Back to Form 8-K [form8-k.htm]
Exhibit 10.1

 
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
     
 
7500 Security Boulevard
Baltimore, Maryland 21244

 
Date:
January 21, 2009
 
To:
Medicare Advantage and 1876 Cost Plan Organizations
 
From:
Louis Polise
Acting Director
Medicare Drug and Health Plan Contract Administration Group
 
Subject:
2009 Contract Renewal – H0117

 
The Centers for Medicare & Medicaid Services (CMS) is pleased to inform you that
your contract has been renewed effective January 1, 2009, through December 31,
2009. This approval/renewal is issued based on our receipt of your 2009 benefit
attestation, all applicable contract addenda, and our approval of your bid. CMS
approves each benefit plan for a particular service area. Your organization's
contractual authority to offer benefits in its CMS-approved service area is
documented by your signed benefit attestation.
 
As required by the Medicare Improvements for Patients and Providers Act of 2008
(MIPPA), if your organization offers a prescription drug plan benefit package,
an executed copy of your new Part D addendum is included as an attachment to
this memo. If your organization applied for and was found qualified to offer new
2009 Employer/Union-Only Group Waiver Plans (EGWP)/ "800 series" plan benefit
packages, an executed EGWP addendum is included as an attachment to this memo.
 
CMS will continue to provide Medicare Advantage and Prescription Drug Benefit
program information (including information about your CMS Central Office and
Regional Office contacts) to contracting organizations through the Health Plan
Management System (HPMS) and the CMS website. It is imperative that you monitor
both websites to stay current on program requirements and information. Please
ensure your organization's contact information in HPMS remains up-to-date since
this is our primary source for contacting our contracting organizations.
 
We look forward to continuing to work with you in serving Medicare beneficiaries
in your service area. If you have any questions, please contact your Regional
Office Account Manager.
 
Attachment(s)

 
 

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

 

ADDENDUM TO CONTRACTS WITH MEDICARE PART D SPONSORS PURSUANT TO SECTIONS 1860D-1
THROUGH 1860D-42 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A VOLUNTARY
MEDICARE PRESCRIPTION DRUG PLAN

 
The Centers for Medicare and Medicaid Services (hereinafter referred to as
"CMS") and WellCare of Ohio, Inc., an organization operating a Voluntary
Medicare Prescription Drug Plan (hereinafter referred to as "the Sponsor")
agree, pursuant to 42 C.F.R. § 423.508(a) to amend the contract (H0117)
governing the Sponsor's Part D operations described in Section 1860D-1 through
1860D-42(with the exception of 1860D-22(a) and 1860D-31) of the Social Security
Act (hereinafter referred to as "the Act") to include the provisions stated
below.
 
This addendum is made pursuant to Subpart L of 42 CFR Part 417, Subpart K of 42
CFR Part 422, and Subpart K of 42 CFR Part 423.
 
NOTE: For the purposes of this addendum, "the Sponsor" includes the following:
standalone prescription drug plan (PDP) sponsors, Medicare managed care
organizations offering Part D benefits (MA-PD), and employer group/union-only
organizations. For a PDP sponsor, this document amends its contract with CMS.
For MA-PD organizations and employer group/union-only benefit sponsors, this
document amends the Part D addendum to their Medicare managed care contracts
with CMS.

 
 

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

 

Article I
Medicare Voluntary Prescription Drug Benefit

 
A.
This addendum is in no way intended to supersede or modify 42 CFR, Parts 417,
422 or 423, except as to any requirements set forth in 42 CFR Part 423 that are
specifically waived or modified for Sponsors offering a prescription drug
benefit exclusively to Part D eligible individuals enrolled in employment-based
retiree prescription drug coverage as provided in applicable employer/union-only
group waiver guidance and/or in this addendum. Failure to reference a regulatory
requirement in this addendum does not affect the applicability of such
requirements to the Sponsor and CMS.

 
B.
In the event of a conflict between the employer/union-only group waiver guidance
issued prior to the execution of the contract and this addendum, the provisions
of this addendum shall control. In the event of any conflict between the
employer/union-only group waiver guidance issued after the execution of the
contract and this addendum, the provisions of the employer/union-only group
guidance shall control.

 
C.
In the event of any conflict between the provisions of this addendum and any
other provision of the contract, the terms of this addendum shall control.

 

Article II
Sponsor Reimbursement to Pharmacies

 
A.
Effective January 1, 2010, Sponsor will issue, mail, or otherwise transmit
payment with respect to all clean claims submitted by pharmacies (other than
pharmacies that dispense
drugs by mail order only or are located in, or contract with, a long-term care
facility) within 14 days of receipt of an electronically submitted claim or
within 30 days of receipt of a claim submitted otherwise.

 
B.
Effective January 1,2010, Sponsor must ensure that a pharmacy located in, or
having a contract with, a long-term care facility will have not less than 30
days (but not more than 90 days) to submit claims to the Sponsor for
reimbursement.

 
C.
Effective January 1, 2009, if Sponsor uses a standard for reimbursement of
pharmacies based on the cost of a drug will update such standard not less
frequently than once every 7 days, beginning with an initial update on January 1
of each year, to accurately reflect the market price of acquiring the drug.

 
Article III
Record Retention and Reporting Requirements

 
 

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

 

The section entitled "RECORD MAINTENANCE AND ACCESS" is amended to include the
following provision: "Sponsor agrees to maintain records and provide access in
accordance with 42 CFR §§ 423.505 (b)(10) and 423.505(i)(2)(ii)."

Article IV
CMS Notice of Sponsor Contract Non-Renewal
 
Paragraph 1 of the section entitled "QUALIFICATION TO RENEW ADDENDUM" is revised
to read as follows:
 
"1. In accordance with 42 CFR §423.507, the Sponsor will be determined qualified
to renew this addendum annually only if—
(a)
   The Sponsor has not provided CMS with a notice of intention not to renew in
accordance with Article VII of this addendum, and
 (b)
   CMS has not provided the Sponsor with a notice of intention not to renew."

          

Article IV
Addendum Term

 
This addendum is effective from the date of CMS' authorized representative's
signature and shall remain in effect for as long as the Sponsor remains a Part D
sponsor under contract with CMS.
 
Article VI
Modification or Termination of Addendum by Mutual Consent
 
This addendum may be modified or terminated at any time by written mutual
consent in accordance with 42 CFR 423.508.

Article XII
Severability
 
Severability of the addendum shall be in accordance with 42 CFR §423.504(e).
 
Article XIII
Miscellaneous

 
 A.
Terms not otherwise defined in this addendum shall have the meaning given such
terms at 42 CFR Part 423 or, as applicable, 42 CFR Part 422 or Part 417.

 
 

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

 

B.
The Sponsor agrees that it has not altered in any way the terms of the addendum
presented for signature by CMS. Sponsor agrees that any alterations to the
original text the Sponsor may make to this addendum shall not be binding on the
parties.

 
 

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

 

In witness whereof, the parties hereby execute this contract modification

FOR THE SPONSOR

Heath Schiesser                                  
Printed Name
 
 
President and CEO                                         
Title
/s/ Heath Schiesser                             
Signature
 
9/5/08                                                               
Date
 
WellCare of Ohio, Inc.                        
Organization
 
8735 Henderson Rd., Tampa, FL 33634       
Address

 
FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES
 

/s/ Cynthia Tudor                                
Cynthia Tudor, Ph.D.
Director
9/18/08                                                              
Date

Medicare Drug Benefit Group and
   C & D Data Group
Center for Drug and Health Plan Choice

 

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

 
Medicare Advantage Attestation of Benefit Plan
WELLCARE OF OHIO, INC.
H0117
Date: 08/29/2008

 
I attest that I have examined the Plan Benefit Packages (PBPs) identified below
and that the benefits identified in the PBPs are those that the above-stated
organization will make available to eligible beneficiaries in the approved
service area during program year 2009.  I further attest that we have reviewed
the bid pricing tools (BPTs) with the certifying actuary and have determined
them to be consistent with the PBPs being attested to here.
 
I further attest that these benefits will be offered in accordance with all
applicable Medicare program authorizing statutes and regulations and program
guidance that CMS has issued to date and will issue during the remainder of 2008
and 2009, including but not limited to, the 2009 Call Letter, the 2009
Solicitations for New Contract Applicants, the Medicare Prescription Drug
Benefit Manual, the Medicare Managed Care Manual, and the CMS memoranda issued
through the Health Plan Management System (HPMS).

Plan
ID
Segment
ID
Version
Plan Name
Plan Type
Transaction Type
MA Premium
Part D Premium
CMS Approval Date
Effective Date
004*
0
9
WellCare Value
HMO
Renewal
0.00
0.00
08/29/2008
01/01/2009
005
0
7
WellCare Value
HMO
Renewal
0.00
0.00
08/29/2008
01/01/2009
007
0
7
WellCare Access
HMO
Renewal
0.00
28.40
08/29/2008
01/01/2009
008
0
7
WellCare Select
HMO
Renewal
0.00
28.40
08/29/2008
01/01/2009
009
0
7
WellCare Select
HMO
Renewal
0.00
26.00
08/29/2008
01/01/2009
010**
0
7
WellCare Reserve
HMO
Renewal
0.00
28.40
08/29/2008
01/01/2009

 
*As disclosed in the cover letter to this Attestation of Benefit Plan, WellCare
of Ohio, Inc. may not be able to offer Medicare Advantage Coordinated Care Plan
coverage in Geauga, Mahoning and Trumbull Counties due to a licensing issue with
the Ohio Department of Insurance. Therefore, Plan ID 004 may only be offered in
Cuyahoga, Lake and Lorain Counties.
 
**As disclosed in the cover letter to this Attestation of Benefit Plan, WellCare
of Ohio, Inc. may not be able to offer Medicare Advantage Coordinated Care Plan
coverage in Geauga, Mahoning and Trumbull Counties due to a licensing issue with
the Ohio Department of Insurance. Therefore, Plan ID 010 may not be offered in
any county.
 
Page 1 of 2    - WELLCARE OF OHIO, INC. - H0117 - 08/29/2008

 
 

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

 
 

/s/ Heath Schiesser              
CEO:
Heath Schiesser
CEO/President
8735 Henderson Road
Tampa, FL 33634
813-290-6205
 
9/5/08                            
Date:
     
/s/ Thomas L. Tran               
CFO:
Tom Tran
CFO
8735 Henderson Road
Tampa, FL 33634
813-290-6200 (1770)
 
9/5/08                            
Date:

Page 2 of 2 – WELLCARE OF OHIO, INC. – H0117 – 08/29/2008