Return to Form 8-k
[form8k.htm]
 

 HealthEase of Florida, Inc.    Medicaid HMO Non-Reform Contract   AHCA CONTRACT
NO. FA905     AMENDMENT NO. 8        

 

  THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH
CARE
 ADMINISTRATION,  hereinafter  referred  to  as  the  "Agency"  and  HEALTHEASE
 OF FLORIDA, INC., hereinafter referred to as the "Vendor" or “Health Plan,” is
hereby amended as follows:

 

 
1.
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health
Plans, Section D., Service(s) to be Provided, Item 1., Covered Medicaid
Services, sub-item b.(3)(c), is hereby amended to include Table 5-A, Revised
Health Plan Covered Services Chart, as follows.  All references in the Contract
to Table 5, Health Plan Covered Services Chart shall hereinafter also refer to
Table 5-A, Revised Health Plan Covered Services Chart, as appropriate.

 
 

TABLE 5-A
Revised Health Plan Covered Services Chart
Non- Reform Covered
Reform
Covered
Advanced Registered Nurse Practitioner Services
X
 
Ambulatory Surgical Center Services
X
 
Birth Center Services
X
 
Child Health Check-Up Services
X
 
Chiropractic Services
X
 
Community Behavioral Health Services
X
 
County Health Department Services
X
 
Dental Services*
   
Durable Medical Equipment and Medical Supplies
X
 
Dialysis Services
X
 
Emergency Room Services
X
 
Family Planning Services
X
 
Federally Qualified Health Center Services
X
 
Frail/Elderly Program Services*
   
Freestanding Dialysis Centers
X
 
Hearing Services
X
 
Home Health Care Services
X
 
Hospital Services – Inpatient
X
 
Hospital Services – Outpatient
X
 
Immunizations
X
 
Independent Laboratory Services
X
 
Licensed Midwife Services
X
 
Optometric Services
X
 
Physician Services
X
 
Physician Assistant Services
X
 
Podiatry Services
X
 

 
 AHCA Contract No. FA905, Amendment No. 8, Page 1 of 3

--------------------------------------------------------------------------------

 
 

HealthEase of Florida, Inc.    Medicaid HMO Non-Reform Contract

TABLE 5-A
   
Revised Health Plan Covered Services Chart
Non- Reform Covered
Reform
Covered
Portable X-ray Services
X
 
Prescribed Drugs
X
 
Prescribed Pediatric Extended Care Services
   
Primary Care Case Management Services
X
      Private Duty Nursing (for Specialty Plan for Children with Chronic
Conditions ONLY)  
 
Rural Health Clinic Services
X
 
Targeted Case Management
X
 
Therapy Services: Occupational
X
 
Therapy Services: Physical
X
 
Therapy Services: Respiratory
X
 
Therapy Services: Speech
X
 
Transplant Services
X
 
Transportation Services*
   
Vision Services
X
 

 
 
 

 
2.
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health
Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded
Benefits, sub-item a., is hereby amended to include Table 6-B, Revised Expanded
Services, as follows.  All references in the Contract to Table 6, Expanded
Services, and Table 6-A, Revised Expanded Services shall hereinafter also refer
to Table 6-B, as appropriate.

 
TABLE 6-B
Revised Expanded Services
Effective January 1, 2012
Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies.

 
 

 
3. 
Effective September 1, 2011, Attachment I, Scope of  Services, Capitated Health
Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective
September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit
2-NR-C, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011,
attached hereto and made a part of this Contract.  All references in the
Contract to Exhibit 2-NR-B, shall hereinafter refer to Exhibit 2- NR-C, as
appropriate.

 

  Unless otherwise stated, this amendment is effective upon execution.

 

  All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in the Contract. 

 

  This amendment, and all its attachments, are hereby made part of the Contract.

 
AHCA Contract No. FA905, Amendment No. 8, Page 2 of 3
 

--------------------------------------------------------------------------------

 
 

HealthEase of Florida, Inc.    Medicaid HMO Non-Reform Contract

  This amendment cannot be executed unless all previous amendments to this
Contract have been fully executed.

 

  IN WITNESS WHEREOF, the Parties hereto have caused this eight (8) page
amendment (including all attachments) to be executed by their officials
thereunto duly authorized.

 

HEALTHEASE OF FLORIDA, INC.   STATE OF FLORIDA, AGENCY FOR       HEALTH CARE
ADMINISTRATION           By: /s/Christina Cooper   By: /s/ Tonya Kidd for      
    Name: Christina Cooper   Name: Elizabeth Dudek           Title:  President,
FL & HI Division   Title: Secretary           Date:   12/27/11   Date: 12/29/11
 

 
 
List of Attachments/Exhibits included as part of this amendment:
 
 
Specify
Type
Letter/
Number
 
Description
 Attachment I Exhibit 2-NR-C
Medicaid Non-Reform HMO Capitation Rates,
Effective September 1, 2011 (5 pages)

 
 
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

  AHCA Contract No. FA905, Amendment No. 8, Page 3 of 3
 

--------------------------------------------------------------------------------

 
 
 
 

 ATTACHMENT I  EXHIBIT 2-NR-C  MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS  By Area, Age
and Eligibility Category  Effective September 1, 2011

 
General Rates:
                                                                               
     
TANF
           
SSI-N
   
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                                                             
01
944.58
184.93
99.14
62.81
127.84
67.50
271.85
155.86
430.03
12,534.08
1,853.67
459.10
183.60
219.90
719.01
846.95
304.31
95.72
75.16
02
809.74
158.54
85.26
55.17
110.84
59.12
234.16
134.73
369.40
10,634.20
1,571.89
378.61
129.11
165.06
567.50
702.50
304.31
85.34
66.80
03
977.48
191.38
102.88
66.37
133.57
71.13
282.47
162.44
445.78
13,033.48
1,927.78
480.73
199.09
235.25
760.70
885.63
304.31
86.58
67.80
04
982.26
192.25
101.91
59.51
127.52
64.77
277.81
157.18
443.92
13,413.62
1,983.70
490.64
194.84
234.00
766.84
905.39
304.31
79.94
62.45
05
1,109.71
217.27
116.92
75.94
152.20
81.32
321.19
184.92
506.42
14,476.72
2,141.09
531.81
215.85
257.04
836.50
980.51
304.31
74.93
58.42
06
1,021.04
199.94
108.39
73.89
143.78
78.57
298.90
173.52
468.21
13,062.91
1,932.30
484.19
205.34
240.45
771.66
891.12
304.31
73.50
57.26
07
966.83
189.24
100.39
58.99
125.91
64.15
273.80
155.07
437.19
13,593.51
2,010.10
494.41
190.58
231.59
766.17
913.39
304.31
72.84
56.74
08
952.04
186.41
100.57
66.44
131.76
70.95
276.63
159.73
435.19
12,412.16
1,835.77
456.44
186.23
221.31
719.07
841.38
304.31
80.42
62.84
09
1,032.49
202.14
108.41
68.86
139.93
73.98
297.32
170.54
470.17
14,347.56
2,121.42
519.54
195.54
239.92
799.72
960.67
304.31
82.17
64.25
10
1,028.53
201.37
108.26
69.90
140.62
74.92
297.28
170.98
469.11
17,915.36
2,649.60
657.40
265.37
316.67
1,032.39
1,212.35
304.31
92.58
72.64
11
1,187.84
232.59
125.70
84.02
165.46
89.59
346.10
200.24
543.62
15,014.29
2,220.47
549.99
220.03
263.49
861.45
1,014.60
304.31
120.99
95.51
6B *
1,020.54
199.85
108.39
74.07
143.91
78.73
298.94
173.63
468.11
13,061.73
1,932.14
484.22
205.49
240.58
771.87
891.14
304.31
73.50
57.26

 
 
TABLE 2
General + Mental Health Rates:
                                                                               
   
TANF
           
SSI-N
   
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                                                             
01
944.69
185.04
101.42
73.90
138.20
77.86
281.21
165.22
436.32
12,535.85
1,855.44
479.56
233.51
260.16
798.67
877.14
321.65
105.67
85.11
02
809.82
158.62
86.94
63.35
118.47
66.75
241.06
141.63
374.03
10,636.65
1,574.34
406.90
198.14
220.74
677.67
744.25
321.65
95.29
76.75
03
977.58
191.48
104.95
76.48
143.01
80.57
291.00
170.97
451.51
13,035.03
1,929.33
498.65
242.81
270.52
830.48
912.07
321.65
96.53
77.75
04
982.44
192.43
105.47
76.86
143.72
80.97
292.45
171.82
453.76
13,415.57
1,985.65
513.21
249.90
278.41
854.72
938.69
321.65
89.89
72.40
05
1,109.82
217.38
119.15
86.82
162.35
91.47
330.37
194.10
512.59
14,478.63
2,143.00
553.88
269.70
300.48
922.45
1,013.08
321.65
84.88
68.37
06
1,021.10
200.00
109.62
79.88
149.37
84.16
303.96
178.58
471.61
13,064.26
1,933.65
499.77
243.36
271.12
832.34
914.11
321.65
83.45
67.21
07
967.00
189.41
103.81
75.65
141.46
79.70
287.85
169.12
446.63
13,595.73
2,012.32
520.10
253.26
282.15
866.20
951.30
321.65
82.79
66.69
08
952.12
186.49
102.22
74.49
139.28
78.47
283.42
166.52
439.76
12,413.76
1,837.37
474.89
231.24
257.62
790.90
868.60
321.65
90.37
72.79
09
1,032.61
202.26
110.86
80.78
151.06
85.11
307.38
180.60
476.93
14,350.11
2,123.97
548.96
267.31
297.81
914.26
1,004.08
321.65
92.12
74.20
10
1,028.64
201.48
110.43
80.47
150.48
84.78
306.20
179.90
475.10
17,917.79
2,652.03
685.44
333.77
371.85
1,141.56
1,253.72
321.65
102.53
82.59
11
1,187.93
232.68
127.53
92.93
173.78
97.91
353.62
207.76
548.67
15,016.41
2,222.59
574.45
279.72
311.64
956.71
1,050.70
321.65
130.94
105.46
6B *
1,020.60
199.91
109.57
79.84
149.30
84.12
303.81
178.50
471.38
13,063.07
1,933.48
499.73
243.33
271.10
832.26
914.03
321.65
83.45
67.21

 
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 1 of 5 

--------------------------------------------------------------------------------

 
 
 

 ATTACHMENT I  EXHIBIT 2-NR-C  MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS  By Area, Age
and Eligibility Category  Effective September 1, 2011

 
 
 
TABLE 3
                               
General + MH + Dental Rates:
                                                                         
TANF
                 
SSI-N
         
SSI-B
SSI-AB
 
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                                                             
01
944.69
185.06
103.23
76.91
140.85
80.79
282.97
166.83
439.41
12,535.91
1,855.47
481.31
235.72
262.09
800.18
879.25
323.95
106.76
86.03
02
809.83
158.64
89.86
68.21
122.74
71.49
243.79
144.12
378.82
10,636.74
1,574.39
409.58
201.51
223.69
679.30
746.53
323.95
96.63
77.87
03
977.59
191.53
110.77
86.18
151.54
90.02
294.80
174.45
458.19
13,035.24
1,929.45
504.95
250.74
277.45
832.71
915.19
323.95
98.64
79.52
04
982.45
192.46
108.89
82.56
148.73
86.53
296.76
175.76
461.32
13,415.69
1,985.72
516.72
254.31
282.27
857.39
942.42
323.95
92.21
74.35
05
1,109.84
217.44
125.83
97.95
172.14
102.32
334.38
197.77
519.63
14,478.85
2,143.13
560.70
278.28
307.98
924.69
1,016.22
323.95
87.28
70.38
06
1,021.11
200.04
114.54
88.08
156.58
92.15
306.21
180.64
475.56
13,064.42
1,933.74
504.77
249.66
276.62
833.92
916.32
323.95
85.20
68.68
07
967.01
189.46
109.65
85.37
150.01
89.18
290.76
171.78
451.74
13,595.93
2,012.43
526.15
260.87
288.80
868.02
953.84
323.95
84.50
68.13
08
952.14
186.58
112.21
91.13
153.91
94.69
286.81
169.62
445.71
12,414.04
1,837.53
483.35
241.89
266.93
792.93
871.43
323.95
92.29
74.40
09
1,032.63
202.32
118.34
93.24
162.01
97.26
310.56
183.50
482.50
14,350.33
2,124.09
555.67
275.75
305.19
916.18
1,006.76
323.95
93.99
75.77
10
1,028.65
201.51
114.40
87.08
156.30
91.23
307.29
180.90
477.01
17,917.96
2,652.12
690.55
340.20
377.47
1,142.86
1,255.53
323.95
103.74
83.61
11
1,188.00
232.75
137.40
108.70
186.71
110.84
355.80
209.75
552.50
15,016.42
2,222.60
586.08
291.88
320.59
959.38
1,054.43
323.95
134.01
108.03
6B *
1,020.61
199.95
114.49
88.04
156.51
92.11
306.06
180.56
475.33
13,063.23
1,933.57
504.73
249.63
276.60
833.84
916.24
323.95
85.20
68.68

 
 
 
TABLE 4
General + MH + Transportation Rates:
                                                                               
 
TANF
           
SSI-N
   
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                                                             
01
951.62
187.12
102.70
74.71
140.05
80.81
284.50
169.78
440.86
12,591.13
1,898.82
487.69
238.50
269.54
826.05
900.84
324.43
109.55
88.28
02
816.21
160.54
88.12
64.09
120.17
69.47
244.09
145.84
378.22
10,685.88
1,612.98
414.14
202.58
229.10
702.06
765.36
324.43
98.51
79.370
03
984.48
193.55
106.22
77.28
144.85
83.50
294.27
175.51
456.03
13,083.83
1,967.63
505.83
247.21
278.80
854.65
932.99
324.43
100.56
81.04
04
988.24
194.17
106.54
77.53
145.26
83.43
295.20
175.63
457.56
13,465.86
2,025.12
520.61
254.44
286.95
879.63
960.26
324.43
94.30
75.99
05
1,114.99
218.93
120.10
87.42
163.73
93.67
332.82
197.50
515.98
14,525.16
2,179.52
560.72
273.90
308.38
945.50
1,033.03
324.43
88.93
71.67
06
1,026.36
201.58
110.59
80.49
150.77
86.40
306.46
182.04
475.06
13,112.00
1,971.11
506.79
247.67
279.22
855.98
934.58
324.43
87.18
70.25
07
972.68
191.11
104.86
76.31
142.97
82.11
290.54
172.85
450.35
13,646.03
2,051.80
527.50
257.80
290.69
891.11
972.87
324.43
85.88
69.21
08
958.75
188.48
103.44
75.26
141.04
81.29
286.56
170.88
444.10
12,462.04
1,875.26
481.99
235.60
265.82
814.81
889.30
324.43
93.02
74.95
09
1,039.33
204.28
112.10
81.56
152.85
87.97
310.57
185.02
481.33
14,399.99
2,163.12
556.29
271.81
306.28
938.96
1,025.47
324.43
96.06
77.41
10
1,034.50
203.24
111.51
81.15
152.04
87.27
308.98
183.75
478.93
17,971.60
2,694.26
693.35
338.63
380.98
1,168.21
1,276.79
324.43
106.30
85.66
11
1,192.81
234.14
128.43
93.50
175.08
99.98
355.93
210.97
551.86
15,061.69
2,258.13
581.11
283.81
319.33
979.14
1,070.12
324.43
134.22
108.13
6B *
1,025.86
201.49
110.54
80.45
150.70
86.36
306.31
181.96
474.83
13,110.81
1,970.94
506.75
247.64
279.20
855.90
934.50
324.43
87.18
70.25

 
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 2 of 5

--------------------------------------------------------------------------------

 

 ATTACHMENT I  EXHIBIT 2-NR-C  MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS  By Area, Age
and Eligibility Category  Effective September 1, 2011

 
 
TABLE 5
                                   
General + Transportation Rates:
                                                                         
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                                                             
01
951.51
187.01
100.42
63.62
129.69
70.45
275.14
160.42
434.57
12,589.36
1,897.05
467.23
188.59
229.28
746.39
870.65
307.09
99.60
78.33
02
816.13
160.46
86.44
55.91
112.54
61.84
237.19
138.94
373.59
10,683.43
1,610.53
385.85
133.55
173.42
591.89
723.61
307.09
88.56
69.42
03
984.38
193.45
104.15
67.17
135.41
74.06
285.74
166.98
450.30
13,082.28
1,966.08
487.91
203.49
243.53
784.87
906.55
307.09
90.61
71.09
04
988.06
193.99
102.98
60.18
129.06
67.23
280.56
160.99
447.72
13,463.91
2,023.17
498.04
199.38
242.54
791.75
926.96
307.09
84.35
66.04
05
1,114.88
218.82
117.87
76.54
153.58
83.52
323.64
188.32
509.81
14,523.25
2,177.61
538.65
220.05
264.94
859.55
1,000.46
307.09
78.98
61.72
06
1,026.30
201.52
109.36
74.50
145.18
80.81
301.40
176.98
471.66
13,110.65
1,969.76
491.21
209.65
248.55
795.30
911.59
307.09
77.23
60.30
07
972.51
190.94
101.44
59.65
127.42
66.56
276.49
158.80
440.91
13,643.81
2,049.58
501.81
195.12
240.13
791.08
934.96
307.09
75.93
59.26
08
958.67
188.40
101.79
67.21
133.52
73.77
279.77
164.09
439.53
12,460.44
1,873.66
463.54
190.59
229.51
742.98
862.08
307.09
83.07
65.00
09
1,039.21
204.16
109.65
69.64
141.72
76.84
300.51
174.96
474.57
14,397.44
2,160.57
526.87
200.04
248.39
824.42
982.06
307.09
86.11
67.46
10
1,034.39
203.13
109.34
70.58
142.18
77.41
300.06
174.83
472.94
17,969.17
2,691.83
665.31
270.23
325.80
1,059.04
1,235.42
307.09
96.35
75.71
11
1,192.72
234.05
126.60
84.59
166.76
91.66
348.41
203.45
546.81
15,059.57
2,256.01
556.65
224.12
271.18
883.88
1,034.02
307.09
124.27
98.18
6B *
1,025.80
201.43
109.36
74.68
145.31
80.97
301.44
177.09
471.56
13,109.47
1,969.60
491.24
209.80
248.68
795.51
911.61
307.09
77.23
60.30

 
 
 
TABLE 6
General + Dental Rates:
                                                                         
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                                                             
01
944.58
184.95
100.95
65.82
130.49
70.43
273.61
157.47
433.12
12,534.14
1,853.70
460.85
185.81
221.83
720.52
849.06
306.61
96.81
76.08
02
809.75
158.56
88.18
60.03
115.11
63.86
236.89
137.22
374.19
10,634.29
1,571.94
381.29
132.48
168.01
569.13
704.78
306.61
86.68
67.92
03
977.49
191.43
108.70
76.07
142.10
80.58
286.27
165.92
452.46
13,033.69
1,927.90
487.03
207.02
242.18
762.93
888.75
306.61
88.69
69.57
04
982.27
192.28
105.33
65.21
132.53
70.33
282.12
161.12
451.48
13,413.74
1,983.77
494.15
199.25
237.86
769.51
909.12
306.61
82.26
64.40
05
1,109.73
217.33
123.60
87.07
161.99
92.17
325.20
188.59
513.46
14,476.94
2,141.22
538.63
224.43
264.54
838.74
983.65
306.61
77.33
60.43
06
1,021.05
199.98
113.31
82.09
150.99
86.56
301.15
175.58
472.16
13,063.07
1,932.39
489.19
211.64
245.95
773.24
893.33
306.61
75.25
58.73
07
966.84
189.29
106.23
68.71
134.46
73.63
276.71
157.73
442.30
13,593.71
2,010.21
500.46
198.19
238.24
767.99
915.93
306.61
74.55
58.18
08
952.06
186.50
110.56
83.08
146.39
87.17
280.02
162.83
441.14
12,412.44
1,835.93
464.90
196.88
230.62
721.10
844.21
306.61
82.34
64.45
09
1,032.51
202.20
115.89
81.32
150.88
86.13
300.50
173.44
475.74
14,347.78
2,121.54
526.25
203.98
247.30
801.64
963.35
306.61
84.04
65.82
10
1,028.54
201.40
112.23
76.51
146.44
81.37
298.37
171.98
471.02
17,915.53
2,649.69
662.51
271.80
322.29
1,033.69
1,214.16
306.61
93.79
73.66
11
1,187.91
232.66
135.57
99.79
178.39
102.52
348.28
202.23
547.45
15,014.30
2,220.48
561.62
232.19
272.44
864.12
1,018.33
306.61
124.06
98.08
6B *
1,020.55
199.89
113.31
82.27
151.12
86.72
301.19
175.69
472.06
13,061.89
1,932.23
489.22
211.79
246.08
773.45
893.35
306.61
75.25
58.73

 
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 3 of 5

--------------------------------------------------------------------------------

 

 ATTACHMENT I  EXHIBIT 2-NR-C  MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS  By Area, Age
and Eligibility Category  Effective September 1, 2011

 
TABLE 7
                                   
General + Dental + Transportation Rates:
                                                                           
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                                                             
01
951.51
187.03
102.23
66.63
132.34
73.38
276.90
162.03
437.66
12,589.42
1,897.08
468.98
190.80
231.21
747.90
872.76
309.39
100.69
79.25
02
816.14
160.48
89.36
60.77
116.81
66.58
239.92
141.43
378.38
10,683.52
1,610.58
388.53
136.92
176.37
593.52
725.89
309.39
89.90
70.54
03
984.39
193.50
109.97
76.87
143.94
83.51
289.54
170.46
456.98
13,082.49
1,966.20
494.21
211.42
250.46
787.10
909.67
309.39
92.72
72.86
04
988.07
194.02
106.40
65.88
134.07
72.79
284.87
164.93
455.28
13,464.03
2,023.24
501.55
203.79
246.40
794.42
930.69
309.39
86.67
67.99
05
1,114.90
218.88
124.55
87.67
163.37
94.37
327.65
191.99
516.85
14,523.47
2,177.74
545.47
228.63
272.44
861.79
1,003.60
309.39
81.38
63.73
06
1,026.31
201.56
114.28
82.70
152.39
88.80
303.65
179.04
475.61
13,110.81
1,969.85
496.21
215.95
254.05
796.88
913.80
309.39
78.98
61.77
07
972.52
190.99
107.28
69.37
135.97
76.04
279.40
161.46
446.02
13,644.01
2,049.69
507.86
202.73
246.78
792.90
937.50
309.39
77.64
60.7
008
958.69
188.49
111.78
83.85
148.15
89.99
283.16
167.19
445.48
12,460.72
1,873.82
472.00
201.24
238.82
745.01
864.91
309.39
84.99
66.61
09
1,039.23
204.22
117.13
82.10
152.67
88.99
303.69
177.86
480.14
14,397.66
2,160.69
533.58
208.48
255.77
826.34
984.74
309.39
87.98
69.03
10
1,034.40
203.16
113.31
77.19
148.00
83.86
301.15
175.83
474.85
17,969.34
2,691.92
670.42
276.66
331.42
1,060.34
1,237.23
309.39
97.56
76.73
11
1,192.79
234.12
136.47
100.36
179.69
104.59
350.59
205.44
550.64
15,059.58
2,256.02
568.28
236.28
280.13
886.55
1,037.75
309.39
127.34
100.75
6B *
1,025.81
201.47
114.28
82.88
152.52
88.96
303.69
179.15
475.51
13,109.63
1,969.69
496.24
216.10
254.18
797.09
913.82
309.39
78.98
61.77

 
 
TABLE 8
General + Mental Health + Dental + Transportation Rates:
                                                                       
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE  (65+)
         
Female
Male
Female
Male
                                                             
01
951.62
187.14
104.51
77.72
142.70
83.74
286.26
171.39
443.95
12,591.19
1,898.85
489.44
240.71
271.47
827.56
902.95
326.73
110.64
89.20
02
816.22
160.56
91.04
68.95
124.44
74.21
246.82
148.33
383.01
10,685.97
1,613.03
416.82
205.95
232.05
703.69
767.64
326.73
99.85
80.49
03
984.49
193.60
112.04
86.98
153.38
92.95
298.07
178.99
462.71
13,084.04
1,967.75
512.13
255.14
285.73
856.88
936.11
326.73
102.67
82.81
04
988.25
194.20
109.96
83.23
150.27
88.99
299.51
179.57
465.12
13,465.98
2,025.19
524.12
258.85
290.81
882.30
963.99
326.73
96.62
77.94
05
1,115.01
218.99
126.78
98.55
173.52
104.52
336.83
201.17
523.02
14,525.38
2,179.65
567.54
282.48
315.88
947.74
1,036.17
326.73
91.33
73.68
06
1,026.37
201.62
115.51
88.69
157.98
94.39
308.71
184.10
479.01
13,112.16
1,971.20
511.79
253.97
284.72
857.56
936.79
326.73
88.93
71.72
07
972.69
191.16
110.70
86.03
151.52
91.59
293.45
175.51
455.46
13,646.23
2,051.91
533.55
265.41
297.34
892.93
975.41
326.73
87.59
70.65
08
958.77
188.57
113.43
91.90
155.67
97.51
289.95
173.98
450.05
12,462.32
1,875.42
490.45
246.25
275.13
816.84
892.13
326.73
94.94
76.56
09
1,039.35
204.34
119.58
94.02
163.80
100.12
313.75
187.92
486.90
14,400.21
2,163.24
563.00
280.25
313.66
940.88
1,028.15
326.73
97.93
78.98
10
1,034.51
203.27
115.48
87.76
157.86
93.72
310.07
184.75
480.84
17,971.77
2,694.35
698.46
345.06
386.60
1,169.51
1,278.60
326.73
107.51
86.68
11
1,192.88
234.21
138.30
109.27
188.01
112.91
358.11
212.96
555.69
15,061.70
2,258.14
592.74
295.97
328.28
981.81
1,073.85
326.73
137.29
110.70
6B *
1,025.87
201.53
115.46
88.65
157.91
94.35
308.56
184.02
478.78
13,110.97
1,971.03
511.75
253.94
284.70
857.48
936.71
326.73
88.93
71.72

 
AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 4 of 5

--------------------------------------------------------------------------------

 
 

 ATTACHMENT I  EXHIBIT 2-NR-C  MEDICAID NON-REFORM HMO CAPITATION RATES
 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS  By Area, Age
and Eligibility Category  Effective September 1, 2011

 
Area
Corresponding  Counties
   
Area 1
Escambia, Okaloosa, Santa Rosa, Walton
Area 2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Madison, Taylor, Washington, Wakulla
Area 3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union
Area 4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
Area 5
Pasco, Pinellas
Area 6
Hardee, Highlands, Manatee, Polk
Area 6B *
Hillsborough
Area 7
Brevard, Orange, Osceola, Seminole
Area 8
Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota
Area 9
Indian River, Okeechobee, St. Lucie, Martin, Palm Beach
Area 10
Broward
Area 11
Dade, Monroe

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 5 of 5