MEDICAID MANAGED CARE MODEL CONTRACT Amendment of Agreement Between City of New York And WellCare of New York, Inc.
Exhibit
10.1
Amendment
of Agreement
Between
City of
New York
And
WellCare
of New York, Inc.
This
Amendment, effective October 1, 2007 unless otherwise noted below, amends the
Medicaid Managed Care Model Contract (hereinafter referred to as the
"Agreement") made by and between the City of New York acting through the New
York City Department of Health and Mental Hygiene (hereinafter referred to as
"DOHMH" or "LDSS") and WellCare of New York, Inc. (hereinafter referred to as
"Contractor" or "MCO").
WHEREAS, the parties entered into an Agreement
effective October 1, 2005, amended April 1, 2006, January 1, 2007, and April 1,
2007 for the purpose of providing prepaid case managed health services to
Medical Assistance recipients residing in New York City; and
WHEREAS, the parties desire to amend said
Agreement to modify certain provisions to reflect current circumstances and
intentions;
NOW THEREFORE, effective October 1, 2007 unless
otherwise noted below, it is mutually agreed by the parties to amend this
Agreement as follows:
1. Amend Section 11.5
"Corrective and Remedial Actions" to read as follows:
11.5 Corrective
and Remedial Actions
a) If the
Contractor's Marketing activities do not comply with the Marketing Guidelines
set forth in Appendix D of this Agreement or the Contractor's approved Marketing
plan, the SDOH and/or the DOHMH may take any of the actions described in (i),
(ii) and (iii) below to protect the interests of Enrollees and the integrity of
the MMC and FHPlus Programs. The Contractor shall take the corrective and
remedial actions directed by the SDOH and/or DOHMH within the specified
timeframes.
i) If the
Contractor or its representative commits a first time infraction of the
Marketing Guidelines and/or the Contractor's approved Marketing plan, and the
SDOH and/or the DOHMH deem the infraction to be minor or unintentional in
nature, the SDOH and/or the DOHMH may issue a warning letter to the
Contractor.
ii) If
the Contractor engages in Marketing activities that SDOH and/or DOHMH
determines, in its sole discretion, to be an intentional or serious breach of
the Marketing Guidelines or the Contractor's approved Marketing plan, or a
pattern of minor breaches, SDOH and/or the DOHMH may require the Contractor to,
and the Contractor shall, prepare and implement a corrective action plan
acceptable to SDOH and/or DOHMH within a specified timeframe. In addition, or
alternatively, SDOH and the DOHMH, in consultation with SDOH, may impose
sanctions, including monetary penalties, as permitted by
law.
iii) If
the Contractor commits further infractions, fails to pay monetary penalties
within the specified timeframe, fails to implement a corrective
action plan in a
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1, 2007 Amendment
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timely
manner or commits an egregious first-time infraction, the SDOH, or DOHMH in
consultation with the SDOH, may in addition to any other legal remedy available
to SDOH and/or DOHMH in law or equity:
A) direct
the Contractor to suspend its Marketing activities for a period up to the end of
the Agreement period;
B) suspend
new Enrollments, other than newborns, 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.
b) The
corrective and remedial actions described in Section 11.5 a) apply to violations
of the reporting requirements in Section 18.5 a) xiii).
2. Amend Section 18.5
"Reporting Requirements" to read as follows:
18.5 Reporting
Requirements
a) The
Contractor shall submit the following reports to SDOH (unless otherwise
specified). The Contractor will certify the data submitted pursuant to this
section as required by SDOH. The certification shall be in the manner and format
established by SDOH and must attest, based on best knowledge, information, and
belief to the accuracy, completeness and truthfulness of the data being
submitted.
i) Annual
Financial Statements:
Contractor
shall submit Annual Financial Statements to SDOH. The due date for annual
statements shall be April 1 following the report closing
date.
ii) Quarterly
Financial Statements:
Contractor
shall submit Quarterly Financial Statements to SDOH. The due date for quarterly
reports shall be forty-five (45) days after the end of the calendar
quarter.
iii)
Other Financial Reports:
Contractor
shall submit financial reports, including certified annual financial statements,
and make available documents relevant to its financial condition to SDOH and the
State Insurance Department (SID) in a timely manner as required by State laws
and regulations, including but not limited to PHL §§ 4403-a, 4404 and 4409,
Title 10 NYCRR Part 98, and applicable SIL §§ 304, 305, 306, and 310. The SDOH
may require the Contractor to submit such relevant financial reports and
documents related to its financial condition to the DOHMH.
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1, 2007 Amendment
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iv)
Encounter Data:
The
Contractor shall prepare and submit encounter data on a monthly basis to SDOH
through SDOH's designated Fiscal Agent. Each provider is required to have a
unique identifier. Submissions shall be comprised of encounter records or
adjustments to previously submitted records, which the Contractor has received
and processed from provider encounter or claim records of all contracted
services rendered to the Enrollee in the current or any preceding months.
Monthly submissions must be received by the Fiscal Agent in accordance with the
time frames specified in the MEDS II data dictionary on the HPN to assure the
submission is included in the Fiscal Agent's monthly production
processing.
v) Quality
of Care Performance Measures:
The
Contractor shall prepare and submit reports to SDOH, as specified in the Quality
Assurance Reporting Requirements (QARR). The Contractor must arrange for an
NCQA-certified entity to audit the QARR data prior to its submission to the SDOH
unless this requirement is specifically waived by the SDOH. The SDOH will select
the measures which will be audited.
vi)
Complaint and Action Appeal Reports:
A) The
Contractor must provide the SDOH on a quarterly basis, and within fifteen (15)
business days of the close of the quarter, a summary of all Complaints and
Action Appeals subject to PHL § 4408-a received during the preceding quarter via
the Summary Complaint Form on the HPN. The Summary Complaint Form has been
developed by the SDOH to categorize the type of Complaints and Action Appeals
subject to PHL § 4408-a received by the Contractor.
B) The
Contractor agrees to provide on a quarterly basis, via Summary Complaint Form on
the HPN, the total number of Complaints and Action Appeals subject to PHL §
4408-a that have been unresolved for more than forty-five (45) days. The
Contractor shall maintain records on these and other Complaints, Complaint
Appeals and Action Appeals pursuant to Appendix F of this Agreement. These
records shall be readily available for review by the SDOH and DOHMH upon
request.
C) Nothing
in this Section is intended to limit the right of the DOHMH, the SDOH or its
designee to obtain information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider Complaint, Complaint Appeal or
Action Appeal.
vii)
Fraud and Abuse Reporting Requirements:
A) The
Contractor must submit quarterly, via the HPN Complaint reporting format, the
number of Complaints of fraud or abuse made to the Contractor that warrant
preliminary investigation by the Contractor.
B) The
Contractor also must submit to the SDOH the following information on an ongoing
basis for each confirmed case of fraud and abuse it identifies through
Complaints, organizational monitoring, contractors, subcontractors, providers,
beneficiaries, Enrollees, or any other source:
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1, 2007 Amendment
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I) The name
of the individual or entity that committed the fraud or
abuse;
II) The
source that identified the fraud or abuse;
III) The type
of provider, entity or organization that committed the fraud or
abuse;
IV) A
description of the fraud or abuse;
V) The
approximate dollar amount of the fraud or abuse;
VI) The legal
and administrative disposition of the case, if available, including actions
taken by law enforcement officials to whom the case has been referred;
and
VII) Other
data/information as prescribed by SDOH.
C) Such
report shall be submitted when cases of fraud and abuse are confirmed, and shall
be reviewed and signed by an executive officer of the
Contractor.
viii)
Participating Provider Network Reports:
The
Contractor shall submit electronically to the HPN an updated provider network
report on a quarterly basis. The Contractor shall submit an annual notarized
attestation that the providers listed in each submission have executed an
agreement with the Contractor to serve Contractor's MMC and/or FHPlus Enrollees,
as applicable. The report submission must comply with the Managed Care Provider
Network Data Dictionary. Networks must be reported separately for each county in
which the Contractor operates.
ix)
Appointment Availability/Twenty-four (24) Hour Access and Availability
Surveys:
The
Contractor will conduct a county specific (or service area if appropriate)
review of appointment availability and twenty-four (24) hour access and
availability surveys annually. Results of such surveys must be kept on file and
be readily available for review by the SDOH or DOHMH, upon
request.
x) Clinical
Studies:
A) The
Contractor will participate in up to four (4) SDOH sponsored focused clinical
studies annually. The purpose of these studies will be to promote quality
improvement.
B) The
Contractor is required to conduct at least one (1) internal performance
improvement project each year in a priority topic area of its choosing with the
mutual agreement of the SDOH and SDOH's external quality review organization.
The Contractor may conduct its performance improvement project in conjunction
with one or more MCOs. The purpose of these projects will be to promote quality
improvement within the Contractor's MMC and/or FHPlus product. SDOH will provide
guidelines which address study structure and reporting format. Written reports
of these projects will be provided to the SDOH and validated by the external
quality review organization.
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1, 2007 Amendment
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xi)
Independent Audits:
The
Contractor must submit copies of all certified financial statements and QARR
validation audits by auditors independent of the Contractor to the SDOH within
thirty (30) days of receipt by the Contractor.
xii) New
Enrollee Health Screening Completion Report:
The
Contractor shall submit a quarterly report within thirty (30) days of the close
of the quarter showing the percentage of new Enrollees for which the Contractor
was able to complete a health screening consistent with Section 13.6(a)(ii) of
this Agreement.
xiii)
Marketing and Facilitated Enroller Staffing Reports:
The
Contractor shall submit a monthly staffing report during the last fifteen (15)
calendar days of each month showing the number of full-time equivalents (FTEs)
employed or funded for purposes of marketing, facilitated enrollment, and/or
community outreach designed to develop enrollment opportunities or present
coverage options for the Medicaid, Family Health Plus, Child Health Plus, and
solely for Medicaid Advantage and/or Medicaid Advantage Plus
programs.
xiv)
Additional Reports:
Upon
request by the SDOH, or as specified by DOHMH in Appendix N, the Contractor
shall prepare and submit other operational data reports. Such requests will be
limited to situations in which the desired data is considered essential and
cannot be obtained through existing Contractor reports. Whenever possible, the
Contractor will be provided with ninety (90) days notice and the opportunity to
discuss and comment on the proposed requirements before work is begun. However,
the SDOH reserves the right to give thirty (30) days notice in circumstances
where time is of the essence.
3. Amend Section 21.21
"Federally Qualified Health Centers (FOHCs)" to read as
follows:
21.21 Federally
Qualified Health Centers (FQHCs)
a) In a
county where Enrollment in the Contractor's MMC product is voluntary, the
Contractor is not required to contract with FQHCs. However, when an FQHC is a
Participating Provider of the Contractor network, the Provider Agreement must
include a provision whereby the Contractor agrees to compensate the FQHC for
services provided to Enrollees at a payment rate that is not less than the level
and amount that the Contractor would pay another Participating Provider that is
not an FQHC for a similar set of services.
b) In a
county where Enrollment in the Contractor's MMC product is mandatory and/or the
Contractor offers an FHPlus product, the Contractor shall contract with FQHCs
operating in that county. The contract with the FQHC must be between the
Contractor and the FQHC clinic, not between the Contractor and an individual
practitioner at the clinic.
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1, 2007 Amendment
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c) The
Department may on a case-by-case basis defer the contracting requirement if it
determines
there is sufficient access to FQHC services in a county. The Department reserves
the right to rescind the deferment at any time should access to FQHC services in
the county change.
d) When
an MCO does not contract with an FQHC, but another MCO in the county
contracts
with an FQHC, marketing and educational materials must inform Potential
Enrollees and Enrollees about the availability of FQHC services. These materials
should also advise Potential Enrollees and Enrollees that they have good cause
to disenroll from an MCO when the MCO does not contract with an FQHC and another
MCO in the county contracts with an FQHC or is an FQHC sponsored
MCO.
4. 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.
5. Amend Appendix
D "New York State Department of Health Marketing Guidelines," Section D.3,
3. c) to add
paragraph iv) to read as follows:
c) The
Contractor shall not offer compensation to Marketing Representatives, including
salary increases or bonuses, based solely on the number of individuals they
enroll. However, the Contractor may base compensation of 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:
i)
"Compensation" shall mean any remuneration required to be reported as income or
compensation for federal tax purposes;
ii) The
Contractor may not pay a "commission" or fixed amount per
enrollment;
iii) 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;
iv)
Sign-on bonuses for Marketing Representatives are prohibited;
6. Effective
January 1. 2008, amend Appendix D "New York State Department of Health Marketing
Guidelines,"
Section D.3, 3. c) to add paragraphs v), vi), vii) viii), and ix) to read as
follows:
v) 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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1, 2007 Amendment
6
vi) 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;
vii) The
Contractor is prohibited from reducing base salaries for Marketing
Representatives for failure to meet productivity targets;
viii) The
Contractor is prohibited from offering non-monetary compensation such as gifts
and trips to Marketing Representatives;
ix) The
Contractor shall have human resources policies and procedures for the earning
and payment of overtime and must be able to provide documentation (such as time
sheets) to support overtime compensation.
7. Amend Appendix D "New
York State Department of Health Marketing Guidelines," Section
D.3,3. to add paragraph e) to read
as follows:
The
Contractor shall limit the staffing (FTEs) involved in the marketing/facilitated
enrollment process. The limit shall be set at 150 FTEs for New York City, 75 for
MCOs that serve county service areas outside New York City, and 225 for MCOs
that serve both, with no more than 150 operating in New York City. FTEs subject
to the limit include Marketing Representatives, Facilitated Enrollers and any
other staff that conduct new enrollments, provide community presentations on
coverage options and/or engage in outreach activities designed to develop
enrollment leads. Managers are not included in the limit as long as they do not
personally conduct enrollments. Retention staff are not subject to the
limit.
8. Amend Appendix
D "New York State Department of Health Marketing Guidelines," Section D.3,
4. a) to add
paragraph v) to read as follows:
The
Contractor shall not engage in the following practices:
i)
misrepresenting the Medicaid fee-for-service, MMC Program or FHPlus Program, or
the program or policy requirements of the LDSS or the SDOH, in Marketing
encounters or materials;
ii)
purchasing or otherwise acquiring or using mailing lists of Eligible Persons
from third party vendors, including providers and LDSS
offices;
iii)
using raffle tickets or event attendance or sign-in sheets to develop mailing
lists of Prospective Enrollees;
iv)
offering incentives (i.e., any type of inducement whose receipt is contingent
upon the individual's Enrollment) of any kind to Prospective Enrollees to enroll
in the Contractor's MMC or FHPlus product;
v)
marketing 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. If
the individual voluntarily suggests
October
1, 2007 Amendment
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dissatisfaction
with the health plan in which he or she is enrolled, the individual should be
referred to the enrollment broker or LDSS for assistance.
9. Amend Appendix G "SDOH
Requirements for the Provision of Emergency Care and Services,"
Section 5 to read as
follows:
5. Emergency
Transportation
When
emergency transportation is included in the Contractor's Benefit Package, the
Contractor shall reimburse the transportation provider for all emergency
ambulance services, without regard to final diagnosis or prudent layperson
standards. Payment by the Contractor for emergency transportation services
provided to an Enrollee by a Participating Provider shall be at the rate or
rates of payment specified in the contract between the Contractor and the
transportation provider. Payment by the Contractor for emergency transportation
services provided to an Enrollee by a Non-Participating Provider shall be at the
Medicaid fee-for-service rate in effect on the date the service was
rendered.
10.
Amend paragraph K and
add paragraph L of Section 6 (a) (V) of Appendix H. "New York State
Department of Health
Requirements for the Processing of Enrollments and Disenrollments in the
MMC and FHPlus Programs," to
read as follows:
K) An
FHPlus Enrollee is pregnant; or
L) The
Contractor does not contract with an FQHC and one or more other MCOs in the
Enrollee's county of fiscal responsibility provide the
service.
11. The attached Appendix N "New
York City Specific Contracting Requirements" is applicable for
the period beginning October
1, 2007.
All other
provisions of said AGREEMENT shall remain in full force and
effect.
October
1, 2007 Amendment
8
This
Amendment is effective October 1, 2007 unless otherwise noted above and the
Agreement, including the modifications made by this Amendment and previous
Amendments, shall remain in effect until September 30, 2009 or until an
extension, renewal or successor Agreement is entered into as provided for in the
Agreement.
IN
WITNESS WHEREOF, the parties have duly executed this Amendment to the Agreement
on the dates appearing below their respective signatures.
|
CONTRACTOR
|
CITY
OF NEW YORK
|
|
By: /s/ Xxxxx
Xxxxxxxxx
(Signature)
|
By: /s/ Xxxxxx
Xxxx
(Signature)
|
|
Xxxxx
Xxxxxxxxx
(Printed
Name)
|
Xxxxxx X. Xxxx
(Printed
Name)
|
|
Title:
President &
CEO
WellCare of New York,
Inc.
(Contractor name)
|
Title:
Chief Operating
Officer/
Executive
Deputy Commissioner
(NYC
DOHMH)
|
|
|
|
|
Date:
2/12/08
|
Date:
3/11/08
|
October
1, 2007 Amendment
0
XXXXX XX
XXXXXXX
XXXXXX XX
XXXXXXXXXXXX
Xx this 12th day of
February, 2008, Xxxxx Xxxxxxxxx came before me, to me known and known to be the
President & CEO of WellCare of New York, Inc., who is duly authorized to
execute the foregoing instrument on behalf of said corporation and he
acknowledged to me that he executed the same for the purposed therein
mentioned.
/s/ Xxxx Xxxxx
Notary
Public
XXXXX XX
XXX XXXX
XXXXXX XX
XXX XXXX
Xx
this 11 day of March, 2008, Xxxxxx Xxxx came before me, to me known and
known to be the COO/ Executive Deputy Commissioner in the New York
City Department of Health and Mental Hygiene, who is duly authorized to execute
the foregoing instrument on behalf of the City and he acknowledged to me that he
executed the same for the purpose therein mentioned.
/s/ Xxxxx
Xxxx
Notary Public
Appendix
N
New
York City Specific Contracting Requirements
APPENDIX
N
October
1, 0000
X-x
Xxxxxxxx
X
Xxx
Xxxx Xxxx Specific Contracting Requirements
1. General
a) In New
York City, the Contractor will comply with all provisions of the main body and
other Appendices of this Agreement, except as otherwise expressly established in
this Appendix.
b) This
Appendix sets forth New York City Specific Contracting Requirements and contains
the following sections:
N. 1
Compensation for Public Health Services
N.2
Coordination with DOHMH on Public Health Initiatives
N.3
Benefits
N.4
Additional Reporting Requirements
N.5
Quality Management
N.6 New
York City Additional Marketing Guidelines
N.7Member
Services and Member Retention
N.8 Guidelines for Processing Enrollments
and Disenrollments in Xxx Xxxx Xxxx
X.0 Xxx
Xxxx Xxxx Transportation Policy Guidelines
Schedule
1 DOHMH Public Health Services Fee Schedule
APPENDIX
N
October
1,2007
N-2
N.l
Compensation
for Public Health Services
1. The
Contractor shall reimburse DOHMH at the rates contained in Schedule 1 of this
Appendix for Enrollees who receive the following services from DOHMH facilities,
except in those instances where DOHMH may xxxx Medicaid
fee-for-service.
a) Diagnosis
and/or treatment of TB
b) HIV
counseling and testing that is not part of an STD or TB visit
c) Adult and
child immunizations
d) Dental
services
e) STD lab
test(s)
2.
Notwithstanding Sections 10.18 (a) (ii) (C) and (b) (ii)(C) of this Agreement,
the following requirements concerning Contractor notification and documentation
of services shall apply in New York City:
a) DOHMH
shall confirm the Enrollee's membership in the Contractor's MMC product on the
date of service through EMEDNY prior to billing for these
services.
b) DOHMH
must submit claims for services provided to Enrollees no later than one year
from the date of service.
c) The
Contractor shall not require pre-authorization, notification to the Contractor
or contacts with the PCP for the above mentioned services.
d) DOHMH
shall make reasonable efforts to notify the Contractor that it has provided the
above mentioned services to an Enrollee.
APPENDIX
N
October
1,2007
N-3
N.2
Coordination
with DOHMH on Public Health Initiatives
1.
Coordination with DOHMH
a) The
Contractor shall provide the DOHMH with existing information requested by DOHMH
to conduct epidemiological investigations.
2.
Provider Reporting Obligations
a) The
Contractor shall make reasonable efforts to assure timely and accurate
compliance by Participating Providers with public health reporting requirements
relating to communicable disease and conditions mandated in the New York City
Health Code pursuant to 24 RCNY §§ 11.03 -11.07 and Article 21 of the NYS Public
Health Law.
b) The
Contractor shall make reasonable efforts to assure timely and accurate
compliance by Participating Providers with other mandated reporting
requirements, including the following:
i) Infants
and toddlers suspected of having a developmental delay or
disability;
ii)
Suspected instances of child abuse;
iii)
Immunization (reporting to immunization registry); and
iv)
Additional reporting requirements adopted by the New York City Health
Code
c)
"Reasonable efforts" shall include:
i) For
mandated reporting requirements described in paragraphs (2)(a) and (2)(b)
above:
A) Educating
Participating Providers on treatment guidelines and instructions for reporting
included in the NYC DOHMH Compendium of Public Health
Requirements and Recommendations.
B) Including
reporting requirements in the Contractor's provider manual or other written
instructions or guidelines.
ii) For
mandated reporting requirements described in paragraph (2)(a) above:
..
A) Letters
from the Contractor to Participating Providers who generated claims that suggest
that an Enrollee may have a reportable disease or condition, encouraging such
providers to report and providing information on how to
report.
B) Other
methods for follow up with Participating Providers, subject to DOHMH approval,
may be employed.
APPENDIX
N
October
1,2007
N-4
3. Matching
to Registries
a) The
Contactor shall participate in matches of its Enrollees to the DOHMH
immunization
and lead registries through submission of files in formats specified by DOHMH
Immunization and Lead Poisoning Prevention Programs.
i) Matches
to the Citywide Immunization Registry shall occur, at a minimum, twice a year,
in April and October, but may occur more frequently at the Contractor's
discretion. The file matches which occur in April and October will include all
children aged 9 through 36 months who are enrolled in the Contractor's MMC
Product at the time of the match, regardless of the children's length of
Enrollment in the Contractor's MMC Product. Additional file matches, done at the
discretion of the Contractor, may include any group of children currently
enrolled in the Contractor's MMC Product at the time of the match and may be
done at any time of year.
ii)
Matches to the Citywide Immunization Registry for adolescents shall occur once a
year at a minimum in July, but may occur more frequently at the Contractor's
discretion. The file matches will include adolescents who turn 12 years old in
the year of the match and those 12 through 18 years old who are enrolled in the
Contractor's MMC Product at the time of the match, regardless of the
adolescent's length of Enrollment in the Contractor's MMC Product. Additional
file matches, done at the discretion of the Contractor, may include any group of
adolescents currently enrolled in the Contractor's MMC Product at the time of
the match and may be done at any time of year.
iii)
Matches to the City Lead Registry shall occur at least twice a year, but may
occur more frequently as agreed by both the Contractor and the DOHMH Lead
Poisoning Prevention Program. Files for these matches shall be submitted in
February and September, and will include all children 9 to 36 months of age who
are enrolled in the Contractor's MMC Product at the time of the match,
regardless of the children's length of Enrollment in the Contractor's MMC
Product.
The
Contractor shall report back to DOHMH in those instances where DOHMH has
identified a child as not tested but the Contractor subsequently determines the
child has been tested.
b) Formats
for reports from the DOHMH to the Contractor based on these matches shall be
developed by the DOHMH upon thirty days written notice to the
Contractor.
c) The
Contractor will follow up with Participating Providers of Enrollees and
Enrollees who have not been appropriately immunized or screened for lead
poisoning to facilitate provision of appropriate services. Results of the
Contractor's follow- up efforts (the percent of children initially identified as
lacking immunization and or lead screening who subsequently received these
services) shall be submitted to the DOHMH six months after receipt of the DOHMH
report on children needing
APPENDIX
N
October
1,2007
N-5
services,
in a format developed by DOHMH upon thirty days written notice to the
Contractor.
d) The
following provisions regarding confidentiality shall apply:
i)
Consistent with the New York City Health Code §11.07 (c) and (d), the Contractor
and DOHMH shall keep confidential all identifying information provided by the
DOHMH and not further disclose to any other person or entity such identifying
information unless compelled by law to disclose such identifying information,
except as provided in provided in paragraph 3(c) above.
ii) The
Contractor shall notify the DOHMH Office of General Counsel for Health in
writing, of the receipt of any document seeking disclosure of identifying
information that is not accompanied by a written consent from the parent or
guardian of an Enrollee authorizing the disclosure of such identifying
information as follows:
A) Such
notice shall be given not later than five days prior to the date on which a
disclosure is required by a subpoena, court order or other document, and shall
attach a copy of the document requesting identifying
information.
B) If a
subpoena, court order or other document requests disclosure to be made within
five days or less after its receipt by the Contractor, the Contractor shall
provide DOHMH with such notice as far in advance of the disclosure date as
possible, but in no circumstance shall the Contractor make such disclosure
without prior notice to the DOHMH.
C) The
Contractor acknowledges that DOHMH may elect to seek a court order prohibiting
the disclosure of identifying information when it deems it appropriate to do so,
and consents to DOHMH's intervention in any proceeding, including, but not
limited to any judicial proceeding, that seeks the disclosure of identifying
information.
4. Enrollee
Outreach/Education
a) The
Contractor shall provide health education to Enrollees on an on-going basis
through methods such as distribution of Enrollee newsletters, health education
classes or individual counseling on preventive health and public health topics.
Each topic below shall be covered at least once every two
years.
i) HIV/AIDS
A) Encourage
Enrollee counseling and testing
B) Inform
Enrollees as to availability of sterile needles and syringes
ii) STDs
A) Inform
Enrollees that confidential STD services are available at DOHMH facilities for
non-enrolled sexual and needle-sharing partners at no charge
iii) Lead
poisoning prevention
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iv) Maternal
and child health, including importance of developmental screening for
children
v) Injury
prevention, including age appropriate anticipatory guidance
vi) Domestic
violence
vii)Smoking
cessation
viii) Asthma
ix) Immunization
x) Mental
health services
xi) Diabetes
xii)
Family planning
xiii) Screening
for Cancer
xiv) Chemical
Dependence
xv) Physical
fitness and nutrition
xvi)
Cardiovascular disease and hypertension
5. Provider
Education
a) DOHMH
shall prepare a public health compendium ("Compendium") with public health
guidelines, protocols, and recommendations which it shall make available
directly to Participating Providers and to the
Contractor.
b) The
Contractor shall adapt public health guidance from the Compendium for its
internal protocols, practice manuals and guidelines.
c) The
Contractor will assist DOHMH in its efforts to disseminate electronic materials
to its Participating Providers by providing electronic addresses if known by
Contractor (fax and/or e-mail) for its Participating Providers, updated semi-
annually.
d) The
Contractor shall promote the use of rapid HIV testing among its Participating
Providers.
6. MCO
Staff Responsibilities and Training
a) Early
Intervention Services
i) The
Contractor shall ensure that appropriate MCO staff, such as member services
staff and case managers are knowledgeable about early intervention services and
provide technical assistance and consultation to Enrollees concerning early
intervention services (including eligibility, referral process and coordination
of services).
b) Domestic
Violence
i) The
Contractor shall designate a domestic violence coordinator who
can:
A)
Provide technical assistance to Participating Providers in documenting cases of
domestic violence;
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B) Provide
referrals to Enrollees or their Participating Providers, to obtain protective,
legal and or supportive social services; and
C) Provide
consultative assistance to other staff within the Contractor's
organization.
ii) The
Contractor shall distribute a directory of resources for victims of domestic
violence to appropriate staff, such as member services staff or case
managers.
7.
Medical Directors
a) The
Contractor's Medical Director shall participate in Medical Directors' Meetings
with the medical directors of the other MCOs participating in the MMC Program in
New York City and representatives of the New York City Department of Health and
Mental Hygiene. The purpose of the Medical Directors' Meetings shall be to share
public health information and data; recommend that certain public health
information be disseminated by the MCOs to their Participating Providers;
discuss public health strategies and outreach efforts and potential
collaborative projects; encourage the development of MCO policies that support
public health strategies; and provide a vehicle for communication between the
MCOs participating in the MMC Program and the various bureaus and divisions of
the NYC Department of Health and Mental Hygiene.
b) The
Contractor's Medical Director shall attend all periodic meetings, which shall
not exceed one every two months. In the event that the Medical Director is
unable to attend a particular meeting, the Contractor will designate an
appropriate substitute to attend the meeting.
c) DOHMH,
following consultation with the Medical Directors, may create workgroups on
particular public health topics. The Contractor's Medical Director may
participate in any or all of the workgroups, but shall participate in at least
one of the designated workgroups.
8.
Take Care New York
a) The
Contractor shall:
i) Educate
Enrollees regarding prevention and treatment of diseases and conditions included
in the Take Care New York initiative (TCNY);
ii)
Disseminate TCNY health passports or materials containing similar content
approved by DOHMH to Enrollees;
iii)
Disseminate reminders to obtain recommended health screenings at age appropriate
intervals to Enrollees; and
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iv)
Educate Participating Providers on recommended clinical guidelines regarding
prevention and treatment/management of diseases and conditions described in the
TCNY initiative.
b) The
Contractor shall select one condition during the contract term from the TCNY
initiative and perform the following:
i) Identify
Enrollees with the condition using information from multiple sources (e.g.,
utilization data, including hospitalizations and ER visits; provider referrals;
new Enrollee screenings using tools consistent with standard medical practice;
self-referrals by Enrollees)
ii)
Develop and submit to DOHMH for approval a proposal to improve receipt of
preventive services for such condition. Proposals will include establishment of
a baseline of current utilization rates using, where appropriate, screening
tools approved by the Department; implementation of a program to improve
delivery and or/receipt of services; and an evaluation of program effectiveness
using process and outcome indicators approved by the Department. Studies based
on these proposals shall be completed within the contract term with interim
progress reports submitted to DOHMH in accordance with a schedule established by
DOHMH.
c) The
Contractor shall, upon request by DOHMH, participate in one or more TCNY
workgroups or other activities sponsored by the DOHMH.
9.
Participation in DOHMH public health detailing campaigns
a) The
Contractor shall participate in a minimum of 4 DOHMH public health detailing
campaigns
(e.g. depression screening, colonoscopy) in high-need neighborhoods designated
by DOHMH including the South Bronx, East and Central Harlem, and North and
Central Brooklyn by providing DOHMH with a list of affiliated network providers
that would benefit from such detailing and a description of the criteria used to
select these providers.
b) For
one detailing campaign selected by the Contractor, the Contractor shall
collaborate
with the Department in an evaluation of the impact of that detailing on
provider
practice in the detailed neighborhood.
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N.3
Benefits
1.
Transitional Home Health Services Pending Placement in Personal Care Agency
Services
a) Transitional
home health services are home health services as defined in Appendix K
of this
Agreement provided by the Contractor to an MMC Enrollee while the Human
Resources Administration's determination regarding a request for the provision
of personal care agency services to the Enrollee is pending. Transitional home
health services are available to MMC Enrollees in addition to the home health
care services otherwise covered under the Benefit Package as medically
necessary.
b) The
Contractor shall be responsible for providing transitional home health services
to MMC Enrollees for up to a thirty (30) day period.
c) For MMC
Enrollees discharged from a hospital or RHCF and for whom personal care agency
services have been requested by the hospital/RHCF discharge planner, the thirty
(30) day period shall commence with the day following the MMC Enrollee's
discharge from the hospital or RHCF.
d) For MMC
Enrollees who have been receiving home health care services in the community and
for whom personal care agency services have been ordered by the Enrollee's
physician, the thirty (30) day period shall commence with the day following the
last day that the Contractor approved home health care services to be medically
necessary.
e) Transitional
home health services shall not be available if the MMC Enrollee was in receipt
of personal care agency services prior to his/her admission to a hospital or
RHCF and both of the following circumstances exist:
1) The MMC
Enrollee was in a hospital and/or RHCF for a cumulative total of fewer than
thirty (30) consecutive days; and
2) The MMC
Enrollee requires the same level and hours of personal care agency services upon
discharge.
f) The
Contractor shall provide reasonable assistance as requested regarding the
completion
of forms required by the Human Resources Administration to initiate the review
of a request for personal care agency services. Such form, commonly referred to
as the Ml 1Q, requires physician orders, signed by the licensed physician, to be
received by HRA within thirty (30) calendar days of the physician's
examination.
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N.4
Additional
Reporting Requirements
1. DOHMH,
will provide Contractor with instructions for submitting the reports required by
paragraphs 4(c) and (d) below. These instructions shall include time frames, and
requisite formats. The instructions, time frames and formats may be modified by
DOHMH upon sixty (60) days written notice to the Contractor.
2. The
Contractor shall submit reports that are required to be submitted to DOHMH by
this Agreement electronically.
3. The
Contractor shall pay liquidated damages of $500 to DOHMH for any report required
by paragraphs 4(c) and (d) below which is materially incomplete, contains
material misstatements or inaccurate information or is not submitted on time in
the requested format. The DOHMH shall not impose liquidated damages for a first
time infraction by the Contractor unless DOHMH deems the infraction to be a
material misrepresentation of fact or the Contractor fails to cure the first
infraction within a reasonable period of time upon notice from the DOHMH.
Liquidated damages may be waived at the sole discretion of
DOHMH.
4. The
Contractor shall submit the following reports to DOHMH:
a) The
Contractor shall provide DOHMH with all reports submitted to SDOH pursuant to
Sections 18.5(a)(i), (ii), (vi), (vii), and (xii) of this
Agreement.
b) Upon
request by DOHMH, the Contractor shall submit to DOHMH reports submitted to SDOH
pursuant to Section 18.5(a)(iii); and Section 18.5(xi) and/or Section 23.2 of
this Agreement.
c) To meet
the appointment availability review requirements of Section 18.5(a)(ix), the
Contractor shall conduct a service area specific review of appointment
availability for two specialist types, to be determined by DOHMH, semi-annually.
Reports on the results of such surveys must be kept on file by the Contractor
and be readily available for review by SDOH and DOHMH, and submitted to the
DOHMH
d) Upon
request by the DOHMH, the Contractor shall prepare and submit other operational
data reports. Such requests will be limited to situations in which the desired
data is considered essential and cannot be obtained through existing Contractor
reports. Whenever possible, the Contractor will be provided with ninety (90)
days notice and the opportunity to discuss and comment on the proposed
requirements before work is begun. However, the DOHMH reserves the right to give
thirty (30) days notice in circumstances where time is of the
essence.
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N.5
Quality
Management
1. The
Contractor's quality management program, as approved by SDOH, must be kept on
file with the DOHMH. The Contractor shall notify the DOHMH when it modifies its
quality management program.
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Xxxx Xxxx Additional Marketing Guidelines
1. Prior
Approvals
a)
Definitions
i)
"Marketing materials" shall mean all materials, including but not limited to
letters, notices, print advertising, broadcast media, posters, billboards,
vehicle signage, printed publications, electronic and web based messages which
have the purpose or effect of "marketing" as defined in Section 1 of the
Agreement.
b) In
addition to the Marketing submission and approval requirements of Section 11 and
Appendix D of this Agreement, the Contractor shall submit simultaneously to
DOHMH and SDOH for review and prior approval, in consultation with SDOH, the
following:
i) The
Contractor's Marketing plan;
A) The
Contractor must have on file with DOHMH an approved Marketing plan describing
the Contractor's marketing activities and venues prior to the contract award
date or before Marketing and Enrollment begin whichever is sooner. Subsequent
changes to the Marketing plan must be submitted to the SDOH and DOHMH for
approval at least 60 days before implementation.
B) The
Marketing plan shall include a copy of the training curriculum for personnel
performing marketing and a description of the following:
i) job
titles, job descriptions and minimum qualifications for personnelperforming
marketing;
ii)
monitoring plan to assure compliance with marketing policies and procedures,
including disciplinary action for non-compliance;
iii)
outreach plan, including any agreements/contracts with
community
based
organizations and linkages with city agencies to target potential areas of the
City and Enrollee populations for public health insurance.
ii) A
copy of all Contractor written policies and procedures related to Marketing to
Prospective Enrollees in New York City.
iii) A
copy of all Marketing materials and scripts for Marketing presentations in New
York City;
a)
Marketing materials disseminated by Participating Providers to their patients
must be pre-approved by DOHMH.
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b)
Marketing materials that are targeted solely to New York City including
electronic and web based messages which have the purpose or effect of marketing
as defined in Section 1 of the Agreement.
2. Reporting
a) The
Contractor shall provide DOHMH with an electronic copy of all reports submitted
to SDOH relating to marketing and facilitated enrollment staffing for Medicaid,
Child Health Plus and FHPlus products.
3. Marketing
Activities
The
following shall apply in New York City:
a) The
Contractor is limited to using one vehicle per borough for marketing and
facilitated
enrollment. Vehicles include recreational vehicles, trailers, cars, SUVs and
vans.
b) The
Contractor is prohibited from deploying vehicles in zipcodes in which the
Contractor has a Community Enrollment Office, subject to any exceptions
delineated in the Marketing Vehicle Protocol issued by DOHMH.
c) Vehicles
are not permitted to be deployed within a two block radius of another MCO's
Community Enrollment Office.
d) Vehicles
shall not be used in restricted areas, as designated by
DOHMH.
e) The
Contractor shall comply with the Marketing Vehicle Protocol issued by the DOHMH,
as amended from time to time.
4. Marketing
Schedules
a) Contractor
shall submit to the DOHMH, a bi-monthly schedule of all Marketing activities in
accordance with instructions for submitting the schedule and requisite formats
provided by DOHMH. The instructions, time frames and formats may be modified by
DOHMH with thirty days prior notice to the Contractor.
b) Contractor
shall submit electronically a monthly schedule of all intended marketing
activities within HRA sites to both HRA and DOHMH.
c) DOHMH
may, in its sole discretion, waive the reporting of certain
activities.
5. Marketing
Materials
a) The
Contractor shall ensure that Marketing brochures or similar materials that
describe Contractor services, benefits and enrollment shall contain the
following information:
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i) Contractor's
name and toll free telephone number and TTY
ii) A
contact telephone number for New York Medicaid CHOICE
iii) The
Potential Enrollee has a choice among several alternative MCOs in his or her
neighborhood
iv) The
Potential Enrollee will have a choice among at least three Primary Care
Providers
v) Upon
Enrollment in an MCO's MMC Product, the Enrollee will be required to use his or
her Primary Care Provider and other MCO Participating Providers exclusively for
medical care, except in certain limited circumstances
vi) Upon
Enrollment in an MCO's MMC Product, the Enrollee will have 90 days to disenroll
without cause, and thereafter will hot be allowed to disenroll or transfer
without good cause for the next nine months
vii) Newborns
will automatically be enrolled in the mother's MCO's MMC
Product
viii)
Language advising Prospective Enrollees to verify with the provider of their
choice that the provider participates in the Contractor's network and is
available to serve the Enrollee
ix) If
the Contractor does not include Family Planning and Reproductive Health services
in its Benefit Package, the Marketing brochure must tell Prospective Enrollees
that:
A) Certain
Family Planning and Reproductive Health services (such as abortion,
sterilization and birth control) are not covered by the
Contractor;
B) Such
services may be obtained through fee-for-service Medicaid from any provider who
accepts Medicaid; and
C) No
referral is needed for such services and that there will be no cost to the
Enrollee for such services.
b)
Foreign language translations of Marketing materials need not be independently
reviewed by DOHMH if the Contractor submits a letter by the translation service
attesting that it has used its best efforts to accurately translate the
Marketing material into the specified languages. At a minimum, the translation
service must perform a reverse translation, (translate the foreign language
version back into English and compare to original document). Translated
materials must meet the readability standards described in Section 13.8 of this
Agreement.
6. Marketing
Encounters
a)
Marketing encounters must clearly inform Potential Enrollees of the Partnership
Plan policies described in paragraphs (5)(a)(iii) through (ix) above, in
addition to meeting any other information requirements of Section 11.1 and
Appendix D of this Agreement.
b)
Marketing Representatives shall ask Prospective Enrollees whether they are
currently enrolled in another MCO's MMC Product, and shall not market to persons
who are enrolled in another MCO's MMC Product.
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c)
Marketing Representatives must give a copy of the document, "What Managed Care
Plans are Available in My Neighborhood" to Prospective Enrollees at each
Marketing encounter.
d)
Marketing Representatives shall ask Prospective Enrollees whether they currently
have a provider whom they would like to continue to see, and shall assist him or
her in making sure that this provider participates in the Contractor's
network.
e)
Marketing Representatives shall give a business card, identifying the name of
the representative, the name of the Contractor, and a telephone contact number
(which may be the Contractor's member services number) to each Prospective
Enrollee so that he or she may ask follow-up questions. In the alternative, the
Marketing Representative may have this information printed or stamped on the
Contractor's Marketing flyers or brochures that are distributed to each
Prospective Enrollee.
f)
Marketing Representatives shall inform Prospective Enrollees that upon
Enrollment they shall receive either a phone call or a welcome package from the
Contractor to assess their health care needs and explain how to access
Contractor services.
7.
Marketing In HRA Facilities
a) Contractor
may conduct Marketing activities within HRA facilities with the prior approval
of NYC HRA and must adhere to HRA procedures. HRA shall give Contractor an
allotted number of allowable Marketing Representatives at each HRA facility, and
Contractor shall not exceed this allotment. No other Marketing Representatives
for Contractor may market within a two block perimeter of an HRA facility.
Additionally, when a Medicaid community office is located in a hospital
facility, Contractor may not market within 60 feet of the Medicaid community
office. The Contractor is required to adhere to all HRA Marketing guidelines
when marketing in HRA facilities. HRA has the right to suspend Marketing
privileges within their facilities for failure to adhere to these
guidelines.
8.
Marketing Sites
a) The
Contractor may not market at sites that were not reported on its Marketing
schedule to DOHMH.
b) The
Contractor shall not market in homeless shelters.
c) The
Contractor shall not market in low income housing projects unless permission is
requested by the Contractor for a special event in the public areas of the
project, and approval is received in writing from the facility, and a copy sent
to DOHMH with the Marketing schedule.
d) The
Contractor shall not market within a two block perimeter of an HRA facility
(except as authorized by paragraph 7 (a) of these
guidelines).
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e) The
Contractor may not market in the same room or immediate proximity of New York
Medicaid CHOICE presentations.
9.
Marketing Conduct
a) All
Marketing activities shall be conducted in an orderly, non-disruptive manner and
shall not interfere with the privacy of Prospective Enrollees or the general
community.
10.
Marketing Representatives
a) The
Contractor's Marketing Representatives must attend Marketing training sessions
provided by DOHMH, upon request from DOHMH.
b) Marketing
Representatives must wear visible badges with the name of the Contractor and the
Marketing Representative's name during all Marketing
activities.
c) Marketing
Representatives may not wear any additional identification badge from a
Participating Provider or facility that is likely to confuse Enrollees or lead
them to believe that the Marketing Representative is an employee of such
organization. The Contractor shall obtain prior approval from DOHMH to wear
identification badges bearing the name of any other
organization.
d) Marketing
Representatives employed by a subcontractor of the Contractor or affiliated with
a community based organization which performs outreach, education and Enrollment
on behalf of the Contractor, shall attend a training session conducted by the
Contractor consistent with the training curriculum approved by
DOHMH.
11.
Marketing Infractions
a) In
addition to the corrective and remedial actions specified in Section 11.5 of
this Agreement, if the Contractor or its representative commits a repeat
violation or an infraction which is not minor or unintentional, DOHMH may,
following consultation with SDOH, impose liquidated damages of $2000.00 for each
such infraction. Imposition of liquidated damages shall be taken at the sole
discretion of the DOHMH except that DOHMH shall not impose liquidated damages
for any infraction of the Contractor where SDOH has imposed a monetary
sanction.
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N.7
Member
Services and Member Retention
1) Member
Services
a) Member
services staff designated by the Contractor shall attend DOHMH sponsored
training on contract requirements related to member service
functions.
2) Member
Retention
a) The
Contractor shall submit an Enrollee retention plan to DOHMH and HRA annually, by
December 1, which shall include a description of the Contractor's member
retention strategy, including the following:
1) annual
member retention target;
2) a
description of activities undertaken by the Contractor for the purpose of
improving retention;
3)
utilization of files from HRA regarding pending recertification of Enrollees or
other satisfactory methods to identify Enrollees who are due for
recertification;
4)
efforts to encourage completion of recertification packets by such
Enrollees.
b) The
Contractor shall report quarterly to HRA and DOHMH on outreach and retention
results in a format mutually agreed upon by the DOHMH and the
Contractor.
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N.8
Guidelines
For Processing Of Enrollments and Disenrollments
in
New York City
1.
Notwithstanding any contrary provisions in Appendix H, in New York City,
Enrollment error reports are generated by the Enrollment Broker to the
Contractor generally within 24-48 hours of Contractor Enrollment submissions and
the Contractor is able to resubmit corrections via the Enrollment Broker before
Roster pulldown. Changes in Enrollee eligibility or Enrollment status that occur
prior to production of the monthly Roster are reported by the State to the
Contractor with their rosters. Changes in Enrollee eligibility status that occur
subsequent to production of the monthly Roster shall be reported by the
Enrollment Broker by means of the electronic bulletin board. Reports of
Disenrollments processed by the Enrollment Broker shall be reported to the
Contractor as they occur by means of the electronic bulletin board. Reports of
Disenrollments processed by HRA shall be reported to the Contractor manually as
they occur or through the HPN. In the event that the electronic bulletin board
notification process is not available for any reason, the Contractor shall use
EMEDNY to verify loss of eligibility.
2.
Paragraph 6(a)(iv) of Appendix H of this Agreement (LDSS responsibilities) is
not applicable in New York City. In the event that an Enrollee loses Medicaid
eligibility, the PCP Enrollment is left on the system and removed thereafter by
SDOH if no eligibility reinstatement occurs.
3.
Paragraph 3(d)(ii) of Appendix H of this Agreement is not applicable in New York
City. The Contractor shall not send verification of the infant's demographic
data to the HRA unless thirty days has expired since the date of birth and the
Contractor has not received confirmation via the HPN of a successful Enrollment
through the automated Enrollment system. When the thirty days has expired the
Contractor shall, within 10 days, send verification of the infant's demographic
data to the HRA including: the mother's name and CIN; and the newborn's name,
CIN, sex and date of birth. Upon receipt of the data, if the Enrollment does not
appear on the system, HRA will process the retroactive
Enrollment.
4. In New
York City, Enrollees may initiate a request for an expedited DisenroUment to the
HRA. The HRA will expedite the DisenroUment process in those cases where: an
Enrollee's request for DisenroUment involves an urgent medical need; the
Enrollee is a homeless individual residing in the shelter system in New York
City; the Enrollee has HIV, ESRD, or a SPMI/SED condition; the request involves
a complaint of non-consenusal Enrollment; or the Enrollee is certified blind or
disabled and meets an exemption criteria. If approved, the HRA
will manually process the DisenroUment.
5.
Notwithstanding paragraph (6)(a)(ix) of Appendix H of this Agreement, in New
York City, further notification by HRA is not required prior to retroactive
DisenroUment in the following instances:
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(a) death
or incarceration of an Enrollee;
(b) an
Enrollee has duplicate CINs and is enrolled in an MCO's MMC or FHPlus product
under more than one of the CINS; or
(c) where
there has been communication between the Contractor and HRA or the Enrollment
Broker regarding the date of disenrollment.
Consistent
with paragraph 6 (a) (ix) of Appendix H of this Agreement, the LDSS remains
responsible for sending a notice to the Contractor at the time of Disenrollment
of the Contractor's responsibility to submit to the SDOH's Fiscal Agent voided
premium claims for any full months of retroactive Disenrollment where the
Contractor was not at risk for the provision of Benefit Package
Services. Such notice shall be completed by the LDSS to
include: the Disenrollment Effective Date, the reason for the retroactive
Disenrollment, and the months for which premiums must be repayed. The Contractor
has 10 days to notify the LDSS should it refute the Disenrollment Effective
Date, based on a belief that the Contractor was at risk for the provision of
Benefit Package Services for any month for which recoupment of premium has been
requested. However failure by the LDSS to so notify the Contractor does not
affect the right of SDOH to recover premium payment as authorized by Section 3.6
of this Agreement.
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Xxxx Xxxx Transportation Policy Guidelines
1. The
Medicaid Managed Care Program contractual Benefit Package in New York City
includes transportation to all medical care and services that are covered under
the Medicaid program, regardless of whether the specific medical service is
included in the Benefit Package or paid for on a fee-for-service basis, except
for transportation costs to Methadone Maintenance Treatment Programs. The
transportation obligation includes the cost of meals and lodging incurred when
going to and returning from a provider of medical care and services when
distance and travel time require these costs.
2.
Generally, the Contractor may provide transportation by giving or reimbursing
the Enrollee subway/bus tokens for the round trip for their medical care and
services, if public transportation is available for such care and services.
The.Contractor is not required to provide transportation if the distance to the
medical appointment is so short that the Enrollee would customarily walk to
perform other routine errands. The Contractor may adopt policies requiring a
minimum distance between an Enrollee's residence and the medical appointment,
which may not be greater than ten blocks; however, the policy must provide
transportation for Enrollees living a lesser distance upon a showing of special
circumstances such as a physical disability on a case-by-case
basis.
3. If the
Enrollee has disabilities or medical conditions which prevent him or her from
utilizing public transportation, the MCO must provide accessible transportation
which is appropriate to the disability or condition such as livery, ambulette,
or taxi. The MCO may require pre-authorization of non-public transportation
except for emergency transportation.
a) The
MCO shall provide livery transportation under the following circumstances,
unless the Enrollee requires transportation by ambulette or
ambulance:
i) The
Enrollee is able to travel independently but due to a debilitating physical or
mental condition, cannot use the mass transit system.
ii) The
Enrollee is traveling to and from a location that is inaccessible by mass
transit.
iii) The
Enrollee cannot access the mass transit system due to temporary severe weather,
which prohibits use of the normal mode of transportation.
b) The
MCO shall provide ambulette transportation under the following circumstances,
unless the Enrollee requires transportation by ambulance:
i) The
Enrollee requires personal assistance from the driver in entering/exiting the
Enrollee's residence, the ambulette and the medical facility.
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ii) The
Enrollee is wheelchair-bound (non-collapsible or requires a specially configured
vehicle).
iii)
The Enrollee has a mental impairment and requires the personal assistance of the
ambulette
driver.
iv) The
Enrollee has a severe, debilitating weakness or is mentally disoriented as a
result of medical treatment and requires the personal assistance of the
ambulette driver.
v) The
Enrollee has a disabling physical condition that requires the use of a walker,
cane, crutch or brace and is unable to use livery service or mass
transportation.
c) The
MCO shall provide non-emergency ambulance transportation when the Enrollee must
be transported on a stretcher and/or requires the administration of life support
equipment by trained medical personnel. The use of non-emergency ambulance is
indicated when the Enrollee's condition would prohibit any other form of
transport.
4.
Emergency transportation may only be provided by accessing 911 emergency
ambulances. Urgent care transportation may be provided by any mode of
transportation so long as such mode is appropriate for the medical condition or
disability experienced by the Enrollee.
5. If an
attendant is Medically Necessary to accompany the Enrollee to the medical
appointment, the Contractor is responsible for the transportation of the
attendant. A medically required attendant (authorized by the attending
physician) may include a family member, friend, legal guardian or home health
worker. When a child travels to medical care and services, and an attendant is
required, the parent or guardian of the child may act as an attendant. In these
situations, the costs of the transportation, lodging and meals of the parent or
guardian may be reimbursable, and authorization of the attending physician is
not required.
APPENDIX
N
October
1,2007
N-22
Schedule
1 of Appendix N
DOHMH
Public Health Services Fee Schedule
|
SERVICE
|
FEE
|
|
TB
CLINIC
|
$125.00
|
|
IMMUNIZATION
|
|
|
Children
under 19 years
|
17.85
|
|
Adults
19 years and older
|
CDC
acquisition
cost
per dose +
$2.00
administration
fee
|
|
HIV
COUNSELING AND TESTING VISIT
|
$
96.47
|
|
HTV
COUNSELING AND NO TESTING
|
$90.12
|
|
HIV
POST TEST COUNSELING
|
|
|
Visit
Positive Result
|
$90.12
|
|
LAB
TESTS
HIV-l/HIV-2
(Single Assay),
|
$15.17
|
|
HIV
Antibody, Confirmatory (Western Blot)
GC/Chlamydia
Combo (GCT) Test
|
$
26.75
|
|
Chlamydia
Trachomatis, Amplified Probe Technique
|
$21.43
|
|
Neisseria
Gonorrhoeae, Amplified Probe Technique
|
$21.43
|
|
Culture
Bacterial (GC Cultures)
|
$8.15
|
|
DENTAL
SERVICES
|
$
108.00
|
APPENDIX
N
October
1,2007
N-23
