Back to 8-k [form8k.htm]  Exhibit 10.4

 

AHCA CONTRACT NO. FA972
AMENDMENT NO. 1

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 HEALTHEASE, hereinafter referred to as the "Vendor," or “Health
Plan,” is hereby amended as follows:
 
1.
Standard Contract, Section III., Item A., Termination, sub-item 3., Termination
for Breach, first paragraph, the third sentence is hereby amended to now read as
follows:

 
If applicable, the Agency may employ the default provisions in Rule
60A-1.006(3), Florida Administrative Code.
 
2.
Effective September 1, 2012, Attachment I, Scope of Services, Capitated Health
Plans, Exhibit 2-NR, Medicaid Non-Reform Capitation Rates, Effective September
1, 2011, is hereby deleted in its entirety and replaced with Exhibit 2-NR,
Medicaid Non-Reform HMO Capitation Rates, September 1, 2012 – August 31, 2013
(90112), attached hereto and made a part of this Contract.

 
3.
Effective January 1, 2013, Attachment II, Core Contract Provisions, Section V,
Covered Services, Item H., Coverage Provisions is hereby amended to include
sub-item 23. as follows:

 
 
23.
Primary Care Services

 
The Health Plan shall process claims for and, if capitated or are approved by
the Agency to subcapitate for certain covered services, pay certain physicians
who provide Florida Medicaid-covered eligible primary care services in
accordance with the Affordable Care Act and 42 CFR sections 438 and 447, for the
period January 1, 2013, through December 31, 2014. Health Plans that are
approved by the Agency to subcapitate for services shall also pay in accordance
with such requirements
 
Unless otherwise stated, this amendment shall be effective upon execution by
both Parties.
 
All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in this Contract.
 
This amendment, and all its attachments, are hereby made part of this Contract.
 
This amendment cannot be executed unless all previous amendments to this
Contract have been fully executed.
 
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
 

AHCA Contract No. FA972, Amendment No. 1, Page  1 of 2

 
 

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IN WITNESS WHEREOF, the Parties hereto have caused this seven (7) 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/ Christina Cooper  
SIGNED
BY:
 /s/Elizabeth Dudek           NAME:  Christina Cooper   NAME:   Elizabeth Dudek
          TITLE:  President, FL and HI Division   TITLE:  Secretary          
DATE:  1/3/13   DATE:  1/10/13

  
 
List of Attachments/Exhibits included as part of this amendment:
                                  
Specify
Type
Number
Description

Attachment I
Exhibit 2-NR
Medicaid Non-Reform HMO Capitation Rates, September 1, 2012 – August 31, 2013
(90112) (5 Pages)

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA972, Amendment No. 1, Page  2 of 2

 
 

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EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 

TABLE 1 

 General Rates:                                            TANF            
 SSI-N        SSI-B
SSI-AB 
           AGE (14-20)  AGE (21-54)                      
    Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
Female                  Male
Female                  Male
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
 AGE (14-20)
AGE (21-54)
AGE (55+)
   AGE (65-)
AGE(65+)
01   1,044.10   176.87   97.38   60.25   120.03   62.88   275.12   123.66  
286.22   23,175.16   2,589.79   260.75   143.76   178.78   725.48   788.53  
353.96   99.74   79.65 02   962.26   163.01   90.13   57.49   112.56   59.89  
255.25   115.67   264.90   21,691.74   2,423.90   237.61   117.79   152.73  
651.93   728.05   353.96   93.24   74.33 03   1,132.49   191.85   106.18   68.14
  132.95   70.97   300.83   136.55   312.05   23,983.47   2,680.18   273.22  
157.59   192.69   765.02   821.29   353.96   92.76   73.94 04   1,224.06  
207.35   113.91   69.29   139.40   72.40   321.40   143.83   334.79   26,645.33
  2,977.63   302.25   171.70   211.14   844.47   910.43   353.96   88.79   70.69
05   1,314.12   222.62   123.01   78.07   153.29   81.36   348.21   157.58  
361.52   26,552.12   2,967.14   297.54   161.57   202.09   826.11   901.56  
353.96   78.87   62.58 06   1,233.32   208.96   116.42   78.18   148.71   81.20
  331.03   152.13   342.09   25,907.64   2,895.25   297.29   175.80   213.01  
835.41   890.51   353.96   78.53   62.31 07   1,189.59   201.49   110.21   64.80
  132.98   67.86   310.16   137.59   323.92   27,626.61   3,087.18   308.28  
164.73   207.33   854.09   936.03   353.96   77.12   61.15 09   1,228.70  
208.14   114.67   71.23   141.58   74.33   324.06   145.83   337.02   28,336.53
  3,166.45   312.52   159.40   204.33   860.57   954.38   353.96   87.68   69.78
10   1,087.72   184.27   101.80   64.51   126.76   67.23   288.12   130.34  
299.17   29,961.41   3,348.10   334.98   180.35   226.33   929.01   1,016.15  
353.96   91.91   73.25 11   1,365.87   231.40   128.48   84.35   162.48   87.72
  364.68   166.55   377.59   26,428.69   2,953.34   295.73   159.73   200.21  
820.51   896.71   353.96   104.17   83.26 6B   1,232.80   208.88   116.40  
78.35   148.84   81.36   331.06   152.23   342.07   25,906.00   2,895.07  
297.32   175.93   213.11   835.58   890.53   353.96   78.53   62.31 8A  
1,220.23   206.73   114.76   75.21   145.02   78.23   325.67   148.67   337.25  
27,586.10   3,082.83   316.74   187.71   227.26   890.38   948.50   353.96  
88.70   70.62 8B   1,111.87   188.36   104.24   66.89   130.51   69.65   295.33
  134.05   306.36   25,996.71   2,905.10   292.67   161.74   200.96   814.57  
884.82   353.96   85.56   68.05

TABLE 2

General + Mental Health Rates:                                                  
                            TANF             SSI-N    SSI-B SSI-AB          
 AGE (14-20)  AGE (21-54)                      
  Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
 AGE (6-13)
Female                 Male
  Female                  Male
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
 AGE (14-20)
AGE (21-54)
AGE (55+)
   AGE (65-)
AGE(65+)
01   1,044.18   176.95   99.62   71.64   131.27   74.12   284.95   133.49  
292.73   23,175.56   2,590.19   279.12   191.60   220.46   802.81   817.07  
371.28   109.99   89.90 02   962.32   163.07   91.81   66.02   120.98   68.31  
262.61   123.03   269.78   21,692.25   2,424.41   261.25   179.34   206.35  
751.43   764.78   371.28   103.49   84.58 03   1,132.56   191.92   108.06  
77.70   142.38   80.40   309.07   144.79   317.51   23,983.81   2,680.52  
288.85   198.29   228.15   830.81   845.57   371.28   103.01   84.19 04  
1,224.16   207.45   116.80   83.98   153.90   86.90   334.07   156.50   343.19  
26,645.73   2,978.03   320.91   220.29   253.47   923.02   939.42   371.28  
99.04   80.94 05   1,314.20   222.70   125.39   90.16   165.22   93.29   358.64
  168.01   368.43   26,552.60   2,967.62   319.79   219.52   252.58   919.79  
936.13   371.28   89.12   72.83 06   1,233.37   209.01   117.68   84.62   155.06
  87.55   336.58   157.68   345.77   25,907.96   2,895.57   312.03   214.19  
246.45   897.46   913.41   371.28   88.78   72.56 07   1,189.71   201.61  
113.51   81.62   149.57   84.45   324.67   152.10   333.53   27,627.14  
3,087.71   332.73   228.41   262.80   957.02   974.02   371.28   87.37   71.40
09   1,228.79   208.23   117.24   84.30   154.48   87.23   335.33   157.10  
344.49   28,337.15   3,167.07   341.28   234.28   269.56   981.61   999.05  
371.28   97.93   80.03 10   1,087.79   184.34   103.79   74.63   136.75   77.22
  296.85   139.07   304.96   29,961.97   3,348.66   360.85   247.71   285.01  
1,037.89   1,056.34   371.28   102.16   83.50 11   1,365.94   231.47   130.32  
93.71   171.72   96.96   372.76   174.63   382.94   26,429.18   2,953.83  
318.30   218.50   251.41   915.52   931.78   371.28   114.42   93.51 6B  
1,232.84   208.92   117.63   84.58   154.99   87.51   336.44   157.61   345.63  
25,906.32   2,895.39   312.01   214.18   246.43   897.41   913.35   371.28  
88.78   72.56 8A   1,220.29   206.79   116.43   83.72   153.41   86.62   333.01
  156.01   342.11   27,586.43   3,083.16   332.24   228.07   262.42   955.61  
972.58   371.28   98.95   80.87 8B   1,111.94   188.43   106.09   76.29   139.79
  78.93   303.44   142.16   311.73   25,997.15   2,905.54   313.10   214.93  
247.30   900.55   916.55   371.28   95.81   78.30

 
 
 

 
 
AHCA Contract No. FA972, Attachment I, Exhibit 2-NR, Page 1 of 5
 

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EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
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   1,044.18   176.96   101.49   74.61   134.03   77.30  
286.70   135.13   295.93   23,175.56   2,590.20   281.06   194.04   222.64  
804.38   819.27   373.69   110.98   90.72 02   962.33   163.09   95.76   72.29  
126.81   75.04   266.15   126.34   276.24   21,692.26   2,424.43   265.21  
184.33   210.80   753.49   767.67   373.69   104.93   85.77 03   1,132.58  
191.95   114.35   87.70   151.68   91.12   312.29   147.80   323.38   23,983.82
  2,680.55   295.56   206.73   235.69   833.00   848.62   373.69   104.94  
85.78 04   1,224.17   207.47   120.41   89.72   159.24   93.05   337.91   160.09
  350.20   26,645.74   2,978.05   324.64   224.98   257.66   925.96   943.53  
373.69   101.15   82.68 05   1,314.22   222.73   132.37   101.25   175.54  
105.18   362.92   172.02   376.25   26,552.61   2,967.65   326.50   227.96  
260.12   922.47   939.88   373.69   91.44   74.74 06   1,233.38   209.04  
123.44   93.77   163.57   97.37   338.87   159.82   349.94   25,907.97  
2,895.59   317.31   220.83   252.38   899.06   915.65   373.69   90.36   73.86
07   1,189.73   201.64   120.12   92.13   159.35   95.73   327.55   154.80  
338.79   27,627.15   3,087.74   339.32   236.70   270.20   959.00   976.79  
373.69   89.18   72.89 09   1,228.81   208.27   125.84   97.98   167.20   101.90
  338.50   160.06   350.27   28,337.16   3,167.10   349.01   244.00   278.24  
983.98   1,002.36   373.69   99.99   81.73 10   1,087.80   184.36   108.23  
81.68   143.31   84.78   298.21   140.34   307.44   29,961.98   3,348.68  
366.05   254.26   290.86   1,039.64   1,058.79   373.69   103.56   84.65 11  
1,366.02   231.55   139.28   108.79   184.83   110.07   374.98   176.70   386.98
  26,429.18   2,953.83   329.16   230.76   260.96   918.53   935.98   373.69  
117.45   96.01 6B   1,232.85   208.95   123.39   93.73   163.50   97.33   338.73
  159.75   349.80   25,906.33   2,895.41   317.29   220.82   252.36   899.01  
915.59   373.69   90.36   73.86 8A   1,220.32   206.84   127.98   102.09  
170.49   106.32   336.78   159.53   348.99   27,586.45   3,083.20   342.39  
240.83   273.82   958.31   976.35   373.69   101.47   82.95 8B   1,111.97  
188.48   116.21   92.38   154.76   96.19   306.24   144.78   316.84   25,997.16
  2,905.57   321.27   225.21   256.48   902.57   919.37   373.69   97.46   79.66

TABLE 4
General + MH + Transportation Rates:
                                                                       
TANF
           
SSI-N
   
SSI-B
SSI-AB
          AGE (14-20)  AGE (21-54)                       
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
Female
Male
 Female
 Male
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20) 
 AGE (21-54)
AGE (55+)
  AGE (65-)  
AGE (65+)
01   1,050.20   178.92   100.80   72.42   132.86   76.58   287.64   137.29  
296.27   23,220.19   2,624.21   287.27   197.37   229.60   827.01   838.17  
374.89   114.19   93.11 02   967.80   164.86   92.88   66.73   122.43   70.55  
265.06   126.49   273.00   21,732.42   2,455.03   268.58   184.53   214.57  
773.21   783.77   374.89   107.00   87.26 03   1,138.56   193.89   109.23  
78.48   143.97   82.85   311.76   148.58   321.04   24,023.02   2,710.41  
296.01   203.36   236.18   852.07   864.10   374.89   107.41   87.55 04  
1,229.96   209.35   117.94   84.73   155.43   89.27   336.66   160.16   346.61  
26,691.49   3,012.91   329.26   226.20   262.84   947.83   961.05   374.89  
104.55   85.15 05   1,318.77   224.20   126.29   90.75   166.43   95.16   360.69
  170.90   371.12   26,589.93   2,996.07   326.60   224.34   260.22   940.03  
953.77   374.89   93.73   76.35 06   1,238.15   210.58   118.62   85.24   156.32
  89.50   338.72   160.70   348.59   25,947.17   2,925.46   319.19   219.26  
254.48   918.72   931.95   374.89   92.87   75.68 07   1,194.72   203.25  
114.49   82.27   150.89   86.49   326.91   155.26   336.48   27,668.14  
3,118.96   340.22   233.71   271.19   979.25   993.40   374.89   90.67   73.92
09   1,234.50   210.10   118.36   85.04   155.99   89.56   337.89   160.71  
347.85   28,377.81   3,198.06   348.70   239.54   277.88   1,003.65   1,018.27  
374.89   102.51   83.53 10   1,093.71   186.28   104.95   75.40   138.31   79.64
  299.50   142.81   308.45   30,012.86   3,387.45   370.14   254.29   295.43  
1,065.48   1,080.39   374.89   106.75   87.00 11   1,370.41   232.93   131.19  
94.29   172.90   98.78   374.76   177.45   385.57   26,466.18   2,982.03  
325.06   223.28   258.98   935.58   949.27   374.89   117.89   96.16 6B  
1,237.62   210.49   118.57   85.20   156.25   89.46   338.58   160.63   348.45  
25,945.53   2,925.28   319.17   219.25   254.46   918.67   931.89   374.89  
92.87   75.68 8A   1,226.17   208.72   117.58   84.48   154.96   89.02   335.64
  159.72   345.57   27,626.55   3,113.74   339.56   233.26   270.63   977.36  
991.54   374.89   101.08   82.50 8B   1,117.96   190.40   107.27   77.07  
141.38   81.39   306.13   145.96   315.27   26,035.24   2,934.58   320.06  
219.85   255.10   921.20   934.56   374.89   99.43   81.07

 
 

  AHCA Contract No. FA972, Attachment I, Exhibit 2-NR, Page 2 of 5   
 

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EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
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   1,050.12   178.84   98.56   61.03   121.62   65.34  
277.81   127.46   289.76   23,219.79   2,623.81   268.90   149.53   187.92  
749.68   809.63   357.57   103.94   82.86 02   967.74   164.80   91.20   58.20  
114.01   62.13   257.70   119.13   268.12   21,731.91   2,454.52   244.94  
122.98   160.95   673.71   747.04   357.57   96.75   77.01 03   1,138.49  
193.82   107.35   68.92   134.54   73.42   303.52   140.34   315.58   24,022.68
  2,710.07   280.38   162.66   200.72   786.28   839.82   357.57   97.16   77.30
04   1,229.86   209.25   115.05   70.04   140.93   74.77   323.99   147.49  
338.21   26,691.09   3,012.51   310.60   177.61   220.51   869.28   932.06  
357.57   94.30   74.90 05   1,318.69   224.12   123.91   78.66   154.50   83.23
  350.26   160.47   364.21   26,589.45   2,995.59   304.35   166.39   209.73  
846.35   919.20   357.57   83.48   66.10 06   1,238.10   210.53   117.36   78.80
  149.97   83.15   333.17   155.15   344.91   25,946.85   2,925.14   304.45  
180.87   221.04   856.67   909.05   357.57   82.62   65.43 07   1,194.60  
203.13   111.19   65.45   134.30   69.90   312.40   140.75   326.87   27,667.61
  3,118.43   315.77   170.03   215.72   876.32   955.41   357.57   80.42   63.67
09   1,234.41   210.01   115.79   71.97   143.09   76.66   326.62   149.44  
340.38   28,377.19   3,197.44   319.94   164.66   212.65   882.61   973.60  
357.57   92.26   73.28 10   1,093.64   186.21   102.96   65.28   128.32   69.65
  290.77   134.08   302.66   30,012.30   3,386.89   344.27   186.93   236.75  
956.60   1,040.20   357.57   96.50   76.75 11   1,370.34   232.86   129.35  
84.93   163.66   89.54   366.68   169.37   380.22   26,465.69   2,981.54  
302.49   164.51   207.78   840.57   914.20   357.57   107.64   85.91 6B  
1,237.58   210.45   117.34   78.97   150.10   83.31   333.20   155.25   344.89  
25,945.21   2,924.96   304.48   181.00   221.14   856.84   909.07   357.57  
82.62   65.43 8A   1,226.11   208.66   115.91   75.97   146.57   80.63   328.30
  152.38   340.71   27,626.22   3,113.41   324.06   192.90   235.47   912.13  
967.46   357.57   90.83   72.25 8B   1,117.89   190.33   105.42   67.67   132.10
  72.11   298.02   137.85   309.90   26,034.80   2,934.14   299.63   166.66  
208.76   835.22   902.83   357.57   89.18   70.82

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   1,044.10   176.88   99.25   63.22   122.79   66.06  
276.87   125.30   289.42   23,175.16   2,589.80   262.69   146.20   180.96  
727.05   790.73   356.37   100.73   80.47 02   962.27   163.03   94.08   63.76  
118.39   66.62   258.79   118.98   271.36   21,691.75   2,423.92   241.57  
122.78   157.18   653.99   730.94   356.37   94.68   75.52 03   1,132.51  
191.88   112.47   78.14   142.25   81.69   304.05   139.56   317.92   23,983.48
  2,680.21   279.93   166.03   200.23   767.21   824.34   356.37   94.69   75.53
04   1,224.07   207.37   117.52   75.03   144.74   78.55   325.24   147.42  
341.80   26,645.34   2,977.65   305.98   176.39   215.33   847.41   914.54  
356.37   90.90   72.43 05   1,314.14   222.65   129.99   89.16   163.61   93.25
  352.49   161.59   369.34   26,552.13   2,967.17   304.25   170.01   209.63  
828.79   905.31   356.37   81.19   64.49 06   1,233.33   208.99   122.18   87.33
  157.22   91.02   333.32   154.27   346.26   25,907.65   2,895.27   302.57  
182.44   218.94   837.01   892.75   356.37   80.11   63.61 07   1,189.61  
201.52   116.82   75.31   142.76   79.14   313.04   140.29   329.18   27,626.62
  3,087.21   314.87   173.02   214.73   856.07   938.80   356.37   78.93   62.64
09   1,228.72   208.18   123.27   84.91   154.30   89.00   327.23   148.79  
342.80   28,336.54   3,166.48   320.25   169.12   213.01   862.94   957.69  
356.37   89.74   71.48 10   1,087.73   184.29   106.24   71.56   133.32   74.79
  289.48   131.61   301.65   29,961.42   3,348.12   340.18   186.90   232.18  
930.76   1,018.60   356.37   93.31   74.40 11   1,365.95   231.48   137.44  
99.43   175.59   100.83   366.90   168.62   381.63   26,428.69   2,953.34  
306.59   171.99   209.76   823.52   900.91   356.37   107.20   85.76 6B  
1,232.81   208.91   122.16   87.50   157.35   91.18   333.35   154.37   346.24  
25,906.01   2,895.09   302.60   182.57   219.04   837.18   892.77   356.37  
80.11   63.61 8A   1,220.26   206.78   126.31   93.58   162.10   97.93   329.44
  152.19   344.13   27,586.12   3,082.87   326.89   200.47   238.66   893.08  
952.27   356.37   91.22   72.70 8B   1,111.90   188.41   114.36   82.98   145.48
  86.91   298.13   136.67   311.47   25,996.72   2,905.13   300.84   172.02  
210.14   816.59   887.64   356.37   87.21   69.41

AHCA Contract No. FA972, Attachment I, Exhibit 2-NR, Page 3 of 5   
 

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

 
 
EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
 
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   1,050.12   178.85   100.43   64.00   124.38   68.52  
279.56   129.10   292.96   23,219.79   2,623.82   270.84   151.97   190.10  
751.25   811.83   359.98   104.93   83.68 02   967.75   164.82   95.15   64.47  
119.84   68.86   261.24   122.44   274.58   21,731.92   2,454.54   248.90  
127.97   165.40   675.77   749.93   359.98   98.19   78.20 03   1,138.51  
193.85   113.64   78.92   143.84   84.14   306.74   143.35   321.45   24,022.69
  2,710.10   287.09   171.10   208.26   788.47   842.87   359.98   99.09   78.89
04   1,229.87   209.27   118.66   75.78   146.27   80.92   327.83   151.08  
345.22   26,691.10   3,012.53   314.33   182.30   224.70   872.22   936.17  
359.98   96.41   76.64 05   1,318.71   224.15   130.89   89.75   164.82   95.12
  354.54   164.48   372.03   26,589.46   2,995.62   311.06   174.83   217.27  
849.03   922.95   359.98   85.80   68.01 06   1,238.11   210.56   123.12   87.95
  158.48   92.97   335.46   157.29   349.08   25,946.86   2,925.16   309.73  
187.51   226.97   858.27   911.29   359.98   84.20   66.73 07   1,194.62  
203.16   117.80   75.96   144.08   81.18   315.28   143.45   332.13   27,667.62
  3,118.46   322.36   178.32   223.12   878.30   958.18   359.98   82.23   65.16
09   1,234.43   210.05   124.39   85.65   155.81   91.33   329.79   152.40  
346.16   28,377.20   3,197.47   327.67   174.38   221.33   884.98   976.91  
359.98   94.32   74.98 10   1,093.65   186.23   107.40   72.33   134.88   77.21
  292.13   135.35   305.14   30,012.31   3,386.91   349.47   193.48   242.60  
958.35   1,042.65   359.98   97.90   77.90 11   1,370.42   232.94   138.31  
100.01   176.77   102.65   368.90   171.44   384.26   26,465.69   2,981.54  
313.35   176.77   217.33   843.58   918.40   359.98   110.67   88.41 6B  
1,237.59   210.48   123.10   88.12   158.61   93.13   335.49   157.39   349.06  
25,945.22   2,924.98   309.76   187.64   227.07   858.44   911.31   359.98  
84.20   66.73 8A   1,226.14   208.71   127.46   94.34   163.65   100.33   332.07
  155.90   347.59   27,626.24   3,113.45   334.21   205.66   246.87   914.83  
971.23   359.98   93.35   74.33 8B   1,117.92   190.38   115.54   83.76   147.07
  89.37   300.82   140.47   315.01   26,034.81   2,934.17   307.80   176.94  
217.94   837.24   905.65   359.98   90.83   72.18

 
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   1,050.20   178.93   102.67   75.39   135.62   79.76  
289.39   138.93   299.47   23,220.19   2,624.22   289.21   199.81   231.78  
828.58   840.37   377.30   115.18   93.93 02   967.81   164.88   96.83   73.00  
128.26   77.28   268.60   129.80   279.46   21,732.43   2,455.05   272.54  
189.52   219.02   775.27   786.66   377.30   108.44   88.45 03   1,138.58  
193.92   115.52   88.48   153.27   93.57   314.98   151.59   326.91   24,023.03
  2,710.44   302.72   211.80   243.72   854.26   867.15   377.30   109.34  
89.14 04   1,229.97   209.37   121.55   90.47   160.77   95.42   340.50   163.75
  353.62   26,691.50   3,012.93   332.99   230.89   267.03   950.77   965.16  
377.30   106.66   86.89 05   1,318.79   224.23   133.27   101.84   176.75  
107.05   364.97   174.91   378.94   26,589.94   2,996.10   333.31   232.78  
267.76   942.71   957.52   377.30   96.05   78.26 06   1,238.16   210.61  
124.38   94.39   164.83   99.32   341.01   162.84   352.76   25,947.18  
2,925.48   324.47   225.90   260.41   920.32   934.19   377.30   94.45   76.98
07   1,194.74   203.28   121.10   92.78   160.67   97.77   329.79   157.96  
341.74   27,668.15   3,118.99   346.81   242.00   278.59   981.23   996.17  
377.30   92.48   75.41 09   1,234.52   210.14   126.96   98.72   168.71   104.23
  341.06   163.67   353.63   28,377.82   3,198.09   356.43   249.26   286.56  
1,006.02   1,021.58   377.30   104.57   85.23 10   1,093.72   186.30   109.39  
82.45   144.87   87.20   300.86   144.08   310.93   30,012.87   3,387.47  
375.34   260.84   301.28   1,067.23   1,082.84   377.30   108.15   88.15 11  
1,370.49   233.01   140.15   109.37   186.01   111.89   376.98   179.52   389.61
  26,466.18   2,982.03   335.92   235.54   268.53   938.59   953.47   377.30  
120.92   98.66 6B   1,237.63   210.52   124.33   94.35   164.76   99.28   340.87
  162.77   352.62   25,945.54   2,925.30   324.45   225.89   260.39   920.27  
934.13   377.30   94.45   76.98 8A   1,226.20   208.77   129.13   102.85  
172.04   108.72   339.41   163.24   352.45   27,626.57   3,113.78   349.71  
246.02   282.03   980.06   995.31   377.30   103.60   84.58 8B   1,117.99  
190.45   117.39   93.16   156.35   98.65   308.93   148.58   320.38   26,035.25
  2,934.61   328.23   230.13   264.28   923.22   937.38   377.30   101.08  
82.43

 
AHCA Contract No. FA972, Attachment I, Exhibit 2-NR, Page 4 of 5   

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

 
 
 
EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
TABLE
9                                                                                                                                                         

 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   0.08   0.08   2.24   11.39   11.24   11.24   9.83  
9.83   6.51   0.40   0.40   18.37   47.84   41.68   77.33   28.54   17.32  
10.25   10.25 02   0.06   0.06   1.68   8.53   8.42   8.42   7.36   7.36   4.88
  0.51   0.51   23.64   61.55   53.62   99.50   36.73   17.32   10.25   10.25 03
  0.07   0.07   1.88   9.56   9.43   9.43   8.24   8.24   5.46   0.34   0.34  
15.63   40.70   35.46   65.79   24.28   17.32   10.25   10.25 04   0.10   0.10  
2.89   14.69   14.50   14.50   12.67   12.67   8.40   0.40   0.40   18.66  
48.59   42.33   78.55   28.99   17.32   10.25   10.25 05   0.08   0.08   2.38  
12.09   11.93   11.93   10.43   10.43   6.91   0.48   0.48   22.25   57.95  
50.49   93.68   34.57   17.32   10.25   10.25 06   0.05   0.05   1.26   6.44  
6.35   6.35   5.55   5.55   3.68   0.32   0.32   14.74   38.39   33.44   62.05  
22.90   17.32   10.25   10.25 07   0.12   0.12   3.30   16.82   16.59   16.59  
14.51   14.51   9.61   0.53   0.53   24.45   63.68   55.47   102.93   37.99  
17.32   10.25   10.25 09   0.09   0.09   2.57   13.07   12.90   12.90   11.27  
11.27   7.47   0.62   0.62   28.76   74.88   65.23   121.04   44.67   17.32  
10.25   10.25 10   0.07   0.07   1.99   10.12   9.99   9.99   8.73   8.73   5.79
  0.56   0.56   25.87   67.36   58.68   108.88   40.19   17.32   10.25   10.25
11   0.07   0.07   1.84   9.36   9.24   9.24   8.08   8.08   5.35   0.49   0.49
  22.57   58.77   51.20   95.01   35.07   17.32   10.25   10.25 6B   0.04   0.04
  1.23   6.23   6.15   6.15   5.38   5.38   3.56   0.32   0.32   14.69   38.25  
33.32   61.83   22.82   17.32   10.25   10.25 8A   0.06   0.06   1.67   8.51  
8.39   8.39   7.34   7.34   4.86   0.33   0.33   15.50   40.36   35.16   65.23  
24.08   17.32   10.25   10.25 8B   0.07   0.07   1.85   9.40   9.28   9.28  
8.11   8.11   5.37   0.44   0.44   20.43   53.19   46.34   85.98   31.73   17.32
  10.25   10.25

 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 8A    Lee  Area 8B    Charlotte,
Collier, De Soto, Glades, Hendry, Sarasota  Area 9    Indian River, Okeechobee,
St. Lucie, Martin, Palm Beach  Area 10    Broward  Area 11    Dade, Monroe

 
 
 
AHCA Contract No. FA972, Attachment I, Exhibit 2-NR, Page 5 of 5