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 January 1, 2007, 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, 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 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 10.13 "Emergency Services" to read as follows:
10.13
Emergency Services
a)
The
Contractor shall maintain coverage utilizing a toll free telephone number
twenty-four (24) hours per day seven (7) days per week, answered by a live
voice, to advise Enrollees of procedures for accessing services for Emergency
Medical Conditions and for accessing Urgently Needed Services. Emergency mental
health calls must be triaged via telephone by a trained mental health
professional.
b)
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. 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.
c)
The
Contractor agrees to bear the cost of Emergency Services provided to Enrollees
by Participating or Non-Participating Providers.
d)
The
Contractor agrees to cover and pay for services as follows:
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 or
rates of payment specified in the contract between the Contractor
and
January
1, 2007 Amendment
1
the
hospital. Such contracted rate or rates shall be paid without regard to whether
such services meet the definition of Emergency Medical Condition.
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 or rates of payment specified
in the contract between the Contractor and the physician. Such contracted rate
or rates shall be paid without regard to whether such services meet the
definition of Emergency Medical Condition.
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 without regard to whether such services meet
the
definition of Emergency Medical Condition.
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 the service was rendered without regard to whether such
services meet the definition of Emergency Medical Condition.
e)
The
Contractor agrees that it will not require prior authorization for services
in a
medical or behavioral health emergency. 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 may
not
deny payments to a Participating Provider or a Non-Participating Provider for
failure of the Emergency Services provider or Enrollee to give such
notice.
f)
The
Contractor agrees to abide by requirements for the provision and payment of
Emergency Services and Post-stabilization Care Services which are specified
in
Appendix G, which is hereby made a part of this Agreement as if set forth fully
herein.
3.
Amend
Section 10.22 "Member Needs Relating to HIV to read as follows:
10.22
Member Needs Relating to HIV
a)
The
Contractor must inform MMC Enrollees newly diagnosed with HIV infection or
AIDS,
who are known to the Contractor, of their enrollment options including the
ability to return to the Medicaid fee-for-service program or to disenroll from
the Contractor's MMC product and to enrol! into HIV SNPs, if such plan is
available.
b)
The
Contractor will inform Enrollees about HIV counseling and testing services,
including Rapid HIV Testing, available through the Contractor's Participating
Provider network; HIV counseling and testing services available when performed
as part of a Family Planning and Reproductive Health encounter: and anonymous
counseling and testing services available from SDOH, Local Public Health Agency
clinics and other county programs Counseling and testing rendered outside of
a
January
1, 2007 Amendment
2
Family
Planning and Reproductive Health encounter, as well as services provided as
the
result of an HIV- diagnosis, will be furnished by the Contractor in accordance
with standards of care.
c)
The
Contractor agrees that anonymous testing may be furnished to the Enrollee
without prior approval by the Contractor and may be conducted at anonymous
testing sites. Services provided for HIV treatment may only be obtained from
the
Contractor during the period the Enrollee is enrolled in the Contractor's MMC
or
FHPlus product.
d)
The
Contractor shall implement policies and procedures consistent with CDC
recommendations as published in the MMWR where consistent with New York State
laws and SDOH Guidance for HIV Counseling & Testing and New Laboratory
Reporting Requirements, including:
i)
Methods for promoting HIV prevention to all Enrollees. HIV prevention
information, both primary as well as secondary, should be tailored to the
Enrollee's age, sex, and risk factor(s) (e.g., injection drug use and sexual
risk activities), and should be culturally and linguistically appropriate.
HIV
primary prevention means the reduction or control of causative factors for
HIV,
including the reduction of risk factors. HIV Primary prevention includes
strategies to help prevent uninfected Enrollees from acquiring HIV, i.e.,
behavior counseling for HIV negative Enrollees with risk behavior. Primary
prevention also includes strategies to help prevent infected Enrollees from
transmitting HIV infection, i.e., behavior counseling with an HIV infected
Enrollee to reduce risky sexual behavior or providing antiviral therapy to
a
pregnant, HIV infected female to prevent transmission of HIV infection to a
newborn. HIV Secondary Prevention means promotion of early detection and
treatment of HIV disease in an asymptomatic Enrollee to prevent the development
of symptomatic disease. This includes: regular medical assessments; routine
immunization for preventable infections; prophylaxis for opportunistic
.infections; regular dental, optical, dermatological and gynecological care;
optimal diet/nutritional supplementation; and
partner notification services which lead to the early detection and treatment
of
other infected persons. All Enrollees should be informed of the availability
of
HIV counseling, testing, referral and partner notification (CTRPN)
services.
ii)
Policies and procedures that promote HIV counseling and testing as a routine
part of medical care. Such policies and procedures shall include at a
minimum:
assessment
methods for recognizing the early signs and symptoms of HIV disease; initial
and
routine screening for HIV risk factors through administration of sexual behavior
and drug and alcohol use assessments; and the provision of information to all
Enrollees regarding the availability of HIV CTRPN services, including Rapid
HIV
Testing, from Participating Providers or as part of a Family Planning and
Reproductive Health services visit pursuant to Appendix C of this Agreement,
and
the availability of anonymous CTRPN services from New York State, New York
City
and the LPHA.
iii)
Policies and procedures that require Participating Providers to provide HIV
counseling and recommend HIV testing to pregnant women in their care. Such
policies and procedures shall be updated to reflect the most current CDC
recommendations as published in the MMWR where consistent with New York State
laws and SDOH Guidance on HIV Counseling and Testing. The HIV counseling and
testing provided shall be done in accordance with Article 27-F of
January
1, 2007 Amendment
3
the
PHL.
Such policies and procedures shall also direct Participating Providers to refer
any HIV positive women in their care to clinically appropriate services for
both
the women and their newborns.
iv)
A
network of providers sufficient to meet the needs of its Enrollees with HIV.
Satisfaction of the network requirement may be accomplished by inclusion of
HIV
specialists within the network or the provision of HIV specialist consultation
to non-HIV specialists serving as PCPs for persons with HIV infection; inclusion
of Designated AIDS Center Hospitals or other hospitals experienced in HIV care
in the Contractor's network; and contracts or linkages with providers funded
under the ▇▇▇▇ ▇▇▇▇▇ CARE Act. The Contractor shall inform Participating
Providers about how to obtain information about the availability of Experienced
HIV Providers and HIV Specialist PCPs.
v)
Case
Management Assessment for Enrollees with HIV Infection. The Contractor shall
establish policies and procedures to ensure that Enrollees who have been
identified as having HIV infection are assessed for case management services.
The Contractor shall arrange for any Enrollee identified as having HIV infection
and needing case management services to be referred to an appropriate case
management services provider, including Contractor provided case management,
and/or, with appropriate consent of the Enrollee, HIV community-based
psychosocial case management services and/or COBRA Comprehensive Medicaid Case
Management (CMCM) services for MMC Enrollees.
vi)
The
Contractor shall require its Participating Providers to report positive HIV
test
results and diagnoses and known contacts of such persons to the New York State
Commissioner of Health. In New York City, these shall be reported to the New
York City Commissioner of Health. Access to partner notification services must
be consistent with 10 NYCRR Part 63.
vii)
The
Contractor's Medical Director shall review Contractor's HIV practice guidelines
at least annually and update them as necessary for compliance with recommended
SDOH AIDS Institute and federal government clinical standards. The Contractor
will disseminate the HIV Practice Guidelines or revised guidelines to
Participating Providers at least annually, or more frequently as
appropriate.
4.
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 SDOH in Section 18.5 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.
5.
Delete
Section 1 8.4 “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 Professional Discipline: 18.10 "Certification Regarding
Individuals Who Have Been Debarred Or Suspended By Federal. State, or Local
Government:" 18.1 1 "Conflict of Interest Disclosure:"
January
1, 2007 Amendment
4
and
18.12 "Physician Incentive Plan Reporting." as Sections 18.4. 18.5. 18.6, 18.7.
18.8. 18.9. 18.10, and 18.11 respectively.
6.
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.
7.
Renumber
Sections 22.7 "Restrictions on Disclosure:" 22.8 "Transfer of Liability:" 22.9
"Termination of Health Care Professional Agreements:" 22.10 "Health Care
Professional Hearings:'' 22.11 "Non-Renewal of Provider Agreements:" 22.12
"Notice of Participating Provider Termination:" and 22.13 "Physician Incentive
Plan:" as Sections 22.8, 22.9. 22.10, 22.11. 22.12. 22.13. and 22.14
respectively.
8.
The
attached Appendix F "New York State Department of Health Action and Grievance
System Requirements for MMC and FHPlus Programs" will be applicable for the
period beginning January 1.2007.
9.
The
attached Appendix G ''SDOH Requirements for the Provision of Emergency Care
and
Services" will be applicable for the period beginning January 1.
2007.
10.
The
attached Appendix K "Prepaid Benefit Package Definitions of Covered and
Non-Covered Services" will be applicable for the period beginning January 1.
2007.
11.
Amend
Subsections 4 (a). 4 (b). and 4(c) 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), (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(a) (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
January
1, 2007 Amendment
5
12.
The
attached Schedule 1 "DOHMH Public Health Service Fee Schedule 1
of
Appendix N New York City Specific Contracting Requirements" will be applicable
for the period beginning January 1.2007.
All
other
provisions of said AGREEMENT shall remain in full force and effect.
January
1, 2007 Amendment
6
This
Amendment is effective January 1, 2007 and the Agreement, including the
modifications made by this Amendment and previous Amendments, shall remain
in
effect until September 30, 2007 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/ ▇▇▇▇ ▇.
▇▇▇▇▇
|
By:
/s/
▇▇▇▇▇▇ ▇▇▇▇
|
|
|
(Signature)
|
(Signature)
|
|
|
▇▇▇▇
▇. ▇▇▇▇▇
|
▇▇▇▇▇▇
▇▇▇▇
|
|
|
Title:
President & CEO
|
Title:
COO/ EDC
|
|
|
WellCare
of New York, Inc.
|
||
|
(Contractor’s
Name)
|
NYC
DOHMH
|
|
|
Date:
January 4, 2007
|
Date:
January 31, 2007
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|
January
1, 2007 Amendment
▇
▇▇▇▇▇
▇▇
▇▇▇▇▇▇▇
▇▇:
▇▇▇▇▇▇
▇▇
▇▇▇▇▇▇▇▇▇▇▇▇
▇▇
this
4th
Day of
January, 2007, ▇▇▇▇ ▇. ▇▇▇▇▇ 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
STATE
OF
NEW YORK
SS:
COUNTY
OF
NEW YORK
On
this
31 Day of January 2007, ▇▇▇▇▇▇ ▇▇▇▇ came before me, to me 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 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
Payment for Newborns
3.9
Supplemental Maternity Capitation Payment
3.10
Contractor's Financial Liability
3.11
Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care (MMC)
Enrollees
3.12
Mental Health and Chemical Dependence Stop-Loss for MMC Enrollees
3.13
Residential Health Care Facility Stop-Loss for MMC Enrollees
3.14
Stop-Loss Documentation and Procedures for the MMC Program
3.15
Family Health Plus (FHPlus) Reinsurance
3.16
Tracking Visits Provided by Indian Health Clinics - Applies to MMC Program
Only
Section
4
Service
Area
Section
5
Reserved
TABLE
OF
CONTENTS
January
1, 2007
1
Table
of Contents for Model Contract
Section
6 Enrollment
6.1
Populations Eligible for Enrollment
6.2
Enrollment Requirements
6.3
Equality of Access to Enrollment
6.4
Enrollment Decisions
6.5
Auto
Assignment - For MMC Program Only
6.6
Prohibition Against Conditions on Enrollment
6.7
Newborn Enrollment
6.8
Effective Date of Enrollment
6.9
Roster
6.10
Automatic Re-Enrollment
Section
7 Lock-In
Provisions
7.1
Lock-In Provisions in MMC Mandatory Local Social Services Districts and for
Family Health Plus
7.2
Disenrollment During a Lock-In Period
7.3
Notification Regarding Lock-In and End of Lock-In Period
7.4
Lock-In and Change in Eligibility Status
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 Requirements
10.1
Contractor Responsibilities
10.2
Compliance with State Medicaid Plan and Applicable Laws
10.3
Definitions
10.4
Child Teen Health Program/Adolescent Preventive Services
10.5
▇▇▇▇▇▇ Care Children - Applies to MMC Program Only
10.6
Child Protective Services
10.7
Welfare Reform - Applies to MMC Program Only
10.8
Adult Protective Services
10.9
Court-Ordered Services
TABLE
OF
CONTENTS
January
1, 2007
2
Table
of Contents for Model Contract
10.10
Family Planning and Reproductive Health Services
10.11
Prenatal Care
10.12
Direct Access
10.13
Emergency Services
10.14
Medicaid Utilization Thresholds (MUTS)
10.15
Services for Which Enrollees Can Self-Refer
a.
Mental
Health and Chemical Dependence Services
b.
Vision
Services
c.
Diagnosis and Treatment of Tuberculosis
d.
Family
Planning and Reproductive Health Services
e.
Article 28 Clinics Operated by Academic Dental Centers
10.16
Second Opinions for Medical or Surgical Care
10.17
Coordination with Local Public Health Agencies
10.18
Public Health Services
a.
Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
(TB/DOT)
b.
Immunizations
c.
.
Prevention and Treatment of Sexually Transmitted Diseases
d.
Lead
Poisoning - Applies to MMC Program Only
10.19
Adults with Chronic Illnesses and Physical or Developmental
Disabilities
10.20
Children with Special Health Care Needs
10.21
Persons Requiring Ongoing Mental Health Services
10.22
Member Needs Relating to HIV
10.23
Persons Requiring Chemical Dependence Services
10.24
Native Americans
10.25
Women, Infants, and Children (WIC)
10.26
Urgently Needed Services
10.27
Dental Services Provided by Article 28 Clinics Operated by Academic Dental
Centers Not Participating in Contractor's Network- Applies to MMC Program
Only
10.28
Hospice Services
10.29
Prospective Benefit Package Change for Retroactive SSI Determinations -Applies
to MMC Program Only
10.30
Coordination of Services
Section
11 Marketing
11.1
Information Requirements
11.2
Marketing Plan
11.3
Marketing Activities
11.4
Prior Approval of Marketing Materials and Procedures
11.5
Corrective and Remedial Actions
Section
12 Member
Services
12.1
General Functions
12.2
Translation and Oral Interpretation
12.3
Communicating with the Visually, Hearing and Cognitively Impaired
TABLE
OF
CONTENTS
January
1, 2007
3
Table
of Contents for Model Contract
Section
13 Enrollee
Rights and Notification
13.1
Information Requirements
13.2
Provider Directories/Office Hours for Participating Providers
13.3
Member ID Cards
13.4
Member Handbooks
13.5
Notification of Effective Date of Enrollment
13.6
Notification of Enrollee Rights
13.7
Enrollee's Rights
13.8
Approval of Written Notices
13.9
Contractor's Duty to Report Lack of Contact
13.10
LDSS Notification of Enrollee's Change in Address
13.11
Contractor Responsibility to Notify Enrollee of Effective Date of Benefit
Package Change
13.12
Contractor Responsibility to Notify Enrollee of Termination, Service Area
Changes and Network Changes
Section
14 Action
and Grievance System
14.1
General Requirements
14.2
Actions
14.3
Grievance System
14.4
Notification of Action and Grievance System Procedures
14.5
Complaint, Complaint Appeal and Action Appeal Investigation
Determinations
Section
15 Access
Requirements
15.1
General Requirement
15.2
Appointment Availability Standards
15.3
Twenty-Four (24) Hour Access
15.4
Appointment Waiting Times
15.5
Travel Time Standards
15.6
Service Continuation
a.
New
Enrollees
b.
Enrollees Whose Health Care Provider Leaves Network
15.7
Standing Referrals
15.8
Specialist as a Coordinator of Primary Care
15.9
Specialty Care Centers 15.10 Cultural Competence
Quality
Management
16.1
Internal Quality Management Program
16.2
Standards of Care
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
TABLE
OF
CONTENTS
January
1, 2007
4
Table
of Contents for 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
Professional Discipline
18.9
Certification Regarding Individuals Who Have Been Debarred or Suspended by
Federal or State Government
18.10
Conflict of Interest Disclosure
18.11
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, Potential Enrollees.
and Prospective Enrollees
20.2
Medical Records of ▇▇▇▇▇▇ Children
20.3
Confidentiality of Medical Records
20.4
Length of Confidentiality Requirements
Section
21 Provider
Network
21.1
Network Requirements
21.2
Absence of Appropriate Network Provider
21.3
Suspension of Enrollee Assignments to Providers
21.4
Credentialing
21.5
SDOH
Exclusion or Termination of Providers
21.6
Application Procedure
21.7
Evaluation Information
21.8
Choice/Assignment of Primary Care Providers (PCPs)
21.9
Enrollee PCP Changes
21.10
Provider Status Changes
21.11
PCP
Responsibilities
21.12
Member to Providers Ratios
21.13
Minimum PC P Office Hours
a.
General Requirements
b.
Waiver
of Minimum Hours
21.14
Primary Care Practitioners
a.
General Limitations
b.
Specialists and Sub-specialists as PCPs
TABLE
OF
CONTENTS
January
1, 2007
5
Table
of Contents for Model Contract
c.
OB/GYN
Providers as PCPs
d.
Certified Nurse Practitioners as PCPs
21.15
PCP
Teams
a.
General Requirements
b.
Registered Physician Assistants as Physician Extenders
c.
Medical Residents and Fellows
21.16
Hospitals
a.
Tertiary Services
b.
Emergency Services
21.17
Dental Networks
21.18
Presumptive Eligibility Providers
21.19
Mental Health and Chemical Dependence Services Providers
21.20
Laboratory Procedures
21.21
Federally Qualified Health Centers (FQHCs)
21.22
Provider Services Function
21.23
Pharmacies - Applies to FHPlus Program Only
Section
22 Subcontracts
and Provider Agreements
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
Restrictions on Disclosure
22.9
Transfer of Liability
22.10
Termination of Health Care Professional Agreements
22.11
Health Care Professional Hearings
22.12
Non-Renewal of Provider Agreements
22.13
Notice of Participating Provider Termination
22.14
Physician Incentive Plan
Section
23 Fraud
and
Abuse
23.1
General Requirements
23.2
Prevention Plans and Special Investigation Units
Section
24 Americans
With Disabilities Act (ADA) Compliance Plan
Section
25 Fair
Hearings
25.1
Enrollee Access to Fair Hearing Process
25.2
Enrollee Rights to a Fair Hearing
25.3
Contractor Notice to Enrollees
25.4
Aid
Continuing
25.5
Responsibilities of SDOH
25.6
Contractor's Obligations
TABLE
OF
CONTENTS
January
1, 2007
6
Table
of Contents for Model Contract
Section
26 External
Appeal
26.1
Basis for External Appeal
26.2
Eligibility For External Appeal
26.3
External Appeal Determination
26.4
Compliance With External Appeal Laws and Regulations
26.5
Member Handbook
Section
27 Intermediate
Sanctions
27.1
General
27.2
Unacceptable Practices
27.3
Intermediate Sanctions
27.4
Enrollment Limitations
27.5
Due
Process
Section
28 Environmental Compliance
Section
29 Energy Conservation
Section
30 Independent Capacity of Contractor Section 31
Section
31 No
Third
Party Beneficiaries
Section
32 Indemnification
32.1
Indemnification by Contractor
32.2
Indemnification by DOHMH
Section
33 Prohibition
on Use of Federal Funds for Lobbying
33.1
Prohibition of Use of Federal Funds for Lobbying
33.2
Disclosure Form to Report Lobbying
33.3
Requirements of Subcontractors
Section
34 Non-Discrimination
34.1
Equal Access to Benefit Package
34.2
Non-Discrimination
34.3
Equal Employment Opportunity
34.4
Native Americans Access to Services from Tribal or Urban Indian Health
Facility
Section
35 Compliance
with Applicable Laws
35.1
Contractor and DOHMH Compliance With Applicable Laws
35.2
Nullification of Illegal, Unenforceable, Ineffective or Void Contract
Provisions
35.3
Certificate of Authority Requirements
35.4
Notification of Changes In Certificate of Incorporation
35.5
Contractor's Financial Solvency Requirements
35.6
Compliance With Care For Maternity Patients
35.7
Informed Consent Procedures for Hysterectomy and Sterilization
TABLE
OF
CONTENTS
January
1, 2007
7
Table
of Contents for Model Contract
35.8
Non-Liability of Enrollees For Contractor's Debts
35.9
DOHMH Compliance With Conflict of Interest Laws
35.10
Compliance With New York State Public Health Law (PHL) Regarding External
Appeals
Section
36 New York State Standard Contract Clauses and Local Standard Clauses
Signature
Page
TABLE
OF
CONTENTS
January
1, 2007
8
Table
of Contents for Model Contract
APPENDICES
A.
New York State Standard Clauses
B.
Certification Regarding Lobbying
C.
New
York State Department of Health Requirements for the Provision of Family
Planning and Reproductive Health Services
D.
New
York State Department of Health Marketing Guidelines
E.
New
York State Department of Health Member Handbook Guidelines
F.
New
York State Department of Health Action and Grievance System Requirements
for the
MMC and FHPlus Programs
G.
New
York State Department of Health Requirements for the Provision of Emergency
Care
and Services
H.
New York State Department of Health Requirements for the Processing
of
Enrollments and Disenrollments in the MMC and FHPlus Programs
I.
New
York State Department of Health Guidelines for Use of Medical Residents and
Fellows
J.
New
York State Department of Health Guidelines for Contractor Compliance with
the
Federal ▇▇▇
▇.
Prepaid Benefit Package Definitions of Covered and Non-Covered Services
L.
Approved Capitation Payment Rates
M.
Service Area, Benefit Options and Enrollment Elections
N.
New
York City Specific Contracting Requirements
O.
Requirements for Proof of Workers' Compensation and Disability Benefits
Coverage
P.
RESERVED
Q.
RESERVED
R.
New
York City Standard Local Clauses
TABLE
OF
CONTENTS
January
1, 2007
9
APPENDIX
F
New
York State Department of Health Action and Grievance System Requirements for
MMC
and FHPlus Programs
F.1
Action Requirements
F.2
Grievance System Requirements
Appendix
F
January
1, 2007
F-1
F.1
Action
Requirements
1. Definitions
a)
Service Authorization Request means a request by an Enrollee, or a provider
on
the Enrollee's behalf, to the Contractor for the provision of a service,
including a request for a referral or for a non-covered service.
i)
Prior
Authorization Request is a Service Authorization Request by the Enrollee, or
a
provider on the Enrollee's behalf, for coverage of a new service, whether for
a
new authorization period or within an existing authorization period, before
such
service is provided to the Enrollee.
ii)
Concurrent Review Request is a Service Authorization Request by an Enrollee,
or
a provider on Enrollee's behalf, for continued, extended or more of an
authorized service than what is currently authorized by the
Contractor.
b)
Service Authorization Determination means the Contractor's approval or denial
of
a Service Authorization Request.
c)
Adverse Determination means a denial of a Service Authorization Request by
the
Contractor or an approval of a Service Authorization Request in an amount,
duration, or scope that is less than requested.
d)
An
Action means an activity of a Contractor or its subcontractor that results
in:
i)
the
denial or limited authorization of a Service Authorization Request, including
the type or level of service;
ii)
the
reduction, suspension, or termination of a previously authorized
service;
iii)
the
denial, in whole or in part, of payment for a service;
iv)
failure to provide services in a timely manner as defined by applicable
State ▇▇▇▇▇▇
regulation and Section 15 of this Agreement;
v)
failure of the Contractor to act within the timeframes for resolution and
notification of determinations regarding Complaints. Action Appeals and
Complaint Appeals provided in this Appendix; or
vi)
in
rural areas, as defined by 42 CFR §412.62(f)(a), where enrollment in the MMC
program is mandatory and there is only one MCO- the denial of an Enrollee's
request
to obtain services outside the MCO's network pursuant to 42 CFR
§438.52(b)(2)(ii).
Appendix
F
January
1, 2007
F-2
2.
General Requirements
a)
The
Contractor's policies and procedures for Service Authorization Determinations
and utilization review determinations shall comply with 42 CFR Part 438 and
Article 49 of the PHL, including but not limited to the following:
i)
Expedited review of a Service Authorization Request must be conducted when
the
Contractor determines or the provider indicates that a delay would seriously
jeopardize the Enrollee's life or health or ability to attain, maintain, or
regain maximum function. The Enrollee may request expedited review of a Prior
Authorization Request or Concurrent Review Request. If the Contractor denies
the
Enrollee's request for expedited review, the Contractor must handle the request
under standard review timeframes. .
ii)
Any
Action taken by the Contractor regarding medical necessity or experimental
or
investigational services must be made by a clinical peer reviewer as defined
by
PHL §4900(2)(a).
iii)
Adverse Determinations, other than those regarding medical necessity or
experimental/investigational services, must be made by a licensed, certified
or
registered health care professional when such determination is based on an
assessment of the Enrollee's health status or of the appropriateness of the
level, quantity or delivery method of care. This requirement applies to Service
Authorization Requests including but not limited to services included in the
Benefit Package, referrals and out-of-network services.
iv)
The
Contractor is required to provide notice by phone and in writing to the Enrollee
and to the provider of Service Authorization Determinations, whether adverse
or
not, within the timeframe specified in Section 3 below. Notice to the provider
must contain the same information as the Notice of Action for the
Enrollee.
v)
The
Contractor is required to provide the Enrollee written notice of any Action
other than a Service Authorization Determinations within the timeframe specified
in Section 4 below.
3.
Timeframes for Service Authorization Determinations
a)
For
Prior Authorization Requests, the Contractor must make a Service Authorization
Determination and notice the Enrollee of the determination by phone and in
writing as fast as the Enrollee's condition requires and no more
than:
Appendix
F
January
1, 2007
F-3
i)
In the
case of an expedited review, three (3) business days after receipt of the.
Service Authorization Request; or
ii)
In
all other cases, within three (3) business days of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization request.
b)
For
Concurrent Review Requests, the Contractor must make a Service Authorization
Determination and notice the Enrollee of the determination by phone and in
writing as fast as the Enrollee's condition requires and no more
than;
i)
In the
case of an expedited review, one (1) business day after receipt of necessary
information but no more than three (3) business days after receipt of the
Service Authorization Request; or
ii)
In
all other cases, within one (1) business day of receipt of necessary
information, but no more than fourteen (14) days after receipt of the Service
Authorization Request.
c)
Timeframes for Service Authorization Determinations may be extended for up
to
fourteen (14) days if:
i)
the
Enrollee, the Enrollee's designee, or the Enrollee's provider requests an
extension orally or in writing; or
ii)
The
Contractor can demonstrate or substantiate that there is a need for additional
information and how the extension is in the Enrollee's interest. The Contractor
must send notice of the extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to demonstrate, upon SDOH's
request, that the extension was justified.
d)
If the
Contractor extended its review as provided in paragraph 3(c) above, the
Contractor must make a Service Authorization Determination and notice the
Enrollee by phone and in writing as fast as the Enrollee's condition requires
and within three (3) business days after receipt of necessary information for
Prior Authorization Requests or within one (1) business day after receipt of
necessary information for Concurrent Review Requests, but in no event later
than
the date the extension expires.
4.
Timeframes for Notices of Actions Other Than Service Authorizations
Determinations
a)
When
the Contractor intends to reduce, suspend, or terminate a previously authorized
service within an authorization period, it must provide the Enrollee with a
written notice at least ten (10) days prior to the intended Action,
except:
Appendix
F
January
1, 2007
F-4
i)
the
period of advance notice is shortened to five (5) days in cases of confirmed
Enrollee fraud; or
ii)
the
Contractor may mail notice not later than date of the Action for the
following:
A)
the
death of the Enrollee;
B)
a
signed written statement from the Enrollee requesting service termination or
giving information requiring termination or reduction of services (where the
Enrollee understands that this must be the result of supplying the
information);
C)
the
Enrollee's admission to an institution where the Enrollee is ineligible for
further services;
D)
the
Enrollee's address is unknown and mail directed to the Enrollee is returned
stating that there is no forwarding address;
E)
the
Enrollee has been accepted for Medicaid services by another jurisdiction; or
F)
the
Enrollee's physician prescribes a change in the level of medical
care.
b)
The
Contractor must mail written notice to the Enrollee on the date of the Action
when the Action is denial of payment, in whole or in part, except as provided
in
paragraph F.I 6(b) below.
c)
When
the Contractor does not reach a determination within the Service Authorization
Determination timeframes described above, it is considered an Adverse
Determination, and the Contractor must send notice of Action to the Enrollee
on
the date the timeframes expire.
5.
Format and Content of Notices
a)
The
Contractor shall ensure that all notices are in writing, in easily understood
language and are accessible to non-English speaking and visually impaired
Enrollees. Notices shall include that oral interpretation and alternate formats
of written material for Enrollees with special needs are available and how
to
access the alternate formats.
i)
Notice
to the Enrollee that the Enrollee's request for an expedited review has been
denied shall include that the request will be reviewed under standard
timeframes, including a description of the timeframes.
ii)
Notice to the Enrollee regarding a Contractor-initiated extension shall
include:
A)
the
reason for the extension;
B)
an
explanation of how the delay is in the best interest of the
Enrollee;
C)
any
additional information the Contractor requires from any source to make its
determination;
D)
the
right of the Enrollee to file a Complaint (as defined in Appendix F.2 of this
Agreement)regarding the extension;
Appendix
F
January
1, 2007
F-5
E)
the
process for filing a Complaint with the Contractor and the timeframes within
which a Complaint determination must be made;
F)
the
right of an Enrollee to designate a representative to file a Complaint on behalf
of the Enrollee; and G) the right of the Enrollee to contact the New York State
Department of Health regarding his or her Complaint, including the SDOH's
toll-free number for Complaints.
iii)
Notice to the Enrollee of an Action shall include:
A)
the
description of the Action the Contractor has taken or intends to
take;
B)
the
reasons for the Action, including the clinical rationale, if any;
C)
the
Enrollee's right to file an Action Appeal (as defined in Appendix F.2 of this
Agreement), including:
I)
The
fact that the Contractor will not retaliate or take any discriminatory action
against the Enrollee because he/she filed an Action Appeal.
II)
The
right of the Enrollee to designate a representative to file Action Appeals
on
his/her behalf;
D)
the
process and timeframe for filing an Action Appeal with the Contractor, including
an explanation that an expedited review of the Action Appeal can be requested
if
a delay would significantly increase the risk to an Enrollee's health, a
toll-free number for filing an oral Action Appeal and a form, if
used
by
the
Contractor, for filing a written Action Appeal;
E)
a
description of what additional information, if any. must be obtained by the
Contractor from any source in order for the Contractor to make an Appeal
determination;
F)
the
timeframes within which the Action Appeal determination must be
made;
G)
the
right of the Enrollee to contact the New York State Department of Health with
his or her Complaint, including the SDOH's toll-free number for Complaints;
and
H)
the
notice entitled "Managed Care Action Taken" for denial of benefits or for
termination or reduction in benefits, as applicable, containing the Enrollee's
fair hearing and aid continuing rights.
I)
For
Actions based on issues of Medical Necessity or an experimental or
investigational treatment, the notice of Action shall also include;
I)
a
clear statement that the notice constitutes the initial adverse determination
and specific use of the terms "medical necessity" or
"experimental/investigational”;
II)
a
statement that the specific clinical review criteria relied upon in making
the
determination is available upon request; and
III)
a
statement that the Enrollee may be eligible for an External Appeal.
6.
Contractor Obligation to Notice
a)
The
Contractor must provide written Notice of Action to Enrollees and providers
in
accordance with the requirements of this Appendix, including, but not limited
to, the following circumstances (except as provided for in paragraph 6(b)
below):
Appendix
F
January
1, 2007
F-6
i)
the
Contractor makes a coverage determination or denies a request for a referral,
regardless of whether the Enrollee has received the benefit;
ii)
the
Contractor determines that a service does not have appropriate
authorization;
iii)
the
Contractor denies a claim for services provided by a Non-Participating Provider
for any reason;
iv)
the
Contractor denies a claim or service due to medical necessity;
v)
the
Contractor rejects a claim or denies payment due to a late claim
submission;
vi)
the
Contractor denies a claim because it has determined that the Enrollee was not
eligible for MMC or FHPlus coverage on the date of service;
vii)
the
Contractor denies a claim for service rendered by a Participating Provider
due
to lack of a referral;
viii)
the
Contractor denies a claim because it has determined it is not the appropriate
payor; or
ix)
the
Contractor denies a claim due to a Participating Provider billing for Benefit
Package services not included in the Provider. Agreement between the Contractor
and the Participating Provider.
b)
The
Contractor is not required to provide written Notice of Action to Enrollees
in
the following circumstances:
i)
When
there is a prepaid capitation arrangement with a Participating Provider and
the
Participating Provider submits a fee-for-service claim to the Contractor for
a
service that falls within the capitation payment;
ii)
if a
Participating Provider of the Contractor itemizes or "unbundles" a claim for
services encompassed by a previously negotiated global fee
arrangement;
iii)
if a
duplicate claim is submitted by the Enrollee or a Participating Provider, no
notice is required, provided an initial notice has been issued;
iv)
if
the claim is for a service that is carved-out of the MMC Benefit Package and
is
provided to a MMC Enrollee through Medicaid fee-for-service, however, the
Contractor should notify the provider to submit the claim to
Medicaid;
v)
if the
Contractor makes a coding adjustment to a claim (up-coding or down-coding)
and
its Provider Agreement with the Participating Provider includes a provision
allowing the Contractor to make such adjustments;
Appendix
F
January
1, 2007
F-7
vi)
if
the Contractor has paid the negotiated amount reflected in the Provider
Agreement with a Participating Provider for the services provided to the
Enrollee and denies the Participating Provider's request for additional payment;
or
vii)
if
the Contractor has not yet adjudicated the claim. If the Contractor has pended
the claim while requesting additional information, a notice is not required
until the coverage determination has been made.
Appendix
F
January
1, 2007
F-8
F.2
Grievance
System Requirements
1.
Definitions
a)
A
Grievance System means the Contractor's Complaint and Appeal process, and
includes a Complaint and Complaint Appeal process, a process to appeal Actions,
and access to the State's fair hearing system.
b)
For
the purposes of this Agreement, a Complaint means an Enrollee's expression
of
dissatisfaction with any aspect of his or her care other than an Action. A
"Complaint" means the same as a "grievance" as defined by 42 CFR §438.400
(b).
c)
An
Action Appeal means a request for a review of an Action.
d)
A
Complaint Appeal means a request for a review of a Complaint
determination.
e)
An
Inquiry means a written or verbal question or request for information posed
to
the Contractor with regard to such issues as benefits, contracts, and
organization rules. Neither Enrollee Complaints nor disagreements with
Contractor determinations are Inquiries.
2.
Grievance System - General Requirements
a)
The
Contractor shall describe its Grievance System in the Member Handbook, and
it
must be accessible to non-English speaking, visually, and hearing impaired
Enrollees. The handbook shall comply with Section 13.4 and The Member Handbook
Guidelines (Appendix E) of this Agreement.
b)
The
Contractor will provide Enrollees with any reasonable assistance in completing
forms and other procedural steps for filing a Complaint, Complaint Appeal or
Action Appeal, including, but not limited to. providing interpreter services
and
toll-free numbers with TTY/TDD and interpreter capability.
c)
The
Enrollee may designate a representative to file Complaints, Complaint Appeals
and Action Appeals on his/her behalf.
d)
The
Contractor will not retaliate or take any discriminatory action against the
Enrollee because he/she filed a Complaint. Complaint Appeal or Action
Appeal.
Appendix
F
January
1, 2007
F-9
e)
The
Contractor's procedures for accepting Complaints, Complaint Appeals and Action
Appeals shall include:
i)
toll-free telephone number;
ii)
designated staff to receive calls;
iii)
''live" phone coverage at least forty (40) hours a week during normal business
hours;
iv)
a
mechanism to receive after hours calls, including either:
A)
a
telephone system available to take calls and a plan to respond to all such
calls
no later than on the next business day after the calls were recorded;
or
B)
a
mechanism to have available on a twenty-four (24) hour, seven (7) day a week
basis designated staff to accept telephone Complaints; whenever a delay would
significantly increase the risk to an Enrollee's health.
f)
The
Contractor must ensure that personnel making determinations regarding
Complaints, Complaint Appeals and Action Appeals were not involved in previous
levels of review or decision-making. If any of the following applies,
determinations must be made by qualified clinical personnel as specified in
this
Appendix:
i)
A
denial Action Appeal based on lack of medical necessity.
ii)
A
Complaint regarding denial of expedited resolution of an Action
Appeal.
iii)
A
Complaint, Complaint Appeal, or Action Appeal that involves clinical
issues.
3.
Action Appeals Process
a)
The
Contractor's Action Appeals process shall indicate the following regarding
resolution of Appeals of an Action:
i)
The
Enrollee, or his or her designee, will have no less than sixty (60) business
days from the date of the notice of Action to file an Action Appeal. An Enrollee
filing an Action Appeal within 10 days of the notice of Action or by the
intended date of an Action, whichever is later, that involves the reduction,
suspension, or termination of'previously approved services may request "aid
continuing" in accordance with Section 25.4 of this Agreement.
ii)
The
Enrollee may file a written Action Appeal or an oral Action Appeal. Oral Action
Appeals must be followed by a written, signed, Action Appeal. The Contractor
may
provide a written summary of an oral Action Appeal to the Enrollee (with the
acknowledgement or separately) for the Enrollee to review,
Appendix
F
January
1, 2007
F-10
modify
if
needed, sign and return to the Contractor. If the Enrolled or provider requests
expedited resolution, of the Action Appeal, the oral Action Appeal does not
need
to be confirmed in writing. The date of the oral filing of the Action Appeal
will be the date of the Action Appeal for the purposes of the timeframes for
resolution of Action Appeals. Action Appeals resulting from a Concurrent Review
must be handled as an expedited Action Appeal.
iii)
The
Contractor must send a written acknowledgement of the Action Appeal within
fifteen (15) days of receipt. If a determination is reached before the written
acknowledgement is sent. the Contractor may include the written acknowledgement
with the notice of Action Appeal determination (one notice).
iv)
The
Contractor must provide the Enrollee reasonable opportunity to present evidence,
and allegations of fact or law, in person as well as in writing. The Contractor
must inform the Enrollee of the limited time to present such evidence in the
case of an expedited Action Appeal. The Contractor must allow the Enrollee
or
his or her designee, both before and during the Action Appeals process, to
examine the Enrollee's case file, including medical records and any other
documents and records considered during the Action Appeals process. The
Contractor will consider the Enrollee, his or her designee, or legal estate
representative of a deceased Enrollee a party to the Action Appeal.
v)
The
Contractor must have a process for handling expedited Action Appeals. Expedited
resolution of the Action Appeal must be conducted when the Contractor determines
or the provider indicates that a delay would seriously jeopardize the Enrollee's
life or health or ability to attain, maintain, or regain maximum function.
The
Enrollee may request an expedited review of. an Action Appeal. If the Contractor
denies the Enrollee's request for an expedited review, the Contractor must
handle the request under standard Action Appeal resolution timeframes, make
reasonable efforts to provide prompt oral notice of the denial to the Enrollee
and send written notice of the denial within two (2) days of the denial
determination.
vi)
The
Contractor must ensure that punitive action is not taken against a provider
who
either requests an expedited resolution or supports an Enrollee's
Appeal.
vii)
Action Appeals of clinical matters must be decided by personnel qualified to
review the Action Appeal, including licensed, certified or registered health
care professionals who did not make the initial determination, at least one
of
whom must be a clinical peer reviewer, as defined by PHL §4900(2)(a). Action
Appeals of non-clinical matters shall be determined by qualified personnel
at a
higher level than the personnel who made the original
determination.
Appendix
F
January
1, 2007
F-11
4.
Timeframes for Resolution of Action Appeals
a)
The
Contractor's Action Appeals process shall indicate the following specific
timeframes regarding Action Appeal resolution:
i)
The
Contractor will resolve Action Appeals as fast as the Enrollee's condition
requires, and no later than thirty (30) days from the date of the receipt of
the
Action Appeal.
ii)
The
Contractor will resolve expedited Action Appeals as fast as the Enrollee's
condition requires, within two (2) business days of receipt of necessary
information and no later than three (3) business days of the date of the receipt
of the Action Appeal.
iii)
Timeframes for Action Appeal resolution may be extended for up to fourteen
(14)
days if:
A)
the
Enrollee, his or her designee. or the provider requests an extension orally
or
in writing; or
B)
the
Contractor can demonstrate or substantiate that there is a need for additional
information and the extension is in the Enrollee's interest. The Contractor
must
send notice of the extension to the Enrollee. The Contractor must maintain
sufficient documentation of extension determinations to demonstrate, upon SDOH's
request, that the extension was justified.
iv)
The
Contractor will make a reasonable effort to provide oral notice to the Enrollee,
his or her designee, and the provider where appropriate, for expedited Action
Appeals at the time the Action Appeal determination is made.
v)
The
Contractor must send written notice to the Enrollee, his or her designee, and
the provider where appropriate, within two (2) business days of the Action
Appeal determination.
5.
Action Appeal Notices
a)
The
Contractor shall ensure that all notices are in writing and in easily understood
language and are accessible to non-English speaking and visually impaired
Enrollees. Notices shall include that oral interpretation and alternate formats
of written material for Enrollees with special needs are available and how
to
access the alternate formats.
i)
Notice
to the Enrollee that the Enrollee's request for an expedited Action Appeal
has
been denied shall include that the request will be reviewed under standard
Action Appeal timeframes, including a description of the timeframes. This notice
may be combined with the acknowledgement.
Appendix
F
January
1, 2007
F-12
ii)
Notice to the Enrollee regarding an Contractor-initiated extension shall
include:
A)
the
reason for the extension;
B)
an
explanation of how the delay is in the best interest of the
Enrollee;
C)
any
additional information the Contractor requires from any source to make its
determination;
D)
the
right of the Enrollee to file a Complaint regarding the extension;
E)
the
process for filing a Complaint with the Contractor and the timeframes within
which a Complaint determination must be made;
F)
the
right of an Enrollee to designate a representative to file a Complaint on behalf
of the Enrollee; and
G)
the
right of the Enrollee to contact the New York State Department of Health
regarding his or her their Complaint, including the SDOH's toll-free number
for
Complaints.
iii)
Notice to the Enrollee of Action Appeal Determination shall
include:
A)
Date
the Action Appeal was filed and a summary of the Action Appeal;
B)
Date
the Action Appeal process was completed;
C)
the
results and the reasons for the determination, including the clinical rationale,
if any;
D)
If the
determination was not in favor of the Enrollee, a description of
Enrollee's
fair hearing rights, if applicable;
E)
the
right of the Enrollee to contact the New York State Department of
Health
regarding
his or her Complaint, including the SDOH's toll-free number for
Complaints;
and
F)
For
Action Appeals involving Medical Necessity or an experimental or
investigational
treatment, the notice must also include:
I)
a
clear statement that the notice constitutes the final adverse determination
and
specifically use the terms "medical necessity" or
"experimental/investigational;"
II)
the
Enrollee's coverage type;
III)
the
procedure in question, and if available and applicable the name of the provider
and developer/manufacturer of the health care service;
IV)
statement that the Enrollee is eligible to file an External Appeal and the
timeframe for filing;
V)
a copy
of the "Standard Description and Instructions for Health Care Consumers to
Request an External Appeal" and the External Appeal application
form;
VI)
the
Contractor's contact person and telephone number;
VII)
the
contact person, telephone number, company name and full address of the
utilization review agent, if the determination was made by the
agent;
and
VIII)
if
the Contractor has a second level internal review process, the notice shall
contain instructions on how to file a second level Action Appeal and a statement
in bold text that the timeframe for requesting an External Appeal begins upon
receipt of the final adverse determination
Appendix
F
January
1, 2007
F-13
of
the
first level Action Appeal, regardless of whether or not a second level of Action
Appeal is requested, and that by choosing to request a second level Action
Appeal, the time may expire for the Enrollee to request an External
Appeal.
6.
Complaint Process
a)
The
Contractor' Complaint process shall include the following regarding the handling
of Enrollee Complaints:
i)
The
Enrollee, or his or her designee, may file a Complaint regarding any dispute
with the Contractor orally or in writing. The Contractor may have requirements
for accepting written Complaints either by letter or Contractor supplied form.
The Contractor cannot require an Enrollee to file a Complaint in
writing.
ii)
The
Contractor must provide written acknowledgement of any Complaint not immediately
resolved, including the name, address and telephone number of the individual
or
.department handling the Complaint, within fifteen (15) business days of receipt
of the Complaint. The acknowledgement must identify any additional information
required by the Contractor from any source to make a determination. If a
Complaint determination is made before the written acknowledgement is sent,
the
Contractor may include the acknowledgement with the notice of the determination
(one notice).
iii)
Complaints shall be reviewed by one or more qualified personnel.
iv)
Complaints pertaining to clinical matters shall be reviewed by one or more
licensed, certified or registered health care professionals in addition to
whichever non-clinical personnel the Contractor designates.
7.
Timeframes for Complaint Resolution by the Contractor
a)
The
Contractor's Complaint process shall indicate the following specific timeframes
regarding Complaint resolution;
i)
If the
Contractor immediately resolves an oral Complaint to the Enrollee's
satisfaction, that Complaint may be considered resolved without any additional
written notification to the Enrollee. Such Complaints must be logged by the
Contractor and included in the Contractor's quarterly HPN Complaint report
submitted to SDOH in accordance with Section 18 of this Agreement.
ii)
Whenever a delay would significantly increase the risk to an Enrollee's health,
Complaints shall be resolved within forty-eight (48) hours after receipt of
all
necessary information and no more than seven (7) days from the receipt of the
Complaint.
Appendix
F
January
1, 2007
F-14
iii)
All
other Complaints shall be resolved within forty-five (45) days after the receipt
of all necessary information and no more than sixty (60) days from receipt
of
the Complaint. The Contractor shall maintain reports of Complaints unresolved
after forty-five (45) days in accordance with Section 18 of this
Agreement.
8.
Complaint Determination Notices
a)
The
Contractor's procedures regarding the resolution of Enrollee Complaints shall
include the following:
i)
Complaint Determinations by the Contractor shall be made in writing to the
Enrollee or his/her designee and include:
A)
the
detailed reasons for the determination;
B)
in
cases where the determination has a clinical basis, the clinical rationale
for
the determination;
C)
the
procedures for the filing of an appeal of the determination, including a form,
if used by the Contractor, for the filing of such a Complaint Appeal; and notice
of the right of the Enrollee to contact the State Department of Health regarding
his or her Complaint, including SDOH's toll-free number for
Complaints.
ii) If
the Contractor was unable to make a Complaint determination because insufficient
information was presented or available to reach a determination, the Contractor
will send a written statement that a determination could not be made to the
Enrollee on the date the allowable time to resolve the Complaint has
expired.
iii)
In
cases where delay would significantly increase the risk to an Enrollee's health,
the Contractor shall provide notice of a determination by telephone directly
to
the Enrollee or to the Enrollee's designee, or when no phone is available,
some
other method of communication, with written notice to follow within three (3)
business days.
9.
Complaint Appeals
a)
The
Contractor's procedures regarding Enrollee Complaint Appeals shall include
the
following:
i)
The
Enrollee or designee has no less than sixty (60) business days after receipt
of
the notice of the Complaint determination to file a written Complaint Appeal.
Complaint Appeals may be submitted by letter or by a form provided by the
Contractor.
ii)
Within fifteen (15) business days of receipt of the Complaint Appeal, the
Contractor shall provide written acknowledgement of the Complaint Appeal,
including the name. address and telephone number of the individual designated
to
Appendix
F
January
1, 2007
F-15
respond
to the Appeal. The Contractor shall indicate what additional information, if
any, must be provided for the Contractor to render a determination.
iii)
Complaint Appeals of clinical matters must be decided by personnel qualified
to
review the Appeal, including licensed, certified or registered health care
professionals who did not make the initial determination, at least one of whom
must be a clinical peer reviewer, as defined by PHL §4900(2)(a).
iv)
Complaint Appeals of non-clinical matters shall be determined by qualified
personnel at a higher level than the personnel who made the original Complaint
determination.
v)
Complaint Appeals shall be decided and notification provided to the Enrollee
no
more than:
A)
two
(2) business days after the receipt of all necessary information when a delay
would significantly increase the risk to an Enrollee's health; or
B)
thirty
(3.0) business days after the receipt of all necessary information in all other
instances.
vi)
The
notice of the Contractor's Complaint Appeal determination shall
include:
A)
the
detailed reasons for the determination;
B)
the
clinical rationale for the determination in cases where the determination has
a
clinical basis;
C)
the
notice shall also inform the Enrollee of his/her option to also contact the
State Department of Health with his/her Complaint, including the SDOH's
toll-free number for Complaints;
D)
instructions for any further Appeal, if applicable.
10. Records
a)
The
Contractor shall maintain a file on each Complaint, Action Appeal and Complaint
Appeal. These records shall be readily available for review by the SDOH, upon
request. The file shall include:
i)
date
the Complaint was filed;
ii)
copy
of the Complaint, if written;
iii)
date
of receipt of and copy of the Enrollee's written confirmation, if
any;
iv)
log
of Complaint determination including the date of the determination and the
titles of the personnel and credentials of clinical personnel who reviewed
the
Complaint;
v)
date
and copy of the Enrollee's Action Appeal or Complaint Appeal;
Appendix
F
January
1, 2007
F-16
vi)
Enrollee or provider requests for expedited Action Appeals and Complaint Appeals
and the Contractor's determination;
vii)
necessary documentation to support any extensions;
viii)
determination and date of determination of the Action Appeals and Complaint
Appeals;
ix)
the
titles and credentials of clinical staff who reviewed the Action Appeals and
Complaint Appeals; and
x)
Complaints unresolved for greater than forty-five (45) days.
Appendix
F
January
1, 2007
F-17
APPENDIX
G
SDOH
Requirements for the Provision
of
Emergency Care and Services
Appendix
G
January
1, 2007
G-1
SDOH
Requirements for the
Provision
of Emergency Care and Services
1. Definitions
a)
"Emergency Medical Condition" means a medical or behavioral condition, the
onset
of which is sudden, that manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, possessing an average knowledge
of medicine and health, could reasonably expect the absence of immediate medical
attention to result in:
i)
placing the health of the person afflicted with such condition in serious
jeopardy or, in the case of a pregnant woman, the health of the woman or her
unborn child or, in the case of a behavioral condition, placing the health
of
the person or others in serious jeopardy; or
ii)
serious impairment to such person's bodily functions; or
iii)
serious dysfunction of any bodily organ or part of such person; or
iv)
serious disfigurement of such person.
b)
"Emergency Services"
means
covered inpatient and outpatient health care procedures, treatments or services
that are furnished by a provider qualified to furnish these services and that
are needed to evaluate or stabilize an Emergency Medical Condition including
psychiatric stabilization and medical detoxification from drugs or
alcohol.
c)
"Post-stabilization Care Services"
means
covered services, related to an emergency medical condition, that are provided
after an Enrollee is stabilized in order to maintain the stabilized condition,
or, under the circumstances described in Section 3 below, to improve or resolve
the Enrollee's condition.
2.
Coverage and Payment of Emergency Services
a)
The
Contractor must cover and pay for Emergency Services regardless of whether
the
provider that furnishes the services has a contract with the
Contractor.
b)
The
Contractor shall cover and pay for services as follows:
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 or
rates of payment specified in the contract between the Contractor
and
Appendix
G
January
1, 2007
G-2
the
hospital. Such contracted rate or rates shall be paid without regard to whether
such services meet the definition of Emergency Medical Condition.
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 or rates of payment specified
in the contract between the Contractor and the physician. Such contracted rate
or rates shall be paid without regard to whether such services meet the
definition of Emergency Medical Condition.
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 without regard to whether such services meet
the
definition of Emergency Medical Condition.
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 the service was rendered without regard to whether such
services meet the definition of Emergency Medical Condition.
c)
The
Contractor must advise Enrollees that they may access Emergency Services at
any
Emergency Services provider.
d)
Prior
authorization for treatment of an Emergency Medical Condition is never
required.
e)
The
Contractor may not deny payment for treatment obtained in either of the
following circumstances:
i)
An
Enrollee had an Emergency Medical Condition, including cases in which the
absence of immediate medical attention would not have had the outcomes specified
in the definition of Emergency Medical Condition above.
ii)
A
representative of the Contractor instructs the Enrollee to seek Emergency
Services.
f)
A
Contractor may not:
i)
limit
what constitutes an Emergency Medical Condition based on lists of diagnoses
or
symptoms; or
ii)
refuse to cover emergency room services based on the failure of the provider
or
the Enrollee to give the Contractor notice of the emergency room
visit.
Appendix
G
January
1, 2007
G-3
g)
An
Enrollee who has an Emergency Medical Condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient.
h)
The
attending emergency physician, or the provider actually treating the Enrollee,
is responsible for determining when the Enrollee is sufficiently stabilized
for
transfer or discharge, and that determination is binding on the Contractor
for
payment.
3.
Coverage and Payment of Post-stabilization Care Services
a)
The
Contractor is financially responsible for Post-stabilization Care Services
furnished by a provider within or outside the Contractor's network
when:
i)
they
are pre-approved by a Participating . Provider, as authorized by the Contractor,
or other authorized Contractor representative;
ii)
they
are not pre-approved by a Participating Provider, as authorized by the
Contractor, or other authorized Contractor representative, but administered
to
maintain the Enrollee's stabilized condition within one (1) hour of a request
to
the Contractor for pre-approval of further Post-stabilization Care
Services;
iii)
they
are not pre-approved by a Participating Provider, as authorized by the
Contractor, or other authorized Contractor representative, but administered
to
maintain, improve or resolve the Enrollee's stabilized condition
if;
A)
The
Contractor does not respond to a request for pre-approval within one
(l)hour;
B)
The
Contractor cannot be contacted; or
C)
The
Contractor's representative and the treating physician cannot reach an agreement
concerning the Enrollee's care and a plan physician is not available for
consultation. In this situation, the Contractor must give the treating physician
the opportunity to consult with a plan physician and the treating physician
may
continue with care of the patient until a plan physician is reached or one
of
the criteria in 3(b) is met.
iv)
The
Contractor must limit charges to Enrollees for Post-stabilization Care Services
to an amount no greater than what the organization would charge the Enrollee
if
he or she had obtained the services through the Contractor.
b)
The
Contractor's financial responsibility to the treating emergency provider for
Post-stabilization Care Services it has not pre-approved ends when:
i)
A plan
physician with privileges at the treating hospital assumes responsibility for
the Enrollee's care;
Appendix
G
January
1, 2007
G-4
ii)
A
plan physician assumes responsibility for the Enrollee's care through
transfer;
iii)
A
Contractor representative and the treating physician reach an agreement
concerning the Enrollee's care or
iv)
The
Enrollee is discharged.
4.
Protocol for Acceptable Transfer Between Facilities
a)
All
relevant COBRA requirements must be met.
b)
The
Contractor must provide for an appropriate (as determined by the emergency
department physician) transfer method/level with personnel as
needed.
c)
The
Contractor must contact/arrange for an available, accepting physician and
patient bed at the receiving institution.
d)
If a
patient is not transferred within eight (8) hours to an appropriate inpatient
setting after the decision to admit has been made, then admission at the
original facility is deemed authorized.
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.
Appendix
G
January
1, 2007
G-5
APPENDIX
K
PREPAID
BENEFIT PACKAGE DEFINITIONS OF COVERED AND NON-COVERED
SERVICES
K.1
Chart
of Prepaid Benefit Package
-
Medicaid Managed Care Non-SSI (MMC Non-SSI)
-
Medicaid Managed Care SSI (MMC SSI)
-
Medicaid Fee-for-Service (MFFS)
-
Family
Health Plus (FHPlus)
K.2
Prepaid Benefit Package Definitions of Covered Services
K.3
Medicaid Managed Care Definitions of Non-Covered Services
K.4
Family Health Plus Non-Covered Services
Appendix
K
January
1, 2007
K-1
APPENDIX
K
PREPAID
BENEFIT PACKAGE
DEFINITIONS
OF COVERED AND NON-COVERED SERVICES
1. General
a)
The
categories of services in the Medicaid Managed Care and Family Health Plus
Benefit Packages, including optional-covered services shall be provided by
the
Contractor to MMC Enrollees and FHPlus Enrollees. respectively, when medically
necessary under the terms of this Agreement. The definitions of covered and
non-covered services herein are in summary form; the full description and scope
of each covered service as established by the New York Medical Assistance
Program are set forth in the applicable NYS Medicaid Provider Manual, except
for
the Eye Care and Vision benefit for FHPlus Enrollees which is described in
Section 19 of Appendix K.2.
b)
All
care provided by the Contractor, pursuant to this Agreement, must be provided,
arranged, or authorized by the Contractor or its Participating Providers with
the exception of most behavioral health services to SSI or SSI related
beneficiaries, and emergency services, emergency transportation, Family Planning
and Reproductive Health services, mental health and chemical dependence
assessments (one (1) of each per year), court ordered services, and services
provided by Local Public Health Agencies as described in Section 10 of this
Agreement.
c)
This
Appendix contains the following sections:
i)
K.I -
"Chart of Prepaid Benefit Package'' lists the services provided by the
Contractor
to all Medicaid Managed Care Non-SSI Enrollees. Medicaid Managed Care SSI
Enrollees, Medicaid fee-for-service coverage for carved out and wraparound
benefits, and Family Health Plus Enrollees.
ii)
K.2 -
''Prepaid Benefit Package Definitions Of Covered Services" describes the covered
services, as numbered in K. 1. Each service description applies to both MMC
and
FHPlus Benefit Package unless otherwise noted.
iii)
K.3
- "Medicaid Managed Care Definitions of Non-Covered Services'' describes
services that are not covered by the MMC Benefit Package. These services are
covered by the Medicaid fee-for-service program unless otherwise
noted.
iv)
K.4 -
"Family Health Plus Non-Covered Services" lists the services that are not
covered by the FHPlus Benefit Package. There is no Medicaid fee-for-service
coverage available for any service outside of the FHPlus Benefit
Package.
K.I
PREPAID
BENEFIT PACKAGE
|
*
|
Covered
Services
|
MMC
Non-SSI
|
MMC
SSI
|
MFFS
|
FHPlus
**
|
|
|
1.
|
Inpatient
Hospital Services
|
Covered,
unless admit date precedes Effective Date of
Enrollment
(see § 6.8 of this Agreement)
|
Covered,
unless admit date precedes Effective Date of Enrollment (see § 6.8 of this
Agreement)
|
Stay
covered only when admit date precedes Effective Date of Enrollment
(see
§6.8 of this Agreement)
|
Covered,
unless admit date precedes Effective Date of Enrollment (see § 6.8 of this
Agreement)
|
|
|
2
|
Inpatient
Stay Pending Alternate Level of Medical Care
|
Covered
|
Covered
|
Covered
|
||
|
3.
|
Physician
Services
|
Covered
|
Covered
|
Covered
|
||
|
4.
|
Nurse
Practitioner Services
|
Covered
|
Covered
|
Covered
|
||
|
5.
|
Midwifery
Services
|
Covered
|
Covered
|
Covered
|
||
|
6.
|
Preventive
Health Services
|
Covered
|
Covered
|
Covered
|
||
|
7.
|
Second
Medical/Surgical Opinion
|
Covered
|
Covered
|
Covered
|
||
|
8.
|
Laboratory
Services
|
Covered
|
Covered
|
HIV
phenotypic, virtual phenotypic and genotypic drug resistance
tests
|
Covered
|
|
|
9.
|
Radiology
Services
|
Covered
|
Covered
|
Covered
|
||
|
10.
|
Prescription
and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral
Formula
|
Pharmaceuticals
and medical supplies routinely furnished or administered as part
of a
clinic or office visit, except ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ [▇▇▇ ▇▇▇▇▇▇▇▇ ▇.▇,
▇. b
xi) of this Agreement]
|
Pharmaceuticals
and medical supplies routinely furnished or administered as part
of a
clinic or office visit, except ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ [▇▇▇ ▇▇▇▇▇▇▇▇ ▇.▇,
▇.
b)xi) of this Agreement]
|
Covered
outpatient drugs from the list of Medicaid reimbursable prescription
drugs, subject to any applicable co-payments
|
Covered,
may be limited to generic. .Vitamins (except to treat an illness
or
condition), OTCs. and medical supplies are not covered
|
|
|
11.
|
Smoking
Cessation Products
|
Covered
|
Covered
|
|||
|
12.
|
Rehabilitation
Services
|
Covered
|
Covered
|
Covered
for short term inpatient, and limited to 20 visits per calendar
year for
outpatient PT and OT
|
||
|
13.
|
EPSDT
Services/Child Teen Health Program (C/THP)
|
Covered
|
Covered
|
Covered
|
APPENDIX
K
January
1, 2007
K-3
|
*
See K 2 for Scope of Benefits
|
|
|
Note:
If cell is blank there is no coverage
|
**
No Medicaid fee for service-wrap around is available
Subject
to applicable co-pays
|
|
*
|
Covered
Services
|
MMC
Non-SSI
|
MMCSSI
|
MFFS
|
|
FHPlus
**
|
|
14.
|
Home
Health Services
|
Covered
|
Covered
|
|
|
Covered
for 40 visits in lieu of a skilled nursing facility stay or
hospitalization, plus 2 post pal-turn home visits for high risk
women
|
|
15
|
Private
Duty Nursing Services
|
Covered
|
Covered
|
|
|
Not
covered
|
|
16
|
Hospice
|
|
|
Covered
|
|
Covered
|
|
17.
|
Emergency
Services
Post-Stabilization
Care Services (see also Appendix G of this Agreement)
|
Covered
Covered
|
Covered
Covered
|
|
|
Covered
Covered
|
|
18.
|
Foot
Care Services
|
Covered
|
Covered
|
|
|
Covered
|
|
19.
|
Eye
Care and Low Vision Services
|
Covered
|
Covered
|
|
|
Covered
|
|
20.
|
Durable
Medical Equipment (DME)
|
Covered
|
Covered
|
|
|
Covered
|
|
21.
|
Audiology,
Hearing Aids Services A/Products
|
Covered
except for hearing aid batteries
|
Covered
except for hearing aid batteries
|
Hearing
aid batteries
|
|
Covered
including hearing aid batteries
|
|
22.
|
Family
Planning and Reproductive Health Services
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
Agreement
|
Covered
pursuant to Appendix C of Agreement
|
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement or through the DTP Contractor
|
|
23.
|
Non-Emergency
Transportation
|
Covered
if included in Contractor's Benefit Package as
per
Appendix M of this Agreement
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement
|
Covered
if not included in Contractor's Benefit Package
|
|
Not
covered, except for transportation to C/THP services for 19 and
20 year
olds
|
|
24
|
Emergency
Transportation
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement
|
Covered
if not included in Contractor's Benefit Package
|
|
Covered
|
APPENDIX K
January
1, 2007
K-4
|
*
See K 2 for Scope of Benefits
|
|
|
Note:
If cell is blank there is no coverage
|
**
No Medicaid fee for service-wrap around is available
Subject
to applicable co-pays
|
|
*
|
Covered
Services
|
MMC
Non-SSI
|
MMC
SSI
|
MFFS
|
FHPlus
**
|
|
|
25.
|
Dental
Services
|
Covered
if included in Contractor's Benefit Package as per Appendix M of
this
Agreement, except orthodontia
|
Covered
if included in
Contractor's
Benefit Package as per Appendix M of this Agreement, except
orthodontia
|
Covered
if not included in the Contractor's Benefit Package, Orthodontia
in all
instances
|
Covered,
if included in Contractor's Benefit Package as per Appendix
M
of this Agreement, excluding orthodontia
|
|
|
26.
|
Court-Ordered
Services
|
Covered,
pursuant to court order (see also §10.9 of this Agreement)
|
Covered,
pursuant to court order (see also §10.9 of this Agreement)
|
Covered,
pursuant to court order (see also §10.9 of this
Agreement)
|
||
|
27.
|
Prosthetic/Orthotic
Services/Orthopedic
Footwear
|
Covered
|
Covered
|
Covered,
except orthopedic shoes
|
||
|
28.
|
Mental
Health Services
|
Covered
subject to stop loss
|
Covered
for SSI Enrollees
|
Covered
subject to calendar year benefit limit of 30 days inpatient, 60
visits
outpatient,
combined with chemical dependency services
|
||
|
29.
|
Detoxification
Services
|
Covered
|
Covered
|
Covered
|
||
|
30.
|
Chemical
Dependence Inpatient Rehabilitation and
Treatment
Services
|
Covered
subject to stop loss
|
Covered
for SSI recipients
|
Covered
subject to calendar year benefit limit 30 days combined with mental
health
services
|
||
|
31
|
Chemical
Dependence Outpatient
|
Covered
|
Covered
subject to calendar year benefit limits of 60 visits combined with
mental
health
services
|
|||
|
32.
|
Experimental
and/or Investigational Treatment
|
Covered
on a case by case basis
|
Covered
on a case by case basis
|
Covered
on a case by case basis
|
||
|
33.
|
Renal
Dialysis
|
Covered
|
Covered
|
Covered
|
||
|
34.
|
Residential
Health Care Facility
Services
(RHCF)
|
Covered
subject to stop loss, except for individuals in permanent
placement
|
Covered
subject to stop loss, except for individuals in permanent
placement
|
APPENDIX
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1.2007
K-5
|
*
See K 2 for Scope of Benefits
|
|
|
Note:
If cell is blank there is no coverage
|
**
No Medicaid fee for service-wrap around is available
Subject
to applicable co-pays
|
K.2
PREPAID
BENEFIT PACKAGE DEFINITIONS OF COVERED SERVICES
Service
definitions in this Section pertain to both MMC and FHPlus unless otherwise
indicated.
1.
Inpatient Hospital Services
Inpatient
hospital services, as medically necessary, shall include, except as otherwise
specified, the care, treatment, maintenance and nursing services as may be
required, on an inpatient hospital basis, up to 365 days per year (366 days
in
leap year). The Contractor will not be responsible for hospital stays that
commence prior to the Effective Date of Enrollment (see Section 6.8 of this
Agreement), but will be responsible for stays that commence prior to the
Effective Date of Disenrollment (see Section 8.5 of this Agreement).
Among, other services, inpatient hospital services encompass a full range of
necessary diagnostic and therapeutic care including medical, surgical, nursing,
radiological, and rehabilitative services. Services are provided under the
direction of a physician, certified nurse practitioner, or dentist.
2.
Inpatient Stay Pending Alternate Level of Medical Care
Inpatient
stay pending alternate level of medical care, or continued care in a hospital,
Article 31 mental health facility, or skilled nursing facility pending placement
in an alternate lower medical level of care, consistent with the provisions
of
18 NYCRR § 505.20 and 10 NYCRR Part 85.
3.
Physician Services
a)
"Physician services," whether furnished in the office, the Enrollee's home,
a
hospital, a skilled nursing facility, or elsewhere, means services furnished
by
a physician:
i)
within
the scope of practice of medicine as defined in law by the New York State
Education Department; and
ii)
by or
under the personal supervision of an individual licensed and currently
registered by the New York State Education Department to practice
medicine.
b)
Physician services include the full range of preventive care services, primary
care medical services and physician specialty services that fall within a
physician's scope of practice under New York State law.
c)
The
following are also included without limitations:
i)
pharmaceuticals and medical supplies routinely furnished or administered as
part
of a clinic or office visit:
APPENDIX
K
January
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K-6
ii)
physical examinations, including those which are necessary for employment,
school, and camp;
iii)
physical and/or mental health, or chemical dependence examinations of children
and their parents as requested by the LDSS to fulfill its statutory
responsibilities for the protection of children and adults and for children
in
▇▇▇▇▇▇ care;
iv)
health and mental health assessments for the purpose of making recommendations
regarding a Enrollee's disability status for Federal SSI
applications;
v)
health
assessments for the Infant /Child Assessment Program (I CHAP);
vi)
annual preventive health visits for adolescents;
vii)new
admission exams for school children if required by the LDSS;
viii)health
screening, assessment and treatment of refugees, including completing SDOH/LDSS
required forms;
ix)
Child/Teen Health Program (C/THP) services which are comprehensive primary
health care services provided to persons under twenty-one (21) years of age
(see
Section 10.4 of this Agreement).
4.
Certified Nurse Practitioner Services
a)
Certified nurse practitioner services include preventive services, the diagnosis
of illness and physical conditions, and the performance of therapeutic and
corrective measures, within the scope of the certified nurse practitioner's
licensure and collaborative practice agreement with a licensed physician in
accordance with the requirements of the NYS Education Department.
b)
The
following services are also included in the certified nurse practitioner's
scope
of services, without limitation:
i)
Child/Teen Health Program(C/THP) services which are comprehensive primary health
care services provided to persons under twenty-one (21) (see Item 13 of this
Appendix and Section 10.4 of this Agreement);
ii)
Physical examinations, including those which are necessary for employment,
school and camp.
APPENDIX
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K-7
5.
Midwifery Services
SSA
§
1905 (a)(l 7). Education Law § 6951 (i).
Midwifery
services include the management of normal pregnancy, childbirth and postpartum
care as well as primary preventive reproductive health care to essentially
healthy women as specified in a written practice agreement and shall include
newborn evaluation, resuscitation and referral for infants. The care may be
provided on an inpatient or outpatient basis, including in a birthing center
or
in the Enrollee's home as appropriate. The midwife must be licensed by the
NYS
Education Department.
6.
Preventive Health Services
a)
Preventive health services means care and services to avert disease/illness
and/or its consequences. There are three (3) levels of preventive health
services: 1) primary, such as immunizations, aimed at preventing disease; 2)
secondary, such as disease screening programs aimed at early detection of
disease; and 3) tertiary, such as physical therapy, aimed at restoring function
after the disease has occurred. Commonly, the term "preventive care" is used
to
designate prevention and early detection programs rather than restorative
programs.
b)
The
Contractor must offer the following preventive health services essential for
promoting and preventing illness:
i)
General health education classes.
ii)
Pneumonia and influenza immunizations for at risk populations.
iii)
Smoking cessation classes, with targeted outreach for adolescents and pregnant
women.
iv)
Childbirth education classes.
v)
Parenting classes covering topics such as bathing, feeding, injury prevention,
sleeping, illness prevention, steps to follow in an emergency, growth and
development, discipline, signs of illness, etc. vi) Nutrition counseling, with
targeted outreach for diabetics and pregnant women. vii) Extended care
coordination, as needed, for pregnant women.
viii)HIV
counseling and testing.
7.
Second
Medical/Surgical Opinions
The
Contractor will allow Enrollees to obtain second opinions for diagnosis of
a
condition, treatment or surgical procedure by a qualified physician or
appropriate specialist, including one. affiliated with a specialty care center.
In the event that the Contractor determines that it does not have a
Participating Provider in its network with appropriate training and experience
qualifying the Participating Provider to provide a second opinion, the
Contractor shall make a referral to an appropriate Non-Participating Provider.
The Contractor shall pay for the cost of the services associated with obtaining
a second opinion regarding medical or surgical care, including diagnostic and
evaluation services, provided by the Non-Participating Provider.
APPENDIX
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January
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K-8
8.
Laboratory Services
18NYCRR§505.7(a)
a)
Laboratory services include medically necessary tests and procedures ordered
by
a qualified medical professional and listed in the Medicaid fee schedule for
laboratory services.
b)
All
laboratory testing sites providing services under this Agreement must have
a
permit issued by the New York State Department of Health and a Clinical
Laboratory Improvement Act (CLIA) certificate of waiver, a physician performed
microscopy procedures (PPMP) certificate, or a certificate of registration
along
with a CLIA identification number. Those laboratories with certificates of
waiver or a PPMP certificate may perform only those specific tests permitted
under the terms of their waiver. Laboratories with certificates of registration
may perform a full range of laboratory tests for which they have been certified.
Physicians providing laboratory testing may perform only those specific limited
laboratory procedures identified in the Physician's NYS Medicaid Provider
Manual.
c)
For
MMC only: coverage for HIV phenotypic. HIV virtual phenotypic and HIV genotypic
drug resistance tests are covered by Medicaid fee-for-service.
9.
Radiology Services
l8NYCRR§505.17(c)(7)(d)
Radiology
services include medically necessary services provided by qualified
practitioners in the provision of diagnostic radiology, diagnostic ultrasound;
nuclear medicine, radiation oncology, and magnetic resonance imaging (MRI).
These services may only be performed upon the order of a qualified
practitioner.
10.
Prescription and Non-Prescription (OTC) Drugs, Medical Supplies and Enteral
Formulas
a)
For
Medicaid fee-for-service only: Medically necessary prescription and
non-prescription (OTC) drugs, medical supplies and enteral formula are covered
when ordered by a qualified provider.
b)
MMC
Enrollees are covered for prescription drugs through the Medicaid
fee-for-service program. Pharmaceutical s and medical supplies routinely
furnished or administered as part of a clinic or office visit are covered by
the
MMC Program. Self-administered injectable drugs (including those administered
by
a family member) and injectable drugs administered during a home care visit
are
covered by Medicaid fee-for-service if the drug is on the list of Medicaid
reimbursable prescription drugs or covered by the Contractor, subject to medical
necessity, if the drug is not on the list of Medicaid reimbursable prescription
drugs.
APPENDIX
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K-9
c)
For
Family Health Plus only:
i)
Prescription drugs are covered, but may be limited to generic medications where
medically acceptable. All medications used for preventive and therapeutic
purposes are covered, as well as family planning or contraceptive medications
or
devices.
ii)
Coverage includes enteral formulas for home use for which a physician or other
provider authorized to prescribe has issued a written order. Enteral formulas
for the treatment of specific diseases shall be distinguished from nutritional
supplements taken electively. Coverage for certain inherited diseases of amino
acid and organic acid metabolism shall include modified solid food products
that
are low-protein or which contain modified protein. Vitamins are not covered
except when necessary to treat a diagnosed illness or condition.
iii)
Experimental and/or investigational drugs are generally excluded, except where
approved in the course of experimental/investigational treatment.
iv)
Drugs
prescribed for cosmetic purposes are excluded.
v)
Over-the-counter items are excluded with the exception of diabetic supplies,
including insulin and smoking cessation agents. Non-prescription (OTC) drugs
and
medical supplies are not covered.
11.
Smoking Cessation Products
a)
MMC
Enrollees are covered for smoking cessation products through the Medicaid
fee-for-service program.
b)
For
Family Health Plus only: At least two courses of smoking cessation therapy
per
person per year, as medically necessary are covered. A course of therapy is
defined as no more than a ninety (90)day supply (an original prescription and
two (2) refills, even if less than a thirty (30)day supply is dispensed in
any
fill). Duplicative use of one agent is not allowed (i.e., same drug/same dosage
form/same strength). Both prescription and over-the-counter therapies/agents
are
covered; this includes nicotine patches, inhalers, nasal sprays, gum, and Zyban
(bupropion).
12.
Rehabilitation Services
18NYCRR§505.11
a)
Rehabilitation services are provided for the maximum reduction of physical
or
mental disability and restoration of the Enrollee to his or her best functional
level. Rehabilitation services include care and services rendered by physical
therapists. speech-language pathologists and occupational therapists.
Rehabilitation services may be provided in an Article 28 inpatient or outpatient
facility, in an Enrollee's home, in an approved home health agency, in the
office of a qualified private practicing therapist or speech pathologist, or
for
a child in a school, pre-school or
APPENDIX
K
January
1, 2007
K-10
community
setting, or in a Residential Health Care Facility (RHCF) as long as the
Enrollee's stay is classified as a rehabilitative stay and meets the
requirements for covered RHCF services as defined herein. For the MMC Program,
rehabilitation services provided in Residential Health Care Facilities are
subject to the stop-loss provisions specified in Section 3.13 of this Agreement.
Rehabilitation services are covered as medically necessary, when ordered by
the
Contractor's Participating Provider.
b)
For
Family Health Plus only: Outpatient visits for physical and occupational therapy
is limited to twenty (20) visits per calendar year. Coverage for speech therapy
services is limited to those required for a condition amenable to significant
clinical improvement within a two month period.
13.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services Through
the Child Teen Health Program (C/THP) and Adolescent Preventive
Services
18NYCRR§508.8
Child/Teen
Health Program (C/THP) is a package of early and periodic screening, including
inter-periodic screens and, diagnostic and treatment services that New York
State offers all Medicaid eligible children under twenty-one (21) years of
age.
Care and services shall be provided in accordance with the periodicity schedule
and guidelines developed by the New York State Department of Health. The care
includes necessary health care, diagnostic services, treatment and other
measures (described in §1905(a) of the Social Security Act) to correct or
ameliorate defects, and physical and mental illnesses and conditions discovered
by the screening services (regardless of whether the service is otherwise
included in the New York State Medicaid Plan). The package of services includes
administrative services designed to assist families obtain services for children
including outreach, education, appointment scheduling, administrative case
management and transportation assistance.
14.
Home Health Services
18NYCRR§505.23(a)(3)
a)
Home
health care services are provided to Enrollees in their homes by a home health
agency certified under Article 36 of the PHL (Certified Home Health Agency
-CHHA). Home health services mean the following services when prescribed by
a
Provider and provided to a Enrollee in his or her home:
i)
nursing services provided on a part-time or intermittent basis by a CHHA or,
if
there is no CHHA that services the county/district, by a registered professional
nurse or a licensed practical nurse acting under the direction of the Enrollee's
PCP;
ii)
physical therapy, occupational therapy, or speech pathology and audiology
services; and
APPENDIX
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K-11
iii)
home
health services provided by a person who meets the training requirements of
the
SDOH, is assigned by a registered professional nurse to provide home health
aid
services in accordance with the Enrollee's plan of care, and is supervised
by a
registered professional nurse from a CHHA or if the Contractor has no CHHA
available, a registered nurse, or therapist.
b)
Personal care tasks performed by a home health aide incidental to a certified
home health care agency visit, and pursuant to an established care plan, are
covered.
c)
Services include care rendered directly to the Enrollee and instructions to
his/her family or caretaker such as teacher or day care provider in the
procedures necessary for the Enrollee's treatment or maintenance.
d)
The
Contractor must provide up to two (2) post partum home visits for high risk
infants and/or high risk mothers, as well as to women with less than a
forty-eight (48) hour hospital stay after a vaginal delivery or less than a
ninety-six (96) hour stay after a cesarean delivery. Visits must be made by
a
qualified health professional (minimum qualifications being an RN with
maternal/child health background), the first visit to occur within forty-eight
(48) hours of discharge.
e)
For
Family Health Plus only: coverage is limited to forty (40) home health care
visits per calendar year in lieu of a skilled nursing facility stay or
hospitalization. Post partum home visits apply only to high risk mothers. For
the purposes of this Section, visit is defined as the delivery of a discreet
service (e.g. nursing, OT, PT, ST. audiology or home health aide). Four (4)
hours of home health aide services equals one visit.
15.
Private Duty Nursing Services - For MMC Program Only
a)
Private duty nursing services shall be provided by a person possessing a license
and current registration from the NYS Education Department to practice as a
registered professional nurse or licensed practical nurse. Private duty nursing
services must be provided in the MMC Enrollee's home and can be provided through
an approved certified home health agency, a licensed home care agency, or a
private Practitioner.
b)
Private duty nursing services are covered only 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's or certified nurse practitioner's written
treatment plan.
16.
Hospice Services
a)
Hospice Services means a coordinated hospice program of home and inpatient
services which provide non-curative medical and support services for Enrollees
certified by a physician to be terminally ill with a life expectancy of six
(6)
months or less.
APPENDIX
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January
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K-12
b)
Hospice services include palliative and supportive care provided to an Enrollee
to meet the special needs arising out of physical, psychological, spiritual,
social and economic stress which are experienced during the final stages of
illness and during dying and bereavement. Hospices must be certified under
Article 40 of the New York State Public Health Law. 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 Enrollee and the Enrollee's
family. Family members are eligible for up to five visits for bereavement
counseling.
c)
Medicaid Managed Care Enrollees receive coverage for hospice services through
the Medicaid fee-for-service program.
17.
Emergency Services
a)
Emergency conditions, medical or behavioral, the onset of which is sudden,
manifesting itself by symptoms of sufficient severity, including severe pain.
that a prudent layperson, possessing an average knowledge of medicine and
health, could reasonably expect the absence of medical attention to result
in
(a) placing the health of the person afflicted with such condition in serious
jeopardy, or in the case of a behavioral condition, placing the health of such
person or others in serious jeopardy;
(b)
serious impairment of such person's bodily functions; (c) serious dysfunction
of
any bodily organ or part of such person; or (d) serious disfigurement of such
person are covered. Emergency services include health care procedures,
treatments or services needed to evaluate or stabilize an Emergency Medical
Condition including psychiatric stabilization and medical detoxification from
drugs or alcohol. A medical assessment (triage) is covered for non-emergent
conditions. See also Appendix G of this Agreement.
b)
Post
Stabilization Care Services means services related to an emergency medical
condition that are provided after an Enrollee is stabilized in order to maintain
the stabilized condition, or to improve or resolve the Enrollee's condition.
These services are covered pursuant to Appendix G of this
Agreement.
18.
Foot Care Services
a)
Covered services must include routine foot care when the physical condition
of
any Enrollee (regardless of age) poses a hazard due to the presence of localized
illness, injury or symptoms involving the foot, or when performed as a necessary
and integral part of otherwise covered services such as the diagnosis and
treatment of diabetes, ulcers, and infections.
b)
Services provided by a podiatrist for persons under twenty-one (21) must be
covered upon referral of a physician, registered physician assistant, certified
nurse practitioner or licensed midwife.
APPENDIX
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K-13
c)
Routine hygienic care of the feet, the treatment of corns and calluses, the
trimming of nails, and other hygienic care such as cleaning or soaking feet,
is
not covered in the absence of a pathological condition.
19.
Eye Care and Low Vision Services
18NYCRR§505.6(b)(l-3)
SSL§369-ee(l)(e)(xh)
a)
For
Medicaid Managed Care only:
i)
Emergency, preventive and routine eye care services are covered. Eye care
includes the services of ophthalmologist, optometrists and ophthalmic
dispensers, and includes eyeglasses, medically necessary contact lenses and
polycarbonate lenses, artificial eyes (stock or custom-made), low vision aids
and low vision services. Eye care coverage includes the replacement of lost
or
destroyed eyeglasses. The replacement of a complete pair of eyeglasses must
duplicate the original prescription and frames. Coverage also includes the
repair or replacement of parts in situations where the damage is the result
of
causes other than defective workmanship. Replacement parts must duplicate the
original prescription and frames. Repairs to, and replacements of, frames and/or
lenses must be rendered as needed.
ii)
If
the Contractor does not provide upgraded eyeglass frames or additional features
(such as scratch coating, progressive lenses or photo-▇▇▇▇ lenses) as part
of
its covered vision benefit, the Contractor cannot apply the cost of its covered
eyeglass benefit to the total cost of the eyeglasses the Enrollee wants and
▇▇▇▇
only the difference to the Enrollee. The Enrollee can choose to purchase the
upgraded frames and/or additional features by paying the entire cost of the
eyeglasses as a private customer. For example, if the Contractor covers standard
bifocal eyeglasses and the Enrollee wants no-line bifocal eyeglasses, the
Enrollee must choose between taking the standard bifocal eyeglasses or paying
the full price of the no-line bifocal eyeglasses (not just the difference
between the cost of biofocal lenses and the no-line lenses). The Enrollee must
be informed of this fact by the vision care provider at the time that the
glasses are ordered.
iii)
Examinations for diagnosis and treatment for visual defects and/or eye disease
are provided only as necessary and as required by the Enrollee's particular
condition. Examinations which include refraction are limited to once every
twenty four (24) months unless otherwise justified as medically
necessary.
iv)
Eyeglasses do not require changing more frequently than once every twenty four
(24) months unless medically indicated, such as a change in correction greater
than Vi
diopter,
or unless the glasses are lost, damaged, or destroyed.
v)
An
ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist
and supplies eyeglasses or other vision aids upon the order of a qualified
practitioner.
APPENDIX
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K-14
vi)
MMC
Enrollees may self-refer to any Participating Provider of vision services
(optometrist or ophthalmologist) for refractive vision services not more
frequently than once every twenty four (24) months, or if otherwise justified
as
medically necessary or if eyeglasses are lost, damaged or destroyed as described
above.
b)
For
Family Health Plus only:
i)
Covered Services include emergency vision care and the following preventive
and
routine vision care provided once in any twenty-four (24) month
period:
A)
one
eye examination;
B)
either: one pair of prescription eyeglass lenses and a frame, or prescription
contact lenses where medically necessary; and
C)
one
pair of medically necessary occupational eyeglasses.
ii)
An
ophthalmic dispenser fills the prescription of an optometrist or ophthalmologist
and supplies eyeglasses or other vision aids upon the order of a qualified
practitioner.
iii)
FHPlus Enrollees may self-refer to any Participating Provider of vision services
(optometrist or ophthalmologist) for refractive vision services not more
frequently than once every twenty four (24) months.
iv)
If
the Contractor does not provide upgraded frames or additional features that
the
Enrollee wants (such as scratch coating, progressive lenses or photo-▇▇▇▇
lenses) as part of its covered vision benefit, the Contractor cannot apply
the
cost of its covered eyeglass benefit to the total cost of the eyeglasses the
Enrollee wants and ▇▇▇▇ only the difference to the Enrollee. The Enrollee can
choose to purchase the upgraded frames and/or additional features by paying
the
entire cost of the eyeglasses as a private customer. For example, if the
Contractor covers standard bifocal eyeglasses and the Enrollee wants no-line
bifocal eyeglasses, the Enrollee must choose between taking the standard bifocal
glasses or paying the full price for the no-line bifocal eyeglasses (not just
the difference between the cost of bifocal lenses and no-line lenses). The
Enrollee must be informed of this fact by the vision care provider at the time
that the glasses are ordered.
v)
Contact lenses are covered only when medically necessary. Contact lenses shall
not be covered solely because the FHPlus Enrollee selects contact lenses in
lieu
of receiving eyeglasses.
vi)
Coverage does not include the replacement of lost, damaged or destroyed
eyeglasses.
vii)
The
occupational vision benefit for FHPlus Enrollees covers the cost of job-related
eyeglasses if that need is determined by a Participating Provider through
special testing, done in conjunction with a regular vision examination.
Such
APPENDIX
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K-15
examination
shall determine whether a special pair of eyeglasses would improve the
performance of job-related activities. Occupational eyeglasses can be provided
in addition to regular glasses but are available only in conjunction with a
regular vision benefit once in any twenty-four (24) month period. FHPlus
Enrollees may purchase an upgraded frame or lenses for occupational eyeglasses
by paying the entire cost as a private customer. Sun-sensitive and polarized
lens options are not available for occupational eyeglasses.
20.
Durable Medical Equipment (DME)
18
NYCRR
§ 505.5(a)(l) and Section 4.4 of the NYS Medicaid DME, Medical and Surgical
Supplies and Prosthetic and Orthotic Appliances Provider Manual
a)
Durable Medical Equipment (DME) are devices and equipment, other than
medical/surgical supplies, enteral formula, and prosthetic or orthotic
appliances, and have the following characteristics:
i)
can
withstand repeated use for a protracted period of time;
ii)
are
primarily and customarily used for medical purposes;
iii)
are
generally not useful to a person in the absence of illness or injury; and iv)
are usually not fitted, designed or fashioned for a particular individual's
use.
Where
equipment is intended for use by only one (1) person, it may be
either
custom
made or customized.
b)
Coverage includes equipment servicing but excludes disposable medical
supplies.
21.
Audiology, Hearing Aid Services and Products
18
NYCRR
§ 505.31 (a)(1)(2) and Section 4.7 of the NYS Medicaid Hearing Aid Provider
Manual
a)
Hearing aid services and products are provided in compliance with Article 37-A
of the General Business Law when medically necessary to alleviate disability
caused by the loss or impairment of hearing. Hearing aid services include:
selecting, fitting and dispensing of hearing aids, hearing aid checks following
dispensing of hearing aids, conformity evaluation, and hearing aid
repairs.
b)
Audiology services include audiometric examinations and testing, hearing aid
evaluations and hearing aid prescriptions or recommendations, as medically
indicated.
c)
Hearing aid products include hearing aids, earmolds. special fittings, and
replacement parts.
d)
Hearing aid batteries:
i)
For
Family Health Plus only: Hearing aid batteries are covered as part of the
prescription drug benefit.
APPENDIX
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K-16
ii)
For
Medicaid Managed Care only: Hearing aid batteries are covered through the
Medicaid fee-for-service program.
22.
Family Planning and Reproductive Health Care
a)
Family
Planning and Reproductive Health Care services means the offering, arranging
and
furnishing of those health services which enable Enrollees, including minors
who
may be sexually active, to prevent or reduce the incidence of unwanted
pregnancy, as specified in Appendix C of this Agreement.
b)
HIV
counseling and testing is included in coverage when provided as part of a Family
Planning and Reproductive Health visit.
c)
All
medically necessary abortions are covered, as specified in Appendix C of this
Agreement.
d)
Fertility services are not covered.
e)
If the
Contractor excludes Family Planning and Reproductive Health services from its
Benefit Package, as specified in Appendix M of this Agreement, the Contractor
is
required to comply with the requirements of Appendix C.3 of this Agreement
and
still provide the following services:
i)
screening, related diagnosis, ambulatory treatment, and referral to
Participating Provider as needed for dysmenorrhea, cervical cancer or other
pelvic abnormality/pathology;
ii)
screening, related diagnosis, and referral to Participating Provider for anemia,
cervical cancer, glycosuria, proteinuria, hypertension, breast disease and
pregnancy.
23.
Non-Emergency Transportation
a)
Transportation expenses are covered for MMC Enrollees when transportation is
essential in order for a MMC 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 Medicaid fee-for-service). Non-emergent
transportation guidelines may be developed in conjunction with the LDSS, based
on the LDSS' approved transportation plan.
b)
Transportation services means transportation by ambulance, ambulette fixed
wing
or airplane transport, invalid coach, taxicab, livery, public transportation,
or
other means appropriate to the MMC Enrollee's medical condition; and a
transportation attendant to accompany the MMC 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 MMC Enrollee's family.
APPENDIX
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c)
When
the Contractor is capitated for non-emergency transportation, the Contractor
is
also responsible for providing transportation to Medicaid covered services
that
are not part of the Contractor's Benefit Package.
d)
Non-emergency transportation is covered for FHPlus Enrollees that are nineteen
(19) or twenty (20) years old and are receiving C/THP services.
e)
For
MMC Enrollees with disabilities, the method of transportation must reasonably
accommodate their needs, taking into account the severity and nature of the
disability.
24.
Emergency Transportation
a)
Emergency transportation can only be provided by an ambulance service, including
air ambulance service. Emergency ambulance transportation means the provision
of
ambulance transportation 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.
b)
Emergency Services means the health care procedures, treatments or services
needed to evaluate or stabilize an Emergency Medical Condition including, but
not limited to, the treatment of trauma, ▇▇▇▇▇, respiratory, circulatory and
obstetrical emergencies.
c)
Emergency ambulance transportation is transportation to a hospital emergency
room generated by a "Dial 911" emergency system call or some other request
for
an immediate response to a medical emergency. Because of the urgency of the
transportation request, insurance coverage or other billing provisions are
not
addressed until after the trip is completed. When the Contractor is capitated
for this benefit, emergency transportation via 911 or any other emergency call
system is a covered benefit and the Contractor is responsible for payment.
The
Contractor shall reimburse the transportation provider for all emergency
ambulance services without regard for final diagnosis or prudent layperson
standard.
25.
Dental Services
a)
Dental
care includes preventive, prophylactic and other routine dental care, services,
supplies and dental \prosthetics required to alleviate a serious health
condition, including one which affects employability. Orthodontic services
are
not covered.
b)
Dental
surgery performed in an ambulatory or inpatieni setting is the responsibility
of
the Contractor, whether dental services are included in the Benefit Package
or
not. Inpatient claims and referred ambulatory claims for dental services
provided in an inpatient or outpatient hospital setting for surgery,
anesthesiology. X-rays, etc. are the responsibility of the Contractor. The
Contractor shall set up procedures to prior approve dental services provided
in
inpatient and ambulatory settings.
c)
For
Medicaid Managed Care only:
APPENDIX
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i)
As
described in Sections 10.15 and 10.27 of this Agreement, Enrollees may
self-refer to Article 28 clinics operated by academic dental centers to obtain
covered
dental
services if dental services are included in the Benefit Package.
ii)
Professional services of a dentist for dental surgery performed in an
ambulatory 01-inpatient setting are billed Medicaid fee-for-service if the
Contractor does not include dental services in the benefit package.
d)
For
Family Health Plus only: professional services of a dentist for dental surgery
performed in an ambulatory or inpatient setting are not covered.
26.
Court Ordered Services
Court
ordered services are those services ordered by a court of competent jurisdiction
which are performed by or under the supervision of a physician, dentist, or
other provider qualified under State law to furnish medical, dental, behavioral
health (including treatment for mental health and/or chemical dependence),
or
other covered services. The Contractor is responsible for payment of those
services included in the benefit package.
27.
Prosthetic/Orthotic Orthopedic Footwear
Section
4.5, 4.6 and 4.7 of the NYS Medicaid DME, Medical and Surgical Supplies and
Prosthetic and Orthotic Appliances Provider Manual
a)
Prosthetics are those appliances or devices which replace or perform the
function of any missing part of the body. Artificial eyes are covered as part
of
the eye care benefit.
b)
Orthotics are those appliances or devices which are used for the purpose of
supporting a weak or deformed body part or to restrict or eliminate motion
in a
diseased or injured part of the body.
c)
Medicaid Managed Care: Orthopedic Footwear means shoes, shoe modifications,
or
shoe additions which are used to correct, accommodate or prevent a physical
deformity or range of motion malfunction in a diseased or injured part of the
ankle or foot; to support a weak or deformed structure of the ankle or foot,
or
to form an integral part of a brace.
28.
Mental Health Services
a)
Inpatient Services
All
inpatient mental health services, including voluntary or involuntary admissions
for mental health services. The Contractor may provide the covered benefit
for
medically necessary mental health inpatient services through hospitals licensed
pursuant to Article 28 of the PHL.
b)
Outpatient Services
APPENDIX
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K-19
Outpatient
services including but not limited to: assessment, stabilization, treatment
planning, discharge planning, verbal therapies, education, symptom management.
case management services, crisis intervention and outreach services, chlozapine
monitoring and collateral services as certified by the New York State Office
of
Mental Health (OMH). Services may be provided in-home, in an office or in the
community. Services may be provided by licensed OMH providers or by other
providers of mental health services, including clinical psychologists and
physicians.
c)
Family
Health Plus Enrollees have a combined mental health/chemical dependency benefit
limit of thirty (30) days inpatient and sixty (60) outpatient visits per
calendar year.
d)
MMC
SSI Enrollees obtain all mental health services through the Medicaid
fee-for-service program.
29.
Detoxification Services
a)
Medically Managed Inpatient Detoxification
These
programs provide medically directed twenty-four (24) hour care on an inpatient
basis to individuals who are at risk of severe alcohol or substance abuse
withdrawal, incapacitated, a risk to self or others, or diagnosed with an acute
physical or mental co-morbidity. Specific services include, but are not limited
to: medical management, bio-psychosocial assessments, stabilization of medical
psychiatric / psychological problems, individual and group counseling, level
of
care determinations and referral and linkages to other services as necessary.
Medically Managed Detoxification .Services are provided by facilities licensed
by OASAS under Title 14 NYCRR § 816.6 and the Department of Health as a general
hospital pursuant to Article 28 of the Public Health Law or by the Department
of
Health as a general hospital pursuant to Article 28 of the Public Health
Law.
b)
Medically Supervised Withdrawal
i)
Medically Supervised Inpatient Withdrawal
These
programs offer treatment for moderate withdrawal on an inpatient basis. Services
must include medical supervision and direction under the care of a physician
in
the treatment for moderate withdrawal. Specific services must include, but
are
not limited to: medical assessment within twenty four (24) hours of admission;
medical supervision of intoxication and withdrawal conditions; bio-psychosocial
assessments; individual and group counseling and linkages to other services
as
necessary. Maintenance on methadone while a patient is being treated for
withdrawal from other substances may be provided where the provider is
appropriately authorized. Medically Supervised Inpatient Withdrawal services
are
provided by facilities licensed under Title 14 NYCRR § 816.7.
ii)
Medically Supervised Outpatient Withdrawal
APPENDIX
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These
programs offer treatment for moderate withdrawal on an outpatient basis.
Required services include, but are not limited to: medical supervision of
intoxication and withdrawal conditions; bio-psychosocial assessments; individual
and group counseling; level of care determinations; discharge planning; and
referrals to appropriate services. Maintenance on methadone while a patient
is
being treated for withdrawal from other substances may be provided where the
provider is appropriately authorized. Medically Supervised Outpatient Withdrawal
services are provided by facilities licensed under Title 14 NYCRR
§816.7.
c)
For
Medicaid Managed Care only: all detoxification and withdrawal services are
a
covered benefit for all Enrollees. including those categorized as SSI or
SSI-related. Detoxification Services in Article 28 inpatient hospital facilities
are subject to the inpatient hospital stop-loss provisions specified in Section
3.11 of this Agreement.
30.
Chemical Dependence Inpatient Rehabilitation and Treatment
Services
a)
Services provided include intensive management of chemical dependence symptoms
and medical management of physical or mental complications from chemical
dependence to clients who cannot be effectively served on an outpatient basis
and who are not in need of medical detoxification or acute care. These services
can be provided in a hospital or free-standing facility. Specific services
can
include, but are not limited to: comprehensive admission evaluation and
treatment planning;
individual
group, and family counseling; awareness and relapse prevention;
education
about self-help groups; assessment and referral services; vocational and
educational assessment; medical and psychiatric consultation; food and housing;
and HIV and AIDS education. These services may be provided by facilities
licensed by the New York State Office of Alcoholism and Substance Abuse Services
(OASAS) to provide Chemical Dependence Inpatient Rehabilitation and Treatment
Services under Title 14 NYCRR Part 818. Maintenance on methadone while a patient
is being treated for withdrawal from other substances may be provided where
the
provider is appropriately authorized.
b)
Family
Health Plus Enrollees have a combined mental health/chemical dependency benefit
limit of thirty (30) days inpatient and sixty (60) outpatient visits per
calendar year.
31.
Outpatient Chemical Dependency Services
a)
Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs
Medically
Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are
licensed under Title 14. NYCRR Part 822 and provide chemical dependence
outpatient treatment to individuals who suffer from chemical abuse or dependence
and their family members or significant others.
b)
Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs
APPENDIX
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Medically
Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full
or half-day services to meet the needs of a specific target population of
chronic alcoholic persons who need a range of services which are different
from
those typically provided in an alcoholism outpatient clinic. Programs are
licensed by as Chemical Dependence Outpatient Rehabilitation Programs under
Title 14 NYCRR § 822.9.
c)
Outpatient Chemical Dependence for Youth Programs
Outpatient
Chemical Dependence for Youth Programs (OCDY) are licensed under Title 14 NYCRR
Part 823. OCDY programs offer discrete, ambulatory clinic services to
chemically-dependent youth in a treatment setting that supports abstinence
from
chemical dependence (including alcohol and substance abuse)
services.
d)
Medicaid Managed Care Enrollees access outpatient chemical dependency services
through the Medicaid fee-for-service program.
32.
Experimental and/or Investigational Treatment
a)
Experimental and/or investigational treatment are covered on a case by case
basis.
b)
Experimental and/or investigational treatment for life-threatening and/or
disabling illnesses may also be considered for coverage under the external
appeal process pursuant to the requirements of Section 4910 of the PHL under
the
following conditions:
i)
The
Enrollee has had coverage of a health care service denied on the basis that
such
service is experimental and/or investigational, and
ii)
The
Enrollee's attending physician has certified that the Enrollee has a
life-threatening or disabling condition or disease:
A)
for
which standard health services or procedures have been ineffective or would
be
medically inappropriate, or
B)
for
which there does not exist a more beneficial standard health service or
procedure covered by the Contractor, or
C)
for
which there exists a clinical trial, and
iii)
The
Enrollee's provider, who must be a licensed, board-certified or
board-eligible physician, qualified to practice in the area of practice
appropriate to treat the Enrollee's life-threatening or disabling condition
or
disease, must have recommended either:
A)
a
health service or procedure that, based on two (2) documents from the available
medical and scientific evidence, is likely to be more beneficial to the Enrollee
than any covered standard health service or procedure; or
APPENDIX
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B)
a
clinical trial for which the Enrollee is eligible; and
iv)
The
specific health service or procedure recommended by the attending physician
would otherwise be covered except for the Contractor's determination that the
health service or procedure is experimental and/or investigational.
33.
Renal Dialysis
Renal
dialysis may be provided in an inpatient hospital setting, in an ambulatory
care
facility, or in the home on recommendation from a renal dialysis
center.
34.
Residential Health Care Facility (RHCF) Services - For MMC Program
Only
a)
Residential Health Care Facility (RHCF) Services means inpatient nursing home
services provided by facilities licensed under Article 28 of the New York State
Public Health Law, including AIDS nursing facilities. Covered services includes
the following health care services: medical supervision, twenty-four (24) hour
per day nursing care, assistance with the activities of daily living, physical
therapy, occupational therapy, and speech/language pathology services and other
services as specified in the New York State Health Law and Regulations for
residential health care facilities and AIDS nursing facilities. These services
should be provided to an MMC Enrollee:
i)
Who is
diagnosed by a physician as having one or more clinically determined illnesses
or conditions that cause the MMC Enrollee to be so incapacitated, sick, invalid,
infirm, disabled, or convalescent as to require at least medical and nursing
care; and
ii)
Whose
assessed health care needs, in the professional judgment of the MMC Enrollee's
physician or a medical team:
A)
do not
require care or active treatment of the MMC Enrollee in a general or special
hospital;
B)
cannot
be met satisfactorily in the MMC Enrollee's own home or home substitute
through provision of such home health services, including medical and other
health and health-related services as are available in or near his or her
community; and
C)
cannot
be met satisfactorily in the physician's office, a hospital clinic, or other
ambulatory care setting because of the unavailability of medical or other health
and health-related services for the MMC Enrollee in such setting in or near
his
or her community.
b)
The
Contractor is also responsible for respite days and bed hold days authorized
by
the Contractor.
c)
The
Contractor is responsible for all medically necessary and clinically appropriate
inpatient Residential Health Care Facility services authorized by the Contractor
up to a sixty (60) day calendar year stop-loss for MMC Enrollees who are not
in
Permanent Placement Status as determined by LDSS.
APPENDIX
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K.3
Medicaid
Managed Care Prepaid Benefit Package Definitions of Non-Covered
Services
The
following services are excluded from the Contractor's Benefit Package, but
are
covered, in most instances, by Medicaid fee-for-service:
1.
Medical Non-Covered Services
a)
Personal Care Agency Services
i)
Personal care services (PCS) are 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
service has to be ordered by a physician, and there has to be a medical need
for
the service. Licensed home care services agencies, as opposed to certified
home
health agencies, are the primary providers of PCS. Enrollees receiving PCS
have
to have a stable medical condition and are generally expected to be in receipt
of such services for an extended period of time (years).
ii)
Services rendered by a persona] care agency which are approved by the LDSS
are
not covered under the Benefit Package. 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 with the personal care agency to develop a plan
of care.
b)
Residential Health Care Facilities (RHCF)
Services
provided in a Residential Health Care Facility (RHCF) to an individual who
is
determined by the LDSS to be in Permanent Status are not covered.
c)
Hospice Program
i)
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.
ii)
Hospices are organizations which must be certified under Article 40 of the
PHL.
All services must be provided by qualified employees and volunteers of
the
APPENDIX
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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.
iii)
If
an Enrollee 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 Medicaid fee-for-service.
d)
Prescription and Non-Prescription (OTC) Drugs, Medical Supplies, and Enteral
Formula
Coverage
for drugs dispensed by community pharmacies, over the counter drugs,
medical/surgical supplies and enteral formula are not included in the Benefit
Package and 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.
2.
Non-Covered Behavioral Health Services
a)
Chemical Dependence Services
i)
Outpatient Rehabilitation and Treatment Services
A)
Methadone Maintenance Treatment Program (MMTP)
Consists
of drug detoxification, drug dependence counseling, and rehabilitation services
which include chemical management of the patient with methadone. Facilities
that
provide methadone maintenance treatment do so as their principal mission and
are
certified by OASAS under 14 NYCRR Part 828.
B)
Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic
Programs
Medically
Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are
licensed under Title 14 NYCRR Part 822 and provide chemical dependence
outpatient treatment to individuals who suffer from chemical abuse or dependence
and their family members or significant others.
APPENDIX
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C)
Medically Supervised Chemical Dependence Outpatient Rehabilitation
Programs
Medically
Supervised Chemical Dependence Outpatient Rehabilitation Programs provide full
or half-day services to meet the needs of a specific target population of
chronic alcoholic persons who need a range of services which are different
from
those typically provided in an alcoholism outpatient clinic. Programs are
licensed by as Chemical Dependence Outpatient Rehabilitation Programs under
Title 14 NYCRR § 822.9.
D)
Outpatient Chemical Dependence for Youth Programs
Outpatient
Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR
Part
823, establish programs and service regulations for OCDY programs. OCDY programs
offer discrete, ambulatory clinic services to chemically-dependent youth in
a
treatment setting that supports abstinence from chemical dependence (including
alcohol and substance abuse) services.
ii)
Chemical Dependence Services Ordered by the LDSS
A)
The
Contractor is not responsible for the provision and payment of Chemical
Dependence Inpatient Rehabilitation and Treatment Services ordered by the LDSS
and provided to Enrollees who have:
I)
been
assessed as unable to work by the LDSS and are mandated to receive Chemical
Dependence Inpatient Rehabilitation and Treatment Services as a condition of
eligibility for Public Assistance or Medicaid, or
II)
have
been determined to be able to work with limitations (work limited) and are
simultaneously mandated by the LDSS into Chemical Dependence Inpatient
Rehabilitation and Treatment Services (including alcohol and substance abuse
treatment services) pursuant to work activity requirements.
B)
The
Contractor is not responsible for the provision and payment of Medically
Supervised Inpatient and Outpatient Withdrawal Services ordered by the LDSS
under Welfare Reform (as indicated by Code 83).
C)
The
Contractor is responsible for the provision and payment of Medically Managed
Detoxification Services in this Agreement.
D)
If the
Contractor is already providing an Enrollee with Chemical Dependence Inpatient
Rehabilitation and Treatment Services and Detoxification Services and the LDSS
is satisfied with the level of care and services, then the Contractor will
continue to be responsible for the provision and payment of these
services.
APPENDIX
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b)
Mental
Health Services
i)
Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)
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, to intervene with psychiatric rehabilitative
technologies to overcome functional disabilities. IPRT services are certified
by
OMH under 14NYCRRPart587.
ii)
Day
Treatment
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. Services
are expected to be of six (6) months-duration. These services are certified
by
OMH under 14 NYCRR Part 587.
iii)
Continuing Day Treatment
Provides
treatment designed to maintain or enhance current levels of functioning and
skills, maintain community living, and develop self-awareness and self-esteem.
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 14 NYCRR Part 587.
iv)
Day
Treatment Programs Serving Children
Day
treatment programs are characterized by a blend of mental health and special
education services provided in a fully integrated program. Typically these
programs include: special education in small classes with an emphasis on
individualized instruction, individual and group counseling, family services
such as family counseling, support and education, crisis intervention,
interpersonal skill development, behavior modification, art and music
therapy.
v)
Home
and Community Based Services Waiver for Seriously Emotionally Disturbed
Children
This
waiver is in select counties for children and adolescents who would otherwise
be
admitted to an institutional setting if waiver services were not provided.
The
services include individualized care coordination, respite, family support,
intensive in-home skill building, and crisis response.
APPENDIX
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vi)
Case
Management
The
target population consists of individuals who are seriously and persistently
mentally ill (SPMI), require intensive, personal and proactive intervention
to
help them obtain those services which will permit functioning in the community
and either have symptomology which is difficult to treat in the existing mental
health care system or are unwilling or unable to adapt to the existing mental
health care system. Three case management models are currently operated pursuant
to an agreement with OMH or a local governmental unit, and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 506. Please note: See generic definition
of Comprehensive Medicaid Case Management (CMCM) under Item 3 - "Other
Non-Covered Services."
vii)
Partial Hospitalization
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 NYCRR Part
587.
viii)
Services Provided Through OMH Designated' Clinics for Children With A Diagnosis
of Serious Emotional Disturbance (SED)
These
are
services provided by designated OMH clinics to children and adolescents with
a
clinical diagnosis of SED.
ix)
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;
are
operated pursuant to approval or certification by OMH; and receive Medicaid
reimbursement pursuant to 14 NYCRR Part 508.
x)
Personalized Recovery Oriented Services (PROS)
PROS,
licensed and reimbursed pursuant to 14 NYCRR Part 512, 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.
APPENDIX
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xi)
Risperdal Consta, an injectable mental health drug used for management of
patients with schizophrenia, furnished as part of a clinic or office
visit.
c)
Rehabilitation Services Provided to Residents of OMH Licensed Community
Residences (CRs) and Family Based Treatment Programs, as follows:
i)
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.
ii)
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 natural family, community, school or
independent living situations. Such services are provided in consideration
of a
child's developmental stage. Those children determined eligible for admission
are placed in surrogate family homes for care and treatment.
*
These
services are certified by OMH under 14 NYCRR § 586.3 and Parts 594 and
595.
d)
Office
of Mental Retardation and Developmental Disabilities (OMRDD)
Services
i)
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 14 NYCRR Part 679 (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.
ii)
Day
Treatment
APPENDIX
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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 ICF or
a
comparable setting. These services are certified by OMRDD under 14 NYCRR Pail
690.
iii)
Medicaid Service Coordination (MSC)
Medicaid
Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
which assists persons with developmental disabilities and mental retardation
to
gain access to necessary services and supports appropriate to the needs of
the
needs of the individual. MSC is provided by qualified service coordinators
and
uses a person centered planning process in developing, implementing and
maintaining an Individualized Service Plan (ISP) with and for a person with
developmental disabilities and mental retardation. MSC promotes the concepts
of
a choice, individualized services and consumer satisfaction. MSC is provided
by
authorized vendors who have a contract with OMRDD, and who are paid monthly
pursuant to such contract. Persons who receive MSC must not permanently reside
in an ICF for persons with developmental disabilities, a developmental center,
a
skilled nursing facility or any other hospital or Medical Assistance
institutional setting that provides service coordination. They must also not
concurrently be enrolled in any other comprehensive Medicaid long term service
coordination program/service including the Care at Home Waiver. Please note:
See
generic definition of Comprehensive Medicaid Case Management (CMCM) under Item
3
"Other Non-Covered Services."
iv)
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 SSA § 1915(c) waiver from
DHHS.
v)
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 SSA § 1915(c) waiver from DHHS.
APPENDIX
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3.
Other Non-Covered Services
a)
The
Early Intervention Program (EIP) - Children Birth to Two (2) Years of
Age
i)
This
program provides early intervention services to certain children, from birth
through two (2) years of age, who have a developmental delay or a diagnosed
physical or mental condition that has a high probability of resulting in
developmental delay. All managed care providers
must
refer
infants and toddlers suspected of having a delay to the local designated Early
Intervention agency in their area. (In most municipalities, the County Health
Department is the designated agency, except: New York City - the Department
of
Health and Mental Hygiene; Erie County - The Department of Youth Services;
Jefferson County -the Office of Community Services; and Ulster County - the
Department of Social Services).
ii)
Early
intervention services provided to this eligible population are categorized
as
Non-Covered. These services, which are designed to meet the developmental needs
of the child and the needs of the family related to enhancing the child's
development, will be identified on eMedNY by unique rate codes by which only
the
designated early intervention agency can claim reimbursement. Contractor covered
and authorized services will continue to be provided by the Contractor.
Consequently, the Contractor, through its Participating Providers, will be
expected to refer any enrolled child suspected of having a developmental delay
to the locally designated early intervention agency in their area and
participate in the development of the Child's Individualized Family Services
Plan (IFSP). Contractor's participation in the development of the IFSP is
necessary in order to coordinate the provision of early intervention services
and services covered by the Contractor.
iii)
SDOH
will instruct the locally designated early intervention agencies on how to
identify an Enrollee and the need to contact the Contractor or the Participating
Provider to coordinate service provision.
b)
Preschool Supportive Health Services-Children Three (3) Through Four (4) Years
of Age
i)
The
Preschool Supportive Health Services Program (PSHSP) enables counties and New
York City to obtain Medicaid reimbursement for certain educationally related
medical services provided by approved preschool special education programs
for
young children with disabilities. The Committee on Preschool Special Education
in each school district is responsible for the development of an Individualized
Education Program (IEP) for each child evaluated in need of special education
and medically related health services.
ii)
PSHSP
services rendered to children three (3) through four (4) years of age in
conjunction with an approved IEP are categorized as Non-Covered.
APPENDIX
K
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K-32
iii)
The
PSHSP services will be identified on eMedNY by unique rate codes through which
only counties and New York City can claim reimbursement. In addition, a limited
number of Article 28 clinics associated with approved pre-school programs are
allowed to directly ▇▇▇▇ Medicaid fee-for-service for these services. Contractor
covered and authorized services will continue to be provided by the
Contractor.
c)
School
Supportive Health Services-Children Five (5) Through Twenty-One (21) Years
of
Age
i)
The
School Supportive Health Services Program (SSHSP) enables school districts
to
obtain Medicaid reimbursement for certain educationally related medical services
provided by approved special education programs for children with disabilities.
The Committee on Special Education in each school district is responsible for
the development of an Individualized Education Program (IEP) for each child
evaluated in need of special education and medically related
services.
ii)
SSHSP
services rendered to children five (5) through twenty-one (21) years of age
in
conjunction with an approved IEP are categorized as Non-Covered.
iii)
The
SSHSP services are identified on eMedNY by unique rate codes through which
only
school districts can claim Medicaid reimbursement. Contractor covered and
authorized services will continue to be provided by the Contractor.
d)
Comprehensive Medicaid Case Management (CMCM)
A
program
which provides "social work" case management referral services to a targeted
population (e.g.: pregnant 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. Some of these services are:
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 must 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 and informed on the need to contact the
Contractor to coordinate service provision.
e)
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 included
in
the Benefit Package, TB/DOT where applicable, can be billed directly to eMedNY
by any SDOH approved Medicaid fee-for-service TB/DOT Provider. The
APPENDIX
K
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K-33
Contractor
remains responsible for communicating, cooperating and coordinating clinical
management of TB with the TB/DOT Provider.
f)
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.
g)
HIV
COBRA Case Management
The
HIV
COBRA (Community Follow-up Program) Case Management Program is a program that
provides intensive, family-centered case management and community follow-up
activities by case managers, case management technicians, and community
follow-up workers. Reimbursement is through an hourly rate billable to
Medicaid.
Reimbursable
activities include intake, assessment, reassessment, service plan development
and implementation, monitoring, advocacy, crisis intervention, exit planning,
and case specific supervisory case-review conferencing.
h)
Adult
Day Health Care
i)
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 individualized health care plan, ongoing implementation and coordination
of
the health care plan, and transportation.
ii)
Registrant means a person who is a nonresident of the residential health care
facility who is functionally impaired and not homebound and who requires certain
preventive, diagnostic, therapeutic, rehabilitative or palliative items or
services provided by a general hospital, or residential health care facility;
and whose assessed social and health care needs, in the professional judgment
of
the physician of record, nursing staff. Social Services and other professional
personnel of the adult day health care program can be met in whole or in part
satisfactorily by delivery of appropriate services in such program.
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i)
Persona] Emergency Response Services (PERS)
Personal
Emergency Response Services (PERS) are not included in the Benefit Package.
PERS
are covered on a fee-for-service basis through contracts between the -LDSS
and
PERS vendors.
j)
School-Based Health Centers
A
School-Based Health Center (SBHC) is an Article 28 extension clinic that is
located in a school and provides students with primary and preventive physical
and mental health care services, acute or first contact care, chronic care,
and
referral as needed. SBHC services include comprehensive physical and mental
health histories and assessments, diagnosis and treatment of acute and chronic
illnesses, screenings (e.g., vision, hearing, dental, nutrition, TB), routine
management of chronic diseases (e.g., asthma, diabetes), health education,
mental health counseling and/or referral, immunizations and physicals for
working papers and sports.
APPENDIX
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K-35
K.4
Family
Health Plus Non-Covered Services
1. Non-Emergent
Transportation Services (except for 19 and 20 year olds receiving C/THP
Services)
2. Personal
Care Agency Services
3. Private
Duty Nursing Services
4. Long
Term
Care - Residential Health Care Facility Services
5. Non-Prescription
(OTC) Drugs and Medical Supplies
6. Alcohol
and Substance Abuse (ASA) Services Ordered by the LDSS
7. Office
of
Mental Health/ Office of Mental Retardation and Developmental Disabilities
Services
8. School
Supportive Health Services
9. Comprehensive
Medicaid Case Management (CMCM)
10. Directly
Observed Therapy for Tuberculosis Disease
11. AIDS
Adult Day Health Care
12. HIV
COBRA
Case Management
13. Home
and
Community Based Services Waiver
14. Methadone
Maintenance Treatment Program
15. Day
Treatment
16. IPRT
17. Infertility
Services
18. Adult
Day
Health Care
19. School
Based Health Care Services
20. Personal
Emergency Response Systems
APPENDIX
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Schedule
1 of Appendix N
|
SERVICE
|
FEE
|
|
TB
CLINIC
|
$125.00
|
|
IMMUNIZATION
|
$50.00
|
|
LEAD
POISONING SCREENING
|
$15.00
|
|
HIV
COUNSELING AND TESTING VISIT
|
$96.47
|
|
HIV
COUNSELING AND NO TESTING
|
$90.12
|
|
HIV
POST TEST COUNSELING
Visit
Positive Result
|
$90.12
|
|
LAB
TEST
|
|
|
HIV
1 (ELISA Test)
|
$12.27
|
|
HIV
Antibody, Confirmatory (Western Blot)
|
$26.75
|
|
DENTAL
SERVICES
|
$108.00
|