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AGREEMENT NO. SNP001

 
 
                                                                                                
STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION
                                                                                                                      
COORDINATION OF BENEFITS AGREEMENT

 
THIS COORDINATION OF BENEFITS AGREEMENT is entered into between the State of
Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the
"Agency" whose address is 2727 Mahan Drive, Tallahassee, Florida 32308, and
WELLCARE OF FLORIDA, INC. hereinafter referred to as the "Health Plan" whose
address is 8735 Henderson Road, Renaissance 2, Tampa, Florida 33634-1143. The
Agency and the Health Plan collectively are referred to herein as the "Parties,"
and each individually as a "Party."
                                                                                                                                                                
                                                                                                                                                                           RECITALS
WHEREAS, the Health Plan contracts with the Centers for Medicare and Medicaid
Services, U.S. Department of Health and Human Services ("CMS") to sponsor
Medicare Advantage Plans under Title XVIII of the Social Security Act, including
Medicare Advantage Special Needs Plan(s) ("SNP(s)") that arrange for the
provision of Medicare services for individuals who are dually-eligible for both
Medicare and Medicaid benefits pursuant to Titles XVIII and XIX of the Social
Security Act;
 
 
WHEREAS, the Health Plan sponsors SNP(s) ("Health Plan's SNP(s)") in the State
of Florida ("State") and enrolls residents of the State who are eligible for
Medicare benefits, eligible for Medicaid pursuant to the State's Medicaid Plan
(the "the Medicaid State Plan") as administered by the Agency, and eligible to
enroll in the SNP;
 
 
WHEREAS, the Medicare Improvements for Patients and Providers Act of 2008 and
its implementing regulations issued by CMS require that the Health Plan enter
into a contract with the Agency to coordinate benefits and/or services for
members of the Health Plan's SNP(s) within the State; and
 
 
WHEREAS, the Health Plan and the Agency desire to enter into an arrangement
regarding the provision of Medicare and Medicaid benefits by the Health Plan's
SNP(s) within the State in an effort to improve the integration and coordination
of such benefits as well as to improve the quality of care and reduce the costs
and administrative burdens associated with delivering such care.

 
NOW THEREFORE, in consideration of the terms and conditions set forth in this
Agreement, and for other good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, the undersigned Parties agree as
follows:

 
I.              DEFINITIONS

 

 
A.  "Coinsurance" means the fixed percentage of the total amount of the cost of
medical services for which an individual normally would be financially
responsible pursuant to his or her Medicare health care coverage.

 
Agreement No. SNP001, Page 1 of 14

 
 

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AGREEMENT NO. SNP001

 

 
B.  "Co-payment" means a fixed dollar amount that is a portion of the total cost
of covered services for which an individual normally would be financially
responsible pursuant to his or her Medicare health care coverage.

 

 
C.  "Cost-Sharing" means the portion of the cost of covered services for which
an individual normally would be financially responsible pursuant to his or her
Medicare health care coverage. Cost-sharing includes deductibles, coinsurance,
and co-payments, but does riot include any premiums.

 

 
D.  "Cost-Sharing Obligations" mean those financial payment obligations to be
paid by the Agency in satisfaction of (i) deductibles, coinsurance, and
co-payments for the Medicare Part A and Medicare Part B programs with respect to
certain dual eligible beneficiaries, as set forth in Exhibit A. Such financial
payment obligations shall not include premiums or cost-sharing relating to
Medicare Part D benefits.

 

 
E.  "Dual Eligible Beneficiary" or "Dual Eligible Beneficiaries" means those
categories of individuals identified in Exhibit A that are eligible for Medicare
benefits as well as medical assistance under the Medicaid State Plan. Medical
assistance may include Medicaid coverage of medical services, assistance in
paying Medicare Part A and/or Part B premiums, and cost-sharing obligations for
Medicare-covered services.

 

 
F.  "MA Contract" means the contract between the Health Plan and CMS pursuant to
which the Health Plan sponsors Medicare Advantage Plan(s), including the Health
Plan's SNP(s).

 

           G. "Medicare Laws" means any and all laws, rules, regulations,
statutes, orders and standards, instructions and guidance applicable to the
Medicare Advantage Program and Medicare Advantage Organizations, as the term is
defined in 42 C.F.R. § 422.4, including the Health Plan in its capacity as the
sponsor of the Health Plan's SNP(s).  

 
 
.
H.  "Medicare Advantage Premium" means the amount Medicare Advantage plans may
charge for mandatory and/or optional Supplemental Benefits beyond basic Medicare
services.

 
            I.  "Member" means an individual eligible to enroll in, and who has
enrolled in, the Health Plan's SNP.

 
            J.  "Premium" means the amount the Agency pays for Medicare Part A
and/or Part B premium on behalf of certain dual eligible beneficiaries pursuant
to Section 1905 of the Social Security Act.

 
                                                                                                                                                        
Agreement No. SNP001, Page 2 of 14

 
 

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AGREEMENT NO. SNP001

 
 
K.  "Service Area" means the geographic area in which the Health Plan's SNP(s)
operate(s) pursuant to Health Plan's MA Contract as listed in Exhibit B. The
Health Plan agrees to notify the Agency if the Health Plan is approved to expand
the service area under the MA Contract.

 
 
L.  "Supplemental Benefit" means Medicare Advantage SNP benefits beyond basic
Medicare Part A and Part B services, including limits on out-of-pocket spending,
reduction in premiums, or optional health care services.

 
 
M.  "Wrap-Around Benefits" mean those items and services that are (i) covered by
the Medicaid State Plan for certain individuals identified in Exhibit A, (ii)
not eligible for coverage as basic benefits under the Medicare Program and (iii)
not covered by Health Plan's SNP(s) as a Supplemental Benefit.

 
II.           SCOPE

 
A.          Coordination of Benefits

 
                           1.
Coordination. The Health Plan will perform a substantial role coordinating and
arranging the Medicare and/or Medicaid benefits and services for dual eligible
beneficiaries who are members of the Health Plan's SNP(s), as set forth in
Exhibit A and Sections III and VI.

 

 
           2.
Financial Responsibilities. Pursuant to the Medicaid State Plan, the Agency will
remain financially responsible for cost-sharing obligations and wrap-around
benefits for certain dual eligible beneficiaries, who are members of Health
Plan's SNP(s). The Agency may have financial responsibility for Medicare Part A
and/or Part B premiums for select categories of dual eligible beneficiaries, as
set forth in Exhibit A. The Agency is not responsible for payment of Medicare
Advantage premiums for mandatory or optional Supplemental Benefits, unless
specifically prescribed in the Medicaid State Plan.

 

 
           3.
Claims Processing. The Agency shall receive, process, and adjudicate claims for
cost-sharing obligations and wrap-around benefits, in accordance with the
Agency's processes and procedures for claims administration. The Health Plan
shall receive, process and adjudicate claims for basic Medicare services and
Supplemental Benefits.

 
Agreement No. SNP001, Page 3 of 14

 
 

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AGREEMENT NO. SNP001

 
III.         HEALTH PLAN RESPONSIBILITIES

 
 
            A.
Medicare Benefits and the Health Plan Programs. The Health Plan shall provide to
its members the Medicare benefits set out in the Health Plan's SNP benefit
package, including basic and supplemental benefits, pursuant to the Health
Plan's MA Contract. The Health Plan shall provide such benefits and otherwise
sponsor the Health Plan’s SNP(s) in accordance with the Health Plan's MA
Contract and applicable Medicare Law.

 
B.    Integrated Medicaid Benefits.

 
                   1.
Comprehensive Written Statement of Benefits. Prior to enrolling any individual
into the Health Plan's SNP, the Health Plan shall provide such individual with a
comprehensive written statement describing the Medicare and Medicaid benefits
and cost-sharing protections the individual would receive as a Member of Health
Plan's SNP. Such written statement shall include such information and be
formatted in accordance with the requirements established by CMS. The Health
Plan and the Agency agree that the Medicaid State Plan sets forth the Medicaid
benefits that the Agency will provide members, and the Health Plan will document
in the comprehensive written statement of benefits.

 
                   2.
Summary of Benefits. To the extent required of Medicare Advantage Organizations
sponsoring Medicare Advantage Special Needs Plans for dual eligible individuals
by CMS, the Health Plan shall integrate into a single Summary of Benefits all
Medicare and Medicaid benefits a Member may be eligible to receive upon
enrollment in Health Plan's SNP(s).

 
                   3.
Medicare Advantage Supplemental Benefits. The Agency acknowledges that (i) the
Health Plan's plan benefit design, including the benefits and cost-sharing
obligations, provided under such design may vary from plan-to-plan and from
year-to-year; (ii) in any given benefit year, the plan benefit packages offered
by the Health Plan's SNP may include certain Medicare Supplemental Benefits that
may overlap with Medicaid benefits covered by the Medicaid State Plan; and (iii)
for services that are covered as Supplemental Benefits under the Health Plan's
SNP(s) as well as benefits under the Medicaid State Plan, the Health Plan shall
first adjudicate claims for in-network services under the Supplemental Benefit
offered by the Health Plan's SNP(s) before denying such claims as Agency
responsibility under the Medicaid State Plan.  The Health Plan shall ensure that
claims are processed and comply with the federal and state requirements set
forth in 42 CFR 447.45 and 447.46 and Chapter 641, F.S.

 
Agreement No. SNP001, Page 4 of 14

 
 

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AGREEMENT NO. SNP001

 
            C.     Cost-Sharing Obligations.

 
                     1.
Cost-Sharing Obligation by Plan Design. The Agency acknowledges and agrees that
based on the Health Plan's benefit package design and its bid to CMS, the Health
Plan determines varying levels of cost-sharing obligations for certain dual
eligible beneficiary members. The Agency further acknowledges and agrees that as
a result of these benefit package designs, the Health Plan’s actual cost-sharing
obligations for such members may be reduced or equal zero.

 
                     2.
Nothing in this Agreement precludes the Health Plan from entering into
agreements with providers that vary the amount or method of payment by the
Health Plan for cost-sharing obligations.

 
            D.     Member Protections.

 
                     1.
Hold Harmless Member Cost-Sharing. With respect to its members for whom the
State Medicaid Agency is otherwise required by law, and/or voluntarily has
assumed responsibility in the Medicaid State Plan to cover cost-sharing
obligations, the Health Plan agrees that it shall include in its written
communication with providers that providers acknowledge and agree that they
shall not bill or charge such members the balance of ("balance bill"), and that
such members are not liable for, those cost-sharing obligations. The Health Plan
further agrees that in accordance with 42 C.F.R. §422.504(g)(1)(iii) that it
will include in its provider agreements that the provider will accept the Health
Plan's payment as payment in full or will bill the appropriate State source if
the Health Plan has not assumed the State's financial responsibility under an
agreement between the Health Plan and the State.

 
                      2.
Limitation on Cost-Sharing Obligations. Notwithstanding Paragraph III.D.1, in
the case of a dual eligible beneficiary who is enrolled in the Health Plan's
SNP, the Health Plan agrees that it may not impose cost-sharing that exceeds the
amount of cost-sharing that would be permitted with respect to such individual
pursuant to Medicaid if the individual were not a member of the Health Plan.

 
                      3.
Member Hold Harmless from Health Plan and Agency Financial Responsibility.
Notwithstanding any provision in this Agreement to the contrary, the Health Plan
shall prohibit providers from, under any circumstance including but not limited
to non-payment by the Health Plan, insolvency of the Health Plan or breach of
the Health Plan's agreement with provider, from billing, charging, collecting a
deposit from, seeking compensation or remuneration from or having any recourse
against any member for fees that are the responsibility of Health Plan or the
Agency.

 
                                                                                                                                                                           
Agreement No. SNP001, Page 5 of 14

 
 

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AGREEMENT NO. SNP001

 
            E.          Reporting.

 
 

   The Health Plan shall submit to the Agency such reports and data mutually
agreed to by the Parties at such intervals mutually agreed to by the Parties.
Such reports and data shall include the following:

 
 

   (i).  A summary identifying the Health Plan's service area(s) (Exhibit B);

 
 

 
 
(ii). An annual Summary of Benefits of the Health Plan's SNP benefits offered
under the plan benefit packages, including Supplemental Benefits; and

 

 
 
(iii).The Health Plan agrees to submit to the Agency the duplicate copies of
quality reports, measures, and findings generated from the Health Plan's SNP(s)
quality management programs as required by and submitted to CMS.

 
            F.
Prompt Pay. The Health Plan shall pay all claims for items and services in
accordance with Medicare Law.

 
IV.              DATA EXCHANGE

 
            A.
Privacy and Security. The Parties agree that any data or other information
transmitted pursuant to this Agreement shall comply with the Health Insurance
Portability and Accountability Act of 1996 and its implementing regulations
including the Privacy, Security, Electronic Transaction Rules (collectively,
"HIPAA"). The Parties acknowledge that the use and disclosure of information is
for payment and other purposes permissible under HIPAA

 
            B.
Initial Eligibility Verification. The Agency shall provide the Health Plan
access to information verifying the eligibility of dual eligibles through the
use of the Medicaid Fiscal Agent's Provider Secured Web Portal. The Health Plan
shall ensure individuals enrolled in the SNP(s) are eligible for both Medicare
and Medicaid.

 
 
            C.       Ongoing Eligibility Verification.
 
                       1.
The Parties agree to exchange Medicare and Medicaid eligibility and enrollment
data to facilitate the Parties' performance under this Agreement. The Agency
shall transmit to the Health Plan the Agency's eligibility data that shall
verify the active or inactive status of dual eligible beneficiaries and identify
the dual eligibility beneficiary categories of members. The Parties agree that
the Health Plan will reconcile the data and the Parties shall work in good faith
to resolve any discrepancies that the Health Plan or Agency may identify.

 
                                                                                                                                                              
Agreement No. SNP001, Page 6 of 14

 
 

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AGREEMENT NO. SNP001

                     2.
To the extent the Health Plan determines allowable, the Health Plan shall
undertake certain activities intended to facilitate eligibility
redeterminations, such as assistance with applications for medical assistance on
behalf of its members and conducting member education regarding maintaining
Medicaid eligibility.

 
 

   D.  Provider Participation File Exchange. On a quarterly basis, the Agency
will provide the Health Plan a listing of all providers with whom the Agency has
active Medicaid agreements on file in order to ensure network adequacy and
promote continuity of care. The Health Plan shall electronically transmit
provider participation files to the Agency upon request by the Agency. The
Health Plan shall include in the provider participation files all network
providers contracted by the Health Plan to serve its members who are dual
eligible beneficiaries. The Agency agrees to define reasonable requirements for
the provider participation files for the Health Plan's submission to Agency

 
 
 
V.           TERM, TERMINATION, RENEWAL AND AMENDMENT PROCEDURE
 
 

  A. Term. This Agreement shall begin upon execution by both Parties or January
1, 2012 (whichever is later) and end on December 31, 2012, inclusive (Initial
Term). Upon expiration, of the Initial Term, this Agreement shall automatically
renew for a one (1) year period, unless either party gives ten (10) business
days notice prior thereto that is does not wish to renew the contract.

 

 

 
B.
Termination. This Agreement shall automatically terminate upon the termination
or expiration of the Health Plan's MA Contract with CMS to sponsor the Health
Plan's SNP(s), regardless of the reason for such termination or expiration.
Furthermore, either Party may terminate this Agreement without cause upon thirty
(30) days advance written notice to the other Party, or earlier upon mutual
consent.

 
 

  C. Renewal. This Agreement may be renewed for a period that may not exceed
three (3) years or the term of the original Agreement, whichever period is
longer. Renewal shall be in writing and subject to the same terms and conditions
set forth in the initial Agreement.

 
 

  D. Amendment. This Agreement may be amended upon written Agreement signed by
Parties.

 
 
 
VI.         COORDINATION OF SERVICES

 
              A.            Marketing and Education.

 

 
 1.
The Parties agree that the Health Plan is subject to, and shall comply with, all
Medicare Laws relating to marketing of Medicare Advantage Plans.  In

 
                                                                                                                                                            
Agreement No. SNP001, Page 7 of 14

 
 

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AGREEMENT NO. SNP001

 
connection therewith, the Health Plan agrees to submit its marketing materials
to CMS for approval and agrees to only use CMS approved marketing material in
the State. The Agency agrees that CMS approval shall be sufficient for the
Health Plan's use of such materials in the State.
 
 

   2.
Any releases of information pertaining to this Agreement to the media, the
public or other entities require prior approval from the Agency.

 
 

   3. The Health Plan shall establish functions and activities governing program
integrity in order to reduce the incidence of fraud and abuse and shall comply
with all state and federal program integrity requirements, including but not
limited to the applicable provisions of the Social Security Act, ss. 1128, 1902,
1903 and 1932; 42 CFR 431, 433, 434, 435, 438, 441, 447 and 455; 45 CFR part 74;
Chapters 409, 414, 458, 459, 460, 461, 626, 636, 641 and 932, F.S., and
59A-12.0073, 59G and 69D-2, FAC.

 
 

 
 4.
The Agency shall retain responsibility for developing and distributing materials
and conducting educational activities relating to the State Medicaid Program and
benefits and services covered under the Medicaid  State Plan, including, without
limitation, provider directories and identification cards.

 
B.           Appeals and Grievances.
 
 
 

   1. The Health Plan is subject to, and shall comply with, all Medicare Laws
relating to member grievances and appeals. To the extent practicable, the Health
Plan shall seek to incorporate into its grievance and appeals process applicable
requirements relating to grievances and appeals as required under the Medicaid
State Plan and as provided by the Agency. In circumstances where both appeals
processes could potentially apply, the Health Plan agrees that it shall use the
more restrictive procedures required of the Health Plan and apply the more
liberal beneficiary protections, such as the Medicaid continuation of benefits
policies. The Health Plan and State further agree to the extent possible to
avoid duplicate appeals.

 
 

 
 2.
As set forth in the Health Plan's policies and procedures, providers and members
must exhaust the Health Plan's internal processes and procedures, including
appeal provisions, prior to seeking an external hearing or review as permitted
under Medicare Law.

 

   3. The Health Plan shall refer any grievance or appeal filed by a member or
member’s representative relating to a Medicaid benefit available solely under
the Medicaid State Plan to the Agency.

 
 
 
 
 

 
                                                                                                                                                                     
Agreement No. SNP001, Page 8 of 14

 
 

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AGREEMENT NO. SNP001

 
            C.         Plan Management.

 

 
                          1.
The Parties agree that the Health Plan's administration of the Health Plan's
SNP(s), including, without limitation, plan benefit package design, provider
network adequacy, provider credentialing, utilization management programs,
quality improvement programs, and payment processes and procedures
(collectively, "Administrative Services"), shall be subject to Medicare Laws.

 

 
2.
The Agency acknowledges and agrees that the Health Plan's compliance with
Medicare Laws with respect to its Administrative Services shall be sufficient
for approval by the Agency, and the Agency shall not require additional approval
of such services, including, requiring providers to be credentialed by the
Agency or enrolled in the State Medicaid Program.

 
VII.             MISCELLANEOUS

 
            A.
Survival. Any provision of this Agreement that requires or reasonably
contemplates the performance or existence of obligations by either Party after
termination of this Agreement shall survive such termination, regardless of the
reason for termination.

 
            B.
Compliance with Federal, State and Local laws and Third Party Liability. The
Health Plan agrees to comply with all federal, state and local laws,- including
those relating to third party liability and coordination of benefits, applicable
to the performance of this Agreement.

 
            C.
Work Authorization Program. The Immigration Reform and Control Act of 1968
prohibits employers from knowingly hiring illegal workers. The Health Plan shall
only employ individuals who may legally work in the United States - either U.S.
citizens or foreign citizens who are authorized to work in the U.S. The Health
Plan shall use the U.S. Department of Homeland Security's E-Verify Employment
Eligibility Verification system to verify the employment eligibility of:

 
                                  ■          all persons employed by the Health
Plan, during the term of this Agreement, to perform employment duties within
Florida; and,
 
                                  ■          all persons (including
subcontractors) assigned by the Health Plan to perform work pursuant to this
Agreement

 
Agreement No. SNP001, Page 9 of 14

 
 

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AGREEMENT NO. SNP001

 
            D.          Exhibits.

 
                          1.
The following Exhibits are incorporated by reference into this Agreement and
attached hereto:

 
                                 a.    Exhibit A, "Categories of Dual-Eligible
Beneficiaries"
 
                                 b.    Exhibit B, “MA SNPS Applicable Service
Areas and Dual Eligible and Other Dual Eligible Categories

 
                         2.
Unless otherwise specifically provided in this Agreement, in the event of any
conflict between this Agreement and any of the Exhibits this Agreement shall
control.

 
            E.
Contact Information. All matters pertaining to this Agreement shall be directed
to the contact persons below for appropriate action or disposition. A change in
contact person by either Party shall be reduced to writing.

 
                           The contact person for the Agency is as follows:
 
 Jennifer Barrett
Agency for Health Care Administration
2727 Mahan Drive, MS #19
Tallahassee, FL 32308
(850)412-4137
Jennifer.Barrett@ahca.myflorida.com
 
The contact person for the Health Plan is as follows:

Robert Diaz
Wellcare Health Plans, Inc.
Division Vice President, Regulatory & Government Affairs Florida & Hawaii
Division
8735 Henderson Road, Renaissance 2
Tampa, Florida 33634-1143
(813) 206-1758
Robert.Diaz@wellcare.com

 
                                                                                                                                                        
Agreement No. SNP001, Page 10 of 14

 
 

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AGREEMENT NO. SNP001

 
IN WITNESS WHEREOF, authorized representatives of the Parties have caused this
fourteen (14) page Agreement, which includes any referenced exhibits, to be
executed. This Agreement is not valid until signed and dated by both parties.
 

WELLCARE OF FLORIDA, INC.
 
STATE OF FLORIDA AGENCY FOR
   
HEALTH CARE ADMINISTRATION
     
SIGNED
 
SIGNED
BY:
/s/ Chrissie Cooper
 
BY:
/s/ Elizabeth Dudek
         
NAME:
Chrissie Cooper
 
NAME:
Elizabeth Dudek
         
TITLE:
President; Florida & Hawaii Division
 
TITLE:
Secretary
         
DATE:
6/2/11
 
DATE:
6/16/2011

 
List of Exhibits included as part of this Agreement:

 
Exhibit A - Categories of Dual-Eligible Beneficiaries (2 pages)
Exhibit B - MA SNPS Applicable Service Areas (1 page)

 

 

 
                                                                                                                                                                      
Agreement No. SNP001, Page 11 of 14

 
 

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EXHIBIT A
CATEGORIES OF DUAL-ELIGIBLE BENEFICIARIES

 
The following categories of Dual Eligible Beneficiaries are recognized within
the scope of this Agreement:

 

 
 1.
A "Full Benefit Dual Eligible" or "FBDE" is an individual who is eligible for
full Medicaid benefits under the Medicaid State Plan because the individual
falls within a federal mandatory coverage group or an optional coverage group
(such as medically needy) but who does not meet the income or resource criteria
for QMB or SLMB. Under the Medicaid State Plan, FBDEs are eligible for some
financial assistance from the Agency in connection with Medicare Part A
premiums, and in some cases Medicare Part B premiums. Medicare cost-sharing
obligations may effectively be covered by the State Medicaid benefit, but
certain conditions must be met, including 1) the service is also covered by
Medicaid, 2) the provider is also a Medicaid provider, and 3) the Medicaid fee
schedule amount is greater than the Medicare amount paid.

 

   2. A "Qualified Disabled and Working Individual" or "QDWI" is an individual
who lost his or her Medicare Part A benefits because he or she returned to work,
but who is eligible to purchase Medicare Part A benefits. A QDWI (i) is eligible
to purchase Medicare Part A benefits; (ii) has an annual income of 200% of the
Federal Poverty Level ("FPL") or less; (iii) has resources that do not exceed
twice the Supplemental Security Income ("SSI") limit; and (iv) who otherwise is
not eligible for Medicaid benefits under the Medicaid State Plan. Under the
State Medicaid Program, a QDWI is eligible for financial assistance from the
Agency to pay the individual's Medicare Part A premiums.

 
 

 
 3.
A "Qualifying Individual" or "Ql" is an individual (i) who is entitled to
Medicare Part A; (ii) who has an annual income that is at least 120% FPL, but
less than 135% FPL; (iii) who has resources that do not exceed twice the SSI
limit; and (iv) who otherwise is not eligible for Medicaid benefits under the
Medicaid State Plan. Under the State Medicaid Program, a Ql is eligible for
financial assistance from the Agency in connection with certain Medicare
benefits, including payment of the individual's Medicare Part B premiums.

 

 
 4.
A "Qualified Medicare Beneficiary" or "QMB Only" is an individual (i) who is
entitled to Medicare Part A; (ii) who has income that does not exceed 100% FPL;
and (iii) whose resources do not exceed twice the SSI limit. Under the State
Medicaid Program, a QMB is eligible for financial assistance from the Agency in
connection with certain Medicare benefits, including Medicare Part A and Part B
premiums and cost-sharing obligations.

 

 
 5.
A "QMB-Plus" is an individual who meets all of the eligibility requirements for
QMBs and who also meets the financial criteria for full Medicaid coverage under
the Medicaid State Plan. Under the Medicaid State Plan, a QMB-Plus is eligible
for full Medicaid benefits as well as financial assistance from the Agency in
connection with certain Medicare benefits, including Medicare Part A and Part B
premiums and cost-sharing obligations.

 
Agreement No. SNP001, Exhibit A, Page 1 of 2

 
 

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     6.
A "Specific Low Income Medicare Beneficiary" or "SLMB Only" is an individual (i)
who is entitled to Medicare Part A benefits; (ii) who has annual income that
exceeds 100% FPL but is less than 120% FPL; and (iii) whose resources do not
exceed twice the SSI limit. Under the Medicaid State Plan, a SLMB is eligible
for financial assistance from the Agency in connection with certain Medicare
benefits, including payment of Medicare Part B premiums.

 

 
7.
A "SLMB-Plus" is an individual (i) who meets all the financial criteria for
SLMBs and who also meets the financial criteria for full Medicaid coverage under
the Medicaid State Plan. Under the Medicaid State Plan, a SLMB-Plus is eligible
for full Medicaid benefits as well as financial assistance from the Agency in
connection with certain Medicare benefits, including payment of Medicare Part B
premiums. Medicare cost-sharing obligations may effectively be covered by state
Medicaid benefit, but certain conditions must be met, including 1) the service
is also covered Medicaid, 2) the provider is also a Medicaid provider, and 3)
the Medicaid fee schedule amount is greater than the Medicare amount paid,

 
 
 
 
 
 
 
 
 
Agreement No. SNP001, Exhibit A, Page 2 of 2

 
 

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EXHIBIT B

MA SNPS
APPLICABLE SERVICE AREAS AND
DUAL ELIGIBLE AND OTHER DUAL ELIGIBLE CATEGORIES

MA SNP PLAN NAME
H#
SERVICE AREA BY COUNTY OR ZIP CODE
CATEGORY OF SNP (Dual, Chronic, Institutional)
APPLICABLE CATEGORY OF DUAL ELIGIBLE
WellCare Select
H1032061
Brevard, Broward,
Dade, Duval, Hernando,
Highlands, Hillsborough, Indian River, Lake, Manatee, Marion,
Martin, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Seminole, Sumter,
St. Lucie
Dual
FBDE, QDWI, QI, QMB, QMB+, SLMB, SLMB+
WellCare Select
H1032101
Bay, Calhoun, Citrus, Escambia, Franklin, Gadsden, Gulf, Holmes, Jefferson,
Leon, Liberty, Madison, Okaloosa, Santa Rosa, Wakulla, Washington
Dual
FBDE, QDWI, QI, QMB, QMB+, SLMB, SLMB+
WellCare Access
H1032124
Bay, Broward, Brevard, Calhoun, Citrus, Duval, Escambia, Franklin, Gadsden,
Gulf, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jefferson, Lake,
Leon, Liberty, Madison, Manatee, Marion, Martin, Okaloosa, Orange, Osceola, Palm
Beach, Pasco, Pinellas, Polk, Santa Rosa, Seminole, St. Lucie, Sumter, Wakulla,
Washington
Dual
FBDE, QMB, QMB+, SLMB+
WellCare Access
H1032170
Dade
Dual
FBDE, QMB, QMB+, SLMB+

Agreement No. SN001, Exhibit B, Page 1 of 1

 
 

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