AGREEMENT BETWEEN
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County Name or City of New York
And
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Contractor Name
This Agreement is made by and between
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County Name or City of New York (" County" or "City")
Acting through,
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Department of Social Services (" LDSS")or Health (" CDOH")
Located at
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And
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Contractor Name (" the Contractor")
Located At
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Recitals
Page 1 of 2
October 1, 1999
RECITALS
Pursuant to Title XIX of the Federal Social Security Act, codified as 42
U. S. C. Section 1396 et seq. (the "Social Security Act"), and Title 11 of
Article 5 of the New York State Social Services Law ("SSL"), codified as
N.Y.S.S.L. Section 363 et seq., a comprehensive program of Medical Assistance
for needy persons exists in the State of New York ("Medicaid").
Pursuant to Article 44 of the Public Health Law (" P. H. L."), the New
York State Department of Health (" SDOH") is authorized to issue Certificates of
Authority to establish Health Maintenance Organizations ("HMOs"), P. H. L.
Section 4400 et seq., Prepaid Health Services Plans. ("PHSPs"), P. H. L. Section
4403-a, and Integrated Delivery Systems ("IDS"), P. H. L. Section 4408-a.
The State Social Services Law defines Medicaid to include payment of
part or all of the cost of care and services furnished by an HMO, PHSP or an
IDS, identified as Managed Care Organizations ("MCOs") in this Agreement, to
Eligible Persons, as defined in this Agreement, residing in the geographic area
specified in Appendix M (Service Area) when such care and services are furnished
in accordance with an agreement approved by the SDOH that meets the requirements
of federal law and regulations.
The Contractor is a corporation organized under the laws of New York
State and is certified under Article 44 of the State Public Health Law or
Article 43 of the NYS Insurance Law.
The Contractor offers a comprehensive health services plan and
represents that it is able to make provision for furnishing medical and health
service benefits and has proposed to ______________________________________to
[INSERT LDSS OR CDOH]
provide these services to Eligible Persons; and
The Contractor has applied to participate in the Medicaid Managed Care
Program and the SDOH and ____________________________________ have determined
[INSERT LDSS OR CITY OF NEW YORK]
that the Contractor meets the qualification criteria established for
participation.
NOW THEREFORE, the parties agree as follows:
Recitals
Page 2 of 2
October 1, 1999
EXHIBIT 10.9
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 and Extensions
2.3 Approvals
2.4 Entire Agreement
2.5 Renegotiation
2.6 Assignment and Subcontracting
2.7 Termination
a. LDSS Initiated Termination of Contract
b. Contractor and LDSS 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 Contractor Financial Liability
3.10 Inpatient Hospital Stop-Loss Insurance
3.11 Mental Health and Alcohol/Substance Abuse Stop-Loss
3.12 Enrollment Limitations
3.13 Tracking Visits Provided by Indian Health Clinics
Section 4 Service Area
▇▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇ and Excluded Populations
5.1 Eligible Populations
5.2 Exempt Populations
5.3 Excluded Populations
5.4 Family Enrollment
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
Section 6 Enrollment
6.1 Enrollment Guidelines
6.2 Equality of Access to Enrollment
6.3 Enrollment Decisions
6.4 Auto Assignment
6.5 Prohibition Against Conditions on Enrollment
6.6 Family 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 Voluntary Counties
7.2 Lock-In Provisions in Mandatory Counties
7.3 Lock-In Provisions in New York City
7.4 Disenrollment During Lock-In Period
7.5 Notification Regarding Lock-In and End of Lock-In Period
Section 8 Disenrollment
8.1 Disenrollment Guidelines
8.2 Disenrollment Prohibitions
8.3 Reasons for Voluntary Disenrollment
8.4 Processing of Disenrollment Requests
8.5 Contractor Notification of Disenrollments
8.6 Contractor's Liability
8.7 Enrollee Initiated Disenrollment
a. Disenrollment for Good Cause
b. Expedited Disenrollment
8.8 Contractor Initiated Disenrollment
8.9 LDSS Initiated Disenrollment
Section 9 Guaranteed Eligibility
Section 10 Benefit Package, Covered and Non-Covered Services
10.1 Contractor Responsibilities
10.2 Compliance with State Medicaid Plan and Applicable Laws
10.3 Definitions
10.4 Provision of Services Through Participating and
Non-Participating Providers
10.5 Child Teen Health Program /Adolescent Preventive Services
10.6 ▇▇▇▇▇▇ Care Children
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
10.7 Child Protective Services
10.8 Welfare Reform
10.9 Adult Protective Services
10.10 Court Ordered Services
10.11 Family Planning and Reproductive Health Services
10.12 Prenatal Care
10.13 Direct Access
10.14 Emergency Services
10.15 Medicaid Utilization Thresholds (MUTS)
10.16 Services for Which Enrollees Can Self-Refer
a. Mental Health and Alcohol/Substance Abuse
b. Vision Services
c. Diagnosis and Treatment of Tuberculosis
d. Family Planning/Reproductive Health
e. Sexually Transmitted Disease (STD) Services
10.17 Second Opinions for Medical or Surgical Care
10.18 Coordination with Local Public Health Agencies
10.19 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
10.20 Adults with Chronic Illnesses and Physical or
Developmental Disabilities
10.21 Children with Special Health Care Needs
10.22 Persons Requiring Ongoing Mental Health Services
10.23 Member Needs Relating to HIV
10.24 Persons Requiring Alcohol/Substance Abuse Services
10.25 Native Americans
10.26 Women, Infants, and Children (WIC)
10.27 Coordination of Services
Section 11 Marketing
11.1 Marketing Plan
11.2 Marketing Activities
11.3 Prior Approval of Marketing Materials, Procedures,
Subcontracts
11.4 Marketing Infractions
11.5 LDSS Option to Adopt Additional Marketing Guidelines
Section 12 Member Services
12.1 General Functions
12.2 Translation and Oral Interpretation
12.3 Communicating with the Visually, Hearing and Cognitively
Impaired
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
Section 13 Enrollee Notification
13.1 Provider Directories/Office Hours for Participating
Providers
13.2 Member ID Cards
13.3 Member Handbooks
13.4 Notification of Effective Date of Enrollment
13.5 Notification of Enrollee Rights
13.6 Enrollee's Rights To Advance Directives
13.7 Approval of Written Notices
13.8 Contractor's Duty to Report Lack of Contact
13.9 Contractor Responsibility to Notify Enrollee of Expected
Effective Date of Enrollment
13.10 LDSS Notification of Enrollee's Change in Address
Section 14 Complaint and Appeal Procedure
14.1 Contractor Program to Address Complaints
14.2 Notification of Complaint and Appeal Program
14.3 Guidelines for Complaint and Appeal Program
14.4 Complaint Investigation Determinations
Section 15 Access Requirements
15.1 Appointment Availability Standards
15.2 Twenty-Four (24) Hour Access
15.3 Appointment Waiting Times
15.4 Travel Time Standards
15.5 Service Continuation
a. New Enrollees
b. Enrollees Whose Health Care Provider Leaves Network
15.6 Standing Referrals
15.7 Specialist as a Coordinator of Primary Care
15.8 Specialty Care Centers
Section 16 Quality Assurance
16.1 Internal Quality Assurance Program
16.2 Standards of Care
Section 17 Monitoring and Evaluation
17.1 Right To Monitor Contractor Performance
17.2 Cooperation During Monitoring And Evaluation
17.3 Cooperation During Annual On-Site Review
17.4 Cooperation During Review of Services by External Review
Agency
Section 18 Contractor Reporting Requirements
18.1 Time Frames for Report Submissions
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
18.2 SDOH Instructions for Report Submissions
18.3 Liquidated Damages
18.4 Notification of Changes in Report Due Dates, Requirements
or Formats
18.5 Reporting Requirements
a. Annual Financial Statements
b. Quarterly Financial Statements
c. Other Financial Reports
d. Encounter Data
e. Quality of Care Performance Measures
f. Complaint Reports
g. Fraud and Abuse Reporting Requirements
h. Participating Provider Network Reports
i. Appointment Availability/Twenty-Four Hour (24) Access
and Availability Surveys
j. Clinical Studies
k. Independent Audits
l. PCP Auto Assignments
m. No Contact Report
n. Additional Reports
o. LDSS Specific Reports
18.6 Ownership and Related Information Disclosure
18.7 Revision of Certificate of Authority
18.8 Public Access to Reports
18.9 Professional Discipline
18.10 Certification Regarding Individuals Who Have Been Debarred
or Suspended by Federal or State Government
18.11 Conflict of Interest Disclosure
18.12 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 Medicaid
Recipients and Applicants
20.2 Medical Records of ▇▇▇▇▇▇ Children
20.3 Confidentiality of Medical Records
20.4 Length of Confidentiality Requirements
Section 21 Participating Providers
21.1 Network Requirements
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
21.2 Credentialing
21.3 SDOH Exclusion or Termination of Providers
21.4 Evaluation Information
21.5 Payment In Full
21.6 Choice/Assignment of PCPs
21.7 PCP Changes
21.8 PCP Status Changes
21.9 PCP Responsibilities
21.10 Member to Provider Ratios
21.11 Minimum Office Hours
21.12 Primary Care Practitioners
21.13 PCP Teams
21.14 Hospitals
21.15 Dental Networks
21.16 Presumptive Eligibility Providers
21.17 Mental Health, Alcohol and Substance Abuse Providers
21.18 Laboratory Procedures
21.19 School-Based Health Centers
21.20 Federally Qualified Health Centers (FQHCs)
21.21 Provider Services Function
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 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 Physician Incentive Plan
Section 23 Fraud and Abuse Prevention Plan
Section 24 Americans With Disabilities Act 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
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
25.5 Responsibilities of SDOH
25.6 Contractor's Obligations
Section 26 External Appeal
26.1 Basis for External Appeal
26.2 Eligibility For External Appeal
26.3 External Appeal Determinations
26.4 Compliance With External Appeal Laws and Regulations
Section 27 Intermediate Sanctions
Section 28 Environmental Compliance
Section 29 Energy Conservation
Section 30 Independent Capacity of Contractor
Section 31 No Third Party Beneficiaries
Section 32 Indemnification
32.1 Indemnification by Contractor
32.2 Indemnification by LDSS
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
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 LDSS 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
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
35.8 Non-Liability of Enrollees For Contractor's Debts
35.9 LDSS Compliance With Conflict of Interest Laws
35.10 Compliance With PHL Regarding External Appeals
Section 36 New York State Standard Contract Clauses
Section 37 Insurance Requirements
Signature Page
Table of Contents
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October 1, 1999
TABLE OF CONTENTS FOR MODEL CONTRACT
APPENDICES
A. New York State Standard Clauses and Local Standard Clauses, if
applicable
B. Certification Regarding Lobbying
C. New York State Department of Health Guidelines 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 Managed Care Complaint and Appeals
Program Guidelines
G. New York State Department of Health Guidelines for the Provision of
Emergency Care and Services
H. New York State Department of Health Guidelines for the Processing of
Enrollments and Disenrollments
I. New York State Department of Health Guidelines for Use of Medical
Residents
J. New York State Department of Health Guidelines of Federal Americans with
Disabilities Act
K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services
L. Approved Upper Payment Limit and Capitation Payment Rates
M. Service Area
N. Contractor-County Specific Agreements
Copies of Appendices will be abailable upon request.
Table of Contents
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October 1, 1999
1. DEFINITIONS
"ALCOHOL AND SUBSTANCE ABUSE SERVICE" means the treatment of addiction
to alcohol and/or one or more drugs or the treatment of impairments to
normal development or functioning including, but not limited to, social,
emotional, familial, educational, vocational or physical impairments due
to use of alcohol or drugs.
"AUTO-ASSIGNMENT" means a process by which an Eligible Person, who is
mandated to enroll in managed care, but who has not chosen to enroll
within sixty (60) days of receipt of the mandatory notice, is assigned
to a MCO contracted with the LDSS as a Medicaid Managed Care Provider in
accordance with the auto-assignment algorithm determined by the SDOH.
"BEHAVIORAL HEALTH SERVICE" means the assessment or treatment of mental
and/or alcohol disorders and/or substance abuse disorders.
"BENEFIT PACKAGE" means the covered services described in Appendix K of
this Agreement to be provided to the Enrollee, as Enrollee is
hereinafter defined, by or through the Contractor.
"CAPITATION RATE" means the fixed monthly amount that the Contractor
receives for an Enrollee to provide that Enrollee with the Benefit
Package.
"CHILD/TEEN HEALTH PROGRAM" or "C/THP" means the program of early and
periodic screening, including inter-periodic, diagnostic and treatment
services (EPSDT) that New York State offers all Medicaid eligible
children under twenty-one (21) years of age. Care and services are
provided in accordance with the periodicity schedule and guidelines
developed by the New York State Department of Health. The services
include administrative services designed to help families obtain
services for children including outreach, information, appointment
scheduling, administrative case management and transportation
assistance, to the extent that transportation is included in the Benefit
Package.
"COURT-ORDERED SERVICES" means those services that the Contractor is
required to provide to Enrollees pursuant to orders of courts of
competent jurisdiction, provided however, that such ordered services are
within the Contractor's Medicaid managed care Benefit Package and
reimbursable under Title XIX of the Federal Social Security Act (SSL
364-j(4)(r)).
"DAYS" means calendar days except as otherwise stated.
"DISENROLLMENT" means the process by which an Enrollee's membership in
the Contractor's plan terminates.
SECTION 1
(DEFINITIONS)
October 1, 1999
1-1
"EFFECTIVE DATE OF DISENROLLMENT" means the date on which an Enrollee
may no longer receive services from the Contractor, pursuant to Section
6.8(b) and Appendix H of this Agreement.
"EFFECTIVE DATE OF ENROLLMENT" means the date on which an Enrollee may
receive services from the Contractor, pursuant to Section 6.8(b) and
Appendix H of this Agreement.
"ELIGIBLE PERSON" means a person whom the LDSS, state or federal
government determines to be eligible for Medicaid and who meets all the
other conditions for enrollment in Medicaid managed care as set forth in
this Agreement.
"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 lay person,
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 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.
"ENROLLEE" means an Eligible Person who, either personally or through an
authorized representative, has enrolled (or who has been auto-assigned)
in the Contractor's plan pursuant to Section 6 of this Agreement.
"ENROLLMENT" means the process by which an Enrollee's membership in a
Contractor's Plan begins.
"ENROLLMENT BROKER" means the state and/or county-contracted entity that
provides enrollment, education, and outreach services; effectuates
enrollments and disenrollments in Medicaid managed care; and provides
other contracted services on behalf of the SDOH and the LDSS.
"FAMILY" means a mother and child(ren), a father and child(ren), a
father and mother and child(ren), or a husband and wife residing in the
same household or persons included in the same case for purposes of
family enrollment in mandatory counties.
"FISCAL AGENT" means the entity that processes or pays vendor claims on
behalf of the Medicaid state agency pursuant to an agreement between the
entity and such agency.
"GUARANTEED ELIGIBILITY" means the period beginning on the Enrollee's
Effective Date of Enrollment with the Contractor and ending six (6)
months thereafter, during which the Enrollee may be entitled to
continued enrollment in the Contractor's plan despite the loss of
Medicaid eligibility as set forth in Section 9 of this Agreement.
SECTION 1
(DEFINITIONS)
October 1, 1999
1-2
"HEALTH PROVIDER NETWORK" or "HPN" means a closed communication network
dedicated to secure data exchange and distribution of health related
information between various health facility providers and the SDOH. HPN
functions include: collection of Medicaid complaint and disenrollment
information; collection of Medicaid financial reports; collection and
reporting of managed care provider networks systems (PNS); and the
reporting of Medicaid encounter data systems (MEDS).
"INSTITUTION FOR MENTAL DISEASE" or "MID" means a hospital, nursing
facility, or other institution of more than sixteen (16) beds that is
primarily engaged in providing diagnosis, treatment or care of persons
with mental diseases, including medical attention, nursing care and
related services. Whether an institution is an Institution for Mental
Disease is determined by its overall character as that of a facility
established and maintained primarily for the care and treatment of
individuals with mental diseases, whether or not it is licensed as such.
An institution f or the mentally retarded is not an Institution for
Mental Diseases.
"LOCAL PUBLIC HEALTH Agency" means ___________________________________.
Insert Name of Agency
"LOCK-IN PERIOD" means the period of time during which the Enrollee may
not disenroll from the Contractor's plan, unless the Enrollee becomes
eligible for an exclusion or an exemption or can demonstrate good cause
as established in state law and in 18 NYCRR Section 360-10.13.
"MANAGED CARE ORGANIZATION" or "MCO" means a health maintenance
organization ("HMO "), prepaid health service plan ("PHSP"), or
integrated delivery system ("IDS") certified under Article 44 of the New
York State P. H. L.
"MARKETING" means any activity of the Contractor, subcontractor or
individuals or entities affiliated with the Contractor by which
information about the Contractor is made known to Eligible Persons for
the purpose of persuading such persons to enroll with the Contractor.
"MARKETING Representative" means any individual or entity engaged by the
Contractor to market on behalf of the Contractor.
"MEDICAID MANAGEMENT INFORMATION System" or "MMIS" means the Medical
Assistance Information and Payment System of the SDOH.
"MEDICAL RECORD" means a complete record of care rendered by a provider
documenting the care rendered to the Enrollee, including inpatient,
outpatient, and emergency care, in accordance with all applicable
federal, state and local laws, rules and regulations. Such record shall
be signed by the medical professional rendering the services.
"MEDICALLY NECESSARY" means health care and services that are necessary
to prevent, diagnose, manage or treat conditions in the person that
cause acute suffering, endanger
SECTION 1
(DEFINITIONS)
October 1, 1999
1-3
life, result in illness or infirmity, interfere with such person's
capacity for normal activity, or threaten some significant handicap.
"NATIVE AMERICAN" means, for purposes of this contract, a person
identified in the Medicaid eligibility system as a Native American.
"NON-PARTICIPATING PROVIDER" means a provider of medical care and/or
services with which the Contractor has no Provider Agreement.
"PARTICIPATING PROVIDER" means a provider of medical care and/or
services that has a Provider Agreement with the Contractor.
"PHYSICIAN INCENTIVE PLAN" or "PIP" means any compensation arrangement
between the Contractor or one of its contracting entities and a
physician or physician group that may directly or indirectly have the
effect of reducing or limiting services furnished to Medicaid recipients
enrolled by the MCO.
"PREPAID CAPITATION PLAN ROSTER" OR "ROSTER" means the enrollment list
generated on a monthly basis by SDOH by which LDSS and Contractor are
informed of specifically which recipients the Contractor will be serving
for the coming month, subject to any revisions communicated in writing
or electronically by SDOH, LDSS, or the Enrollment Broker.
"PRESUMPTIVE ELIGIBILITY PROVIDER" means a provider designated by the
SDOH as qualified to determine the presumptive eligibility for pregnant
women to allow them to receive prenatal services immediately. Such
providers assist recipients with the completion of the full application
for Medicaid and they may be comprehensive Prenatal Care Programs, Local
Public Health Agencies, Certified Home Health Agencies, Public Health
Nursing Services, Article 28 facilities, and individually licensed
physicians and nurse practitioners.
"PREVENTIVE CARE" means the care or services rendered to avert
disease/illness and/or its consequences. There are three levels of
preventive care: primary, such as immunizations, aimed at preventing
disease; secondary, such as disease screening programs aimed at early
detection of disease; and 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 treatment programs.
"PRIMARY CARE PROVIDER" or "PCP" means a qualified physician, or nurse
practitioner or team of no more than four (4) qualified physicians/nurse
practitioners which provides all required primary care services
contained in the Benefit Package to Enrollees.
"PROVIDER AGREEMENT" means any written contract between the Contractor
and Participating Providers to provide medical care and/or services to
Contractor's Enrollees.
"SCHOOL BASED HEALTH CENTERS" or "SBHC" are SDOH approved centers which
provide comprehensive primary and mental health services including
health assessments,
SECTION 1
(DEFINITIONS)
October 1, 1999
1-4
diagnosis and treatment of acute illnesses, screenings and
immunizations, routine management of chronic diseases, healtheducation,
mental health counseling and treatment on-site in schools. Services are
offered by multi-disciplinary staff from sponsoring Article 28 licensed
hospitals and community health centers.
"SERIOUSLY EMOTIONALLY DISTURBED" or "SED" means, a child through
seventeen (17) years of age who has utilized the following during the
twelve (12) month period prior to scheduled enrollment:
- ten (10) or more encounters, including visits to a mental health
clinic, psychiatrist or psychologist, and inpatient hospital days
relating to a psychiatric diagnosis; or
- one (1) or more specialty mental health visits (i. e., psychiatric
rehabilitation treatment program; day treatment; continuing day
treatment; comprehensive case management; partial hospitalization;
rehabilitation services provided to residents of Office of Mental
Health (OMH) licensed community residences and family-based
treatment; and mental health clinics for seriously emotionally
disturbed children).
"SERIOUSLY AND PERSISTENTLY MENTALLY ILL" or "SPMI" means an adult
eighteen (18) years or older who has utilized the following during the
twelve (12) month period prior to scheduled enrollment:
- ten (10) or more encounters, including visits to a mental health
clinic, psychiatrist or psychologist, and inpatient hospital days
relating to a psychiatric diagnosis; or
- one (1) or more specialty mental health visits (i. e., psychiatric
rehabilitation treatment program; day treatment; continuing day
treatment; comprehensive case management; partial hospitalization;
rehabilitation services provided to residents of OMH licensed
community residences and family-based treatment; and mental health
clinics for seriously emotionally disturbed children).
"SUPPLEMENTAL NEWBORN CAPITATION PAYMENT" means the fixed amount paid to
the Contractor for the inpatient birthing costs for a newborn enrolled
in the plan, limited to those cases in which the plan has evidence of
payment to the hospital for the newborn hospital stay.
"TUBERCULOSIS DIRECTLY OBSERVED THERAPY" or "TB/DOT" means the direct
observation of ingestion of oral TB medications to assure patient
compliance with the physician's prescribed medication regimen.
"URGENT MEDICAL CONDITION" means a medical or behavioral condition other
than an emergency condition, manifesting itself by acute symptoms of
sufficient severity that, in the assessment of a "prudent lay person",
possessing an average knowledge of medicine and health, could reasonably
be expected to result in serious impairment of bodily functions, serious
dysfunction of a bodily organ, body part, or mental ability, or any
other condition that would place the health or safety of the Enrollee or
another individual in serious jeopardy in the absence of medical or
behavioral treatment within twenty-four (24) hours.
SECTION 1
(DEFINITIONS)
October 1, 1999
1-5
2. AGREEMENT TERM, AMENDMENTS, EXTENSIONS, AND GENERAL CONTRACT
ADMINISTRATION PROVISIONS
2.1 Term
a) This Agreement is effective October 1, 1999 and shall
remain in effect until September 30, 2001 or until the
execution of an extension, renewal or successor
Agreement approved by the SDOH and the Department of
Health and Human Services (DHHS), whichever occurs
first.
b) The parties to this Agreement shall have the option to
renew this Agreement for an additional two (2) year term
and for a subsequent one (1) year term, subject to the
approval of the LDSS, SDOH, DHHS, and any other entities
as required by law or regulation.
c) However, in no event, shall the maximum duration of this
Agreement exceed five (5) years.
2.2 Amendments and Extensions
a) This Agreement may only be modified in writing. Unless
otherwise specified in this Agreement, modifications
must be signed by the parties and approved by the SDOH,
DHHS, and any other entities as required by law or
regulation, prior to the end of the quarter in which the
amendment is to be effective.
b) This Agreement shall not be automatically renewed at its
expiration. This Agreement may be extended by written
amendment, in accordance with the procedures set forth
in this Section.
c) An extension to this Agreement may be granted for
reasons including, but not limited, to the following:
i) Negotiations for a successor Agreement will not
be completed by the expiration date of the
current contract; or
ii) The Contractor has submitted a termination
notice and transition of Enrollees will not be
completed by the expiration date of the current
contract.
d) The parties will submit, to the extent practicable, the
proposed signed and dated extensions, including all
necessary local government approvals, to SDOH prior to
the scheduled expiration date of this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-1
2.3 Approvals
This Agreement and any amendments to this Agreement shall not be
effective or binding unless and until approved, in writing, by
the DHHS, the SDOH and any other entity as required in law and
regulation. SDOH will provide a notice of each such approval to
the Contractor and the LDSS upon such approval.
2.4 Entire Agreement
This Agreement shall supersede all prior Agreements between the
Contractor and the LDSS. This Agreement, including those
attachments, schedules, appendices, exhibits, and addenda that
have been specifically incorporated herein and written plans
submitted by the Contractor and maintained on file by SDOH
and/or LDSS pursuant to this Agreement, contains all the terms
and conditions agreed upon by the parties, and no other
Agreement, oral or otherwise, regarding the subject matter of
this Agreement shall be deemed to exist or to bind any of the
parties or vary any of the terms contained in this Agreement. In
the event of any inconsistency or conflict among the document
elements of this Agreement, such inconsistency or conflict
shall be resolved by giving precedence to the document elements
in the following order:
1) The body of this Agreement;
2) The appendices attached to the body of this
Agreement;
3) The Contractor's approved:
i) Marketing Plan on file with SDOH and
LDSS
ii) Complaint and Appeals Procedure on file
with SDOH and LDSS
iii) Quality Assurance Plan on file with SDOH
and LDSS
iv) Americans with Disabilities Act
Compliance Plan on file with SDOH and
LDSS
v) Fraud and Abuse Prevention Plan on file
with SDOH and LDSS.
2.5 Renegotiation
The parties to this Agreement shall have the right to
renegotiate the terms and conditions of this Agreement in the
event applicable local, state or federal law, regulations or
policy are altered from those existing at the time of this
Agreement in order to be in continuous compliance therewith.
This Section shall not limit the right of the parties to this
Agreement from renegotiating or amending other terms and
conditions of this agreement. Such changes shall only be made
with the consent of the parties and the prior approval of the
SDOH and the DHHS.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-2
2.6 Assignment and Subcontracting
a) The Contractor shall not, without LDSS and SDOH's prior
written consent, assign, transfer, convey, sublet, or
otherwise dispose of this Agreement; of the Contractor's
right, title, interest, obligations, or duties under the
Agreement; of the Contractor's power to execute the
Agreement; or, by power of attorney or otherwise, of any
of the Contractor's rights to receive monies due or to
become due under this Agreement. Any assignment,
transfer, conveyance, sublease, or other disposition
without LDSS and SDOH's consent shall be void.
b) Contractor may not enter into any subcontracts related
to the delivery of services to Enrollees, except by a
written agreement, as set forth in Section 22 of this
Agreement. The Contractor may subcontract for provider
services and management services including, but not
limited to, marketing, quality assurance and utilization
review activities and such other services as are
acceptable to LDSS. If such written agreement would be
between Contractor and a provider of health care or
ancillary health services or between Contractor and an
independent practice association, the agreement must be
in a form previously approved by SDOH. If such
subcontract is for management services under 10 NYCRR
'98.11, it must be approved by SDOH prior to its
becoming effective. Other such subcontracts are subject
to the prior approval of the LDSS unless prior approval
is waived by the LDSS. Any subcontract entered into by
Contractor shall fulfill the requirements of 42 CFR
Parts 434 and 438 that are appropriate to the service or
activity delegated under such subcontract. Contractor
agrees that it shall remain legally responsible to LDSS
for carrying out all activities under this Agreement and
that no subcontract shall limit or terminate
Contractor's responsibility.
[ ] The LDSS has elected to waive prior approval of
subcontracts not related to provider services and
management services.
OR
[ ] The LDSS has elected to prior approve all subcontracts.
2.7 Termination
a) LDSS Initiated Termination of Contract
i) LDSS shall have the right to terminate this
Agreement, in whole or in part if the
Contractor:
A) takes any action that threatens the
health, safety, or welfare of its
Enrollees;
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-3
B) has engaged in an unacceptable practice
under 18 NYCRR, Part 515, that affects
the fiscal integrity of the Medicaid
program;
C) has its Certificate of Authority
suspended, limited or revoked by SDOH;
D) materially breaches the Agreement or
fails to comply with any term or
condition of this Agreement that is not
cured within twenty (20) days, or to
such longer period as the parties may
agree, of LDSS's written request for
compliance;
E) becomes insolvent;
F) brings a proceeding voluntarily, or has
a proceeding brought against it
involuntarily, under Title 11 of the
U. S. Code (the Bankruptcy Code);
G) changes the provider net work, such that
Enrollees access to the Contractor's
services is no longer consistent with
the standards set forth in Sections 15,
21 and 22 and Appendix I of this
Agreement; or
H) knowingly has a director, officer,
partner or person owning or controlling
more than five percent (5%) of the
Contractor's equity, or h as a n
employment, consulting, or other
agreement with such a person for the
provision of items and/or services that
are significant to the Contractor's
contractual obligation who has been
debarred or suspended by the federal,
state or local government, or other wise
excluded from participating in
procurement activities.
ii) The LDDSs will notify the Contractor of its
intent to terminate this Agreement for the
Contractors failure to meet the requirements of
this Agreement and provide Contractor with a
hearing prior to the termination.
iii) If SDOH suspends, limits or revokes Contractors
Certificate of Authority under P. H. L. '4404,
this Agreement shall expire on the date the
Contractor ceases to have authority to serve the
geographic area of the LDSS. No hearing will be
required if the contract expires due to SDOH
suspension, limitation or revocation of the
Contractors Certificate of Authority.
iv) Prior to the effective date of the termination
the LDSS shall notify Enrollees of the
termination, or delegate responsibility for such
notification to the Contractor, and such notice
shall include a statement that Enrollees may
disenroll immediately without cause.
b) Contractor and LDSS Initiated Termination
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-4
The Contractor and the LDSS each shall have the right to
terminate this Agreement in the event that SDOH and the
Contractor fail to reach agreement on the monthly
Capitation Rates. In such event, the party exercising
its right shall give the other party, LDSS, and SDOH
written notice specifying the reason for and the
effective date of termination, which shall not be less
time than will permit an orderly disenrollment of
Enrollees to the Medicaid fee-for-service payment
mechanism or transfer to another MCO, as determined by
LDSS, but no more than ninety (90) days.
c) Contractor Initiated Termination
i) The Contractor shall have the right to terminate
this Agreement in the event that LDSS materially
breaches the Agreement or fails to comply with
any term or condition of this Agreement that is
not cured within twenty (20) days, or to such
longer period as the parties may agree, of the
Contractor's written request for compliance. The
Contractor shall give LDSS written notice
specifying the reason for and the effective date
of the termination, which shall not be less time
than will permit an orderly disenrollment of
Enrollees to the Medicaid fee-for-service
payment mechanism or transfer to another managed
care program, as determined by LDSS, but no more
than ninety (90) days.
ii) The Contractor shall have the right to terminate
this Agreement in the event that its obligations
are materially changed by modifications to this
Agreement and its Appendices by SDOH or LDSS. In
such event, Contractor shall give LDSS and SDOH
written notice within thirty (30) days of
notification of changes to the Agreement or
Appendices specifying the reason and the
effective date of termination, which shall not
be less time than will permit an orderly
disenrollment of Enrollees to the Medicaid
fee-for-service program or transfer to another
MCO, as determined by the LDSS, but no more than
ninety (90) days.
iii) The Contractor shall also have the right to
terminate this Agreement if the Contractor is
unable to provide services pursuant to this
Agreement because of a natural disaster and/or
an act of God to such a degree that Enrollees
cannot obtain reasonable access to services
within the Contractor's organization, and, after
diligent efforts, the Contractor cannot make
other provisions for the delivery of such
services. The Contractor shall give LDSS written
notice of any such termination that specifies:
A) the reason for the termination, with
appropriate documentation of the
circumstances arising from a natural
disaster and/or an act of God that
preclude reasonable access to services;
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-5
B) the Contractor's attempts to make other
provision for the delivery of services;
and
C) the effective date of the termination,
which shall not be less time than will
permit an orderly disenrollment of
Enrollees to the Medicaid
fee-for-service payment mechanism or
transfer to another MCO, as determined
by LDSS, but no more than ninety
(90)days.
d) Termination Due To Loss of Funding
In the event that State and/or Federal funding used to
pay for services under this Agreement is reduced so that
payments cannot be made in full, this Agreement shall
automatically terminate, unless both parties agree to a
modification of the obligations under this Agreement.
The effective date of such termination shall be ninety
(90) days after the Contractor receives written notice
of the reduction in payment, unless available funds are
insufficient to continue payments in full during the
ninety (90) day period, in which case LDSS shall give
the Contractor written notice of the earlier date upon
which the Agreement shall terminate. A reduction in
State and/or Federal funding cannot reduce monies due
and owing to the Contractor on or before the effective
date of the termination of the Agreement.
2.8 Close-Out Procedures
Upon termination or expiration of this Agreement and in the
event that it is not scheduled for renewal, the Contractor shall
comply with close-out procedures that the Contractor develops in
conjunction with LDSS and that the LDSS, and the SDOH have
approved. The close-out procedures shall include the following:
a) The Contractor shall promptly account for and repay
funds advanced by SDOH for coverage of Enrollees for
periods subsequent to the effective date of termination;
b) The Contractor shall give LDSS, SDOH, and other
authorized federal, state or local agencies access to
all books, records, and other documents and upon
request, portions of such books, records, or documents
that may be required by such agencies pursuant to the
terms of this Agreement;
c) The Contractor shall submit to LDSS, SDOH, and other
authorized federal, state or local agencies, within
ninety (90) days of termination, a final financial
statement and audit report relating to this Agreement,
made by a certified public accountant or a licensed
public accountant, unless the Contractor requests of
LDSS and receives written approval from LDSS, SDOH and
all other governmental agencies from which approval is
required, for an extension of time for this submission;
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-6
d) The Contractor shall furnish to SDOH immediately upon
receipt all information related to any request for
reimbursement of any medical claims that result from
services delivered after the date of termination of this
Agreement;
e) The Contractor shall establish an appropriate plan
acceptable to and prior approved by the LDSS and SDOH
for the orderly disenrollment of Enrollees to the
Medicaid fee-for-service program or enrollment into
another MCO. This plan shall include the provision of
pertinent information to identified Enrollees who are:
pregnant; currently receiving treatment for a chronic or
life threatening condition; prior approved for services
or surgery; or whose care is being monitored by a case
manager to assist them in making decisions which will
promote continuity of care.
f) The Contractor shall allow an Enrollee to continue
treatment with a Participating Provider if the Enrollee
has entered the second trimester of pregnancy, for a
transitional period that includes the provision of
post-partum are directly related to the delivery; only
if a participating provider is willing to:
i) accept reimbursement from the Contractor at
rates established by the Contractor as payment
in full, which rates shall be no more than the
level of reimbursement applicable to similar
providers within the Contractor's network for
such services;
ii) adhere to the Contractor's quality assurance
requirements and agree to provide to the
Contractor necessary medical information related
to such care; and
iii) otherwise adhere to the Contractor's policies
and procedures including, but not limited to,
procedures regarding referrals and obtaining
preauthorization in a treatment plan approved by
the Contractor;
g) SDOH shall promptly pay all claims and amounts owed to
the Contractor;
h) Any termination of this Agreement by either the
Contractor or LDSS shall be done by amendment to this
Agreement, unless the contract is terminated by the LDSS
due to conditions in Section 2.7 a.(i) or Appendix A of
this Agreement.
2.9 Rights and Remedies
The rights and remedies of LDSS and the Contractor provided
expressly in this Article shall not be exclusive and are in
addition to all other rights and remedies provided by law or
under this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-7
2.10 Notices
All notices to be given under this Agreement shall be in writing
and shall be deemed to have been given when mailed to, or, if
personally delivered, when received by the Contractor, LDSS, and
the SDOH at the following addresses:
For LDSS:
----------------------------------
----------------------------------
----------------------------------
----------------------------------
[Insert Name and Address]
For SDOH:
New York State Department of Health
Empire ▇▇▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇. ▇▇▇▇
▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇
For the Contractor:
--------------------------------
--------------------------------
--------------------------------
--------------------------------
[Insert Name and Address]
2.11 Severability
If this Agreement contains any unlawful provision that is not an
essential part of this Agreement and that was not a controlling
or material inducement to enter into this Agreement, the
provision shall have no effect and, upon notice by either party,
shall be deemed stricken from this Agreement without affecting
the binding force of the remainder of this Agreement.
SECTION 2
(AGREEMENT TERM, AMENDMENTS, EXTENSIONS,
AND GENERAL CONTRACT ADMINISTRATION PROVISIONS)
October 1, 1999
2-8
3. COMPENSATION
3.1 Capitation Payments
Compensation to the Contractor shall consist of a monthly
capitation payment for each Enrollee and the Supplemental
Newborn Capitation Payment where applicable.
a) In no event shall monthly capitation payments to the
Contractor for the Benefit Package exceed the cost of
providing the Benefit Package on a fee-for-service basis
to an actuarially equivalent, non-enrolled population
group Upper Payment Limit (UPL) as determined by SDOH.
b) The monthly Capitation Rates are attached hereto as
Appendix L and shall be deemed incorporated into this
Agreement without further action by the parties.
c) The monthly capitation payments and the Supplemental
Newborn Capitation Payment to the Contractor shall
constitute full and complete payments to the Contractor
for all services that the Contractor provides pursuant
to this Agreement subject to stop-loss provisions set
forth in Section 3.10 and 3.11 of this Agreement.
d) Capitation Rates shall be effective for the entire
contract period, except as described in Section 3.2.
3.2 Modification of Rates During Contract Period
a) Any technical modification to Capitation Rates during
the term of the Agreement as agreed to by the
Contractor, including but not limited to, changes in
reinsurance or the Benefit Package, shall be deemed
incorporated into this Agreement without further action
by the parties, upon approval by SDOH, and upon written
notice by SDOH to the LDSS.
b) Any other modification to Capitation Rates, as agreed to
by SDOH and the Contractor, during the term of the
Agreement shall be deemed incorporated into this
Agreement without further action by the parties upon
approval of such modifications by the SDOH and the State
Division of the Budget, and upon written notice by SDOH
to the LDSS.
c) In the event that SDOH and the Contractor fail to reach
agreement on modifications to the monthly Capitation
Rates, the SDOH will provide formal written notice to
the Contractor and LDSS of the amount and effective date
of the modified Capitation Rates approved by the State
Division of the Budget. The Contractor shall have the
option of terminating this Agreement if such
SECTION 3
COMPENSATION
October 1, 1999
3-1
approved modified Capitation Rates are not acceptable.
In such case, the Contractor shall give written notice
to the SDOH and the LDSS within thirty (30) days of the
d ate of the formal written notice of the modified
Capitation Rates from SDOH specifying the reasons for
and effective date of termination. The effective date of
termination shall be ninety (90) days from the date of
the Contractor's written notice, unless the SDOH
determines that an orderly disenrollment to Medicaid
fee-for-service or transfer to another MCO can be
accomplished in fewer days. During the period commencing
with the effective date of the SDOH modified Capitation
Rates through the effective date of termination of the
Agreement, the Contractor shall have the option of
continuing to receive capitation payments at the expired
Capitation Rates or at the modified Capitation Rates
approved by SDOH and State Division of the Budget for
the rate period.
If the Contractor fails to exercise its right to
terminate in accordance with this Section, then the
modified Capitation Rates approved by SDOH and the State
Division of the Bud get shall be deemed incorporated
into this Agreement without further action by the
parties as of the effective date of the modified
Capitation Rates as established by SDOH and approved by
State Division of the Budget.
3.3 Rate Setting Methodology
Capitation Rates are determined using a prospective methodology
whereby cost, utilization and other rate-setting data available
for the time period prior to the time period covered by the
rates are used to establish premiums. Capitation rates will not
be retroactively adjusted to reflect actual fee-for-service data
or plan experience for the time period covered by the rates.
3.4 Payment of Capitation
a) The monthly Capitation payments for each Enrollee are
due to the Contractor from the Effective D ate of
Enrollment until the Effective Date of Disenrollment of
the Enrollee or termination of this Agreement, which
ever occurs first. The Contractor shall receive a full
month's capitation payment for the month in which
disenrollment occurs. The Roster generated by SDOH with
any modification communicated electronically or in
writing by the LDSS or the Enrollment Broker prior to
the end of the month in which the Roster is generated,
shall be the enrollment list for purposes of MMIS
premium billing and payment, as discussed in Section 6.9
and Appendix H.
b) Upon receipt by the Fiscal Agent of a properly completed
claim for monthly capitation payments submitted by the
Contractor pursuant to this Agreement, the Fiscal Agent
will promptly process such claim for payment through
MMIS and use its best efforts to complete such
processing within thirty (30) business
SECTION 3
COMPENSATION
October 1, 1999
3-2
days from date of receipt of the claim by the Fiscal
Agent. Processing of Contractor claims shall be in
compliance with the requirements of 42 CF R 447.45. The
Fiscal Agent will also use its best efforts to resolve
any billing problem relating to the Contractor's claims
as soon as possible. In accordance with Section 41 of
the State Finance Law, the State and LDSS shall have no
liability under this Agreement to the Contractor or
anyone else beyond funds appropriated and available for
payment of Medical Assistance care, services and
supplies.
3.5 Denial of Capitation Payments
If the Health Care Financing Administration (HCFA) denies
payment for new Enrollees, as authorized by Social Security Act
(SSA) '1903(m)(5)and 42 CFR ' 434.67, or such other applicable
federal statutes or regulations, based upon a determination that
Contractor failed substantially to provide medically necessary
items and services, imposed premium amounts or charges in excess
of permitted payments, engaged in discriminatory practices as
described in SSA ' 1932(e)(1)(A)(iii), misrepresented or
falsified information submitted to HCFA, SDOH, LDSS, the
Enrollment Broker, or an Enrollee, potential Enrollee, or health
care provider, or failed to comply with federal requirements (i.
e. 42 CFR ' 417.479 and 42 CFR '434.70) relating to the
Physician Incentive Plans, SDOH and LDSS will deny capitation
payments to the Contractor for the same Enrollees for the period
of time for which HCFA denies such payment.
3.6 SDOH Right to Recover Premiums
The parties acknowledge and accept that the SDOH has a right to
recover premiums paid to the Contractor for Enrollees listed on
the monthly Roster who are later determined f or the entire
applicable payment month, to have been in an institution; to
have been incarcerated; to have moved out of the Contractor's
service area subject to any time remaining in the Enrollee's
Guaranteed Eligibility period; or to have died. In any event,
the State may only recover premiums paid for Medicaid Enrollees
listed on a Roster if it is determined by the SDOH that the
Contractor was not at risk for provision of medical services
for any portion of the payment period.
3.7 Third Party Health Insurance Determination
The Contractor and the LDSS will make diligent efforts to
determine whether Enrollees have third party health insurance
(TPHI). The LDSS shall use its best efforts to maintain third
party information on the WMS/MMIS Third Party Resource System.
The Contractor shall make good faith efforts to coordinate
benefits with and collect TPHI recoveries from other insurers,
and must inform the LDSS of any known changes in status of TPHI
insurance eligibility within thirty (30) days of learning of a
change in TPHI. The Contractor may use the Roster as
SECTION 3
COMPENSATION
October 1, 1999
3-3
one method to determine TPHI information. The Contractor will be
permitted to retain 100 per cent of any reimbursement for
Benefit Package services obtained from TPHI. Capitation Rates
are net of TPHI recoveries. In no instances may an Enrollee be
held responsible for disputes over these recoveries.
3.8 Payment For Newborns
a) The Contractor shall be responsible for all costs and
services included in the Benefit Package associated with
the Enrollee's newborn, unless the child is excluded
from Medicaid Managed Care.
b) The Contractor shall receive a capitation payment from
the first day of the newborn's month of birth and, in
instances where the plan pays the hospital for the
newborn hospital stay, a Supplemental Newborn Capitation
Payment.
c) Capitation Rate and Supplemental Newborn Capitation
Payment for a newborn will beg in the month following
certification of the newborn's eligibility and
enrollment, retroactive to the first day of the month in
which the child was born.
d) The Contractor must maintain on file evidence of payment
to the hospital of the inpatient claim f or the newborn
hospital stay to be eligible to receive a Supplemental
Newborn Capitation Payment. Failure to have supporting
records may, upon an audit, result in recoupment of the
supplemental newborn payment by SDOH.
3.9 Contractor Financial Liability
Contractor shall not be financially liable for any services
rendered to an Enrollee prior to his or her Effective Date of
Enrollment in the Contractor's plan.
3.10 Inpatient Hospital Stop-Loss Insurance
The Contractor must obtain stop-loss coverage for inpatient
hospital services. A Contractor may elect to purchase stop-loss
cove rage from New York State. In such cases, the Capitation
Rates paid to the Contractor shall be adjusted to reflect the
cost of such stop-loss coverage. The cost of such coverage shall
be determined by SDOH.
Under NYS stop-loss coverage, if the hospital inpatient expenses
incurred by the Contractor for an individual Enrollee during any
calendar year reaches $50,000, the Contractor shall be
compensated for 80% of the cost of hospital inpatient services
in excess of this amount up to a maximum of $250,000. Above that
amount, the Contractor will be compensated for 100% of cost. All
compensation shall be based on the lower of the Contractor's
negotiated hospital rate or Medicaid rates of payment.
SECTION 3
COMPENSATION
October 1, 1999
3-4
[ ] The Contractor has elected to have NYS provide stop-loss
reinsurance.
OR
[ ] Contractor has not elected to have NYS provide stop-loss
reinsurance.
3.11 Mental Health and Alcohol/Substance Abuse Stop-Loss
a) The Contractor will be compensated for medically
necessary and clinically appropriate Medicaid
reimbursable mental health treatment outpatient visits
in excess of twenty (20) visits during any calendar year
at rates set forth in contracted fee schedules. Any
Court Ordered Services for mental health treatment
outpatient visits which specify the use of Non
Participating Providers shall be compensated at the
Medicaid rate of payment.
b) The Contractor will be compensated for medically
necessary and clinically appropriate Medicaid
reimbursable alcohol and substance abuse treatment
outpatient visits in excess of sixty (60) visits during
a calendar year at rates set forth in contracted fee
schedules. Any Court Ordered Services for alcohol and
substance abuse treatment outpatient visits, which
specify the use of Non-Participating Providers, shall be
compensated at the Medicaid rate of payment.
c) The Contractor will be compensated for medically
necessary and clinically appropriate Medicaid
reimbursable inpatient mental health services and/or
inpatient alcohol and substance abuse treatment services
as defined in Appendix K in excess of a combined total
of thirty (30) days during a calendar year at the lower
of the Contractor's negotiated inpatient rate or
Medicaid rate of payment. The stop-loss insurance does
not apply to inpatient detoxification services provided
in Article 28 hospitals.
3.12 Enrollment Limitations
a) For purposes of this Agreement, enrollment shall not
exceed _________ Medicaid recipients. The upper limit
may be modified by mutual written agreement of the
Contractor, the LDSS, the SDOH and DHHS or HCFA.
b) LDSS shall have the right, upon consultation with and
notice to the SDOH, to limit, suspend, or terminate
enrollment activities by the Contractor and/or
enrollment into the Contractor's plan upon ten (10) days
written notice to the Contractor, specifying the actions
contemplated and
SECTION 3
COMPENSATION
October 1, 1999
3-5
the reason(s) for such action(s). Nothing in this paragraph
limits other remedies available to the LDSS under this
Agreement.
3.13 Tracking Visits Provided by Indian Health Clinics
The SDOH shall monitor all visits provided by tribal or Indian
health clinics or urban Indian health facilities or centers to
enrolled Native Americans, so that the SDOH can reconcile
payment made for those services, should it be deemed necessary
to do so.
SECTION 3
COMPENSATION
October 1, 1999
3-6
4. SERVICE AREA
The Service Area described in Appendix M of this Agreement, which is
hereby made a part of this Agreement as if set forth fully herein, is
the specific geographic area within which Eligible Persons must reside
to enroll in the Contractor's plan.
SECTION 4
(SERVICE AREA)
October 1, 1999
4-1
5. ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS
5.1 Eligible Populations
a) Except as specified in Section 5.1(b) and 5.3 be low,
all persons in the following Medicaid-eligible
beneficiary categories who reside in the service area
shall be eligible for enrollment in the Contractor's
plan:
i) Singles/Childless Couples -Cash and Medicaid
only
ii) Low Income Families with Children -Cash and
Medicaid only
iii) Aid to Families with Dependent Children
-Medicaid only
iv) Pregnant women whose net available income is at
or below one hundred and eighty-five percent
(185 %) of the federal poverty level for the
applicable household size.
v) Children aged one (1) year or below whose
family's net available income is at or below one
hundred and eighty-five percent (185%) of the
federal poverty level for the applicable
household size.
vi) Children between ages one (1) and five (5),
whose family's net available income is at or
below one hundred and thirty-three percent
(133%) of the federal poverty level for the
applicable household size.
vii) Children six (6) to nine teen (19), whose
family's net available income is at or below one
hundred percent (100%) of the federal poverty
level for the applicable household size.
viii) Transitional Medical Assistance Beneficiaries
ix) Supplemental Security Income (cash) and
Supplemental Security Income Related (Medicaid
only).
b) All Medicaid eligible individuals in the following
categories may be eligible for enrollment in the
Contractor 's plan at the LDSS' option, as indicated by
an X below.
i) ▇▇▇▇▇▇ care children in the direct care of LDSS.
YES______ NO_______
ii) Homeless persons living in shelters outside
of New York City may be eligible for enrollment
if so determined by the LDSS.
YES______ NO_______
5.2 Exempt Populations
The following populations are exempt from mandatory enrollment
in Medicaid managed care, but may enroll on a voluntary basis,
if otherwise eligible.
Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 1999
5-1
a) Individuals who are HIV+ or have AIDS.
b) Individuals who are Seriously and Persistently Mentally Ill or
Seriously Emotionally Disturbed.
c) Individuals for whom a Man aged Care Provider is not
geographically accessible so as to reasonably provide services.
To qualify for this exemption, an individual must demonstrate
that no participating MCO has a provider located within thirty
(30) minute s travel time /thirty (30) mile s travel distance
from the individual's home, who is accepting new patients, and
that there is a fee-for-service Medicaid provider available
within the thirty (30) minutes travel time /thirty (30) miles
travel distance.
d) Pregnant women who are already receiving prenatal care from a
provider authorized to provide such care not participating in
any Medicaid managed care plan. This status will last through a
woman's pregnancy, extend through the sixty (60) day post-partum
period and end at the end of the month in which the sixtieth
(60th) day occurs.
e) Individuals with a chronic medical condition who, for at least
six (6) months, have been under active treatment with a
non-participating sub-specialist physician who is not a network
provider for any MCO participating in the Medicaid managed care
program service area. This status will last as long as the
individual's chronic medical condition exists or until the
physician joins a participating MCO's network. The SDOH 's
Office of Managed Care, Medical Director will, upon the request
of an individual or his/her guardian or legally authorized
representative (health care agent authorized through a health
care proxy), review cases of individuals with unusually severe
chronic care needs for a possible exemption from mandatory
enrollment in managed care if such individuals are not otherwise
eligible for an exemption (i. e., meet one of the seventeen (17)
criteria listed here). The SDOH's OMC Medical Director may also
authorize a plan disenrollment for such individuals.
Diserollment requests should be made in a manner consistent with
the over all disenrollment request process for "good cause"
disenrollment.
f) Individuals with End Stage Renal Disease (ESRD).
g) Individuals who are residents of Intermediate Care Facilities
for the Mentally Retarded ("ICF/MR").
h) Individuals with characteristics and needs similar to those who
are residents of ICF/MRs based on criteria cooperatively
established by the State Office of Mental Retardation and
Developmental Disabilities (OMRDD) and the SDOH.
i) Individuals already scheduled for a major surgical procedure
(within thirty (30) days of scheduled enrollment) with a
provider who is not a participant in the
Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 1999
5-2
network of a Medicaid MCO under contract with the LDSS.
This exemption will only apply until such time as the
individual's course of treatment is complete.
j) Individuals with a developmental or physical disability
who receive services through a Medicaid
Home-and-Community-Based Services Waiver or Medicaid
Model Waiver (care-at-home) through a Section 1915c
waiver, or individuals having characteristics and needs
similar to such individuals (including individuals on
the waiting list), based on criteria cooperatively
established by OMRDD and SDOH.
k) Individuals who are residents of Alcohol and Substance
Abuse Long Term Residential Treatment Programs.
l) In New York City, individuals who are homeless and do
not reside in a Department of Homeless Services (DHS)
shelter are exempt. Homeless individuals residing in a
NYC DHS shelter and already enrolled in a plan at the
time they enter the shelter may choose to remain
enrolled. In areas outside of NYC, exemption of homeless
individuals residing in the shelter system is at the
discretion of the LDSS -see Section 5.1b.
m) Native Americans
n) Individuals who cannot be served by a managed care
provider due to a language barrier which exists when the
individual is not capable of effectively communicating
his or her medical needs in English or in a secondary
language for which PCPs are available within the
Medicaid managed care pro gram. Individuals with a
language barrier will be deemed able to be served if
they have a choice of three (3) PCPs, at least one (1)
of which is able to communicate in the primary language
of the eligible individual or has a person on his/her
staff capable of translating medical terminology, and
the other two (2) PCPs have access to Language Line
Services as an alternative to communicating directly
with the eligible individual in his/her language.
Individuals will be eligible for an exemption when:
I) The individual has a relationship with a primary care
provider who:
A) has the language capability to serve the
individual;
B) does not participate in any of the Medicaid
managed care plans within a thirty (30) minute
/thirty (30) mile radius of the eligible
individual's residence; OR
ii) The three following circumstances exist:
A) neither a fee-for-service provider nor the above
described three (3) participating PCPs are
available within the thirty (30) minute /thirty
(30) mile radius; and
Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 1999
5-3
B) a fee-for-service provider with the language
capability to serve the individual is available
outside the thirty (30) minute/thirty (30) mile
radius; and
C) the above described three (3) participating PCPs
are not available outside the thirty (30)
minute/thirty (30) mile radius.
o) Individuals temporarily residing out of district, (e.
g., college students) will be exempt until the last day
of the month in which the purpose of the absence is
accomplished. The definition of temporary absence is set
forth in Social Services regulations 18 NYCRR Section
360-1.4 (p).
p) SST and SS I-related beneficiaries are considered exempt
and may enroll on a voluntary basis.
5.3 Excluded Populations
The following populations are ineligible for enrollment in
Medicaid managed care.
a) Individuals who are Dually Eligible for
Medicare/Medicaid.
b) Individuals who become eligible for Medicaid only after
spending down a portion of their income (Spend-down).
c) Individuals who are residents of State-operated
psychiatric facilities or residential treatment
facilities for children and youth.
d) Individuals who are residents of Residential Health Care
Facilities ("RHCF") at the time of enrollment and
individuals who enter a RHCF subsequent to enrollment,
except for short term rehabilitative stays anticipated
to be no greater than thirty (30) days.
e) Individuals enrolled in managed long term care
demonstrations authorized under Article 4403-f of the
New York State P. H. L.
f) Medicaid-eligible infants living with incarcerated
mothers.
g) Infants weighing less than 1200 grams at birth and other
infants under six (6) months of age who meet the
criteria for the SSI or SSI related category (shall not
be enrolled or shall be disenrolled retroactive to date
of birth).
h) Individuals with access to comprehensive private health
care coverage including those already enrolled in an
MCO. Such health care coverage, purchased either
partially or in full, by or on behalf of the individual,
must be determined to be cost effective by the local
social services district.
Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 1999
5-4
i) ▇▇▇▇▇▇ children in the placement of a voluntary agency.
j) Certified blind or disabled children living or expected
to b e living separate and apart from the parent for
thirty (30) days or more.
k) Individuals expected to be eligible for Medicaid for
less than six (6) months, except for pregnant women (e.
g., seasonal agricultural workers).
l) ▇▇▇▇▇▇ children in direct care (unless LDSS opts to
enroll them see Section 5.1(b)).
m) Homeless individuals residing in a NYCDHS shelter and
not enrolled in a Managed Care plan at the time they
enter the shelter.
n) Individuals in receipt of institutional long-term care
services through Long Term Home Health Care programs, or
Child Care Facilities (except ICF services for the
Developmentally Disabled).
o) Individuals eligible for Medical assistance benefits
only with respect to TB related services.
p) Individuals placed in State Office of Mental Health
licensed family care homes pursuant to NYS Mental
Hygiene Law, Section 31.03.
q) Individuals enrolled in the Restricted Recipient
Program.
r) Individuals with a "County of Fiscal Responsibility"
code of 99.
s) Individuals admitted to a Hospice program a t the time
of enrollment (if an Enrollee enters a Hospice program
while enrolled in the Contractor's plan, he/she may
remain enrolled in the Contractor's plan to maintain
continuity of care with his/her PCP). Hospice services
are accessed through the fee-for-service Medicaid
Program.
t) Individuals with a "County of Fiscal Responsibility"
code of 97 (OMH in MMIS) or 98 (OMRDD in MMIS).
5.4 Family Enrollment
Upon implementation of the 1115 waiver in a county, the Contractor agrees that
members of the same family (defined as mother and her child(ren), father and his
child(ren), a husband, wife and child(ren) or a husband and wife residing in the
same household, or persons included in the same case) will be required to enroll
in the same health plan, in accordance with Section 6.6 of this Agreement.
Section 5
(ELIGIBLE, EXEMPT AND EXCLUDED POPULATIONS)
October 1, 1999
5-5
6. ENROLLMENT
6.1 Enrollment Guidelines
a) The LDSS may employ a variety of methods and programs
for enrollment of Eligible Persons including, but not
limited to enrollment assisted by the Contractor,
enrollment assisted by an Enrollment Broker, enrollment
by LDSS, or a combination of such. The policies and
procedural guidelines which will be used for enrollment
a reset forth in Appendix H, which is hereby made a part
of this Agreement as if set forth fully herein.
b) The LDSS and the Contractor agree to conduct enrollment
of eligible individuals in accordance with the
guidelines set forth in Appendix H.
c) The SDOH and LDSS, upon mutual agreement, may make
modifications to the guidelines set forth in Appendix H.
The parties further acknowledge that such modifications
shall be effective and made a part of t his Agreement
without further action by the parties upon sixty (60)
days written notice to the LDSS and the Contractor.
6.2 Equality of Access to Enrollment
Eligible Person's shall be enrolled in the Contractor's plan, in
accordance with the requirements set forth in Appendix H,
Section A. In those instances in which the Contractor is
directly involved in enrolling eligible recipients, the
Contractor shall accept enrollments in the order they are
received without regard to the Eligible Person's age, sex, race,
creed, physical or mental handicap/developmental disability,
national origin, sexual orientation, type of illness or
condition, need for health services or to the Capitation Rate
that the Contractor will receive for such Eligible Person.
6.3 Enrollment Decisions
An Eligible Person's decision to enroll in the Contractor's plan
shall be voluntary except as otherwise provided in Section 6.4
of the Agreement.
6.4 Auto Assignment
Upon implementation of the 1115 Waiver, or other applicable
waivers of federal requirements, an Eligible Person whose
enrollment in a MCO is mandatory and who fails to select a MCO
within sixty (60) days of receipt of notice of mandatory
enrollment may be assigned by the LDSS to the Contractor's plan
pursuant to NYS Social Services Law Section 364-j and in
accordance with Appendix H.
SECTION 6
(ENROLLMENT)
October 1, 1999
6-1
6.5 Prohibition Against Conditions on Enrollment
Unless otherwise required by law or this agreement, neither the
Contractor nor LDSS shall condition any Eligible Person's
enrollment upon the performance of any act or suggest in any way
that failure to enroll may result in a loss of Medicaid
benefits.
6.6 Family Enrollment
a) Upon implementation of the 1115 Waiver, all eligible
members of the Eligible Person's Family shall be
enrolled into the same plan.
b) Upon implementation of the 1115 Waiver, the LDSS must inform
Enrollees who have Family members enrolled in other MCOs
that if anyone in the Family wishes to change plans, all
members of the Family must enroll together in the
newly-selected plan. The LDSS shall also notify the
Enrollee that all members of the Family will be required
to enroll together in a single MCO at the time of their
next recertification for Medicaid eligibility unless
waiver of this requirement is approved by the LDSS.
c) Notwithstanding the foregoing, the LDSS may, on a
case-by-case basis, approve enrollment of Family
member(s) of an Enrollee in another MCO if one or more
members of the Family are receiving prenatal care and/or
continuing care for a complex/chronic medical condition
from Non Participating Providers.
6.7 Newborn Enrollment
a) All newborn children not in an excluded category shall be
enrolled in the MCO of the mother, effective from the
first day of the child's month of birth.
b) In addition to the responsibilities set forth in
Appendix H, the Contractor is responsible for doing all
of the following with respect to newborns:
i) Coordinating with the LDSS the efforts to ensure
that all newborns are enrolled in the managed
care plan;
ii) Issuing a letter informing parent(s) about
newborn child's enrollment or a member
identification card within 14 days of the date
on which the Contractor becomes aware of the
birth;
iii) Assuring that enrolled pregnant women select a
PCP for an infant prior to
SECTION 6
(ENROLLMENT)
October 1, 1999
6-2
birth and the mother to make an appointment with
the PCP immediately upon birth; and
iv) Ensuring that the newborn is linked with a PCP
prior to discharge from the hospital, in those
instances in which the Contractor has received
appropriate notification of the birth prior to
discharge.
c) The LDSS shall be responsible for ensuring that timely
Medicaid Eligibility determination and enrollment of the
newborns is effected consistent with state laws,
regulations, and policy and with the newborn enrollment
guidelines set forth in Appendix H, Section B of this
Agreement.
6.8 Effective Date of Enrollment
a) The Contractor and the LDSS must notify the Enrollee of
the expected Effective Date of Enrollment. This may be
accomplished through a "Welcome Letter". To the extent
practicable, such notification must precede the
Effective Date of Enrollment. In the event that the
actual Effective Date of Enrollment changes, the
Contractor and the LDSS must notify the Enrollee of the
change.
b) As of the Effective Date of Enrollment, and until the
Effective Date of Disenrollment from the Contractor's
plan, the Contractor shall be responsible for the
provision and cost of all care and services covered by
the Benefit Package and provided to Enrollees whose
names appear on the Prepaid Capitation Plan Roster,
except as hereinafter provided.
i) Contractor shall not be liable for the cost of any
services rendered to an Enrollee prior to his or
her Effective Date of Enrollment.
ii) Contractor shall not be liable for the cost of
hospitalization for an Eligible Person, who is
hospitalized after completing and submitting an
enrollment form to enroll in the Contractor's
plan, and who remains hospitalized on or after
the Effective Date of Enrollment.
iii) Except for newborns, an Enrollee's Effective
Date of Enrollment shall be the first day of the
month on which the Enrollee's name appears on
the PCP roster for that month.
6.9 Roster
a) The first and second monthly Rosters generated by SDOH in
combination shall serve as the official Contractor
enrollment list for purposes of MMIS premium billing and
payment, subject to on going eligibility of the
Enrollees as of the first (1st) day of the enrollment
month. Modifications to the first (1st) Roster may be
made electronically or in writing by the LDSS
SECTION 6
(ENROLLMENT)
October 1, 1999
6-3
or the Enrollment Broker prior to the end of the month
in which the Roster is generated.
b) The LDSS shall make data on eligibility determinations
available to the Contractor and SDOH to resolve
discrepancies that may arise between the Roster and the
Contractor's enrollment files in accordance with the
provisions in Appendix H, Section D.
c) If LDSS or Enrollment Broker notifies the Contractor in writing
or electronically of changes in the first (1st ) Roster
and provides supporting information as necessary prior
to the effective date of the Roster, the Contractor will
accept that notification in the same manner as the
Roster. If the Contractor does not receive the Roster
before the last business day of the month prior to the
Roster effective date, the Contractor shall receive the
applicable monthly Capitation Rate for any individual
who is no longer on the Roster, was eligible the prior
month, and is inadvertently served by the Contractor
before receipt of the Roster.
d) All Contractors must have the ability to receive these
Rosters electronically.
6.10 Automatic Re-Enrollment
The Contractor agrees that Eligible Persons who are disenrolled
from the Contractor's plan due to loss of Medicaid eligibility
and who regain eligibility within three (3) months will
automatically be prospectively re-enrolled with the Contractor's
plan, subject to availability of enrollment capacity in the
plan.
SECTION 6
(ENROLLMENT)
October 1, 1999
6-4
7. LOCK-IN PROVISIONS
7.1 Lock-In Provisions in Voluntary Counties
All Enrollees in local social service districts where enrollment
in managed care is voluntary shall be subject to a Lock-In
Period under this Agreement if so required by the LDSS as
indicated by an x below:
[ ] Enrollees are subject to a twelve (12) month Lock-In
Period following the Effective Date of Enrollment in the
Contractor's plan with an initial ninety (90) day grace
period to disenroll from the Contractor's plan without
cause.
[ ] Enrollees are not subject to a Lock-In Period.
7.2 Lock-In Provisions in Mandatory Counties
All Enrollees in local social service districts, except New York
City, where enrollment in managed care is mandatory, are subject
to a twelve (12) month Lock-In period following the Effective
Date of Enrollment in the Contractor's plan, with an initial
thirty (30) day Grace period in which to disenroll from the
Contractor's plan without cause, or a sixty (60) day grace
period in which to disenroll from the Contractor's plan without
cause, if the Enrollee was auto assigned by the LDSS to the
Contractor's plan.
7.3 Lock-In Provisions in New York City
All Enrollees residing in New York City are subject to a twelve
(12) month Lock-In Period following the Effective Date of
Enrollment in the Contractor's plan with an initial ninety (90)
day grace period in which to disenroll without cause from the
Contractor 's Plan, regardless of zip code of residence, and
regardless of whether the Enrollee selected or was auto-assigned
to the Contractor's plan.
7.4 Disenrollment During Lock-In Period
An Enrollee, subject to Lock-In, may disenroll from the
Contractor's plan during the Lock-In period for "good cause" as
established in 18 NYCRR Section 360-10.13 or, if the Enrollee be
comes eligible for an exemption or exclusion from Medicaid
Managed Care as set forth in Sections 5.2 and 5.3 of this
Agreement.
7.5 Notification Regarding Lock-In and End of Lock-In Period
LDSS, either directly or through the Enrollment Broker, shall
notify Enrollees of their right to change MCOs in the enrollment
confirmation notice sent to individuals after they have selected
a CO or been auto-assigned (the latter being applicable to areas
where the mandatory program is in effect). LDSS and the
Section 7
(LOCK-IN PROVISIONS)
October 1, 1999
7-1
Enrollment Broker will be responsible for providing a notice of
end of Lock-In and the right to change MCOs at least sixty (60)
days prior to the first plan enrollment anniversary date.
Section 7
(LOCK-IN PROVISIONS)
October 1, 1999
7-2
8. DISENROLLMENT
8.1 Disenrollment Guidelines
a) Disenrollment of an Enrollee from the Contractor's Plan
may be initiated by the Enrollee, LDSS, and/or the
Contractor under the conditions specified in Sections
8.7, 8.8 and 8.9 and as detailed in Appendix H, Section
E of this Agreement.
b) The LDSS and the Contractor agree to conduct
disenrollment in accordance with the guidelines set
forth in Appendix H, Section E.
c) The SDOH and LDSS, upon mutual agreement, may modify
Appendix H of this Agreement upon sixty (60) days prior
written notice to the Contractor and such modifications
shall become binding and incorporated into this
Agreement without further action by the parties.
d) LDSS shall make the final determination concerning
disenrollment, except for Contractor initiated
disenrollments and expedited disenrollments, which ma y
be subject to SDOH approval as specified elsewhere in
this Agreement.
8.2 Disenrollment Prohibitions
Disenrollment shall not be based in whole or in part on any of
the following reasons:
a) an existing condition or a change in the Enrollee's
health which would necessitate disenrollment pursuant to
the terms of this Agreement, unless the change
i) results in the Enrollee being reclassified into
an excluded category for Medicaid managed care
as listed in Section 5.3 of this Agreement;
ii) results in the Enrollee being reclassified into
an exempt category as listed in Section 5.2 of
this Agreement and the Enrollee wants to
disenroll from managed care.
b) any of the factors listed in Section 34 -
Non-Discrimination of this Agreement; or
c) on the Capitation Rate payable to the Contractor r
elated to the Enrollee's participation with the
Contractor.
8.3 Reasons for Voluntary Disenrollment
Section 8
(Disenrollment)
October 1, 1999
8-1
The LDSS or the Contractor, as agreed upon between the LDSS and
Contractor, shall provide Enrollees who disenroll voluntarily
with an opportunity to identify, in writing, their reason(s) for
disenrollment.
8.4 Processing of Disenrollment Requests
Unless otherwise specified in Appendix H, Section F
disenrollment requests will be processed to take effect on the
first (1st) day of the next month if the request is made before
the date specified in Appendix H. In no event shall the
Effective Date of Disenrollment be later than the first (1st)
day of the second (2nd) month after the month in which an
Enrollee requests a disenrollment.
8.5 Contractor Notification of Disenrollments
Notwithstanding anything herein to the contrary, the Roster,
along with any changes sent by the LDSS to the Contractor in
writing or electronically, shall serve as official notice to the
Contractor of disenrollment of an Enrollee.
8.6 Contractor's Liability
The Contractor is not responsible for providing the Benefit
Package under this Agreement after the Effective Date of
Disenrollment unless the Enrollee is admitted to a hospital
prior to the expected Effective Date of Disenrollment and is not
discharged from the hospital until after the expected Effective
Date of Disenrollment, in which case the Contractor is
responsible for the entire hospital claim. The Contractor shall
notify the LDSS that the Enrollee remains in the hospital and
provide the LDSS with information regarding his or her medical
status. The Contractor is required to cooperate with the
Enrollee and the new MCO (if applicable) on a timely basis to
ensure a smooth transition and continuity of care.
8.7 Enrollee Initiated Disenrollment
a) Disenrollment For Good Cause
i) An Enrollee subject to Lock-In may initiate
disenrollment from the Contractor's plan for
"good cause" as defined in 18 NYCRR '360-10.13
at any time during the Lock-In period and may
disenroll for any reason at any time after the
twelfth (12th) month following the Effective
Date of Enrollment.
ii) An Enrollee subject to Lock-In may initiate
disenrollment for "good cause" by filing a
written request with the LDSS or the Contractor.
The Contractor must notify the LDSS of the
request. The LDSS must respond with a
determination within thirty (30) days after
receipt of the request.
Section 8
(Disenrollment)
October 1, 1999
8-2
iii) Enrollees granted disenrollment for "good cause"
in a voluntary county may join another plan, if
one is available, or participate in Medicaid
fee-for-service program. In mandatory counties,
unless the Enrollee becomes exempt or excluded,
he/she may be required to enroll with another
MCO.
iv) In the event that the LDSS denies an Enrollee's request
for disenrollment for "good cause", the LDSS
must inform the Enrollee of the denial of the re
quest with a written notice which explains the
reason for the denial, states the facts upon
which denial is based, cites the statutory and
regulatory authority and advises the recipient
of his or her right to a fair hearing pursuant
to 18 NYCRR Part 358. In the event that the
Enrollee's request to disenroll is approved, the
notice must state the Effective Date of
Disenrollment.
v) Once the Lock-In Period has expired, an Enrollee
may disenroll from the Contractor's plan at any
time, for any reason.
b) Expedited Disenrollment
i) In cases where the Enrollee's request for
disenrollment includes an urgent medical need to
disenroll from the Contractor 's plan without
delay, the SDOH or the LDSS may approve an
expedited disenrollment as set forth in Chapter
23 of New York State 's 1115 Waiver Operational
Protocol, and as set forth in Appendix H. The
LDSS will make this decision unless the LDSS
delegates this responsibility to SDOH.
ii) In cases where an Enrollee's request for disenrollment
may include a complaint of non-consensual
enrollment, Enrollees may initiate a request for
an expedited disenrollment to the LDSS or the
SDOH. Substantiation of such a request by the
LDSS or the SDOH may result in an expedited
disenrollment as set forth in Chapter 23 of New
York State's 1115 Waiver Operational Protocol
and as set forth in Appendix H.
8.8 Contractor Initiated Disenrollment
a) Contractor initiated disenrollment(s) will be limited to
circumstances wherein there is clear and consistent
documentation that the individual's behavior is verbally
or physically abusive and/or causes harm to other
Enrollees or to the plan providers and staff, or is
repeatedly non-compliant. Disenrollment may not be
initiated due to an Enrollee's refusal to accept a
specific treatment nor for behavior resulting from an
underlying medical condition, alcohol or substance
abuse, mental illness, mental retardation or other
developmental disability.
b) To request disenrollment of an Enrollee, the Contractor
must do the following if applicable:
Section 8
(Disenrollment)
October 1, 1999
8-3
i) show evidence of professional evaluation ruling
out an underlying medical condition, alcohol or
substance abuse, mental illness, mental
retardation or other developmental disability as
cause for Enrollee behavior.
ii) document difficulty encountered with the
Enrollee; nature, extent and frequency of
abusive or harmful behavior, violence, inability
to treat or engage client.
iii) identify and document unique issue s that may be
affecting the Contractor's ability to provide
treatment effectively to certain Enrollees as
well as the appropriateness of providers in
network.
iv) document special training offered to providers
to improve their ability to deal with difficult,
non-compliant patients, or those having the
above mentioned conditions.
c) The Contractor must make a reasonable effort to identify
for the Enrollee, both verbally and in writing, those
actions of the Enrollee that have interfered with the
effective provision of covered services as well as
explain what actions or procedures are acceptable.
d) Prior to requesting disenrollment by the LDSS of an
Enrollee for whom an agency other than the LDSS provides
oversight, the Contractor must make reasonable efforts
to engage the Enrollee, directly or by working with such
agencies.
e) The Contractor shall give prior verbal and written
notice to the Enrollee, with a copy to the LDSS, of its
intent to request disenrollment. The notice shall advise
the Enrollee that the request has been forwarded to the
LDSS f or review and approval. The written notice must
include the mailing address and telephone number of the
LDSS.
f) The Contractor shall keep the LDSS informed of decisions
related to all complaints filed by an Enrollee as a
result of, or subsequent to, the notice of intent to
disenroll.
g) The SDOH or LDSS will review each Contractor initiated
disenrollment request in accordance with protocols
established by SDOH in conjunction with the applicable
over sight agency. Where applicable, as set out in those
protocols, the LDSS or the SDOH, through or with the
cooperation of the LDSS, shall consult with local mental
health and substance abuse authorities in the County
when making the determination to approve or disapprove a
Contractor initiated disenrollment request.
h) The LDSS will render a decision within thirty (30) days
of receipt of the final request. Final written
determination will be provided to the Enrollee and the
Contractor. If the LDSS determination upholds the
Contractor's request to disenroll, the LDSS's written
determination must inform the
Section 8
(Disenrollment)
October 1, 1999
8-4
Enrollee of the Effective Date of Disenrollment and
include a notice of rights to a fair hearing. Should an
Enrollee request a fair hearing as a result of the LDSS
determination, the LDSS shall inform the Contractor of
the fair hearing request and the Enrollee will remain
enrolled in the Contractor's plan until disposition of
the fair hearing.
i) Once an Enrollee has been disenrolled at the
Contractor's request, he/she will not be re-enrolled
with the Contractor's plan unless the Contractor first
agrees to such re-enrollment.
j) In New York City, the Metropolitan Regional Office of
the SDOH will assume the LDSS responsibility for
reviewing and approving requests as set forth in
Sections 8.8(g) and (h) of this Agreement.
8.9 LDSS Initiated Disenrollment
a) LDSS will promptly initiate disenrollment when:
i) an Enrollee is no longer eligible for any
Medicaid benefits; or
ii) the Guaranteed Eligibility period ends (See
Section 9) and an Enrollee is no longer eligible
for any Medicaid benefits; or
iii) an Enrollee is no longer the financial
responsibility of the LDSS; or
iv) an Enrollee becomes ineligible for enrollment
pursuant to Section 5.3 of this Agreement, as
appropriate; or
v) an Enrollee resides out side the Service Area
covered by this Agreement, unless Contractor can
demonstrate that the Enrollee has made an
informed choice to continue enrollment with
Contractor and that Enrollee will have
sufficient access to Contractor's provider
network.
Section 8
(Disenrollment)
October 1, 1999
8-5
9. GUARANTEED ELIGIBILITY
Except as may otherwise be required by law:
9.1 New Enrollees, other than those identified in Sections 9.2 who would
otherwise lose Medicaid eligibility during the first six (6)
months of enrollment will retain the right to remain enrolled in
the Contractor's plan under this Agreement for a period of six
(6) months from their Effective Date of Enrollment.
9.2 Guaranteed eligibility is not available to Enrollees who lose
Medicaid eligibility for one of the following reasons:
a. death, moving out of State, incarceration, or the LDSS
is unable to locate;
b. engagement in fraudulent activities prior to the Effective Date
of Enrollment, which would render them ineligible for
Medicaid;
c. commitment of an international program violation by a single
childless adult between the age of twenty-one (21) to
sixty-five (65 ) who is not pregnant o r disabled prior
to the Effective Date of Enrollment;
d. being a woman with a net available income in excess of medically
necessary income but at or below 185% of the federal
poverty level who is only eligible for Medicaid while
she is pregnant and then through the end of the month in
which the sixtieth (60th) day following the end of the
pregnancy occurs.
9.3 If, during the first six (6) months of enrollment in the Contractor's
plan, an Enrollee becomes eligible for Medicaid only as a
spend-down, the Enrollee will be eligible to remain enrolled in
the Contractor's plan for the remainder of the six (6) month
guarantee period. During the six (6) month guarantee period, an
Enrollee eligible for spend-down and in need of wraparound
services has the option of spending down to gain full Medicaid
eligibility for the wraparound services. In this situation, the
LDSS will monitor the Enrollee's need for wrap around services
and manually set coverage codes as appropriate.
9.4 The services covered during the Guaranteed Eligibility period
shall be those contained in the Benefit Package, as specified in
Appendix K, including free access to family planning services as
s et forth in Section 10.12 of this Agreement. During the
Guaranteed Eligibility period Enrollees are also eligible for
pharmacy services on a Medicaid fee-for service basis.
9.5 An Enrollee-initiated disenrollment from the Contractor's plan
terminates the Guaranteed Eligibility period.
SECTION 9
(GUARANTEED ELIGIBILITY)
October 1, 1999
9-1
9.6 Enrollees who lose and regain Medicaid eligibility within a three (3)
month period will not be entitled to a new period of six (6)
months Guaranteed Eligibility.
9.7 During the guarantee period, an Enrollee may not change health
plans. An Enrollee may choose to disenroll from the Contractor's
Plan during the guarantee period but is not eligible to enroll
in any other MCO because he/she has lost eligibility for
Medicaid.
SECTION 9
(GUARANTEED ELIGIBILITY)
October 1, 1999
9-2
10. BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES
10.1 Contractor Responsibilities
Contractor must provide all services set forth in the Benefit
Package (Appendix K) that are cove red under the Medic aid fee
for service program except for services specifically excluded by
the contract, or enacted or affected by Federal or State Law
during the period of this agreement. SDOH and LDSS shall assure
the continued availability and accessibility of Medicaid
services not covered in the Benefit Package.
10.2 Compliance with State Medicaid Plan and Applicable Laws
Benefit Package services provided by the Contractor under this
Agreement shall comply with all standards of the State Medicaid
Plan established pursuant to Section 363-a of the State Social
Services Law and shall satisfy all applicable requirements of
the State Public Health and Social Services Laws.
10.3 Definitions
Benefit Package and Non-Covered Service definitions agreed to by
the Contractor and the LDSS are contained in Appendix K, which
is hereby made a part of this contract as if set forth fully
herein.
10.4 Provision of Services Through Participating and
Non-Participating Providers
With the exception of Emergency services described in Section
10.14 of this Agreement, Family Planning Services described in
Section 10.11 of this Agreement, and services for which
Enrollees can self refer as described in Section 10.16 of this
Agreement, the Benefit Package must be provided and authorized
by the Contractor through Provider Agreements with Participating
Providers, a s specified in Section 22 of this Agreement. A plan
may also arrange for specialty or other services for Enrollees
with Non -Participating Providers, in accordance with Section
21.1(b) of this Agreement.
10.5 Child Teen Health Program/Adolescent Preventive Services
a) The Contractor and its Participating Providers are
required to provide the Child Teen Health Program C/THP
services outlined in Appendix K (Benefit Package) and
comply with applicable EPSDT requirements specified in
42 CFR, Part 441, sub-part B, 18NYCRR, Part 508 and the
New York State Department of Health C/THP manual. The
Contractor and its Participating Providers are required
to provide C/THP services to Medicaid Enrollees under 21
years of age when:
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i) The care or services are essential to prevent,
diagnose, prevent the worsening of , alleviate
or a meliorate the effects of an illness,
injury, disability, disorder or condition.
ii) The care or services are essential to the
overall physical, cognitive and mental growth
and developmental needs of the child.
iii) The care or service will assist the individual
to achieve or maintain maximum functional
capacity in performing daily activities, taking
into account both the functional capacity of the
individual and those functional capacities that
are appropriate for individuals of the same age.
The Contractor shall base its determination on medical and other
relevant information provided by the Enrollee's PCP, other
health care providers, school, local social services, and/or
local public health officials that have evaluated the child.
b) The Contractor and its Participating Providers must
comply with the C/THP program standards and must do at
least the following with respect to all Enrollees under
age 21:
i) Educate pregnant women and families with under
age 21 Enrollees about the program and its
importance to a child's or adolescent's health.
ii) Educate network providers about the pro gram and
their responsibilities under it.
iii) Conduct outreach, including by mail, telephone,
and through home visits (where appropriate), to
ensure children are kept cur rent with respect t
o their periodicity schedules.
iv) Schedule appointments for children and
adolescents pursuant to the periodicity
schedule, assist with referrals, and conduct
follow-up with children and adolescents who miss
or cancel appointments.
v) Ensure that all appropriate diagnostic and
treatment services, including specialist
referrals, are furnished pursuant to findings
from a C/THP screen.
vi) Achieve and maintain an acceptable compliance
rate for screening schedules during the contract
period.
c) In addition to C/THP requirements, the
Contractor and its Participating Providers are
required to comply with the American Medical
Association's Guidelines for Adolescent
Preventive Services which require annual well
adolescent preventive visits which focus on
health guidance, immunizations, and screening
for physical, emotional, and behavioral
conditions.
10.6 ▇▇▇▇▇▇ Care Children
Section 10
(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 1999
10-2
The Contractor shall comply with the health requirements for
▇▇▇▇▇▇ children specified in 18 NYCRR Section 441.22 and Part
507 and any subsequent amendments thereto. These requirements
include thirty (30) day obligations for a comprehensive physical
and behavioral health assessment and assessment of the risk that
the child may be HIV+ and should be tested.
10.7 Child Protective Services
The Contractor shall comply with the requirements specified for
child protective examinations, provision of medical information
to the child protective services investigation and court ordered
services as specified in 18 NYCRR Section 432, and any
subsequent amendments thereto. Medically necessary services,
whether provided in or out of plan, must be provided. Out of
plan providers will be reimbursed at the Medicaid fee schedule
by the Contractor.
10.8 Welfare Reform
a) The LDSS must determine whether each public assistance
or combined public assistance/Medicaid applicant is
incapacitated or can participate in work activities. As
part of this work determination process, the LDSS may
require medical documentation and/or an initial mental
and/or physical examination to determine whether an
individual has a mental or physical impairment that
limits his/her ability to engage in work (12 NYCRR
Section 1300.2(d)(13)(i)). The LDSS may not require the
Contractor to provide the initial district mandated or
requested medical examination necessary for an Enrollee
to meet welfare reform work participation requirements.
b) The Contractor shall arrange for the provision of
medical documentation and health, mental health and
alcohol and substance abuse assessments as follows:
i) Within ten (10) days of a request of an Enrollee
or a former Enrollee, currently receiving public
assistance or who is applying for public
assistance, the Enrollee's or former Enrollee's
PCP or specialist provider, as appropriate,
shall provide medical documentation concerning
the Enrollee or former Enrollee's health or
mental health status to the LDSS or to the LDSS'
designee. Medical documentation includes but is
not limited to drug prescriptions and reports
from the Enrollee's PCP or specialist provider.
The Contractor shall include the foregoing as a
responsibility of the PCP and specialist
provider in its provider contracts or in their
provider manuals.
ii) Within ten (10) days of a request of an
Enrollee, who has already undergone, or is
scheduled to under go, an initial LDSS required
mental and/or physical examination, the
Enrollee's PCP shall provide a health,
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(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 1999
10-3
or mental health and/or alcohol and substance abuse
assessment, mental and/or medical examination or other
services as appropriate to identify or quantify an
Enrollee's level of incapacitation. Such assessment must
contain a specific diagnosis resulting from any
medically appropriate tests and specify any work
limitations. The LDSS, may, upon written notice to the
Contractor, specify the format and instructions for such
an assessment.
c) The Contractor is not responsible for the provision and
payment of alcohol and substance abuse treatment
services mandated by the LDSS for Enrollees as a
condition of eligibility for Public Assistance or
Medicaid. Public Assistance or Medicaid recipients who
are mandated into alcohol and substance abuse treatment
will be identified by the LDSS by the use of Welfare
Reform Exception Code 83 except:
i) The Contractor will continue to be responsible
for a base Benefit Package of Alcohol and
Substance Abuse Services (ASA) and for the
provision and payment of ASA services to
Enrollees when such treatment is underway and
the LDSS is satisfied with the health care and
treatment plan.
ii) The Contractor will continue to be responsible
for the provision and payment of inpatient
detoxification services in acute settings.
iii) The Contractor will continue to be responsible
for Court Ordered Services as specified in
Section 10.10 of this Agreement.
(iv) The Contractor will continue to be responsible
for Alcohol and Substance Abuse Services
specified in Section 10.16(a) of this Agreement.
(v) The Contractor will continue to be responsible
for Alcohol and Substance Abuse Services
specified in Section 10.24 of this Agreement.
(vi) The Contractor will continue to be responsible
for evaluation and treatment services when the
PCP or other designated Participating Provider
refers the patient to a Participating Provider
for evaluation and/or treatment.
10.9 Adult Protective Services
The Contractor shall cooperate with LDSS in the implementation
of 18 NYCRR Part 457 and any subsequent amendments thereto with
regard to medically necessary health and mental health services
and all Court Ordered Services for adults. These services are to
be provided in or out of plan. Out of plan providers will be
reimbursed at the Medicaid fee schedule.
10.10 Court-Ordered Services
a) The Contractor shall provide any Benefit Package
services to Enrollees as ordered by a court of competent
jurisdiction, regardless of whether such services are
provided by Participating Providers within the plan or
by a
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Non-Participating Provider in compliance with such court
order. The Non-Participating Provider shall be
reimbursed by the Contractor at the Medicaid fee
schedule.
b) Court Ordered Services are those services ordered by the
court performed by, or under the supervision of a
physician, dentist, or other provider qualified under
State Law to furnish medical, dental, behavior al health
(including treatment f or mental health and/or alcohol
and/or substance abuse or dependence), or other Medicaid
covered services. The plan is responsible f or payment
of those Medicaid services as covered by the Benefit
Package.
c) Court Ordered Services are not covered if they are
ordered for the purpose of determining some legal
disposition, e. g., custody or visitation
determinations.
10.11 Family Planning and Reproductive Health Services
a) Nothing in this Agreement shall restrict the right of
Enrollees to receive Family Planning and Reproductive
Health Services from any qualified Medicaid provider,
regardless of whether the provider is a participating
provider or a non-participating provider, without
referral from the Enrollee's PCP and without approval
from the Contractor.
b) The Contractor agrees to permit Enrollees to exercise
their right to obtain Family Planning and Reproductive
Health Services as defined in Part C-1 of Appendix C,
which is hereby made a part of this contract as if s et
forth fully herein, from either the Contractor, if
family planning is a part of the Contractor's Benefit
Package, or from any appropriate Medicaid enrolled
Non-Participating Family Planning Provider without a
referral from the Enrollee's PCP and without approval by
the Contractor.
c) The Contractor agrees to permit Enrollees to obtain pre
and post-test HIV counseling and blood testing when
performed as part of a Family Planning encounter from
the Contractor, if Family Planning is a part of the
Contractor's Benefit Package, or from any appropriate
Medicaid enrolled Non-Participating family planning
Provider without a referral from the Enrollee's PCP and
without approval by the Contractor.
d) The Contractor will inform Enrollees about the
availability of in-plan HIV counseling and testing
services, out-of-plan HIV counseling and testing
services when performed as part of a Family Planning
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 Family Planning 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.
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(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 1999
10-5
e) Contractor must comply with federal, state, and local
laws, regulations and policies regarding informed
consent and confidentiality. Providers who are employed
by the Contractor may share patient information with
appropriate Contractor personnel for the purposes of
claims payment, utilization review and quality
assurance. Providers who have a contract with the
Contractor, with a n appropriate consent, may share
patient information with the Contractor for purposes of
claims payment, utilization review and quality
assurance. Contractor must ensure that a n individual's
use of family planning services remains confidential and
is not disclosed to family members or other unauthorized
parties.
f) Contractor must inform its practitioners and
administrative personnel about policies concerning free
access to family planning services, HIV counseling and
testing, reimbursement, enrollee education and
confidentiality. Contractor must inform its providers
that they must comply with professional medical
standards of practice, the Contractor 's practice
guidelines, and all applicable federal, state, and local
laws. These include but are not limited to, standards
established by the American College of Obstetricians and
Gynecologists, the American Academy of Family
Physicians, the U. S. Task Force on Preventive Services
and the New York State Child/Teen Health Program. These
standards and laws indicate that family planning
counseling is an integral part of primary and preventive
care.
g) The Contractor agrees that if Family Planning is part of
the Contractor's Benefit Package, the Contractor will be
charged for the services of out of network providers at
the applicable Medicaid rate or fee. In such instances,
out of network providers will ▇▇▇▇ Medicaid and the SDOH
will issue a confidential charge back to the Contractor.
Such charge back mechanism will comply with all
applicable patient confidentiality requirements.
h) If Contractor includes family planning and reproductive
health services in its benefits package, the Contractor
shall comply with the requirements for informing
Enrollees about family planning and reproductive health
services set forth in Part C-2 of Appendix C, which is
hereby made a part of this contract as if set forth
herein.
i) If Contractor does not include family planning and
reproductive health services in its Benefit Package,
within ninety (90) days of signing this Agreement,
Contractor must submit to the SDOH and LDSS a statement
of the policy and procedure that the Contractor will use
to ensure that its Enrollees are fully informed of their
rights to access a full range of family planning and
reproductive health services. Refer to Part C-3 of
Appendix C for the SDOH Guidelines for Plans That Do Not
Provide Family
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October 1, 1999
10-6
Planning Services in their Capitation. Contractor shall
ensure that prospective Enrollees and Enrollees are
advised of the family planning services which are not
provided by the Contractor and of their right of access
to such services in accordance with the provisions of P
art C -3 of Appendix C, which is hereby made a p art of
this contract as if set forth fully herein.
j) SDOH with DHHS approval may issue modifications to
Appendix (C) consistent with relevant provisions of
federal and state statutes and regulations. Once issued
and upon sixty (60) days notice to the LDSS and
Contractor, such modifications shall be deemed
incorporated into t his Agreement without further action
by the parties.
10.12 Prenatal Care
Contractors are responsible for the provision of comprehensive
Prenatal Care Services to all pregnant woman including all
services enumerated in Subdivision 1, Section 2522 of the Public
Health Law in accordance with 10 NYCRR Part 85.40 (Prenatal Care
Assistance Program).
10.13 Direct Access
The Contractor shall offer female Enrollees direct access to
primary and preventive obstetrics and gynecology services,
follow-up care as a result of a primary and preventive visit,
and any care related to pregnancy from the Contractor's network
providers without referral from the PCP as set forth in Public
Health Law Section 4406-b(1).
10.14 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 Emergency
Health Care Services and Urgent Health Care Services.
Emergency mental health calls must be triaged via
telephone by a trained mental health professional.
b) The Contractor agrees that it will not require prior
authorization for services in a medical or behavioral
health emergency. The Contractor agrees to inform its
Enrollees that access to Emergency Services is not
restricted and Emergency Services may be obtained from a
Non-Participating Provider without penalty. The
Contractor must pay for Emergency Medical Services. The
Contractor also may require Enrollees to notify the plan
or their PCP within a specified time after receiving
emergency care and to obtain prior authorization for any
follow-up care delivered pursuant to the emergency, as
stated in Appendix G.
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c) Emergency Services rendered by Non-Participating
Providers: 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 shall bear the
cost of providing Emergency Services through
Non-Participating Providers.
d) The Contractor agrees to abide by guidelines for the
provision and payment of Emergency Care and Services
which are specified in Appendix G, which is hereby made
a part of this contract as if set forth fully herein.
e) When emergency transportation is included in the
Contractor's Benefit Package, the Contractor shall
reimburse for all emergency ambulance services without
regard to final diagnosis or prudent layperson
standards.
10.15 Medical Utilization Thresholds (MUTS)
The Contractors Enrollees are not subject to Medicaid
Utilization Thresholds (MUTS), limitations on, or copayments for
services included in the Benefit Package. Enrollees may be
subject to MUTS for outpatient pharmacy services which are
billed Medicaid fee-for-service.
10.16 Services for Which Enrollees Can Self-Refer
a) Mental Health and Alcohol/Substance Abuse
The Contractor will allow Enrollees or LDSS officials on
the Enrollee's behalf to make self referral or referral
for one mental health and one alcohol/substance abuse
assessment from a Participating Provider in any calendar
year period without requiring preauthorization or
referral from the Enrollee's Primary Care Provider. In
the case of children, such self-referrals may originate
at the request of a school guidance counselor (with
parental or guardian consent, or pursuant to procedures
set forth in Section 33.21 of the Mental Hygiene Law),
LDSS Official, Judicial Official, Probation Officer,
parent or similar source.
i) The Contractor shall make available to all
Enrollees a complete listing of their
participating mental health and
alcohol/substance abuse providers. The listing
should specify which provider groups or
practitioners specialize in children's mental
health services.
ii) The Contractor will also ensure that its
Participating Providers have available and use
formal assessment instruments to identify
Enrollees requiring mental health and
alcohol/substance abuse services, and to
determine the types of services that should be
furnished.
iii) The Contractor will implement policies and
procedures to ensure that Enrollees receive
follow-up services from appropriate providers
based on the findings of their assessment.
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b) Vision Services
The Contractor will allow its Enrollees to self-refer to
any participating provider of vision services
(optometrist or opthalmologist) for refractive vision
services. (See Appendix K).
c) Diagnosis and Treatment of Tuberculosis
Enrollees may self-refer to public health agency
facilities for the diagnosis and/or treatment of TB.
d) Family Planning and Reproductive Health Services.
Enrollees may self-refer to family planning and
reproductive health services as described in this
Section and Appendix C of this Agreement.
e) Sexually Transmitted Disease (STD) Services
Enrollees may self refer to any qualified Medicaid
provider for STD services as described in Section
10.19(c) of this Agreement.
10.17 Second Opinions for Medical or Surgical Care
The Contractor will allow Enrollees to obtain a second opinion
within the Contractor's network of providers for diagnosis of a
condition, treatment or surgical procedure.
10.18 Coordination with Local Public Health Agencies
The Contractor will coordinate its public health-related
activities with the Local Public Health Agency. Coordination
mechanisms and operational protocols for addressing public
health issues will be negotiated with the Local Public Health
and Social Services Departments and be customized to reflect
County public health priorities. Negotiations must result in
agreements regarding required health plan activities related to
public health. The outcome of negotiations may take the form of
an informal agreement among the parties which may include memos;
a separate memorandum of understanding signed by the Local
Public Health Agency, LDSS , and the Contractor; or an appendix
to the contract between the LDSS and the Contractor which shall
be included in Appendix N as if set forth fully herein.
10.19 Public Health Services
a) Tuberculosis Screening, Diagnosis and Treatment;
Directly Observed
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Therapy(TB\DOT):
i) Consistent with New York State law, public
health clinics are required to provide or
arrange for treatment to individuals presenting
with tuberculosis, regardless of the person's
insurance or enrollment status. It is the
State's preference that the Contractor's
Enrollees receive TB diagnosis and treatment
through the Contractor's plan, to the extent
that providers experienced in this type of care
are available in the Contractor's network of
Participating Providers, although Enrollees may
self-refer to public health agency facilities
for the diagnosis and/or treatment of TB. The
Contractor agrees to reimburse public health
clinics when physician visit and patient
management or laboratory and radiology services
are rendered to their Enrollees, within the
context of TB diagnosis and treatment.
ii) The Contractor's Participating Providers must
report T B cases to the Local Public Health
Agency. The LDSS will have the Local Public
Health Agency review the tuberculosis treatment
protocols and networks of Participating
Providers of the Contractor, to verify their
readiness to treat Tuberculosis patients. The
Contractor's protocols will be evaluated against
State and local guidelines. State and local
departments of health also will be available to
offer technical assistance to the Contractor in
establishing TB policies and procedures.
iii) The Contractor may require the Local Public
Health Agency to give notification before
delivering services, unless these services are
ordered by a court of competent jurisdiction.
The Local Public Health Agency will: 1) make
reasonable efforts to verify with the Enrollee's
PCP that he/she has not already provided TB care
and treatment, and 2) provide documentation of
services rendered along with the claim.
iv) The Contractor may use locally negotiated fees.
In addition, SDOH will establish fee schedules
for these services, which the Contractor may use
in the absence of locally negotiated fees.
v) Contractors may require prior authorization for
non-emergency inpatient hospital admissions,
except that prior authorization will not be
required for an admission pursuant to a court
order or an order of detention issued by the
Local Commissioner or Director of Public Health.
vi) The Contractor shall provide the Local Public
Health Agency with access to health care
practitioners on a twenty-four (24) hour a day,
seven (7) day a week basis who can authorize
inpatient hospital admissions. The Contractor
shall respond to the Local Public Health
Agency's request for authorization within the
same day.
vii) The Contractor Will not be capitated or
financially liable for Directly Observed Therapy
(DOT) costs. The Contractor also will not be
financially liable for treatments rendered to
Enrollees who have been institutionalized due to
non-compliance with TB care regimens. The
Contractor agrees to make all reasonable efforts
to ensure coordination with DOT providers
regarding clinical care and services. HIV
counseling
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and testing during a TB related visit at a
public health clinic will be covered by Medicaid
Fee-For-Service (FFS) at a rate established by
the State.
viii) While all other clinical management of
tuberculosis is covered by the Contractor,
TB/DOT where applicable, can be billed directly
to Medicaid by any SDOH approved fee-for-service
Medicaid TB/DOT provider. The Contractor remains
responsible for communicating, cooperating, and
coordinating clinic management of TB with the TB
/DOT provider. The Enrollee reserves the right
to use any fee-for-service DOT provider because
TB/DOT is a non-covered benefit.
b) Immunizations
i) Immunizations for adults and administration of
immunizations for children will be included in
the Benefit Package and the Contractor will be
required to reimburse the Local Public Health
Agency when Enrollees self-refer.
ii) In order to be eligible for reimbursement, a
Local Public Health Agency must make reasonable
efforts to (1) determine the Enrollee's managed
care membership status; and (2) ascertain the
Enrollee's immunization status. Such efforts
shall consist of client interviews and, when
available, access to the Immunization Registry.
When an Enrollee presents a membership card with
a PCP's name, the Local Public Health Agency
shall all the PCP. If the agency is unable to
verify the immunization status from the PCP or
learns that immunization is needed, the agency
shall proceed to deliver the service as
appropriate, and the Contractor will reimburse
the Local Public Health Agency at the negotiated
rate or at a fee schedule to be used in the
absence of a negotiated rate. Upon
implementation of the immunization registry, the
Local Public Health Agency shall not be required
to contact the PCP.
iii) If the immunization is administered by the PCP,
immunization materials for children should be
obtained free of charge from the "Vaccine For
Children Program". The Contractor will be
reimbursed only for administering the vaccine to
children.
c) Prevention and Treatment of Sexually Transmitted
Diseases
The Contractor will be responsible for ensuring that its
Participating Providers educate their Enrollees about
the risk and prevention of sexually transmitted disease
(STD). The Contractor also will be responsible for
ensuring that its Participating Providers screen and
treat Enrollees for STDs and report cases of STD to
Local Public Health Agency and cooperate in contact
investigation, in accordance with existing state and
local laws and regulations. HIV counseling and testing
provided during a STD related visit at a public health
clinic will be covered by Medicaid FFS at a rate
established by the State. Nothing in this Agreement
shall restrict the right of Enrollees to receive STD
services from any qualified Medicaid provider,
regardless of whether the provider is a
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Participating Provider or a Non-Participating Provider,
without referral from the Enrollee's PCP and without
approval from the Contractor
d) Lead Poisoning
The Contractor will be responsible for carrying out and
ensuring that its Participating Providers comply with
lead poisoning screening and follow-up as specified in
10 NYCRR, Sub-part 67.1. The Contractor shall coordinate
the care of such children with Local Public Health
Agencies to assure appropriate follow-up in terms of
environmental investigation, risk management and
reporting requirements.
10.20 Adults with Chronic Illnesses and Physical or Developmental
Disabilities
The Contractor will implement all of the following to meet the
needs of their adult Enrollees with chronic illnesses and
physical or developmental disabilities:
a) Satisfactory methods for ensuring that the Contractor
and it Participating Providers are in compliance with
the Americans with Disabilities Act ("ADA") and with the
SDOH Guidelines for Medicaid MCO Compliance with the ADA
which are set forth in Appendix J, which is hereby made
a part of this Agreement as if set forth fully herein,
and in accordance with Section 24 of this Agreement.
(see Section 24).
b) Satisfactory methods/guidelines for identifying persons
at risk of, or having, chronic diseases and disabilities
and determining their specific needs in terms of
specialist physician referrals, durable medical
equipment, home health services, etc.
c) Satisfactory case management systems.
d) Satisfactory systems for coordinating service delivery
with out-of-network providers, including behavioral
health providers for all Enrollees.
e) Policies and procedures to allow for the continuation of
existing relationships with out-of-network providers,
consistent with P. H. L. 4403 6(e ) and Section 15.5 of
this Agreement.
10.21 Children with Special Health Care Needs
Children with special health care needs are those who have or
are suspected of having a serious or chronic physical,
developmental, behavioral, or emotional condition and who also
require health and related services of a type or amount beyond
that required by children generally. The Contractor will be
responsible
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for performing all of the same activities for this population as
for adults. In addition, the Contractor will implement the
following for these children:
a) Satisfactory methods for interacting with school
districts, preschool services, child protective service
agencies, early intervention officials, behavioral
health, and developmental disabilities service
organizations for the purpose of coordinating and
assuring appropriate service delivery.
b) An adequate network of pediatric providers and
sub-specialists, contractual relationships with tertiary
institutions, to meet their medical needs.
c) Satisfactory methods for assuring that children with
serious, chronic, and rare disorders receive appropriate
diagnostic work-ups on a timely basis.
d) Satisfactory arrangements for assuring access to
specialty centers in and out of New York State for
diagnosis and treatment of rare disorders.
e) A satisfactory approach for assuring access to allied
health professionals (Physical Therapists, Occupational
Therapists, Speech Therapists, and Audiologists)
experienced in dealing with children and families.
10.22 Persons Requiring Ongoing Mental Health Services
These individuals, while not diagnosed as SPMI or SED, may have
relatively significant needs for mental health services.
Accordingly, the Contractor will implement all of the following
for its Enrollees with chronic or ongoing mental health service
needs:
a) Inclusion of all of the required provider types listed
in Section 21 of this Contract.
b) Satisfactory methods for identifying persons requiring
such services and encouraging self-referral and early
entry into treatment.
c) Satisfactory case management system.
d) Satisfactory systems for coordinating service delivery
between physical health, alcohol/substance abuse, and
mental health providers, and coordinating services with
other available services, including Social Services.
The Contractor agrees to participate in the local planning
process for serving persons with mental health needs to the
extent requested by the LDSS. At the LDSS' discretion, the
Contractor will develop linkages with local governmental units
on coordination, procedures and standards related to mental
health services and related activities.
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10.23 Member Needs Relating to HIV
HIV positive (+) persons will be permitted to enroll voluntarily
into health plans at the start of this program, and plans must
inform newly diagnosed HIV (+) Enrollees known to the plan of
their enrollment options due to such exemption status.
The Contractor agrees that anonymous testing may be furnished
without prior approval by the Contractor and may be conducted at
anonymous testing sites available to clients. Services provided
for HIV treatment may only be obtained from the Contractor if
the individual chooses to enroll and stay enrolled in the
Contractor's plan.
To adequately address the HIV prevention needs of uninfected
Enrollees, as well as the special needs of HIV positive (+)
individuals who do enroll in managed care, the Contractor shall
have in place all of the following:
a) Methods for promoting HIV prevention to all Plan
Enrollees. H IV prevention information, both primary
(targeted to uninfected Enrollees ), as well as
secondary (targeted to those Enrollees with HIV
infection) should be tailored to the Enrollee's age,
sex, and risk factor(s), including sexual orientation
and injection drug use, and must be culturally and
linguistically appropriate. All plan Enrollees should be
informed of the availability of both in-plan HIV
counseling and testing services, out-of-plan HIV
counseling and testing services when performed as part
of a family planning encounter, as well as HIV
counseling and testing services available through SDOH,
local health units and Anonymous Counseling and Testing
Programs.
b) Satisfactory methods for assuring the performance of
risk assessments, risk reduction counseling, diagnosis
and early entry into treatment.
c) The Contractor shall comply with the requirements in
Title 10 NYCRR which mandate that HIV counseling with
testing , presented as a clinical recommendation, be
provided to all women in prenatal care and their
newborns.
d) Satisfactory case management system linkages must be
established with traditional HIV providers, including
Designated AIDS Center Hospitals, HIV primary care
providers, providers funded under the ▇▇▇▇ ▇▇▇▇▇ CARE
Act and clinical education providers, as available.
e) The Contractor shall assure that its Participating
Providers shall report positive HIV results to the Local
Public Health Agency and assist in contact
investigation.
10.24 Persons Requiring Alcohol/Substance Abuse Services
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The Contractor will have in place all of the following for its
Enrollees requiring alcohol/substance abuse services:
a) Participating Provider networks consisting of licensed
providers, as defined in Section 21.17 of this contract.
b) Satisfactory methods for identifying persons requiring
such services and encouraging self-referral and early
entry into treatment. In the case of pregnant women,
having methods for referring to OASAS for appropriate
services beyond the Contractor's Benefit Package (e. g.,
halfway houses).
c) Satisfactory systems of care (provider networks and
referral processes sufficient to ensure that emergency
services can be provided in a timely manner), including
crisis services.
d) Satisfactory case management systems.
e) Satisfactory systems for coordinating service delivery
between physical health, alcohol/substance abuse, and
mental health providers, and coordinating in-plan
services with other services, including Social Services.
The Contractor agrees to also participate in the local planning
process for serving persons with alcohol and substance
addictions, to the extent requested by the LDSS. At the LDSS's
discretion, the Contractor will develop linkages with local
governmental units on coordination procedures and standards
related to Alcohol/Substance Abuse Services and related
activities.
10.25 Native Americans
If the Contractor 's Enrollee is a Native American and the
Enrollee chooses to access primary care services through their
tribal health center, the PCP authorized by the Contractor to
refer the Enrollee for plan benefits must develop a relationship
with the Enrollee's PCP at the tribal health center to
coordinate services for said Native American Enrollee.
10.26 Women, Infants, and Children (WIC)
The Contractor shall develop linkage agreements or other
mechanisms to ensure women and children enrollees are referred
to W IC services if qualified to receive such services. The
Contractor shall refer pregnant women and children, five (5)
years of age or younger, to W IC local agencies for nutritional
assessments and supplements.
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10.27 Coordination of Services
The Contractor shall coordinate care for Enrollees with:
a) the court system (for court ordered evaluations and
treatment);
b) specialized providers of health care for the homeless,
and other providers of services for victims of domestic
violence;
c) family planning clinics, community health centers,
migrant health centers, rural health centers;
d) WIC, Head Start, Early Intervention;
e) special needs plans;
f) programs funded through the ▇▇▇▇ ▇▇▇▇▇ CARE Act;
g) other pertinent entities that provide services out of
network;
h) Prenatal Care Assistance Program (PCAP) Providers;
i) local governmental units responsible for public health,
mental health, mental retardation or alcohol and
substance abuse services; and
j) specialized providers of long term care for people with
developmental disabilities.
Coordination may involve contracts or linkage agreements (if entities
are willing to enter into such agreement), or other mechanisms to ensure
coordinated care for Enrollees.
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(BENEFIT PACKAGE, COVERED AND NON-COVERED SERVICES)
October 1, 1999
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11. MARKETING
11.1 Marketing Plan
The Contractor shall have a Marketing Plan, that has been
prior-approved by the SDOH and/or LDSS, that describes the
Marketing activities the Contractor will undertake within the
local district during the term of this Agreement.
The Marketing Plan and all marketing activities must be
consistent with the Marketing Guidelines which are set forth in
Appendix D, which is hereby made a part of this Agreement as if
set forth fully herein.
The Marketing Plan shall be kept on file in the offices of the
Contractor, LDSS, and the SDOH. The Marketing Plan may be
modified by the Contractor subject to prior written approval by
the SDOH and/or the LDSS. The LDSS or SDOH must take action on
the changes submitted within sixty (60) calendar days of
submission or the Contractor may deem the changes approved.
11.2 Marketing Activities
Marketing activities by the Contractor shall conform to the
approved Marketing Plan.
11.3 Prior Approval of Marketing Materials, Procedures,
Subcontractors
The Contractor shall submit all subcontracts, procedures, and
materials related to Marketing to Eligible Persons to the SDOH
and/or LDSS for prior written approval. The Contractor shall not
enter into any subcontracts or use any marketing subcontractors,
procedures, or materials that the SDOH and/or LDSS has not
approved.
11.4 Marketing Infractions
Infractions of the Marketing Guidelines may result in the
following actions being taken by the LDSS to protect the
interests of the program and its clients. These actions shall be
taken at the sole discretion of the LDSS.
a) If an MCO or its representative commits a first time
infraction of marketing guidelines and the LDSS deems
the infraction to be minor or unintentional in nature,
the LDSS may issue a warning letter to the MCO.
b) For subsequent or more serious infractions, the LDSS may
impose liquidated damages of $2,000 or other appropriate
non-monetary sanction for each infraction.
SECTION 11
(MARKETING)
October 1, 1999
11-1
c) The LDSS may require the MCO to prepare a corrective
action plan with a specified deadline for
implementation.
d) If the MCO commits further infractions, fails to pay
liquidated damages within the specified timeframe, fails
to implement a corrective action plan in a timely manner
or commits an egregious first-time infraction, the LDSS
may:
i) prohibit the plan from conducting any marketing
activities for a period up to the end of the
contract period;
ii) suspend new enrollments, other than newborns,
for a period up to the remainder of the
contract; or
iii) terminate the contract pursuant to termination
procedures described therein.
11.5 LDSS Option to Adopt Additional Marketing Guidelines
The LDSS may adopt, subject to SDOH approval, additional and/or
more restrictive terms in the Marketing Guidelines to the extent
appropriate to local conditions and circumstances, which shall
be appended to Appendix D, Section E.
SECTION 11
(MARKETING)
October 1, 1999
11-2
12. MEMBER SERVICES
12.1 General Functions
The Contractor shall operate a Member Services function during
regular business hours, which must be accessible to Enrollees
via a toll-free telephone line. Personnel must also be available
via a toll-free telephone line (which can be the member services
toll-free line or separate toll-free lines) not less than during
regular business hours to address complaints and utilization
review inquiries. In addition, the Contractor must have a
telephone system capable of accepting, recording or providing
instruction to incoming calls regarding complaints and
utilization review during other than normal business hours and
measures in place to ensure a response to those calls the next
business day after the call was received. At a minimum, the
Member Services Department must be staffed at a ratio of at
least one (1) full time equivalent Member Service Representative
for every 4,000 or fewer Enrollees. Member Services staff must
be responsible for the following:
a) Explaining the Contractor's rules for obtaining services
and assisting Enrollees in making appointments.
b) Assisting Enrollees to select or change Primary Care
Providers.
c) Fielding and responding to Enrollee questions and
complaints, and advising Enrollees of the prerogative to
complain to the SDOH and LDSS at any time.
d) Clarifying information in the member handbook for
Enrollees.
e) Advising Enrollees of the Contractor's complaint and
appeals program, the utilization review process, and
Enrollee's rights to a fair hearing or external review.
f) Clarifying for potential Enrollees current categories of
exemptions and/or exclusions the Contractor may refer to
the LDSS or the Enrollment Broker, where one is in
place, if necessary, for more information on exemptions
and exclusions.
12.2 Translation and Oral Interpretation
a) The Contractor must make available written marketing and
other informational materials (e. g., member handbooks)
in a language other than English whenever at least five
percent (5 %) of the potential Enrollees of the
Contractor in any county of the service area speak that
particular language and do not speak English as a first
language.
SECTION 12
(MEMBER SERVICES)
October 1, 1999
12-1
b) In addition, verbal interpretation services must be made
available to Enrollees who speak a language other than
English as a primary language. Interpreter services must
be offered in person where practical, but otherwise may
be offered by telephone.
c) The SDOH will determine the need for other than English
translations based on County-specific census data or
other available measures.
12.3 Communicating With The Visually, Hearing and Cognitively
Impaired
The Contractor also must have in place appropriate alternative
mechanisms for communicating effectively with persons with
visual, hearing, speech, physical or developmental disabilities.
These alternative mechanisms include Braille or audio tapes for
the visually impaired, TTY access for those with certified
speech or hearing disabilities, and use of American Sign
Language and/or integrative technologies.
SECTION 12
(MEMBER SERVICES)
October 1, 1999
12-2
13. ENROLLEE NOTIFICATION
13.1 Provider Directories/Office Hours for Participating Providers
a) The Contractor will provide the following information to
each Enrollee, and upon request, to each prospective
Enrollee a list of Participating Providers by specialty
and a list of facilities, for the county/borough in
which the Enrollee or prospective Enrollee resides. Such
list shall include names, office addresses, telephone
numbers, board certification for physicians, and
information on language capabilities and wheelchair
accessibility of Participating Providers. This
information ma y be provided in the form of a Provider
Directory and must be updated by the Contractor
annually, or twice a year at the option of the LDSS. Mid
year updates may be accomplished through an insert which
lists additions or deletions of Participating Providers.
b) In addition, the Contractor must make available to the
LDSS the office hours for Participating Providers. This
requirement may be satisfied by providing a copy of the
list or Provider Directory described in this Section
with the addition of office hours or by providing a
separate listing of office hours for Participating
Providers
13.2 Member ID Cards
a) The Contractor must issue an identification card to the
Enrollee containing the following information:
i) the name of the Enrollee's clinic (if
applicable);
ii) the name of the Enrollee's PCP and the PCP's
telephone number;
iii) the member services toll free telephone number;
and
iv) the twenty-four (24) hour toll free telephone
number that Enrollees may use to access
information on obtaining services when his/her
PCP is not available.
b) If an Enrollee is being served by a PCP team, the name
of the individual shown on the card should be the lead
provider. PCP information may be embossed on the card or
affixed to the card by a sticker.
c) The Contractor shall issue an identification card within
fourteen (14) days of an Enrollees Effective Date of
Enrollment. If unforeseen circumstances, such as the
lack of identification of a PCP, prevent the MCO from
forwarding the official identification card to new
Enrollees within the fourteen (14) day period,
alternative measures by which Enrollees may identify
themselves such as use of a Welcome Letter or a
temporary identification card shall be deemed acceptable
until such time as a PCP is either chosen by the
Enrollee or auto assigned by the Contractor. The
Contractor agrees to implement an alternative method by
which individuals may identify themselves as Enrollees
prior to receiving the card (e.g., using a "welcome
letter" from the plan) and to
Section 13
(ENROLLEE NOTIFICATION)
October 1, 1999
13-1
update PCP information on the identification card.
Newborns of Enrollees need not present ID cards in order
to be seen by the MCO and its Participating Providers.
13.3 Member Handbooks
The Contractor shall issue to a new Enrollee within fourteen
(14) days of the Effective Date of Enrollment a Member Handbook,
which is consistent with the SDOH guidelines described in
Appendix E, which is hereby made a part of this Agreement as if
set forth fully herein.
13.4 Notification of Effective Date of Enrollment
The Contractor shall inform each Enrollee in writing within
fourteen (14) days of the Effective Date of Enrollment of any
restriction on the Enrollee's right to terminate enrollment. The
initial enrollment information and the Member Handbook shall be
adequate to convey this notice.
13.5 Notification of Enrollee Rights
The Contractor agrees to make all reasonable efforts to contact
new Enrollees, in person, by telephone, or by mail, within
thirty (30) days of their Effective Date of Enrollment.
"Reasonable efforts" are defined to me an at least three (3)
attempts, with more than one method of contact being employed.
Upon contacting the new Enrollee(s), the Contractor agrees to do
at least the following:
a) Inform the Enrollee about the Contractor's policies with
respect to obtaining medical services, including
services for which the Enrollee may self-refer, and what
to do in an emergency.
b) Conduct a brief health screening to assess the
Enrollee's need for any special health care (e.g.,
prenatal or behavioral health services) or
language/communication needs. If a special need is
identified, the Contractor shall assist the Enrollee in
arranging for an appointment with his/her PCP or other
appropriate provider.
c) Offer assistance in arranging an initial visit to the
Enrollee's PCP for a baseline physical and other
preventive services, including an assessment of the
Enrollee's potential risk, if any, for specific diseases
or conditions.
d) Inform new Enrollees about their rights for continuation
of certain existing services.
e) Provide the Enrollee with the Contractor's toll free
telephone number that may be called twenty-four (24)
hours a day, seven (7) days a week if the Enrollee has
questions about obtaining services and cannot reach
his/her PCP (this
Section 13
(ENROLLEE NOTIFICATION)
October 1, 1999
13-2
telephone number need not be the Member Services line
and need not be staffed to respond to Member
Services-related inquiries). The Contractor must have
appropriate mechanisms in place to accommodate Enrollees
who do not have telephones and therefore cannot readily
receive a Call back.
f) Advise Enrollee about opportunities available to learn
about MCO policies and benefits in greater detail (e.g.,
welcome meeting, Enrollee orientation and education
sessions).
g) Provide the Enrollee with a complete list of network
providers that may be accessed directly, without
referral. The list should group providers by service
type and must include addresses and telephone numbers.
h) Assist the Enrollee in selecting a primary care provider
if one has not already been chosen.
13.6 Enrollee's Rights to Advance Directives
The Contractor shall, in compliance with the requirements of 42
FR 434.28, maintain written policies and procedures regarding
advance directives and inform each Enrollee in writing at the
time of enrollment of an individual 's rights under State law to
formulate advance directives and of the Contractor's policies
regarding the implementation of such rights. The Contractor
shall include in such written notice to the Enrollee materials
relating to advance directives and health care proxies as
specified in 10 NYCRR Sections 98.14(f) and 700.5.
13.7 Approval of Written Notices
The Contractor shall submit the format and content of all
written notifications described in this Section to LDSS for
review and prior approval by LDSS or SDOH. All written
notifications must be written at a fourth (4th) to sixth (6th)
grade level and in at least ten (10) point print.
13.8 Contractor's Duty to Report Lack of Contact
The Contractor must inform the LDSS of any Enrollee they are
unable to contact within ninety (90) days of enrollment using
reasonable efforts as defined in Section 13.5 of the Agreement
and who have not presented for any health care services through
the Contractor or its Participating Providers.
13.9 Contractor Responsibility to Notify Enrollee of Expected
Effective Date of Enrollment
The Contractor must notify the Enrollee of the expected
Effective Date of Enrollment. In the event that the actual
Effective Date of Enrollment is different
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(ENROLLEE NOTIFICATION)
October 1, 1999
13-3
from that given to the Enrollee the Contractor must notify the
Enrollee of the actual date of enrollment. This ma y be
accomplished through a Welcome Letter. To the extent
practicable, such notification must precede the Effective Date
of Enrollment.
13.10 LDSS Notification of Enrollee's Change in Address
The LDSS must notify the Contractor of any known change in
address of Enrollees in the Contractor's plan.
Section 13
(ENROLLEE NOTIFICATION)
October 1, 1999
13-4
14. COMPLAINT AND APPEAL PROCEDURE
14.1 Contractor's Program to Address Complaints
a) The Contractor shall establish and maintain a
comprehensive program designed to address clinical and
other complaints, and appeals of complaint
determinations, which may be brought by Enrollees,
consistent with Articles 44 and 49 of the New York State
P. H. L.
b) The program must include methods for prompt internal
adjudication of Enrollee complaints and appeals and
provide for the maintenance of a written record of all
complaints and appeals received and reviewed and their
disposition.
c) The Contractor shall ensure that persons with authority
to require corrective action participate in the
complaint and appeal process.
14.2 Notification of Complaint and Appeal Program
a) The Contractor's specific complaint and appeal program
shall be described in the Contractor's member handbook
and shall be made available to all Enrollees.
b) The Contractor will advise Enrollees of their right to a
fair hearing as appropriate and comply with the
procedures established by SDOH for the Contractor to
participate in the fair hearing process, asset forth in
Section 25 of this Agreement. The Contractor will also
advise Enrollees of their right to an external appeal,
in accordance with Section 26 of this Agreement.
14.3 Guidelines for Complaint and Appeal Program
a) The Contractor's complaint and appeal program will
comply with the Managed Care Complaint and Appeals
Program Guidelines described in Appendix F, which is
hereby made apart of this Agreement as if set forth
fully herein. The SDOH and LDSS may modify Appendix F of
this Agreement upon sixty (60) days prior written notice
to the Contractor and such modifications shall become
binding and incorporated into this Agreement without
further action by the parties.
b) The Contractor's complaint and appeal procedures shall
be approved by the SDOH and LDSS and kept on file with
the Contractor, LDSS and SDOH.
c) The Contractor shall not modify its complaint and
appeals procedure without the prior written approval of
SDOH, in consultation with LDSS, and shall provide LDSS
and SDOH with a copy of the approved modification within
fifteen (15) days after its approval.
Section 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 1999
14-1
14.4 Complaint Investigation Determinations
The MCO must adhere to determinations resulting from complaint
investigations conducted by SDOH.
Section 14
(COMPLAINT AND APPEAL PROCEDURE)
October 1, 1999
14-2
15. ACCESS REQUIREMENTS
15.1 Appointment Availability Standards
The Contractor shall comply with the following appointment
availability standards.(1)
a) For emergency care: immediately upon presentation at a
service delivery site.
b) For urgent care: within twenty-four (24) hours of
request.
c) Non-urgent "sick" visit: within forty-eight (48) to
seventy-two (72) hours of request, as clinically
indicated.
d) Routine non-urgent, preventive appointments: within four
(4) weeks of request.
e) Specialist referrals (not urgent): within four (4) to
six (6) weeks of request.
f) Initial prenatal visit: within three (3) weeks during
first trimester, within two (2) weeks during the second
trimester and within one (1) week during the third
trimester.
g) Adult Baseline and routine physicals: within twelve (12)
weeks from enrollment. (Adults >21).
h) Well child care: within four (4) weeks of request.
i) Initial family planning visits: within two (2) weeks of
request.
j) In-plan mental health or substance abuse follow-up
visits (pursuant to an emergency or hospital discharge):
within five (5 ) days of request, or as clinically
indicated.
k) In-plan, non-urgent mental health or substance abuse
visits: within two (2) weeks of request.
l) Initial PCP office visit for newborns: within two (2)
weeks of hospital discharge.
m) Provider visits to make health, mental health and
substance abuse assessments for the purpose of making
recommendations regarding a recipient's ability to
perform work when requested by a LDSS: within ten (10)
days of request by an Enrollee, in accordance with
Section 10.8 of this Agreement.
15.2 Twenty-Four (24) Hour Access
a) The Contractor must provide access to medical services
and coverage to Enrollees, either directly or through
their PCPs, on a twenty-four (24) hour a day, seven (7)
day a week basis. The Contractor must instruct Enrollees
on what to do to obtain services after business hours
and on weekends.
Section 15
(EQUALITY OF ACCESS AND TREATMENT
October 1, 1999
15-1
--------------------
(1) These are general standards and are not intended to supersede sound clinical
judgement as to the necessity for care and services on a more expedient basis,
when judged clinically necessary and appropriate.
b) The Contractor may satisfy the requirement in Section
15.2(a) by requiring their PCPs to have primary
responsibility for serving as an after hours "on-call"
telephone resource to members with medical problems.
Under no circumstances may the Contractor routinely
refer calls to an emergency room.
15.3 Appointment Waiting Times
Enrollees with appointments shall not routinely be made to wait
longer than one hour.
15.4 Travel Time Standards
The Contractor will maintain a network that is geographically
accessible to the population to be served.
a) Primary Care
Travel time/distance to primary care sites shall not
exceed 30 minutes in Metropolitan areas or 30 minutes/30
miles in non-metropolitan areas, except in rural areas
where the State has granted the Contractor an exemption
from this requirement based on community standards.
Enrollees may, at their discretion, select participating
PCPs located farther from their homes as long as they
are able to arrange and pay for transportation to the
PCP themselves.
b) Other Providers
Travel time/distance to specialty care, hospitals,
mental health, lab and x-ray providers shall not exceed
30 minutes/30 miles, except in rural areas where the
SDOH has granted the Contractor an exemption from this
requirement based on community standards.
15.5 Service Continuation
a) New Enrollees
If a new Enrollee has an existing relationship with a
health care provider who is not a member of the
Contractor's provider network, the contractor shall
permit the Enrollee to continue an on going course of
treatment by the Non-Participating Provider during a
transitional period of up to sixty (60) days from the
Effective Date of Enrollment, if, (1) the Enrollee has a
life-threatening disease or condition or a degenerative
and disabling disease or condition, or (2) the Enrollee
has entered the second trimester of pregnancy at the
Effective Date of Enrollment, in which case the
transitional period shall
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(EQUALITY OF ACCESS AND TREATMENT
October 1, 1999
15-2
include the provision of post-partum care directly
related to the delivery up until sixty (60) days post
partum. If the Enrollee elects to continue to receive
care from such Non-Participating Provider, such care
shall be authorized by the Contractor for the
transitional period only if the Non-Participating
Provider agrees to:
i) accept reimbursement from the Contractor at
rates established by the Contractor as payment
in full, which rates shall be no more than the
level of reimbursement applicable to similar
providers within the Contractor's network for
such services; and
ii) adhere to the Contractor's quality assurance
requirements and agrees to provide to the
Contractor necessary medical information related
to such care; and
iii) otherwise adhere to the Contractor's policies
and procedures including, but not limited to
procedures regarding referrals and obtaining
preauthorization in a treatment plan approved by
the Contractor.
In no event shall this requirement be construed to require the
Contractor to provide coverage for benefits not otherwise
covered.
b) Enrollees Whose Health Care Provider Leaves Network
The Contractor shall permit an Enrollee, whose health
care provider has left the Contractor's network of
providers, for reasons other than imminent harm to
patient care, a determination of fraud or a final
disciplinary action by a state licensing board that
impairs the health professional's ability to practice,
to continue an ongoing course of treatment with the
Enrollee's current health care provider during a
transitional period, consistent with New York State P.
H. L. Section 4403(6)(e).
The transitional period shall continue up to ninety (90)
days from the date of notice to the Enrollee of the
provider's disaffiliation from the network; or, if the
Enrollee has entered the second trimester of pregnancy,
for a transitional period that includes the provision of
post-partum care directly related to the delivery
through sixty (60) days post partum. If the Enrollee
elects to continue to receive care from such
Non-Participating Provider, such care shall be
authorized by the Contractor for the transitional period
only if the Non Participating Provider agrees to:
i) accept reimbursement from the Contractor at
rates established by the Contractor as payment
in full, which rates shall be no more than the
level of reimbursement applicable to similar
providers within the Contractor's network for
such services;
ii) adhere to the Contractor's quality assurance
requirements and agrees to provide to the
Contractor necessary medical information related
to such care; and
Section 15
(EQUALITY OF ACCESS AND TREATMENT
October 1, 1999
15-3
iii) otherwise adhere to the Contractor's policies
and procedures including, but not limited to
procedures regarding referrals and obtaining
preauthorization in a treatment plan approved by
the Contractor.
In no event shall this requirement be construed to require the
Contractor to provide coverage for benefits not otherwise
covered.
15.6 Standing Referrals
The Contractor will implement policies and procedures to allow
for standing referrals to specialist physicians for Enrollees
who have ongoing needs for care from such specialists,
consistent with P. H. L. Section 4403(6)(b).
15.7 Specialist as a Coordinator of Primary Care
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or degenerative and disabling
disease or condition, which requires prolonged specialized
medical care, to receive a referral to a specialist, who will
then function as the coordinator of primary and specialty care
for that Enrollee, consistent with P. H. L. Section 4403(6)(c).
15.8 Specialty Care Centers
The Contractor will implement policies and procedures to allow
Enrollees with a life-threatening or a degenerative and
disabling condition or disease, which requires prolonged
specialized medical care to receive a referral to an accredited
or designated specialty care center with expertise in treating
the life-threatening or degenerative and disabling disease or
condition, consistent with New York State P. H. L. Section
4403(6)(d).
Section 15
(EQUALITY OF ACCESS AND TREATMENT
October 1, 1999
15-4
16. QUALITY ASSURANCE
16.1 Internal Quality Assurance Program
a) Contractor must operate a quality assurance program
which is approved by SDOH and which includes methods and
procedures to control the utilization of Medicaid
services consistent with P H.L. Article 49 and 42 CFR
Part 456. Recipients records must include information
needed to perform utilization review as specified in 42
CFR "456.111 and 456.211. The Contractor's approved
quality assurance program must be kept on file by the
Contractor and the LDSS. The Contractor shall not modify
the quality assurance program without the prior written
approval of the SDOH, and notice to the LDSS.
b) The Contractor shall incorporate the findings from
reports in Section 18 of this Agreement into its quality
assurance program. Where performance is less than the
statewide average or another standard as defined by the
SDOH and developed in consultation with plans and
appropriate clinical experts, the Contractor will be
required to develop a plan for improving performance
that is approved by the SDOH and LDSS. The Contractor
agrees to me et with the SDOH and LDSS up to twice a
year to review improvement plans and quality
performance.
16.2 Standards of Care
The Contractor must adopt practice guidelines consistent with
current standards of care, complying with recommendations of
professional specialty groups such as the American Academy of
Pediatrics, the American Academy of Family Physicians, the U.S.
Task Force on Preventive C are, the New York State Child/Teen
Health Program (C/THP) standards for provision of care to
individuals under age 21, the American Medical Association's
Guidelines for Adolescent and Preventive Services, the US
Department of Health and Human Services Center for Substance
Abuse Treatment, the American College of Obstetricians and
Gynecologists and the AIDS Institute Clinical Standards for
Adult and Pediatric Care.
Section 16
(QUALITY ASSURANCE)
October 1, 1999
16-1
17. MONITORING AND EVALUATION
17.1 Right to Monitor Contractor Performance
The SDOH, LDSS, and DHHS shall each have the right, during the
Contractor's normal operating hours, and at any other time a
Contractor function or activity is being conducted, to monitor
and evaluate, through inspection or other means, the
Contractor's performance, including, but not limited to, the
quality, appropriateness, and timeliness of services provided
under this Agreement.
17.2 Cooperation During Monitoring and Evaluation
The Contractor shall cooperate with and provide reasonable
assistance to the SDOH, LDSS, and DHHS in the monitoring and
evaluation of the services provided under this Agreement.
17.3 Cooperation During Annual On-Site Review
The Contractor shall cooperate with SDOH and LDSS in an annual
on-site review of the MCO's operations. SDOH shall give the
Contractor notification of the annual review and survey format
at least forty-five (45) days prior to the annual site visit.
This requirement shall not preclude LDSS or SDOH from site
visits upon shorter notice for other monitoring purposes.
17.4 Cooperation During Review of Services by External Review Agency
The Contractor shall comply with all requirements associated
with the annual review of the quality of services rendered to
its Enrollees to be performed by an external review agent
selected by the SDOH.
Section 17
(MONITORING AND EVALUATION)
October 1, 1999
17-1
18. CONTRACTOR REPORTING REQUIREMENTS
18.1 Time Frames for Report Submissions
Except as otherwise specified herein, the Contractor shall
prepare and submit to SDOH and the LDSS the reports required
under this Agreement in an agreed media format within sixty (60)
days of the close of the applicable semi-annual or annual
reporting period, and within fifteen (15) business days of the
close of the applicable quarterly reporting period.
18.2 SDOH Instructions for Report Submissions
SDOH, with prior notice to the LDSS, will provide Contractor
with instructions for submitting the reports required by Section
18.5 (a) through (n), including time frames, and requisite
formats. The instructions, time frames and formats may be
modified by SDOH with prior notice to the LDSS, and thereafter
upon sixty (60) days written notice to the Contractor. The LDSS,
with prior notice to SDOH, shall provide the Contractor with
instructions for submitting the reports, required by Section
18.5(o) including time frames and requisite formats.
18.3 Liquidated Damages
The Contractor shall pay liquidated damages of $2,500 if any
report required pursuant to this Section is materially
incomplete, contains material misstatements or inaccurate
information, or is not submitted on time in the requested
format. The Contractor shall pay liquidated damages of $2,500 to
the LDSS if its monthly encounter data submission is not
received by the Fiscal Agent by the due date specified in
Section 18.5(d). The Contractor shall pay liquidated damages of
$500 to the LDSS for each day other reports required by this
Section are late. The LDSS shall not impose liquidated damages
for a first time infraction by the Contractor unless the LDSS
deems the infraction to be a material misrepresentation of fact
or the Contractor fails to cure the first infraction within a
reasonable period of time upon notice from the LDSS. Liquidated
damages may be waived at the sole discretion of LDSS. Nothing in
this Section shall limit other remedies or rights available to
LDSS and SDOH relating to the timeliness, completeness and/or
accuracy of Contractor's reporting submission.
18.4 Notification of Changes in Report Due Dates Requirements or
Formats
SDOH or LDSS may extend due dates, or modify report requirements
or formats upon a written request by the Contractor to the SDOH
or LDSS with a copy of the request to the other agency, where
the Contractor has demonstrated a good and compelling reason for
the extension or modification. The determination to grant a
modification or, extension of time shall be made by SDOH with
regard to annual and quarterly statements, complaint reports,
audits, encounter data, change of ownership, clinical studies,
QARR, and provider network reports. The
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-1
determination to grant a modification or extension of time shall
be made by the LDSS with respect to No-Contact, PCP auto
assignment, and reports required by Sections 18.5 (n) and (o) of
the Agreement.
18.5 Reporting Requirements
The Contractor shall submit the following reports to SDOH and to
the LDSS except in those instances in which t his Agreement
specifies the reports shall be submitted solely to SDOH:
a) Annual Financial Statements:
The due date for annual statements shall be April 1
following the report closing date.
b) Quarterly Financial Statements:
The due date for quarterly reports shall be forty-five
(45) days after the end of the calendar quarter.
c) Other Financial Reports:
Contractor shall submit financial reports, including
certified annual financial statements, and make
available documents relevant to its financial condition
to SDOH and the State Insurance Department (SID) in a
timely manner as required by State laws and regulations
including but not limited to PHL' '4403-a, 4404 and
4409, Title 10 NYCRR "98.11, 98.16 and 98.17 and
applicable Insurance Law "304, 305, 306, and 310. The
LDSS reserves the right to require Contractor to submit
such relevant financial reports and documents related to
the financial condition of the MCO to the LDSS, as set
forth in Section 18.5(o) of this Agreement.
d) Encounter Data:
The Contractor shall prepare and submit encounter data
on a monthly basis to SDOH through its designated Fiscal
Agent. Each provider is required to have a unique
identifier. Submissions shall be comprised of encounter
records, or adjustments to previously submitted records,
which the Contractor has received and processed from
provider encounter or claim records of any contracted
services rendered to the Enrollee in the current or any
preceding months. Monthly submissions must be received
by the Fiscal Agent by the Tuesday before the last
Monday of the month to assure the submission is included
in the Fiscal Agent's monthly production processing.
e) Quality of Care Performance Measures:
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-2
The Contractor shall prepare and submit reports to SDOH,
as specified in the Quality Assurance Reporting
Requirements (QARR). The Contractor must arrange for an
NCQA-certified entity to audit the QARR data prior to
its submission to the SDOH, unless this requirement is
specifically waived by the SDOH. The SDOH will select
the measures which will be audited
f) Complaint Reports:
The Contractor must provide the SDOH on a quarterly
basis, and within fifteen (15) business days of the
close of the quarter, a summary of all complaints
received during the preceding quarter on the Health
Provider Network ("HPN").
The Contractor also agrees to provide on a quarterly
basis, via the HPN, the total number of complaints that
have been unresolved for more than forty-five (45) days.
The Contractor shall maintain records on these and other
complaints which shall include all correspondence
related to the complaint, and an explanation of
disposition. These records shall be readily available
for review by the SDOH or LDSS upon request.
Nothing in this Section is intended to limit the rig ht
of the SDOH and the LDSS to obtain information
immediately from a Contractor pursuant to investigating
a particular Enrollee or provider complaint.
The LDSS reserves the right to require the Contractor to
submit a hardcopy of complaint reports in Section
18.5(o) of this Agreement.
g) Fraud and Abuse Reporting Requirements
i) The Contractor must submit quarterly, via the
HPN complaint reporting format, the number of
complaints of fraud or abuse made to the
Contractor that warrant preliminary
investigation by the Contractor.
ii) The Contractor must also submit to the SDOH the
following on an ongoing basis for each confirmed
case of fraud and abuse it identifies through
complaints, organizational monitoring,
contractors, subcontractors, providers,
beneficiaries, Enrollees, etc:
A) The name of the individual or
entity that committed the fraud
or abuse;
B) The source that identified the
fraud or abuse;
C) The type of provider, entity or
organization that committed the
fraud or abuse;
D) A description of the fraud or
abuse;
E) The approximate range of dollars
involved;
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-3
F) The legal and administrative
disposition of the case
including actions taken by law
enforcement officials to whom
the case has been referred; and
G) Other data/information as
prescribed by SDOH.
iii) Such report shall be submitted when cases of
fraud and abuse are confirmed, and shall be
reviewed and signed by an executive officer of
the Contractor.
h) Participating Provider Network Reports:
The Contractor shall submit electronically, to the HPN,
an updated provider network report on a quarterly basis.
The Contractor shall submit an annual notarized
attestation that the providers listed in each submission
have executed an agreement with the Contractor to serve
Contractor's Medicaid Enrollees. The report submission
must comply with the Managed Care Provider Network Data
Dictionary. Networks must be reported separately for
each county in which the Contractor operates.
i) Appointment Availability/Twenty-four (24) Hour/Access
and Availability Surveys:
The Contractor will conduct a county specific (or
service area if appropriate) review of appointment
availability and twenty-four (24) hour access and
availability surveys annually. Results of such surveys
must be kept on file and be readily available for review
by the SDOH or LDSS, upon request. Guidelines for such
studies may be obtained by contacting the SDOH, Office
of Managed Care, Bureau of Certification and
Surveillance.
The LDSS reserves the right to require the Contractor to
conduct appointment availability and twenty-four (24)
hour access studies twice a year, and to submit these
reports to the LDSS, as stated in Section 18.5(o) of
this Agreement.
j) Clinical Studies:
The Contractor will participate in up to four (4) SDOH
sponsored focused clinical studies annually. The purpose
of these studies will be to promote quality improvement
within the MCO.
The Contractor will be required to conduct at least one
(1) internal focused clinical study each year in a
priority topic area of its choosing, from a list to be
generated through the mutual agreement of the SDOH and
the Contractor's Medical Director. The purpose of these
studies will be to promote quality improvement within
the MCO. SDOH will provide
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-4
guidelines for the studies' structure. Results of these
studies will be provided to the SDOH and the LDSS.
k) Independent Audits:
The Contractor must submit copies of all certified
financial statements and a QARR validation audit by
independent auditors of their plan to the SDOH and the
LDSS within thirty (30) days of receipt by the
Contractor.
l) PCP Auto Assignments:
The Contractor shall submit semi-annually to the SDOH
and the LDSS a report showing the percentage of PCP
assignments for Enrollees which were made automatically
by the Contractor, rather than by the Enrollee.
m) No Contact Report:
The Contractor shall submit a monthly report within
thirty (30) days of the close of the reporting period to
the LDSS of any Enrollee it is unable to contact,
through reasonable means, including by mail, and by
telephone, using methods described in Section 13.5,
and/or of any Enrollees who have not utilized any health
care services through the Contractor or its
Participating Providers, within ninety (90) days of the
Effective Date of Enrollment.
n) Additional Reports:
Upon request by the SDOH and/or the LDSS, the Contractor
shall prepare and submit other operational data reports.
Such requests will be limited to situations in which the
desired data is considered essential and cannot be
obtained through existing Contractor reports. Whenever
possible, the Contractor will be provided with ninety
(90) days notice and the opportunity to discuss and
comment on the proposed requirements before work is
begun. However, the SDOH and the LDSS reserve the right
to give thirty (30) days notice in circumstances where
time is of the essence.
o) LDSS Specific Reports:
{INSERT LDSS SPECIFIC REPORTS AS APPLICABLE}
18.6 Ownership and Related Information Disclosure
The Contractor shall report ownership and related information to
SDOH and the LDSS, and upon request to the Secretary of
Department of Health and Human Services and the Inspector
General of Health and Human Services, in accordance with 42 U.
S. C. Section 1320a-3 and 1396b(m)(4) (Sections 1124 and
1903(m)(4) of the Federal Social Security Act).
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-5
18.7 Revision of Certificate of Authority
The Contractor shall give prompt written notice to LDSS of any
revisions of its Certificate of Authority issued pursuant to
Article 44 of the State Public Health Law.
18.8 Public Access to Reports
Any data, information, or reports collected and prepared by the
Contractor and submitted to NYS authorities in the course of
performing their duties and obligation under this program will
be deemed to be owned by the State of New York subject to and
consistent with the requirements of Freedom of Information Law.
This provision is made in consideration of the Contractor's use
of public funds in collecting and preparing such data,
information, and reports.
18.9 Professional Discipline
a) Pursuant to P. H. L. Section 4405-b, the Contractor
shall have in place policies and procedures to report to
the appropriate professional disciplinary agency within
thirty (30) days of occurrence, any of the following:
i) the termination of a health care provider
contract pursuant to Section 4406-d of the
Public Health Law for reasons relating to
alleged mental and physical impairment,
misconduct or impairment of patient safety or
welfare;
ii) the voluntary or involuntary termination of a
contract or employment or other affiliation with
such Contractor to avoid the imposition of
disciplinary measures; or
iii) the termination of a health care provider
contract in the case of a determination of fraud
or in a case of imminent harm to patient health.
b) The Contractor shall make a report to the appropriate
professional disciplinary agency within sixty (60) days
of obtaining knowledge of any information that
reasonably appears to show that a health professional is
guilty of professional misconduct as defined in Articles
130 and 131(a) of the State Education Law.
18.10 Certification Regarding Individuals Who Have Been Debarred Or
Suspended By Federal or State Government
Contractor will certify to the SDOH and LDSS initially and
immediately upon changed circumstances from the last such
certification that it does not knowingly have an individual who
has been debarred or suspended by the federal or state
government, or otherwise excluded from participating in
procurement activities:
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-6
a) as a director, officer, partner or person with
beneficial ownership of more than 5% of the Contractor's
equity; or
b) as a party to an employment, consulting or other
agreement with the Contractor for the provision of items
and services that are significant and material to the
Contractors obligations in the Medicaid managed care
program, consistent with requirements of SSA '1932
(d)(1).
18.11 Conflict of Interest Disclosure
Contractor shall report to SDOH, in a format specified by SDOH,
documentation, including but not limited to the identity of and
financial statements of, person(s) or corporation(s) with an
ownership or contract interest in the managed care plan, or with
any subcontract(s) in which the managed care plan has a 5% or
more ownership interest, consistent with requirements of SSA
'1903 (m)(2)(a)(viii) and 42 CFR "455.100 B 455.104.
18.12 Physician Incentive Plan Reporting
The Contractor shall submit to SDOH annual reports containing
the information on all of its Physician Incentive Plan
arrangements in accordance with 42 CFR Section 434.70 or, if no
such arrangements are in place, attest to that. The contents and
time frame of such reports shall comply with the requirements of
42 CFR Section 417.479 and be in a format provided by SDOH.
SECTION 18
(CONTRACTOR REPORTING REQUIREMENTS)
October 1, 1999
18-7
19. RECORDS MAINTENANCE AND AUDIT RIGHTS
19.1 Maintenance of Contractor Performance Records
The Contractor shall maintain and shall require its
subcontractors, including its Participating Providers, to
maintain appropriate records relating to Contractor performance
under this Agreement, including:
a) records related to services provided to Enrollees,
including a separate Medical Record for each Enrollee;
b) all financial records and statistical data that LDSS,
SDOH and any other authorized governmental agency may
require including books, accounts, journals, ledgers,
and all financial records relating to capitation
payments, third party health insurance recovery, and
other revenue received and expenses incurred under this
Agreement;
c) appropriate financial records to document fiscal
activities and expenditures, including records relating
to the sources and application of funds and to the
capacity of the Contractor or its subcontractors,
including its Participating Providers, if relevant, to
bear the risk of potential financial losses.
19.2 Maintenance of Financial Records and Statistical Data
The Contractor shall maintain all financial records and
statistical data according to generally accepted accounting
principles.
19.3 Access to Contractor Records
The Contractor shall provide LDSS, SDOH, the Comptroller of the
State of New York, DHHS, the Comptroller General of the United
States, and their authorized representatives with access to all
records relating to Contractor performance under this Agreement
for the purposes of examination, audit, and copying (at
reasonable cost to the requesting party) of such records. The
Contractor shall give access to such records on two (2) business
days prior written notice, during normal business hours, unless
otherwise provided or permitted by applicable laws, rules, or
regulations.
19.4 Retention Periods
The Contractor shall preserve and retain all records relating to
Contractor performance under this Agreement in readily
accessible form during the term of this Agreement and for a
period of six (6) years thereafter. All provisions of this
Agreement relating to record maintenance and audit access shall
survive the termination of this Agreement and shall bind the
Contractor until the expiration of
Section 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 1999
19-1
a period of six (6) years commencing with termination of this
Agreement or if an audit is commenced, until the completion of
the audit, whichever occurs later.
Section 19
(RECORDS MAINTENANCE AND AUDIT RIGHTS)
October 1, 1999
19-2
20. CONFIDENTIALITY
20.1 Confidentiality of Identifying Information about Medicaid
Recipients and Applicants
All information relating to services to Medicaid recipients and
applicants which is obtained by the Contractor shall be
confidential pursuant to the New York State P. H. L. including
P. H. L. Article 27 F, the provisions of Section 369(4) of the
NYS Social Services Law, 42 U .S. C. Section 1396a(a)(7)
(Section 1902(a)(7) of the Federal Social Security Act), Section
33.13 of the Mental Hygiene Law, and regulations promulgated
under such laws including 42 CFR Part 2 pertaining to Alcohol
and Substance Abuse Services. Such information including
information relating to services to Medicaid recipients and
applicants as these relate to the provision of services to the
recipient or applicant under this Agreement shall be used or
disclosed by the Contractor only for a purpose directly
connected with performance of the Contractor's obligations. It
shall be the responsibility of the Contractor to inform its
employees and contractors of the confidential nature of Medicaid
information.
20.2 Medical Records of ▇▇▇▇▇▇ Children
Medical records of enrolled Medicaid recipients enrolled in
▇▇▇▇▇▇ care programs shall be disclosed to local social service
officials in accordance with State Social Services Law including
Sections 358-a, 384-a and 392 and 18 NYCRR Section 507.1.
20.3 Confidentiality of Medical Records
Medical records of Medicaid recipients enrolled pursuant to this
Agreement shall be confidential and shall be disclosed to and by
other persons within the Contractor's organization including
Participating Providers, only as necessary to provide medical
care, to conduct quality assurance functions and peer review
functions, or as necessary to respond to a complaint and appeal
under the terms of this Agreement.
20.4 Length of Confidentiality Requirements
The provisions of this Section shall survive the termination of
this Agreement and shall bind the Contractor so long as the
Contractor maintains any individually identifiable information
relating to Medicaid recipients and applicants.
Section 20
(CONFIDENTIALITY)
October 1, 1999
20-1
21. PARTICIPATING PROVIDERS
21.1 Network Requirements
a) Sufficient Number
i) The Contractor will establish and maintain a
network of Participating Providers.
ii) The Contractor's network must contain all of the
provider types necessary to furnish the prepaid
Benefit Package, including but not limited to:
hospitals, physicians (primary care and
specialists), mental health and substance abuse
providers, allied health professionals,
ancillary providers, DME providers and home
health providers.
iii) To be considered accessible, the network must
contain a sufficient number and array of
providers to meet the diverse needs of the
Enrollee population. This includes being
geographically accessible (meeting time/distance
standards) and being accessible for the
disabled.
iv) The Contractor shall not include in its network
any provider who has been sanctioned or
prohibited from serving Medicaid recipients or
receiving Medical Assistance payments.
b) Absence of Appropriate Network Provider
In the event that the Contractor determines that it does
not have a Participating Provider with appropriate
training and experience to meet the particular health
care needs of an Enrollee, the Contractor shall make a
referral to an appropriate Non-Participating Provider,
pursuant to a treatment plan approved by the Contractor
in consultation with the Primary Care Provider, the
Non-Participating Provider and the Enrollee or the
Enrollee's designee. The Contractor shall pay for the
cost of the services in the treatment plan provided by
the Non-Participating Provider.
c) Suspension of Enrollee Assignments To Providers
The Contractor shall ensure that there is sufficient
capacity, consistent with SDOH standards, to serve
Enrollees under this Agreement. In the event any of the
Contractor's Participating Providers are no longer able
to accept assignment of new Enrollees due to capacity
limitations, as determined by the SDOH and the LDSS, the
Contractor will suspend assignment of any additional
Enrollees to such Participating Provider until it is
capable of further accepting Enrollees. When a
Participating Provider has more than one (1) site, the
suspension will be made by site.
d) Notice of Provider Termination
Section 21
(PROVIDER NETWORK AND AGREEMENTS)
October 1, 1999
21-1
At least thirty (30 ) days prior to termination, of any
Provider Agreement that substantially alters or limits
Enrollees access to the Contractor's services, as
determined by the LDSS, the Contractor shall notify the
LDSS and SDOH and specify how services previously
furnished by the Participating Provider will be
provided. In the event a Provider Agreement is
terminated effective immediately or with less than
thirty (30) days notice, the Contractor shall notify
LDSS and SDOH promptly and in no event in more than
seventy-two (72) hours after the termination becomes
effective.
21.2 Credentialing
a) Licensure
The Contractor shall ensure, in accordance with Article
44 of the Public Health Law, that persons and entities
providing care and services for the Contractor in the
capacity of physician, dentist, physician's assistant,
registered nurse, other medical professional or
paraprofessional, or other such person or entity satisfy
all applicable licensing, certification, or
qualification requirements under New York law and that
the functions and responsibilities of such persons and
entities in providing Benefit Package services under
this Agreement do not exceed those permissible under New
York law.
b) Minimum Standards
The Contractor agrees that all network physicians will
meet at least one (1) of the following standards, except
as specified in Section 21.13(b) and Appendix I of this
agreement:
i) Be board-certified or -eligible in their area of
specialty;
ii) Have completed an accredited residency program;
or
iii) Have admitting privileges at one (1) or more
hospitals participating in the Contractor's
network.
c) Credentialing/Recredentialing Process
The Contractor shall have in place a formal process for
credentialing Participating Providers on a periodic
basis (not less than once every two (2) years) and for
monitoring Participating Providers performance.
d) Application Procedure
The Contractor shall establish a written application
procedure to be used by a health care professional
interested in serving as a Participating Provider with
the Contractor. The criteria for selecting providers,
including the minimum qualification requirements that a
health care professional must meet to be considered by
the Contractor, must be defined in writing and developed
in consultation with appropriately qualified health care
professionals. Upon
Section 21
PROVIDER NETWORK AND AGREEMENTS)
October 1, 1999
21-2
request, the application procedures and minimum
qualification requirements must be made available to
health care professionals.
21.3 SDOH Exclusion or Termination of Providers
If SDOH excludes or terminates a provider from its Medicaid
Program, the Contractor shall, upon learning of such exclusion
or termination, immediately terminate the provider agreement
with the Participating Provider as it pertains to the
Contractor's Medicaid program, and agrees to no longer utilize
the services of the subject provider, as applicable. The
Contractor will receive a paper listing of currently excluded
Medic aid providers mailed monthly to their correspondence
address, that the Contractor specified to SDOH during the
initial provider enrollment process. Such paper shall be deemed
to constitute constructive notice. This notification should not
be the sole basis for identifying current exclusions or
termination of previously approved providers. Should the
Contractor become aware, through any source, of an SDOH
exclusion or termination, the Contractor shall validate this
information with the Office of Medicaid Management, Bureau of
Enforcement Activities and comply with the provisions of this
Section.
21.4 Evaluation Information
The Contractor shall develop and implement policies and
procedures to ensure that health care professionals are
regularly advised of information maintained by the Contractor to
evaluate the performance or practice of health care
professionals. The Contractor shall consult with health care
professionals in developing methodologies to collect and analyze
health care professional profiling data. The Contractor shall
provide any such information and profiling data and analysis to
health care professionals. Such information, data or analysis
shall be provided on a periodic basis appropriate to the nature
and amount of data and the volume and scope of services
provided. Any profiling data used to evaluate the performance or
practice of a health care professional shall be measured against
stated criteria and an appropriate group of health care
professionals using similar treatment modalities serving a
comparable patient population. Upon presentation of such
information or data, each health care professional shall be
given the opportunity to discuss the unique nature of the health
care professional's patient population which ma y have a bearing
on the health care professional's profile and to work
cooperatively with the Contractor to improve performance.
21.5 Payment In Full
Contractor must limit participation to providers who agree that
payment received from the Contractor for services included in
the Benefit Package is payment in full for services provided to
Enrollees.
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21.6 Choice/Assignment of PCP's
a) The Contractor shall offer each Enrollee the choice of
no fewer than three (3) Primary Care Providers within
program distance/travel time standards. Contractor must
assign a PCP to individuals that fail to select a PCP.
The assignment of a PCP by the Contractor may occur
after written notification of Contractor by LDSS of the
enrollment (through Roster or other method) and after
written notification of the Enrollee by the Contractor
but in no event later than thirty (30) days after
notification of enrollment, and only after the
Contractor has made reasonable efforts as set forth in
Section 13.5 of this Agreement to contact the Enrollee
and inform him/her of his/her right to choose a PCP.
b) PCP assignments should be made taking into consideration
the following:
i) Enrollee's geographic location;
ii) any special health care needs, if known by the
Contractor; and
iii) any special language needs, if known by the
Contractor.
c) In circumstances where the Contractor operates or
contracts with a multiprovider clinic to deliver primary
care services, the Enrollee must choose or be assigned a
specific provider or provider team within the clinic to
serve as his/her PCP. This " lead" provider will be held
accountable for performing the PCP duties.
21.7 PCP Changes
a) The Contractor must allow Enrollees the freedom to
change PCPs, without cause, within thirty (30) days of
the Enrollee's first appointment with the PCP. After the
first thirty (30) days PCP may be changed once every six
(6) months without cause.
b) The Contractor must process a request to change PCPs and
advise the Enrollee of the effective date of the change
within forty-five (45) days of receipt of the request.
The change must be effective no later than the first
(1st) day of the second (2nd) month following the month
in which the request is made.
c) The Contractor will provide Enrollees with an
opportunity to select a new PCP in the event that the
Enrollee's current PCP leaves the network or otherwise
becomes unavailable. Such changes shall not be
considered in the calculation of changes for cause
allowed within a six (6) month period.
d) In the event that an assignment of a new PCP is
necessary due to the unavailability of the Enrollee's
former PCP, such assignment shall be made in accordance
with the requirements of Section 21.7 of this Agreement.
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e) In addition to those conditions and circumstances under
which the Contractor may assign an Enrollee a PCP when
the Enrollee fails to make an affirmative choice of a
PCP, the Contractor may initiate a PCP change for an
Enrollee under the following circumstances:
i) The Enrollee requires specialized care for an
acute or chronic condition and the Enrollee and
Contractor agree that reassignment to a
different PCP is in the Enrollee's interest.
ii) The Enrollee's place of residence has changed
such that he/she has moved beyond the PCP travel
time/distance standard.
iii) The Enrollee's PCP ceases to participate in the
Contractor's network.
iv) The Enrollee's behavior toward the PCP is
disruptive and the PCP has made all reasonable
efforts to accommodate the Enrollee.
v) The Enrollee has taken legal action against the
PCP.
f) Whenever initiating a change, the Contractor must offer
affected Enrollees the opportunity to select a new PCP
in the manner described in this Section.
21.8 PCP Status Changes
The Contractor agrees to notify its Enrollees of any of the
following PCP changes:
a) Enrollees will be notified within three (3) business
days from the date on which the Contractor becomes aware
of the change if:
i) Office address/telephone number change.
ii) Office hours change.
b) Enrollees will be notified within fifteen (15) days from
the date on which the Contractor became aware of the
change if:
i) An Enrollee's PCP ceases participation with the
Contractor (in such cases, the Contractor must
ensure that a new PCP is assigned within thirty
(30) days of the date of notice to the
Enrollee).
ii) An Enrollee is in an on going course of
treatment with another Participating Provider
who becomes unavailable to continue to provide
services to such Enrollee. In such cases, the
notice shall also describe the procedures for
continuing care.
21.9 PCP Responsibilities
In conformance with the Benefit Package, the PCP shall provide
health counseling and advice; conduct baseline and periodic
health examinations; diagnose and treat conditions not requiring
the services of a specialist; arrange inpatient care,
consultation with specialists, and laboratory and radiological
services when medically necessary; coordinate the findings of
consultants and
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laboratories; and interpret such findings to the Enrollee and
the Enrollee's family, subject to the confidentiality provisions
of Section 20 of this Agreement, and maintain a current medical
record for the Enrollee. The PCP shall also be responsible for
determining the urgency of a consultation with a specialist and
shall arrange for all consultation appointments within
appropriate time frames.
21.10 Member to Provider Ratios
The Contractor agrees to adhere to the member -to-PCP ratios
shown below. These ratios are for Medicaid Enrollees only, are
Contractor-specific, and assume the practitioner is a full time
equivalent (FTE)(defined as a provider practicing forty (40)
hours per week for the Contractor):
i) No more than 1,500 Medic aid Enrollees for each
physician, o r 2,400 for a physician practicing in
combination with a physician assistant or a nurse
practitioner.
ii) No more than 1,000 Medicaid Enrollees for each nurse
practitioner.
The Contractor agrees that these ratios will be prorated for
Participating Providers who represent less than a FTE to the
Contractor.
21.11 Minimum Office Hours
a) General Requirements
A PCP must practice a minimum of sixteen (16) hours a
week at each primary care site.
b) The minimum office hours requirement may be waived under
certain circumstances. A request for a waiver must be
submitted by the MCO to the Medical Director of the
Office of Managed Care for review and approval; and the
physician must be available at least eight hours/week;
and the physician must be practicing in a Health
Provider Shortage Area (HAPS) or other similarly
determined shortage area; and the physician must be able
to fulfill the other responsibilities of a PCP (as
described in this Section); and the waiver request must
demonstrate there are systems in place to guarantee
continuity of care and to meet all access and
availability standards, (24-hr/7 day week cover age,
appointment availability, et c.). SDOH shall notify the
LDSS when a waiver has been granted.
21.12 Primary Care Practitioners
a) General Limitations
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The Contractor agrees to limit its PCPs to the following
primary care specialties: Family Practice, General
Practice, General Pediatrics, General Internal Medicine,
except as specified in (b), (c), (d)and (e) of this
Section.
b) Specialist and Sub-specialist as PCPs
The Contractor is permitted to use specialist and
sub-specialist physicians as PCPs when such an action is
considered by the Contractor to be medically appropriate
and cost-effective. As an alternative, the Contractor
may restrict it's PCP network to primary care
specialties only, while relying on standing referrals to
specialists and sub-specialists for Enrollees who
require regular visits to such physicians.
c) OB/GYN Providers as PCPs
The Contractor, at its option, is permitted to use OB
/GYN providers as PCPs, subject to SDOH qualifications.
d) Nurse Practitioners as PCPs
The Contractor is permitted to use nurse practitioners
as PCPs, subject to their scope of practice limitations
under New York State Law.
e) Physician's Assistants as Physician Extenders
The Contractor is permitted to use physician's
assistants as physician-extenders, subject to their
scope of practice limitations under New York State Law.
21.13 PCP Teams
a) General Requirements
The Contractor may designate teams of physicians/nurse
practitioners to serve as PCPs for Enrollees. Such teams
may include no more than four (4) physicians/nurse
practitioners and, when an Enrollee chooses or is
assigned to a team, one of the practitioners must be
designated as "lead provider" for that Enrollee. In the
case of teams comprised of medical residents under the
supervision of an attending physician, the attending
physician must be designated as the lead physician.
b) Medical Residents
The Contractor shall comply with SDOH Guidelines for use
of Medical Residents as found in Appendix I, which is
hereby made a part of this Agreement as if set forth
fully herein.
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21.14 Hospitals
a) Tertiary Services
The Contractor will establish hospital networks capable
of furnishing the full range of tertiary services to
Enrollees. Contractors shall ensure that all Enrollees
have access to at least one (1) general a cute care
hospital within thirty (30) minutes/thirty (30) Miles
travel time (by car or public transportation) from the
Enrollee's residence, unless none are located within
such a distance. If none are located within thirty (30)
minutes travel time/ thirty (30) miles travel distance,
the Contractor must include the next closest site in its
network.
b) Emergency Services
The Contractor shall ensure and demonstrate that it
maintains relationships with hospital emergency
facilities, including comprehensive psychiatric
emergency programs (where available) within and around
its Service Area to provide Emergency Services.
21.15 Dental Networks
If the Contractor includes dental services in it's Benefit
Package, the Contractor's dental network shall include
geographically accessible general dentists sufficient to offer
each Enrollee a choice of two (2) primary care dentists in their
Service Area and to achieve a ratio of at least one (1) primary
care dentist for each 2,000 Enrollees. Networks must also
include at least one (1) pediatric dentist and one (1) oral
surgeon. Orthognathic surgery, temporal mandibular disorders
(TMD) and oral/maxillofacial prosthodontics must be provided
through any qualified dentist, either in-network or by referral.
Periodontists and endodontists must also be available by
referral. The network should include dentists with expertise in
serving special needs populations (e.g., HIV+ and
developmentally disabled patients).
Dental surgery performed in an ambulatory or inpatient setting
is the responsibility of the Contractor whether dental services
are a covered benefit or not, as set forth in Appendix K-II
-B-Optional Service, Dental Services.
21.16 Presumptive Eligibility Providers
Contractors must offer Presumptive Eligibility Providers the
opportunity to contract at terms which are at least as favorable
as the terms offered to other providers performing equivalent
services (prenatal care). Contractors need not contract with
every Presumptive Eligibility Provider in their County, but must
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include a sufficient number in their networks of Participating
Providers to meet the distance/travel time standards defined for
primary care.
21.17 Mental Health, Alcohol and Substance Abuse Providers
The Contractor will include a full array of mental health and
substance abuse providers in its networks, in sufficient numbers
to assure accessibility to services on the part of both children
and adults, using either individual, appropriately licensed
practitioners or New York State Office of Mental Health (OMH)
and Office of Alcohol and Substance Abuse Services (OASAS)
licensed programs and clinics, or both.
The State defines mental health and substance abuse providers to
include the following: Individual Practitioners, Psychiatrists,
Psychologists, Psychiatric Nurse Practitioners, Psychiatric
Clinical Nurse Specialists, Licensed Certified Social Workers,
OMH and OASAS Programs and Clinics, and Providers of mental
health and/or alcoholism/substance abuse services certified or
licensed pursuant to Article 23 or 31 of Mental Hygiene Law, as
appropriate. OASAS programs include Certified Drug and Alcohol
Counselors, employed only by OASAS licensed programs.
21.18 Laboratory Procedures
The Contractor agrees to restrict its laboratory provider
network to entities having either a CLIA certificate of
registration or a CLIA certificate of waiver.
21.19 School-Based Health Centers
a) By January 1, 2000, the Contractor must develop, in
collaboration with school-based health centers in their
Service Areas, protocols for reciprocal referral and
communication of data and clinical information on MCO
Enrollees enrolled in school-based health centers.
b) By March 31, 2000, the Contractor must enter into
contractual and payment arrangements with school-based
health centers in their Service Area consistent with
SDOH clinical coordination guidelines and the protocols
referred to in (a) above.
21.20 Federally Qualified Health Centers (FQHCs)
In voluntary counties, the Contractor is not required to
contract with FQHCs.
However, when an FQHC is part of the provider network (voluntary
or mandatory counties) the Provider Agreement must include a
provision whereby the Contractor agrees to compensate the FQHC
for services provided to Enrollees at a
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payment rate that is not less than the level and amount for a
similar set of services which the Contractor would make to a
provider that is not an FQHC.
In mandatory counties, the Contractor shall contract with FQHCs
operating in its Service Area. However, the Contractor has the
option to make a written request to the SDOH for an exemption
from the FQHC contracting requirement, if the Contractor can
demonstrate, with supporting documentation, that it has adequate
capacity and will provide a comparable level of clinical and
enabling services (e. g., outreach, referral services, social
support services, culturally sensitive services such as training
for medical and administrative staff, medical and non-medical
and case management services) to vulnerable populations in lieu
of contracting with an FQHC in its Service Area. Written
requests for exemption from this requirement are subject to
approval by HCFA.
When the Contractor is participating in a county where an MCO
that is sponsored, owned and/or operated by one or more FQHCs
exists, the Contractor is not required to include any FQHCs
within its network in that county.
21.21 Provider Services Function
The Contractor will operate a Provider Services function during
regular business hours. At a minimum, the Contractor's Provider
Services staff must be responsible for the following:
a) Assisting providers with prior authorization and
referral protocols.
b) Assisting providers with claims payment procedures.
c) Fielding and responding to provider questions and
complaints.
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22. SUBCONTRACTS AND PROVIDER AGREEMENTS
22.1 Written Subcontracts
Contractor may not enter into any subcontracts related to the
delivery of services to Enrollees, except by a written
agreement.
22.2 Permissible Subcontracts
Contractor may subcontract for provider services as set forth in
Section 2.6 and 21 of this contract and management services
including, but not limited to, marketing, quality assurance and
utilization review activities and such other services as are
acceptable to the LDSS.
22.3 Provisions of Services through Provider Agreements
All medical care and/or services covered under this Agreement,
with the exception of seldom used subspecialty and Emergency
Services, Family Planning Services, and services for which
Enrollees can self refer, shall be provided through Provider
Agreements with Participating Providers.
22.4 Approvals
a) Provider Agreements shall require the approval of SDOH
as set forth in P.H.L. 4402 and 10 NYCRR Part 98.
b) If a subcontract is for management services under 10
NYCRR Section 98.11, it must be approved by SDOH prior
to its becoming effective.
c) LDSS may require that the Contractor submit any
subcontracts, including Provider Agreements with
Participating Providers, and including material
amendments to and renewals of such sub-contracts to
LDSS.
d) The Contractor shall notify SDOH of any material
amendments to any Provider Agreement as set forth in 10
NYCRR 98.8. The Contractor shall provide LDSS with a
copy of any such amendment within fifteen (15) days
after its approval by SDOH, unless LDSS notifies the
Contractor otherwise.
22.5 Required Components
a) The Contractor shall impose obligations and duties on
its subcontractors, including its Participating
Providers, that are consistent with this Agreement, and
that do not impair any rights accorded to LDSS, SDOH, or
DHHS.
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b) No subcontract, including any Provider Agreement shall
limit or terminate the Contractor's duties and
obligations under this Agreement.
c) Nothing contained in this Agreement between LDSS and the
Contractor shall create any contractual relationship
between any subcontractor of the Contractor, including
Participating Providers, and the County or LDSS.
d) Any sub contract entered into by the Contractor shall
fulfill the requirements of 42 C FR Part 434 that are
appropriate to the service or activity delegated under
such subcontract.
e) The Contractor shall also ensure that, in the event the
Contractor fails t o pay any subcontractor, including
any Participating Provider in accordance with the
subcontract or Provider Agreement, the subcontractor or
Participating Provider will not seek payment from the
LDSS, the Enrollees, or their eligible dependents.
f) The Contractor shall include in every Provider Agreement
a procedure for the resolution of disputes between the
Contractor and its Participating Providers.
g) The Contractor shall ensure that all Provider Agreements
entered into with Providers require acceptance of a
woman's enrollment in the MCO as sufficient to provide
services to her newborn, unless the newborn is excluded
from participating in Medicaid managed care.
22.6 Timely Payment
Contractor shall make payments to affiliated health care
providers for items and services covered under this Agreement on
a timely basis, consistent with the claims payment procedures
described in NYS Insurance Law Section 3224-a.
22.7 Restrictions on Disclosure
The Contractor shall not by contract or written policy o r
written procedure prohibit or restrict any health care provider
from the following:
a) disclosing to any subscriber, Enrollee, patient,
designated representative or, where appropriate,
prospective Enrollee any information that such provider
deems appropriate regarding:
i) a condition or a course of treatment with such
subscriber, Enrollee, patient, designated
representative or prospective Enrollee,
including the availability of other therapies,
consultations, or tests; or
ii) The provisions, terms, or requirements of the
Contractor's products as they relate to the
Enrollee, where applicable.
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b) filing a complaint, making a report or comment to an
appropriate governmental body regarding the policies or
practices of the Contractor when they believe that the
policies or practices negatively impact upon the quality
of, or access to, patient care.
c) advocating to the Contractor on behalf of the Enrollee
for approval or coverage of a particular treatment or
for the provision of health care services.
22.8 Transfer of Liability
No contract or agreement between the Contractor and a health
care provider shall contain any clause purporting to transfer to
the health care provider, other than a medical group, by
indemnification or otherwise, any liability relating to
activities, actions or omissions of the Contractor as opposed to
those of the health care provider.
22.9 Termination of Health Care Professional Agreements
The Contractor shall not terminate a contract with a health care
professional unless the Contractor provides to the health care
professional a written explanation of the reasons for the
proposed termination and an opportunity for a review or hearing
as hereinafter provided. For purposes of this Section a health
care professional is an individual licensed, registered or
certified pursuant to Title 8 of the Education Law.
These requirements shall not apply in cases involving imminent
harm to patient care, a determination of fraud, or a final
disciplinary action by a state licensing board or other
governmental agency that impairs the health care professional's
ability to practice.
When the Contractor desires to terminate a contract with a
health care professional, the notification of the proposed
termination by the Contractor to the health care professional
shall include:
a) the reasons for the proposed action;
b) notice that the health care professional has the right
to request a hearing or review, at the provider's
discretion, before a panel appointed by the Contractor;
c) a time limit of not less than thirty (30) days within
which a health care professional may request a hearing;
and
d) a time limit for a hearing date which must be held
within thirty (30) days after the date of receipt of a
request for a hearing.
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No contract or agreement between the Contractor and a
health care professional shall contain any provision
which shall supersede or impair a health care
professional's right to notice of reasons for
termination and the opportunity for a hearing or review
concerning such termination.
22.10 Health Care Professional Hearings
A health care professional that has been notified of his or her
proposed termination must be allowed a hearing. The procedures
for this hearing must meet the following standards:
a) The hearing panel shall be comprised of at least three
persons appointed by the Contractor. At least one person
on such panel shall be a clinical peer in the same
discipline and the same or similar specialty as the
health care professional under review. The hearing panel
may consist of more than three persons, provided how
ever that the number of clinical peers on such panel
shall constitute one-third or more of the total
membership of the panel.
b) The hearing panel shall render a decision on the
proposed action in a timely manner. Such decision shall
include reinstatement of the health care professional by
the Contractor, provisional reinstatement subject to
conditions set forth by the Contractor or termination of
the health care professional. Such decision shall be
provided in writing to the health care professional.
c) A decision by the hearing panel to terminate a health
care professional shall be effective not less than
thirty (30) days after the receipt by the health care
professional of the hearing panel's decision.
Notwithstanding the termination of a health care
professional for cause or pursuant to a hearing, a plan
shall permit an Enrollee to continue an on-going course
of treatment for a transition period of up to ninety
(90) days, and post-partum care, subject to provider
agreement, pursuant to P. H. L. Section 4406(6)(e).
d) In no event shall termination be effective earlier than
sixty (60) days from the receipt of the notice of
termination.
22.11 Non-Renewal of Provider Agreements
Either party to a contract may exercise a right of non-renewal
at the expiration of the contract period set forth therein or,
for a contract without a specific expiration date, on each
January first occurring after the contract has been in effect
for at least one year, upon sixty (60) days notice to the other
party; provided, however, that any non -renewal shall not
constitute a termination for the purposes of this Section.
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22.12 Physician Incentive Plan
If Contractor elects t o operate a Physician Incentive Plan,
Contractor agrees that no specific payment will be made directly
or indirectly under the plan to a physician or physician group
as an inducement to reduce or limit medically necessary services
furnished to an Enrollee. Contractor agrees to submit to SDOH
annual reports containing the information on its physician
incentive plan in accordance with 42 CFR Section 434.70. The
contents of such reports shall comply with the requirements of
42 CFR Section 417.479 and be in a format to be provided by
SDOH.
The Contractor must ensure that any agreements for contracted
services covered by this Agreement, such as agreements between
the Contractor and other entities or between the Contractor's
subcontracted entities and their contractors, at all levels
including the physician level, include language requiring that
the physician incentive plan information be provided by the
sub-contractor in an accurate and timely manner to the
Contractor, in the format requested by SDOH.
In the event that the incentive arrangements place the physician
or physician group at risk for services beyond those provided
directly by the physician or physician group for an amount
beyond the risk threshold of 25% of potential payments for
covered services (substantial financial risk), the Contractor
must comply with all additional requirements listed in
regulation, such as: conduct enrollee/disenrollee satisfaction
surveys; disclose the requirements for the physician incentive
plans to its beneficiaries upon request; and ensure that all
physicians and physician groups at substantial financial risk
have adequate stop-loss protection. Any of these additional
requirements that are passed on to the subcontractors must be
clearly stated in their Agreement.
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23. FRAUD AND ABUSE PREVENTION PLAN
A Fraud and Abuse Prevention Plan for the detection,
investigation and prevention of fraudulent activities must be
filed by the Contractor with the Commissioner of Health to the
extent required by SDOH regulations. A copy of this plan must be
submitted to the LDSS, upon request of the LDSS.
24. AMERICANS WITH DISABILITIES ACT COMPLIANCE PLAN
Contractor must comply with the Americans with Disabilities Act (ADA)
and Section 504 of the Rehabilitation Act of 1973 for program
accessibility, and must develop an ADA Compliance Plan consistent with
the guidelines in Appendix J of this Agreement. Said plan must be
approved by the SDOH and/or the LDSS, and filed with the Contractor,
SDOH and the LDSS.
25. FAIR HEARINGS
25.1 Enrollee Access To Fair Hearing Process
Enrollees may access the fair hearing process in accordance with
applicable federal and state laws and regulations. Contractors
must abide by and participate in New York State's Fair Hearing
Process and comply with determinations made by a fair hearing
officer.
25.2 Enrollee Rights to a Fair Hearing
Enrollees may request a fair hearing regarding adverse LDSS
determinations concerning enrollment, disenrollment and
eligibility, and regarding the denial, termination, suspension
or reduction of a clinical treatment or other Benefit Package
services by the Contractor. For issues related to disputed
services, Enrollees must have received an adverse determination
from the Contractor or its approved utilization review agent
either overriding are commendation to provide services by a
Participating Provider or confirming the decision of a
Participating Provider to deny those services. An Enrollee may
also seek a fair hearing for a failure by the Contractor to act
with reasonable promptness with respect to such services.
Reasonable promptness shall mean compliance with the time frames
established for review of grievances and utilization review in
Sections 44 and 49 of the Public Health Law.
25.3 Contractor Notice to Enrollees
a) Contractor must issue a written Notice of Adverse
Determination and Fair Hearing Rights to any Enrollee:
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i) When Contractor or its utilization review a gent
ha s denied a request to approve a Benefit
Package service ordered by an MCO provider; or
ii) When an Enrollee is denied a requested service
or benefit by an MCO provider and has exhausted
the Contractor's approved internal complaint and
appeal procedures or utilization review
processes; or
iii) At least 10 days before the effective date of
Contractor's termination, suspension or
reduction of a benefit or treatment already in
progress for that Enrollee.
b) Contractor agrees to serve notice on affected Enrollees
by mail and must maintain documentation of such.
c) Contractor's Notice of Adverse Determination and Notice
of a Right to Request a Fair Hearing shall include the
following:
i) A description of the action Contractor intends
to take;
ii) Contractor's reasons for the intended action;
iii) The circumstances under which expedited
complaint or utilization review is available and
how to request it;
iv) Notice of Enrollee's right to file a complaint
with the Contractor, a complaint with SDOH,
and/or to request a State fair hearing through
the Office of Administrative Hearings (OAH);
v) Instructions to the Enrollee regarding how the
Enrollee may file complaints, utilization
appeals and State fair hearing requests,
including use of the Notice of Right to Request
a Fair Hearing which will inform Enrollees of
their possible right to aid continuing and that
such aid can be accessed only if the Enrollee
requests a State fair hearing.
25.4 Aid Continuing
Contractor shall be required to continue the provision of the
Benefit Package services that are the subject of the fair
hearing to an Enrollee (hereafter referred to as "aid
continuing") if so ordered by the OAH under the following
circumstances:
i) Contractor has or is seeking to reduce, suspend
or terminate a treatment or Benefit Package
service currently being provided;
ii) Enrollee has filed a timely request for a fair
hearing with OAH; and
iii) There is a valid order for the treatment or
service from a participating provider.
Contractor shall provide aid continuing until
the matter has been resolved to the Enrollee's
satisfaction or until the administrative process
is completed and there is a determination from
OAH that Enrollee is not entitled to receive the
service, the Enrollee withdraws the request for
aid continuing and/or the fair hearing in
writing, or the treatment or service originally
ordered by the provider has been completed,
whichever occurs first.
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iv) If the services and/or benefits in dispute have
been terminated, suspended or reduced and the
Enrollee timely requests a fair hearing,
Contractor shall, at the direction of either
SDOH or LDSS, restore the disputed services
and/or benefits consistent with the provisions
of Section 25.4(iii) of this Agreement.
25.5 Responsibilities of SDOH
SDOH will make every reasonable effort to ensure that the
Contractor receives timely notice in writing by fax, or e-mail,
of all requests, schedules and directives regarding fair
hearings.
25.6 Contractor's Obligations
a) Contractor shall appear at all scheduled fair hearings
concerning its clinical determinations and/or
Contractor-initiated disenrollments to present evidence
as justification for its determination or submit written
evidence as justification for its determination
regarding the disputed benefits and/or services. If
Contractor will not be making a personal appearance at
the fair hearing, the written material must be submitted
to OAH and Enrollee or Enrollee's representative at
least three (3) business days prior to the scheduled
hearing. If the hearing is scheduled fewer than three
(3) business days after the request, Contractor must
deliver the evidence to the hearing site no later than
one (1) business day prior to the hearing, otherwise
Contractor must appear in person. Notwithstanding the
above provisions, Contractor may be required to make a
personal appearance at the discretion of the hearing
officer and/or SDOH.
b) Despite an Enrollee's request for a State fair hearing
in any given dispute, Contractor is required to maintain
and operate in good faith its own internal complaint and
appeal process as required under state and federal laws
and by Section 14 and Appendix F of this Agreement.
Enrollees may seek redress of adverse determinations
simultaneously through Contractor's internal process and
the State fair hearing process. If Contractor has
reversed its initial determination and provided the
service to the Enrollee, Contractor may request a waiver
from appearing at the hearing and, in submitted papers,
explain that it has withdrawn its initial determination
and is providing the service or treatment formerly in
dispute.
c) Contractor shall comply with all determinations rendered
by OAH at fair hearings. Contractor shall cooperate with
SDOH efforts to ensure that Contractor is in compliance
with fair hearing determinations. Failure by Contractor
to maintain such compliance shall constitute breach of
this Agreement. Nothing in this Section shall limit the
remedies available to SDOH, LDSS or the federal
government relating to any non-compliance by Contractor
with a fair hearing determination or Contractor's
refusal to provide disputed services.
Section 23 --Section 39
October 1, 1999
-3
d) If SDOH investigates a complaint that has as its basis
the same dispute that is the subject of a pending fair
hearing and, as a result of its investigation, concludes
that the disputed services and/or benefits should be
provided to the Enrollee, Contractor shall comply with
SDOH's directive to provide those services and/or
benefits and provide notice to OAH and Enrollee as
required by Section 25.6(b) of this Agreement.
e) If S DOH, through its complaint investigation process,
or OAH, by a determination after a fair hearing, directs
Contractor to provide a service that was initially
denied by Contractor, Contractor may either directly
provide the service, arrange for the provision of that
service or pay for the provision of that service by a
Non-Participating Provider.
f) Contractor agrees to abide by changes made to this
Section of the Agreement with respect to the fair
hearing, grievance and complaint processes by SDOH in
order to comply with any amendments to applicable state
or federal statutes or regulations. Such changes shall
become effective without need for any further action by
the parties to this Agreement.
g) Contractor agrees to identify a contact person within
its organization who will serve as a liaison to SDOH for
the purpose of receiving fair hearing requests,
scheduled fair hearing dates and adjourned fair hearing
dates and compliance with State directives. Such
individual: shall be accessible to the State by e-mail;
shall monitor e-mail for correspondence from the State
at least once every business day; and shall agree, on
behalf of Contractor, to accept notices to Contractor
transmitted via e-mail as legally valid.
h) The information describing fair hearing rights, aid
continuing, complaint procedures and utilization review
appeals shall be included in all Medicaid managed care
member handbooks and shall comply with SDOH's member
handbook guidelines.
i) Contractor shall bear the burden of proof at hearings
regarding the reduction, suspension or termination of
ongoing services. In the event that Contractor 's
initial adverse determination is upheld as a result of a
fair hearing, any aid continuing provided pursuant to
that hearing request, may be recouped by Contractor.
26. EXTERNAL APPEAL
26.1 Basis for External Appeal
Effective July 1, 1999, managed care Enrollees will be able to
request an external appeal when one or more covered health care
services have been denied by the
Section 23 --Section 39
October 1, 1999
-4
Contractor on the basis that the service(s) is not medically
necessary or is experimental or investigational.
26.2 Eligibility for External Appeal
An Enrollee is eligible for an external appeal when the Enrollee
has exhausted the Contractor's internal utilization review
procedure or both the Enrollee and the Contractor have agreed to
waive internal appeal procedures in accordance with New York
State P. H. L. Section 4914(2)2(a). A provider is also eligible
for an external appeal of retrospective denials.
26.3 External Appeal Determination
The external appeal determination is binding on the Contractor,
how ever, a fair hearing determination supercedes an external
appeal determination for Medicaid Enrollees.
26.4 Compliance with External Appeal Laws and Regulations
MCOs must comply with the provisions of New York State P. H. L.
Sections 4910-4914 and Title 10 of NYCRR Subpart 98-1 regarding
the external appeal program.
27. INTERMEDIATE SANCTIONS
Contractor is subject to the imposition of sanctions as authorized by
State law including the SDOH's right to impose sanctions for
unacceptable practices as set forth in Title 18 of the Official
Compilation of Codes, Rules and Regulations of the State of New York
(NYCRR) Part 515 and civil and monetary penalties pursuant to 18 NYCRR
Part 516 and such other sanctions and penalties as are authorized by
local laws and ordinances and resultant administrative c odes, rules and
regulations related to the Medical Assistance Program or to the delivery
of the contracted for services.
28. ENVIRONMENTAL COMPLIANCE
The Contractor shall comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act 42 U. S. C.
Section 1857(h), Section 508 of the Clean Water Act (33 U. S. C. Section
1368), Executive Order 11738, and the Environmental Protection Agency ("
EPA") regulations (40 C FR, Part 15) that prohibit the use of the
facilities included on the EPA List of Violating Facilities. The
Contractor shall report violations to SDOH and to the Assistant
Administrator for Enforcement of the EPA.
Section 23 --Section 39
October 1, 1999
-5
29. ENERGY CONSERVATION
The Contractor shall comply with any applicable mandatory standards and
policies relating to energy efficiency that are contained in the State
Energy Conservation regulation issued in compliance with the Energy
Policy and Conservation Act of 1975 (Pub. L. 94-165) and any amendment
to the Act.
30. INDEPENDENT CAPACITY OF CONTRACTOR
The parties agree that the Contractor is an independent Contractor, and
that the Contractor, its a gents, officers, and employees act in an
independent capacity and not as officers or employees of LDSS, DHHS or
the SDOH.
31. NO THIRD PARTY BENEFICIARIES
Only the parties to this Agreement and their successors in interest and
assigns have any rights or remedies under or by reason of this
Agreement.
32. INDEMNIFICATION
32.1 Indemnification by Contractor
The Contractor shall indemnify, defend, and hold harmless the
LDSS, its officers, agents, and employees and the Enrollees and
their eligible dependents from:
a) any and all claims and losses accruing or resulting to
any and all Contractors, subcontractors, materialmen,
laborers, and any other person, firm, or corporation
furnishing or supplying work, services, materials, or
supplies in connection with the performance of this
Agreement;
b) any and all claims and losses accruing or resulting to
any person, firm, or corporation that may be injured or
damaged by the Contractor, its officers, agents,
employees, or subcontractors, including Participating
Providers, in connection with the performance of this
Agreement;
c) any liability, including costs and expenses, for
violation of proprietary rights, copyrights, or rights
of privacy, arising out of the publication, translation,
reproduction, delivery, performance, use, or disposition
of any data furnished under this Agreement, or based on
any libelous or otherwise unlawful matter contained in
such data.
i) The LDSS will provide the Contractor with prompt
written notice of any claim made against the
LDSS, and the Contractor, at its sole option,
shall defend or settle said claim. The LDSS
shall cooperate with the Contractor to the
extent necessary for the Contractor to discharge
its obligation under Section 32.1.
Section 23 --Section 39
October 1, 1999
-6
ii) The Contractor shall have no obligation under
this section with respect to any claim or cause
of action for damages to persons or property
solely caused by the negligence of LDSS, its
employees, or agents.
32.2 Indemnification by LDSS
The LDSS shall indemnify and hold h armless the Contractor and
its officers, agents, and employees from any and all claims for
damages resulting from actions by the LDSS or their Contractors
in connection with their performance under this Agreement,
except for such damages, costs, and expenses resulting from the
negligence or culpable act of the Contractor, its officers,
agents, employees, or subcontractors, including Participating
Providers.
33. PROHIBITION ON USE OF FEDERAL FUNDS FOR LOBBYING
33.1 Prohibition of Use of Federal Funds for Lobbying
The Contractor agrees, pursuant to 31 U. S. C. Section 1352 and
45 CF R Part 93, that no Federally appropriated funds have been
paid or will be paid to any person by or on behalf of the
Contractor for the purpose of influencing or attempting to
influence an officer o r employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of
a Member of Congress in connection with the award of any Federal
contract, the making of any federal grant, the making of any
Federal loan, the entering into of any cooperative agreement, or
the extension, continuation, renewal, amendment, or modification
of any Federal contract, grant, loan, or cooperative agreement.
The Contractor agrees to complete and submit the " Certification
Regarding Lobbying", Appendix B attached hereto and incorporated
herein, if this Agreement exceeds $100,000.
33.2 Disclosure Form to Report Lobbying
If any funds other than Federally appropriated funds have been
paid or will be paid to any person for the purpose of
influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a M ember of Congress in connection
with the award of any Federal contract, the making of any
Federal grant, the making of any Federal loan, the entering into
of any cooperative agreement, or the extension, continuation,
renewal, amendment, or modification of any Federal contract,
grant, loan, or cooperative agreement, and the Agreement exceeds
$100,000, the Contractor shall complete and submit Standard Form
LLL. "Disclosure Form to Report Lobbying," in accordance with
its instructions.
33.3 The Contractor shall include the provisions of this section in
its subcontracts, including its Provider Agreements. For all
subcontracts, including Provider
Section 23 --Section 39
October 1, 1999
-7
Agreements, that exceed $100,000, the Contractor shall require
the subcontractor, including any Participating Provider to
certify and disclose accordingly to the Contractor.
34. NON-DISCRIMINATION
34.1 Equal Access to Benefit Package
Except as otherwise provided in applicable sections of this
Agreement the Contractor shall provide the Benefit Package to
all Enrollees in the same manner, in accordance with the same
standards, and with the same priority as Enrollees of the
Contractor under any other contracts.
34.2 Non-Discrimination
The Contractor shall not discriminate against Eligible Persons
or Enrollees on the basis of age, sex , race, creed, physical or
mental handicap/developmental disability, national origin,
sexual orientation or type of illness or condition.
34.3 Equal Employment Opportunity
Contractor must comply with Executive Order 11246, entitled
"Equal Employment Opportunity," as amended by Executive Order
11375, and as supplemented in Department of Labor regulations.
34.4 Native Americans Access to Services From Tribal or Urban Indian
Health Facility
The Contractor shall not prohibit, restrict or discourage
enrolled Native Americans from receiving care from or accessing
Medicaid reimbursed health services from or through a tribal
health or Urban Indian health facility or center.
35. COMPLIANCE WITH APPLICABLE LAWS
35.1 Contractor and LDSS Compliance With Applicable Laws
The Contractor and L DDSs shall comply with all applicable
requirements of the State Public Health Law; the State Social
Services Law; Title IX of the Social Security Act; Title V I of
the Civil Rights Act of 1964 and 45 C. F .R. Part 80, as
amended; Section 504 of the Rehabilitation Act of 1973 and 45 C.
F. R. Part 84, as amended; Age Discrimination Act of 1975 and 45
C. F. R. Part 91, as amended; and the Americans with
Disabilities Act; and Title X III of the Federal Public Health
Services Act, 42 U.S.C. Section 300e et seq., regulations
promulgated thereunder; and all other applicable legal and
regulatory requirements in effect at the time that this
Agreement is signed and as adopted or amended during the term of
this Agreement. The parties agree that this Agreement shall be
interpreted according to the laws of the State of New York.
Section 23 --Section 39
October 1, 1999
-8
35.2 Nullification of Illegal, Unenforceable, Ineffective or Void
Contract Provisions
Should any provision of this Agreement be declared or found to
be illegal or unenforceable, ineffective or void, then each
party shall be relieved of any obligation arising from such
provision; the balance of this Agreement, if capable of
performance, shall remain in full force and effect.
35.3 Certificate of Authority Requirements
The Contractor must satisfy conditions for issuance of a
certificate of authority, including proof of financial solvency,
as specified in 10 NYCRR, '98.6.
35.4 Notification of Changes in Certificate to Incorporation
The Contractor shall notify LDSS of any amendment t o its
Certificate of Incorporation in the same manner as and
simultaneously with the notice given to SDOH pursuant to 10
NYCRR Section 98.4(a).
35.5 Contractor's Financial Solvency Requirements
The Contractor, for the duration of this Agreement, shall remain
in compliance with all applicable state requirements for
financial solvency for MCOs participating in the Medicaid
Program. The Contractor shall continue to be financially
responsible as defined in PHL '4403(1)(c) and shall comply with
the contingent reserve fund and escrow deposit requirements of
10 NYCRR " 98.11(d) and 98.11(e), respectively, and must meet
minimum net worth requirements established by SDOH and the State
Insurance Department. The Contractor shall make provision,
satisfactory to SDOH, for protections for SDOH, LDSS and the
Enrollees in the event of HMO or sub contractor insolvency,
including but not limited to, hold harmless and continuation of
treatment provisions in all provider agreements which protect
SDOH, LDSS and Enrollees from costs of treatment and assures
continued access to care for Enrollees.
35.6 Compliance With Care for Maternity Patients
Contractor must comply with '2803-n of the Public Health Law and
'3216 (i) (10)(a) of the State Insurance Law related to hospital
care for maternity patients.
35.7 Informed Consent Procedures for Hysterectomy and Sterilization
The Contractor is required and shall require Participating
Providers to comply with the informed consent procedures for
Hysterectomy and Sterilization specified in 42 CFR, Part 441,
sub-part F, and 18 NYCRR Section 505.13.
Section 23 --Section 39
October 1, 1999
-9
35.8 Non-Liability of Enrollees for Contractor's Debts
Contractor agrees that in no event shall the Enrollee become
liable for the Contractor's debts as set forth in SSA
'1932(b)(6).
35.9 LDSS Compliance With Conflict of Interest Laws
LDSS and its employees shall comply with General Municipal Law
Article 18 and all other appropriate provisions of New York
State law, local laws and ordinances and all resultant codes,
rules and regulations pertaining to conflicts of interest.
35.10 Compliance With PHL Regarding External Appeals
Contractor must comply with Article 49 Title II of the Public
Health Law regarding external appeal of adverse determinations.
36. NEW YORK STATE STANDARD CONTRACT CLAUSES
The parties agree to be bound by the standard clauses for all New York
State contracts and standard clauses, if any, for local government
contracts contained in Appendix A, attached to and incorporated as if
set forth fully herein, and any amendment thereto.
37. INSURANCE REQUIREMENTS
MODEL CON TRACT NOTE: The LDSS may propose insurance requirements based
on the contract practices of its Count y. Such requirements must be
reasonable and consistent with the attainment of managed care program
objectives.
[ ] The LDSS has insurance requirements (attached) as Section 37 of
this Agreement.
[ ] The LDSS does not have insurance requirements.
Section 23 --Section 39
October 1, 1999
-10
[MODEL CON TRACT NOTE: Format of signature pages is established by the
LDSS. However, the "Term of Agreement" should be specified on the
signature pages.]
In Witness Whereof, the parties have duly executed this Agreement on the
date set opposite their respective signatures.
By: /s/ By: /s/
------------------------------ ---------------------------------
AmeriChoice of New York, Inc. City of New York
Signature Page
September 10, 1999
Second Contract Amendment
Between
City of New York
And
AmeriChoice of New York, Inc.
This Amendment, effective April 1, 2002, amends the Medicaid
Managed Care Model Contract (hereinafter referred to as the
"Agreement") made by and between the City of New York
(hereinafter referred to as "CDOH") and AmeriChoice of New York,
Inc. (hereinafter referred to as "MCO" or "Contractor").
WHEREAS, the parties entered into an Agreement effective October
1, 1999, amended October 1, 2001, for the purpose of providing
prepaid case managed health services to Medical Assistance
recipients residing in the City of New York;
WHEREAS, the parties desire to amend said Agreement to modify
certain provisions to reflect current circumstances and
intentions;
NOW THEREFORE, effective April 1, 2002, it is mutually agreed by
the parties to amend this Agreement as follows:
The attached "Table of Contents for Model Contract" is
substituted for the period beginning April 1, 2002.
Delete from Section 1, Definitions, the definition for "Alcohol
and Substance Abuse Services."
Amend Section 1, Definitions, the definition for "Behavioral
Health Service," to read as follows:
"BEHAVIORAL HEALTH SERVICE" means services to address mental
health disorders and/or chemical dependence.
Add to Section 1, Definitions, a definition for "Chemical
Dependence Services," to read as follows:
"CHEMICAL DEPENDENCE SERVICES" means examination, diagnosis,
level of care determination, treatment, rehabilitation, or
habilitation of persons suffering from chemical abuse or
dependence, and includes the provision of alcohol and/or
substance abuse services.
Add to Section 1, Definitions, a new definition for
"Detoxification Services," to read as follows:
"DETOXIFICATION SERVICES" means Medically Managed Detoxification
Services; and Medically Supervised Inpatient and Outpatient
Withdrawal Services as defined in Appendix K.
Rename Section 3.11, "Mental Health and Chemical Dependence Stop
Loss," and delete
Section 3.11 b).
Renumber Section 3.11 c), "Mental Health and Chemical
Dependence," as 3.11 b), and amend to read as follows:
b) The Contractor will be compensated for medically
necessary and clinically appropriate inpatient mental
health services and/or Chemical Dependence Inpatient
Rehabilitation and Treatment Services as defined in
Appendix K in excess of a combined total of thirty (30)
days during a calendar year at the lower of the
Contractor's negotiated inpatient rate or Medicaid rate
of payment.
Add a new Section 3.11 c), "Mental Health and Chemical
Dependence," to read as follows:
c) Detoxification Services in Article 28 inpatient hospital
facilities are subject to the stop-loss provisions
specified in Section 3.10 of this Agreement.
Amend Section 5.1 a) v), "Eligible Populations," to read as
follows:
v) Children age one (1) year or below whose family's net
available income is at or below two hundred percent
(200%) of the federal poverty level for the applicable
household size.
Amend Section 5.1 a) vii), "Eligible Populations," to read as
follows:
vii) Children age six (6) up to age nineteen (19), whose
family's net available income is at or below one hundred
and thirty-three percent (133%) of the federal poverty
level for the applicable household size.
Amend Section 5.2 k) "Exempt Populations," to read as follows:
k) Individuals who are residents of Alcohol and Substance
Abuse or Chemical Dependence Long Term Residential
Treatment Programs.
Add Section 5.2 r), "Exempt Populations," to read as follows:
r) Effective April 1, 2003, individuals who are eligible
for Medical Assistance pursuant to the "Medicaid buy-in
for the working disabled" (subparagraphs twelve or
thirteen of paragraph (a) of subdivision one of Section
366 of the Social Services Law), and who, pursuant to
subdivision 12 of Section 367-a of the Social Services
Law, are not required to pay a premium.
Add Sections 5.3 w) and 5.3x), "Excluded Populations," to read
as follows:
w) Effective April 1, 2003, individuals who are eligible
for Medical Assistance pursuant to the "Medicaid buy-in
for the working disabled" (subparagraphs twelve or
thirteen of paragraph (a) of subdivision one of Section
366 of the Social Services Law), and who, pursuant to
subdivision 12 of Section 367-a of the Social Services
Law, are required to pay a premium.
x) Effective October 1, 2002, individuals who are eligible
for Medical Assistance
April 1, 2002 Amendment
119
pursuant to paragraph (v) of
subdivision four of Section 366 of the Social Services
Law (persons who are under 65 years of age, have been
screened for breast and/or cervical cancer under the
Centers for Disease Control and Prevention Breast and
Cervical Cancer Early Detection Program and need
treatment for breast or cervical cancer, and are not
otherwise covered under creditable coverage as defined
in the Federal Public Health Service Act).
Amend Section 6.6, "Family Enrollment," to read as follows:
6.6 Family Enrollment
a) Upon implementation of the 1115 Waiver, all eligible
members of the Eligible Person's Family shall be
enrolled into the same plan.
b) Upon implementation of the 1115 Waiver, the LDSS must
inform Enrollees who have Family members enrolled in
other MCOs that if anyone in the Family wishes to change
plans, all members of the Family must enroll together in
the newly-selected plan. The LDSS shall also notify the
Enrollee that all members of the Family will be required
to enroll together in a single MCO at the time of their
next recertification for Medicaid eligibility unless
waiver of this requirement is approved by the LDSS.
c) Notwithstanding the forgoing,
i) the LDSS may, on a case-by-case basis, waive the same family
rule specified in Sections 6.6 (a) and (b) to preserve
continuity of care:
1) if one or more members of the Family are receiving prenatal
care and/or continuing care for a complex chronic medical
condition from Non-Participating Providers; or
2) if one or more members of the Family transition from one
government-sponsored insurance program to another.
ii) the LDSS must allow HIV SNP-eligible individuals within a
family to enroll in an HIV SNP, in Service Areas in which an HIV
SNP exists.
Amend Section 7.2, Lock-In Provisions in Mandatory Counties," to
read as follows:
7.2 Lock-In Provisions in Mandatory Counties and New York
City
All Enrollees in local social service districts where
enrollment in managed care is mandatory and in New York
City are subject to a twelve (12) month Lock-In period
following the Effective Date of Enrollment in the
Contractor's plan, with an initial ninety (90) day grace
period in which to disenroll from the Contractor's plan
without cause, regardless of whether the Enrollee
selected or was auto- assigned to the Contractor's plan.
Delete Section 7.3, "Lock-In Provisions in New York City," and
renumber Sections 7.4, "Disenrollment During Lock-In Period" and
7.5 "Notification Regarding Lock-In and End of Lock-In Period,"
as Sections 7.3 and 7.4 respectively.
Amend Section 10.8 b), "Welfare Reform," to read as follows:
April 1, 2002 Amendment
120
b) The Contractor shall require that its Participating
Providers, upon Enrollee consent, provide medical documentation
and health, mental health and chemical dependence assessments as
follows:
i) Within ten (10) days of a request of an Enrollee or a
former Enrollee, currently receiving public assistance
or who is applying for public assistance, the Enrollee's
or former Enrollee's PCP or specialist provider, as
appropriate, shall provide medical documentation
concerning the Enrollee or former Enrollee's health or
mental health status to the LDSS or to the LDSS'
designee. Medical documentation includes but is not
limited to drug prescriptions and reports from the
Enrollee's PCP or specialist provider. The Contractor
shall include the foregoing as a responsibility of the
PCP and specialist provider in its provider contracts or
in their provider manuals.
ii) Within ten (10) days of a request of an Enrollee, who
has already undergone, or is scheduled to undergo, an
initial LDSS required mental and/or physical
examination, the Enrollee's PCP shall provide a health,
or mental health and/or chemical dependence assessment,
examination or other services as appropriate to identify
or quantify an Enrollee's level of incapacitation. Such
assessment must contain a specific diagnosis resulting
from any medically appropriate tests and specify any
work limitations. The LDSS, may, upon written notice to
the Contractor, specify the format and instructions for
such an assessment
Amend Section 10.8 c),"Welfare Reform," and add Sections 10.8 d)
through 10.8 g), to read as follows:
c) The Contractor will continue to be responsible for the
provision and payment of Chemical Dependence Services in
the Benefit Package for Enrollees mandated by the LDSS
under Welfare Reform if such services are already
underway and the LDSS is satisfied with the level of
care and services.
d) The Contractor is not responsible for the provision and
payment of Chemical Dependence Inpatient Rehabilitation
and Treatment Services for Enrollees mandated by the
LDSS as a condition of eligibility for Public Assistance
or Medicaid under Welfare Reform (as indicated by Code
83) unless such services are already under way as
described in (c) above.
e) The Contractor is not responsible for the provision and
payment of Medically Supervised Inpatient and Outpatient
Withdrawal Services for Enrollees mandated by the LDSS
under Welfare Reform (as indicated by Code 83) unless
such services are already under way as described in (c)
above.
f) The Contractor is responsible for the provision and
payment of Medically Managed Detoxification Services
ordered by the LDSS under Welfare Reform.
g) The Contractor is responsible for the provisions of
Sections 10.10, 10.16 (a) and 10.24 of this Agreement
for Enrollees requiring LDSS mandated Chemical
Dependence Services.
Amend Section 10.10 b), "Court-Ordered Services," to read as
follows:
April 1, 2002 Amendment
121
b) Court Ordered Services are those services ordered by the
court performed by, or under the supervision of a
physician, dentist, or other provider qualified under
State Law to furnish medical, dental, behavioral health
(including mental health and/or Chemical Dependence), or
other Medicaid covered services. The Contractor is
responsible for payment of those Medicaid services as
covered by the Benefit Package, even when the providers
are not in the Contractor's provider network.
Amend Section 10.16 a), "Services for Which Enrollees Can
Self-Refer," to read as follows:
a) Mental Health and Chemical Dependence Services
The Contractor will allow Enrollees or LDSS officials on
the Enrollee's behalf to make self-referral or referral
for one mental health assessment from a Participating
Provider and one chemical dependence assessment from a
Detoxification or Chemical Dependence Inpatient
Rehabilitation and Treatment Participating Provider in
any calendar year period without requiring pre-
authorization or referral from the Enrollee's Primary
Care Provider. In the case of children, such
self-referrals may originate at the request of a school
guidance counselor (with parental or guardian consent,
or pursuant to procedures set forth in Section 33.21 of
the Mental Hygiene Law), LDSS Official, Judicial
Official, Probation Officer, parent or similar source.
i) The Contractor shall make available to all
Enrollees a complete listing of their participating
mental health and Chemical Dependence Services
providers. The listing should specify which provider
groups or practitioners specialize in children's mental
health services.
ii) The Contractor will also ensure that its
Participating Providers have available and use formal
assessment instruments to identify Enrollees requiring
mental health and Chemical Dependence Services, and to
determine the types of services that should be
furnished.
iii) The Contractor will implement policies and
procedures to ensure that Enrollees receive follow-up
Benefit Package services from appropriate providers
based on the findings of their mental health and/or
Detoxification or Chemical Dependence Inpatient
Rehabilitation and Treatment assessment(s).
iv) The Contractor will implement policies and
procedures to ensure that Enrollees are referred to
appropriate Chemical Dependence outpatient
rehabilitation and treatment providers based on the
findings of the Chemical Dependence assessment by the
Contractor's Participating Provider.
Amend Section 10.22 d), "Persons Requiring Ongoing Mental Health
Services," to read as follows:
d) Satisfactory systems for coordinating service delivery
between physical health, chemical dependence, and mental
health providers, and coordinating services with other
available services, including Social Services.
April 1, 2002 Amendment
122
Amend Section 10.24, title, leader language, 10.24 e), and last
paragraph of 10.24, "Persons Requiring Alcohol/Substance Abuse
Services," to read as follows:
10.24 Persons Requiring Chemical Dependence Services
The Contractor will have in place all of the following
for its Enrollees requiring Chemical Dependence
Services:
e) Satisfactory systems for coordinating service delivery
between physical health, chemical dependence, and mental
health providers, and coordinating in-plan services with
other services, including Social Services.
The Contractor agrees to also participate in the local
planning process for serving persons with chemical
dependence, to the extent requested by the LDSS. At the
LDSS's discretion, the Contractor will develop linkages
with local governmental units on coordination procedures
and standards related to Chemical Dependence Services
and related activities.
Amend Section 10.27 i), "Coordination of Services," to read as
follows:
i) local governmental units responsible for public health,
mental health, mental retardation or Chemical Dependence
Services; and
Amend Section 18.5(m), "No Contact Report" to read as follows:
18.5(m) No Contact Report:
The Contractor shall submit a quarterly report within
thirty (30) days of the close of the reporting period to
the CDOH of any Enrollee it is unable to contact,
through reasonable means, including by mail, and by
telephone, using methods and performing the activities
described in Section 13.5, within thirty days of their
effective date of enrollment.
Amend Section 21.17, "Mental Health, Alcohol and Substance Abuse
Providers," to read as follows:
21.17 Mental Health and Chemical Dependence Services Providers
The Contractor will include a full array of mental health and
Chemical Dependence Services providers in its networks, in
sufficient numbers to assure accessibility to Benefit Package
services on the part of both children and adults, using either
individual, appropriately licensed practitioners or New York
State Office of Mental Health (OMH) and Office of Alcohol and
Substance Abuse Services (OASAS) licensed programs and clinics,
or both.
The State defines mental health and Chemical Dependence Services
providers to include the following: Individual Practitioners,
Psychiatrists, Psychologists, Psychiatric Nurse Practitioners,
Psychiatric Clinical Nurse Specialists, Licensed Certified
Social Workers, OMH and OASAS Programs and Clinics, and
providers of mental health and/or Chemical Dependence Services
certified or licensed pursuant to Article 31 or 32 of the
April 1, 2002 Amendment
123
Mental Hygiene Law, as appropriate.
Amend Section 21.19, "School-Based Health Centers," to read as
follows:
21.19 School-Based Health Centers
a) The Contractor must develop, in collaboration with
school-based health centers in their Service Areas,
protocols for reciprocal referral and communication of
data and clinical information on MCO Enrollees enrolled
in school-based health centers.
b) By March 31, 2003, the Contractor must enter into
contractual and payment arrangements with school-based
health centers in their Service Area, consistent with
the protocols referred to in (a) above.
The attached Appendix K, "Prepaid Benefit Package Definitions of
Covered and Non-Covered Services," is substituted for the period
beginning April 1, 2002.
This Amendment is effective April 1, 2002, and the
Agreement, including the modifications made by this
Amendment, shall remain in effect until September 30,
2003 or until the execution of an extension, renewal or
successor agreement as provided for in the Agreement.
April 1, 2002 Amendment
124
In Witness Whereof, the parties have duly executed this
Amendment to the Agreement on the dates appearing below their
respective signatures below.
By /s/ By /s/
-------------------------- --------------------------
AmeriChoice of New York, Inc. City of New York
Date
--------------------------
Date
--------------------------
April 1, 2002 Amendment
▇▇▇
▇▇▇▇▇ ▇▇ ▇▇▇ ▇▇▇▇)
SS:
COUNTY OF _________
On this _____ day of ____, 200__, _________________ came
before me, to me known and known to be the
______________________________ of ________________________, who
is duly authorized to execute the foregoing instrument on behalf
of said corporation and s/he acknowledged to me that s/he
executed the same for the purpose therein mentioned.
/s/
--------------------------
NOTARY PUBLIC
STATE OF NEW YORK)
SS:
COUNTY OF NEW YORK
On this ______ day of ______, 20____, _________ came
before me, to me known and known to be the
___________________________ in the New York City Department of
Health, who is duly authorized to execute the foregoing
instrument on behalf of the City and/he acknowledged to me that
s/he executed the same for the purpose therein mentioned.
/s/
--------------------------
NOTARY PUBLIC
April 1, 2002 Amendment
126