Agency Code 12000 Contract No. C-014386
Exhibit
10.74
APPENDIX
X
| Agency Code 12000 | Contract No. C-014386 |
| Period 10/1/1997 - 6/30/2007 | Funding Amount for Period $107,510,771 |
This
is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through the
Department
of Health. having
its principal office at Corning
Tower. Empire State Plaza. Albany, NY,
(hereinafter referred to as the STATE), and Wellcare of New York, Inc.
hereinafter referred to as the CONTRACTOR), for modification of -Contract
Number
C-014386 as reflected in the attached revisions to Section I.B.I, of the
Agreement and Appendices A, A-2, E and L, and to extend the period of the
contract through June 30, 2007.
All
other
provisions of said AGREEMENT shall remain in full force and effect.
IN
WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
dates
appearing under their signatures.
|
CONTRACTOR
SIGNATURE
|
STATE
AGENCY SIGNATURE
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By:/s/
▇▇▇▇ ▇. ▇▇▇▇▇
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By:
/s/
▇▇▇▇▇▇ ▇▇▇▇▇▇
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|
▇▇▇▇
▇▇▇▇▇
Printed
Name
|
▇▇▇▇▇▇
▇▇▇▇▇▇
Printed
Name
|
|
Title:
President and CEO
|
Title:
Deputy Commissioner
Division
of Planning, Policy & resource Development
|
|
Date:
11/17/2006
|
Date:
11/22/06
|
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|
|
|
|
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."
|
STATE
OF
FLORIDA) SS.:
COUNTY
OF
HILLSBOROUGH)
On
the
17th
day of
November 2006, before me personally appeared ▇▇▇▇ ▇. ▇▇▇▇▇ to me known, who
being by me duly sworn, did depose and say that he/she resides at Tampa,
Florida, that he is the President and CEO of the WellCare of New York., the
corporation described herein which executed the foregoing instrument; and
that
he/she signed his/her name thereto by order of the board of directors of
said
corporation.
(Notary)
/s/ ▇▇▇▇▇▇▇ ▇▇▇▇
STATE
OF NEW YORK AGREEMENT
Section
I.B. 1. is revised to read as follows:
I.
Conditions of Agreement
B.I.
This
AGREEMENT is extended through June 30,2007.
STANDARD
CLAUSES FOR NYS CONTRACTS
APPENDIX
A
STANDARD
CLAUSES FOR NYS CONTRACTS
The
parties to the attached contract, license, lease, amendment or other agreement
of any kind (hereinafter, "the contract" or "this contract") agree to be
bound
by the following clauses which are hereby made a part of the contract (the
word
"Contractor" herein refers to any party other than the State, whether a
contractor, licenser, licensee, lessor, lessee or any other party):
1.
EXECUTORY
CLAUSE.
In
accordance with Section 41 of the State
Finance Law, the State shall have no liability under this contract to the
Contractor or to anyone else beyond funds appropriated and available for
this
contract.
2.
NON-ASSIGNMENT
CLAUSE.
In
accordance with Section 138 of the State Finance Law, this contract may not
be
assigned by the Contractor or its right, title or interest therein assigned,
transferred, conveyed, sublet or otherwise disposed of without the previous
consent, in writing, of the State and any attempts to assign the contract
without the State's written consent are null and void. The Contractor may,
however, assign its right to receive payment without the State's prior written
consent unless this contract concerns Certificates of Participation pursuant
to
Article 5-A of the State Finance Law.
3.
COMPTROLLER'S
APPROVAL.
In
accordance with Section 112 of the State Finance Law (or, if this contract
is
with the State University or City University of New York, Section 355 or
Section
6218 of the Education Law), if this contract exceeds $50,000 (or the minimum
thresholds agreed to by the Office of the State Comptroller for certain S.U.N.Y.
and C.U.N.Y. contracts), or if this is an amendment for any amount to a contract
which, as so amended, exceeds said statutory amount, or if, by this contract,
the State agrees to give something other than money when the value or reasonably
estimated value of such consideration exceeds $10,000, it shall not be valid,
effective or binding upon the State until it has been approved by the State
Comptroller and filed in his office. Comptroller's approval of contracts
let by
the Office of General Services is required when such contracts exceed $85,000
(State Finance Law Section 163.6.a).
4.
WORKERS'
COMPENSATION BENEFITS.
In
accordance with Section 142 of the State Finance Law, this contract shall
be
void and of no force and effect unless the Contractor shall provide and maintain
coverage during the life of this contract for the benefit of such employees
as
are required to be covered by the provisions of the Workers' Compensation
Law.
5.
NON-DISCRIMINATION
REQUIREMENTS.
To the
extent required by Article 15 of the Executive Law (also known as the Human
Rights Law) and all other State and Federal statutory and constitutional
non-discrimination provisions, the Contractor will not discriminate against
any
employee or applicant for employment because of race, creed, color, sex,
national origin, sexual orientation, age, disability, genetic predisposition
or
carrier status, or marital status. Furthermore, in accordance with Section
220-e
of the Labor Law, if this is a contract for the construction, alteration
or
repair of any public building or public work or for the manufacture, sale
or
distribution of materials, equipment or supplies, and to the extent that
this
contract shall be performed within the State of New York, Contractor agrees
that
neither it nor its subcontractors shall, by reason of race, creed, color,
disability, sex, or national origin: (a) discriminate in hiring against any
New
York State citizen who is qualified and available to perform the work; or
(b)
discriminate against or intimidate any employee hired for the performance
of work under this contract. If this is a building service contract as defined
in Section 230 of the Labor Law, then, in accordance with Section 239 thereof,
Contractor agrees that neither it nor its subcontractors shall by reason
of
race, creed, color, national origin, age, sex or disability: (a) discriminate
in
hiring against any New York State citizen who is qualified and available
to
perform the work; or (b) discriminate against or intimidate any employee
hired
for the performance
of work under this contract. Contractor is subject to fines of $50,00 per
person
per day for any violation of Section 220-e or Section 239 as well as possible
termination of this contract and forfeiture of all moneys due hereunder for
a
second or subsequent violation.
6.
WAGE
AMP HOURS PROVISIONS.
If this
is a public work contract
covered by Article 8 of the Labor Law or a building service contract covered
by
Article 9 thereof, neither Contractor's employees nor the employees of its
subcontractors may be required or permitted to work more than the number
of
hours or days stated in said statutes, except as otherwise provided in the
Labor
Law and as set forth in prevailing wage and supplement schedules issued by
the
State Labor Department. Furthermore, Contractor and its subcontractors must
pay
at least the prevailing wage rate and pay or provide the prevailing supplements,
including the premium rates for overtime pay, as determined by the State
Labor
Department in accordance with the Labor Law.
7.
NON-COLLUSIVE BIDDING CERTIFICATION.
In
accordance with
Section 139-d of the State Finance Law, if this contract was awarded based
upon
the submission of bids. Contractor affirms, under penalty of perjury, that
its
bid was arrived at independently and without collusion aimed at restricting
competition. Contractor further affirms that, at the time Contractor submitted
its bid, an authorized and responsible person executed and delivered to the
State a non-collusive bidding certification on Contractor's behalf.
8.
INTERNATIONAL
BOYCOTT PROHIBITION.
In
accordance with
Section 220-f of the Labor Law and Section 139-h of the State Finance Law,
if
this contract exceeds $5,000, the Contractor agrees, as a material condition
of
the contract, that neither the Contractor nor any substantially owned or
affiliated person, firm, partnership or corporation has participated, is
participating, or shall participate in an international boycott in violation
of
the federal Export Administration Act of 1979 (50 USC App. Sections 2401
et
seq.) or regulations thereunder. If such Contractor, or any of the aforesaid
affiliates of Contractor, is convicted or is otherwise found to have violated
said laws or regulations upon the final determination of the United States
Commerce Department or any other appropriate agency of the United States
subsequent to the contract's execution, such contract, amendment or modification
thereto shall be rendered forfeit and void. The Contractor shall so notify
the
State Comptroller within five (5) business days of such conviction,
determination or disposition of appeal (2NYCRR 105.4).
9.
SET-OFF
RIGHTS.
The
State shall have all of its common law, equitable and statutory rights of
set-off. These rights shall include, but not be limited to, the State's option
to withhold for the purposes of set-off any moneys due to the Contractor
under
this contract up to any amounts due and owing to the State with regard to
this
contract, any other contract with any State department or agency, including
any
contract for a term commencing prior to the term of this contract, plus any
amounts due and owing to the State for any other reason including, without
limitation, tax delinquencies, fee delinquencies or monetary penalties relative
thereto. The State shall exercise its set-off rights in accordance with normal
State practices including, in cases of set-off pursuant to an audit, the
finalization of such audit by the State agency, its representatives, or the
State Comptroller.
10.
RECORDS.
The
Contractor shall establish and maintain complete and accurate books, records,
documents, accounts and other evidence directly pertinent to performance
under
this contract (hereinafter, collectively, "the Records"). The Records must
be
kept for the balance of the calendar year in which they were made and for
six
(6) additional years thereafter. The State Comptroller, the Attorney General
and
any other person or entity authorized to conduct an examination, as well
as the
agency or agencies involved in this contract, shall have access to the Records
during normal business hours at an office of the Contractor
Page
1
June,
2006
STANDARD
CLAUSES FOR NYS CONTRACTS
APPENDIX
A
within
the State of New York or, if no such office is available, at a mutually
agreeable and reasonable venue within the State, for the term specified above
for the purposes of inspection, auditing and copying. The State shall take
reasonable steps to protect from public disclosure any of the Records which
are
exempt from disclosure under Section 87 of the Public Officers Law (the
"Statute") provided that: (i) the Contractor shall timely inform an appropriate
State official, in writing, that said records should not be disclosed; and
(ii)
said records shall be sufficiently identified; and (iii) designation of said
records as exempt under the Statute is reasonable. Nothing contained herein
shall diminish, or in any way adversely affect, the State's right to discovery
in any pending or future litigation.
11.
IDENTIFYING
INFORMATION AND PRIVACY NOTIFICATION,
(a)
FEDERAL EMPLOYER IDENTIFICATION NUMBER and/or FEDERAL SOCIAL SECURITY NUMBER.
All invoices or New York State standard vouchers submitted for payment for
the
sale of goods or services or the lease of real or personal property to a
New
York State agency must include the payee's identification number, i.e., the
seller's or lessor's identification number. The number is either the payee's
Federal employer identification number or Federal social security number,
or
both such numbers when the payee has both such numbers. Failure to include
this
number or numbers may delay payment. Where the payee does not have such number
or numbers, the payee, on its invoice or New York State standard voucher,
must
give the reason or reasons why the payee does not have such number or
numbers.
(b)
PRIVACY
NOTIFICATION. (1) The authority to request the above personal information
from a
seller of goods or services or a lessor of real or personal property, and
the
authority to maintain such information, is found in Section 5 of the State
Tax
Law. Disclosure of this information by the seller or lessor to the State
is
mandatory. The principal purpose for which the information is collected is
to
enable the State to identify individuals, businesses and others who have
been
delinquent in filing tax returns or may have understated their tax liabilities
and to generally identify persons affected by the taxes administered by the
Commissioner of Taxation and Finance. The information will be used for tax
administration purposes and for any other purpose authorized by
law.
(2)
The
personal information is requested by the purchasing unit of the agency
contracting to purchase the goods or services or lease the real or personal
property covered by this contract or lease. The information is maintained
in New
York State's Central Accounting System by the Director of Accounting Operations,
Office of the State Comptroller, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇.
12.
EQUAL
EMPLOYMENT OPPORTUNITIES FOR MINORITIES AND WOMEN.
In
accordance with Section 312 of the Executive Law, if this contract is: (i)
a
written agreement or purchase order instrument, providing for a total
expenditure in excess of $25,000.00, whereby a contracting agency is committed
to expend or does expend funds in return for labor, services, supplies,
equipment, materials or any combination of the foregoing, to be performed
for,
or rendered or furnished to the contracting agency; or (ii) a written agreement
in excess of $100,000.00 whereby a contracting agency is committed to expend
or
does expend funds for the acquisition, construction, demolition, replacement,
major repair or renovation of real property and improvements thereon; or
(iii) a
written agreement in excess of $100,000.00 whereby the owner of a State assisted
housing project is committed to expend or does expend funds for the acquisition,
construction, demolition, replacement, major repair or renovation of real
property and improvements thereon for such project, then:
(a)
The
Contractor will not discriminate against employees or applicants
for employment because of race, creed, color, national origin, sex, age,
disability or marital status, and will undertake or continue existing programs
of affirmative action to ensure that minority group members and women are
afforded equal employment opportunities without discrimination. Affirmative
action shall mean recruitment, employment,
job assignment, promotion, upgradings, demotion, transfer, layoff, or
termination and rates of pay or other forms of compensation;
(b)
at
the request of the contracting agency, the Contractor shall request each
employment agency, labor union, or authorized representative of workers with
which it has a collective bargaining or other agreement or understanding,
to
furnish a written statement that such employment agency, labor union or
representative will not discriminate on the basis of race, creed, color,
national origin, sex, age, disability or marital status and that such union
or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein; and
(c)
the
Contractor shall state, in all solicitations or advertisements for employees,
that, in the performance of the State contract, all qualified applicants
will be
afforded equal employment opportunities without discrimination because of
race,
creed, color, national origin, sex, age, disability or marital
status.
Contractor
will include the provisions of "a", "b", and "c" above, in every subcontract
over $25,000.00 for the construction, demolition, replacement, major repair,
renovation, planning or design of real property and improvements thereon
(the
"Work") except where the Work is for the beneficial use of the Contractor.
Section 312 does not apply to: (i) work, goods or services unrelated to this
contract; or (ii) employment outside New York State; or (iii) banking services,
insurance policies or the sale of securities. The State shall consider
compliance by a contractor or subcontractor with the requirements of any
federal
law concerning equal employment opportunity which effectuates the purpose
of
this section. The contracting agency shall determine whether the imposition
of
the requirements of the provisions hereof duplicate or conflict with any
such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful
rules
and regulations of the Governor's Office of Minority and Women's Business
Development pertaining hereto.
13.
CONFLICTING
TERMS.
In the
event of a conflict between the terms of the contract (including any and
all
attachments thereto and amendments thereof) and the terms of this Appendix
A,
the terms of this Appendix A shall control.
14.
GOVERNING
LAW.
This
contract shall be governed by the laws of the State of New York except where
the
Federal supremacy clause requires otherwise.
15. LATE
PAYMENT.
Timeliness of payment and any interest to be paid to Contractor for late
payment
shall be governed by Article 11-A of the State Finance Law to the extent
required by law.
16.
NOARBITRATION.
Disputes
involving this contract, including the breach or alleged breach thereof,
may not
be submitted to binding arbitration (except where statutorily authorized),
but
must, instead, be heard in a court of competent jurisdiction of the State
of New
York.
17.SERVICE
OF
PROCESS.
In
addition to the methods of service allowed by the State Civil Practice Law
&
Rules ("CPLR"), Contractor hereby consents to service of process upon it
by
registered or certified mail, return receipt requested. Service hereunder
shall
be complete upon Contractor's actual receipt of process or upon the State's
receipt of the return thereof by the United States Postal Service as refused
or
undeliverable. Contractor must promptly notify the State, in writing, of
each
and every change of address to which service of process can be made. Service
by
the State to the last known address shall be sufficient. Contractor will
have
thirty (30) calendar days after service hereunder is complete in which to
respond.
Page
2
June,2006
STANDARD
CLAUSES FOR NYS CONTRACTS
18.
PROHIBITION
ON PURCHASE OF TROPICAL HARDWOODS.
The
Contractor certifies and warrants that all wood products to be used under
this
contract award will be in accordance with, but not limited to, the
specifications and provisions of State Finance Law §165. (Use of Tropical
Hardwoods) which prohibits purchase and use of tropical hardwoods, unless
specifically exempted, by the State or any governmental agency or political
subdivision or public benefit corporation. Qualification for an exemption
under
this law will be the responsibility of the contractor to establish to meet
with
the approval of the State.
In
addition, when any portion of this contract involving the use of ▇▇▇▇▇, whether
supply or installation, is to be performed by any subcontractor, the prime
Contractor will indicate and certify in the submitted bid proposal that the
subcontractor has been informed and is in compliance with specifications
and
provisions regarding use of tropical hardwoods as detailed in §165 State Finance
Law. Any such use must meet with the approval of the State; otherwise, the
bid
may not be considered responsive. Under bidder certifications, proof of
qualification for exemption will be the responsibility of the Contractor
to meet
with the approval of the State.
19.
MACBRTDE
FAIR EMPLOYMENT PRINCIPLES.
In
accordance
with the ▇▇▇▇▇▇▇▇ Fair Employment Principles (Chapter 807 of the Laws of
1992),
the Contractor hereby stipulates that the Contractor either (a) has no business
operations in Northern Ireland, or (b) shall take lawful steps in good faith
to
conduct any business operations in Northern Ireland in accordance with the
▇▇▇▇▇▇▇▇ Fair Employment Principles (as described in Section 165 of the New
York
State Finance Law), and shall permit independent monitoring of compliance
with
such principles.
20.
OMNIBUS
PROCUREMENT ACT OF 1992.
It is
the policy of New York State to maximize opportunities for the participation
of
New York State business enterprises, including minority and women-owned business
enterprises as bidders, subcontractors and suppliers on its procurement
contracts.
Information
on the availability of New York State subcontractors and suppliers is available
from:
NYS
Department of Economic Development
Division
for Small Business
▇▇
▇▇▇▇▇
▇▇▇▇▇ ▇▇ - ▇▇▇
▇▇▇▇▇
Albany,
New York 12245
Telephone:
▇▇▇-▇▇▇-▇▇▇▇
Fax:
▇▇▇-▇▇▇-▇▇▇▇
▇▇▇▇://▇▇▇▇.▇▇▇▇▇▇.▇▇▇▇▇.▇▇.▇▇
A
directory of certified minority and women-owned business enterprises is
available from:
NYS
Department of Economic Development
Division
of Minority and Women's Business Development
▇▇
▇▇▇▇▇
▇▇▇▇▇ ▇▇ - ▇▇▇ Floor
Albany,
New York 12245
Telephone:
▇▇▇-▇▇▇-▇▇▇▇
Fax:
▇▇▇-▇▇▇-▇▇▇▇
▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇▇▇.▇▇.▇▇
The
Omnibus Procurement Act of 1992 requires that by signing this bid proposal
or
contract, as applicable. Contractors certify that whenever the total bid
amount
is greater than $1 million:
(a)
The
Contractor has made reasonable efforts to encourage the participation of
New
York State Business Enterprises as suppliers and subcontractors, including
certified minority and women-owned business enterprises, on this project,
and
has retained the documentation of these efforts to be provided upon request
to
the State;
(b)
The
Contractor has complied with the Federal Equal Opportunity Act of 1972 (P.L.
92-261), as amended;
(c)
The
Contractor agrees to make reasonable efforts to provide notification to New
York
State residents of employment opportunities on this project through listing
any
such positions with the Job Service Division of the New York State Department
of
Labor, or providing such notification in such manner as is consistent with
existing collective bargaining contracts or agreements. The Contractor agrees
to
document these efforts and to provide said documentation to the State upon
request; and
(d)
The
Contractor acknowledges notice that the State may seek to obtain offset credits
from foreign countries as a result of this contract and agrees to cooperate
with
the State in these efforts.
21.
RECIPROCITY AND SANCTIONS PROVISIONS.
Bidders
are
hereby
notified that if their principal place of business is located in a country,
nation, province, state or political subdivision that penalizes New York
State
vendors, and if the goods or services they offer will be substantially produced
or performed outside New York State, the Omnibus Procurement Act 1994 and
2000
amendments (Chapter 684 and Chapter 383, respectively) require that they
be
denied contracts which they would otherwise obtain. NOTE: As of May 15, 2002,
the list of discriminatory jurisdictions subject to this provision includes
the
states of South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii.
Contact NYS Department of Economic Development for a current list of
jurisdictions subject to this provision.
22. PURCHASES
OF APPAREL.
In
accordance with State Finance Law
162
(4-a), the State shall not purchase any apparel from any vendor unable or
unwilling to certify that: (i) such apparel was manufactured in compliance
with
all applicable labor and occupational safety laws, including, but not limited
to, child labor laws, wage and hours laws and workplace safety laws, and
(ii)
vendor will supply, with its bid (or, if not a bid situation, prior to or
at the
time of signing a contract with the State), if known, the names and addresses
of
each subcontractor and a list of all manufacturing plants to be utilized
by the
bidder.
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June,
2006
APPENDIX
A-2
PROGRAM
SPECIFIC CLAUSES
Section
111.N.2 is revised to read as follows:
2.
Targeted Verification
The
CONTRACTOR shall verify the information taken by their marketers/facilitators
with the family or employer (if applicable), using a sample of applications,
which include the following three categories:
•
Applications with non-applying children or adults (if applicable) that impact
eligibility.
•
Applications with a self-declaration of income. ,..-. ,-., ,
•
Applications with a declaration of no income/letter of support.
CONTRACTORS
that do not take applications from applicants other than through the mail
shall
not be required to conduct verification phone calls provided such applications
do not contain a high volume of the above three categories as determined
by the
STATE. The STATE will conduct special audits of the applications taken by
these
plans through the mail to determine whether additional verification is
required.
The
CONTRACTOR shall conduct verification phone calls on a stratified sample
of
applications to confirm the information provided by the applicant prior to
its
being submitted to the LOSS, another health plan, or enrolled in CHPlus B.
The
CONTRACTOR may develop its own process for conducting the verification phone
calls. The sample may be drawn monthly or quarterly. For large plans (more
than
300 applications completed by facilitators per month) the sample shall be
at
least 10 percent of all applications in the period (month or quarter). Smaller
plans (less than 300 per month) will need to verify 30 applications in these
categories, collectively, per period. The CONTRACTOR is not required to track
applications by the three categories above. That is one option for drawing
the
sample. Another option is to take a random sample of all applications at
a
percent believed to be high enough that the sample captures applications
from
each of the three categories above. The CONTRACTOR'S methodology for completing
the verification phone calls shall be approved by the STATE prior to
implementation and must be based on a projected number of applications to
be
received within each category.
The
CONTRACTOR shall over sample in the categories to be verified to permit
replacement of those the plan is unable to reach. The CONTRACTOR may drop
and
replace applicants they are unable to verify due to an inability to reach
the
family after three attempts. There is no limit on the number that can be
replaced as long as the final sample meets the number agreed upon in the
CONTRACTOR'S plan approved by the STATE that shall be submitted pursuant
to this
agreement The CONTRACTOR is required to provide information to the STATE
on the
dropped cases including the number dropped in a period, the reasons for
replacement (e.g., unable to contact, refused to cooperate). The CONTRACTOR
shall make at least three attempts to contact the family at different times
of
the day (e.g., morning, afternoon, evening) prior to dropping the case. The
replacement case shall fall within the same category as the sample case.
For
example, if the dropped case includes non-applying people affecting eligibility,
the replacement case shall include non-applying people,
Applications
must be verified by the CONTRACTOR on a prospective basis, however, the
CONTRACTOR is prohibited from delaying enrollment in order to implement such
verification. The CONTRACTOR shall determine the sample and conduct the calls
on
an ongoing basis so as not to delay enrollment. The CONTRACTOR shall develop
a
methodology to conduct verification, based on the expected number of
applications in each category.
If
the
applicant concurs with all the information on the application, the CONTRACTOR
is
not required to take additional steps to verify the information. The CONTRACTOR
must still complete the checklist.
If
the
CONTRACTOR, through a verification phone call, finds that the application
includes inaccurate information or misrepresentation of the applicant's
circumstances, the CONTRACTOR must make best efforts todetermine if the
inaccuracy was due to actions of the marketer/facilitator. The CONTRACTOR
must
investigate if the marketer/facilitator acted with the intent to falsify
the
application. The CONTRACTOR must not enroll the applicant if the new information
renders them ineligible.
If
the
CONTRACTOR finds that the marketer/facilitator's action did result in false
information on the application, the CONTRACTOR shall remove the employee
as a
facilitator immediately and follow the CONTRACTOR'S process for employee
disciplinary action. In addition, the CONTRACTOR shall review one month of
prior
applications taken by that marketer/facilitator.
If
evidence of fraud is found on any one of those applications, the CONTRACTOR
shall review an additional two months of prior applications taken by the
marketer/facilitator.
If
the
intent is unclear or it is determined the marketer/facilitator made a mistake,
the CONTRACTOR shall re-train the employee immediately. The CONTRACTOR shall
review all subsequent applications submitted by the marketer/facilitator
for the
next month to ensure compliance. If continued mistakes are found on those
applications, the CONTRACTOR shall remove the employeeas a facilitator
immediately and follow the CONTRACTOR'S employee disciplinary action procedures.
The review of individual marketer/facilitator applications shall encompass
all
applications for the period and does not need to be sorted into the three
categories above.
Verification
of a specific facilitator's applications cannot substitute for the CONTRACTOR'S
sample review required by this section of the AGREEMENT. The CONTRACTOR must
make the appropriate adjustments to claims for CHPIus B applications fourd
to be
ineligible and must report their findings to the STATE. If CHPIus A, Medicaid,
or FHPIus applicants appear ineligible for those programs, the CONTRACTOR
shall
refer those cases to the appropriate LOSS for review and action,
The
CONTRACTOR shall protect applicants who have been subjected to facilitator
fraud. For those applications that are verified prior to enrollment the
CONTRACTOR shall:
•
Enroll
applicants or forward to the LDSS those applications in which the information
is
verified by the applicant. '
•
Enroll
applicants or forward with corrections to the LDSS those applications in
which
information was omitted by the facilitator, but the individual is still
eligible. The CONTRACTOR may obtain the corrected information over the phone,
initial the application, and send a copy of the updated information to the
applicant.
•
Forward
all signed Medicaid applications to LDSS batched according to whether applicants
appear eligible or ineligible.
For
cases
in which the CONTRACTOR retroactively reviewed the applications of a facilitator
found to have committed fraud, the CONTRACTOR shall;
•
Do
nothing with enrollees who confirm the information on the
application.
•
Inform
the LDSS of any Medicaid enrollees who may not be eligible based on the
retrospective review.
•
Allow
CHPIus B enrollees to reapply if it appears that they may still be eligible
for
coverage. Coverage for a CHPIus B enrollee may be continued for two months
while
the new application is completed and processed. During this time any CHPIus
B
applicant found to be eligible in a higher family contribution category will
be
permitted to remain enrolled provided they remit the appropriate family
contribution. A new code will be added to the KIDS system to permit the
CONTRACTOR to track these children.
•
Forward
all new CHPIus A, Medicaid, and FHPIus applications to the LDSS with an
explanation of the results of the verification.
If
during
the course of the verification process, the CONTRACTOR identifies cases of
fraud
committed byapplicants and/or enrollees, those cases, with supporting evidence,
shall be submitted to the STATE.
Section
111.N.5 is revised to read as follows:
5.
Reports
The
CONTRACTOR must submit quarterly reports on the results of these monitoring
activities. Thereport is due 30 days after the end of the quarter beginning
immediately after the STATE has approved the field monitoring programs.
Thereafter, each quarterly report shall be due within 30 days following the
end
of the quarter. The reports shall include:
•
The
total number of applications received each month and the number of applications
requiring further review.
•
The
number of applications in each of the three categories to be
verified.
•
The
number of observed interviews and/or secret shopping encounters.
This
report will be added to the current list of reports, via certified letter
to the
CONTRACTOR'S Chief Executive Officer, and subject to the 2 percent penalty
for
late reports.
APPENDIX
E
Financial
Information
Sections
A is revised to read as follows:
B.
Wellcare of New York, Inc. shall receive, for the period January 1, 2007
through
June 30, 2007, an amount up to, but not to exceed, $8,700,000 to provide
and
administer a Child Health Plus program for uninsured children in the counties
identified in Appendix A-2, Section n.B.l of this AGREEMENT or as modified
by
the STATE. Payment of this amount is based on the CONTRACTOR meeting the
responsibilities provided in this AGREEMENT.
Additional
Premium Information:
For
Bronx, Kings, New York and Queens county(ies):
The
total
monthly premium shall be: $118.37
The
State
share of the total monthly premium shall be $118.37 or the total monthly
premium
for children in families with gross household income less than 160% of the
federal poverty level and children who are American Indians or
Alaskan Natives (AI/AN).
The
State
share of the total monthly premium shall be $ 10 9.3 7 or the total monthly
premium minus $9 for children in families with gross household income between
160% and 222% of the federal poverty level with a maximum of $27 per month
per
family. The State share is the total monthly premium less $9 for each of
the
first three children. For additional children, the State share is the total
monthly premium.
The
State
share of the total monthly premium shall be $103.37 or the total monthly
premium
minus $15 for children in families with gross household income between 223%
and
250% of the federal poverty level with a maximum of $45 per month per family.
The State share is the total monthly premium less $15 for each of the first
three children. For additional children, the State share is the total monthly
premium.
For
Dutchess, Orange, Rockland, ▇▇▇▇▇▇▇▇ and Ulster county(ies):
The
total
monthly premium shall be: $ 106.67
The
State
share of the total monthly premium shall be $106.67 or the total monthly
premium
for children in families with gross household income less than 160% of the
federal poverty level and children who are American Indians or Alaskan Natives
(AI/AN).
The
State
share of the total monthly premium shall be $97.67 or the total monthly premium
minus $9 for children in families with gross household income between 160%
and
222% of the federal poverty level with a maximum of $27 per month per family.
The State share is the total monthly premium less $9 for each of the first
three
children. For additional children, the State share is the total monthly
premium.
The
State
share of the total monthly premium shall be $91.67 or the total monthly premium
minus $ 15 for children in families with gross household income between 223%
and
250% of the federal poverty level with a maximum of $45 per month per family.
The State share is the total monthly premium less $15 for each of the first
three children. For additional children, the State share is the total monthly
premium.
For
Albany, Columbia, ▇▇▇▇▇▇, Rensselaer county(ies):
The
total
monthly premium shall be: $105.68
The
State
share of the total monthly premium shall be $105.68 or the total monthly
premium
for children in families with gross household income less than 160% of the
federal poverty level and children who are American Indians or Alaskan Natives
(AI/AN).
The
State
share of the total monthly premium shall be $96.68 or the total monthly premium
minus $9 for children in families with gross household income between 160%
and
222% of the federal poverty level with a maximum of $27 per month per family.
The State share is the total monthly premium less $9 for each of the first
three
children. For additional children, the State share is the total monthly
premium.
The
State
share of the total monthly premium shall be $90.68 or the total monthly premium
minus $15 for children in families with gross household income between 223%
and
250% of the federal poverty level with a maximum of $45 per month per family.
The State share is the total monthly premium less $15 for each of the first
three children. For additional children, the State share is the total monthly
premium.
In
the
absence of an approved premium modification by the Department of Health and
State Insurance Department, the premium above or subsequent premium approved
(whichever is in effect) shall continue as the State's subsidy through June
30,
2007.
Appendix
L
Privacy
and Confidentiality
Section II
is revised as follows:
II.
Effective April 14, 2003, the CONTRACTOR shall comply with the following
agreement:
Federal
Health Insurance Portability and Accountability Act (HIPAA) Business Associate
Agreement ("Agreement")
This
Business Associate Agreement between the New York State Department of Health
and
Wellcare of New York, Inc. hereinafter referred to as the Business Associate,
is
effective on April
14. 2003 to June 30. 2007.