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INDEX NO. E180898/2023
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023
MISCELLANEOUS/CONSULTANT SERVICES
(Non-Competitive Award)
Managed Long Term Care Partial Capitation Contract
STATE AGENCY (Name and Address): NYS Comptroller’s Number: C036369
New York State Department of Health Originating Agency GLBU: DOHO1
Office of Health Insurance Programs Department ID: 3450000
Division of Health Plan Contracting and Oversight
One Commerce Plaza
99 Washington Avenue, 16'* Floor TYPE OF PROGRAM:
Albany, NY 12210 Partial Capitation Managed Long Term Care
CONTRACTOR (Name and Address):
CONTRACT TERM:
Kalos Health Inc.
2424 Niagara Falls Blvd. FROM: January 1, 2022
Niagara Falls, N.Y. 14304 TO: December 31, 2026
CHARITIES REGISTRATION NUMBER:
44-09-08
FUNDING AMOUNT FOR CONTRACT TERM:
CONTRACTOR HAS () HAS NOT () TIMELY $483,013, 122.00
FILED WITH THE ATTORNEY GENERAL’S
CHARITIES BUREAU ALL REQUIRED
PERIODIC OR ANNUAL WRITTEN REPORTS
THIS CONTRACT IS NOT RENEWABLE.
FEDERAL TAX IDENTIFICATION NUMBER:
461066844
New York State Vendor Identification Number:
1100106489
MUNICIPALITY NUMBER (if applicable):
STATUS:
CONTRACTOR IS [] IS NOT [X]
A SECTARIAN ENTITY
CONTRACTOR IS [X] IS NOT [ ]
A NOT-FOR-PROFIT ORGANIZATION
CONTRACTOR IS [X] IS NOT [ ]
ANY STATE BUSINESS ENTERPRISE
BID OPENING DATE: N/A — Contractor is legislatively named in accordance with §4403-f.
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APPENDICES TO THIS AGREEMENT AND
INCORPORATED BY REFERENCE INTO THE AGREEMENT
APPENDIX A Standard Clauses for New York State Contracts
APPENDIX B New York State Department of Health Guidelines For Contractor Compliance
with the Federal Americans with Disabilities Act
APPENDIX C. Certification Regarding Lobbying
APPENDIX D Reserved
APPENDIX E-1 Proof of Workers’ Compensation Coverage
APPENDIX E-2 Proof of Disability Insurance Coverage
APPENDIX F Service Area and Ages of Population Served
APPENDIX G Covered and Non-Covered Services
APPENDIX H Schedule of Capitation Rates
APPENDIX I Reserved
APPENDIX J Definitions
APPENDIX K Grievance and Appeal System, Member Handbook Language and Service
Authorization Requirements
APPENDIX L Enrollee Rights
APPENDIX M Plan Information Requirements
APPENDIX N New York State Department of Health Risk Sharing Mechanisms
APPENDIX O Nursing Home Transition
APPENDIX P State Directed Payments
APPENDIX X Modification Agreement Form
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TABLE OF CONTENTS
Article I Contract Term, Renewal, and Termination
Term of Agreement
Renewal
Termination of the Agreement by the Department
Termination of the Agreement by the Contractor
Other Termination Reasons
Requirements Pertaining to Service Area Reductions and Mergers, Acquisitions and
Other Arrangements
G. Agreement Expiration and Contractor Termination/Phase-out Plan
H. Effect of Termination on New Enrollments
Article II Statutory and Regulatory Compliance
Article II Contractor Service Area and Age Groups Served
A Service Area
B Ages Served
Cc Contractor Obligation to Notify Enrollees of Service Area Modifications
D. Contractor Obligation to Notify Enrollees of Change in Age Groups Served
Article IV Eligibility for Partial Capitation Managed Long Term Care
Populations Eligible for Enrollment
Eligibility Requirements
Populations Excluded from Enrollment
Populations Exempted from Enrollment
Conflict Free Evaluation and Enrollment Center (CFEEC)
Article V Obligations of the Contractor
Provision of Benefits
Eligibility Activities of Contractor
Enrollment Process
Disenrollment Policy and Process
Enrollee Protections
Quality Assurance and Performance Improvement Program
Marketing
Information for Potential Enrollees, Applicants and Enrollees
Member and Provider Services
Person Centered Service Planning and Care Management
Consumer Directed Personal Assistance Services (CDPAS)
Enrollee Health and Welfare
Advance Directives
Use of Health Information Technology (HIT) to Link Services
Multiple CINs
Contractor Responsibilities Related to Public Health
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Fair Hearings
Aid Continuing
Contractor Responsibilities to the Department
Elections Based on Moral or Religious Grounds
Emergency Preparedness
Discharge Planning
Cost-Effective Alternative Services
Requirements for the “Money Follows the Person” (MFP) Demonstration
Contractor Program Integrity Responsibilities
Compliance with State Medicaid Plan, Applicable Laws and Regulations
Article VI Payment
Capitation Payments
Modification of Capitation Rates during Agreement Period
Rate-Setting Methodology
Payment of Capitation
Denial of Capitation Payments
Department Right to Recover Premiums and Contractor Duty to Repay
Third Party Health Insurance Determination
Other Insurance and Settlements
Contractor Financial Liability
Spenddown and Net Available Monthly Income
No Recourse Against Enrollees
Notification Requirements to LDSS or Entity Designated by the Department Regarding
Enrollees
Contractor’s Fiscal Solvency Requirements
Prohibition on Payments to Institutions or Entities Located Outside of the United States
High-Cost, High-Need Risk Pool
Nursing Home Price Mitigation Pool
Conditions on Incentive Arrangements
Risk Sharing Mechanisms
Article VII Contractor Relationship with Providers
Provider Relations
Full Responsibility Retained
Required Provisions
Network Requirements for Covered Services
Provider Termination Notice
Recovery of Over Payments to Providers
Optometry Services Provided by Article 28 Clinics Affiliated with the College of
Optometry of the State University of New York
Dental Services Provided by Article 28 Clinics Operated by Academic Dental Centers
not Participating in Contractor’s Network
Department Exclusion or Termination of Providers
Health Home Services and Care Management Coordination
Home Care Worker Wage Parity
Fair Labor Standards Act
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Minimum Wage
Fiscal Intermediaries (FI)
Value Based Payment (VBP) Arrangements
Native Americans
Indian Health Care Providers
State Directed Payments
Article VIII Records, Reporting and Certification Requirements
A General Requirements
B Maintenance of Contractor Performance Records, Records Evidencing Enrollment Fraud
and Documentation Concerning Multiple CINs
Maintenance of Financial Records and Statistical Data
Access to Contractor Records
Retention Periods
Reporting Requirements
Data Certifications
Notification of Changes in Reporting Due Dates Requirements or Formats
Ownership and Related Information Disclosure
Public Access to Reports
Certification Regarding Individuals Who Have Been Debarred or Suspended By Federal
or State Government
Conflict of Interest Disclosure
OMIG’s Right to Audit and Recover Overpayments Caused by Contractor Submission
of Misstated Reports
OMIG’s Right to Audit and Recover Overpayments Which Were Caused by the
Contractor’s Misstated Encounter Data
0 OMIG Audit Authority
P OMIG Compliance Review Authority
Q Notification to Audit
Article [X Intermediate Sanctions
Article X General Requirements
Authorized Representative with Respect to Agreement
Confidentiality
Additional Actions and Documents
Relationship of the Parties, Status of the Contractor
Nondiscrimination
Employment Practices
Dispute Resolution
Assignment
Binding Effect
Limitation on Benefits of this Agreement
Entire Agreement
Conflicting Provisions
Modification
Headings
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Pronouns
Notices
Partial Invalidity
Reserved
Survival
State Standard Appendix A
Indemnification
Environmental Compliance
Energy Conservation
Prohibition on Use of Federal Funds for Lobbying
Waiver of Breach
Choice of Law
AA Executory Provision and Federal Funds
BB. Renegotiation
CC. Affirmative Action
DD. Omnibus Procurement Act of 1992
EE. Nondiscrimination in Employment in Northern Ireland
FF. Contract Insurance Requirements
GG. Minority And Women Owned Business Policy Statement
HH. Provisions Related to NY State Information Security Breach and Notification Act
IL Accessibility of State Agency Web-based Intranet and Internet Information and
Applications
JJ. New York State Tax Law Section 5-a
KK. Provisions Related to New York State Procurement Lobbying Law
LL. Piggybacking
MM. Lead Guidelines
NN Payment
0O. M/WBE Utilization Plan for Subcontracting and Purchasing
PP. On-going Vendor Responsibility
QQ Veterans Protections
Cultural and Linguistic Competence
SS Native Americans Access to Services From Tribal or Urban Indian Health Facility
TT Physical Location
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APPENDICES
APPENDIX A Standard Clauses for New York State Contracts
APPENDIX B New York State Department of Health Guidelines for Contractor
Compliance with the Federal Americans with Disabilities Act
APPENDIX C Certification Regarding Lobbying
APPENDIX D Reserved
APPENDIX E-1 Requirements for Proof of Workers’ Compensation Coverage
APPENDIX E-2 Requirements for Proof of Disability Insurance Coverage
APPENDIX F Service Area and Ages of Population To Be Served
APPENDIX G Covered and Non-Covered Services
APPENDIX H Schedule of Capitation Rates
APPENDIXI Reserved
APPENDIX J Definitions
APPENDIX K Grievance and Appeal System, Member Handbook Language, and Service
Authorization Requirements
APPENDIX L Enrollee Rights
APPENDIX M Plan Information Requirements
APPENDIX N New York State Department of Health Risk Sharing Mechanisms
APPENDIX O Nursing Home Transition
APPENDIX P State Directed Payments
APPENDIX X Modification Agreement Form
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PARTIAL CAPITATION MANAGED LONG TERM CARE AGREEMENT
This AGREEMENT is hereby made by and between the State of New York Department of
Health, hereinafter called the “Department” and ; hereinafter called the
“Contractor” identified on the face page hereof.
WHEREAS, the Department is the single State agency charged with the responsibility for
administration of the New York State Medical Assistance Program (Medicaid), Title 11 of
Article 5 of the Social Services Law (SSL); and
WHEREAS, the Contractor has been certified as a managed long term care plan pursuant to
New York State Public Health Law (PHL) §4403-f; and
WHEREAS, the Contractor represents that the Contractor is able and willing to provide and
arrange for health and long term care services on a capitated basis in accordance with PHL
§4403-£:
NOW, THEREFORE, in consideration of the foregoing and of the covenants and agreements
hereinafter set forth, the Parties hereto agree as follows:
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ARTICLE I
CONTRACT TERM, RENEWAL, AND TERMINATION
A. Term of Agreement
Term: The Agreement shall begin on and, unless terminated sooner as permitted by the terms
of this Agreement, end on the dates identified on the face page hereof.
B. Renewal
This Agreement is not renewable.
C. Termination of the Agreement by the Department
1 The Department shall have the right to terminate this Agreement, if the Contractor, in the
Department’s determination:
a. takes any action that threatens the health, safety, or welfare of any Enrollee;
b. has engaged in an unacceptable practice under 18 NYCRR 515, that affects the fiscal
integrity of the Medicaid program, or has engaged in an unacceptable practice
pursuant to section B of Article IX of this Agreement;
has failed to substantially comply with applicable standards of Public Health Law
(PHL) and regulations or has had its certificate of authority suspended, limited, or
revoked;
materially breaches this Agreement or fails to comply with any term or condition of
this Agreement and such breach or failure is not cured within twenty (20) days, or
such longer period as the Department may allow, of the Department’s notice of
breach or noncompliance;
becomes unable to meet its obligations in the normal course of business including
but not limited to circumstances beyond its control and changes to the provider
network affecting Enrollee access; or
brings a proceeding voluntarily, or has a proceeding brought against it involuntarily,
under Title 11 of the U.S. Code (Bankruptcy Code), and the petition is not vacated
within thirty (30) days of its filing.
2 The Department shall give the Contractor written notice of termination of this Agreement,
specifying the applicable termination provision(s) and the effective date of termination.
D. Termination of the Agreement by the Contractor
1 The Contractor shall have the right to terminate this Agreement if the Department:
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a. fails to make agreed-upon payments in a timely and accurate manner; or
b. materially breaches the Agreement or fails to comply with any material term or
condition of this Agreement.
Contractor shall allow thirty (30) days, or such longer period as the Contractor may
permit, from the time of the Contractor’s written notice of deficiency, for the Department
to cure the identified deficiency.
The Contractor shall give the Department written notice specifying the reason(s) 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 (FFS) program or
transfer to another managed long term care plan (MLTCP), but no more than ninety (90)
days.
Other Termination Reasons
This Agreement may be terminated by the Contractor or the Department as of the last day
of any month upon no more than ninety (90) days prior written notice to the other Party
so as to ensure an orderly transition. Notwithstanding this provision, the Contractor
agrees to comply with sections F and G of this Article.
This Agreement shall be terminated immediately if federal financial participation in the
costs hereof becomes unavailable or if state funds sufficient to fulfill the obligation of the
Department hereunder are not appropriated by the New York State Legislature. The
Department will give the Contractor prompt written notice of such termination of this
Contract.
This Agreement may be terminated in accordance with the provisions of section BB of
Article X of this Agreement.
Requirements Pertaining to Service Area Reductions and Mergers, Acquisitions and
Other Arrangements
1 Requests to reduce the Contractor’s service area, or to alter or cease Contractor operations
by merging with or being acquired by another MLTC plan, or by other arrangement, must
be submitted in writing to the Department, and receive specific endorsement, prior to any
action by the Contractor.
Enrollees may not be transitioned or disenrolled until the request for service area
reduction, merger, acquisition, or other acceptable arrangement, and all Enrollee
notifications, have been approved by the Department.
Any such arrangements shall be subject to the phase-out plan requirements, as applicable,
in this Agreement for contractor-initiated terminations, including Section G of Article I.
G. Agreement Expiration and Contractor Termination/Phase-Out Plan
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The Contractor hereby agrees that in the event this Agreement is terminated by either
Party, or Contractor receives Department approval for an arrangement described in
Section F of Article I of this Agreement, that the Contractor will continue to provide
Covered Services to Enrollees until Enrollees are reinstated to FFS care or transferred to
another MLTCP. To the extent that such services are provided by the Contractor to
Enrollees prior to their disenrollment into a FFS program or transfer to another MLTCP,
the Contractor will continue to be reimbursed a premium for such Enrollee. Upon
expiration and non-renewal or termination of this Agreement, the Contractor shall comply
with the termination plan that the Contractor has developed and that the Department has
approved.
In the event that the Contractor gives notice to terminate this Agreement, the Contractor
shall submit a termination plan for Department approval with the Contractor’s notice of
termination.
In the event that the Department gives notice to terminate this Agreement, the Contractor
shall submit within fifteen (15) days of notice or such longer period as the Department
may allow a termination plan for Department approval.
Sixty (60) days prior to the date of termination, or as otherwise determined by the
department pursuant to guidance, the Contractor shall advise all current Enrollees of the
termination by regular first class mail. In the event that the termination date is established
less than sixty (60) days in advance, letters shall be mailed by regular first class mail
within five (5) business days ofthe establishment of the termination date.
The Contractor shall communicate with Local Department of Social Services (LDSS) or
entity designated by the Department within fifteen (15) days of the establishment of the
termination date to offer LDSS(s) or entity designated by the Department assistance and
information necessary to reinstate each Enrollee’s Medicaid benefits through the FFS
system or facilitate enrollment in another MLTCP or managed care plan.
As soon as a termination date has been established and appropriate notice given pursuant
to this Agreement by either the Contractor or the Department:
a. The Contractor shall work with the LDSS or entity designated by the state to
ensure enrollees are informed oftheir MLTCP and FFS options, and to effectuate
transfer to the plan or option selected by the Enrollee.;
the Contractor shall contact other community resources to determine the
availability of other programs to accept the Enrollees into their programs;
the Contractor shall assist Enrollees by referring them and by making their care
management record and other enrollee service records available as appropriate
to health care providers and/or programs;
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In conjunction with such termination and disenrollment, the Contractor shall provide such
other reasonable assistance as the Department may request in effecting that transition.
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Enrollees will be provided with education on all available plan options. Contractor must
accept the transfer of all Enrollees affected by the termination of another MLTCP that
select or are auto-assigned to Contractor. These transferring Enrollees are presumed to
meet the eligibility requirements for MLTC. Contractor must accept enrollment of these
Enrollees, and is not required to conduct an assessment prior to enrollment.
Within sixty (60) days of the date of termination of the Agreement, an accounting shall
be prepared and submitted to the Department by or on behalf of the Contractor for the
establishment of a sum to be repaid to the Department by the Contractor of funds
advanced by the Department, if any, for coverage of Enrollees for periods subsequent to
the date of termination.
10. The Contractor shall maintain all books, records and other documents that may be
required pursuant to this Agreement regarding the Partial Capitation MLTCP and make
such records available to the Department and all authorized representatives of the state
and federal government throughout the period that such records are required to be
maintained pursuant to this Agreement.
H. Effect of Termination on New Enrollments
Once either Party has given notice of its intentions to terminate this Agreement, the Contractor
shall suspend enrollment into its Partial Capitation MLTCP and it will be removed from auto
assignment.
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ARTICLE II
STATUTORY AND REGULATORY COMPLIANCE
The Contractor agrees to operate in compliance with the requirements of this Agreement,
legislative and regulatory requirements including, but not limited to, 42 Code of Federal
Regulation (CFR) Parts 434 and 438 and PHL §4403-f and other applicable provisions of
PHL Articles 44 and 49.
Covered services provided by the Contractor under this Agreement shall comply with all
standards of the New York State Medicaid Plan established pursuant to New York Social
Services Law (SSL) § 363-a and satisfy all other applicable requirements of SSL and PHL,
and Titles 10 and 18 of the New York Code of Rules and Regulations (NYCRR), title XIX of
the Social Security Act and regulations promulgated pursuant thereto, the terms and
conditions of any federal waiver applicable to the provision of Medicaid services by a
managed care plan approved by CMS under Section 1115 of the Social Security Act, and all
other applicable federal and state statutes, regulations, guidelines and directives.
C. The Contractor agrees to comply with all applicable laws, regulations, and rules and to not
violate statutes and regulations, including but not limited to:
Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR Part 80;
The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR Part 91;
The Rehabilitation Act of 1973 as implemented by regulations at 45 CFR Part 84;
The Americans with Disabilities Act (ADA);
The Health Insurance Portability and Accountability Act (HIPAA);
The Patient Protection and Affordable Care Act;
False Claims Act 31 U.S.C. 3729(a);
CMS Managed Care regulations 42 CFR Part 438;
9 Social Services Law 145-b;
10. Social Services Law §366-f;
11. State Finance Law § 189 et seq.
12. Other laws applicable to recipients of federal funds; and
13. The New York City Health Code for Contractors operating in New York City.
The Contractor must comply with Title II of the ADA and section 504 of the Rehabilitation
Act of 1973 for program accessibility, and must develop an ADA Compliance Plan consistent
with the New York State Department of Health Guidelines for Contractor Compliance with
the ADA set forth in Appendix B, which is hereby made a part of this Agreement as if set forth
fully herein. Said plan must be approved by the Department, be filed with the Department, and
be kept on file by the Contractor.
The Contractor agrees to implement a compliance plan in accordance with the
requirements of 42 CFR § 438.608, New York Social Services Law Section 363-d, and Title
18 New York Codes of Rules and Regulations Part 521.
F. The Contractor is receiving federal and state payments under this Agreement. The Contractor
and subcontractors paid by the Contractor to fulfill its obligations under this Agreement are
subject to certain laws that are applicable to individuals and entities receiving federal and state
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funds. The Contractor agrees to inform all subcontractors that payments that they receive are,
in whole or in part, from federal funds.
In the event that any provisions of this Agreement conflicts with the provisions of any statute
or regulations applicable to a Contractor, the provisions of the statute or regulations shall have
control.
The Contractor agrees to abide by any and all applicable guidance issued in writing by the
Department to Partial Capitation MLTC plans.
The Contractor shall comply with all applicable guidance contained within the Medicaid
Update publication issued by the Department.
The Contractor shall not expend any funds provided through this Agreement for roads,
bridges, stadiums, or any item or service not described in the State Medicaid Plan, except
when such expenditures are for an item or service:
1 otherwise permissible under this Agreement;
2. allowable under 42 CFR 438.3; or
3. that the Contractor has been directed by the Department to provide pursuant to Article
V.A.2 of this Agreement.
a) Should any part of the scope of work under this Agreement relate to a program or activity
of the State Medicaid Program that is no longer authorized by law (e.g., which has been
vacated by a court of law, or for which CMS has withdrawn federal authority, or which is
the subject of a legislative repeal), the Contractor shall do no work on that part after the
effective date of the loss of authority. The SDOH shall adjust Capitation Rates to remove
costs that are specific to any program or activity that is no longer authorized by law. If the
Contractor works on a program or activity no longer authorized by law after the date the
legal authority for the work ends, the Contractor shall not be paid for that work. If the state
paid the Contractor in advance to work on a no-longer-authorized program or activity and
under the terms of this Agreement the work was to be performed after the date the legal
authority ended, the payment for that work should be returned to the state in accordance
with direction from SDOH. However, if the Contractor worked on a program or activity
prior to the date legal authority ended for that program or activity, and the state included
the cost of performing that work in its payments to the Contractor, the Contractor may keep
the payment for that work even if the payment was made after the date the program or
activity lost legal authority.
b) The SDOH shall provide notice to the Contractor that shall include the effective date of the
loss of authority for a program or activity of the State Medicaid Program and identify the
affected parts of this Agreement pursuant to the requirements of Article II, Section K(a) of
this Agreement.
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c) Notwithstanding the requirements of paragraphs (a) and (b) above, as directed by SDOH,
the Contractor shall continue work under this Agreement related to a program or activity
of the State Medicaid Program that is solely authorized under New York State law. Such
work may not be subject to federal financial participation.
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ARTICLE III
CONTRACTOR SERVICE AREA AND AGE GROUPS SERVED
A. Service Area
1 For purposes of this Agreement, the Contractor's service area shall consist of the
geographic area described in Appendix F.
2. To reduce its service area, the Contractor must request written Department approval
in accordance with the provisions of this Agreement and applicable guidelines. The
Contractor shall not take any actions to modify its service area until it has received
such approval from the Department.
To expand its service area, the Contractor must file a Service Area Expansion
Application with the Department. Upon review and approval, the Department will issue
a written notification of approval to expand. The Contractor shall not begin any
enrollment activities in the new service area until and unless it has received approval
from the Department.
Any modifications made to Appendix F resulting from an approved request to expand
or reduce the Contractor’s service area shall become effective on the date written
Department approval is issued.
B. Ages Served
1 The age groups served by the Contractor are identified in Appendix F.
2. The Contractor must request written Department approval to make any changes in the
age groups served through this Agreement. The Contractor shall not modify the age
groups served until it has received such approval from the Department.
Any modifications made to Appendix F resulting from an approved request to change
the age groups served by the Contractor through this Agreement shall become effective
the date the written Department approval is issued
C. Contractor Obligation to Notify Enrollees of Service Area Modifications
In the event of a service area modification, it is the responsibility of the Contractor to provide
affected Enrollees with prior notification. No Service Area modification activities will
commence until the Department approves a transition plan and the content of Enrollee
notification communications.
D. Contractor Obligation to Notify Enrollees of Change in Age Groups Served
In the event of a change in age groups served, it is the responsibility of the Contractor to provide
affected Enrollees prior notification.
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ARTICLE IV
ELIGIBILITY FOR PARTIAL CAPITATION MANAGED LONG TERM CARE
A. Populations Eligible for Enrollment
1. Mandatory Enrollment Counties:
Upon approval of the Department and CMS, counties are designated as Mandatory
for MLTC (Mandatory). The Contractor will be notified at least sixty (60) days in
advance when a county is designated as Mandatory. In these counties, dual eligible
individuals (having both Medicare and Medicaid), who are age 21 and older and
who are assessed as needing community based long term care services listed in
section B subsection 6 of this Article for a continuous period of more than 120
days must enroll in MLTC in order to receive those services. These individuals are
defined as MLTC Mandatory Persons.
In Mandatory counties, the following may voluntarily enroll in MLTC:
a. dual eligible individuals, age 18-20, who have been assessed by the Contractor
as eligible for nursing home level of care at time of enrollment and also
assessed as needing community based long term care services for a continuous
period of more than 120 days; and
non-dual eligible individuals, age 18 and older, who have been ass ssed as
eligible for nursing home level of care at time of enrollment and also assessed
as needing community based long term care services for a continuous period
of more than 120 days.
2. Non-Mandatory Enrollment Counties:
In Non-Mandatory Enrollment Counties, the following may voluntarily enroll in
MLTC:
a. dual eligible individuals, age 18 and older, who have been assessed as
eligible for nursing home level of care at time of enrollment and also
assessed as needing community based long term care for a continuous
period of more than 120 days may choose to enroll in MLTC;
b. non-dual eligible individuals age 18 and older, who are not otherwise
considered mandatory for managed care, who have been assessed as
eligible for nursing home level; and
c. dual eligible individuals who are age 21 or older, who are assessed as
needing community based long term care services for a continuous period
of more than 120 days, may choose to enroll in MLTC.
10
INDEX NO. E180898/2023
NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023
B. Eligibility Requirements
Except as specified in section C of this Article, an Applicant who completes an
enrollment agreement shall be eligible to enroll under the terms of this Agreement if
he/she:
1 meets the age requirements identified in Appendix F;
2 is a resident in the Contractor’s service area;
is determined eligible for Medicaid by the LDSS or entity designated by the
Preview
INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 MISCELLANEOUS/CONSULTANT SERVICES (Non-Competitive Award) Managed Long Term Care Partial Capitation Contract STATE AGENCY (Name and Address): NYS Comptroller’s Number: C036369 New York State Department of Health Originating Agency GLBU: DOHO1 Office of Health Insurance Programs Department ID: 3450000 Division of Health Plan Contracting and Oversight One Commerce Plaza 99 Washington Avenue, 16'* Floor TYPE OF PROGRAM: Albany, NY 12210 Partial Capitation Managed Long Term Care CONTRACTOR (Name and Address): CONTRACT TERM: Kalos Health Inc. 2424 Niagara Falls Blvd. FROM: January 1, 2022 Niagara Falls, N.Y. 14304 TO: December 31, 2026 CHARITIES REGISTRATION NUMBER: 44-09-08 FUNDING AMOUNT FOR CONTRACT TERM: CONTRACTOR HAS () HAS NOT () TIMELY $483,013, 122.00 FILED WITH THE ATTORNEY GENERAL’S CHARITIES BUREAU ALL REQUIRED PERIODIC OR ANNUAL WRITTEN REPORTS THIS CONTRACT IS NOT RENEWABLE. FEDERAL TAX IDENTIFICATION NUMBER: 461066844 New York State Vendor Identification Number: 1100106489 MUNICIPALITY NUMBER (if applicable): STATUS: CONTRACTOR IS [] IS NOT [X] A SECTARIAN ENTITY CONTRACTOR IS [X] IS NOT [ ] A NOT-FOR-PROFIT ORGANIZATION CONTRACTOR IS [X] IS NOT [ ] ANY STATE BUSINESS ENTERPRISE BID OPENING DATE: N/A — Contractor is legislatively named in accordance with §4403-f. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 APPENDICES TO THIS AGREEMENT AND INCORPORATED BY REFERENCE INTO THE AGREEMENT APPENDIX A Standard Clauses for New York State Contracts APPENDIX B New York State Department of Health Guidelines For Contractor Compliance with the Federal Americans with Disabilities Act APPENDIX C. Certification Regarding Lobbying APPENDIX D Reserved APPENDIX E-1 Proof of Workers’ Compensation Coverage APPENDIX E-2 Proof of Disability Insurance Coverage APPENDIX F Service Area and Ages of Population Served APPENDIX G Covered and Non-Covered Services APPENDIX H Schedule of Capitation Rates APPENDIX I Reserved APPENDIX J Definitions APPENDIX K Grievance and Appeal System, Member Handbook Language and Service Authorization Requirements APPENDIX L Enrollee Rights APPENDIX M Plan Information Requirements APPENDIX N New York State Department of Health Risk Sharing Mechanisms APPENDIX O Nursing Home Transition APPENDIX P State Directed Payments APPENDIX X Modification Agreement Form ii = INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 ‘ IN WITNESS WHEE lhe purtics hereto five cxeculed ov approved this AGIREEMENT as of the ilttes appan: ring wider t STEM UTES CONTRACTOR STATE AGHINCY alt Wg) by: ev hy a Vuh Le Ba Ee USN vd 4 Printed Mame Vine Nom QO Vithe Vraaykyont 6.0 Pitle aeduc “PHICO Cy\ Aq 4.5, Date Dale £04 ca State Aveney Certification in addition to the plance af shis contract, | also certify that orig Al coy of this signature page will he attached to all ather exact copies of this contract. STATE OF NEW YORK SS. eae County ar dy Ay 5 pet, Onihe OH mi the year before me, the undersigned personally a ppedred Lerre & porseially know tame ar proved. me on the basis of sill 101 vidence to be the individual(s) wh nar si is Gare) subscriied to the within in rutnertt wid acknowledged to ne that fetshesthe vculed the sirnie ius bis! h h Mackeytie and that by hi fier tiac Hurets) om the instrument the ireckivdelunaly, tH the person apo behalf of which the indivicialts) ated, ON uted fhe instrument Ki iat db te Hes ey) Fe ait hy Dap geo Nots Approwed!: Approved: ATTORNEY GENERAL STATE COMPTROLLE errr a ~ Tih aaa Fitle; Date Date ii INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 TABLE OF CONTENTS Article I Contract Term, Renewal, and Termination Term of Agreement Renewal Termination of the Agreement by the Department Termination of the Agreement by the Contractor Other Termination Reasons Requirements Pertaining to Service Area Reductions and Mergers, Acquisitions and Other Arrangements G. Agreement Expiration and Contractor Termination/Phase-out Plan H. Effect of Termination on New Enrollments Article II Statutory and Regulatory Compliance Article II Contractor Service Area and Age Groups Served A Service Area B Ages Served Cc Contractor Obligation to Notify Enrollees of Service Area Modifications D. Contractor Obligation to Notify Enrollees of Change in Age Groups Served Article IV Eligibility for Partial Capitation Managed Long Term Care Populations Eligible for Enrollment Eligibility Requirements Populations Excluded from Enrollment Populations Exempted from Enrollment Conflict Free Evaluation and Enrollment Center (CFEEC) Article V Obligations of the Contractor Provision of Benefits Eligibility Activities of Contractor Enrollment Process Disenrollment Policy and Process Enrollee Protections Quality Assurance and Performance Improvement Program Marketing Information for Potential Enrollees, Applicants and Enrollees Member and Provider Services Person Centered Service Planning and Care Management Consumer Directed Personal Assistance Services (CDPAS) Enrollee Health and Welfare Advance Directives Use of Health Information Technology (HIT) to Link Services Multiple CINs Contractor Responsibilities Related to Public Health iv INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 Fair Hearings Aid Continuing Contractor Responsibilities to the Department Elections Based on Moral or Religious Grounds Emergency Preparedness Discharge Planning Cost-Effective Alternative Services Requirements for the “Money Follows the Person” (MFP) Demonstration Contractor Program Integrity Responsibilities Compliance with State Medicaid Plan, Applicable Laws and Regulations Article VI Payment Capitation Payments Modification of Capitation Rates during Agreement Period Rate-Setting Methodology Payment of Capitation Denial of Capitation Payments Department Right to Recover Premiums and Contractor Duty to Repay Third Party Health Insurance Determination Other Insurance and Settlements Contractor Financial Liability Spenddown and Net Available Monthly Income No Recourse Against Enrollees Notification Requirements to LDSS or Entity Designated by the Department Regarding Enrollees Contractor’s Fiscal Solvency Requirements Prohibition on Payments to Institutions or Entities Located Outside of the United States High-Cost, High-Need Risk Pool Nursing Home Price Mitigation Pool Conditions on Incentive Arrangements Risk Sharing Mechanisms Article VII Contractor Relationship with Providers Provider Relations Full Responsibility Retained Required Provisions Network Requirements for Covered Services Provider Termination Notice Recovery of Over Payments to Providers Optometry Services Provided by Article 28 Clinics Affiliated with the College of Optometry of the State University of New York Dental Services Provided by Article 28 Clinics Operated by Academic Dental Centers not Participating in Contractor’s Network Department Exclusion or Termination of Providers Health Home Services and Care Management Coordination Home Care Worker Wage Parity Fair Labor Standards Act INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 Minimum Wage Fiscal Intermediaries (FI) Value Based Payment (VBP) Arrangements Native Americans Indian Health Care Providers State Directed Payments Article VIII Records, Reporting and Certification Requirements A General Requirements B Maintenance of Contractor Performance Records, Records Evidencing Enrollment Fraud and Documentation Concerning Multiple CINs Maintenance of Financial Records and Statistical Data Access to Contractor Records Retention Periods Reporting Requirements Data Certifications Notification of Changes in Reporting Due Dates Requirements or Formats Ownership and Related Information Disclosure Public Access to Reports Certification Regarding Individuals Who Have Been Debarred or Suspended By Federal or State Government Conflict of Interest Disclosure OMIG’s Right to Audit and Recover Overpayments Caused by Contractor Submission of Misstated Reports OMIG’s Right to Audit and Recover Overpayments Which Were Caused by the Contractor’s Misstated Encounter Data 0 OMIG Audit Authority P OMIG Compliance Review Authority Q Notification to Audit Article [X Intermediate Sanctions Article X General Requirements Authorized Representative with Respect to Agreement Confidentiality Additional Actions and Documents Relationship of the Parties, Status of the Contractor Nondiscrimination Employment Practices Dispute Resolution Assignment Binding Effect Limitation on Benefits of this Agreement Entire Agreement Conflicting Provisions Modification Headings vi INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 Pronouns Notices Partial Invalidity Reserved Survival State Standard Appendix A Indemnification Environmental Compliance Energy Conservation Prohibition on Use of Federal Funds for Lobbying Waiver of Breach Choice of Law AA Executory Provision and Federal Funds BB. Renegotiation CC. Affirmative Action DD. Omnibus Procurement Act of 1992 EE. Nondiscrimination in Employment in Northern Ireland FF. Contract Insurance Requirements GG. Minority And Women Owned Business Policy Statement HH. Provisions Related to NY State Information Security Breach and Notification Act IL Accessibility of State Agency Web-based Intranet and Internet Information and Applications JJ. New York State Tax Law Section 5-a KK. Provisions Related to New York State Procurement Lobbying Law LL. Piggybacking MM. Lead Guidelines NN Payment 0O. M/WBE Utilization Plan for Subcontracting and Purchasing PP. On-going Vendor Responsibility QQ Veterans Protections Cultural and Linguistic Competence SS Native Americans Access to Services From Tribal or Urban Indian Health Facility TT Physical Location vii INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 APPENDICES APPENDIX A Standard Clauses for New York State Contracts APPENDIX B New York State Department of Health Guidelines for Contractor Compliance with the Federal Americans with Disabilities Act APPENDIX C Certification Regarding Lobbying APPENDIX D Reserved APPENDIX E-1 Requirements for Proof of Workers’ Compensation Coverage APPENDIX E-2 Requirements for Proof of Disability Insurance Coverage APPENDIX F Service Area and Ages of Population To Be Served APPENDIX G Covered and Non-Covered Services APPENDIX H Schedule of Capitation Rates APPENDIXI Reserved APPENDIX J Definitions APPENDIX K Grievance and Appeal System, Member Handbook Language, and Service Authorization Requirements APPENDIX L Enrollee Rights APPENDIX M Plan Information Requirements APPENDIX N New York State Department of Health Risk Sharing Mechanisms APPENDIX O Nursing Home Transition APPENDIX P State Directed Payments APPENDIX X Modification Agreement Form viii INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 PARTIAL CAPITATION MANAGED LONG TERM CARE AGREEMENT This AGREEMENT is hereby made by and between the State of New York Department of Health, hereinafter called the “Department” and ; hereinafter called the “Contractor” identified on the face page hereof. WHEREAS, the Department is the single State agency charged with the responsibility for administration of the New York State Medical Assistance Program (Medicaid), Title 11 of Article 5 of the Social Services Law (SSL); and WHEREAS, the Contractor has been certified as a managed long term care plan pursuant to New York State Public Health Law (PHL) §4403-f; and WHEREAS, the Contractor represents that the Contractor is able and willing to provide and arrange for health and long term care services on a capitated basis in accordance with PHL §4403-£: NOW, THEREFORE, in consideration of the foregoing and of the covenants and agreements hereinafter set forth, the Parties hereto agree as follows: INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 ARTICLE I CONTRACT TERM, RENEWAL, AND TERMINATION A. Term of Agreement Term: The Agreement shall begin on and, unless terminated sooner as permitted by the terms of this Agreement, end on the dates identified on the face page hereof. B. Renewal This Agreement is not renewable. C. Termination of the Agreement by the Department 1 The Department shall have the right to terminate this Agreement, if the Contractor, in the Department’s determination: a. takes any action that threatens the health, safety, or welfare of any Enrollee; b. has engaged in an unacceptable practice under 18 NYCRR 515, that affects the fiscal integrity of the Medicaid program, or has engaged in an unacceptable practice pursuant to section B of Article IX of this Agreement; has failed to substantially comply with applicable standards of Public Health Law (PHL) and regulations or has had its certificate of authority suspended, limited, or revoked; materially breaches this Agreement or fails to comply with any term or condition of this Agreement and such breach or failure is not cured within twenty (20) days, or such longer period as the Department may allow, of the Department’s notice of breach or noncompliance; becomes unable to meet its obligations in the normal course of business including but not limited to circumstances beyond its control and changes to the provider network affecting Enrollee access; or brings a proceeding voluntarily, or has a proceeding brought against it involuntarily, under Title 11 of the U.S. Code (Bankruptcy Code), and the petition is not vacated within thirty (30) days of its filing. 2 The Department shall give the Contractor written notice of termination of this Agreement, specifying the applicable termination provision(s) and the effective date of termination. D. Termination of the Agreement by the Contractor 1 The Contractor shall have the right to terminate this Agreement if the Department: INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 a. fails to make agreed-upon payments in a timely and accurate manner; or b. materially breaches the Agreement or fails to comply with any material term or condition of this Agreement. Contractor shall allow thirty (30) days, or such longer period as the Contractor may permit, from the time of the Contractor’s written notice of deficiency, for the Department to cure the identified deficiency. The Contractor shall give the Department written notice specifying the reason(s) 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 (FFS) program or transfer to another managed long term care plan (MLTCP), but no more than ninety (90) days. Other Termination Reasons This Agreement may be terminated by the Contractor or the Department as of the last day of any month upon no more than ninety (90) days prior written notice to the other Party so as to ensure an orderly transition. Notwithstanding this provision, the Contractor agrees to comply with sections F and G of this Article. This Agreement shall be terminated immediately if federal financial participation in the costs hereof becomes unavailable or if state funds sufficient to fulfill the obligation of the Department hereunder are not appropriated by the New York State Legislature. The Department will give the Contractor prompt written notice of such termination of this Contract. This Agreement may be terminated in accordance with the provisions of section BB of Article X of this Agreement. Requirements Pertaining to Service Area Reductions and Mergers, Acquisitions and Other Arrangements 1 Requests to reduce the Contractor’s service area, or to alter or cease Contractor operations by merging with or being acquired by another MLTC plan, or by other arrangement, must be submitted in writing to the Department, and receive specific endorsement, prior to any action by the Contractor. Enrollees may not be transitioned or disenrolled until the request for service area reduction, merger, acquisition, or other acceptable arrangement, and all Enrollee notifications, have been approved by the Department. Any such arrangements shall be subject to the phase-out plan requirements, as applicable, in this Agreement for contractor-initiated terminations, including Section G of Article I. G. Agreement Expiration and Contractor Termination/Phase-Out Plan INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 The Contractor hereby agrees that in the event this Agreement is terminated by either Party, or Contractor receives Department approval for an arrangement described in Section F of Article I of this Agreement, that the Contractor will continue to provide Covered Services to Enrollees until Enrollees are reinstated to FFS care or transferred to another MLTCP. To the extent that such services are provided by the Contractor to Enrollees prior to their disenrollment into a FFS program or transfer to another MLTCP, the Contractor will continue to be reimbursed a premium for such Enrollee. Upon expiration and non-renewal or termination of this Agreement, the Contractor shall comply with the termination plan that the Contractor has developed and that the Department has approved. In the event that the Contractor gives notice to terminate this Agreement, the Contractor shall submit a termination plan for Department approval with the Contractor’s notice of termination. In the event that the Department gives notice to terminate this Agreement, the Contractor shall submit within fifteen (15) days of notice or such longer period as the Department may allow a termination plan for Department approval. Sixty (60) days prior to the date of termination, or as otherwise determined by the department pursuant to guidance, the Contractor shall advise all current Enrollees of the termination by regular first class mail. In the event that the termination date is established less than sixty (60) days in advance, letters shall be mailed by regular first class mail within five (5) business days ofthe establishment of the termination date. The Contractor shall communicate with Local Department of Social Services (LDSS) or entity designated by the Department within fifteen (15) days of the establishment of the termination date to offer LDSS(s) or entity designated by the Department assistance and information necessary to reinstate each Enrollee’s Medicaid benefits through the FFS system or facilitate enrollment in another MLTCP or managed care plan. As soon as a termination date has been established and appropriate notice given pursuant to this Agreement by either the Contractor or the Department: a. The Contractor shall work with the LDSS or entity designated by the state to ensure enrollees are informed oftheir MLTCP and FFS options, and to effectuate transfer to the plan or option selected by the Enrollee.; the Contractor shall contact other community resources to determine the availability of other programs to accept the Enrollees into their programs; the Contractor shall assist Enrollees by referring them and by making their care management record and other enrollee service records available as appropriate to health care providers and/or programs; 7 In conjunction with such termination and disenrollment, the Contractor shall provide such other reasonable assistance as the Department may request in effecting that transition. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 Enrollees will be provided with education on all available plan options. Contractor must accept the transfer of all Enrollees affected by the termination of another MLTCP that select or are auto-assigned to Contractor. These transferring Enrollees are presumed to meet the eligibility requirements for MLTC. Contractor must accept enrollment of these Enrollees, and is not required to conduct an assessment prior to enrollment. Within sixty (60) days of the date of termination of the Agreement, an accounting shall be prepared and submitted to the Department by or on behalf of the Contractor for the establishment of a sum to be repaid to the Department by the Contractor of funds advanced by the Department, if any, for coverage of Enrollees for periods subsequent to the date of termination. 10. The Contractor shall maintain all books, records and other documents that may be required pursuant to this Agreement regarding the Partial Capitation MLTCP and make such records available to the Department and all authorized representatives of the state and federal government throughout the period that such records are required to be maintained pursuant to this Agreement. H. Effect of Termination on New Enrollments Once either Party has given notice of its intentions to terminate this Agreement, the Contractor shall suspend enrollment into its Partial Capitation MLTCP and it will be removed from auto assignment. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 ARTICLE II STATUTORY AND REGULATORY COMPLIANCE The Contractor agrees to operate in compliance with the requirements of this Agreement, legislative and regulatory requirements including, but not limited to, 42 Code of Federal Regulation (CFR) Parts 434 and 438 and PHL §4403-f and other applicable provisions of PHL Articles 44 and 49. Covered services provided by the Contractor under this Agreement shall comply with all standards of the New York State Medicaid Plan established pursuant to New York Social Services Law (SSL) § 363-a and satisfy all other applicable requirements of SSL and PHL, and Titles 10 and 18 of the New York Code of Rules and Regulations (NYCRR), title XIX of the Social Security Act and regulations promulgated pursuant thereto, the terms and conditions of any federal waiver applicable to the provision of Medicaid services by a managed care plan approved by CMS under Section 1115 of the Social Security Act, and all other applicable federal and state statutes, regulations, guidelines and directives. C. The Contractor agrees to comply with all applicable laws, regulations, and rules and to not violate statutes and regulations, including but not limited to: Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR Part 80; The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR Part 91; The Rehabilitation Act of 1973 as implemented by regulations at 45 CFR Part 84; The Americans with Disabilities Act (ADA); The Health Insurance Portability and Accountability Act (HIPAA); The Patient Protection and Affordable Care Act; False Claims Act 31 U.S.C. 3729(a); CMS Managed Care regulations 42 CFR Part 438; 9 Social Services Law 145-b; 10. Social Services Law §366-f; 11. State Finance Law § 189 et seq. 12. Other laws applicable to recipients of federal funds; and 13. The New York City Health Code for Contractors operating in New York City. The Contractor must comply with Title II of the ADA and section 504 of the Rehabilitation Act of 1973 for program accessibility, and must develop an ADA Compliance Plan consistent with the New York State Department of Health Guidelines for Contractor Compliance with the ADA set forth in Appendix B, which is hereby made a part of this Agreement as if set forth fully herein. Said plan must be approved by the Department, be filed with the Department, and be kept on file by the Contractor. The Contractor agrees to implement a compliance plan in accordance with the requirements of 42 CFR § 438.608, New York Social Services Law Section 363-d, and Title 18 New York Codes of Rules and Regulations Part 521. F. The Contractor is receiving federal and state payments under this Agreement. The Contractor and subcontractors paid by the Contractor to fulfill its obligations under this Agreement are subject to certain laws that are applicable to individuals and entities receiving federal and state 6 INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 funds. The Contractor agrees to inform all subcontractors that payments that they receive are, in whole or in part, from federal funds. In the event that any provisions of this Agreement conflicts with the provisions of any statute or regulations applicable to a Contractor, the provisions of the statute or regulations shall have control. The Contractor agrees to abide by any and all applicable guidance issued in writing by the Department to Partial Capitation MLTC plans. The Contractor shall comply with all applicable guidance contained within the Medicaid Update publication issued by the Department. The Contractor shall not expend any funds provided through this Agreement for roads, bridges, stadiums, or any item or service not described in the State Medicaid Plan, except when such expenditures are for an item or service: 1 otherwise permissible under this Agreement; 2. allowable under 42 CFR 438.3; or 3. that the Contractor has been directed by the Department to provide pursuant to Article V.A.2 of this Agreement. a) Should any part of the scope of work under this Agreement relate to a program or activity of the State Medicaid Program that is no longer authorized by law (e.g., which has been vacated by a court of law, or for which CMS has withdrawn federal authority, or which is the subject of a legislative repeal), the Contractor shall do no work on that part after the effective date of the loss of authority. The SDOH shall adjust Capitation Rates to remove costs that are specific to any program or activity that is no longer authorized by law. If the Contractor works on a program or activity no longer authorized by law after the date the legal authority for the work ends, the Contractor shall not be paid for that work. If the state paid the Contractor in advance to work on a no-longer-authorized program or activity and under the terms of this Agreement the work was to be performed after the date the legal authority ended, the payment for that work should be returned to the state in accordance with direction from SDOH. However, if the Contractor worked on a program or activity prior to the date legal authority ended for that program or activity, and the state included the cost of performing that work in its payments to the Contractor, the Contractor may keep the payment for that work even if the payment was made after the date the program or activity lost legal authority. b) The SDOH shall provide notice to the Contractor that shall include the effective date of the loss of authority for a program or activity of the State Medicaid Program and identify the affected parts of this Agreement pursuant to the requirements of Article II, Section K(a) of this Agreement. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 c) Notwithstanding the requirements of paragraphs (a) and (b) above, as directed by SDOH, the Contractor shall continue work under this Agreement related to a program or activity of the State Medicaid Program that is solely authorized under New York State law. Such work may not be subject to federal financial participation. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 ARTICLE III CONTRACTOR SERVICE AREA AND AGE GROUPS SERVED A. Service Area 1 For purposes of this Agreement, the Contractor's service area shall consist of the geographic area described in Appendix F. 2. To reduce its service area, the Contractor must request written Department approval in accordance with the provisions of this Agreement and applicable guidelines. The Contractor shall not take any actions to modify its service area until it has received such approval from the Department. To expand its service area, the Contractor must file a Service Area Expansion Application with the Department. Upon review and approval, the Department will issue a written notification of approval to expand. The Contractor shall not begin any enrollment activities in the new service area until and unless it has received approval from the Department. Any modifications made to Appendix F resulting from an approved request to expand or reduce the Contractor’s service area shall become effective on the date written Department approval is issued. B. Ages Served 1 The age groups served by the Contractor are identified in Appendix F. 2. The Contractor must request written Department approval to make any changes in the age groups served through this Agreement. The Contractor shall not modify the age groups served until it has received such approval from the Department. Any modifications made to Appendix F resulting from an approved request to change the age groups served by the Contractor through this Agreement shall become effective the date the written Department approval is issued C. Contractor Obligation to Notify Enrollees of Service Area Modifications In the event of a service area modification, it is the responsibility of the Contractor to provide affected Enrollees with prior notification. No Service Area modification activities will commence until the Department approves a transition plan and the content of Enrollee notification communications. D. Contractor Obligation to Notify Enrollees of Change in Age Groups Served In the event of a change in age groups served, it is the responsibility of the Contractor to provide affected Enrollees prior notification. INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 ARTICLE IV ELIGIBILITY FOR PARTIAL CAPITATION MANAGED LONG TERM CARE A. Populations Eligible for Enrollment 1. Mandatory Enrollment Counties: Upon approval of the Department and CMS, counties are designated as Mandatory for MLTC (Mandatory). The Contractor will be notified at least sixty (60) days in advance when a county is designated as Mandatory. In these counties, dual eligible individuals (having both Medicare and Medicaid), who are age 21 and older and who are assessed as needing community based long term care services listed in section B subsection 6 of this Article for a continuous period of more than 120 days must enroll in MLTC in order to receive those services. These individuals are defined as MLTC Mandatory Persons. In Mandatory counties, the following may voluntarily enroll in MLTC: a. dual eligible individuals, age 18-20, who have been assessed by the Contractor as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for a continuous period of more than 120 days; and non-dual eligible individuals, age 18 and older, who have been ass ssed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for a continuous period of more than 120 days. 2. Non-Mandatory Enrollment Counties: In Non-Mandatory Enrollment Counties, the following may voluntarily enroll in MLTC: a. dual eligible individuals, age 18 and older, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care for a continuous period of more than 120 days may choose to enroll in MLTC; b. non-dual eligible individuals age 18 and older, who are not otherwise considered mandatory for managed care, who have been assessed as eligible for nursing home level; and c. dual eligible individuals who are age 21 or older, who are assessed as needing community based long term care services for a continuous period of more than 120 days, may choose to enroll in MLTC. 10 INDEX NO. E180898/2023 NYSCEF DOC. NO. 25 RECEIVED NYSCEF: 12/01/2023 B. Eligibility Requirements Except as specified in section C of this Article, an Applicant who completes an enrollment agreement shall be eligible to enroll under the terms of this Agreement if he/she: 1 meets the age requirements identified in Appendix F; 2 is a resident in the Contractor’s service area; is determined eligible for Medicaid by the LDSS or entity designated by the