APPENDIX X [Amendment Number 6]
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Agency
Code 12000
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Contract
No. C020454
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Period
10/1/07-9/30/08
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Funding
Amount for Period Based on approved
capitation rates
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This is
an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York State
Department of Health, having its principal office at Corning Tower, Room ▇▇▇▇,
▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, (hereinafter referred to as the
STATE), and WellCare
of New York,
Inc., (hereinafter referred to as the CONTRACTOR), to modify Contract Number
C020454 as set forth below. The effective date of these modifications is
October 1, 2007, unless otherwise noted below.
1.
Amend Section 11.5
"Corrective and Remedial Actions" to read as follows:
11.5 Corrective
and Remedial Actions
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a) |
If
the Contractor's Marketing activities do not comply with the Marketing
Guidelines set forth in Appendix D of this Agreement or
the Contractor's approved
Marketing plan, the SDOH, in consultation with the LDSS, may take any of
the following actions as
it, in its sole discretion, deems necessary
to protect the interests of Enrollees and the integrity of the MMC and
FHPlus Programs.
The Contractor shall take the corrective and
remedial actions directed by the SDOH within the specified
timeframes.
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i) |
If
the Contractor or its representative commits a first time infraction of
the Marketing Guidelines and/or the Contractor's approved Marketing plan,
and the SDOH, in consultation with the LDSS, deems the infraction to be
minor or unintentional in nature, the SDOH and/or the LDSS may issue a
warning letter to the
Contractor.
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ii) |
If
the Contractor engages in Marketing activities that SDOH determines, in it
sole discretion, to be an intentional or serious breach of the Marketing
Guidelines or the Contractor's approved Marketing plan, or a pattern of
minor breaches, SDOH, in consultation with the LDSS, may require the
Contractor to, and the Contractor shall, prepare and implement a
corrective action plan acceptable to SDOH within a specified timeframe. In
addition, or alternatively, SDOH may impose sanctions, including monetary
penalties, as permitted by
law.
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iii) |
If
the Contractor commits further infractions, fails to pay monetary
penalties within the specified timeframe, fails to implement a corrective
action plan in a timely manner or commits an egregious first-time
infraction, the SDOH, in consultation with the LDSS, may in addition to
any other legal remedy available to SDOH in law or
equity:
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A) |
direct
the Contractor to suspend its Marketing activities for a period up to the
end of the Agreement period;
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B) |
suspend
new Enrollments, other than newborns, for a period up to the remainder of
the Agreement period; or
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C) |
terminate
this Agreement pursuant to termination procedures described in Section 2.7
of this Agreement.
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Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
1
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b) |
The
corrective and remedial actions described in Section 11.5 a) apply to
violations of the reporting requirements in Section 18.5 a)
xiii).
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2.
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Amend Section 18.5
"Reporting Requirements" to read as
follows:
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18.5
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Reporting
Requirements
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a) |
The
Contractor shall submit the following reports to SDOH (unless otherwise
specified). The Contractor will certify the data
submitted pursuant to this section as required by SDOH. The certification
shall be in the manner and format established by SDOH and must
attest, based on best knowledge, information, and belief
to the accuracy, completeness and truthfulness of the data
being submitted.
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i) |
Annual
Financial Statements:
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Contractor
shall submit Annual Financial Statements to SDOH. The due date for annual
statements shall be April 1 following the report closing
date.
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ii) |
Quarterly
Financial Statements:
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Contractor
shall submit Quarterly Financial Statements to SDOH. The due date for quarterly
reports shall be forty-five (45) days after the end of the calendar
quarter.
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iii) |
Other
Financial Reports:
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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 Part 98; and when applicable, SIL §§ 304, 305, 306,
and 310. The SDOH may require the Contractor to submit such relevant financial
reports and documents related to its financial condition to the
LDSS.
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iv) |
Encounter
Data:
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The
Contractor shall prepare and submit encounter data on a monthly basis to SDOH
through SDOH's 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 all contracted
services rendered to the Enrollee in the current or any preceding months.
Monthly submissions must be received by the Fiscal Agent in accordance with the
time frames specified in the MEDS II data dictionary on the HPN to assure the
submission is included in the Fiscal Agent's monthly production
processing.
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v) |
Quality
of Care Performance Measures:
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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.
Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
2
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vi) |
Complaint
and Action Appeal Reports:
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A) |
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 and Action Appeals subject to PHL § 4408-a
received during the preceding quarter via the Summary Complaint Form on
the Health Provider Network. The Summary Complaint Form has been developed
by the SDOH to categorize the type of Complaints and Action Appeals
subject to PHL § 4408-a
received by the Contractor.
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B) |
The
Contractor agrees to provide on a quarterly basis, via Summary Complaint
Form on the HPN, the total number of Complaints and Action Appeals subject
to PHL § 4408-a that
have been unresolved for more than forty-five (45) days. The Contractor
shall maintain records on these and other Complaints, Complaint Appeals
and Action Appeals pursuant to Appendix F of this
Agreement.
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C) |
Nothing
in this Section is intended to limit the right of the SDOH or its designee
to obtain information immediately from a Contractor pursuant to
investigating a particular Enrollee or provider Complaint, Complaint
Appeal or Action Appeal.
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vii) |
Fraud
and Abuse Reporting
Requirements:
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A) |
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.
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B) |
The
Contractor also must submit to the SDOH the following information on an
ongoing basis for each confirmed case of fraud and abuse it identifies
through Complaints, organizational monitoring, contractors,
subcontractors, providers, beneficiaries, Enrollees, or any other
source:
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I) |
The
name of the individual or entity that committed the fraud or
abuse;
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II) |
The
source that identified the fraud or
abuse;
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III) |
The
type of provider, entity or organization that committed the fraud or
abuse;
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IV) |
A
description of the fraud or abuse;
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V) |
The
approximate dollar amount of the fraud or
abuse;
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VI) |
The
legal and administrative disposition of the case, if available, including
actions taken by law enforcement officials to whom the case has been
referred; and
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VII) |
Other
data/information as prescribed by
SDOH;
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C) |
Such
report shall be submitted when cases of fraud and abuse are confirmed, and
shall be reviewed and signed by an executive officier of the
Contractor.
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Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
3
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viii) |
Participating
Provider Network Reports:
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The
Contractor shall submit electronically, the 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 MMC and/or FHPlus Enrollees,
as applicable. 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.
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ix) |
Appointment
Availability/Twenty-four (24) Hour Access and Availability
Surveys:
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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.
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x) |
Clinical
Studies:
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A) |
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.
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B) |
The
Contractor is required to conduct at least one (1) internal performance
improvement project each year in a priority topic area of its choosing
with the mutual agreement of the SDOH and SDOH's external quality review
organization. The Contractor may conduct its performance improvement
project in conjunction with one or more MCOs. The purpose of these
projects will be to promote quality improvement within the Contractor's
MMC and/or FHPlus product. SDOH will provide guidelines which address
study structure and reporting format. Written reports of these projects
will be provided to the SDOH and validated by the external quality review
organization.
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xi) |
Independent
Audits:
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The
Contractor must submit copies of all certified financial statements and QARR
validation audits by auditors independent of the Contractor to the SDOH within
thirty (30) days of receipt by the Contractor.
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xii) |
New
Enrollee Health Screening Completion
Report:
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The
Contractor shall submit a quarterly report within thirty (30) days of the close
of the quarter showing the percentage of new Enrollees for which the Contractor
was able to complete a health screening consistent with Section 13.6(a)(ii) of
this Agreement.
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xiii) |
Marketing
and Facilitated Enroller Staffing
Reports:
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The
Contractor shall submit a monthly staffing report during the last fifteen (15)
calendar days of each month showing the number of full-time equivalents (FTEs)
employed or funded for purposes of marketing, facilitated enrollment, and/or
community outreach designed to develop enrollment opportunities or present
coverage options for the Medicaid, Family Health Plus, and Child Health Plus
programs, and solely for Medicaid Advantage and/or Medicaid Advantage Plus
programs, as applicable.
Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
4
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xiv) |
Additional
Reports
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Upon
request by the SDOH, 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 reserves the right to give
thirty (30) days notice in circumstances where time is of the
essence.
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3.
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Amend Section 21.21
"Federally Qualified Health Centers (FQHCs)" to read as
follows:
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21.21
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Federally
Qualified Health Centers
(FQHCs)
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a) |
In
a county where Enrollment in the Contractor's MMC product is voluntary,
the Contractor is not required to contract with FQHCs. However, when an
FQHC is a Participating Provider of the Contractor network, the Provider
Agreement must include a provision whereby the Contractor agrees to
compensate the FQHC for services provided to Enrollees at a payment rate
that is not less than the level and amount that the Contractor would pay
another Participating Provider that is not an FQHC for a similar set of
services.
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b) |
In
a county where Enrollment in the Contractor's MMC product is mandatory
and/or the Contractor offers an FHPlus product, the Contractor shall
contract with FQHCs operating in that county. The contract with the FQHC
must be between the Contractor and the FQHC clinic, not between the
Contractor and an individual practitioner at the
clinic.
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c) |
The
Department may on a case-by-case basis defer the contracting
contracting requirement
if it determines there is sufficient access to FQHC services in a county.
The Department reserves the right to rescind the deferment at any time
should access
to FQHC services in the county
change.
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d) |
When
an MCO does not contract with an FQHC, but another MCO in the county contracts
with an FQHC, marketing and educational materials must inform Potential
Enrollees
and Enrollees about the availability of FQHC services. These materials
should also advise Potential Enrollees and Enrollees that they have good
cause to
disenroll from an MCO when the MCO does not contract with an FQHC and
another MCO in the county contracts with an FQHC or is an FQHC sponsored
MCO.
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4.
Amend
Section 22.7 "Recovery of Overpayments to Providers" to read as
follows:
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22.7
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Recovery
of Overpayments to Providers
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Consistent
with the exception language in Section 3224-b of the Insurance Law, the
Contractor shall have and retain the right to audit participating providers'
claims for a six year period from the date the care, services or supplies were
provided or billed, whichever is later, and to recoup any overpayments
discovered as a result of the audit. This six year limitation does not apply to
situations in which fraud may be involved or in which the provider or an agent
of the provider prevents or obstructs the Contractor's
auditing.
Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
5
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5.
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Amend Appendix D "New
York State Department of Health Marketing Guidelines," Section
D.3,
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3. c) to add paragraph
iv) to read as
follows:
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c)
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The
Contractor shall not offer compensation to Marketing Representatives,
including salary increases or bonuses, based solely on the number of
individuals they enroll. However, the Contractor may base compensation of
Marketing Representatives on periodic performance evaluations which
consider Enrollment productivity as one of several performance factors
during a performance period, subject to the following
requirements:
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i) |
"Compensation"
shall mean any remuneration required to be reported as income or
compensation for federal tax
purposes;
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ii) |
The
Contractor may not pay a "commission" or fixed amount per
enrollment;
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iii) |
The
Contractor may not award bonuses more frequently than quarterly, or for
an annual amount that exceeds ten percent (10%) of a
Marketing Representative's total annual
compensation;
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iv) |
Sign-on
bonuses for Marketing Representatives are
prohibited;
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6.
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Effective January 1,
2008, amend Appendix D "New York State Department of Health Marketing
Guidelines." Section
D.3, 3. c) to add paragraphs v), vi), vii) viii), and ix) to read as
follows:
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v) |
Where
productivity is a factor in the bonus determination, bonuses must be
structured in such a way that productivity carries a weight of no more
than 30% of the total bonus and that application quality/accuracy must
carry a weight equal to or greater than the productivity
component;
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vi) |
The
Contractor must limit salary adjustments for Marketing Representatives to
annual adjustments except where the adjustment occurs during the first
year of employment after a traditional trainee/probationary period or in
the event of a company wide
adjustment;
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vii) |
The
Contractor is prohibited from reducing base salaries for Marketing
Representatives for failure to meet productivity
targets;
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viii) |
The
Contractor is prohibited from offering non-monetary compensation such as
gifts and trips to Marketing
Representatives;
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ix) |
The
Contractor shall have human resources policies and procedures for the
earning and payment of overtime and must be able to provide documentation
(such as time sheets) to support overtime
compensation.
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Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
6
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7.
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Amend Appendix D "New
York State Department of Health Marketing Guidelines," Section
D.3.3. to
add paragraph e) to read as
follows:
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e) |
The
Contractor shall limit the staffing (FTE's) involved in the
marketing/facilitated enrollment process. The limit shall be set at 150
FTEs for New York City, 75 for MCOs that serve county service areas
outside New York City, and 225 for MCOs that serve both, with no more than
150 operating in New York City. FTEs subject to the limit include
Marketing Representatives, Facilitated Enrollers and any other staff that
conduct new enrollments, provide community presentations on coverage
options and/or engage in outreach activities designed to develop
enrollment leads. Managers are not included in the limit as long as they
do not personally conduct enrollments. Retention staff are not subject to
the limit.
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8.
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Amend Appendix D "New
York State Department of Health Marketing Guidelines," Section D.3. 4. a)
to add paragraph v) to read as
follows:
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a) |
The
Contractor shall not engage in the following
practices:
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i) |
misrepresenting
the Medicaid fee-for-service, MMC Program or FHPlus Program, or the
program or policy requirements of the LDSS or the SDOH, in Marketing
encounters or materials;
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ii) |
purchasing
or otherwise acquiring or using mailing lists of Eligible Persons from
third party vendors, including providers and LDSS
offices;
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iii) |
using
raffle tickets or event attendance or sign-in sheets to develop mailing
lists of Prospective
Enrollees;
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iv) |
offering
incentives (i.e., any type of inducement whose receipt is contingent upon
the individual's Enrollment) of any kind to Prospective Enrollees to
enroll in the Contractor's MMC or FHPlus
product;
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v) |
marketing
to enrollees of other health plans. If the Contractor becomes aware during
a marketing encounter that an individual is enrolled in another health
plan, the marketing encounter must be promptly terminated. If the
individual voluntarily suggests dissatisfaction with the health plan in
which he or she is enrolled, the individual should be referred to the
enrollment broker or LDSS for
assistance.
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9.
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Amend Appendix G "SDOH
Requirements for the Provision of Emergency Care and Services." Section 5
to read as follows:
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5. Emergency
Transportation
When
emergency transportation is included in the Contractor's Benefit Package, the
Contractor shall reimburse the transportation provider for all emergency
ambulance services, without regard to final diagnosis or prudent layperson
standards. Payment by the Contractor for emergency transportation services
provided to an Enrollee by Participating Provider shall be at the rate or rates
of payment specified in the contract between the Contractor and the
transportation provider. Payment by the Contractor for emergency transportation
services provided to an Enrollee by a Non-Participating Provider
shall be at the Medicaid fee-for-service rate in effect on the date the service
was rendered.
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10.
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Amend paragraph K and
add paragraph L of Section 6 (a) (v) of Appendix H, "New York State
Department of Health Requirements for the Processing of Enrollments and
Disenrollments in the MMC and FHPlus Programs," to read as
follows:
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K)
An FHPlus Enrollee is pregnant;
or
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Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
7
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L)
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The
Contractor does not contract with an FQHC and one or more other MCOs in
the Enrollee's count of fiscal responsibility provide the
service
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All other
provisions of said AGREEMENT shall remain in full force and
effect.
Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
8
CONTRACTOR
SIGNATURE STATE
AGENCY SIGNATURE
By: /s/ ▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ By: /s/ ▇▇▇▇▇▇▇▇▇
▇▇▇▇▇
▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇
(Printed
Name) (Printed
Name)
Title: President &
CEO Title: Deputy Director, DMC &
PE
Date: 4/15/08
Date: 5/1/08
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
15th day of April 2008, before me personally appeared
▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, to me
known, who being by me duly sworn, did depose and say
that he/she resides at ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇, ▇▇▇▇▇▇▇
▇▇▇▇▇, that
he/she is the President & CEO of WellCare of NY, 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.
/s/
▇▇▇▇ ▇▇▇▇▇
(Notary)
| Approved: | Approved: |
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| ATTORNEY GENERAL | ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ |
| STATE COMPTROLLER |
| Title: Approved as to Form NYS Attorney General | Title: Approved, Dept. of Audit & Control |
| Date: May 7, 2008 | Date: June 5, 2008 |
| /s/ ▇▇▇▇▇▇▇▇ ▇. ▇▇▇▇ | /s/ Illegible |
Appendix
X
MMC/FHPlus
Contract Amendment
October
1, 2007
Page
9