HIV SPECIAL NEEDS PLAN/ HEALTH AND RECOVERY PLAN MODEL CONTRACTSpecial Needs Plan • April 4th, 2022
STATE AGENCY (Name and Address): New York State Department of Health Office of Health Insurance Programs Division of Health Plan Contracting and OversightOne Commerce Plaza Room 1609Albany, NY 12260 NYS Comptroller’s Number: Originating Agency GLBU: DOH01 Department ID: 3450000 (Use Unit ID) CONTRACTOR (Name and Address): TYPE OF PROGRAM(S): Medicaid Managed Care and/orFamily Health Plus and/or HIV Special Needs Plan CHARITIES REGISTRATION NUMBER: Contractor has ( ) has not ( ) timely filed with the Attorney General’s Charities Bureau all required period or annual written reports. FEDERAL TAX IDENTIFICATION NUMBER: NYS VENDOR IDENTIFICATION NUMBER:MUNICIPALITY NUMBER (if applicable): CONTRACT TERM: FROM: March 1, 2019TO: February 29, 2024 FUNDING AMOUNT FOR CONTRACT TERM: 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 ( ) IF MARKED HERE, THIS CONTRACT IS RENEWAB
