Medicaid Managed Care/Family Health Plus/ HIV Special ...

1 Medicaid Managed care / FAMILY Health PLUS/ HIV Special NEEDS PLAN/ Health AND RECOVERY PLAN MODEL CONTRACT March 1, 2019 _____ _____ _____ _____ _____ _____ _____ _____ MISCELLANEOUS/CONSULTANT SERVICES (Award Without Formal Request For Proposal) STATE AGENCY (Name and Address): New York State Department of Health Office of Health Insurance Programs Division of Health Plan Contracting and Oversight One Commerce Plaza Room 1609 Albany, NY 12260 CONTRACTOR (Name and Address): CHARITIES REGISTRATION NUMBER: Contractor has ( ) has not ( ) timely filed with the Attorney General s Charities Bureau all required period or annual written reports.

2 FEDERAL TAX IDENTIFICATION NUMBER: NYS VENDOR IDENTIFICATION NUMBER: MUNICIPALITY NUMBER (if applicable): STATUS: CONTRACTOR IS [ ] IS NOT [ ] A SECTARIAN ENTITY CONTRACTOR IS [ ] IS NOT [ ] A NOT-FOR-PROFIT ORGANIZATION CONTRACTOR IS [ ] IS NOT [ ] A NY STATE BUSINESS ENTERPRISE NYS Comptroller s Number: Originating Agency GLBU: DOH01 Department ID: 3450000 (Use Unit ID) TYPE OF PROGRAM(S): Medicaid Managed care and/or Family Health Plus and/or HIV Special Needs Plan CONTRACT TERM: FROM: March 1, 2019 TO: February 29, 2024 FUNDING AMOUNT FOR CONTRACT TERM: ( ) IF MARKED HERE, THIS CONTRACT IS RENEWABLE FOR ____ ADDITIONAL ONE-YEAR PERIOD(S) AT THE SOLE OPTION OF THE STATE AND SUBJECT TO THE APPROVAL OF THE NEW YORK STATE DEPARTMENT OF Health , THE UNITED STATES DEPARTMENT OF Health AND HUMAN SERVICES AND THE OFFICE OF THE STATE COMPTROLLER.

3 APPENDICES TO THIS AGREEMENT AND INCORPORATED BY REFERENCE INTO THE AGREEMENT -X- appendix A. Standard Clauses for New York State Contracts -X- appendix B. Certification Regarding Lobbying -X- appendix B-1. Certification Regarding MacBride Fair Employment Principles -X- appendix C. New York State Department of Health Requirements for the Provision of Family Planning and Reproductive Health Services -X- appendix D.

4 New York State Department of Health MCO Outreach/Advertising Activities -X- appendix E. New York State Department of Health Member Handbook Guidelines -X- appendix F. New York State Department of Health Action and Grievance and Appeal System Requirements for the MMC and FHPlus Programs -X- appendix G. New York State Department of Health Requirements for the Provision of Emergency care and Services -X- appendix H. New York State Department of Health Requirements for the Processing of Enrollments and Disenrollments in the MMC and FHPlus Programs -X- appendix I. New York State Department of Health Guidelines for Use of Medical Residents and Fellows -X- appendix J.

5 New York State Department of Health Guidelines for Contractor Compliance with the Federal Americans with Disabilities Act -X- appendix K. Prepaid Benefit Package Definitions of Covered and Non-Covered Services -X- appendix L. Approved Capitation Payment Rates -X- appendix M. Service Area and Benefit Package Options -X- appendix N. RESERVED -X- appendix O. Requirements for Proof of Workers Compensation and Disability Benefits Coverage -X- appendix P. Facilitated Enrollment and Federal Health Insurance Portability and Accountability Act ( HIPAA ) Business Associate Agreements -X- appendix Q.

6 New York State Department of Health Recipient Restriction Program Requirements for MMC and FHPlus Programs -X- appendix R. Additional Specifications for the MMC and FHPlus Agreement -X- appendix S. New York State Department of Health Requirements for Long Term Services and Supports for MMC and FHPlus Programs -X- appendix T. Additional Requirements for the HARP and HIV SNP Programs -X- appendix U. Intellectual/Developmental Disabilities (I/DD) Specialized I/DD Plan (SIP) -X- appendix X. Modification Agreement Form _____ _____ _____ IN WITNESS WHEREOF, the parties hereto have executed or approved this AGREEMENT as of the dates appearing under their signatures.

7 CONTRACTOR SIGNATURE By: _____ _____ Printed Name Title: _____ Date: _____ STATE OF NEW YORK ) ) SS.: County of ) STATE AGENCY SIGNATURE By: _____ _____ Printed Name Title: _____ Date: _____ State Agency Certification: In addition to the acceptance of this contract, I also certify that original copies of this signature page will be attached to all other exact copies of this contract. On the _____ day of _____in the year_____, before me, the undersigned, personally appeared _____, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose names(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their/ capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

8 (Notary) ATTORNEY GENERAL Title: _____ Date: _____ Thomas P. DiNapoli STATE COMPTROLLER Title: _____ Date: _____ Table of Contents for Model Contract Recitals Section 1 Definitions Section 2 Agreement Term, Amendments, Extensions, and General Contract Administration Provisions Term Amendments Approvals Entire Agreement Renegotiation Assignment and Subcontracting Termination a. SDOH Initiated Termination b. Contractor and SDOH Initiated Termination c.

9 Contractor Initiated Termination d. Termination Due to Loss of Funding Close-Out Procedures Rights and Remedies Notices Severability Section 3 Compensation Capitation Payments Modification of Rates During Contract Period Rate Setting Methodology Payment of Capitation Denial of Capitation Payments SDOH Right to Recover Premiums Third Party Health Insurance Determination Other Insurance and Settlements Payment for Newborns Supplemental Maternity Capitation Payment Contractor Financial Liability Inpatient Hospital Stop-Loss Insurance for Medicaid Managed care (MMC)

10 Enrollees Mental Health Stop-Loss for MMC Enrollees Residential Health care Facility (Nursing Home) Stop-Loss for MMC Enrollees Stop-Loss Documentation and Procedures for the MMC Program Family Health Plus (FHPlus) Reinsurance Tracking Visits Provided by Indian Health Clinics Applies to MMC Program Only Payment for Patient Centered Medical Homes and Adirondack Health care Home Multipayor Demonstration Program Prohibition on Payments to Institutions or Entities Located Outside of the United States TABLE OF CONTENTS March 1, 2019 1 Table of Contents for Model Contract Primary care Rate Increase Payment for Long Term Placement in Residential Health care Facilities (Nursing Homes)