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State of New York Department of HealthDelivery System Reform Incentive Payment (DSRIP) ProgramProject Design Grant Application

Application Due on: June 26, 2014There will be no extensions for this application. Any application submitted past the due date will not be considered.

Section 1Lead Applicant Info & Project Point of ContactSection 6List of VendorsSection 2Partner Organization - Contact InfoSection 7Design Grant TimelineSection 3Partner Organizations & Service AreaSection 8Data RequestSection 4Project Program Overview & DescriptionSection 9Design Grant BudgetSection 5Community Needs Assessment & Stakeholder Engagement**Section 10 Project Advisory Committee (PAC) Form - (RELOCATED)^ Due to changes, this section has been RELOCATED and made as a separate form which still needs to be filled out and can be found on the DSRIP website under "DSRIP Project Design Grant Application".

To understand the Project Design Grant Application, carefully and thoroughly read through the Instructions before completing this application.

As a reminder and an addition to the instructions, you MUST read through the following state documents which are provided on the DSRIP website (see link below).

Special Terms & ConditionsAttachment IAttachment J(Recommend)- PowerPoint/WebinarDSRIP LINK:https://www.health.ny.gov/health_care/medicaid/redesign/delivery_system_reform_incentive_payment_program.htm

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https://www.health.ny.gov/health_care/medicaid/redesign/delivery_system_reform_incentive_payment_program.htm

Section 1_Lead Info

Project Point of ContactLead Applicant InformationPrimary ContactContact Person:Phil Hirschhorn, DDS1.1)Organization Name:AMERICAN DENTAL OFFICES PLLCAddressCityStateZip CodeOperating Certificate # (Opcert):Organization Address:390 N. BROADWAY, SUITE 110JERICHONY11753Provider Type:OtherContact Phone Number:5168228700Extension:108Provider Type - OTHER:LARGE DENTAL PROVIDER ACTING AS DENTAL HOSPITALContact Email:[email protected] MMIS:30474181.4)Billing Entity ID:Secondary ContactNPI #1: 1295997724Contact Person:KATHY BECCARINONPI #2: AddressCityStateZip CodeFederal Employer ID (FEIN):Organization Address:390 N. BROADWAY, SUITE 110JERICHONY11753Contact Phone Number:5168228700Extension:249Contact Email:[email protected]

1.2)Please provide a brief statement as to why the lead organization is qualified to serve in this capacity. ( Restricted to 3000 characters)We are the largest provider of private dental services in New York State. We have treated over 1 million patients in our 50 years of business! Our dental health delivery system is different and more efficient than a typical dental office. Our facilities are called dental super-centers because they are large in size and have a large capacity to see many families at the same time. These facilities are more like dental hospitals where each one has a full complement of general dentists as well as specialists. As the largest Dental care provider organization in the State of NY, American Dental Offices PLLC (ADO) has pioneered the concept of delivering quality care at a reasonable cost while making a profit. We are like a Dental Hospital, however we do not operate like hospitals and do not have any form of inpatient care. Through the use of technology, the inclusion the patients at the center of their care, the use of highly qualified professionals to deliver and manage the care, we have been growing our Medicaid patient volume over the past 5 years to the point we are now the preferred dental organization for a number of Managed Care and TPA in the NY region. Having been such a model of efficiency for 50 years, ADO is best placed to lead the formation of the PPS in our region and truly work towards reducing hospital admissions by 25% over the next 5 years of the program. Being in dentistry, ADO has learned to manage on lower levels of reimbursement and developed protocols, policies and procedures along with the proper governance to ensure success to any PPS. These lessons learned can serve as a basis to model after in all other areas of medical care delivery to ensure a higher level of care and patient satisfaction while keeping cost in line.In order to truly redesign Medicaid and improve care delivery to the recipients while reducing cost, we have to have a new approach and in our opinion, it will have to come from outside of the main stream care delivery system that has been less than fully willing and capable of delivering on the promise of better care at lower cost. American Dental Offices PLLC have successfully demonstrated this is possible and we are willing to take the lead role in the formation of PPS and share our experience with the rest of the care delivery system.

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1.3)Based on the lead applicant provider type, please fill out the applicable section below to verify that you meet the DSRIP safety- net definition (Either Hospital OR Non-hospital based) :

Hospital: A hospital must meet one of the three following criteria to participate in a performing provider system:ORNon-Hospital Based Provider - Must meet the following criteria:

#1Is the lead applicant one of the following providers? None of the aboveNot participating as part of a state-designated Health Home, must have at least 35 percent of all patient volume in their primary lines of business and must be associated with Medicaid, uninsured and Dual Eligible individuals. (Please indicate what %)%ORSelect One#2 - Must pass both A & B test (Please indicate what % for both tests)%A.At least 35 percent of patient volume in their outpatient lines of business must be associated with Medicaid, uninsured, and Dual Eligible individuals2ASelect OneB. At least 30 percent of inpatient treatment associated with Medicaid, uninsured, and Dual Eligible individuals2B

ORMust serve at least 30 percent of all Medicaid, uninsured and Dual Eligible members in the proposed county or multi-county community. (The state will use Medicaid claims and encounter data as well as other sources to verify this claim. The state reserves the right to increase this percentage on a case by case basis so as to ensure that the needs of each community's Medicaid members are met.(Please indicate what %)#3YES337.51

For Safety-net definition, please see link: https://www.health.ny.gov/health_care/medicaid/redesign/docs/safety_net_definitions.pdf

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&12NYS DOH DSRIP_Project Design Grant Application &12Page 1&12Applicant Info_Project Contact_Partner Organizations

&12NYS DOH DSRIP_Project Design Grant Application &12Page 1&12Applicant Info_Project Contact_Partner Organizations

&12NYS DOH DSRIP_Project Design Grant Application &12Section 1&12Applicant Info_Project Contact_Partner Organizations

https://www.health.ny.gov/health_care/medicaid/redesign/docs/safety_net_definitions.pdf

Section 2_Partner Org.

2.1)Partner Organizations - Contact Information

1Organization Name:2Organization Name:Qualified Under Safety Net Definition?Select One(Please select Yes or No)Qualified Under Safety Net Definition?Select One(Please select Yes or No)AddressCityStateZip CodeAddressCityStateZip CodeOrganization Address:Organization Address:Contact Person:Contact Person:Contact Phone Number:Extension:Contact Phone Number:Extension:Contact Email:Contact Email:Provider Type:Select OneProvider Type:Select OneProvider Type - OTHER:MMIS:Provider Type - OTHER:MMIS:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:NPI #1: NPI #1: NPI #2: NPI #2: Federal Employer ID (FEIN):Federal Employer ID (FEIN):

3Organization Name:4Organization Name:Qualified Under Safety Net Definition?Select One(Please select Yes or No)Qualified Under Safety Net Definition?Select One(Please select Yes or No)AddressCityStateZip CodeAddressCityStateZip CodeOrganization Address:Organization Address:Contact Person:Contact Person:Contact Phone Number:Extension:Contact Phone Number:Extension:Contact Email:Contact Email:Provider Type:Select OneProvider Type:Select OneProvider Type - OTHER:MMIS:Provider Type - OTHER:MMIS:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:NPI #1: NPI #1: NPI #2: NPI #2: Federal Employer ID (FEIN):Federal Employer ID (FEIN):

5Organization Name:6Organization Name:Qualified Under Safety Net Definition?Select One(Please select Yes or No)Qualified Under Safety Net Definition?Select One(Please select Yes or No)AddressCityStateZip CodeAddressCityStateZip CodeOrganization Address:Organization Address:Contact Person:Contact Person:Contact Phone Number:Extension:Contact Phone Number:Extension:Contact Email:Contact Email:Provider Type:Select OneProvider Type:Select OneProvider Type - OTHER:MMIS:Provider Type - OTHER:MMIS:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:NPI #1: NPI #1: NPI #2: NPI #2: Federal Employer ID (FEIN):Federal Employer ID (FEIN):

7Organization Name:8Organization Name:Qualified Under Safety Net Definition?Select One(Please select Yes or No)Qualified Under Safety Net Definition?Select One(Please select Yes or No)AddressCityStateZip CodeAddressCityStateZip CodeOrganization Address:Organization Address:Contact Person:Contact Person:Contact Phone Number:Extension:Contact Phone Number:Extension:Contact Email:Contact Email:Provider Type:Select OneProvider Type:Select OneProvider Type - OTHER:MMIS:Provider Type - OTHER:MMIS:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:Operating Certificate Number (OPCERT):Billing/Provider Entity ID:NPI #1:

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