MEDICAID ADVANTAGE MODEL CONTRACT
Exhibit
10.3
Amendment
of Agreement Between The City of New York And WellCare of New York,
Inc.
This
Amendment, effective January 1, 2007, amends the Medicaid Advantage Model
Contract (hereinafter referred to as the "Agreement") made by and between
the
City of New York, acting through the New York City Department of Health and
Mental Hygiene (hereinafter referred to as "LDSS" or "DOHMH") and WellCare
of
New York, Inc. (hereinafter referred to as "Contractor" or "MCO").
WHEREAS
the parties entered into an Agreement effective April 1, 2006 for the purpose
of
providing Medicare and Medicaid Advantage Products to eligible recipients
residing in New York; and
WHEREAS
the parties desire to amend said Agreement to modify certain provisions to
reflect current circumstances and intentions, and, as authorized in Section
2.1
of the Agreement, to extend the term of the Agreement until December 31,
2007;
NOW
THEREFORE, effective January 1, 2007, it is mutually agreed by the parties
to
amend this Agreement as follows:
1.
The
attached "Table of Contents" will be applicable for the period beginning
January
1, 2007.
2.
Amend
Section 9.3 "Covered Services During Guaranteed Eligibility" to read as
follows:
9.3
Covered Services During Guaranteed Eligibility
The
services covered during the Guaranteed Eligibility period shall be those
contained in the Medicaid Advantage Benefit Package, as specified in Appendix
K-2, and free access to family planning and reproductive health services
as set
forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
period, Enrollees are also eligible for Medicaid pharmacy benefits as 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 Enrol xxx is
unable
to receive them from his/her Medicare Advantage plan) on a Medicaid
fee-for-service basis.
3.
Amend
Section 10.7 "Emergency and Post Stabilization Care Services" to read as
follows:
10.7
Emergency and Post Stabilization Care Services
a)
The
Contractor shall provide Emergency and Post Stabilization Care Services in
accordance with applicable federal and state requirements, including 42 CFR
§422.113.
b)
The
Contractor shall ensure that Enrollees are able to access Emergency Services
twenty four (24) hours per day, seven (7) days per week.
Medicaid
Advantage Contract Amendment
January
1.2007
Page
1
c)
The
Contractor agrees that it will not require prior authorization for services
in a
medical or behavioral health emergency. The Contractor agrees to inform its
Enrollees that access to Emergency Services is not restricted and that Emergency
Services may be obtained from a Non-Participating Provider without penalty.
Nothing herein precludes the Contractor from entering into contracts with
providers or facilities that require providers or facilities to provide
notification to the Contractor after Enrollees present for Emergency Services
and are subsequently stabilized. The Contractor must pay for services for
Emergency Medical Conditions whether provided by a Participating Provider
or a
Non-Participating Provider, and may not deny payments for failure of the
Emergency Services provider or Enrollee to give notice.
d)
The
Contractor shall advise its Enrollees how to obtain Emergency Services when
it
is not feasible for Enrollees to receive Emergency Services from or through
a
Participating Provider.
e)
Coverage and payment for Emergency Services that meet the prudent layperson
definition shall be covered and paid in accordance with the requirements
of the
federal Medicare program.
f)
In
addition, the Contractor shall cover and reimburse for general hospital
emergency department services and physician services provided to an Enrollee
while the Enrollee is receiving general hospital emergency department services,
in accordance with the following requirements when such services do not meet
the
prudent layperson standard:
i)
Participating Providers
A)
Payment by the Contractor for general hospital emergency department services
provided to an Enrollee by a Participating Provider shall be at the rate
of
payment specified in the contract between the Contractor and the general
hospital for emergency services.
B)
Payment by the Contractor for physician services provided to an Enrollee
by a
Participating Provider while the Enrollee is receiving general hospital
emergency department services shall be at the rate of payment specified in
the
contract between the Contractor and the physician.
ii)
Non-Participating Providers
A)
Payment by the Contractor for general hospital emergency department services
provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
fee-for-service rate, inclusive of the capital component, in effect on the
date
that the service was rendered.
B)
Payment by the Contractor for physician services provided to an Enrollee
by a
Non-Participating Provider while the Enrollee is receiving general hospital
emergency department services shall be at the Medicaid fee-for-service rate
in
effect on the date that the service was rendered.
Medicaid
Advantage Contract Amendment
January
1, 2007
Page
2
4.
Amend
Subsection 16.3 "Quality Management and Performance Improvement" to read
as
follows:
16.3
The
Contractor agrees to conduct performance improvement projects and to measure
performance using standard measures required by CMS, and to report results
to
CMS and SDOH. Standard Measures will include, but not be limited
to:
•
Health
Plan and Employer Data Information Set (HEDIS);
•
Consumer Assessment of Health Plans Survey (CAHPS); and
•
Health
Outcomes Survey (HOS).
5.
Amend
Section 18.3 "SDOH Instructions for Report Submissions" to read as
follows:
18.3
SDOH
Instructions for Report Submissions
SDOH,
with notice to DOHMH, will provide Contractor with instructions for submitting
the reports required by Section 18.5 (a) (i) through (x) of this Agreement,
including time frames, and requisite formats. The instructions, time frames
and
formats may be modified by SDOH upon sixty (60) days written notice to the
Contractor.
6.
Delete
Section 18.4 "Liquidated Damages, " and renumber Sections 18.5 "Notification
of
Changes in Report Due Dates, Requirements or Formats:" 18.6 "Reporting
Requirements;" 18.7 "Ownership and Related Information Disclosure;" 18.8
"Public
Access to Reports:" 18.9 "Certification Regarding Individuals Who Have Been
Debarred Or Suspended By Federal. State, or Local Government:" 18.10 "Conflict
of Interest Disclosure:" and 18.11 "Physician Incentive Plan Reporting:"
as
Sections 18.4. 18.5. 18.6. 18.7. 18.8. 18.9. and 18.10
respectively.
7.
Amend
Section 21.5 "Dental Networks " to read as follows:
21.5
Dental Networks
If
the
Contractor includes dental services in its Medicaid Advantage Benefit Package,
the Contractor's dental network shall include geographically accessible general
dentists sufficient to offer each Enrollee a choice of two (2) primary care
dentists in his or her Service Area and to achieve a ratio of at least one
(1)
primary care dentist for each 2,000 Enrollees. Networks must also include
at
least one (1) oral surgeon. Orthognathic surgery, temporal mandibular disorders
(TMD) and oral/maxillofacial prosthodontics must be provided through any
qualified dentist, either in-network or by referral. Periodontists and
endodontists must also be available by referral. The network should include
dentists with expertise in serving special needs populations (e.g., HIV+
and
developmentally disabled patients).
Medicaid
Advantage Contract Amendment
January
1, 2007
Page
3
8.
Add
a
new 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 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.
9.
Renumber
Section 22.7 "Physician Incentive Plan" as Section 22.8.
10.
Amend
Section 3(b) (in) "LDSS Responsibilities" of Appendix H "New York State
Department of Health Guidelines for the Processing ofMedicaid Advantage
Enrollments and Disenrollments" to read as follows:
iii)
In
the event that the LDSS leams 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.
11.
The
attached Appendix K "Medicare and Medicaid Advantage Products and Non-Covered
Services"
will be applicable for the period beginning January 1, 2007.
12.
The
attached Appendix L "Approved Capitation Payment Rates" will be applicable
for
the period beginning
January 1, 2007.
13.
The
attached Appendix M "Service Area" will be applicable for the period beginning
January 1, 2007.
14.
Amend
Subsections 4 (a) and 4 (b) of Section N.4 "Additional Reporting Requirements"
of Appendix N "New York City Specific Contracting Requirements" to read as
follows:
a)
The
Contractor shall provide DOHMH with all reports submitted to SDOH pursuant
to
Sections 18.5(a)(i), (ii), (vi) and (vii) of this Agreement.
b)
Upon
request by DOHMH, the Contractor shall submit to DOHMH reports submitted
to SDOH
pursuant to Section 18.5(a) (iii) of this Agreement.
15.
The
attached Schedule ] "DOHMH Public Health Service Fee Schedule" of Appendix
N
"New York City Specific Contracting Requirements" will be applicable for
the
period beginning January 1.2007.
Medicaid
Advantage Contract Amendment
January
1,2007
Page
4
This
Amendment is effective January 1, 2007 and the Agreement, including the
modifications made by this Amendment, shall remain in effect until December
31,
2007 or until an extension, renewal or successor Agreement is entered into
as
provided for in Section 2.1 of the Agreement.
IN
WITNESS WHEREOF, the parties have duly executed this Amendment to the Agreement
on the dates appearing below their respective signatures.
|
CONTRACTOR
|
CITY
OF NEW YORK
|
|
By:
/s/
Xxxx X. Xxxxx
|
By:
/s/
Xxxxxx Xxxx
|
|
Printed
Name: Xxxx X. Xxxxx
|
Printed
Name: Xxxxxx Xxxx
|
|
Title:
President and CEO
|
Title:
COO
|
|
WellCare
of New York, Inc.
|
NYC
DOHMH
|
|
Date:
11/28/2006
|
Date:
12/11/2006
|
Medicaid
Advantage Contract Amendment
January
1,2007
Page
0
XXXXX
XX
XXXXXXX
XXXXXX
XX
XXXXXXXXXXXX
Xx
this
28th
Day of
November 2006, Xxxx
X. Xxxxx came
before me, to me known and known to be the President
and CEO,
of
WellCare
of New York, Inc. who
is
duly authorized to execute the foregoing instrument on behalf of said
corporation and s/he acknowledged to me that s/he executed the same for the
purpose therein mentioned.
NOTARY
PUBLIC
XXXXX
XX
XXX XXXX
XXXXXX
XX
XXX XXXX
Xx
this
11 day of December, 2006, Xxxxxx Xxxx came before me, to me known and known
to
be the 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 s/he acknowledged to me that s/he executed the
same
for the purpose therein mentioned.
NOTARY
PUBLIC
Table
of Contents for Medicaid Advantage Model Contract
Recitals
Section
1 Definitions
Section
2
Agreement Term, Amendments, Extensions, and General Contract Administration
Provisions
2.1
Term
2.2
Amendments
2.3
Approvals
2.4
Entire Agreement
2.5
Renegotiation
2.6
Assignment and Subcontracting
2.7
Termination
a.
DOHMH
Initiated Termination
b.
Contractor and DOHMH Initiated Termination
c.
Contractor Initiated Termination
d.
Termination Due to Loss of Funding
2.8
Close-Out Procedures
2.9
Rights and Remedies
2.10
Notices
2.11
Severability
Section
3
Compensation
3.1
Capitation Payments
3.2
Modification of Rates During Contract Period
3.3
Rate
Setting Methodology
3.4
Payment of Capitation
3.5
Denial of Capitation Payments
3.6
SDOH
Right to Recover Premiums
3.7
Third
Party Health Insurance Determination
3.8
Contractor Financial Liability
3.9
Tracking Services Provided by Indian Health Clinics
Section
4
Service Area
Section
5
Eligibility For Enrollment in Medicaid Advantage
5.1
Eligible to Enroll in the Medicaid Advantage Program
5.2
Not
Eligible to Enroll in the Medicaid Advantage Program
5.3
Change in Eligibility Status
Section
6
Enrollment
6.1
Enrollment Requirements
6.2
Equality of Access to Enrollment
6.3
Enrollment Decisions
6.4
Prohibition Against Conditions on Enrollment
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City
January
1, 2007
1
Table
of Contents for Medicaid Advantage Model Contract
6.5
Effective Date of Enrollment
6.6
Contractor Liability
6.7
Roster
6.8
Automatic Re-Enrollment
6.9
Failure to Enroll in Contractor's Medicare Advantage Product
6.10
Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility
6.11
Newborn Enrollment
Section
7
RESERVED
Section
8
Disenrollment
8.1
Disenrollment Requirements
8.2
Disenrollment Prohibitions
8.3
Disenrollment Requests
a.
Routine Disenrollment Requests
b.
Non-routine Disenrollment Requests
8.4
Contractor Notification of Disenrollments
8.5
Contractor's Liability
8.6
Enrollee Initiated Disenrollment
8.7
Contractor Initiated Disenrollment
8.8
LDSS
Initiated Disenrollment
Section
9
Guaranteed Eligibility
9.1
General Requirements
9.2
Right
to Guaranteed Eligibility
9.3
Covered Services During Guaranteed Eligibility
9.4
Disenrollment During Guaranteed Eligibility
Section
10 Benefit Package, Covered and Non-Covered Services
10.1
Contractor Responsibilities
10.2
SDOH
and LDSS Responsibilities
10.3
Benefit Package and Non-Covered Services Descriptions
10.4
Adult Protective Services
10.5
Court-Ordered Services
10.6
Family Planning and Reproductive Health Services
10.7
Emergency and Post Stabilization Care Services
10.8
Medicaid Utilization Thresholds (MUTS)
10.9
Services for Which Enrollees Can Self-Refer
a.
Diagnosis and Treatment of Tuberculosis
b.
Family
Planning and Reproductive Health Services
c.
Article 28 Clinics Operated by Academic Dental Centers
10.10
Coordination with Local Public Health Agencies
10.11
Public Health Services
a.
Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
(TB/DOT)
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City January 1, 2007
2
Table
of Contents for Medicaid Advantage Model Contract
b.
Immunizations c. Prevention and Treatment of Sexually Transmitted
Diseases
10.12
Adults with Chronic Illnesses and Physical or Developmental
Disabilities
10.13
Persons Requiring Ongoing Mental Health Services
10.14
Member Needs Relating to HIV
10.15
Persons Requiring Chemical Dependence Services
10.16
Native Americans
10.17
Urgently Needed Services
10.18
Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network
10.19
Coordination of Services
Section
11 Marketing
11.1
Marketing Requirements
Section
12 Member Services
12.1
General Functions
12.2
Translation and Oral Interpretation
12.3
Communicating with the Visually, Hearing and Cognitively Impaired
Section
13 Enrollee Notification
13.1
General Requirements
13.2
Member ID Cards
13.3
Member Handbooks
13.4
Enrollee Rights
Section
14 Organization Determinations, Actions, and Grievance System
14.1
General Requirements
14.2
Filing and Modification of Medicaid Advantage Action and Grievance System
Procedures
14.3
Medicaid Advantage Action and Grievance System Additional
Provisions
14.4
Notification of Medicaid Advantage Action and Grievance System
Procedures
14.5
Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
Section
15 Access Requirements
Section
16 Quality Management and Performance Improvement
Section
17 Monitoring and Evaluation
17.1
Right To Monitor Contractor Performance
17.2
Cooperation During Monitoring And Evaluation
17.3
Cooperation During On-Site Reviews
17.4
Cooperation During Review of Services by External Review Agency
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City January 1, 2007
3
Table
of Contents for Medicaid Advantage Model Contract
Section
18 Contractor Reporting Requirements
18.1
General Requirements
18.2
Time
Frames for Report Submissions
18.3
SDOH
Instructions for Report Submissions
18.4
Notification of Changes in Report: Due Dates, Requirements or
Formats
18.5
Reporting Requirements
18.6
Ownership and Related Information Disclosure
18.7
Public Access to Reports
18.8
Certification Regarding Individuals Who Have Been Debarred or Suspended by
Federal or State Government
18.9
Conflict of Interest Disclosure
18.10
Physician Incentive Plan Reporting
Section
19 Records Maintenance and Audit Rights
19.1
Maintenance of Contractor Performance Records
19.2
Maintenance of Financial Records and Statistical Data
19.3
Access to Contractor Records
19.4
Retention Periods
Section
20 Confidentiality
20.1
Confidentiality of Identifying Information about Enrollees, Eligible Persons
and
Prospective Enrollees
20.2
Confidentiality of Medical Records
20.3
Length of Confidentiality Requirements
Section
21 Participating Providers
21.1
General Requirements
21.2
Medicaid Advantage Network Requirements
21.3
SDOH
Exclusion or Termination of Providers
21.4
Payment in Full
21.5
Dental Networks
Section
22 Subcontracts and Provider Agreements for Medicaid Only Covered
Services
22.1
Written Subcontracts
22.2
Permissible Subcontracts
22.3
Provision of Services Through Provider Agreements
22.4
Approvals
22.5
Required Components
22.6
Timely Payment
22.7
Recovery of Overpayments to Providers
22.8
Physician Incentive Plan
Section
23 Americans With Disabilities Act Compliance Plan
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City
January
1, 2007
4
Table
of Contents for Medicaid Advantage Model Contract
Section
24 Fair Hearings
24.1
Enrollee Access to Fair Hearing Process
24.2
Enrollee Rights to a Fair Hearing
24.3
Contractor Notice to Enrollees
24.4
Aid
Continuing
24.5
Responsibilities of SDOH
24.6
Contractor's Obligations
Section
25 External Appeal
25.1
Basis for External Appeal
25.2
Eligibility for External Appeal
25.3
External Appeal Determination
25.4
Compliance with External Appeal Laws and Regulations
25.5
Member Handbook
Section
26 Intermediate Sanctions
26.1
General Practices
26.2
Unacceptable Practices
26.3
Intermediate Sanctions
26.4
Enrollment Limitations
26.5
Due
Process
Section
27 Environmental Compliance
Section
28 Energy Conservation Independent
Section
29 Independent Capacity of Contractor
Section
30 No Third Party Beneficiaries
Section
31 Indemnification
31.1
Indemnification by Contractor
31.2
Indemnification by DOHMH
Section
32 Prohibition on Use of Federal Funds for Lobbying
32.1
Prohibition of Use of Federal Funds for Lobbying
32.2
Disclosure Form to Report Lobbying
32.3
Requirements of Subcontractors
Section
33 Non-Discrimination
33.1
Equal Access to Benefit Package
33.2
Non-Discrimination
33.3
Equal Employment Opportunity
33.4
Native Americans Access to Services From Tribal or Urban Indian Health
Facility
Medicaid
Advantage Contract 1
TABLE
OF
CON CONTENTS
New
York
City
January
1, 2007
Table
of Contents for Medicaid Advantage Model Contract
Section
34 Compliance with Applicable Laws and Regulations
34.1
Contractor and DOHMH Compliance with Applicable Laws
34.2
Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
34.3
Certificate of Authority Requirements
34.4
Notification of Changes in Certificate of Incorporation
34.5
Contractor's Financial Solvency Requirements
34.6
Non-Liability of Enrollees for Contractor's Debts
34.7
DOHMH Compliance with Conflict of Interest Laws
34.8
Compliance Plan
Section
35 New York State Standard Contract Clauses and New York City Standard
Clauses
Signature
Page
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City
January
1. 2007
6
Table
of Contents for Medicaid Advantage Model Contract
APPENDICES
A.
New
York State Standard Clauses
B.
Certification Regarding Lobbying
C.
New
York State Department of Health Requirements for Provision of Free Access
to
Family Planning and Reproductive Health Services
D.
New
York State Department of Health Medicaid Advantage Marketing
Guidelines
E.
New
York State Department of Health Medicaid Advantage Model Member Handbook
Guidelines
F.
New
York State Department of Health Medicaid Advantage Action and Grievance Systems
Requirements
G.
RESERVED
H.
New
York State Department of Health Guidelines for the Processing of Medicaid
Advantage Enrollments and Disenrollments
I.
RESERVED
J.
New
York State Department of Health Guidelines of Federal Americans with
Disabilities Act
K.
Medicare and Medicaid Advantage Products and Non-Covered Services L. Approved
Capitation Payment Rates
M.
Service Area
N.
New
York City Specific Contracting Requirements
0.
RESERVED
P.
RESERVED
Q.
RESERVED
R.
New
York City Standard Clauses
Medicaid
Advantage Contract
TABLE
OF
CONTENTS
New
York
City
January
1.2007 7
APPENDIX
K
Medicare
and Medicaid Advantage Products And Non-Covered Services
Medicaid
Advantage Contract
APPENDIX
K
New
York
City
January
1. 2007
K-l
APPENDIX
K
Appendix
K is organized into three parts:
I.
Appendix K-l
Medicare
Advantage Product
II.
Appendix K-2
Medicaid
Advantage Product
Description
of Medicaid Only Covered Services
III.
Appendix K-3
Non-Covered
Services
`
Medicaid
Advantage Contract
APPENDIX
K
New
York
City
January
1. 2007
K-2
APPENDIX
K.1
MEDICARE
ADVANTAGE PRODUCT
|
Medicare
Advantage Benefit Package for Dual Eligibles -
Upstate Counties
|
|
|
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). $300 per stay
co-payment.
|
|
Inpatient
Mental Health
|
Medically
necessary care. $300 per stay 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. $10 per visit
co-payment
|
|
PCP
Office Visits
|
Primary
care doctor office visits. Subject to $10 co-payment per
visit.
|
|
Specialist
Office Visits
|
Specialist
office visits. Subject to $20 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 $20 co-payment.
|
|
Podiatry
|
Medically
necessary foot care, including care for medical
conditions
affecting lower limbs, subject to $20 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. $35 per visit to ambulatory surgery or outpatient
hospital.
|
|
Ambulance
|
Transportation
provided by an ambulance service, including air ambulance. Emergency
transportation if for the purpose of obtaining hospital service
for an
enrollee who suffers from severe, life-threatening or potentially
disabling conditions
|
Medicaid
Advantage Contract
APPENDIX
K
New
York
City January 1. 2007
K-3
|
Medicare
Advantage Benefit Package for Dual Eligibles -
Upstate Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
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". $50 co-payment.
|
|
|
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 $20
co-payment.
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Occupational
therapy, physical therapy and speech and language therapy subject
to $20
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 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 bars).
No
co-payment or coinsurance.
|
|
Prosthetics
|
Medicare
and Medicaid covered prosthetics, orthotics and orthopedic footwear.
No
diabetic or temporary impairment 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-payment.
|
|
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.
Vaccines/Toxoids. 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.
|
Medicaid
Advantage Contract
APPENDIX
K
New
York
City January 1. 2007
K-4
|
Medicare
Advantage Benefit Package for Dual Eligibles -
Upstate Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
Prostate
Cancer Screening
|
Prostate
Cancer Screening exams for men age 50 and older.
No
co-payment
|
|
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
|
Medicaid
and Medicare 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 surgery. No co-payment
|
|
Routine
Physical Exam 1/year
|
Up
to one routine physical per year. Subject to $10. co-
payment
per visit.
|
|
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
New
York
City January 1, 2007
K-5
|
Medicare
Advantage Benefit Package for Dual Eligibles -
Upstate Counties
|
|||
|
Category
of Service
|
Included
in
|
Medicare
|
Capitation
|
Medicaid
Advantage Contract
APPENDIX
K
New
York
City January 1, 2007
K-6
|
Medicare
Advantage Benefit Package for Dual Eligibles
NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
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 9 II". No
co-payment.
|
Medicaid
Advantage Contract
APPENDIX
K New York City January 1. 2007
K-7
|
Medicare
Advantage Benefit Package for Dual Eligibles
NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
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.
|
|
Outpatient
Drugs
|
Medicare
Part B covered prescription drugs and other drugs obtained by a
provider
and administered in a physician
office
|
Medicaid
Advantage Contract
APPENDIX
K
New
York
City January 1. 2007
K-8
|
Medicare
Advantage Benefit Package for Dual Eligibles
NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
Category
of Service
|
Included
in Medicare Capitation
|
|
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 I/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
New
York
City January 1. 2007
K-9
APPENDIX
K2
MEDICAID
ADVANTAGE PRODUCT
|
Medicaid
Advantage Benefit Package for Dual Eligibles - Upstate
Counties
|
|
|
Category
of Service
|
Included
in Medicaid Capitation
|
|
Inpatient
Hospital Care Including Substance Abuse and Rehabilitation
Services
|
Elimination
of $300 per stay co-payment.
|
|
Inpatient
Mental Health
|
Elimination
of $300 per stay co-payment, plus days in excess of the Medicare
190-day
lifetime maximum.
|
|
Home
Health
|
Elimination
of $10 co-payment per Medicare covered visit. Non-Medicare covered
home
health services (e.g. home health aide services with nursing supervision
to medically
unstable individuals).
|
|
PCP
Office Visits
|
Elimination
of $10 co-payment
|
|
Specialist
Office Visits
|
Elimination
of $20 co-payment
|
|
Podiatry
|
Elimination
of $20 co-payment for medically necessary foot
care
|
|
Outpatient
Mental Health
|
Elimination
of $20 co-payment
|
|
Outpatient
Substance Abuse
|
Elimination
of $20 co-payment
|
|
Outpatient
Surgery
|
Elimination
of $35 co-payment
|
|
Ambulance
|
Elimination
of $50 co-payment
|
|
Emergency
Room
|
Elimination
of $50 co-payment
|
|
Urgent
Care
|
Elimination
of $20 co-payment
|
|
Outpatient
Rehabilitation (OT, PT, Speech)
|
Elimination
of $20 co-payment
|
|
Dental
(Optional
benefit)
|
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.
|
|
Routine
Physical Exam I/year
|
Elimination
of $10 co-payment
|
|
Transportation
- Routine (Optional
benefit)
|
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
New
York
City
January
,. 2007
K-10
|
Medicaid
Advantage Benefit Package for Dual Eligibles
NYC,
Nassau, Suffolk, Westchester, Rockland, Orange and Xxxxxx
Counties
|
|
|
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
New
York
City
January
1, 2007
K-ll
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 E'epartment 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
New
York
City
January
I, 2007
K-12
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 EPS 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
New
York
City January 1, 2007
K-13
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
o
Intensive Psychiatric Rehabilitation Treatment Programs
o
Day
Treatment
o
Continuing Day Treatment
o
Case
Management for Seriously and Persistently Mentally 111 (sponsored by state
or
local mental health units)
o
Partial
Hospitalizations o Assertive Community Treatment (ACT) o Personalized Receiving
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 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
Medicaid
Advantage Contract
APPENDIX
K
New
York
City
January
1, 2007
K-14
Both
of
these services, however, are mandatory in NYC.
Medicaid
Advantage Contract
APPENDIX
K
New
York
City
January
1, 2007
K-15
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 a 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
New
York
City January 1, 2007
K-16
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
Formula 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
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K-17
(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 111 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
Medicaid
Advantage Contract
APPENDIX
K
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January
1, 2007
K-18
pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to Part 506 of 14 NYCRR.
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 the 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
Medicaid
Advantage Contract
APPENDIX
K
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January
1, 2007
K-19
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.
12.
Office of Mental Retardation and Developmental Disabilities (OMRDD)
Services
a.
Long
Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
or
Article 28 Facilities
These
services are provided to persons with developmental disabilities including
medical or remedial services recommended by a physician or other licensed
practitioner of the healing arts for a maximum reduction of the effects of
physical or mental disability and restoration of the person to his or her
best
possible functional level. It also includes the fitting, training, and
modification of assistive devices by licensed practitioners or trained others
under their direct supervision. Such services are designed to ameliorate
or
limit the disabling condition and to allow the person to remain in or move
to,
the least restrictive residential and/or day setting. These services are
certified by OMRDD under Part 679 of 14 NYCRR (or they are provided by Article
28 Diagnostic and Treatment Centers that are explicitly designated by the
SDOH
as serving primarily persons with developmental disabilities). If care of
this
nature is provided in facilities other than Article 28 or Article 16 centers,
it
is a covered service.
b.
Day
Treatment
A
planned
combination of diagnostic, treatment and rehabilitation services provided
to
developmentally disabled individuals in need of a broad range of services,
but
who do not need intensive twenty-four (24) hour care and medical supervision.
The services provided as identified in the comprehensive assessment may include
nutrition, recreation, self-care, independent living, therapies, nursing,
and
transportation services. These services are generally provided in an
Intermediate Care Facility (ICF) or a comparable setting. These services
are
certified by OMRDD under Part 690 of 14 NYCRR.
c.
Medicaid Service Coordination (MSC)
Medicaid
Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
which assists persons with developmental disabilities and mental retardation
to
gain access to necessary services and supports appropriate to the needs of
the
needs of the individual. MSC is provided by qualified service coordinators
and
uses a person centered planning process in developing, implementing and
maintaining an Individualized Service Plan (ISP) with and for a person with
developmental disabilities and mental retardation. MSC promotes the concepts
of
a choice, individualized services and consumer satisfaction.
MSC
is
provided by authorized vendors who have a contract with OMRDD, and who are
paid
monthly pursuant to such contract. Persons who receive MSC must not permanently
reside in an ICF for persons with developmental disabilities, a developmental
center, a skilled nursing facility or any other hospital or Medical Assistance
institutional setting that provides service
Medicaid
Advantage Contract
APPENDIX
K
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January
1, 2007
K-20
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.
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-for-service 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
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January
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K-21
15.
AIDS Adult Day Health Care
Adult
Day
Health Care Programs (ADHCP) are programs designed to assist individuals
with
HIV disease to live more independently in the community or eliminate the
need
for residential health care services. Registrants in ADHCP require a greater
range of comprehensive health care services than can be provided in any single
setting, but do not require the level of services provided in a residential
health care setting. Regulations require that a person enrolled in an ADHCP
must
require at least three (3) hours of health care delivered on the basis of
at
least one (1) visit per week. While health care services are broadly defined
in
this setting to include general medical care, nursing care, medication
management, nutritional services, rehabilitative services, and substance
abuse
and mental health services, the latter two (2) cannot be the sole reason
for
admission to the program. Admission criteria must include, at a minimum,
the
need for general medical care and nursing services.
16.
HIV COBRA Case Management
The
HP/
COBRA (Community Follow-up Program) Case Management Program is a program
that
provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
Reimbursable activities include intake, assessment, reassessment, service
plan
development and implementation, monitoring, advocacy, crisis intervention,
exit
planning, and case specific supervisory case-review. conferencing.
17.
Adult Day Health Care
Adult
Day Health Care
means
care and services provided to a registrant in a residential health care facility
or approved extension site under the medical direction of a physician and
which
is provided by personnel of the adult day health care program in accordance
with
a comprehensive assessment of care needs and an individualized health care
plan,
and providing ongoing implementation and coordination of the health care
plan,
and transportation.
Registrant
means a
person who is a nonresident of the residential health care facility who is
functionally impaired and not homebound, and who requires certain preventive,
diagnostic, therapeutic, rehabilitative or palliative items or services provided
by a general hospital, or residential health care facility; and whose assessed
social and health care needs, in the professional judgment of the physician
of
record, nursing staff. Social Services and other professional personnel of
the
aduit 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
New
York
City
January
1, 0000
X-00
XXXXXXXX
L
Approved
Capitation Payment Rates
Medicaid
Advantage Contract
APPENDIX
L
New
York
City
January
1,2007
L-l
Wellcare
of New York, Inc
Dual
Eligible Medicaid Managed Care Rates
|
MM1S
ID#:
|
02645710
|
Effective
Date: 01/01/07
|
|
Region:
|
NYC
|
|
|
County:
|
NYC
|
|
Rate
Code
|
Premium
Group
|
Rate
Amount
|
|
2370
|
DUALLY
ELIGIBLE SSI 21-64 MALE/FEMALE
|
$42.58
|
|
2371
|
DUALLY
ELIGIBLE SSI 65+ MALE/FEMALE
|
$43.38
|
Optional
Benefits Offered:
R
Dental E
Non
R
Emergent
Transportation
Box
will be checked if the optional benefit is covered by the
plan
APPENDIX
M
Service
Area
Medicaid
Advantage Contract
APPENDIX
M
New
York
City
January
1, 2007
M-l
The
Contractor’s Medicaid Advantage service area is comprised of the following
Counties in their entirety
New
York
Medicaid
Advantage Contract
APPENDIX
M
New
York
City
January
1, 2007
M-2
Schedule
1 of Appendix N
DOHMH
Public Health Services Fee Schedule
|
SERVICE
|
FEE
|
|
TB
CLINIC
|
$125.00
|
|
IMMUNIZATION
|
$
50.00
|
|
HIV
COUNSELING AND TESTING VISIT
|
$96.47
|
|
HIV
COUNSELING AND NO TESTING
|
$90.12
|
|
HIV
POST TEST COUNSELING
Visit
Positive Result
|
$90.12
|
|
LAB
TESTS
|
|
|
HIV
1 (ELISA Test)
|
$12.27
|
|
HIV
Antibody, Confirmatory (Western Blot)
|
$
26.75
|
|
DENTAL
SERVICES
|
$
108.00
|
APPENDIX
N
New
York
City January 1. 2007
N-15
