LIFEPlan CCO NY, LLC Participation Agreement. Provider:

Transcription

1 LIFEPlan CCO NY, LLC Participation Agreement This Agreement made between LIFEPlan CCO NY, LLC 1020 Mary Street, Utica, NY And Provider: Provider and LIFEPlan may each be referred to individually as a Party or collectively as the Parties. LIFEPlan CCO NY, LLC was formed in 2017 to seek designation as a New York State Care Coordination Organization ( CCO) to offer conflict free care management ( CFCM ) to people with intellectual and developmental disabilities in two OPWDD regions of the State including the counties of Albany, Broome, Cayuga, Chenango, Clinton, Columbia, Cortland, Delaware, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Orange, Oswego, Otsego, Putnam, Rensselaer, Rockland, St. Lawrence, Saratoga, Schenectady, Schoharie, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington, and Westchester The Provider wishes to become a preferred participating provider of LIFEPlan CCO once it achieves designation as a CCO. The parties agree as follows: 1.) The Provider agrees not to enter into any arrangement or agreement regarding the provision of CFCM with any other potential entities responding, or which have responded, to the Requests For Application for the provision of CFCM in the counties identified above pending LIFEPlan s approval as a CCO (the Exclusivity Period ). In

2 the event that LIFEPlan is not designated as a CCO, the Exclusivity Period shall terminate. 2.) Upon LIFEPlan s designation as a CCO, the parties shall enter into a more definitive agreement setting forth and defining their respective rights and responsibilities. 3.) Provider authorizes LIFEPlan to identify and incorporate Provider as a participant in its application to OPWDD to become a care coordination organization. 4.) The Parties agree, during the Exclusivity Period, to cooperate and negotiate in good faith for the purpose of consummating this transaction and entering into a more definitive agreement. 5.) The Parties acknowledge and agree that this agreement is only concerned with targeted case management services (funded by the State and Federal Government) and Plan of Care of Support Services funded through the HCBS Waiver and does not pertain to any other payors whether commercial or otherwise, or any other types of services that the Parties may provide. 6.) This Agreement shall be executed in duplicate original, and all notices and amendments made as provided herein shall be made in duplicate and attached to the respective duplicate originals. Both duplicate originals shall together constitute one and the same instrument. This Agreement may only be amended or canceled by a written instrument subscribed to by the parties hereto. Provider: Name: Title: Date: LIFEPlan CCO NY, LLC Name: Title: Date: - 2 -

3 The following information MUST be provided in order to include your organization as a part of the LIFEPlan CCO Provider Network Partner Name Partner NPI (10 digit provider #) Date Joined CCO/HH network Are you a Medicaid Service Coordination (MSC) Agency? (yes/no) If yes, provide the number of individuals your MSC Agency currently serves Regions/Counties in which the provider will provide Care Coordination services Care Management Agency Regions/Counties in which the provider will provide Care Management services Instructions: For Partners that provide more than one Developmental Disability Service, please select all that apply and please indicate if where selected services are provided. For Developmental Disability Service Providers- Please indicate services provided (yes/no) Regions/Counties served See Charts Assistive Technology- Adaptive Devices/ Environmental Modifications Community Habilitation Day Habilitation Family Education and Training Fiscal Intermediary Intensive Behavioral Services (IBP) Pathway to Employment Pre-Vocational Services IRA Supervised IRA Supported Family Care Respite Supported Employment - 3 -

4 For Health/Behavioral Health Care Service Providers- Please indicate services provided (yes/no) Regions/Counties served See Charts Behavioral Health Rehabilitation Services Free Standing Clinic Home Health Inpatient Hospital LTSS: Adult Day Health LTSS: Personal Care Medical Care Providers Nursing Outpatient Hospital Regional START Team Skilled Nursing Facility Supportive Health Services Miscellaneous Specify Miscellaneous Service Regions: Region 2 - All Broome Cayuga Chenango Clinton Cortland Delaware Essex Franklin Hamilton Herkimer Jefferson Lewis Madison Oneida Onondaga Oswego Otsego St. Lawrence Tioga Tompkins Region 3 - All Albany Columbia Dutchess Fulton Greene Montgomery Orange Putnam Rensselaer Rockland Saratoga Schenectady Schoharie Sullivan Ulster Warren Washington Westchester - 4 -

5 Counties Served, if not entire region: Please send the completed form to or - 5 -