Contractor engages in Marketing activities that the SDOH determines,
in its sole discretion, to be an intentional or serious breach of the
Medicaid Advantage Marketing Guidelines or the Contractor's approved
Medicaid Advantage Marketing Plan, or a pattern of minor breaches, SDOH,
in consultation with the LDSS, may require the Contractor to, and the
Contractor shall prepare and implement a corrective action plan acceptable
to the SDOH within a specified timeframe. In addition, or alternatively,
SDOH may impose sanctions, including monetary penalties, as permitted by
law.
|
Medicaid
Advantage Contract Amendment
Appendix D
State January 1,
2008
D-8
3.
|
If
the Contractor commits further infractions, fails to pay monetary
penalties within the specified timeframe, fails to implement a corrective
action plan in a timely manner or commits an egregious first time
infraction, the SDOH, in consultation with the LDSS, may in addition to
any other legal remedy available to the SDOH in law or
equity:
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|
a)
|
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)
|
suspend
new Medicaid Advantage Enrollments, for a period up to the remainder of
the Agreement period; or
|
c)
|
terminate
this Agreement pursuant to termination procedures described in Section 2.7
of this Agreement.
|
Medicaid
Advantage Contract Amendment
Appendix D
State January 1,
2008
D-9
APPENDIX H
New
York State Department of Health Guidelines for the
Processing
of Medicaid Advantage Enrollments and Disenrollments
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-1
State January 1, 2008
H-1
Appendix
H
SDOH
Guidelines
For
the Processing of Medicaid Advantage Enrollments and
Disenroliments
1. General
The
Contractor's Enrollment and Disenrollment procedures for Medicaid Advantage
shall be consistent with these requirements, except that to allow LDSS and the
Contractor flexibility in developing processes that will meet the needs of both
parties, the SDOH, 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. Enrollment
a)
SDOH Responsibilities:
|
i)
|
The
SDOH is responsible for monitoring Local District program activities and
providing technical assistance to the LDSS and the Contractor to ensure
compliance with the State's policies and
procedures.
|
|
ii)
|
SDOH reviews and
approves proposed Enrollment materials prior to the Contractor publishing
and disseminating or otherwise using the
materials.
|
b)
LDSS Responsibilities:
|
i)
|
The
LDSS has the primary responsibility for processing Medicaid Advantage
enrollments.
|
|
ii)
|
Each
LDSS determines Medicaid eligibility. To the extent practicable, the LDSS
will follow up with Enrollees when the Contractor provides documentation
of any change in status which may affect the Enrollee's Medicaid and/or
Medicaid Advantage eligibility.
|
iii)
|
LDSS
is responsible for providing pre-enrollment information on Medicaid
Advantage to Dually Eligible beneficiaries, consistent with Social
Services Law, Section 364-j (4)(e)(iv) and train persons providing
enrollment counseling to Eligible
Persons.
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-2
State 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. The transfer of enrollment information may be accomplished by
any of the
following:
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008 H-3 |
|
A)
|
LDSS
directly enters data into PCP Subsystem;
or
|
|
B)
|
LDSS
or Contractor submits a tape to the State, to be edited and entered into
PCP Subsystem; or
|
C)
|
LDSS
electronically transfers data via a dedicated line, from eMedNY to the PCP
Subsystem.
|
xiv)
|
Extensive
use of the secondary roster will be utilized to coordinate the Effective
Dates of Enrollment for Medicaid and Medicare
Advantage.
|
xv)
|
The
LDSS is responsible for prospectively re-enrolling an Enrollee who is
disenrolled from the Contractor's Medicaid Advantage Product due to loss
of Medicaid eligibility, who regains eligibility within three months, in
the Contractor's Medicaid Advantage Product, provided that the individual
remains enrolled in the Contractor's Medicare Advantage
Product.
|
xvi)
|
The
LDSS is responsible for processing new Enrollment applications to transfer
a member of the Contractor's Medicaid managed care product to the
Contractor's Medicaid Advantage Product if the Enrollee, upon gaining
Medicare eligibility, wishes to enroll in the Contractor's Medicaid
Advantage Product. To the extent possible, such Enrollments shall be made
effective the first day of the month that the Enrollee's Medicare
Advantage Coverage is
effective.
|
xvii)
|
The
LDSS is responsible for sending the following notices to Eligible
Persons:
|
|
A)
|
Enrollment
Confirmation Notice: This notice indicates the Effective Date of
Enrollment, the name of the Medicaid Advantage Product and the individual
who is being enrolled. This notice must also include a statement advising
the individual that if his/her Medicare Advantage enrollment is denied by
CMS, the individual's Medicaid Advantage Enrollment will be voided
retroactively back to the Effective Date of Enrollment. In such instances,
the individual may be responsible for the cost of any Medicaid Advantage
Benefit rendered during the retroactive period if the benefit was provided
by a non-Medicaid participating
provider.
|
|
B)
|
Notice
of Denial of Enrollment: This notice is used when an individual has been
determined by LDSS to be ineligible for enrollment into a Medicaid
Advantage Product. This notice must include fair hearing
rights.
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-4
State 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
State January 1, 2008
H-5
State 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 CIN, must convey that information in writing to the
LDSS.
|
|
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
State January 1, 2008
H-6
State 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
State January 1, 2008
H-7
State 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 Enrolhnent 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 2" 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 lst
and 2" Rosters (see Appendix H, page 7), adjusted to add Eligible
Persons enrolled by the LDSS after Roster production and to remove
individuals disenrolled by LDSS after Roster production (as notified to
the Contractor). In the cases of retroactive Disenrollments, the
Contractor is responsible for submitting an adjustment to void any
previously paid premiums for the period of retroactive Disenrollment,
where the Contractor was not at risk for the provision of Benefit Package
services. Payment of sub-capitation does not constitute "provision of
Benefit Package
services."
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-8
State 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 eligbile for Medicaid Advantage Enrollment. The LDSS
is responsibile for providing Enrollees with a notice of their right to
request a fair hearing.
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-9
State 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 not the 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
State January 1, 2008
H-10
State 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 Term Home Health Care Program (LTHHCP),
including
when an Enrollee is admitted to a hospital that 1) is certified by
Medicare as a
long-term
care hospital and 2) has an average length of stay for all patients
greater than
ninety-five
(95) days as reported in the Statewide Planning and Research
Cooperative
System
(SPARCS) Annual Report 2002.
|
·First day of
the month of entry or first day of the month of classification of the stay
as
permanent,
subsequent to entry (note-Contractor is at risk for covered services only
to
the
date of entry or classification of the stay as permanent subsequent to
entry, and is
entitled
to the capitation payment for the month of entry or classification of the
stay as
permanent
subsequent to entry).
|
·Individual
enrolled while ineligible for enrollment
|
·Effective Date
of Enrollment in the Contractor's Plan.
|
·Non-consensual
Enrollment
|
·Retroactive to
the first day of the month of Enrollment
|
·Enrollee moved
outside of the District/County of Fiscal Responsibility
|
·First day of
the month after the update of the system with the new
address*
|
·Urgent medical
need
|
·First day of
the next month after determination except where medical need requires
an
earlier
Disenrollment
|
·Homeless
Enrollees in Medicaid Advantage residing in the shelter system in
NYC
|
·Retroactive to
the first day of the month of the request
|
·An Enrollee
with more than one Client Identification Number (CIN) is enrolled in
the
Contractor's
Medicaid Advantage Product under more than one of the
CINs.
|
·First day of
the month the duplicate Enrollment
began.
|
*
In counties outside of New York City, LDSSs should work together to ensure
continuity of care through the Contractor if the Contractor's service area
includes the county to which the Enrollee has moved and the Enrollee, with
continuous eligibility, wishes to stay enrolled in the Contractor's plan.
In New York City, Enrollees, not in guaranteed status, who move out of the
Contractor's 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.
|
Medicaid
Advantage Contract
APPENDIX
H
State January 1, 2008
H-11
State January 1, 2008
H-11
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 AdvantageProduct. 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
State January 1, 2008
H-12
State 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 LDS S-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 forms may be faxed to the
LDSS with the hard copy to follow.
|
|
ii)
|
The
Contractor must accept and transmit all requests for voluntary
Disenrollments from its Enrollees to the LDSS, and shall not impose any
barriers to Disenrollment requests. The Contractor may require that a
Disenrollment request be in writing, contain the signature of the
Enrollee, and state the Enrollee's correct Contractor or Medicaid
identification number.
|
iii)
|
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
State January 1, 2008
H-13
State 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
State January 1, 2008
H-14
State January 1, 2008
H-14
APPENDIX
K
Medicare
and Medicaid Advantage Products
And
Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
K
State January 1, 2008
K-1
State January 1, 2008
K-1
APPENDIX
K
Appendix
K is organized into three parts:
I. Appendix
K-I
Medicare
Advantage Product
II. Appendix
K-2
Medicaid Advantage Product
Contractor/County
Election of Coverage for Optional Services Description of Medicaid Only Covered
Services
III. Appendix
K-3
Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
K
State January 1, 2008
K-2
State 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
State January 1, 2008
K-3
State 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 older. No co payment.
|
Immunizations
|
Flu,
hepatitis B vaccine for people who are at risk, Pneumonia vaccine. No
co-payment.
|
Mammograms
|
Annual
screening for women age 40 and older. No referral necessary. No
co-payment.
|
Pap
Smear and Pelvic Exams
|
Pap
smears and Pelvic Exams for women. No co-payment.
|
Prostate
Cancer Screening
|
Prostrate
Cancer Screening exams for men age 50 and older. No
co-payment.
|
Medicaid
Advantage Contract
APPENDIX
K
State January 1, 2008
K-4
State 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, earmolds, special fittings and replacement parts.
No co-payment or limitations.
|
Vision
Care Services
|
Services
of optometrists, ophthalmologists and ophthalmic dispensers including
eyeglasses, medically necessary contact lenses and poly-carbonate lenses,
artificial eyes (stock or custom-made), low vision aids and low vision
services. Coverage includes the replacement of lost or destroyed glasses
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 not
require changing more frequently than every two (2) years unless medically
necessary or unless the glasses are lost, damaged or destroyed. No
prerequisite of cataract services. No co-payment.
|
Routine
Physical Exam 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
State January 1, 2008
K-5
State 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
State January 1, 2008
K-6
State January 1, 2008
K-6
MCO
COVERAGE
OF
OPTIONAL SERVICES
MEDICAID
ADVANTAGE BENEFIT PACKAGE
MCO:
WellCare of New York,
Inc.
Service
Area
|
Medicaid
Advantage Coverage Status
|
|
Dental
Services
|
Non-Emergency
Transportation
|
|
Albany
|
Not
Covered
|
Not
Covered
|
Medicaid
Advantage Contract
APPENDIX
K
State January 1, 2008
K-7
State January 1, 2008
K-7
DESCRIPTION
OF MEDICAID ONLY SERVICES IN
MEDICAID
ADVANTAGE BENEFIT PACKAGE:
Inpatient
Mental Health Over 190-Day Lifetime Limit
All
inpatient mental health services, including voluntary or involuntary admissions
for mental health services over the Medicare 190-Day Lifetime Limit. The
Contractor may provide the covered benefit for medically necessary mental health
impatient services through hospitals licensed pursuant to Article 28 of the New
York State P.H.L.
Non-Medicare
Covered Home Health Services
Medicaid
covered home health services include the provision of skilled services not
covered by Medicare (e.g. physical therapist to supervise maintenance program
for patients who have reached their maximum restorative potential or nurse to
pre-fill syringes for disabled individuals with diabetes) and /or home health
aide services as required by an approved plan of care developed by a certified
home health agency.
Private
Duty Nursing Services
Private
duty nursing services provided by a person possessing a license and current
registration from the NYS Education Department to practice as a registered
professional nurse or licensed practical nurse. Private duty nursing services
can be provided through an approved certified home health agency, a licensed
home care agency, or a private Practitioner.
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
State January 1, 2008
K-8
State January 1, 2008
K-8
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
State January 1, 2008
K-9
State January 1, 2008
K-9
APPENDIX K3
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:
|
|
·
|
Intensive
Psychiatric Rehabilitation Treatment
Programs
|
|
·
|
Day
Treatment
|
|
·
|
Continuing
Day Treatment
|
|
·
|
Case
Management for Seriously and Persistently Mentally Ill (sponsored by state
or local mental health units)
|
|
·
|
Partial
Hospitalizations
|
|
·
|
Assertive
Community Treatment (ACT)
|
|
·
|
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
State January 1, 2008
K-10
State January 1, 2008
K-10
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
State January 1, 2008
K-11
State January 1, 2008
K-11
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
State January 1, 2008
K-12
State January 1, 2008
K-12
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)
8.
Non-Emergency Transportation (when not in benefit package)
Medicaid
Advantage Contract
APPENDIX
K
State January 1, 2008
K-13
State January 1, 2008
K-13
(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
State January 1, 2008
K-14
State January 1, 2008
K-14
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 determined 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
State January 1, 2008
K-15
State January 1, 2008
K-15
12.
Office of Mental Retardation and Developmental Disabilities (OM D)
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
State January 1, 2008
K-16
State January 1, 2008
K-16
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
State January 1, 2008
K-17
State January 1, 2008
K-17
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
COB Case Management
The HIV
COBRA (Community Follow-up Program) Case Management Prograrn 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
State January 1, 2008
K-18
State January 1, 2008
K-18
APPENDIX
L
Approved
Capitation Payment Rates
Medicaid
Advantage Contract
APPENDIX
L
State January 1, 2008
L1
State January 1, 2008
L1
WELLCARE
OF NEW YORK, INC.
Dual
Eligible Medicaid Managed Care Rates
MMIS
ID#:
|
02645710
|
Effective
Date: 01/01/08
|
Region:
|
Upstate
|
|
County:
|
Albany
|
Rate
Code
|
Premium Group
|
Rate Amount
|
2370
|
DUALLY
ELIGIBLE SSI 21-64 MALE/FEMALE
|
$35.37
|
2371
|
DUALLY
ELIGIBLE SSI 65+ MALE/FEMALE
|
$33.54
|
Optional Benefits
Offered:-
o
|
Dental
|
o
|
Non-Emergent
Transportation
|
Box
will be checked if the optional benefit is covered by the
plan