Back to Form 10-Q [form10-q.htm]
EXHIBIT 10.11
 

 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida    

                                                                                 
AHCA CONTRACT NO. FA904
AMENDMENT NO. 3

 
THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE
ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA,
INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the
"Vendor," or "Health Plan," is hereby amended as follows:
 
1.
Standard Contract, Section III., Item C, Contract Managers, sub-item 1., the
Agency's Contract Manager's telephone number is hereby amended to now read as
follows:

 
        (850) 412-4067

 
2.
Attachment II, Core Contract Provisions, Section I, Definitions and Acronyms,
Item A., Definitions, the following definitions are hereby amended to now read
as follows:

 
Catastrophic Component Threshold - (Capitated Reform Health Plans that are
approved to offer comprehensive services only) - The point at which the cost of
covered services, based on Medicaid fee-for-service payment levels, reaches
$50,000 for an enrollee in a Contract year. For a Health Plan that accepts the
comprehensive capitation rate only, the Agency begins reimbursing the Health
Plan for the cost of covered services received by the enrollee for the remainder
of the Contract year. This reimbursement is based on a percentage of Medicaid
fee-for-service payment levels.

 
Comprehensive Component - (Capitated Reform Health Plans that are approved to
offer comprehensive services only) - The amount of financial risk assumed by a
Health Plan to provide covered service up to $50,000 per enrollee based on
Medicaid fee-for-service payment levels.

 
3.
Attachment II, Core Contract Provisions, Section IV, Enrollee Services,
Community Outreach and Marketing, Item A., Enrollee Services, sub-item 3.a.(6)
is hereby amended to now read as follows:

 
        (6)
A request to update the enrollee's name, address (home and mailing), county of
residence, and telephone number, and include information on how to update this
information with the health plan and through DCF and/or the Social Security
Administration;

 
4.
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item
A., Quality Improvement, is hereby amended to include sub-item 3.c.(6) as
follows:

 
        (6)
The Agency may offer incentives to high-performing Health Plans. The Agency will
notify the Health Plan annually on or before December 31 of the incentives that
will be offered for the following calendar year. Incentives may be awarded to
all high-performing Health Plans or may be offered on a competitive basis.
Incentives may include, but are not limited to, quality designations, quality
awards, and enhanced auto-assignments. The Agency, at its discretion, may
disqualify a Health Plan for any reason the Agency deems appropriate including,
but not limited to, Health Plans that received a monetary sanction for
performance measures or any other sanctionable offense.

 
5.
Attachment II, Core Contract Provisions, Section VIII, Quality Management, Item
B., Utilization Management (UM), sub-item 2., Care Management, is hereby deleted
in its entirety and replaced as follows:

 
The Health Plan shall be responsible for the management and continuity of
medical care for all enrollees. The Health Plan shall maintain written case
management and continuity of care protocols that include the following minimum
functions:

 
        a.
Appropriate referral and scheduling assistance for enrollees needing specialty
health care or transportation services, including those identified through CHCUP
screenings;

 
AHCA Contract No. FA904, Amendment No. 3, Page 1 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
        b.
Determination of the need for non-covered services and referral of the enrollee
for assessment and referral to the appropriate service setting (to include
referral to WIC and Healthy Start) with assistance, as needed, by the area
Medicaid office;

 
        c.
Case management follow-up services for children/adolescents whom the Health Plan
identifies through blood screenings as having abnormal levels of lead;

 
        d.
A mechanism for direct access to specialists for enrollees identified as having
special health care needs, as appropriate for their conditions and identified
needs;

 
        e.
An outreach program and other strategies for identifying every pregnant
enrollee. This shall include case management, claims analysis, and use of health
risk assessment, etc. The Health Plan shall require its participating providers
to notify the plan of any Medicaid enrollee who is identified as being pregnant;

 
        f.
Documentation of referral services in enrollee medical records, including
reports resulting from the referral;

 
        g.
Monitoring of enrollees with ongoing medical conditions and coordination of
services for high utilizers to address the following, as appropriate: acting as
a liaison between the enrollee and providers, ensuring the enrollee is receiving
routine medical care, ensuring the enrollee has adequate support at home,
assisting enrollees who are unable to access necessary care due to their medical
or emotional conditions or who do not have adequate community resources to
comply with their care, and assisting the enrollee in developing community
resources to manage a medical condition;

 
        h.
Documentation of emergency care encounters in enrollee medical records with
appropriate medically indicated follow-up;

 
        i.
Coordination of hospital/institutional discharge planning that includes
post-discharge care, including skilled short-term rehabilitation, and skilled
nursing facility care, as appropriate;

 
        j.
Sharing with other Health Plans serving the enrollee the results of its
identification and assessment of any enrollee with special health care needs so
that those activities need not be duplicated;

 
        k.
Ensuring that in the process of coordinating care, each enrollee's privacy is
protected consistent with the confidentiality requirements in 45 CFR parts 160
and 164. 45 CFR Part 164 specifically describes the requirements regarding the
privacy of individually identifiable health information.

 
6.
Attachment II, Core Contract Provisions, Section XII, Reporting Requirements,
Item A., Health Plan Reporting Requirements, Table 2-A, Summary of Submission
Requirements, is hereby deleted in its entirety and replaced with the following
Table 2-B, Revised Summary of Submission Requirements. All references in the
Contract to Table 2-A shall hereinafter refer to Table 2-B.

 
TABLE 2-B

 
REVISED SUMMARY OF SUBMISSION REQUIREMENTS
 
 
2.     Other Health Plan submissions (not in Table 1-A) required by the Agency
are as follows:

 
AHCA Contract No. FA904, Amendment No. 3, Page 2 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Attachment I, Section B., Item 3.a.
Increase in enrollment levels
Capitated Health Plans; FFS PSNs; CCC
Before increases occur
BMHC and HSD
Attachment I, Section D., Item 3.b.
Changes to optional or expanded services
FFS PSNs; CCC
Annually, by June 15th
HSD
Attachment I, Section D., Item 3.c.
Changes to optional or expanded services
Capitated Health Plans
    Annually, by June 15th
HSD
 
Subsequent references are to Attachment II and its Exhibits
Section II, Item D.4.
Policies, procedures, model provider agreements & amendments, subcontracts, All
materials related to Contract for distribution to enrollees, providers,
public
All
Before beginning use; whenever changes occur
BMHC
Section II, Item D.4.a.
Written materials
All
Forty-five (45) calendar days before effective date
BMHC
Section II, Item D.4.b
Written notice of change to enrollees
All
Thirty (30) calendar days before effective date
Enrollees affected by change
Section II, Item D.6.
Enrollee materials, PDL, provider & enrollee handbooks
All
Available on Health Plan's web site without log-in
Plan web site
    Section III, Item B.3.c.(l)
Enrollee pregnancy
All
Upon confirmation
DCF & MPI
Section III, Item B.3.c.(3)
Unborn activation notice
All
Presentation for delivery
DCF & MPI
Section III, Item B.3.d.
Birth information if no unborn activation
All
Upon delivery
DCF
Section III, Item C.4.b.
Involuntary disenrollment request
All
Forty-five (45) calendar days before effective date
BMHC
Section III, Item C.4.e.
Notice that Health Plan is requesting disenrollment in next Contract month
All
Before effective date
Enrollee affected

 
AHCA Contract No. FA904, Amendment No. 3, Page 3 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section IV, Item A.1.e.
Notice of reinstatement of enrollee
All
By 1st calendar day of month after learning of reinstatement or within five (5)
calendar days from receipt of enrollment file, whichever is later
Person being reinstated
Section IV, Item A.2.a. and Item A. 6.a.(17); Section VIII, Item A.4.
How to get Health Plan information in alternative formats
All
Include in cultural competency plan and enrollee handbook, and upon request
Enrollees &
potential enrollees
Section IV, Item A.2.c.
Right to get information about Health Plan
All
Annually
Enrollees
Section IV, Item A.7.c.
Provider directory online file
All
Update monthly & submit attestation
BMHC
Section IV, Item A.9.a.
Enrollee assessments
All
Within thirty (30) calendar days of enrollment notify about pregnancy screening
Enrollees
Section IV, Item A.9.c.
Enrollees more than 2 months behind in periodicity screening
All
Contact twice, if needed
Enrollees who
meet criteria
Section IV, Item A.11.f.
Toll-free help line performance standards
All
Get approval before beginning operation
BMHC
Section IV, Item A.12. and Item A.,6.a.(17); Section VIII, Item A.4.
How to access translation services
All
Include in cultural competence plan and enrollee handbook
Enrollees
Section IV, Item A.14.a.
Incentive program
All
Get approval before offering
BMHC
Section IV, Item A.14.g.
Pre-natal care programs
All
Before implementation
BMHC
Section IV, Item A.17.c
Notice of change in participation in redetermination notices
All
If change in participation, annually, by June 1st
BMHC
Section IV, Item A.17.c.(1)
Redetermination policies & procedures
All
When Health Plan agrees to  participate
BMHC
Section IV, Item A.17.c.(1)(a)
Notice in writing to discontinue Medicaid redetermination date data use
All
Thirty (30) calendar days before stopping
BMHC

 
AHCA Contract No. FA904, Amendment No. 3, Page 4 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section IV, Item B.3.c.
Member services phone script responding to community outreach calls and outreach
materials
All
Before use
BMHC
Section IV, Item B.4.c.
In case of force majeure, notice of participation in health fair or other public
event
All
By day of event
BMHC
Section IV, Item B.6.f.
Report of staff or community outreach rep. violations
All
Within fifteen (15) calendar days of knowledge
BMHC
Section V, Item C.1.
Written details of expanded services
All
Before implementation
HSD
Section V, Item F.
Decision to not offer a service on moral/religious grounds
All
One-hundred and twenty (120) calendar days before implementation
 
Thirty (30) calendar days before implementation
BMHC
 
Enrollees
 
 
 
Section V, Item H.10.b.2.
UNOS form & disenrollment request for specified transplants
All
When enrollee listed
BMHC
Section V, Item H.14.e.
Attestation that the Health Plan has
advised providers to enroll in VFC program
All
Annually, by October 1st
BMHC
Section V, Item H.16.a.(4)
PDL update
All
Annually, by October 1st.
 
Thirty (30) calendar days written notice of change.
BMHC and Bureau of Medicaid Pharmacy Services
Section VII, Item A.2.
Capacity to provide
covered services
All
Before taking enrollment
BMHC
Section VII, Item C.1.
Request for initial or expansion review
All
When requesting initial enrollment or expansion into a county.
BMHC and HSD

 
AHCA Contract No. FA904, Amendment No. 3, Page 5 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section VII, Item C.2.
Compliance with access requirements following significant changes in service
area or new populations
All
Before expansion
BMHC and HSD
Section VII, Item C.3.
Significant network changes
All
Within seven (7) business days
BMHC
Section VII, Item C.5.
When PCP leaves network
All
Within fifteen (15) calendar days of knowledge.  A copy of the enrollee notice
for terminated providers is due no more than fifteen (15) calendar days after
receipt of the PCP termination notice.
BMHC & affected enrollees
Section VII, Item D.2.jj.
Waiver of provider agreement indemnifying clause
All
Approval before use
BMHC
Section VII, Item E.3.
Notice of terminated providers due to imminent danger/impairment
All
Immediate
BMHC and Provider
Section VII, Item E.4.
Termination or suspension of providers; for "for cause" terminations, include
reasons for termination
All
Sixty (60) calendar days before termination effective date
BMHC, affected enrollees, & provider
Section VIII, Item A.1.b.
Written Quality Improvement Plan
All
Within thirty (30) calendar days of initial Contract execution; Thereafter,
Annually by April 1st
BMHC
Section VIII, Item A.3.a.(6)
Measurement periods and methodologies
All
Any new PIPs before initiation
BMHC
Section VIII, Item A.3.a.(7)
Proposal for each planned PIP
All
Ninety (90) calendar days after Contract execution; Thereafter, Annually by June
1st
BMHC
Section VIII, Item A.3.c.(1)
Performance measure data and auditor certification
All
Annually by July 1st
BMQM

 
AHCA Contract No. FA904, Amendment No. 3, Page 6 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section VIII, Item A.3.c.(4)
Performance measure action plan
All
Within thirty (30) calendar days of determination of unacceptable performance
BMQM
Section VIII, Item A.3.e.(7)
Written strategies for medical record review
All
Before use
BMHC
Section VIII, Item  B.1.a.(4)(a)
Service authorization protocols & any changes
All
Before use
BMHC
Section VIII, Item B.4.
Changes to UM component
All
Thirty (30) calendar days before effective date
BMHC
Section IX, Item A.8.
Complaint log
All
Upon request
BMHC
Section X, Item B.2.
Changes in staffing
All
Five (5) business days of any change
BMHC & HSD
Section X Item B.2.b.
Full-Time Administrator
All
Before designating duties of any other position
BMHC
Section X, Item D. 3. a.
Reform and non-Reform historical encounter data for all typical and atypical
services
All
According to Agency-approved schedules and no later than 10/31/09
MEDS team & Fiscal Agent
Section X, Item D.3.b.
Encounter data for all typical and atypical services
All
Within sixty (60) calendar days following end of month in which Health Plan paid
claims for services, and as specified in MEDS Companion Guide
MEDS Team & Agency Fiscal Agent
Section X, Item E.4.
Fraud & abuse compliance plan & policies & procedures
All
Before implementation
MPI
Section XI, Item D.4.a.
Any problem that threatens system performance
All
Within one (1) hour
Applicable Agency staff
Section XI, Item D.8.a.
Business Continuity-Disaster Recovery Plan
All
Before beginning operation and certification if plan is unchanged by April 30
annually thereafter;
 
Changes within ten (10) calendar days of change
BMHC

 
AHCA Contract No. FA904, Amendment No. 3, Page 7 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section XI, Item E.1.
System changes
All
Ninety (90) calendar days before change
HSD
Section XIV, Item A.1.(a)
Corrective action plan
 
All
Within ten (10) business days of notice of violation or non-compliance with
Contract
Agency Bureau sending violation notice
Section XIV, Item A.1.(b)
Performance measure action plan
All
Within thirty (30) calendar days of notice of failure to meet a performance
standard
Agency Bureau sending violation notice
Section XV, Item C.
Proof of working capital
All
Before enrollment
BMHC
Section XV, Item G.2.
Physician incentive plan
All
Written description before use
BMHC
Section XV, Item H.
Third party coverage identified
All
As soon as known
Medicaid Third Party Liability Vendor
Section XV, Item I.
Proof of fidelity bond coverage
All
Within sixty (60) calendar days of Contract execution & before delivering health
care
HSD Contract manager
Section XVI, Item C.1.
Request for assignment or transfer of contract in approved merger/acquisition
All
Ninety (90) days before effective date
HSD
Section XVI, Item M.
Use of "Medicaid" or "AHCA"
All
Before use
BMHC
Section XVI, Item O.
All subcontracts for Agency approval
All
Before effective date
BMHC
Section XVI, Item O.1.f.
Subcontract monitoring schedule
All
Annually, by December 1
BMHC
Section XVI, Item V.1.
Ownership & management disclosure forms
All
With initial application; and then annually by September 1
HSD - for initial application; BMHC & HSD for annual
Section XVI, Item V.1.
Changes in ownership & control
All
Within five (5) calendar days of knowledge & sixty (60) days before effective
date
BMHC & HSD
Section XVI, Item V.4.
Fingerprints for principals
All
Before Contract execution; Thereafter, Annually by September 1
HSD

 
AHCA Contract No. FA904, Amendment No. 3, Page 8 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Section XVI, Item V.4.c.
Fingerprints of newly hired principals
All
Within thirty (30) calendar days of hire date
HSD
Section XVI, Item V.5.
Information about offenses listed in 435.03
All
Within five (5) business days of
knowledge
HSD
Section XVI, Item V.6.
Corrective action plan related to principals committing offenses under 435.03
All
As prescribed by the Agency
HSD
Section XVI, Item Y.
General insurance policy declaration pages
All except CCC
Annually upon renewal
BMHC
Section XVI, Item Z.
Workers' compensation insurance declaration page
All except CCC
Annually upon renewal
BMHC
Section XVI, Item BB.
Emergency Management Plan
All
Before beginning operation and by May 31 annually thereafter
BMHC
Exhibit 2, Section II, Item D.4.c.
Policies & procedures for screening for clinical eligibility & any changes to
them
CCC
Before implementation
BMHC
Exhibit 3, Section III, Item C.5.
Disenrollment notice
CCC
Get template approved before use
 
At least two (2) months before anticipated effective date of involuntary
disenrollment
BMHC
 
Enrollee
 
 
Exhibit 5, Section V, Item A.6.
Letters about exhaustion of benefits under customized benefit package
Reform capitated Health Plans
Before use
BMHC
Exhibit 5, Section V, Item H.20.g.
Transportation subcontract
NR HMO offering transportation; Reform Health Plans
Before execution
BMHC
Exhibit 5, Section V, Item H.20.h.
Transportation policies & procedures
NR HMO offering transportation; Reform Health Plans
Before use
BMHC

 
AHCA Contract No. FA904, Amendment No. 3, Page 9 of 14

 
 

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 WellCare of Florida, Inc. 
 
 
 Medicaid HMO Non-Reform Contract  d/b/a Staywell Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Exhibit 5, Section V, Item H.20.i.
Transportation adverse incidents
NR HMO offering transporation; Reform Health Plans
Within two (2) business days of the occurrence
BMHC
Exhibit 5, Section V, Item H.20.i.
Transportation suspected fraud
NR HMO offering transportation; Reform Health Plans
Immediately upon identification
MPI
Exhibit 5, Section V, Item H.20.p.
Performance measures
NR HMO offering transportation; Reform Health Plans
Annually report by July 1
BMQM
Exhibit 5, Section V, Item H.20.q. & r.
Attestation that Health Plan complies with transportation policies & procedures
& drivers pass background checks & meet qualifications
NR HMO offering transportation; Reform Health Plans
Annually by January 1
BMHC
Exhibit 6, Item A.3.
Review & approval of behavioral health services staff & subcontractors for
licensure compliance
Reform Health Plans & NR HMOs
Before providing services
BMHC
Exhibit 6, Item B.9.
Model agreement with community mental health centers
Reform Health Plans & NR HMOs
Before agreement is executed
BMHC
Exhibit 6, Item C.3.e.
Denied appeals from providers for emergency services claims
Plans covering behavioral health
Within ten (10) days after Health Plan's final denial
BMHC
Exhibit 6, Item C.5.a.(3)
Medical necessity criteria for community mental health services
Plans covering behavioral health
Before use and before changes implemented
BMHC
Exhibit 6, Item L.2.
MBHO staff  psychiatrist and model contracts for each specialty type
Plans covering behavioral health
Before execution
BMHC
Exhibit 6, Item M.
Optional services
Plans covering behavioral health
Before offering
BMHC
Exhibit 6, Item R.3.a.
Schedule for administrative and program monitoring and clinical record review
Plans covering behavioral health
Annually by July 1
BMHC
Exhibit 8, Section VIII, Item B.5.
Substitute disease management initiatives
CCC
Within sixty (60) calendar days of Contract execution
BMHC

 
AHCA Contract No. FA904, Amendment No. 3, Page 10 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
Contract Section
Submission
Plan Type
Frequency
Submit To
Exhibit 8, Section VIII, Item A.3.f.
Provider satisfaction survey
All Reform Health Plans
By end of 8th month of Contract
BMHC
Exhibit 8, Section VIII, Item B.5.b.
Policies and procedures and program descriptions for each disease management
program
All Reform Health Plans
Annually, by April 1
BMHC
Exhibit 8, Section VIII, Item B. 1. e. (5)
Caseload maximums for case managers
HIV/AIDS specialty plan
Before providing services
BMHC
Exhibit 10, Section X, Item C. 5. a.
Discrepancies in ERV
FFS Health Plans; CCC
Within ten (10) business days of discovery
HSD analyst
Exhibit 15, Section XV, Item A. 1. a.
Plan for transition from FFS to prepaid capitated plan
FFS PSNs; CCC
Last calendar day of 24th month of
Health Plan's initial Reform operation
HSD
Exhibit 15, Section XV, Item A. 1. b.
Conversion application to capitated Health
Plan
FFS PSNs; CCC
 
By August 1 of 4th year of Reform operation
HSD
Exhibit 15, Section XV, Item I.
Proof of coverage for any non-government subcontractor
CCC
Within sixty (60) calendar days of execution and before delivery of care
BMHC

NR HMO = Non-Reform health maintenance organization, includes Health Plans
covering
Frail/Elderly Program services as specified in Attachment I
Ref HMO = Reform health maintenance organization
Ref Cap PSN = Reform capitated provider service network
Ref FFS PSN = Reform Fee-for-Service Provider Service Network
NR Cap PSN = Non-Reform Capitated Provider Service Network
NR FFS PSN = Non-Reform Fee-for-Service Provider Service Network
CCC = Specialty plan for children with chronic conditions
HIV/AIDS = Specialty plan for recipients living with HIV/AIDS

 
7.
Attachment II, Core Contract Provisions, Section XIII, Method of Payment, the
third line of the title, is hereby amended to now read as follows:

 
See Attachment II, Exhibit 13

 
8.
Attachment II, Core Contract Provisions, Section XIV, Sanctions, Item G., is
hereby included as follows:

 
 
G.   Performance Measure Sanctions

          
 
The Agency shall sanction the Health Plan for failure to achieve minimum scores
on HEDIS performance measures after the first year of poor performance. The
Agency may impose monetary sanctions as described below in the event that the
PMAP fails to result in performance consistent with the Agency's expected
minimum standards, as specified in sub-items 2.a. and 2.b. of this item.

 
AHCA Contract No. FA904, Amendment No. 3, Page 11 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
The Agency shall assign performance measures a point value that correlates to
the National Committee for Quality Assurance HEDIS National Means and
Percentiles. The scores will be assigned according to the table below.
Individual performance measures will be grouped and the scores averaged within
each group.
 
PM Ranking
Score
>90th percentile
6
75th-89th percentile
5
60th-74th percentile
4
50th-59th percentile
3
25th- 49th percentile
2
10th,-24th percentile
1
<10th percentile
0

 
 
1.     PMAP Sanctions

 
The Health Plan shall complete a PMAP after the first year of poor performance
as described in Attachment II, Section VIII, A.3.c.(5). If the PMAP fails to
result in scores above the minimum performance standard, the Health Plan may be
assessed monetary sanctions under this section.

 
2.     Monetary sanctions

 

 
 
a.   The Health Plan may receive a monetary sanction of up to $10,000 for each
performance measure group where the group score is two (2) or lower but above
zero (0). Performance measure groups are as follows:

 
  (1)      Mental Health and Substance Abuse
 
                        (a)      Follow-Up Hospitalization After Mental Illness
(7 day)
 
                        (b)      Antidepressant Medication Management
 
                        (c)      Follow-Up Care for Children Prescribed ADHD
Medication

 
  (2)      Well-Child
 
(a)      Childhood Immunization Status
 
(b)      Well-Child Visits in the First 15 Months of Life (6 or more)
 
(c)      Well-Child Visits 3rd, 4th, 5th, and 6th Years of Life

 
(d)      Adolescent Well-Care Visits

(e)      Lead Screening in Children

 
(3)    Other Preventive Care
 
(a)      Breast Cancer Screening
 
(b)      Cervical Cancer Screening
 
(c)      Adults' Access to Preventive/Ambulatory Health Services

(d)      Annual Dental Visits

 
AHCA Contract No. FA904, Amendment No. 3, Page 12 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 
(e) BMI Assessment

 
(4)      Prenatal/Postpartum

  (a)      Prenatal and Postpartum Care (includes two (2) measures)

  (b)      Frequency of Ongoing Prenatal Care

 
(5)      Chronic Care
 
   (a)      Use of Appropriate Medications for People with Asthma
 
   (b)      Controlling High Blood Pressure

   (c)      Persistence of Beta-Blocker Treatment After a Heart Attack

 
(6)      Diabetes - Comprehensive Diabetes Care (excluding the blood pressure
submeasures)

 

 
  b.
If the Health Plan receives a score of zero (0) on any of the individual
measures in the following performance measure groups: Mental Health and
Substance Abuse, Chronic Care, or Diabetes; the Health Plan may be sanctioned
for individual performance measures, which will result in a sanction of $500 for
each member of the denominator not present in the numerator of the performance
measure, as defined in the HEDIS manual. If the Health Plan fails to improve
these performance measures in subsequent years, the Agency shall impose a
sanction of $1,000 per member.

 

 
  c.
The Agency may amend the performance measure groups with sixty (60) days'
advance notice.

 
3.
 Implementation - Performance measure sanctions will be implemented following
the phase-in schedule below.

 
      a.      2010 Submission - PMAP assessed for all measures scored at two (2)
or below.

  b.      2011 Submission - Individual measure sanctions as described in 2.b.
above.
        
      c.
2012 Submission - Group sanctions as described in 2.a. above for all group
scores that fall below the equivalent of the 40th percentile

  
      d. 
2013 Submission - Group sanctions as described in 2.a. above for all group
scores that fall below the equivalent of the 50th percentile

 
 9.
     Attachment II, Core  Contract  Provisions,  Section
XV,   Financial  Requirements,  Item  D.,  Surplus Requirement, the first
sentence, is hereby amended to now read as follows:

 
 In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at
all times in the form of cash, investments that mature in less than 180 calendar
days and allowable as admitted assets by the Department of Financial Services,
and restricted funds of deposits controlled by the Agency (including the Health
Plan's insolvency protection account) or the Department of Financial Services, a
surplus amount equal to the greater of $1.5 million, ten percent (10%) of total
liabilities, or two percent (2%) of the annualized amount of the Health Plan's
prepaid revenues.

 
AHCA Contract No. FA904, Amendment No. 3, Page 13 of 14

 
 

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 WellCare of Florida, Inc.     Medicaid HMO Non-Reform Contract  d/b/a Staywell
Health Plan of Florida  

 

 10.
 
 Attachment II, Core Contract Provisions, Section XVI, Terms and Conditions,
Item O., Subcontracts, sub-item I.e., is hereby deleted in its entirety and
replaced with the following:

 

 
c.
The Agency encourages use of minority business enterprise subcontractors. See
Attachment II, Section VII, Provider Network, Item D., Provider Contract
Requirements, for provisions and requirements specific to provider contracts.
See Attachment II, Section XVI, Terms and Conditions, Item W., Minority
Recruitment and Retention Plan, for other minority recruitment and retention
plan requirements. The Health Plan shall provide a monthly Minority
Participation Report (see Attachment II, Section XII, Reporting Requirements,
Table 1), to BMHC and the HSD designated minority participation report contact,
summarizing the business it does with minority subcontractors or vendors.

 
 11.
Attachment II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans,
Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs,
sub-item P., Community Behavioral Health Services Annual 80/20 Expenditure
Report (HMOs serving non-Reform populations only), the third sentence is hereby
amended to now read as follows:

 
In the event the Health Plan expends less than eighty percent (80%) of the
capitation rate, the Health Plan shall return the difference to the Agency no
later than April 1st of each Contract year.

 
 12.
Attachment II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health
Plans, Behavioral Health Care, Item 1., Reform Health Plans and Non-Reform HMOs,
sub-item S., Behavioral Health Reporting Requirements, sub-item 5., the second
sentence is hereby amended to now read as follows:

 
For Health Plans operating less than one (1) year, the Health Plan shall submit
this report to BMHC quarterly, forty-five (45) calendar days after the end of
the quarter being reported.
 
Unless otherwise stated, this Amendment is effective upon execution by both
parties or May 1, 2010 (whichever is later).

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.

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 fourteen (14) page
Amendment (including all attachments) to be executed by their officials
thereunto duly authorized.

WELLCARE OF FLORIDA, INC.
D/B/A/ STAYWELL HEALTH PLAN OF
FLORIDA
 
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED
BY:
 
 
/s/ Thomas L. Tran
 
SIGNED
BY:
 
 
/s/ Thomas W. Arnold
NAME:
 
Thomas Tran
 
NAME:
 
Thomas W. Arnold
TITLE:
 
Chief Financial Officer
 
TITLE:
 
Secretary
DATE:
 
April 29, 2010
 
DATE:
 
5/3/10

 
AHCA Contract No. FA904, Amendment No. 3, Page 14 of 14