Back to Form 8-K [form8k.htm]
Exhibit 10.1
 

   July    2012    Contract XT220

 
FLORIDA DEPARTMENT OF ELDER AFFAIRS
STANDARD CONTRACT
 
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT
 
THIS CONTRACT is entered into between the State of Florida Department of Elder
Affairs (Department) and WellCare of Florida Inc. dba HealthEase, (Contractor),
and collectively referred to as the “Parties.” The term contractor for this
purpose may designate a vendor, subgrantee or subrecipient, the status to be
further identified in ATTACHMENT III, Exhibit-2 as necessary.
 
WITNESSETH THAT:
WHEREAS, the Department has determined that it is in need of certain services as
described herein; and
WHEREAS, the Contractor has demonstrated that it has the requisite expertise and
ability to faithfully perform such services as an independent contractor of the
Department.
NOW THEREFORE, in consideration of the services to be performed and payments to
be made, together with the mutual covenants and conditions hereinafter set
forth, the Parties agree as follows:
 

1. Purpose of Contract   The purpose of this contract is to provide services in
accordance with the terms and conditions specified in this contract including
all attachments, forms and exhibits, which constitute the contract document.    
1.2 Department Mission Statement   To foster an environment that promotes
well-being for Florida’s elders and enables them to remain in their homes and
communities. The Department’s vision is of all Floridians aging with dignity,
purpose, and independence. Area agencies, lead agencies and local service
providers as partners and stakeholders in Florida’s aging services network are
expected to support the Department’s mission, vision, and program priorities.  
  2. Incorporation of Documents within the Contract   The contract will
incorporate attachments, proposal(s), state plan(s), grant agreements, relevant
Department handbooks, manuals or desk books, as an integral part of the
contract, except to the extent that the contract explicitly provides to the
contrary. In the event of conflict in language among any of the documents
referenced above, the specific provisions and requirements of the contract
document(s) shall prevail over inconsistent provisions in the proposal(s) or
other general materials not specific to this contract document and identified
attachments.     3. Term of Contract   This contract shall begin on July 1, 2012
or on the date on which the contract has been signed by the last party required
to sign it, whichever is later. It shall end at midnight, local time in
Tallahassee, Florida, on August 31, 2012.     4.  Contract Amount  
The Department agrees to pay for contracted services according to the terms and
conditions of this contract in an amount not to exceed $60,000,000.00, or the
rate schedule, subject to the availability of funds. Any costs or services paid
for under any other contract or from any other source are not eligible for
payment under this contract.
    5.
 Renewals
 
By mutual agreement of the Parties, in accordance with s. 287.058(1)(g), F.S.,
the Department may renew the contract for a period not to exceed three years, or
the term of the original contract, whichever is longer. The renewal price, or
method for determining a renewal price, is set forth in the bid, proposal, or
reply. No other costs for the renewal may be charged. Any renewal is subject to
the same terms and conditions as the original contract and contingent upon
satisfactory performance evaluations by the Department and the availability of
funds.
    6. Compliance with Federal Law    

 
 
 
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6.1  
If this contract contains federal funds this section shall apply.

 
6.1.1  
The Contractor shall comply with the provisions of 45 CFR 74 and/or 45 CFR 92,
and other applicable regulations.

 
6.1.2  
If this contract contains federal funds and is over $100,000.00, the Contractor
shall comply with all applicable standards, orders, or regulations issued under
s. 306 of the Clean Air Act as amended (42 U.S.C. 7401, et seq.), s. 508 of the
Federal Water Pollution Control Act as amended (33 U.S.C. 1251, et seq.),
Executive Order 11738, as amended, and where applicable Environmental Protection
Agency regulations 40 CFR 30. The Contractor shall report any violations of the
above to the Department.

 
6.1.3  
The Contractor, or agent acting for the Contractor, may not use any federal
funds received in connection with this contract to influence legislation or
appropriations pending before the Congress or any state legislature. If this
contract contains federal funding in excess of $100,000.00, the Contractor must,
prior to contract execution, complete the Certification Regarding Lobbying form,
ATTACHMENT II. All disclosure forms as required by the Certification Regarding
Lobbying form must be completed and returned to the Contract Manager prior to
payment under this contract.

 
6.1.4  
In accordance with Appendix A to 2 CFR 215, the Contractor shall comply with
Executive Order 11246, Equal Employment Opportunity, as amended by Executive
Order 11375 and others, and as supplemented in Department of Labor regulation 41
CFR 60 and 45 CFR 92, if applicable.

 
6.1.5  
If this contract contains federal funds and provides services to children up to
age 18, the Contractor shall comply with the Pro-Children Act of 1994 (20 U.S.C.
6081).

 
6.1.6  
A contract award with an amount expected to equal or exceed $25,000.00 and
certain other contract awards will not be made to parties listed on the
government-wide Excluded Parties List System, in accordance with the OMB
guidelines at 2 CFR 180 that implement Executive Orders 12549 and 12689,
“Debarment and Suspension.” The Excluded Parties List System contains the names
of parties debarred, suspended, or otherwise excluded by agencies, as well as
parties declared ineligible under statutory or regulatory authority other than
Executive Order 12549. The Contractor shall comply with these provisions before
doing business or entering into subcontracts receiving federal funds pursuant to
this contract. The Contractor shall complete and sign ATTACHMENT V prior to the
execution of this contract.

 
6.2  
The Contractor shall not employ an unauthorized alien. The Department will
consider the employment of unauthorized aliens a violation of the Immigration
and Nationality Act (8 U.S.C. 1324a) and the Immigration Reform and Control Act
of 1986 (8 U.S.C. 1101). Such violation will be cause for unilateral
cancellation of this contract by the Department.

 
6.3  
If the Contractor is a non-profit provider and is subject to Internal Revenue
Service (IRS) tax exempt organization reporting requirements (filing a Form 990
or Form 990-N) and has its tax exempt status revoked for failing to comply with
the filing requirements of the Pension Protection Act of 2006 or for any other
reason, the Contractor must notify the Department in writing within thirty (30)
days of receiving the IRS notice of revocation.

 
6.4  
The Contractor shall comply with Title 2 CFR Part 175 regarding Trafficking in
Persons.

 
6.5  
Unless exempt under 2 CFR Part 170.110(b), the Contractor shall comply with the
reporting requirements of the Transparency Act as expressed in 2 CFR 170.

 
6.6  
To comply with Presidential Executive Order 12989 and State of Florida Executive
Order Number 11-116, Contractor agrees to utilize the U.S. Department of
Homeland Security's E-verify system to verify the employment of all new
employees hired by Contractor during the contract term. Contractor shall include
in related subcontracts a requirement that subcontractors performing work or
providing services pursuant to the state contract utilize the E-verify system to
verify employment of all new employees hired by the subcontractor during the
contract term. Contractors meeting the terms and conditions of the E-Verify
System are deemed to be in compliance with this provision.

 
 
 
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during the contract term. Contractors meeting the terms and conditions of the
E-Verify System are deemed to be in compliance with this provision.

 
7.  
Compliance with State Law

 
7.1  
This contract is executed and entered into in the State of Florida, and shall be
construed, performed and enforced in all respects in accordance with the Florida
law, including Florida provisions for conflict of laws.

 
7.2  
The Contractor shall comply with requirements of s. 287.058, F.S. as amended.

 
7.2.1  
The Contractor shall provide units of deliverables, including various client
services, and in some instances may include reports, findings, and drafts, as
specified in this contract, which the Contract Manager must receive and accept
in writing prior to payment in accordance with s. 215.971, F.S. (1) and (2).

 
7.2.2  
The Contractor shall submit bills for fees or other compensation for services or
expenses in sufficient detail for a proper pre-audit and post-audit.

 
7.2.3  
If itemized payment for travel expenses is permitted in this contract, the
Contractor shall submit bills for any travel expenses in accordance with s.
112.061, F.S., or at such lower rates as may be provided in this contract.

 
7.2.4  
The Contractor shall allow public access to all documents, papers, letters, or
other public records as defined in subsection 119.011(12), F.S., made or
received by the Contractor in conjunction with this contract except for those
records which are made confidential or exempt by law. The Contractor’s refusal
to comply with this provision will constitute an immediate breach of contract
for which the Department may unilaterally terminate the contract.

 
7.3  
If clients are to be transported under this contract, the Contractor shall
comply with the provisions of Chapter 427, F.S., and Rule 41-2, F. A. C.

 
7.4  
Subcontractors who are on the discriminatory vendor list may not transact
business with any public entity, in accordance with the provisions of s.
287.134, F.S.

 
7.5  
The Contractor shall comply with the provisions of s. 11.062, F.S., and s.
216.347, F.S., which prohibit the expenditure of contract funds for the purpose
of lobbying the legislature, judicial branch or a state agency.

 
7.6  
In accordance with s. 287.135 F.S., any contractor on the Scrutinized Companies
with Activities in Sudan List or the Scrutinized Companies with Activities in
the Iran Petroleum Energy Sector List (Lists), created pursuant to s. 215.473
F.S., is ineligible to enter into or renew a contract with the Department for
goods or services of $1 million or more. Pursuant to s. 287.135 F.S., the
Department may terminate this contract if the Contractor is found to have
submitted a false certification of its status on the Lists or has been placed on
the Lists. Further, the Contractor is subject to civil penalties, attorney’s
fees and costs and any costs for investigations that led to the finding of false
certification. If this contract contains $1 million or more, the Contractor
shall complete and sign ATTACHMENT H, Certification Regarding Scrutinized
Companies Lists, prior to the execution of this contract.

 
8.  
Background Screening

The Contractor shall ensure that the requirements of s. 430.0402 and ch. 435,
F.S., as amended, are met regarding background screening for all persons who
meet the definition of a direct service provider and who are not excepted from
the Department’s level 2 background screening pursuant to s. 430.0402(2)-(3),
F.S. The Contractor must also comply with any applicable rules promulgated by
the Department and the Agency for Health Care Administration regarding
implementation of s. 430.0402 and ch. 435, F.S.
 
8.1  
Further information concerning the procedures for background screening is found
at http: //elderaffairs .state .fl .us/doea/backgroundscreening .php.

 
9.  
Grievance Procedures

 
 
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The Contractor shall develop, implement, and ensure that its subcontractors have
established grievance procedures to process and resolve client dissatisfaction
with or denial of service(s), and address complaints regarding the termination,
suspension or reduction of services, as required for receipt of funds. These
procedures, at a minimum, will provide for notice of the grievance procedure and
an opportunity for review of the subcontractor’s determination(s).
 
10.  
Audits, Inspections, Investigations, Public Records and Retention

 
10.1  
The Contractor shall establish and maintain books, records and documents
(including electronic storage media) sufficient to reflect all assets,
obligations, unobligated balances, income, interest and expenditures of funds
provided by the Department under this contract. Contractor shall adequately
safeguard all such assets and assure they are used solely for the purposes
authorized under this contract. Whenever appropriate, financial information
should be related to performance and unit cost data.

 
10.2  
The Contractor shall retain all client records, financial records, supporting
documents, statistical records, and any other documents (including electronic
storage media) pertinent to this contract for a period of six (6) years after
completion of the contract or longer when required by law. In the event an audit
is required by this contract, records shall be retained for a minimum period of
six (6) years after the audit report is issued or until resolution of any audit
findings or litigation based on the terms of this contract, at no additional
cost to the Department.

 
10.3  
Upon demand, at no additional cost to the Department, the Contractor shall
facilitate the duplication and transfer of any records or documents during the
required retention period in this section 10.2.

 
10.4  
The Contractor shall assure that the records described in this section 10 will
be subject at all reasonable times to inspection, review, copying, or audit by
federal, state, or other personnel duly authorized by the Department.

 
10.5  
At all reasonable times for as long as records are maintained, persons duly
authorized by the Department and federal auditors, pursuant to 45 CFR
92.36(i)(10), will be allowed full access to and the right to examine any of the
Contractor’s contracts and related records and documents pertinent to this
specific contract, regardless of the form in which kept.

 
10.6  
The Contractor shall provide a financial and compliance audit to the Department
as specified in this contract and in ATTACHMENT III and ensure that all related
third-party transactions are disclosed to the auditor.

 
10.7  
The Contractor shall comply and cooperate immediately with any inspections,
reviews, investigations, or audits deemed necessary by the office of the
Inspector General pursuant to s. 20.055, F.S.

 
11.  
Nondiscrimination-Civil Rights Compliance

 
11.1  
The Contractor shall execute assurances in ATTACHMENT VI that it will not
discriminate against any person in the provision of services or benefits under
this contract or in employment because of age, race, religion, color,
disability, national origin, marital status or sex in compliance with state and
federal law and regulations. The Contractor further assures that all
contractors, subcontractors, subgrantees, or others with whom it arranges to
provide services or benefits in connection with any of its programs and
activities are not discriminating against clients or employees because of age,
race, religion, color, disability, national origin, marital status or sex.

 
11.2  
During the term of this contract, the Contractor shall complete and retain on
file a timely, complete and accurate Civil Rights Compliance Checklist
(ATTACHMENT B).

 
11.3  
The Contractor shall establish procedures pursuant to federal law to handle
complaints of discrimination involving services or benefits through this
contract. These procedures will include notifying clients, employees, and
participants of the right to file a complaint with the appropriate federal or
state entity.

 
11.4  
If this contract contains federal funds, these assurances are a condition of
continued receipt of or benefit from federal financial assistance, and are
binding upon the Contractor, its successors, transferees, and assignees for the

 
 
 
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period during which such assistance is provided. The Contractor further assures
that all subcontractors, vendors, or others with whom it arranges to provide
services or benefits to participants or employees in connection with any of its
programs and activities are not discriminating against those participants or
employees in violation of the above statutes, regulations, guidelines, and
standards. In the event of failure to comply, the Contractor understands that
the Department may, at its discretion, seek a court order requiring compliance
with the terms of this assurance or seek other appropriate judicial or
administrative relief, including but not limited to, termination of and denial
of further assistance.

 
12.  
Provision of Services

The Contractor shall provide services in the manner described in ATTACHMENT I.
 
13.  
Monitoring by the Department

The Contractor shall permit persons duly authorized by the Department to inspect
and copy any records, papers, documents, facilities, goods and services of the
Contractor which are relevant to this contract, and to interview any clients,
employees and subcontractor employees of the Contractor to assure the Department
of the satisfactory performance of the terms and conditions of this contract.
Following such review, the Department will provide a written report of its
findings to the Contractor, and where appropriate, the Contractor shall develop
a corrective action plan. The Contractor hereby agrees to correct all
deficiencies identified in the corrective action plan in a timely manner as
determined by the Contract Manager.
 
14.  
Coordinated Monitoring with Other Agencies

If the Contractor receives funding from one or more of the State of Florida
other human service agencies, in addition to the Department of Elder Affairs,
then a joint monitoring visit including such other agencies may be scheduled.
For the purposes of this contract, and pursuant to s. 287.0575, F.S. as amended,
Florida’s human service agencies shall include the Department of Children and
Families, the Department of Health, the Agency for Persons with Disabilities,
the Department of Veterans Affairs, and the Department of Elder Affairs. Upon
notification and the subsequent scheduling of such a visit by the designated
agency’s lead administrative coordinator, the Contractor shall comply and
cooperate with all monitors, inspectors, and/or investigators.
 
15.  
Indemnification

The Contractor shall indemnify, save, defend, and hold harmless the Department
and its agents and employees from any and all claims, demands, actions, causes
of action of whatever nature or character, arising out of or by reason of the
execution of this agreement or performance of the services provided for herein.
It is understood and agreed that the Contractor is not required to indemnify the
Department for claims, demands, actions or causes of action arising solely out
of the Department’s negligence.
 
15.1  
Except to the extent permitted by s. 768.28, F.S., or other Florida law, this
section 15 is not applicable to contracts executed between the Department and
state agencies or subdivisions defined in s. 768.28(2), F.S.

 
16.  
Insurance and Bonding

 
16.1  
The Contractor shall provide continuous adequate liability insurance coverage
during the existence of this contract and any renewal(s) and extension(s) of it.
By execution of this contract, unless it is a state agency or subdivision as
defined by subsection 768.28(2), F.S., the Contractor accepts full
responsibility for identifying and determining the type(s) and extent of
liability insurance necessary to provide reasonable financial protections for
the Contractor and the clients to be served under this contract. The limits of
coverage under each policy maintained by the Contractor do not limit the
Contractor’s liability and obligations under this contract. The Contractor shall
ensure that the Department has the most current written verification of
insurance coverage throughout the term of this contract. Such coverage may be
provided by a self-insurance program established and operating under the laws of
the State of Florida. The Department reserves the right to require additional
insurance as specified in this contract.

 
16.2  
Throughout the term of this agreement, the Contractor shall maintain an
insurance bond from a responsible commercial insurance company covering all
officers, directors, employees and agents of the Contractor authorized to handle
funds received or disbursed under all agreements and/or contracts incorporating
this contract

 
 
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by reference in an amount commensurate with the funds handled, the degree of
risk as determined by the insurance company and consistent with good business
practices.

 
 
17.  
Confidentiality of Information

The Contractor shall not use or disclose any information concerning a recipient
of services under this contract for any purpose prohibited by state or federal
law or regulations except with the written consent of a person legally
authorized to give that consent or when authorized by law.
 
18.  
Health Insurance Portability and Accountability Act

Where applicable, the Contractor shall comply with the Health Insurance
Portability and Accountability Act (42 USC 1320d.), as well as all regulations
promulgated thereunder (45 CFR 160, 162, and 164).
 
19.  
Incident Reporting

 
19.1  
The Contractor shall notify the Department immediately but no later than
forty-eight (48) hours from the Contractor’s awareness or discovery of
conditions that may materially affect the Contractor or subcontractor’s ability
to perform the services required to be performed under this contract. Such
notice shall be made orally to the Contract Manager (by telephone) with an email
to immediately follow.

 
19.2  
The Contractor shall immediately report knowledge or reasonable suspicion of
abuse, neglect, or exploitation of a child, aged person, or disabled adult to
the Florida Abuse Hotline on the statewide toll-free telephone number
(1-800-96ABUSE). As required by Chapters 39 and 415, F.S., this provision is
binding upon both the Contractor and its employees.

 
20.  
New Contract(s) Reporting

The Contractor shall notify the Department within ten (10) days of entering into
a new contract with any of the remaining four (4) state human service agencies.
The notification shall include the following information: (1) contracting state
agency; (2) contract name and number; (3) contract start and end dates; (4)
contract amount; (5) contract description and commodity or service; and (6)
Contract Manager name and number. In complying with this provision, and pursuant
to s. 287.0575, F.S. as amended, the Contractor shall complete and provide the
information in ATTACHMENT D.
 
21.  
Bankruptcy Notification

During the term of this contract, the Contractor shall immediately notify the
Department if the Contractor, its assignees, subcontractors or affiliates file a
claim for bankruptcy. Within ten (10) days after notification, the Contractor
must also provide the following information to the Department of Elder Affairs:
(1) the date of filing of the bankruptcy petition; (2) the case number; (3) the
court name and the division in which the petition was filed (e.g., Northern
District of Florida, Tallahassee Division); and (4) the name, address, and
telephone number of the bankruptcy attorney.
 
22.  
Sponsorship and Publicity

 
22.1  
As required by s. 286.25, F.S., if the Contractor is a non-governmental
organization which sponsors a program financed wholly or in part by state funds,
including any funds obtained through this contract, it shall, in publicizing,
advertising, or describing the sponsorship of the program, state: “Sponsored by
(Contractor’s name) and the State of Florida, Department of Elder Affairs.” If
the sponsorship reference is in written material, the words “State of Florida,
Department of Elder Affairs” shall appear in at least the same size letters or
type as the name of the organization.

 
22.2  
The Contractor shall not use the words “The State of Florida, Department of
Elder Affairs” to indicate sponsorship of a program otherwise financed, unless
specific authorization has been obtained by the Department prior to use.

 
23.  
Assignments

 
 
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23.1  
The Contractor shall not assign the rights and responsibilities under this
contract without the prior written approval of the Department, which shall not
be unreasonably withheld. Any sublicense, assignment, or transfer otherwise
occurring without prior written approval of the Department will constitute a
material breach of the contract.

 
23.2  
The State of Florida is at all times entitled to assign or transfer, in whole or
part, its rights, duties, or obligations under this contract to another
governmental agency in the State of Florida, upon giving prior written notice to
the Contractor. In the event the State of Florida approves transfer of the
Contractor’s obligations, the Contractor remains responsible for all work
performed and all expenses incurred in connection with the contract.

 
23.3  
This contract shall remain binding upon the successors in interest of either the
Contractor or the Department.

 
24.  
Subcontracts

 
24.1  
The Contractor is responsible for all work performed and for all commodities
produced pursuant to this contract, whether actually furnished by the Contractor
or its subcontractors. Any subcontracts shall be evidenced by a written document
and subject to any conditions of approval the Department deems necessary. The
Contractor further agrees that the Department will not be liable to the
subcontractor in any way or for any reason. The Contractor, at its expense,
shall defend the Department against any such claims.

 
24.2  
The Contractor shall promptly pay any subcontractors upon receipt of payment
from the Department or other state agency. Failure to make payments to any
subcontractor in accordance with s. 287.0585, F.S., unless otherwise stated in
the contract between the Contractor and subcontractor, will result in a penalty
as provided by statute.

 
25.  
Independent Capacity of Contractor

It is the intent and understanding of the Parties that the Contractor, or any of
its subcontractors, are independent contractors and are not employees of the
Department and shall not hold themselves out as employees or agents of the
Department without specific authorization from the Department. It is the further
intent and understanding of the Parties that the Department does not control the
employment practices of the Contractor and will not be liable for any wage and
hour, employment discrimination, or other labor and employment claims against
the Contractor or its subcontractors. All deductions for social security,
withholding taxes, income taxes, contributions to unemployment compensation
funds and all necessary insurance for the Contractor are the sole responsibility
of the Contractor.
 
26.  
Payment

Payments shall be made to the Contractor pursuant to s. 215.422, F.S., as
services are rendered and invoiced by the Contractor. The Contract Manager will
have final approval of the invoice for payment, and will approve the invoice for
payment only if the Contractor has met all terms and conditions of the contract,
unless the bid specifications, purchase order, or this contract specify
otherwise. The approved invoice will be submitted to the Department’s finance
section for budgetary approval and processing. Disputes arising over invoicing
and payments will be resolved in accordance with the provisions of s. 215.422
F.S. A Vendor Ombudsman has been established within the Department of Financial
Services and may be contacted at (850) 413-5665.
 
27.  
Return of Funds

The Contractor shall return to the Department any overpayments due to unearned
funds or funds disallowed and any interest attributable to such funds pursuant
to the terms and conditions of this contract that were disbursed to the
Contractor by the Department. In the event that the Contractor or its
independent auditor discovers that an overpayment has been made, the Contractor
shall repay said overpayment immediately without prior notification from the
Department. In the event that the Department first discovers an overpayment has
been made, the Contract Manager will notify the Contractor in writing of such
findings. Should repayment not be made forthwith, the Contractor will be charged
at the lawful rate of interest on the outstanding balance pursuant to s. 55.03,
F.S., after Department notification or Contractor discovery.
 
28.  
Data Integrity and Safeguarding Information

 
 
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The Contractor shall ensure an appropriate level of data security for the
information the Contractor is collecting or using in the performance of this
contract. An appropriate level of security includes approving and tracking all
Contractor employees that request system or information access and ensuring that
user access has been removed from all terminated employees. The Contractor,
among other requirements, must anticipate and prepare for the loss of
information processing capabilities. All data and software shall be routinely
backed up to ensure recovery from losses or outages of the computer system. The
security over the backed-up data is to be as stringent as the protection
required of the primary systems. The Contractor shall ensure all subcontractors
maintain written procedures for computer system backup and recovery. The
Contractor shall complete and sign ATTACHMENT IV prior to the execution of this
contract.
 
29.  
Conflict of Interest

The Contractor shall establish safeguards to prohibit employees, board members,
management and subcontractors from using their positions for a purpose that
constitutes or presents the appearance of personal or organizational conflict of
interest or personal gain. No employee, officer or agent of the Contractor or
subcontractor shall participate in selection, or in the award of an agreement
supported by state or federal funds if a conflict of interest, real or apparent,
would be involved. Such a conflict would arise when: (a) the employee, officer
or agent; (b) any member of his/her immediate family; (c) his or her partner; or
(d) an organization which employs, or is about to employ, any of the above, has
a financial or other interest in the firm selected for award. The Contractor or
subcontractor’s officers, employees or agents will neither solicit nor accept
gratuities, favors or anything of monetary value from contractors, potential
contractors, or parties to subcontracts. The Contractor’s board members and
management must disclose to the Department any relationship which may be, or may
be perceived to be, a conflict of interest within thirty (30) calendar days of
an individual’s original appointment or placement in that position, or if the
individual is serving as an incumbent, within thirty (30) calendar days of the
commencement of this contract. The Contractor’s employees and subcontractors
must make the same disclosures described above to the Contractor’s board of
directors. Compliance with this provision will be monitored.
 
30.  
Public Entity Crime

Pursuant to s. 287.133, F.S., a person or affiliate who has been placed on the
convicted vendor list following a conviction for a public entity crime may not
submit a bid, proposal, or reply on a contract to provide any goods or services
to a public entity; may not submit a bid, proposal, or reply on a contract with
a public entity for the construction or repair of a public building or public
work; may not submit bids, proposals, or replies on leases of real property to a
public entity; may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public entity; and may
not transact business with any public entity in excess of the threshold amount
provided in s. 287.017, F.S., for CATEGORY TWO for a period of 36 months
following the date of being placed on the convicted vendor list.
 
31.  
Purchasing

 
31.1  
The Contractor may purchase articles which are the subject of or are required to
carry out this contract from Prison Rehabilitative Industries and Diversified
Enterprises, Inc., (PRIDE) identified under Chapter 946, F.S., in the same
manner and under the procedures set forth in subsections 946.515(2) and (4),
F.S. For purposes of this contract, the Contractor shall be deemed to be
substituted for the Department insofar as dealings with PRIDE. This clause is
not applicable to subcontractors unless otherwise required by law. An
abbreviated list of products/services available from PRIDE may be obtained by
contacting PRIDE, (800) 643-8459.

 
31.2  
The Contractor may procure any recycled products or materials, which are the
subject of or are required to carry out this contract, in accordance with the
provisions of s. 403.7065, F.S.

 
31.3  
The Contractor may purchase articles that are the subject of, or required to
carry out, this contract from a nonprofit agency for the Blind or for the
Severely Handicapped that is qualified pursuant to Chapter 413, F.S., in the
same manner and under the same procedures set forth in s. 413.036(1) and (2),
F.S. For purposes of this contract, the Contractor shall be deemed to be
substituted for the Department insofar as dealings with such qualified nonprofit
agency are concerned. Additional information about the designated nonprofit
agency and the products it offers is available at
http://www.respectofflorida.org. This clause is not applicable to subcontractors
unless otherwise required by law.

 
 
 
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32.  
Patents, Copyrights, Royalties

If this contract is awarded state funding and if any discovery, invention or
copyrightable material is developed, produced or for which ownership was
purchased in the course of or as a result of work or services performed under
this contract, the Contractor shall refer the discovery, invention or material
to the Department to be referred to the Department of State. Any and all patent
rights or copyrights accruing under this contract are hereby reserved to the
State of Florida in accordance with Chapter 286, F.S. Pursuant to s. 287.0571
(5) (k) 1 and 2 as amended, the only exceptions to this provision shall be those
that are clearly expressed and reasonably valued in the contract.
 
32.1  
If the primary purpose of this contract is the creation of intellectual
property, the State of Florida shall retain an unencumbered right to use such
property, notwithstanding any agreement made pursuant to this section 32.

 
32.2  
If this contract is awarded solely federal funding, the terms and conditions are
governed by 2 CFR 215.36.

 
32.3  
The Contractor may purchase articles that are the subject of, or required to
carry out, this contract from a nonprofit agency for the Blind or for the
Severely Handicapped that is qualified pursuant to Chapter 413, F.S., in the
same manner and under the same procedures set forth in s. 413.036(1) and (2),
F.S. For purposes of this contract, the Contractor shall be deemed to be
substituted for the Department insofar as dealings with such qualified nonprofit
agency are concerned. Additional information about the designated nonprofit
agency and the products it offers is available at
http://www.respectofflorida.org. This clause is not applicable to subcontractors
unless otherwise required by law.

33.  
Emergency Preparedness and Continuity of Operations

 
33.1  
If the tasks to be performed pursuant to this contract include the physical care
and control of clients, or the administration and coordination of services
necessary for client health, safety or welfare, the Contractor shall, within
thirty (30) calendar days of the execution of this contract, submit to the
Contract Manager verification of an emergency preparedness plan. In the event of
an emergency, the Contractor shall notify the Department of emergency
provisions.

 
33.2  
In the event a situation results in a cessation of services by a subcontractor,
the Contractor will retain responsibility for performance under this contract
and must follow procedures to ensure continuity of operations without
interruption.

 
34.  
PUR 1000 Form

The PUR 1000 Form is hereby incorporated by reference. In the event of any
conflict between the PUR 1000 Form and any terms or conditions of this contract
the terms or conditions of this contract shall take precedence over the PUR 1000
Form. However, if the conflicting terms or conditions in the PUR 1000 Form are
required by any section of the Florida Statutes, the terms or conditions
contained in the PUR 1000 Form shall take precedence.
 
35.  
Use of State Funds to Purchase or Improve Real Property

Any state funds provided for the purchase of or improvements to real property
are contingent upon the Contractor or political subdivision granting to the
state a security interest in the property at least to the amount of state funds
provided for at least 5 years from the date of purchase or the completion of the
improvements or as further required by law.
 
36.  
Dispute Resolution

Any dispute concerning performance of the contract shall be decided by the
Contract Manager, who shall reduce the decision to writing and serve a copy on
the Contractor.
 
37.  
Financial Consequences of Non-Performance

If the Contractor fails to meet the minimum level of service or performance
identified in this agreement, or that is customary for the industry, then the
Department must apply financial consequences commensurate with the
 
 
 
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deficiency. Financial consequences may include, but are not limited to, contract
suspension, refusing payment, withholding payments until deficiency is
cured, tendering only partial payments, and/or cancellation of contract and
reacquiring services from an alternate source. 
 
37.1  
The Contractor will not be charged with financial consequences, when a failure
to perform arises out of causes that were the responsibility of the Department.

 
38.  
No Waiver of Sovereign Immunity

Nothing contained in this agreement is intended to serve as a waiver of
sovereign immunity by any entity to which sovereign immunity may be applicable.
 
39.  
Venue

If any dispute arises out of this contract, the venue of such legal recourse
will be Leon County, Florida.
 
40.  
Entire Contract

This contract contains all the terms and conditions agreed upon by the Parties.
No oral agreements or representations shall be valid or binding upon the
Department or the Contractor unless expressly contained herein or by a written
amendment to this contract signed by both Parties.
 
41.  
Force Majeure

The Parties will not be liable for any delays or failures in performance due to
circumstances beyond their control, provided the party experiencing the force
majeure condition provides immediate written notification to the other party and
takes all reasonable efforts to cure the condition.
 
42.  
Severability Clause

The Parties agree that if a court of competent jurisdiction deems any term or
condition herein void or unenforceable the other provisions are severable to
that void provision and shall remain in full force and effect.
 
43.  
Condition Precedent to Contract: Appropriations

The Parties agree that the Department’s performance and obligation to pay under
this contract is contingent upon an annual appropriation by the Legislature.
 
44.  
Addition/Deletion

The Parties agree that the Department reserves the right to add or to delete any
of the services required under this contract when deemed to be in the State of
Florida’s best interest and reduced to a written amendment signed by both
Parties. The Parties shall negotiate compensation for any additional services
added.
 
45.  
Waiver

The delay or failure by the Department to exercise or enforce any of its rights
under this contract will not constitute or be deemed a waiver of the
Department’s right thereafter to enforce those rights, nor will any single or
partial exercise of any such right preclude any other or further exercise
thereof or the exercise of any other right.
 
46.  
Compliance

The Contractor agrees to abide by all applicable current federal statutes, laws,
rules and regulations as well as applicable current state statutes, laws, rules
and regulations. The Parties agree that failure of the Contractor to abide by
these laws shall be deemed an event of default of the Contractor, and subject
the contract to immediate, unilateral cancellation of the contract at the
discretion of the Department.
 
47.  
Final Invoice

The Contractor shall submit the final invoice for payment to the Department as
specified in section 3.2.1 (date for final request for payment) of ATTACHMENT I.
If the Contractor fails to submit final request for payment by the deadline,
then all rights to payment may be forfeited and the Department may not honor any
requests submitted after the aforesaid time period. Any payment due under the
terms of this contract may be withheld until all reports due from the Contractor
and necessary adjustments thereto have been approved by the Department.
 
 
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48.  
Renegotiations or Modifications

Modifications of the provisions of this contract shall be valid only when they
have been reduced to writing and duly signed by both parties. The rate of
payment and the total dollar amount may be adjusted retroactively to reflect
price level increases and changes in the rate of payment when these have been
established through the appropriations process and subsequently identified in
the Department’s operating budget.
 
49.  
Termination

 
49.1  
This contract may be terminated by either party without cause upon no less than
thirty (30) calendar days notice in writing to the other party unless a sooner
time is mutually agreed upon in writing. Said notice shall be delivered by U.S.
Postal Service or any expedited delivery service that provides verification of
delivery or by hand delivery to the Contract Manager or the representative of
the Contractor responsible for administration of the contract.

 
49.2  
In the event funds for payment pursuant to this contract become unavailable, the
Department may terminate this contract upon no less than twenty-four (24) hours
notice in writing to the Contractor. Said notice shall be delivered by U.S.
Postal Service or any expedited delivery service that provides verification of
delivery or by hand delivery to the Contract Manager or the representative of
the Contractor responsible for administration of the contract. The Department
shall be the final authority as to the availability and adequacy of funds. In
the event of termination of this contract, the Contractor will be compensated
for any work satisfactorily completed prior to the date of termination.

 
49.3  
This contract may be terminated for cause upon no less than twenty-four (24)
hours notice in writing to the Contractor. If applicable, the Department may
employ the default provisions in Rule 60A-1.006(3), F.A.C. Waiver of breach of
any provisions of this contract shall not be deemed to be a waiver of any other
breach and shall not be construed to be a modification of the terms and
conditions of this contract. The provisions herein do not limit the Department’s
or the Contractor’s rights to remedies at law or in equity.

 
49.4  
Failure to have performed any contractual obligations with the Department in a
manner satisfactory to the Department will be a sufficient cause for
termination. To be terminated as a contractor under this provision, the
contractor must have (1) previously failed to satisfactorily perform in a
contract with the Department, been notified by the Department of the
unsatisfactory performance and failed to correct the unsatisfactory performance
to the satisfaction of the Department; or (2) had a contract terminated by the
Department for cause.

 
50.          Official Payee and Representatives (Names, Addresses, and Telephone
Numbers):

a.
The Contractor name, as shown on page 1 of this contract, and mailing address of
the official payee to whom the payment shall be made is:
WellCare of Florida, Inc. dba HealthEase
8735 Henderson Road
Tampa, Florida 33634
b.
The name of the contact person and street address where financial and
administrative records are maintained is:
Thomas L. Tran WellCare of Florida, Inc. dba HealthEase
8735 Henderson Road
Tampa, Florida 33634
c.
The name, address, and telephone number of the representative of the Contractor
responsible for administration of the program under this contract is:
Christina C. Cooper WellCare of Florida, Inc. dba HealthEase
8735 Henderson Road
Tampa, Florida 33634
(813) 206-3212

 
 
 
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d.
The section and location within the Department where Requests for Payment and
Receipt and Expenditure forms are to be mailed is:
Department of Elder Affairs Division of Financial Administration
4040 Esplanade Way, Suite 215
Tallahassee, FL 32399-7000
e.
The name, address, and telephone number of the Contract Manager for this
contract is:
Nicole Trainor
4040 Esplanade Way, Suite 360C
Tallahassee, FL 32399-7000
(850) 414-2388
Upon change of representatives (names, addresses, telephone numbers) by either
party, notice shall be provided in writing to the other party and the
notification attached to the originals of this contract.

51.  
All Terms and Conditions Included

  
This contract and its Attachments, I - X, ATTACHMENTS B, D, G, H and J, Exhibits
A - M; and Appendices 1 - 6 referenced in said attachments, together with any
documents incorporated by reference, contain all the terms and conditions agreed
upon by the Parties. There are no provisions, terms, conditions, or obligations
other than those contained herein, and this contract shall supersede all
previous communications, representations or agreements, either written or verbal
between the Parties.

 
By signing this contract, the Parties agree that they have read and agree to the
entire contract.
 
IN WITNESS THEREOF, the Parties hereto have caused this 141 page contract, to be
executed by their undersigned officials as duly authorized.
 
 

 Contractor:  WELLCARE OF FLORIDA, INC. dba    STATE OF FLORIDA,       
 HEALTHEASE    DEPARTMENT OF ELDER AFFAIRS                                
 SIGNED BY:  /s/Christina Cooper    SIGNED BY:  /s/Charles T. Corley            
 NAME:  Christina Cooper    NAME:  CHARLES T. CORLEY              TITLE:
 President, FL & HI Division    TITLE: SECRETARY              DATE:  6/26/2012  
 DATE:  6/27/12                       Federal Tax ID: 59-2583622       Fiscal
Year Ending Date: 12/31      

 
 
 
 
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ATTACHMENTS
 
State of Florida
Department of Elder Affairs
 
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Table of Contents
ATTACHMENT I
SECTION I
SERVICES TO BE PROVIDED
17
1.1
DEFINITIONS OF TERMS AND ACRONYMS
17
1.1.1
CONTRACT ACRONYMS
17
1.1.2
PROGRAM SPECIFIC TERMS
17
1.2
DEPARTMENT MISSION STATEMENT
21
1.3
GENERAL DESCRIPTION
22
1.3.1
General Statement
22
1.3.2
Authority
22
1.3.2.1
Incorporation of Reference Memoranda
22
1.3.3
Contract Terms and Conditions
22
1.3.3.1
Required Long-Term Care Services
22
1.3.3.2
Case Management Services
25
1.3.3.3
Acute-Care Services
25
1.3.3.3.1
Acute-Care Provider Qualifications
26
1.3.3.4
Expanded Services
27
1.4
INDIVIDUALS TO BE SERVED
27
1.4.1
Eligibility for Program
27
1.4.2
Ineligibility for the Program
27
1.4.3
“Medicaid Pending”
27

 
 
SECTION II
MANNER OF SERVICE PROVISION
28
2.1
SERVICE TASKS
28
2.1.1
ENROLLMENT AND DISENROLLMENT
28
2.1.1.1
Enrollment Process
28
2.1.1.2
Optional State Supplementation (OSS)
29
2.1.1.3
Changes in Eligibility and Reenrollment
29
2.1.1.4
Effective Date of Enrollment
29
2.1.1.5
Transition Care Planning
29
2.1.1.6
Orientation
30
2.1.1.7
Enrollee Handbook
30
2.1.1.8
Provider Directory
32
2.1.1.9
Plan ID Card
32
2.1.1.10
Annual Notification
32
2.1.1.11
Care Plan and Service Delivery Requirements
32
2.1.1.12
Initial Care Plan Distribution
33
2.1.1.13
Care Plan Review
34
2.1.1.14
Coordination and Continuity of Care
34
2.1.1.15
Assessments and Reassessments
35
2.1.1.16
Level of Care
35
2.1.1.17
Disenrollment Requested by the Enrollee
35
2.1.1.18
Disenrollment Requested by the Contractor
36
2.1.1.19
Disenrollment Requests
36
2.1.1.20
Cancellations
36
2.2
RECORDS MANAGEMENT AND HEALTH INFORMATION SYSTEMS
37
2.2.1      Background Screening Affidavit of Compliance 38 
2.3
UTILIZATION MANAGEMENT
38
2.4
QUALITY ASSURANCE
39
2.4.1
Quality Assurance Program
39
2.4.2
Quality Assurance Committee
39
2.4.3
Quality Improvement and Performance Measures
40
2.4.4
Performance Measures
41
2.4.5
Incident Reporting
41
2.5
GRIEVANCES AND APPEALS
41
2.5.1
General Requirements
41

 
 
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2.5.2
Categories of Challenges
42
2.5.3
Filing Grievances and Appeals
42
2.5.3.1
Time Limits
42
2.5.3.2
Expedited Appeals
43
2.5.3.3
Assistance
43
2.5.3.4
Requirements
43
2.5.4
Notification of Action
43
2.5.5
Resolution and Notification
44
2.6
MEDICAID FAIR HEARINGS
44
2.6.1
Continuation of Benefits
45
2.7
STAFFING REQUIREMENTS
46
2.7.1
Staffing Levels
46
2.7.2
Positions Required
46
2.7.3
Staff Training
46
2.7.4
Staffing Changes
47
2.8
SERVICE PROVISIONS
47
2.8.1
General Provisions
47
2.8.2
Availability/Accessibility of Services
48
2.8.3
Adult Protective Services
49
2.8.4
Network Expansion
50
2.8.5
Access to Services
50
2.9
CONTRACTOR’S FINANCIAL OBLIGATIONS
50
2.9.1
Insolvency Protection
50
2.9.2
Surplus Requirements
51
2.9.3
Insurance
51
2.9.4
Interest and Savings
51
2.9.5
Third Party Resources
52
2.10
FINANCIAL REPORTING
52
2.10.1
Enrollee Payment Liability Protection
52
2.10.2
Audited Financial Statements
52
2.10.3
Unaudited Quarterly Financial Statements
52
2.11
CONTRACT MANAGEMENT
53
2.11.1
Independent Medical Review
53
2.12
CONTRACTOR RESPONSIBILITIES
53
2.12.1
Contractor Qualifications
53
2.12.2
Contractor Tasks
53
2.12.3
Reporting
55
2.12.4
Provider Relations and Subcontracts
56
2.12.4.1
Credentialing
57
2.12.4.2
Re-Credentialing
58
2.12.4.3
Delegated Credentialing
58
2.12.4.4
Identification of Conditions and Method of Payment
58
2.12.5
Provisions for Monitoring and Inspections
58
2.12.6
Subcontractor Termination
58
2.12.7
Ownership and Management Disclosure
58
2.12.8
Damages from Federal Disallowance
59
2.12.9
Legal Action Notification
59
2.12.10
Conflict
59
2.12.11
Prospective Enrollee Materials
59
2.12.12
Prohibited Activities
59
2.12.13
Sanctions
60
2.12.14
Assignment of Contract
61
2.12.15
Contract Termination
61
SECTION III
METHOD OF PAYMENT
62
3.1
REQUEST FOR PAYMENT
62
3.2
METHOD OF PAYMENT
62

 
 
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3.2.1
Capitation Rates
62
3.2.2
834 Transactions
62
3.2.3
Payment in Full
63
3.2.4
Capitation Payments
63
3.2.5
Payment Discrepancies
63

 
 

ATTACHMENTS  II - X, B and D  
ATTACHMENT II
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND AGREEMENTS
64
ATTACHMENT III
FINANCIAL AND COMPLIANCE AUDIT
65
ATTACHMENT IV
CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR AGREEMENTS, GRANTS, LOANS,
AND COOPERATIVE AGREEMENTS
70
ATTACHMENT V
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY
EXCLUSION FOR LOWER TIER COVERED TRANSACTIONS
71
ATTACHMENT VI
ASSURANCES—NON-CONSTRUCTION PROGRAMS
72
ATTACHMENT VII
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
74
ATTACHMENT VIII
PUBLIC ENTITY CRIMES
77
ATTACHMENT IX
MULTIPLE SIGNATURE VERIFICATION
79
ATTACHMENT X
AGREEMENT TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID PENDING
81
ATTACHMENT B
CIVIL RIGHTS COMPLIANCE CHECKLIST
82
ATTACHMENT D
PROVIDER’S STATE CONTRACTS LIST
86
ATTACHMENT G BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE 87 ATTACHMENT H
CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS 88 ATTACHMENT J VERIFICATION
OF EMPLOYMENT STATUS VERIFICATION 89

 
 
EXHIBITS
A-I, K, L and M
     
EXHIBIT A
CAPITATION RATES
90
EXHIBIT B
DISENROLLMENT SUMMARY REPORT
91
EXHIBIT C
ENCOUNTER DATA REPORT
92
EXHIBIT D
REPORT OF GRIEVANCES AND APPEALS
97
EXHIBIT E
PROVIDER NETWORK AND STAFFING REPORT
98
EXHIBIT F
ENROLLEE SATISFACTION SURVEY
101
EXHIBIT G
SUBCONTRACTOR CONFORMATION
104
EXHIBIT H
RECONCILIATION REPORT
105
EXHIBIT I
REQUEST FOR DISENROLLMENT
106
EXHIBIT J
SUBCONTRACTOR TRAINING ATTESTATION REPORT
108
EXHIBIT K
FINANCIAL REPORTING PACKAGE
109
EXHIBIT L
LEVEL OF CARE (LOC) REDERTERMINATION FORM
127
EXHIBIT M
QUALITY IMPROVEMENT
128

 
 
APPENDICES
1 – 6
     
APPENDIX 1
ADDITIONAL SUB-CONTRACT REQUIREMENTS
129
APPENDIX 2
ADDITIONAL OWNERSHIP AND MANAGEMENT REQUIREMENTS
131
APPENDIX 3
PROGRAMMATIC REPORTS
132
APPENDIX 4
SERVICE PROVIDER QUALIFICATIONS
134
APPENDIX 5
ENROLLEE ROSTER REPORT
139
APPENDIX 6
INCIDENT REPORTING LOG
141

 
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 DEPARTMENT OF ELDER AFFAIRS
 
STATEMENT OF WORK
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT

 

SECTION I: SERVICES TO BE PROVIDED

 
1.1
DEFINITIONS OF TERMS AND ACRONYMS

 
1.1.1 
CONTRACT ACRONYMS
AAA: Area Agency on Aging
ADL: Activities of Daily Living
AHCA: The Agency for Health Care Administration
CARES: Comprehensive Assessment and Review for Long Term Care Services
CCE: Community Care for the Elderly
CFR: Code of Federal Regulations
CMS: Centers for Medicare and Medicaid Services
DCF: The Department of Children and Families
DOEA: The Department of Elder Affairs
DHHS: The United States Department of Health and Human Services
EQRO: External Quality Review Organization
FMMIS: Florida Medicaid Management Information System
HIPAA: Health Insurance Portability and Accountability Act
HMO: Health Maintenance Organization (as certified pursuant to Chapter 64l,
F.S.)
HSAG: Health Services Advisory Group
IADL: Instrumental Activities of Daily Living
ICP: The Medicaid Institutional Care Program
MEDS: Medicaid Encounter Data System
MEVS: Medicaid Eligibility Verification System
MCO: Managed Care Organization
OSS: Optional State Supplementation
PIP: Performance Improvement Project
PSA: Planning Service Area
TPA: Third Party Administrator

 
1.1.2
PROGRAM SPECIFIC TERMS
The following terms as used in this contract, shall be construed and/or
interpreted as follows:
 
Action - In accordance with 42 CFR 438.400(b), “action” means the denial or
limited authorization of a requested service, including the type or level of
service; the reduction, suspension, or termination of a previously authorized
service; the denial, in whole or in part, of payment for a service; the failure
to provide services in a timely manner; the failure of the Contractor to act
within ninety (90)days from the date the Contractor receives a grievance, or
forty-five (45) days from the date the Contractor receives an appeal; or for a
resident of a rural area with only one (1) Contractor, the denial of an
enrollee’s request to exercise the right to obtain services outside the network.
 
Activities of Daily Living - Include dressing, grooming, bathing, eating,
transferring in and out of bed or a chair, walking, climbing stairs, toileting,
bladder/bowel control, and the wearing and changing of incontinent briefs.
 
Adult Protective Services - Services to protect elders and vulnerable adults
from abuse, neglect or exploitation.

 
 
 
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Advance Directives - A written document such as a Living Will or Durable Power
of Attorney or oral statement for healthcare as recognized under Chapter 765,
F.S., authorizing the provision of health care when an individual becomes
incapacitated.
 
Agency - Agency for Health Care Administration.
 
Ancillary Services - Services provided at a hospital include, but are not
limited to, radiology, pathology, neurology, and anesthesiology as specified in
the Hospital Coverage and Limitations Handbook.
 
Appeal - A formal request from an enrollee to seek a review of an action taken
by the Contractor pursuant to 42 CFR 438.400(b).
 
Area Agency on Aging - An agency designated by the Department to develop and
administer a plan for a comprehensive and coordinated system of services for
older persons.
 
Assessment - An individualized comprehensive appraisal of an individual’s
medical, developmental, mental, social, financial, and environmental status
conducted by a qualified individual for the purpose of determining the need for
long term care services.
 
Capitation Rate - The monthly fee paid by the Agency to the Contractor for each
enrollee enrolled under the contract for the provision of services during the
payment period.
 
Care Plan - A plan which describes the service needs of each recipient, showing
the projected duration, desired frequency, type of provider furnishing each
service, and scope of the services to be provided.
 
Comprehensive Assessment and Review for Long Term Care Services - A nursing
facility pre-admission screening program operated by the Agency through an
interagency agreement with DOEA. The program explores all available options to
nursing home placement to ensure that long-term care services are provided in
the setting most appropriate to the needs of the person and consistent with
approved federal waiver programs.
 
Claim - A claim is (1) a bill for services, (2) a line item of service or, (3)
all services for one enrollee within a bill.
 
Clean Claim - A claim that can be processed without obtaining additional
information from the provider (subcontractor) of the service or from a third
party.
 
Cold-call Marketing - Any unsolicited personal contact by the Contractor or
subcontractors with a potential enrollee for the purpose of marketing.
 
Complaint - A complaint means any oral or written expression of dissatisfaction
by an enrollee submitted to the Contractor. Possible complaints include, but are
not limited to, the quality of care, the quality of services provided, aspects
of interpersonal relationships, failure to respect the enrollee’s rights,
Contractor administration, claims practices or provision of services that
relates to the quality of care rendered by a subcontractor pursuant to the
Contractor’s contract. A complaint is an informal component of the grievance
system.
 
Contractor - The organizational entity with whom this agreement is executed.
 
Department - Department of Elder Affairs.
 
Disenrollment - The discontinuance of an enrollee's membership in the
Contractor’s plan.
 
Durable Medical Equipment - Medical equipment that can withstand repeated use is
primarily and customarily used to serve a medical purpose, is generally not
useful in the absence of illness or injury and is appropriate for use in the
recipient's home.
 
Emergency Medical Condition - According to 42 CFR 438.114(a), a medical
condition manifesting itself by acute symptoms of sufficient severity (including
severe pain) that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in the following:
 
(1)  Placing the health of the individual in serious jeopardy;
(2)  Serious impairment to bodily functions; and
(3)  Serious dysfunction of any bodily organ or part.
 
Emergency Services - According to 42 CFR 438.114(a), covered inpatient and
outpatient services that are as follows:
 
(1)  Furnished by a provider that is qualified to furnish these services under
this title; and
(2)  Needed to evaluate or stabilize an emergency medical condition.

 
 
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Enrollee - According to 42 CFR 438.10(a), a Medicaid recipient who is currently
enrolled in an MCO as defined in 42 CFR 438.10(a).
 
Enrollment - The process by which an eligible Medicaid recipient becomes an
enrollee in the Long Term Care Community Diversion Pilot Project.
 
Fiscal Agent - Any corporation or other legal entity that has contracted with
the Agency to receive, process and adjudicate claims under the Medicaid program.
 
Florida Medicaid Management Information System - The Medicaid fiscal agent
utilizes this system for all Medicaid related data and information.
 
Grievance - An expression of dissatisfaction about any matter other than an
action. Possible subjects for grievances include, but are not limited to, the
quality of care, the quality of services provided and aspects of interpersonal
relationships such as rudeness of a subcontractor or Contractor employee or
failure to respect the enrollee’s rights.
 
Health Care Professional - A physician or any of the following: a podiatrist,
optometrist, chiropractor, psychologist, dentist, physician assistant, physical
or occupational therapist, therapist assistant, speech-language pathologist,
audiologist, registered or practical nurse (including nurse practitioner,
clinical nurse specialist, certified registered nurse anesthetist, and certified
nurse midwife), licensed certified social worker, registered respiratory
therapist, and certified respiratory therapy technician.
 
Health Maintenance Organization - An entity that meets the requirements of the
Office of Insurance Regulation of the Financial Services Commission (OIR) for
operation as a health maintenance organization and meets the qualifications for
participation as a managed care organization established by the Agency and the
OIR.
 
Hospital - A facility licensed in accordance with the provisions of Chapter 395,
F.S., or the applicable laws of the state in which the service is furnished.
 
Instrumental Activities of Daily Living - Includes making and answering
telephone calls, shopping, transportation ability, preparing meals, laundry,
light housekeeping, heavy chores, taking medication, and managing money.
 
Ineligible Recipient - A Medicaid recipient that does not qualify for enrollment
in the Long Term Care Community Diversion Pilot Project.
 
Incident Reporting - Reporting of awareness or discovery of conditions that may
materially affect the Contractor’s ability to perform services under this
contract.
 
Insolvency/Insolvent - A financial condition that exists when an entity is
unable to pay its debts as they become due in the usual course of business, or
when the liabilities of the entity exceed its assets.
 
Lead Agency - An entity designated by an area agency on aging and given the
authority and responsibility to coordinate services for functionally impaired
elderly persons.
 
Long-Term Care Record - A record that includes information regarding the medical
and long-term care services an enrollee is receiving including the care plan and
documentation of case management activities including efforts to coordinate and
integrate the delivery of all services to the enrollee.
 
Marketing - Any activity or communication conducted by or on behalf of any
Contractor, including any subcontractor, with a Medicaid recipient who is not
enrolled with the Contractor, which can reasonably be interpreted as intended to
influence the Medicaid recipient to enroll with or disenroll from the particular
Contractor.
 
Medicaid - The medical assistance program authorized by Title XIX of the federal
Social Security Act, 42 U.S.C. s.1396 et seq., and regulations thereunder, as
administered in this state by the Agency.
 
Medicaid HMO - An HMO as defined in the Medicaid State Plan.
 
Medicaid Pending - Individuals who apply for the Long-Term Care Community
Diversion Pilot Project and are determined medically eligible by CARES, but have
not been determined financially eligible for Medicaid by the DCF.
 
Medically Necessary or Medical Necessity - Services provided in accordance with
42 CFR 438.210(a)(4) and
 

 
 
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  as defined in s. 59G-1.010(166), F.A.C., to include that medical or allied
care, goods, or services furnished or ordered must meet the following
conditions:
 

 
a.  
Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;

 

 
b.  
Be individualized, specific, and consistent with symptoms or confirmed diagnosis
of the illness or injury under treatment, and not in excess of the patient’s
needs;

 

 
c.  
Be consistent with the generally accepted professional medical standards as
determined by the Medicaid program, and not experimental or investigational;

 

 
d.  
Be reflective of the level of service that can be safely furnished, and for
which no equally effective and more conservative or less costly treatment is
available, statewide; and

 

 
e.  
Be furnished in a manner not primarily intended for the convenience of the
recipient, the recipient’s caretaker, or the Contractor.

 

 
f.  
Be services furnished in a hospital on an inpatient basis which could not,
consistent with the provisions of appropriate medical care, be effectively
furnished more economically on an outpatient basis or in an inpatient facility
of a different type.

 
 
Note: The fact that a contractor has prescribed, recommended, or approved
medical or allied goods or services does not, in itself, make such care, goods
or services medically necessary or a medical necessity or a covered service.

 

 
Medicare - The medical assistance program authorized by Title XVIII of the
federal Social Security Act, 42 U.S.C. s. 1395 et seq., and regulations
thereunder.
 
Nursing Facility - An institutional care facility licensed under Chapter 395,
F.S. or Chapter 400, F.S. that furnishes medical or allied inpatient care and
services to individuals needing such services.
 
Nursing Home Transition Program - Program through which CARES identifies
individuals that can be transitioned from a nursing facility to safe placement
in the community and are referred for enrollment in the Long Term Care Community
Diversion Program.
 
Other Qualified Provider - A contracted provider who meets the qualifications of
Chapter 430.703(7), F.S.
 
Outpatient - A patient of an organized medical facility or distinct part of that
facility who is expected by the facility to receive and receives professional
services for less than a 24-hour period regardless of the hour of admission,
whether or not a bed is used, or whether or not the patient remains in the
facility past midnight.
 
Peer Review - An evaluation of the professional practices of a provider by peers
of the provider in order to assess the necessity, appropriateness, and quality
of care furnished as such care is compared to that customarily furnished by the
provider's peers and to recognized health care standards.
 
Potential Enrollee - According to 42 CFR 438.10(a), a Medicaid recipient who is
subject to mandatory enrollment or may voluntarily elect to enroll in a given
managed care program, but is not yet an enrollee of a specific managed care
program.
 
Prepaid Health Plan or Plan - The prepaid health care plan developed by the
Contractor in performance of its duties and responsibilities under this
contract; or a contractual arrangement between the Agency and a comprehensive
health care Contractor for the provision of Medicaid care, goods, or services on
a prepaid basis to Medicaid recipients.
 
Primary Care Physician - A Medicaid-participating or prepaid health
plan-affiliated physician practicing as a general or family practitioner,
internist, pediatrician, obstetrician, gynecologist, or other specialty approved
by the Agency, who furnishes primary care and patient management services to an
enrollee.
 
Program - Long Term Care Community Diversion Program.
 
Project - Long Term Care Community Diversion Pilot Project.
 
Protocols - Written guidelines or documentation outlining steps to be followed
for handling a particular situation, resolving a problem, or implementing a plan
of medical, social, nursing, psychosocial, developmental

 
 
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and educational services.
 
Provider - A person or entity that is responsible for or directly provides any
medical or social services authorized by this contract.
 
Provider Handbook - A document that provides information to a Medicaid provider
regarding enrollee eligibility; claims submission and processing; provider
participation; covered care, goods, or services and limitations; procedure codes
and fees; and other matters related to Medicaid program participation.
 
Quality Assurance - The process of assuring that the delivery of health care is
appropriate, timely, accessible, available, and medically necessary.
 
Risk - The potential for loss that is assumed by an entity and that may arise
because the cost of providing care, goods, or services may exceed the capitation
or other payment made by the Agency to the plan under terms of the contract.
 
Service Area - The designated geographical area within which the Contractor is
authorized by contract to furnish covered services to enrollees and within which
the enrollees reside.
 
State - State of Florida.
 
Subcontract - An agreement entered into between the Contractor and subcontractor
for the provision of benefits to enrollees or to perform any administrative
function or service for the Contractor specifically related to securing or
fulfilling the Contractor’s obligations under this contract. Subcontracts
include, but are not limited to the following: agreements with all providers of
medical or ancillary services, unless directly employed by the Contractor;
management or administrative agreements; third party billing or other indirect
administrative/fiscal services, including provision of mailing lists or direct
mail services; and any contract which benefits any person with a controlling
interest in the Contractor’s organization.
 
Subcontractor - Any person to whom the Contractor has contracted or delegated
some of its functions, services or its obligations under this contract.
 
Surplus - Net worth, i.e., total assets minus total liabilities. Surplus has the
same meaning as in Section 641.19(19), F.S.
 
Third Party Resources - An individual, entity, or program, excluding Medicaid,
that is, may be, could be, should be, or has been liable for all or part of the
cost of medical services related to any medical assistance covered by Medicaid.
An example is an individual’s auto insurance company, which typically provides
payment of some medical expenses related to automobile accidents and injuries.
 
Transportation - Transporting services furnished to an enrollee to obtain
services authorized under this contract.
 
Transition Care Services - Services necessary in order to safely maintain a
person in the community both prior to and after the effective date of their
enrollment in the program until the initial Care Plan is implemented.
 
Transition Period - The period of time from the effective date of enrollment
until the initial Care Plan is effective.
 
Violation - Each determination by the Department and/or Agency that a Contractor
failed to act as specified in the contract or in applicable statutes or rules
governing Medicaid prepaid health plans. Each day that an ongoing violation
continues may be considered for the purposes of this contract to be a separate
violation. In addition, each instance of failing to furnish necessary and/or
required services or items to enrollees is considered for purposes of this
contract to be a separate violation.

 
1.2  
DEPARTMENT MISSION STATEMENT

  
The Department’s mission is to foster an optimal quality of life for elder
Floridians. The Department’s vision and shared values are to foster a social,
economic and intellectual environment for all ages, and especially those aged 60
and older, where all can enjoy Florida’s unparalleled amenities in order to
thrive and prosper. Area agencies, lead agencies and local service providers as
partners and stakeholders in Florida’s aging services network are expected to
support the Department’s mission, vision, and program priorities.

 
 
 
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1.3 
GENERAL DESCRIPTION

 
1.3.1
General Statement

 
The Long-Term Care Community Diversion Pilot Project is administered by DOEA in
consultation with the Agency for Health Care Administration and is designed to
provide frail elders age 65 and older with an alternative to nursing home care.
The program offers integrated acute and long-term care services to dually
eligible Medicare and Medicaid recipients by contracting with Health Maintenance
Organizations and Other Qualified Providers. The program enables seniors to
remain safely in the community by providing home and community based services to
individuals who would otherwise qualify for Medicaid nursing home placement.

 
1.3.2
Authority

 
The relevant federal and state authority governing the Long-Term Care Community
Diversion Pilot Project are as follows:

 
(1)  
Rule 58N-1, Florida Administrative Code;

 
(2)  
s. 430.701-709, F.S.;

 
(3)  
Social Security Act , s.1915 (c) Nursing Home Diversion Waiver;

 
(4)  
Title 42 Code of Federal Regulations (CFR) Chapter IV, Subchapter C;

 
(5)  
42 CFR 431, Subpart E, F;

 
(6)  
42 CFR 438

 
(7)  
Chapter 641, F.S.;

 
(8)  
Chapter 400, F.S.;

 
(9)  
Chapter 429, Part I, F.S.;

 
(10)  
Chapter 429, Part III, F.S.;

 
(11)  
s. 430.203 (9), F.S.; and

 
(12)  
s. 288.703 (3), F.S.

 
1.3.2.1
Incorporation of Reference Memoranda

 
In accordance with Chapter 287 F.S., as amended, and Department of Financial
Services’ Chief Financial Officer Memoranda, the following memoranda are
provided for informational purposes and are hereby incorporated by reference:

 
(1)  
CFO Memo No. 02: Release date, August 20, 2010;

 
(2)  
CFO Memo No. 03: Release date, June 29, 2010; and

 
(3)  
CFO Memo No. 06: Release date, June 30, 2010.

 
1.3.3
Contract Terms and Conditions

 
The Contractor shall ensure that all long-term care required service providers
maintain current licenses relevant to the service component rendered or other
credentials and meet all applicable background screening requirements.

 
1.3.3.1
Required Long-Term Care Services

 
With the exception of nursing facility services, the long-term care services in
this section are authorized under the Medicaid home and community-based waiver
and must comply with the waiver. As required by s. 430.705(2)(b) 2, F.S., the
Contractor shall have, at a minimum, two (2) subcontractors for each service as
listed below.

    

 
(1)  
Adult Companion Services: Non-medical care, supervision and socialization
provided to a functionally impaired adult. Companions assist or supervise the
enrollee with tasks such as meal preparation or laundry and shopping but do not
perform these activities as discrete services. The provision of companion
services does not entail hands-on nursing care. This service includes light
housekeeping tasks

 
 
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incidental to the care and supervision of the enrollee. Waiver approved
providers for adult companion services include the following: licensed,
registered or certified home health agencies, licensed, registered or certified
community care for the elderly providers (CCE), and licensed, registered or
certified homemaker/companion agencies.

 

 
(2) 
Adult Day Health Services: Services provided pursuant to Chapter 429, Part III,
F.S. Services furnished in an outpatient setting which encompass both the health
and social services needed to ensure optimal functioning of an enrollee,
including social services to help with personal and family problems and planned
group therapeutic activities. Adult day health services include nutritional
meals. Meals are included as a part of this service when the patient is at the
center during meal times. Adult day health care provides medical screening
emphasizing prevention and continuity of care, including routine blood pressure
checks and diabetic maintenance checks. Physical, occupational and speech
therapies indicated in the enrollee's plan of care are furnished as components
of this service. Nursing services, which include periodic evaluation, medical
supervision and supervision of self-care services directed toward activities of
daily living and personal hygiene, are also a component of this service. The
inclusion of physical, occupational and speech therapy services, and nursing
services as components of adult day health services does not require the
Contractor to contract with the adult day health provider to deliver these
services when they are included in an enrollee’s plan of care. The Contractor
may contract with the adult day health provider for the delivery of these
services or the Contractor may contract with other providers qualified to
deliver these services pursuant to the terms of this contract.

 

 
(3) 
Assisted Living Services: Personal care services, homemaker services, chore
services, attendant care, companion services, medication oversight, and
therapeutic social and recreational programming provided in a home-like
environment in an assisted living facility, licensed pursuant to Chapter 429
Part I, F.S., in conjunction with living in the facility. This service does not
include the cost of room and board furnished in conjunction with residing in the
facility.

 

 
 Note:
Assistive Care Services are covered under this contract and cannot be billed
separately by the assisted living facility. This service includes 24-hour
on-site response staff to meet scheduled or unpredictable needs in a way that
promotes maximum dignity and independence, and provides supervision, safety and
security. Individualized care is furnished to persons who reside in their own
living units (residents). A resident’s own living unit may include dual occupied
units when both occupants consent to the arrangement. Living units contain
bedrooms and toilet facilities and may or may not include kitchenette and/or
living rooms. The resident has a right to privacy. Living units may be locked at
the discretion of the resident, except when a physician or mental health
professional has certified in writing that the resident is sufficiently
cognitively impaired as to be a danger to self or others if given the
opportunity to lock the door. The facility must have a central dining room,
living room or parlor, and common activity areas (which may also serve as living
rooms or dining rooms). The resident retains the right to assume risk, tempered
only by a person's ability to assume responsibility for that risk. Care must be
furnished in a way that fosters the independence of each resident to facilitate
aging in place. Routines of care provision and service delivery must be
resident-driven to the maximum extent possible, and treat each resident with
dignity and respect. Assisted living services may also include the following:
physical therapy, occupational therapy, speech therapy, medication
administration, and periodic nursing evaluations. The Contractor may arrange for
other authorized service providers to deliver care to residents of assisted
living facilities in the same manner as those services would be delivered to a
person in their own home. The Contractor shall be responsible for placing
enrollees in the appropriate assisted living facility setting.

 

 
(4) 
Chore Services: Services needed to maintain the home as a clean, sanitary and
safe living environment, such as heavy household chores (e.g. washing floors,
windows and walls; tacking down loose rugs and tiles; moving heavy items of
furniture in order to provide safe entry and exit) and pest control.

 

 
(5)  
Consumable Medical Supply Services: The provision of disposable supplies used by
the enrollee and caregiver, which are essential to adequately care for the needs
of the enrollee. These supplies enable the enrollee to perform activities of
daily living or stabilize or monitor a health condition. Not included are items
covered under the Medicaid home health service; personal toiletries; household
items such as detergents, bleach, and paper towels; or prescription drugs.

 

 
(6)  
Environmental Accessibility Adaptation Services: Physical adaptations to the
home required by the

 
 
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enrollee's care plan which are necessary to ensure the health, welfare and
safety of the enrollee or which enable the enrollee to function with greater
independence in the home and without which the enrollee would require
institutionalization. Such adaptations may include the installation of ramps and
grab-bars, widening of doorways, modification of bathroom facilities, or
installation of specialized electric and plumbing systems to accommodate the
medical equipment and supplies, which are necessary for the welfare of the
enrollee. Excluded are those adaptations or improvements to the home that are of
general utility and are not of direct medical or remedial benefit to the
enrollee, such as carpeting, roof repair, or central air conditioning.
Adaptations which add to the total square footage of the home are not included
in this benefit. All services must be provided in accordance with applicable
state and local building codes.

 

 
(7) 
Escort Services: Personal escort for enrollees to and from service providers.
Escort providers assist enrollees in gaining access to services. An escort may
provide language interpretation for people who have hearing or speech
impairments or who speak a language different from that of the provider. Waiver
approved providers for escort services include the following licensed providers
or providers meeting federal standards: home health agencies and CCE providers.
This service does not include transportation.

 

 
(8)  
Family Training Services: Training and counseling services for the families of
enrollees served under this contract. For purposes of this service, "family" is
defined as the individuals who live with or provide care to a person served by
the Contractor and may include a parent, spouse, children, relatives, foster
family, or in-laws. "Family" does not include persons who are employed to care
for the enrollee. Training includes instruction and updates about treatment
regimens and use of equipment specified in the plan of care to safely maintain
the enrollee at home.

 

 
(9) 
Financial Assessment/Risk Reduction Services: Assessment and guidance to the
caregiver and enrollee with respect to financial activities. This service
provides instruction for and/or actual performance of routine, necessary,
monetary tasks for financial management such as budgeting and bill paying. In
addition, this service also provides financial assessment to prevent
exploitation by sorting through financial papers and insurance policies and
organizing them in a usable manner. This service provides the following coaching
and counseling to enrollees: (1) avoidance of financial abuse; (2) maintenance
and balancing of accounts that directly relate to the enrollees living
arrangement at home; or (3) lessening the risk of nursing home placement due to
inappropriate money management.

 

 
(10)  
Home Delivered Meals: Nutritionally sound meals to be delivered to the residence
of an enrollee who has difficulty shopping for or preparing food without
assistance. Each meal is designed to provide 1/3 of the Recommended Dietary
Allowance (RDA). Home delivered meals may be hot, cold, frozen, dried, canned or
a combination of hot, cold, frozen, dried, canned with a satisfactory storage
life.

 

 
(11)  
Homemaker Services: General household activities such as meal preparation and
routine household care provided by a trained homemaker.

 

 
(12)  
Nutritional Assessment/Risk Reduction Services: An assessment, hands-on care,
and guidance to caregivers and enrollees with respect to nutrition. This service
teaches caregivers and enrollees to follow dietary specifications that are
essential to the enrollee’s health and physical functioning, to prepare and eat
nutritionally appropriate meals and promote better health through improved
nutrition. This service may include instructions on shopping for quality food
and food preparation.

 

 
(13) 
Nursing Facility Services: Services furnished in a health care facility licensed
under Chapter 395 or Chapter 400, F.S.

 

 
(14)  
Personal Care Services: Assistance with eating, bathing, dressing, personal
hygiene, and other activities of daily living. This service includes assistance
with preparation of meals, but does not include the cost of the meals. This
service may also include housekeeping chores such as bed making, dusting and
vacuuming, which are incidental to the care furnished or are essential to the
health and welfare of the enrollee, rather than the enrollee's family.

 

 
(15) 
Personal Emergency Response Systems (PERS): The installation and service of an
electronic device that enables enrollees at high risk of institutionalization to
secure help in an emergency. The PERS is connected to the person's phone and
programmed to signal a response center once a "help" button is activated. The
enrollee may also wear a portable "help" button to allow for mobility. PERS
services are

 
 
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generally limited to those enrollees who live alone or who are alone for
significant parts of the day and who would otherwise require extensive
supervision.

 

 
(16)
Respite Care Services: Services provided to enrollees unable to care for
themselves furnished on a short­-term basis due to the absence or need for
relief of persons normally providing the care. Respite care does not substitute
for the care usually provided by a registered nurse, a licensed practical nurse
or a therapist. Respite care is provided in the home/place of residence,
Medicaid licensed hospital, nursing facility, or assisted living facility.

 

 
(17) 
Occupational Therapy: Treatment to restore, improve or maintain impaired
functions aimed at increasing or maintaining the enrollee’s ability to perform
tasks required for independent functioning when determined through a
multi-disciplinary assessment to improve an enrollee’s capability to live safely
in the home setting.

 

 
(18)
Physical Therapy: Treatment to restore, improve or maintain impaired functions
by using activities and chemicals with heat, light, electricity or sound, and by
massage and active, resistive, or passive exercise when determined through a
multi-disciplinary assessment to improve an enrollee’s capability to live safely
in the home setting.

 

 
(19) 
Respiratory Therapy: Treatment of conditions that interfere with respiratory
functions or other deficiencies of the cardiopulmonary system. Services include
evaluation and treatment related to pulmonary dysfunction. Examples are
ventilator support, therapeutic and diagnostic use of medical gases, respiratory
rehabilitation, management of life support systems and bronchopulmonary
drainage, breathing exercises, and chest physiotherapy. This service shall
become available to all enrollees on or prior to March 1, 2012.

 

 
(20) 
Speech Therapy: The identification and treatment of neurological deficiencies
related to feeding problems, congenital or trauma-related maxillofacial
anomalies, autism, or neurological conditions that effect oral motor functions.
Therapy services include the evaluation and treatment of problems related to an
oral motor dysfunction when determined through a multi-disciplinary assessment
to improve an enrollee’s capability to live safely in the home setting.

 
1.3.3.2
Case Management Services

 
Case management services contribute to the coordination and integration of care
delivery through the ongoing monitoring of services as prescribed in each
enrollee’s care plan. Case management services facilitate enrollees gaining
access to needed medical, social, transportation, and educational services
regardless of the funding source for the services. The Contractor shall provide
this service directly and the ratio of enrollees to case managers shall be
appropriate to support the needs of the enrollees. The Contractor shall assist
enrollees to ensure continuous financial and medical eligibility in the program
as part of the case management responsibilities.

  
1.3.3.3
Acute-Care Services

 
Acute-care services are covered for Medicaid recipients based on the Medicaid
state plan approved by the federal Centers for Medicare and Medicaid Services.
These services are covered in the project to the extent that they are not
covered by Medicare or are reimbursed by Medicaid pursuant to Medicaid’s
Medicare cost- sharing policies and included in the capitation rate. Services
include, but are not limited to, the following:

    

 
(1) 
Community Mental Health Services: Community-based psychiatric rehabilitative
services recommended or provided by a psychiatrist or other physician. Such
services must be provided in accordance with the policy and service provisions
specified in the Medicaid Community Mental Health Coverage and Limitations
Handbook, except that the provider need not be a community mental health center.

 

 
(2) 
Dental Services: Medically necessary emergency dental care limited to emergency
oral examination, necessary radiographs, extractions, incision and drainage of
abscess and full or partial dentures. Dentures are limited to one set of full or
partial dentures a lifetime. Such services must be provided in accordance with
the policy and service provisions specified in the Medicaid Dental Services
Coverage and Limitations Handbook, and must be provided by providers licensed
under Chapter 466, F.S.

 

 
(3) 
Hearing Services: Medically necessary hearing evaluations and diagnostic testing
for hearing aid candidacy every three (3) years. A hearing aid fitting and
dispensing for each ear every three (3) years.

 
 
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Three (3) hearing aid repairs a year outside the warranty period. One cochlear
implant for either ear, but not both, if medical criterion is met through prior
authorization. Prior authorization may be granted for cochlear implant repairs
outside the warranty period. Such services must be provided in accordance with
the policy and service provisions specified in the Medicaid Hearing Services
Coverage and Limitations Handbook, and must be provided by providers licensed
under Chapter 484, Part II, F.S

 

 
(4)  
Home Health Care Services: Intermittent or part-time nursing services provided
by a registered nurse or licensed practical nurse, or personal care services
provided by a licensed home health aide, with accompanying necessary medical
supplies, appliances, and durable medical equipment. Such services must be
provided in accordance with the policy and service provisions specified in the
Medicaid Home Health Coverage and Limitations Handbook.

 

 
(5) 
Independent Laboratory and Portable X-ray Services: Medically necessary and
appropriate diagnostic laboratory procedures and portable x-rays ordered by a
physician or other licensed practitioner of the healing arts as specified in the
Independent Laboratory and Portable X-ray Services Coverage and Limitations
Handbook.

 

 
(6) 
Inpatient Hospital Services: Medically necessary services, including ancillary
services, furnished to inpatient enrollees, provided under the direction of a
physician or dentist, in a hospital maintained primarily for the care and
treatment of patients with disorders other than mental diseases. Such services
must be provided in accordance with the policy and service provisions specified
in the Medicaid Hospital Coverage and Limitations Handbook.

 

 
(7) 
Outpatient Hospital/Emergency Medical Services: Outpatient preventive,
diagnostic, therapeutic, or palliative care provided under the direction of a
physician at a licensed hospital. Such services include emergency room,
dressings, splints, oxygen, physician ordered services and supplies necessary
for the clinical treatment of a specific diagnosis or treatment as specified in
the Medicaid Hospital Coverage and Limitations Handbook.

 

 
(8)  
Physician Services: Those services and procedures rendered by a licensed
physician at a physician’s office, patient’s home, hospital, nursing facility or
elsewhere when dictated by the need for preventive, diagnostic, therapeutic or
palliative care, or for the treatment of a particular injury, illness, or
disease as specified in the Medicaid Physicians Coverage and Limitations
Handbook.

 

 
(9) 
Prescribed Drug Services: Prescribed drug services for dual eligible Medicaid
beneficiaries are covered as per the Medicare Modernization Act (MMA). However,
section 103(c) of the MMA added s. 1935(d)(2) to the Social Security Act to
allow State Medicaid programs to continue to provide and receive Federal
Financial Participation (FFP) for certain drugs not included in the Medicare
Prescription Drug benefit (Part D). Drugs excluded from Part D coverage are
listed in s. 1927(d)(2) of the Act. Contractors shall provide certain drugs not
included in Part D as described in the Medicaid Prescribed Drugs Services and
Limitations Handbook. The Contractor’s pharmacy benefits management program must
comply with all applicable federal and state laws.

 

 
(10)
Vision Services: Medically necessary eye examinations, eyeglass repairs and
adjustments. Eyeglass frames are limited to one pair every two years. Prior
authorization is required for a second pair every two years, and eyeglass frames
within the two-year period and also for a second pair of lenses within a 365 day
period. Such services must be provided in accordance with the policy and service
provisions specified in the Medicaid Vision Services Coverage and Limitations
Handbook, and must be provided by providers licensed under Chapter 484, Part I,
or 463, F.S.

 

 
(11)
Hospice Services: End of life services provided to enrollees electing hospice
services. Services will be provided in accordance with the policy and services
provisions specified in the Hospice Services Coverage and Limitations Handbook.

 
1.3.3.3.1
Acute Care Provider Qualifications

 
(1)
For the acute care services that are covered under this contract and are also
covered by Medicare, the provider qualifications will be those of the Medicare
program

 
(2)
For the acute care services covered under this contract that are not covered by
Medicare, the Contractor must meet the provider requirements of the Medicaid
programs except that provider type limitations

 

 
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associated with certain services will not apply when other provider types can
legally perform the service.

 
1.3.3.4
Expanded Services

 
 
The Contractor may elect to provide expanded services. If the Contractor elects
to provide expanded services, the services must be offered to all eligible
enrollees following written approval by the Department. Expanded services are
defined as the following:

 
(1)
Services in excess of the amount, duration and scope of those listed in Section
1.3.3 contract Terms and Conditions; and

 

 
(2)
Services and benefits not listed in this ATTACHMENT I, section 1.3.3, Contract
Terms and Conditions.

 
1.4
INDIVIDUALS TO BE SERVED

 
1.4.1
Eligibility for Program

 
 
To be eligible for services under this contract, an individual must meet the
following criteria:

 

 
(1)
Be 65 years of age or older.

 

 
(2)
Have Medicare Parts A & B as reflected in the Florida Medicaid Management
Information System (FMMIS).

 

 
(3)
Be Medicaid eligible with incomes up to the Institutional Care Program (ICP)
level.

 

 
(4)
Reside in the project service area.

 

 
(5)  
Be determined by CARES to be at risk of nursing home placement and meet one or
more of the following clinical criteria:

 
a.  
Require some help with five or more activities of daily living (ADLs); or

 

 
b.  
Require some help with four ADLs plus requiring supervision or administration of
medication; or

 
 
c.  
Require total help with two or more ADLs; or

 

 
d.  
Have a diagnosis of Alzheimer’s disease or another type of dementia and require
assistance or supervision with three or more ADLs; or have a diagnosis of a
degenerative or chronic condition requiring daily nursing services; or

 

 
e.  
Have a diagnosis of a degenerative or chronic condition requiring daily nursing
services.

 

 
(6) 
Be determined by CARES to be a person who, on the effective date of enrollment,
can be safely served with home and community-based services.

 
1.4.2
Ineligibility for the Program

 
The following persons are ineligible for the program:

 

 
(1)
Persons residing outside the project service area.

 

 
(2)
Persons residing in a state hospital, intermediate care facility for persons
with developmental disabilities, or a correctional institution.

 

 
(3)
Persons participating in or enrolled in another Medicaid waiver project on the
effective date of enrollment.

 

 
(4)
Medicaid eligible recipients who are served by the Florida Assertive Community
Treatment Team (FACT team).

 

 
(5)  
Persons enrolled in any other Medicaid capitated long-term care program, in a
Medicaid HMO, MediPass program, on the effective date of enrollment.

 
1.4.3
“Medicaid Pending”

 
(1)
An individual who applies for the Program and is determined medically eligible
by CARES, but has not been determined financially eligible for Medicaid by the
DCF is designated as “Medicaid Pending”.

 

 
(2)
Contractors may elect to provide the “Medicaid Pending” option by completing and
returning Attachment

 
 
 
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X to the Department.

 

 
(3)  
CARES staff will refer individuals identified as “Medicaid Pending” to the
Contractor. The Contractor will assist “Medicaid Pending” individuals in
submitting the ACCESS Florida Application (on-line or hard copy)
(www.myflorida.com/accessflorida) to DCF no later than 30 days from the receipt
of the referral from CARES. Additionally, the Contractor must forward, at a
minimum, the following documentation to DCF: Financial Release (CF FS 2613),
Notification of Level of Care (DOEA-CARES 603), and the Certification of
Enrollment Status (HCBS)(CF-AA 2515).

 

 
(4) 
Once the individual’s financial eligibility is determined by DCF, the Contractor
must notify CARES whether the individual is approved or denied and provide a
copy of the Notice of Case Action or verification of Medicaid eligibility to the
individual within two (2) business days of receipt. If individuals are
determined financially eligible by DCF, the Contractor will be reimbursed a
capitated rate for services rendered retroactive to the first of the month
following the CARES medical eligibility determination.

 

 
(5)  
The Contractor shall submit the enrollment information to the Medicaid fiscal
agent in the HIPAA approved 834 electronic transaction format. This information
must be transmitted to the fiscal agent by the monthly reporting deadline.

 

 
(6)  
If the Contractor decides to change participation in the “Medicaid Pending”
program, the Contractor shall submit a certified letter to the Contract Manager
30 days prior to the intended change.

 

 
(7) 
If the individual is not financially eligible for Medicaid as determined by DCF,
the Contractor may terminate services and seek reimbursement from the
individual. The Contractor may only seek reimbursement from the individual for
documented services, claims, co-payments and deductibles paid on behalf of the
Medicaid Pending individual for services rendered to the individual. The
Contractor shall submit to the individual an itemized bill for services. The
itemized bill and related documentation shall be included in case notes.

 

 
(8)  
An individual identified as Medicaid Pending, who elects to terminate services
in the Nursing Home Diversion Program prior to a Medicaid eligibility
determination, but requests assistance with Medicaid eligibility must sign the
section of Form 608 that states: “I choose not to enroll in the Nursing Home
Diversion Program at this time, but request assistance with the financial
eligibility determination from the following Nursing Home Diversion provider
(Provider’s Name). In order to receive this assistance I must complete the DOEA
Form 606.” The Contractor shall send the signed Form 608 and Form 606 back to
CARES.

 
1.4.3.1  
Providers are required to provide assistance with Medicaid financial eligibility
to prospective program enrollees at no cost to the enrollee/without
reimbursement. An individual who chooses not to receive services, but who elects
to receive assistance with Medicaid financial eligibility, must complete Form
606. The Contractor shall send the signed Form 606 back to CARES.

 
SECTION II: MANNER OF SERVICE PROVISION
 
2.1  
SERVICE TASKS

  The service tasks in this section II must be performed by the Contractor in
support of the contract’s major program goals.
 
2.1.1  
ENROLLMENT AND DISENROLLMENT

 
2.1.1.1  
Enrollment Procedures

 
(1) 
The Contractor will receive a complete referral package from CARES.

 

 
(2) 
Upon receipt, the Contractor will log in and date stamp the CARES referral
package.

 

 
(3) 
The Contractor must check monthly Medicaid eligibility through the FMMIS Web
Portal or other valid system.

 

 
(4)  
Upon receipt of the referral package, the Contractor will confirm through
FMMIS’s Web Portal or other valid system the following:

 
 
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a.
b.
c.
d.
Medicaid eligibility program codes are MS, MMS, or MWA.
The recipient resides in the Contractor’s service area.
The recipient has Medicare Parts A and B.
At the time of enrollment:
1)   The recipient is not residing in a nursing home.
2)   The recipient is not currently enrolled in a Medicaid HMO.
3)   The recipient is not currently enrolled in the MediPass program.
4)   The recipient is not currently enrolled in a Medicaid waiver program.

 

 
(5) 
The Contractor must accept individuals eligible for enrollment in the order in
which they are received from CARES. The Contractor will not discriminate against
individuals eligible to enroll on the basis of race, color, or national origin,
and will not use any policy or practice that has the effect of discriminating on
any basis including but not limited to race, color, or national origin.

 

 
(6)  
A dispute between the CARES assessment and the Contractor’s assessment as to the
appropriateness of the enrollment shall be referred by the Contractor to the
Contract Manager if resolution with CARES is unsuccessful within 48 hours of the
Contractor’s face-to-face project orientation. The Department will review the
dispute within one (1) business day of receipt and issue a final determination
in writing in no more than five (5) business days to the Contractor and the
CARES office.

 

 
(7) 
The CARES referral package shall include a copy of the disenrollment form for
enrollees transferring to a new Contractor.

 
2.1.1.2  
Optional State Supplementation (OSS)

                  The Contractor shall inform and assist enrollees who qualify
under s. 409.212, F.S. with an application for OSS services. OSS is a general
revenue cash assistance program. The purpose of the program is to supplement the
enrollees’ income to help pay the cost of an assisted living facility.
 
2.1.1.3  
Changes in Eligibility and Reenrollment

 
(1) 
The Contractor shall assist enrollees to ensure continuous eligibility in the
program as part of the case management responsibilities. This includes financial
and medical eligibility. The Contractor shall develop a process for tracking the
eligibility re-determination to ensure continuity of care. Contractor case
management performance must include services to help the enrollee maintain
Medicaid financial eligibility. These services must be documented in case notes.

 

 
(2) 
An enrollee who has lost eligibility and regains eligibility within two (2)
months will be automatically reenrolled by the Medicaid fiscal agent’s system
during the next enrollment cycle.
 

 
(3) 
The Contractor shall not deny enrollment to correctly reinstated enrollees.

 

 
(4)  
The Contractor must check monthly Medicaid eligibility through the Medicaid
Eligibility Verification System (MEVS), FMMIS Web Portal or other valid system.

 

 
(5) 
The Contractor will notify the CARES office and DCF of any changes in an
enrollee’s address using the appropriate DCF process.

 
2.1.1.4  
Effective Date of Enrollment

 
 
For all referrals received in a month, enrollment is effective at 12:01 a.m. on
the first day of the calendar month following the month in which the referral
was received. All services must be in place no later than the first day of the
enrollment month for all referrals received prior to the last five business days
of the month and for all imminent risk referrals. All services must be in place
within five calendar days of the effective date of the enrollment month for all
referrals received within the last five business days of the month.

 
2.1.1.5  
Transition Care Planning

 
(1) 
For recipients who are transferring from another home and community based
services waiver program or another Diversion Contractor, the Contractor shall
ensure continuation of needed services in accordance

 
 
 
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with the current care plan until a new care plan is developed during the
transition phase.

 

 
(2)  
By the first date of enrollment, the Contractor must provide transition care
services in collaboration with CARES staff and assume responsibility for meeting
the enrollee’s care needs. The Contractor must ensure that enrollment in the
project does not interrupt or delay the delivery of services needed by the
enrollee.

 
2.1.1.6      Orientation

 
(1)  
The Contractor must provide each new enrollee or their representative with a
written notice of the effective date of enrollment, a plan ID, an enrollee
handbook, and a provider directory. Materials shall be provided prior to
enrollment but no later than the initial face-to-face meeting.

 

 
(2)  
The Contractor must complete face-to-face project orientation within five (5)
business days of enrollment for those enrollees in a community setting,
including “Medicaid Pending” enrollees. The Contractor must complete
face-to-face project orientation within seven (7) business days of enrollment
for those enrollees, including “Medicaid Pending” enrollees, residing in a
facility. Regardless of when orientation takes place, all services must be in
place according to the time frames set forth in section 2.1.1.4 Enrollment
Effective Date.

 

 
(3)  
The Contractor shall assure that appropriate language versions of all materials
including enrollment and disenrollment materials are developed and available to
enrollees and potential enrollees. The Contractor shall provide oral
interpretation free of charge for all potential enrollees or enrollees whose
prevalent language is not English. Non-English versions of written materials are
required, if the population speaking a non-English language in a given county is
greater than five (5) percent of the population.

 

 
(4)  
Prior to use, the Contractor shall obtain approval by the Department for any
materials provided to the enrollee and potential enrollees, including print and
media materials.

 
2.1.1.2   Enrollee Handbook
 
The enrollee handbook must be written in an easily understood format and written
at or below the eighth grade reading level.  The following items must be
included:

 

 
(1)  
Terms, conditions, and procedures for enrollment including the reinstatement
process.

 

 
(2)  
An explanation of the role of the case manager.

 

 
(3)  
Procedures for obtaining required and/or covered services, including second
opinions in accordance with s. 641.51 (5)(c), F.S., and 42 CFR 438.206(b)(3).

 

 
(4)  
The toll free telephone number of the Agency for Health Care Administration
Consumer Hotline (888) 419-3456.

 

 
(5)  
The toll free telephone number of the statewide Abuse Hotline (800) 96ABUSE or
(800) 962-2873.

 

 
(6)  
Instructions on how an enrollee obtains access to services included in their
care plan.

 

 
(7)  
Information about emergency services. In accordance with CFR 438.10(f)(6),
Contractors must provide the following information about emergency services to
enrollees:

 

 
a.  
Prior authorization is not required for emergency services;

 

 
b.  
The Contractor must inform enrollees of the process and procedures for obtaining
emergency services, including use of the 911-telephone system or its local
equivalent; and

 

 
c.  
Providers must inform enrollees of the locations of any emergency settings and
other locations at which providers and hospitals furnish emergency services and
post-stabilization services covered under the contract.

 

 
(8)  
Notification to enrollees of restrictions, if any, on the enrollee’s freedom of
choice among network providers.

 

 
(9)  
The consequences of obtaining care from out-of-network providers.

 

 
(10)  
Information regarding the enrollee’s right to disenroll at any time and
instructions on how to initiate the

 
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disenrollment process. Information must explain that if voluntary disenrollment
is requested on or before thh 15th of the month, disenrollment will be effective
the first of the following month.  If the voluntary disenrollment is requested
after the 15th of the month, disenrollment will be effecetive on the first day
of the second calendar month following the month the request was received.

 

 
(11)  
Information regarding the enrollee’s rights and responsibilities, including the
following:

 

 
a.  
Each managed care enrollee is guaranteed the right to be treated with respect
and with due consideration for his or her dignity and privacy;

 

 
b.  
Each managed care enrollee is guaranteed the right to receive information on
available treatment options and alternatives, presented in a manner appropriate
to the enrollee’s condition and ability to understand;

 

 
c.  
Each managed care enrollee is guaranteed the right to participate in decisions
regarding his or her healthcare, including the right to refuse treatment;

 

 
d.
Each managed care enrollee is guaranteed the right to request and receive a copy
of his or her care plan, and to request that they be amended or corrected, as
specified in 45 CFR part 164; and

 

 
e.  
Each enrollee is free to exercise his or her rights, and the exercise of those
rights does not adversely affect the way the MCO and its providers or the State
agency treat the enrollee.

 

 
(12)  
Description of the grievance and appeals process.

 

 
(13)  
The toll-free numbers that the enrollee can use to file a grievance or appeal by
phone.

 

 
(14)  
Information regarding the confidentiality of enrollee records.

 

 
(15)  
Notification to the enrollee that the following items are available to them upon
request:

 

 
a.  
A detailed description of the Contractor’s authorization and referral process
for services;

 

 
b.  
A detailed description of the Contractor’s process used to determine whether
services are medically necessary;

 

 
c.  
A detailed description of the Contractor’s quality assurance program;

 

 
d.  
A detailed description of the Contractor’s credentialing process;

 

 
e.  
The policies and procedures relating to the confidentiality and disclosure of
the enrollee’s medical records;

 

 
f.  
Information regarding quality performance indicators, including aggregate
enrollee satisfaction data; and

 

 
g.  
Information on the structure and organization of the Contractor.

 

 
(16)  
Information that oral interpretation services for any language and alternative
communication systems are available free of charge and written information is
available for prevalent languages as well as instructions on how to access these
services.

 

 
(17)  
Information that post-stabilization services are provided without prior
authorization in accordance with 42 CFR 422.113(c).

 

 
(18)  
Information that services will continue during an appeal of a suspended
authorization but that the enrollee may have to pay in case of an adverse
ruling.

 

 
(19)  
Information regarding current health care advanced directives pursuant to
sections 765.302 through 765.309 F.S., 42 CFR 438.6(i)(1)-(2) and 42 CFR
422.128, as follows:

 

 
a.  
The Contractor shall provide these policies and procedures to all enrollees and
shall advise enrollees of their rights under state law, including the right to
accept or refuse medical treatment and the right to formulate advance
directives;

 
b.  
The Contractor's written policies respecting the implementation of those rights,
including a statement of a limitation regarding the implementation of advance
directives as a matter of

 
 
 
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conscience; and

 

 
c.  
The information must include a description of state law and must reflect changes
in state law as soon as possible, but no later than ninety (90) calendar days
after the effective change.

 

 
(20)  
Information on how and where enrollees can access any benefits that are
available under the State plan, but are not covered under the contract,
including any cost sharing, and how transportation is provided.

 

 
(21)  
For a counseling or referral service that the Contractor does not cover because
of moral or religious objections, the Contractor need not furnish information on
how and where to obtain the service.

 
 
 2.1.1.8
Provider Directory

 
The Contractor shall compile a directory listing the providers sorted by
individual counties and by services, which includes the following information:

 

 
(1)  
Provider name;

 
(2)  
Service(s) provided;

 
(3)  
Provider location; and

 
(4)  
Provider telephone number.

 
2.1.1.9
Plan ID Card

 
The plan ID card must include the following:

 

 
(1)  
The Contractor’s name;

 
(2)  
The Contractor’s address; and

 
(3)  
The Contractor’s member services telephone number.

 
2.1.1.10
Annual Notification

 
In accordance with 42 CFR 438.10(f)(2), the Contractor must notify enrollees at
least on an annual basis of their right to request and to obtain information
listed in sections 2.1.1.7 and 2.1.1.8.

 

 2.1.1.11
Care Plan and Service Delivery Requirements

 
(1)  
The Contractor is required to develop an individualized plan of care for every
new enrollee referred by the CARES offices. Services included in the care plan
will be determined by the Contractor in consultation with the enrollee or their
representative using the initial assessment provided by CARES as well as the
Contractor’s assessment.

 

 
(2)  
The care plan shall be in a format approved by the Department.

 

 
(3)  
A care plan utilizing case management only will be subject to review by the
Department and the enrollment may be reviewed for appropriateness.

 

 
(4)  
The care plan must be based on a comprehensive assessment of the enrollee’s
health status, physical and cognitive functioning, environment, social supports,
and end-of-life decisions. The care plan must clearly identify barriers and
explore potential solutions with the enrollee and caregivers. The care plan must
detail all interventions designed to address specific barriers to independent
functioning. The care plan must include any services provided through the
enrollee’s own informal network or by volunteers from community social service
agencies or other organizations such as churches and synagogues.

 

 
(5)  
The care plan must include at a minimum the following components as specified in
42 CFR 441.351(f) and as required by the Department:

 

   a.
The enrollee’s name;
   b.
The enrollee’s date of birth or Medicaid Number;
   c.
Care plan effective date;
   d.
Care plan review date;
   e.
Covered services provided including routine medical and HCBS services
   f.
Begin date and end date;
   g.
Providers;
   h.
Amount and frequency;

 
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   i.
Case manager's signature; and
   j.
Enrollee or the enrollee's authorizaed representative's signature and date is
required on the care plan or care plan summary, whichever document is given to
the enrollee.

 
(6)  
In developing the care plan, the Contractor must perform the following:

 

 
a.  
Assess the immediacy of the new enrollee’s service needs and include a
description of the enrollee’s condition, as identified through an appropriate
comprehensive assessment and a medical history review.

 

 
b.  
Identify any existing care plans and service providers and assess the adequacy
of current services.

 

 
c.  
Provide for continuous care to the new enrollee if the enrollee is receiving
active treatment prior to the effective date of enrollment.

 

 
d.  
Ensure that the care plan contains information about the enrollee’s medical
condition, the type of services to be furnished, the amount, frequency and
duration of each service, and the type of provider to furnish each service for
all enrollees whether they reside at home or in an assisted living facility.

 

 
e.  
Ensure that treatment interventions address identified problems, needs, and
conditions. In consultation with the enrollee and, as appropriate, the
enrollee’s representative or caregiver, the care plan must specify the long-term
care service interventions and the medical interventions for the enrollee when
such services are the responsibility of the Contractor.

 

 
f.  
Encourage the development of an informal volunteer network of caregivers,
family, neighbors, and others to assist the enrollee or primary caregiver with
services. These services will be integrated into an enrollee’s care plan when it
is determined through multi-disciplinary assessment and care planning that these
services would improve the enrollee’s capability to live safely in the home
setting and are agreed to and approved by the enrollee or the enrollee’s
authorized representative.

 

 
g.  
Implement a systematic process for determining whether enrollees have advance
directives, health care powers of attorney, do not resuscitate orders, or a
legally appointed guardian if applicable. This information will become part of
the enrollee’s medical record and these orders and preferences will be
integrated into the care coordination process. The Contractor shall include a
copy of the enrollee’s health care powers of attorney or the legally appointed
guardian documents in the enrollee’s file. The Contractor will discuss with the
enrollee the importance of advance directives and do not resuscitate orders and
note the enrollee’s response in the case file.

 

 
(7)  
Care Plan Summary

                             The case manager may provide the enrollee or
enrollee’s representative with a care plan summary for easy reference so long as
the summary contains the following minimum components:

   a.
The enrollee’s name;
   b.
The enrollee’s date of birth or Medicaid Number;
   c.
Covered services provided including routine medical and HCBS services;
   d.
Begin date of services;
   e.
Providers;
   f.
Amount and frequency;
   g.
Case manager’s signature; and
   h.
Enrollee or the enrollee’s authorized representative’s signature and date.

 
2.1.1.12
Initial Care Plan Distribution

 
(1)  
A copy of the care plan must be forwarded to the enrollee’s primary care
physician within ten (10) days of development.

 

 
(2)  
A copy of the care plan must be submitted to the Department via the FTP site at
https://elderaffairs.sharefile.com/ within ten (10) days of development. The
file name must be labeled

 
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care plan, the Contractor name, and the enrollee’s initials or name.

 

   
(3)  
If the enrollee resides in an assisted living facility or a nursing facility, a
copy of the care plan must be forwarded to the facility within ten (10) days of
development.

 
2.1.1.13    Care Plan Review

 
(1)  
Contractors shall contact enrollees at least once a month either by telephone or
face-to-face. This contact must be documented in the case notes. The Contractor
will ensure the review of the care plan is performed through face-to-face
contact with the enrollee at least every third month. The care plan review must
address the adequacy and appropriateness of services and determine that the
services furnished are consistent with the nature and severity of the enrollee’s
needs.

 

 
(2)  
The Contractor will review the care plan if the enrollee or anyone involved in
providing care or services to the enrollee reports a significant change in the
enrollee’s condition.

 

 
(3)  
Revisions to the care plan must be done in consultation with the enrollee, the
caregiver, and when feasible, the primary care physician. If the primary care
physician is not under contract with the Contractor to deliver services to the
enrollee, an effort must be made by the case manager to obtain physician’s input
regarding care plan revisions. Changes in service provision resulting from a
care plan review must be implemented within five (5) business days of the review
date unless otherwise specified.

 

 
(4)  
If any significant change in condition or services is made to the care plan, the
revised care plan shall be distributed in its entirety to the same entities as
the initial care plan.

 
2.1.1.14    Coordination and Continuity of Care

 
(1)  
Pursuant to 42 CFR 438.208(b), the Contractor must implement procedures to
coordinate health care service for all enrollees that:

 

 
a.  
Ensure each enrollee has an ongoing source of primary care appropriate to
his/her needs and a person or entity formally designated as primarily
responsible for coordinating the health care services furnished to the enrollee.

 

 
b.  
Coordinate the services furnished to the enrollee with services the enrollee
receives from any other managed care entity.

 

 
c.  
Share with other managed care organizations serving the enrollee with special
health care needs the results of its identification and assessment of the
enrollee's needs to prevent duplication of those activities.

 

 
d.  
Ensure in the process of coordinating care, each enrollee's privacy is protected
in accordance with the privacy requirements in sections 17 and 18 of the
Standard Contract and 45 CFR Part 160 and 164 Subparts A and E, to the extent
that they are applicable.

 

 
(2)  
The Contractor will be responsible for the following activities to facilitate
care coordination and continuity of care:

 

 
a.  
For enrollees in an assisted living or nursing facility, the Contractor will
ensure coordination with the medical, nursing, or administrative staff
designated by the facility to ensure that the enrollees have timely and
appropriate access to the Contractor’s providers and to coordinate care between
those providers and the facility’s providers.

 

 
b.  
For those enrolled in the Contractor’s Medicare Advantage plan, the Contractor
must have protocols to ensure that all acute care services and long-term care
services are coordinated. The enrollee’s case manager must coordinate with the
primary care physician, as well as the enrollee or other appropriate person, in
the development of acute and long-term care plans. The Contractor must ensure
that all subcontractors, delivering services covered by the contract, agree to
cooperate with the goal of an integrated and coordinated service delivery system
for the enrollee.

 

 
c.  
When contract enrollees elect to remain in the Medicare fee-for-service system,
the Contractor must establish protocols to ensure that services are coordinated
to the maximum extent feasible for enrollees in Medicare fee-for-service. The
case manager must actively pursue coordination with the

 
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enrollee’s primary care physician and other care providers.

 

 
d.  
The Contractor shall assisting enrollees in gaining access to transportation
services, including coordinating transportation with the local Florida
Commission for the Transportation Disadvantaged Program and other transportation
providers.

 

 
e.  
Enrollee’s with Special Health Care Needs

                                  Pursuant to 42 CFR 438.208(c) if an enrollee
is identified with special health care needs, the Contractor must develop
assessment mechanisms using appropriate health care professionals.
 

 
 1)  
The Contractor shall participate with the enrollee’s primary care provider, in
consultation with any specialists, in the development of a treatment plan for an
enrollee determined to need a course of treatment or regular care monitoring, in
accordance with state quality assurance and utilization review standards. The
treatment plan shall be approved in a timely manner.

 

 
 2)  
The Contractor shall have a mechanism in place to allow enrollees to determine
access to a specialist as appropriate for an enrollee’s condition and identified
needs.

 
2.1.1.15    Assessments and Reassessments

 
(1)  
Case managers are responsible for long-term care planning and annual
face-to-face re-assessments using Department form 701B. A copy of the form 701B
may be obtained from the Department’s web site
http://elderaffairs.state.fl.us/english/pubs/pubs/doea701b sep08.pdf.

 

 
(2)  
The Contractor shall submit a paper copy of the Department’s form 701B to the
local CARES office within two-to-four weeks of the one-year anniversary date of
the previously completed LOC form.

 

 
(3)  
The Contractor shall certify all case managers in completing form 701B. The
Contractor shall keep such certifications on file at the Contractor’s location
and shall make such certifications available to the Department upon request.

 
2.1.1.16    Level of Care

 
(1)  
The Contractor is responsible for tracking Level of Care re-determinations to
ensure they are conducted at least annually following the process as provided by
the Department. The Level of Care requests shall be submitted using the form in
EXHIBIT L.

 

 
(2)  
The Level of Care re-determination must be completed within one year of the
approval date entered on the most recent Notification of Level of Care (DOEA
CARES Form 603). This date is found on Form 603 adjacent to the Approval
Signature.

 

 
(3)  
Annual Level of Care re-determinations shall be sent to CARES within two-to-four
weeks of the one- year anniversary date of the previously completed Notification
of Level of Care form.

 

 
(4)  
The Level of Care requests shall be submitted using the form in EXHIBIT L.

 
2.1.1.17    Disenrollment Requested by the Enrollee

 
(1)  
Disenrollment refers to the process of terminating services with a Contractor
after the enrollment effective date.

 

 
(2)  
Enrollees must be allowed to voluntarily disenroll at any time by submitting an
oral or written request to the Contractor. The Contractor must ensure that it
does not restrict the enrollee's right to voluntarily disenroll in any way, and
that it does not deter the enrollee’s contact with the State.

 

 
(3)  
The Contractor must make disenrollment assistance available during business
hours. This assistance must be available through a toll-free telephone number or
face-to-face contact. The Contractor’s written disenrollment procedure must list
the staff responsible for this type of assistance.

 

 
(4)  
Immediately upon receiving a request for disenrollment, the Contractor must
inform the enrollee of disenrollment procedures and the Contractor must process
the disenrollment within the timeframes described herein. If disenrollment is
requested on or before the 15th of the month, disenrollment will be effective
the first of the following month. If disenrollment is requested after the 15th
of the month, disenrollment will be effective on the first day of the second
calendar month following the month in

 
 
 
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which the referral was received.

 

 
(5)  
The Contractor must maintain a log of all oral and written disenrollment
requests and the disposition of such requests.

 
2.1.1.18          Disenrollment Requested by the Contractor

 
(1)  
The Contractor shall disenroll an enrollee only for the following reasons.

   a.
Enrollee death.
   b.
Ineligibility for Medicaid.
   c.
Ineligibility for the project
   d.
Moving outside the Contractor’s service area.
   e.
Enrollee leaves their service area for more than 30 consecutive days.
   f.
Fraudulent use of the enrollee’s Medicaid ID card.
   g.
Incarceration.
   h.
Non-cooperation, subject to Department approval.

 

 
(2)  
If the Contractor requests approval for a disenrollment due to non-cooperation,
the Contractor must submit a written request to the Department. Pursuant to 42
CFR 438.56(b)(2), the Contractor is prohibited from requesting a disenrollment
based on an adverse change in the enrollee’s health status or disruptive
behavior resulting from an enrollee’s special needs. Involuntary disenrollments
without the Department’s approval will be considered an express or intentional
violation of the contract and a cause for termination as specified in section
49.3 of the Standard Contract.

 

 
(3) 
The Contractor must provide at least one verbal and at least one written warning
of the full implications of failure to follow a recommended care plan or if the
enrollee otherwise continues the disruptive behaviors. Enrollees must be given a
reasonable opportunity to comply with the care plan subsequent to each verbal
and written warning before disenrollment is made effective except in instances
where the enrollee’s actions threaten the health, safety, or well being of this
enrollee or others, including service providers or Contractor’s staff or
representatives.

 
2.1.1.19         Disenrollment Requests

 
(1) 
The Contractor must complete disenrollment request forms in their entirety and
submit on EXHIBIT I.

 

 
(2) 
The Contractor shall complete all disenrollments through the submission of the
HIPAA approved format to the Medicaid fiscal agent. The Contractor must provide
disenrollment data via the HIPAA approved format on the first available
transmission to the Medicaid fiscal agent after the date of receipt of the
disenrollment request. The Contractor shall not submit a disenrollment with an
effective date later than 49 calendar days after the Contractor’s receipt of a
voluntary disenrollment request.

 

 
(3)  
The Contractor shall send a completed copy of the disenrollment request form to
the CARES office within 48 hours of receipt of the form from the enrollee or
upon final approval of the Contractor’s request by the Department. The
Contractor shall retain a copy in the enrollee’s case file.

 

 
(4) 
The Contractor shall contact the Department for retroactive disenrollments if
any of the following occurs prior to the enrollment effective date:

   a.
The enrollee moves to an area where services are not available.
   b.
The enrollee decides to remain in a nursing facility.
   c.
The enrollee leaves their service area for more than 30 consecutive days.

 
2.1.1.20    Cancellations
                   Cancellation refers to the process of voiding a referral to a
Contractor prior to the effective enrollment date or the first date of services
for a Medicaid Pending referral. Cancellations do not include withdrawals once
an individual is referred as Medicaid Pending and has received services.
 
 
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(1) 
If a cancellation is initiated by the client with CARES prior to enrollment,
CARES will notify the Contractor immediately and request the referral package be
returned. CARES will also notify the Contract Manager of the cancellation.

 

 
(2)  
If a cancellation is initiated by the client with the Contractor prior to
enrollment, the Contractor shall notify CARES and return the referral package
immediately. The Contractor shall also notify the Contract Manager of the
cancellation.

 
2.2             RECORDS MANAGEMENT AND HEALTH INFORMATION SYSTEMS

 
(1)  
The Contractor must maintain an enrollee records system, which is consistent
with professional standards and permits the prompt retrieval of information upon
request.

 

 
(2) 
The Contractor shall require that all subcontracted providers properly maintain
and report data that documents the care provided to enrollees.

 

 
(3)  
The Contractor must disclose enrollee records, including enrollee and caregiver
identifying information, to the Department and Agency. It is the Department and
Agency’s obligation to oversee the performance or to conduct assessment,
investigation, or evaluation of this contract. Notwithstanding provisions to the
contrary, release of material to the Department and Agency will not be construed
as public disclosure of confidential information.

 

 
(4)  
All records must contain documentation that the member was provided written
information concerning the member’s rights regarding advanced directives, and
whether or not the member has executed an advance directive. The Contractor
shall not, as a condition of treatment, require the member to execute or waive
an advance directive in accordance with s. 765.110, F.S. The Contractor must
comply with the requirements of 42 CFR 422.128 for maintaining written policies
and procedures for advance directives.

 

 
(5) 
The Contractor shall maintain a health information system that collects,
analyzes, integrates, and reports data that can achieve the objectives of 42 CFR
438.242. The system must provide information on areas including, but not limited
to, utilization, grievances and appeals, and disenrollments for other than loss
of Medicaid eligibility.

 

 
(6) 
The Contractor is responsible for maintaining a complete case record for each
enrollee. The case record will contain, at a minimum, the following information:

 
a.  
Copies of eligibility documents, including level of care determinations;

   
b.  
Medical diagnosis;

   
c.  
Needs assessments;

   
d.  
Care plans;

   
e.  
Service authorizations;

   
f.  
CARES referral documents;

   
g.  
Documentation that the enrollee has received the Enrollee Handbook, Provider
Directory and Plan ID;

   
h.  
Documentation that the Care Plan was discussed with the enrollee and of the
provision of the care plan to the enrollee’s primary care physician and any type
of facility in which the enrollee resides;

   
i.  
Documentation of the discussion of Advanced Directives and DNR;

   
j.  
Documentation of the discussion of the procedures for filing complaints and
grievances; and

   
k.  
Case notes.

 

 
(7) 
The Contractor must ensure that all case management activities are recorded in
case notes and be either physically or electronically signed and dated by the
case manager (electronic signatures are acceptable pursuant to applicable
federal and state law), including but not limited to, the following:

 

 
a.  
Orientation, which at a minimum consists of a discussion of the enrollee’s
appearance and demeanor, medical diagnoses, cognitive deficits, ADL and IADL
deficits, the enrollee’s environment, caregiver and how care plan needs are
addressed;

 
 
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b.  
Every third month face-to-face care plan reviews;

 

 
c.  
Monthly contact;

 

 
d.  
Updates on the enrollee’s medical conditions, hospitalizations and placement in
facilities;

 

 
e.  
Annual reviews including the documentation of completion of the 701-B
assessment; and

 

 
f.  
Documentation of service receipt, and enrollee satisfaction with services.

 
2.2.1  
Background Screening Affidavit of Compliance

                   To demonstrate compliance with section 8 of the Standard
Contract, the Contractor shall submit ATTACHMENT G, Background Screening
Affidavit of Compliance annually, by November 1st.
 
2.3  
UTILIZATION MANAGEMENT

 
Contractor and its subcontractors shall have in place and follow written
policies and procedures for processing requests for initial and continuing
authorization of services. The Contractor’s service authorization systems shall
provide authorization numbers, effective dates for the authorization, and
written confirmation to the subcontractor of denials, as appropriate. Pursuant
to 42 CFR 438.210(b)(1), Contractors must have and unfailingly use mechanisms to
ensure consistent application of review criteria for authorization decisions;
and consult with the requesting provider. Pursuant to 42 CFR 438.210(b)(3), any
decision to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested, must be made by a health
care professional who has appropriate clinical expertise in treating the
enrollee's condition or disease. Pursuant to 42 CFR 438.210(c), the Contractor
must notify the requesting provider of any decision to deny a service
authorization request or to authorize a service in an amount, duration, or scope
that is less than requested. The notice to the provider need not be in writing.
The Contractor must notify the enrollee in writing of any decision to deny a
service authorization request or to authorize a service in an amount, duration,
or scope that is less than requested. Pursuant to 42 CFR 438.210(e), the
Contractor must provide that compensation to individuals or entities that
conduct utilization management activities is not structured to provide
incentives for the individual or entity, or deny, limit, or discontinue
medically necessary services to any enrollee.

 
2.3.1 
Pursuant to 42 CFR 438.404(a), 42 CFR 438.404(c) and 42 CFR 438.210(b) and (c),
the Contractor must give the enrollee written notice of any "action" as defined
in this ATTACHMENT I, section 2.5.4, within the timeframes for each type of
action. Pursuant to 42 CFR 438.404(b) and 42 CFR 438.210(c), the notice must
explain the following:

 

 
(1) 
The action the Contractor has taken or intends to take;

 

 
(2) 
The reasons for the action;

 

 
(3) 
The enrollee’s or the provider's right to file a grievance/appeal;

 

 
(4) 
The enrollee's right to request a Medicaid Fair Hearing and the process for
obtaining one;

 

 
(5) 
Procedures for exercising enrollee rights to appeal or grieve

 

 
(6) 
Circumstances under which expedited resolution is available and how to request
it; and

 

 
(7) 
Enrollee rights to request that benefits continue pending the resolution of the
appeal, how to request that benefits be continued, and the circumstances under
which the enrollee may be required to pay the costs of these services.

 
2.3.2 
Pursuant to 42 CFR 438.404 (a) and (c), the notice must be in writing and must
meet the language and format requirements of 42 CFR 438.10(c) and (d) to ensure
ease of understanding.

 
2.3.3  
The Contractor must mail the notice within the following timeframes:

 

 
(1) 
For termination, suspension, or reduction of previously authorized
Medicaid-covered services, within the timeframes specified in 42 CFR 431.211, 42
CFR 431.213, and 42 CFR 431.214.

 

 
(2)  
For denial of payment, at the time of any action affecting the claim.

 
 
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(3)  
For standard service authorization decisions that deny or limit services, within
the timeframe specified in 42 CFR 438.210(d)(1).

 

 
(4) 
For service authorization decisions not reached within the timeframes specified
in 42 CFR 438.210(d) (which constitutes a denial and is thus an adverse action),
on the date that the timeframes expire.

 

 
(5) 
For expedited service authorization decisions, within the timeframes specified
in 42 CFR 438.210(d).

 
2.3.3.1 
If the Contractor extends the timeframe in accordance with 42 CFR 438.210(d)(1),
the Contractor must perform the following :

 

 
(1) 
Give the enrollee written notice of the reason for the decision to extend the
timeframe and inform the enrollee of the right to file a grievance if he or she
disagrees with that decision.

 

 
(2) 
Issue and carry out its determination as expeditiously as the enrollee's health
condition requires and no later than the date the extension expires.

 
2.4  
QUALITY ASSURANCE

 
2.4.1  
Quality Assurance Program

 
The Contractor must formally adopt a quality assurance program for enrollees.
The quality assurance program must include written goals, policies, and
procedures that ensure enhancement of quality of life for enrollees, emphasize
quality patient outcomes, and promote the coordination of acute and long-term
care services. The quality assurance program must have a system to identify and
prioritize problem areas for resolution and a process to design and implement
strategies to resolve identified problems. The system must include: a process
for changing the current quality assurance program as needed; a protocol that
dictates the active involvement of the medical director, the quality assurance
director, medical/clinical providers, and the director of the program; and a
description of the mechanism for measuring the success of quality assurance
strategies and for providing feedback to all providers involved in the program.
Specifically, the Contractor must have a quality assurance program that includes
the following:

 

 
(1)  
A written description of the quality assurance program.

 

 
(2) 
Written responsibilities of the governing body for monitoring, evaluating, and
improving care.

 

 
(3) 
A procedure for quality assurance program supervision.

 

 
(4) 
Assurance of adequate resources to carry out the program’s specified activities
effectively.

 

 
(5) 
A protocol for provider participation in the quality assurance program.

 

 
(6)  
A procedure for delegation of quality assurance responsibilities to designated
personnel.

 

 
(7)  
A procedure for credentialing and re-credentialing providers.

 

 
(8) 
A procedure for informing enrollees about their rights and responsibilities.

 

 
(9) 
Assurance of availability of and accessibility to services and care.

 

 
(10)  
A procedure to ensure the accessibility and availability of medical records, as
well as proper recording and process for record review.

 

 
(11) 
A procedure for utilization review.

 

 
(12)  
A procedure for quality assurance program documentation.

 

 
(13)  
A procedure for coordination of quality assurance activities with other
management activities.

 

 
(14) 
A continuity of care system.

 

 
(15) 
An active quality assurance committee.

 

2.4.2
 
The Contractor must have a quality assurance committee that is either a separate
mechanism for addressing the quality assurance concerns of eligible frail
enrollees, or incorporated into an existing quality assurance committee. The
responsibilities of the quality assurance committee are as follows:

 

 
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(1)  
Oversee quality of life indicators such as, but not limited to, the degree of
personal autonomy, provision of services and supports to assist people in
exercising medical and social choices, self-direction of care and maximum use of
natural support networks.

 

 
(2)  
Review grievances and appeals identified through the Contractor’s policies and
procedures and through external oversight.

 

 
(3)  
Review case records of all fair hearings and document internal
complaint/grievance steps involved in the fair hearing, as well as other
pertinent information for the enrollee.

 

 
(4)  
Review quality assurance policies, standards, and written procedures to ensure
that the needs of the enrollees are adequately addressed.

 

 
(5)  
Review utilization of services with adverse or unexpected outcomes for
enrollees.

 

 
(6)  
Develop and periodically review written guidelines, procedures and protocols
related to areas of concern in the care of the frail elderly.

 

 
(7)  
Develop an ethics committee to review ethical questions such as end-of-life
decisions and advance directives.

 

 
(8)  
Develop a system of peer review by physicians and other service providers.

 
2.4.3         Quality Improvement and Performance Measures
 
The Contractor shall monitor, evaluate, and improve the quality and
appropriateness of care and service delivery (or the failure to provide care or
deliver services) to enrollees through Performance Improvement Projects,
performance measures, surveys, and related activities in accordance with s.
409.912(27)(b) F.S.

 
2.4.3.1      Performance Improvement Projects
 
The Contractor shall perform two (2) Performance Improvement Projects (PIPs)
that have been approved by the Department in consultation with the Agency.

 

 
(1) 
Each PIP must include a statistically significant sample of Enrollees.

 

 
(2) 
One of the PIPs must be the statewide collaboratie PIP coordinated by the
External Quality Review Organization (EQRO).

 

 
(3) 
One PIP must be designed to address deficiencies identified by the plan through
monitoring, performance measure results, member satisfctiono surveys, or other
similar means.

 

 
(4) 
All PIPs must achieve, through ongoing measurements and intervention,
significant improvement to the quality of care and service delivery, sustained
over time, in areas that are expeceted to have a favorable effect on health
outcomes and enrollee satisfaction.  Improvement must be measured through
comparison of a baseline measurement and an initial re-measurement follwoing
application of an intervention.  Change must be statistically significant at the
95% confidence level and must be sustained for a period of two additional
re-measurements.  The Department prior to initiation of the PIP shall approve
measurement periods and methodologies.

 

 
(5)  
PIPs that have successfully achieved sustained improvement as defined by the
EQRO and as approved by the Department will be considered complete and will not
meet the requirement for one of the two PIPs, although the Contractor may wish
to continue to monitor the performacne indicatr as part of the overall quality
management program.  The Contractor shall select and submit a new PIP to the
Department for approval.

 

 
(6) 
By June 1st of the contract year, the Contractor shall submit in writing to the
Department, their current performance improvement projects (PIPs) using the
standardized PIP reporting templates.  Since PIPs are usually spread over three
years, information should be updated to reflect all steps up to time of
submittal.  The Contractor must complete, new PIPs through at least Step 4, with
projections made for Steps 5 and 6.  Details regarding Steps 4-6 may be viewed
at www.myfloridaegro.com.  In the event that the Contractor elects to modify a
portion of the PIP proposal subsequent to initial Department approval, a written
request may be submitted to the Department.  The External Quality Review PIP
Validation Report Form may be obtained from the following website:
www.myfloridagro.com.

 
 

 
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(7)  
See EXHIBIT M for due dates for the current contract year.

 

 
(8) 
Populations selected for study under the PIP must be specific to this contract
and shall not include non­Medicaid enrollees or Medicaid beneficiaries from
other states. In the event that the Contractor contracts with a separate entity
for management of particular services, such as behavioral health or pharmacy,
PIPs conducted by the separate entity shall not include enrollees for other
health plans served by the entity.

 
2.4.4  
Performance Measures

 
The Contractor shall collect, calculate, and report Department-selected
performance measures as specified by the Department. The Contractor shall submit
such performance measures to the Department and the Agency contracted EQRO
according to the following schedule: 1st quarter (January 1-March 31) and 2nd
quarter (April 1- June 30) rates should be submitted to the EQRO prior to the
performance measure site visit; 3rd quarter (July1- September 30), 4th quarter
(October 1 - December 31) and annual roll-up rates shall be submitted by
February 15 of the contract year. The Contractor shall collect the performance
measures based on the previous calendar year (January 1 through December 31)
unless otherwise specified. The Contractor is required to participate with the
EQRO on all performance measure validation activities, including a site visit
and submission of requested documentation. The Department may add, modify or
remove reporting requirements with thirty (30) days advance notice. See EXHIBIT
M for definitions and due dates.

 
2.4.5  
Incident Reporting

 
Notwithstanding section 19.1 of the Standard Contract, the Contractor shall
implement a systematic process for incident reporting and shall require all
subcontractors to comply with this section. The Contractor shall notify the
Department within 48 hours of occurrence of an incident that may jeopardize the
health, safety and welfare of an enrollee or impair continued service delivery.
The Contractor shall maintain an incident log that shall be available for
inspection by the Department. Additionally, the Contractor shall submit the log
found at APPENDIX 6 for every individual member for whom an incident has
occurred to the Department. Reportable conditions include, but are not limited
to, the following:

 

 
(1)  
Closure of subcontracted facilities due to license violations;

 

 
(2)  
Contractor or subcontractor financial concerns/difficulties;

 

 
(3)  
Loss or destruction of enrollee records;

 

 
(4)  
Compromise of data integrity;

 

 
(5)  
Fire or natural disasters; and

 

 
(6)  
Critical issues or adverse incidents that affect the health, safety, and welfare
of enrollees.

 
2.4.5.1  
In the incident log, the Contractor shall include a brief summary of the
problem(s) and proposed corrective action plans and timeframes for
implementation within a reasonable time after the incident is reported.

 
2.4.5.2  
The Contractor shall submit the incident log to the Department within 30 days of
the occurrence date via e-mail to DiversionReports@elderaffairs.org with
password protection for HIPAA related information.

 
2.5 
GRIEVANCES AND APPEALS

  
Federal law requires Medicaid managed care organizations, which for the purposes
of this section include HMOs and Other Qualified Providers, to have internal
grievance procedures under which Medicaid enrollees or their authorized
representatives may challenge denial of coverage or denial of payment for
medical assistance. The Contractor’s grievance system shall comply with the
requirements set forth in s. 641.511, F.S., if applicable, and with all
applicable federal and state laws and regulations, including 42 CFR 431.200 and
42 CFR Part 438, Subpart F, “Grievance System.”

 
2.5.1  
General Requirements

  
All Contractors must implement a grievance procedure for the purpose of
addressing enrollee complaints and grievances that meets the requirements of 42
CFR 438.402. For purposes of this contract, these procedures must include an
opportunity to file a complaint, a grievance, and/or an appeal and to seek a
Medicaid Fair Hearing through DCF. Enrollees must file a grievance through the
Contractor.

 
 
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2.5.1.1
The Contractor shall refer all enrollees who are dissatisfied with the
Contractor or its activities to the Contractor’s grievance/appeal coordinator
for processing and resolution.

 
2.5.1.2 
The Contractor shall include all necessary procedural steps for filing
complaints, grievances, appeals and requests for a Medicaid Fair Hearing in the
enrollee handbook. Enrollees shall be notified of these procedures and the
applicable time limits or deadlines as part of the enrollment process and
annually

 
2.5.1.3 
The Contractor shall provide information about the grievance system to all
subcontractors in the provider handbook when they enter a contract

 
2.5.1.4 
The Contractor must have formal systems in place to acknowledge receipt of any
grievance or appeal and must maintain a record of grievances and appeals and
including the final disposition of a grievance or appeal

 
2.5.1.5 
The Contractor must keep a log of complaints that do not become grievances,
including the name, date, nature of complaint and disposition. A complaint is an
informal component of the grievance system. The Contractor must respond to a
complaint within a reasonable time after receipt and the Contractor shall notify
the complainant of the right to file a written or oral grievance and that the
Contractor is available to assist the enrollee in preparing the written
grievance

 
2.5.1.6 
The Contractor shall acknowledge in writing receipt of each grievance and appeal
unless the enrollee requests and expedited resolution. A grievance, as defined
in 42 CFR 438.400, means an expression of dissatisfaction about any matter other
than ‘action” possible subjects for grievances include, but are not limited to,
the quality of care or services provided, and aspects of interpersonal
relationships such as rudeness of a provider or employee, or failure to respect
the enrollee's rights

 
2.5.1.7 
The Contractor shall ensure that decision makers on grievances and appeals were
not involved in previous levels of review or decision making, and that all
decision makers are health care professionals with clinical expertise in
treating the enrollee’s condition when deciding the following:

 

 
a.  
Appeal of a denial that is based on lack of medical necessity;

 
b.  
A grievance regarding denial of expedited resolution of an appeal; or

 
c.  
A grievance or appeal that involves clinical issues.

 
2.5.2 
Categories of Challenges
Categories of Challenges are as follows:

 

 
(1)  
A complaint is the lowest level of challenge and provides the Contractor an
opportunity to resolve a problem without its becoming a formal grievance.
Complaints shall be resolved within three (3) business days following receipt or
be moved into the grievance category.

 

 
(2)
A grievance expresses dissatisfaction about any matter other than an action
taken by the Contractor.

 

 
(3) 
An action is any denial, limitation, reduction, suspension, or termination of
service; denial of payment; or failure to act in a timely manner.

 

 
(4) 
An appeal is a request for review of an action.

 
2.5.3
Filing Grievances and Appeals

 
 2.5.3.1
Time Limits

 
The following time limits apply:

 

 
(1)
A grievance may be filed orally or in writing within one (1) year of the
occurrence.

 

 
(2) 
An appeal may be filed orally or in writing within thirty (30) calendar days of
the enrollee’s receipt of the notice of action and must be followed with a
written notice within ten (10) calendar days of the oral filing. The date of the
oral notice shall constitute the date of receipt.

 
 
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2.5.3.2      Expedited Appeals
                  The enrollee may file an expedited appeal either orally or
writing. The enrollee is not required to follow-up with a written request when
requesting an expedited appeal.
 

 
(1)  
The Contractor shall have an expedited review process for appeals for use when
taking the time for a standard resolution could seriously jeopardize the
enrollee’s life or health or ability to attain, maintain or regain maximum
function.

 

 
(2)  
The Contractor shall resolve each expedited appeal and provide notice to the
enrollee, as quickly as the enrollee’s health condition requires, not to exceed
three (3) business days after the Contractor receives the appeal request,
whether the appeal was made orally or in writing.

 

 
(3)  
The Contractor must ensure that no punitive action is taken against a
subcontractor who requests or supports a request for an expedited appeal.

 

 
(4)  
If the Contractor denies the request for expedited appeal, it shall immediately
transfer the appeal to the timeframe for standard resolution and so notify the
enrollee.

 
2.5.3.3      Assistance
                  The Contractor shall provide any reasonable help to the
enrollee in completing forms and following the procedures for filing a grievance
or appeal or requesting a Medicaid Fair Hearing. This includes interpreter
services, toll-free calling, and TTY/TTD capability.
 
2.5.3.4      Requirements
 
When handling grievances and appeals, the Contractor shall take the following
actions:

 

 
(1)  
Provide the enrollee a reasonable opportunity to present evidence and
allegations of fact or law in person as well as in writing;

 

 
(2)  
Ensure the enrollee understands any time limits that may apply;

 

 
(3)  
Provide opportunity before and during the process for the enrollee or an
authorized representative to examine the case file, including medical records,
and any other material to be considered during the process; and

 

 
(4)  
Consider as parties to the appeal the enrollee or an authorized representative
or, if the enrollee is deceased, the legal representative of the estate.

 
2.5.4         Notification of Action
                  The Contractor shall provide the enrollee with a written
notice of action in accordance with 42 CFR 438.10, that must include the
following:
 

 
(1)
The action the Contractor has taken or intends to take;

 

 
(2) 
The reasons for the action;

 

 
(3) 
The enrollee’s right to file an appeal with the Contractor;

 

 
(4) 
The enrollee’s right to request a Medicaid Fair Hearing;

 

 
(5) 
The procedures for exercising these rights specified in the notice;

 

 
(6) 
The circumstances under which expedited review and resolution is available and
how to request it; and

 

 
(7) 
The enrollee’s right to have benefits continue pending resolution of the appeal,
how to request that benefits be continued, and the circumstances under which the
enrollee may be required to pay the costs of these services.

 
2.5.4.1      For purposes of this section, an action is defined as follows:
 

 
(1) 
The denial or limited authorization of a requested service, including the type
or level of service, pursuant to 42 CFR 438.400(b);

 
 
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(2)  
The reduction, suspension, or termination of a previously authorized service;

 

 
(3) 
The denial, in whole or in part, of payment for a service;

 

 
(4) 
The failure to provide services in a timely manner;

 

 
(5) 
The failure of the Contractor to act within ninety (90) days from the date the
Contractor receives a grievance, or forty-five (45) days from the date the
Contractor receives an appeal; or

 

 
(6) 
For a resident of a rural area with only one (1) Contractor, the denial of an
enrollee’s request to exercise the right to obtain services outside the network.

 
2.5.4.2
An appeal is a formal request from an enrollee to seek a review of an action
taken by the Contractor pursuant to 42 CFR 438.400(b).

 
2.5.4.3
The Contractor shall mail the notice of action as follows:

 

 
(1) 
For termination, suspension, or reduction of previously authorized
Medicaid-covered services no later than ten (10) calendar days before the action
is to take effect. Certain exceptions apply under 42 CFR 431.213-214.

 

 
(2) 
For standard service authorization decisions that deny or limit services no more
than fourteen (14) calendar days following the request for service or within
three (3) business days following an expedited service request.

 

 
(3) 
For service authorization decisions not reached within the above required
timeframes, on the date the timeframes expire. Such failures constitute a denial
and are, therefore, an adverse action.

 
 2.5.5
Resolution and Notification

 
 2.5.5.1
The Contractor shall review each grievance and send a notice of resolution to
the enrollee no later than ninety (90) calendar days from the date the
Contractor receives the grievance.

 
 2.5.5.2
The Contractor shall hear each appeal and shall send a notice of resolution to
the enrollee no later than forty- five (45) calendar days from the date the
Contractor receives the appeal.

 
 2.5.5.3
The timeframe for a grievance or appeal may be extended up to fourteen (14)
calendar days if the enrollee asks for an extension, or if the Contractor
documents that additional documentation is needed and the delay is in the
enrollee’s interest. If the timeframe is extended other than at the enrollee’s
request, within five (5) business days of the determination to extend, the
Contractor shall notify the enrollee, in writing, of the reasons for the delay.

 
 2.5.5.4
The Contractor shall provide written notice of disposition of an appeal. In the
case of an expedited appeal, the Contractor shall also provide oral notice by
close of business the day of the disposition.

 
 2.5.5.5
The written notice of resolution will include the results of the grievance or
appeal process and the date it was completed. If an appeal or grievance is not
resolved wholly in favor of an enrollee, the written notice must contain
information on the enrollee’s right to request a Medicaid Fair Hearing and how
to do so; the right to receive benefits while the fair hearing is pending and
how to make that request. The notice must also make the enrollee aware that he
or she may be held liable for the cost of those benefits if the fair hearing
decision upholds the Contractor’s action.

 
2.6
MEDICAID FAIR HEARINGS

 
(1)
The Medicaid Fair Hearing policy and process is detailed in Department of
Children and Families Rule 65-2.042 - 2.069, F.A.C. Fair Hearings may be
requested verbally or in writing. No specific form is required.

 

 
(2) 
An enrollee may seek a Medicaid Fair Hearing without having first exhausted the
Contractor’s grievance and appeal process. An enrollee who chooses to exhaust
the Contractor’s grievance and appeal process may still file for a Medicaid Fair
Hearing within ninety (90) calendar days of receipt of the Contractor’s

 
 
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notice of resolution.

 

 
(3) 
An enrollee who chooses to seek a Medicaid Fair Hearing without pursuing the
Contractor’s grievance and appeal process must do so within ninety (90) calendar
days of receipt of the Contractor’s notice of action.

 

 
(4) 
In accordance with 42 CFR 438.400, the Contractor is required to inform an
individual of his/her right to a Medicaid Fair Hearing when the Contractor takes
action to deny, reduce, suspend, limit or terminate previously authorized
services. This includes services requested by the enrollee and those determined
to be unnecessary by the Contractor’s routine review of the care plans.

 

 
(5) 
Enrollees may request a Medicaid Fair Hearing pursuant to 42 CFR 431.200 -
431.250 if they are denied the choice of home and community-based waiver
services as an alternative to institutional level of care specified for in this
waiver; or if their services are denied, reduced, suspended or terminated.

 

 
(6) 
Parties to the Medicaid Fair Hearing include the Contractor as well as the
enrollee or the enrollees authorized representative.

 

 
(7) 
The notice of Fair Hearing rights must contain the following language: “If you
disagree with this decision, you have a right to file an appeal with our Plan or
to request a State Fair Hearing. You do not need to file an appeal before you
request a Fair Hearing. If you would like to request a Fair Hearing you must do
so no later than ninety (90) days from the date of this letter. If you want to
have services continued, you must request a Fair Hearing within ten (10) days
from the date of this letter. You may have to pay for services that you get if
the decision is to uphold the action the Plan has taken.”

 

 
(8) 
The notice must also contain the address and phone number for information and
assistance filing a Fair Hearing. The address is as follows:
 
Department of Children and Families
Office of Public Assistance Appeal Hearings
1317 Winewood Blvd.
Building 5, Room 203
Tallahassee, Florida 32399-0700
(850) 488-1429

 

 
(9) 
To assist enrollees who wish to file a Medicaid Fair Hearing for financial or
medical eligibility determinations, the Contractor must direct the enrollee to
contact the Department of Children & Families and provide the appropriate
contact information.

 

 
(10)
The Contractor must provide information pertaining to the Medicaid Fair Hearing
process and procedure in the member handbook and it must be shared with members
upon enrollment and annually.

 
2.6.1
Continuation of Benefits
Pursuant to 42 CFR 438.420, the Contractor shall continue an enrollee’s benefits
pending an appeal if the enrollee or the enrollee’s authorized representative
files an appeal with the Contractor within ten (10) business days after the
notice of the adverse action is mailed or within ten (10) business days after
the intended effective date of the action, whichever is later; the appeal
involves the termination, suspension, or reduction of a previously authorized
course of treatment; the services were ordered by an authorized provider; the
original period covered by the original authorization has not expired; and the
enrollee requests and extension of benefits.

 
2.6.1.1
If at the enrollee’s request, the Contractor continues or reinstates benefits
while the appeal or fair hearing is pending, the benefits must be continued
until one of the following occurs:

 

 
(1)  
The enrollee withdraws the appeal or fair hearing request;

 

 
(2)
Ten (10) business days pass after the Contractor sends the enrollee the notice
of resolution of appeal against the enrollee, unless the enrollee has requested
a fair hearing within that ten(10) day timeframe;

 

 
(3) 
The Medicaid Fair Hearing officer issues a hearing decision adverse to the
enrollee; or

 

 
(4) 
The time period or service limits of a previously authorized service have been
met.

 
 
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2.6.1.2 
If the Medicaid Fair Hearing officer reverses the Contractor’s action and
services were not furnished to the enrollee while the appeal was pending, the
Contractor shall authorize or provide the disputed services promptly.

 
2.6.1.3 
If the Medicaid Fair Hearing officer reverses the Contractor’s action and the
enrollee received the disputed services while the appeal was pending, the
Contractor shall pay for those services in accordance with this Contract.

 
2.7 
STAFFING REQUIREMENTS

 
2.7.1  
Staffing Levels

 
(1) 
The Contractor must have sufficient staff to conduct daily business in a manner
that provides service delivery to the enrollees. Case managers and member
services staff must be available during business hours to address enrollee
questions and concerns.

 

 
(2) 
The Contractor must have staff available 24 hours per day, 7 days a week to
handle care related inquiries from enrollees and caregivers.

 
2.7.2
Positions Required

 
Contractors are required to designate the following staff:

 

 
(1) 
A full time administrator identified to administer the day-to-day business
activities of the annual contract;

 

 
(2) 
A licensed physician with demonstrated experience in geriatric medicine to serve
as medical director to oversee and be responsible for the proper provision of
covered services;

 

 
(3) 
A designated individual responsible for the health information system with
either a four-year degree in Health Information Management or equivalent
four-year program;

 

 
(4) 
A designated individual with a four-year degree in Health Information Management
or equivalent program and with a Certified Professional in Health Quality (CPHQ)
designation responsible for the provider’s quality assurance program;

 

 
(5) 
A designated person with a four-year degree in Health Information Management or
equivalent four year program to be responsible for the provider’s utilization
control;

 

 
(6) 
A designated person with a four-year degree in Health Information Management or
an equivalent program to provide necessary, accurate and timely reports to the
Department and AHCA; and

 

 
(7) 
A designated person with a four-year degree in Health Information Management or
an equivalent program to be responsible for processing and resolution of
grievances.

 
                            Note: Case Management Supervisors and Case Managers
must meet the qualifications as provided for in Rule 58N-1 F.A.C.
 
2.7.3 
Staff Training

                  All case manager supervisors and case managers, at a minimum,
must attend the following at least annually as provided for in Rule 58N-1.009
F.A.C.
 

 
(1)
Four (4) hours of in-service training on issues affecting the frail elderly.

 

 
(2) 
Abuse, neglect and exploitation training.

 

 
(3) 
Alzheimer’s disease and related disorders continuing education training from a
qualified individual or entity, focusing on newly developed topics in the field.

 

 
(4) 
Newly hired Case Managers must complete these mandatory training sessions within
ninety (90) calendar days of beginning employment with the Contractor.

 

 
(5) 
Any and all training materials to be used by the Contractor must be approved by
the Department in writing prior to implementation.
a.  New materials must be submitted to the Department at least thirty (30) days
before scheduled

 
 
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implementation date.

 

 
b.  
Alzheimer and Abuse, Neglect & Exploitation Training materials that are in use
by the Contractor must be submitted to the Department annually, at the beginning
of the contract year, for review.

 
2.7.4         Staffing Changes
                  The Contractor shall send to the Contract Manager the resume
of any staff changes in the positions listed in this ATTACHMENT I, sections
2.7.2 (1)-(7).
 
2.8             SERVICE PROVISIONS
 
2.8.1          General Provisions

 
(1)
The Contractor may provide services beyond those required in this contract
providing such services are safe, legal, medically prudent, and provided equally
to any enrollee with similar needs without discrimination. Such extra
contractual services must be paid from program cost savings and may not be
included in encounter data as reported under this ATTACHMENT I, section 1.3.3.5.

 

 
(2) 
The Contractor must bear the underwriting risk of all services covered under
this contract. The Contractor shall establish and maintain a network in
conformance with 42 CFR 438.206(b).

 

 
(3) 
The Contractor must not require any co-payment or cost sharing from the
enrollees except where the Florida Department of Children and Families has
assessed a patient responsibility amount for financial contributions by the
enrollee toward nursing facility and assisted living services.

 

 
(4) 
The Contractor must not allow enrollees to be charged for missed appointments.

 

 
(5) 
The Contractor is responsible for Medicare co-insurance and deductibles for
Contractor covered services. The Contractor shall reimburse providers or
enrollees for Medicare deductibles and co-insurance payments made by the
providers or enrollees, according to Medicaid guidelines or the rate negotiated
with the provider.

 

 
(6) 
All services delivered by the Contractor to enrollees, either directly or
through a subcontract, must be guided by the following service delivery
principles:

 

 
a.  
Services must be individualized as a result of a competent, comprehensive
understanding of an enrollee’s multiple needs.

 

 
b.  
Services must be delivered in a timely fashion in the least restrictive,
cost-effective, and appropriate setting.

 

 
c.  
The Contractor must allow each enrollee to choose his or her service delivery
provider. The Contractor assures that each enrollee will be given free choice of
all qualified providers of each service included in his or her written care
plan.

 
 
d.  
The Contractor shall provide the Department with documentation of compliance
with access requirements no less frequently than the following:

 

 
1)  
At the time it enters into a contract with the Department.

 

 
2)  
At any time there has been a significant change in the Contractor’s operations
that would affect adequate capacity and services, such as Contractor services,
benefits, or geographic service area.

 

 
i.  
Long-term care services must be based upon an enrollee’s care plan and include
goals, objectives, and specific treatment strategies. The Contractor shall not
arbitrarily deny or reduce the amount, duration, and scope of required services
solely because of diagnoses, type of illness, or condition. Any limitations on
amount, duration, and scope may be offset by alternative services to address the
health and social services needs of an enrollee.

 

 
ii.  
The Contractor must coordinate services to address comprehensive needs and
provide continuity of care.

 

 
iii.  
The Contractor must deliver services regardless of geographic location within
the service area, level of functioning, cultural heritage, or degree of illness
of the enrollee.

 
 
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iv.  
The Contractor must deliver services in a culturally competent manner to all
enrollees, including those with limited English proficiency and diverse cultural
and ethnic backgrounds.

 

 
v.  
The Contractor shall ensure that the provider’s administration and service
delivery system makes certain the participation of the enrollee in care planning
and delivery, and as appropriate, allows for the participation of the family,
significant others, and caregivers.

 

 
vi.  
The Contractor shall ensure that all facilities providing services to enrollees
be accessible to persons with disabilities, be smoke-free, and have adequate
space, supplies, good sanitation, and fire and safety procedures.

 

 
vii.  
For Contractor performance that is not in compliance with this contract, the
Department shall require a corrective action plan. If the Contractor fails to
provide a corrective action plan within the time specified by the Contract
Manager, the Department will assess penalties or sanctions against the
Contractor as specified by this contract or governing statutes and federal
regulations.

 

 
viii.  
The Contractor shall give each enrollee written notice of any changes (that the
State defines as ‘significant’) in the information found in this ATTACHMENT I,
sections 2.1.1.7 (3), (6) , (7), (8), and (11); 2.5, and 2.6, at least 30 days
before the intended effective date of change.

        

  (7)
Pursuant to 42 CFR 438.608, the Contractor shall maintain a mandatory compliance
plan that is designed to guard against fraud and abuse.

 

 
a.  
The Contractor shall develop and maintain written policies, procedures and
standards of conduct that states the Contractor’s commitment to comply with all
applicable federal and state standards.

 

 
b.  
The Contractor shall designate a compliance officer and a compliance committee
that is accountable to senior management.

 

 
c.  
The Contractor shall ensure effective training and education for the compliance
officer and the Contractor’s employees.

 

 
d.  
The Contractor shall ensure there are effective lines of communication between
the compliance officer and the Contractor’s employees.

 

 
e.  
The Contractor shall enforce standards through well-published disciplinary
guidelines.

 

 
f.  
The Contractor shall have a provision for internal monitoring and auditing.

 

 
g.  
The Contractor shall have a provision for prompt response to detected offenses,
and for development of corrective action initiatives relating to this contract.

 
2.8.2  
Availability/Accessibility of Services

 
2.8.2.1
Pursuant to 42 CFR 438.12(b), this section may not be construed to require the
Contractor to contract with providers beyond the number necessary to meet the
needs of its enrollees and the contract with the Department, preclude the
Contractor from using different reimbursement amounts for different
practitioners in the same specialty; or preclude the Contractor from
establishing measures that are designed to maintain quality of services and
control costs and is consistent with its responsibilities to the enrollee.

 
2.8.2.2 
The Contractor must make available and accessible sufficient facilities, service
locations, service sites, and personnel to provide the services. The Contractor
must inform the enrollee of any restrictions, if any, on the enrollee’s freedom
of choice among network providers. The Contractor’s network of providers must be
accessible to the enrollees in its service area. Services covered under this
contract must be available to enrollees to the same extent that such services
are available in the project service area to persons with comparable functional
impairment and health conditions that are not served under this contract.

 
2.8.2.3 
In accordance with 42 CFR 438.206(b)(4), if the network is unable to provide
necessary services, covered under the contract to a particular enrollee, the
Contractor must adequately and timely cover these services out

 
 
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                  of the network for the enrollee, for as long as the Contractor
is unable to provide them within the network.
 
2.8.2.4 
In accordance with 42 CFR 438.206(b)(5), out-of-network subcontractors are
required to coordinate with the Contractor with respect to payment to ensure
that costs to the enrollee is no greater than it would be if the services were
furnished within the network.

 
2.8.2.5 
The Contractor must establish appropriate scheduling guidelines for service
delivery. These guidelines must be communicated in writing to providers in the
Contractor’s network. The Contractor must develop a process for monitoring the
scheduling of service delivery and the actual time enrollees must wait to
receive the service. When the service delivery scheduling or waiting times are
excessive, the Contractor must take appropriate action to ensure adequate
service delivery.

 
2.8.3 
Adult Protective Services

 
DOEA and DCF have defined processes for ensuring elderly victims of abuse,
neglect or exploitation in need of home and community-based services are
referred to the aging network, tracked, and served in a timely manner.
Requirements for serving elderly victims of abuse, neglect and exploitation can
be found in s. 430.205 (5)(a), F.S.

 

 
(1) 
DCF assigns a risk-level designation of “low,” “intermediate” or “high” for each
referral. If the individual needs immediate protection from further harm, which
can be accomplished completely or in part with the provision of home and
community-based services, the referral is designated "high” risk. The Contractor
must serve individuals who have been designated “high” risk within 72 hours
after being referred to the AAA or lead agency, as mandated by Florida statute.

 

 
a.  
Reports of abuse, neglect and exploitation begin with the DCF-administered
Florida Abuse Hotline. Victims aged 60 and older in need of home and
community-based services are referred to the appropriate AAA or CCE lead agency.

 

 
b.  
Reports received on individuals determined to be enrolled in the diversion
program will be referred to the appropriate Contractor.

 

 
(2) 
Upon receipt of a referral, the AAA or CCE lead agency will contact the
Contractor via the telephone using the contact information provided. Any changes
to the names or phone numbers of the primary, secondary or 24-hour contacts must
be sent to the Contract Manager. Once the Contractor is contacted and provides
assurance that the enrollee’s needs will be met, the AAA or CCE lead agency will
fax or hand-deliver to the Contractor the DCF referral packet, which contains
the following:

 

 
a.  
Adult Protective Services Referral Form;

 

 
b.  
Adult Safety Assessment of Safety Factors;

 

 
c.  
Capacity to Consent Form (if the referral has the capacity to consent) or
Provision of Voluntary Protective Services Form (required if consent is provided
by the caregiver/guardian); and

 

 
d.  
Court Order, if services were court ordered.

 

 
(3) 
The Contractor is responsible for contacting the AAA or CCE lead agency once the
crisis is resolved. All contact and discussions with AAA or CCE lead agency
staff must be included in the Contractor’s case manager’s notes. In addition, a
copy of the referral packet must be kept in the case file for each referral.

 

 
(4) 
When contacted by the AAA or CCE lead agency in regard to a high-risk referral,
the Contractor shall be required to provide assurance that the crisis will be
addressed. If the CCE lead agency or AAA attempts to contact the Contractor
during business hours and the Contractor cannot be contacted or cannot provide
assurance that the crisis will be addressed, the CCE lead agency is required to
provide the crisis resolving services until such assurance is received. If
contacted by the AAA or lead agency after business hours (including evenings,
weekends and holidays), the Contractor must provide assurance to the AAA or lead
agency within 24 hours that the crisis will be addressed. The cost of the crisis
resolving services provided by the CCE lead agency while awaiting assurance
outside of the allowable delay will be reimbursed by the Contractor.

 
 
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2.8.4  
Network Expansion

 
The Contractor may expand into any county in Florida following successful review
by the Department of the following information submitted to the Contract Manager
for each requested service area: letter of expansion request; copies of the
first page and signature page of the executed subcontracts; applicable active
licenses (the name of the subcontractor should be the same as the license);
completed provider network template (electronic and hard copy); and for
Contractors licensed as a HMO, a copy of the health care provider certificate
for the requested service area; a certification from each subcontractor (EXHIBIT
G); geo access map or other Department approved mapping software for all
facilities and subcontractors providing services outside of an enrollee’s home
services. The Contractor must credential all network subcontractors prior to
submitting the expansion request to the Department. Networks for existing
counties of operation must meet contract qualifications prior to expansion to
additional counties.

 
2.8.4.1 
The requirement for submission of at least two providers for each contractually
required service cannot be waived unless certain conditions are met for
underserved areas. For underserved areas, alternate providers from a neighboring
county may be accepted under certain circumstances, if approved by the
Department. In counties where less than two Diversion contractors are currently
approved, and/or other underserved areas where there are barriers to the
establishment of a network of at least two providers for each required service,
the Contractor shall be required to submit additional information to the
Department on the Provider Network and Staffing Report.

 
2.8.4.2 
If there are two or more service providers in the area and less than two
providers agree to provide the contractually required service, the applicant
must maintain and provide to the Department all correspondence and documentation
related to the good faith contracting efforts, including the rate offered, for
those providers who decline to participate.

 
2.8.5 
Access to Services

 
Unless otherwise specified in this document, when an enrollee uses non-emergency
services available under the project from a non-subcontracted provider, the
Contractor is not liable for the cost of such utilization unless the Contractor
referred the enrollee to the non-subcontracted provider or authorized such
out-of-network utilization. The Contractor must provide timely approval or
denial of authorization of out-of-network use through the assignment of a prior
authorization number that refers to and documents the approval. The Contractor
shall not require paper authorization as a condition of an enrollee receiving
treatment if the Contractor has an automated authorization system. Written
follow-up documentation of the approval must be provided to the out-of-network
provider within one business day from the request for approval. The enrollee is
liable for the cost of such unauthorized use of contract-covered services from
non-subcontracted providers.

 
2.8.5.1 
In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the Contractor must
also cover post-stabilization services without authorization, regardless of
whether the enrollee obtains the service within or outside the Contractor’s
network, for the following situations:

 

 
(1) 
Post-stabilization care services that were pre-approved by the Contractor, or
were not pre-approved by the Contractor because the Contractor did not respond
to the treating provider’s request for pre-approval within one (1) hour after
being requested to approve such care, or could not be contacted for
pre­approval.

 

 
(2) 
Post-stabilization services are services subsequent to an emergency that a
treating physician views as medically necessary after an emergency medical
condition has been stabilized. These are not emergency services, but are
non-emergency services that the Contractor could choose not to cover
out-of-contractor network except in the circumstances described above.

 
2.9             CONTRACTOR’S FINANCIAL OBLIGATIONS
 
2.9.1          Insolvency Protection

 
(1) 
In accordance with s. 430.705(2)(b)4 F.S., the Contractor must establish and
maintain a restricted insolvency protection account in a FDIC insured bank
located in the state of Florida with an opening balance of at least $100,000.00.
The Contractor shall make monthly deposits into the account that equal at least
5 percent of premiums received under the project from the initial contract with
the Department,

 
 
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to current date, until the balance equals 2 percent of the total contract
amount. The Contractor shall establish the account with such terms as to ensure
that funds may only be withdrawn with the signature approval of designated
Department representatives. A Multiple Signature Verification Agreement form can
be found in ATTACHMENT IX.

 

 
(2) 
In the event that a determination is made by the Department that the Contractor
is insolvent as defined in this ATTACHMENT I, section 1.1, the Department may
draw upon the account solely with the authorized signatures of representatives
of the Department and funds may be disbursed as provided in the Multiple
Signature Verification Agreement in order to meet financial obligations incurred
by the Contractor under this contract.

 

 
(3) 
The Contractor must cover continuation of services to enrollees for the duration
of the period for which payment has been made, as well as for inpatient
admissions up until discharge.

 

 
(4) 
If this contract is subsequently terminated, expired, or not renewed, the
account balance shall be released by the Department to the Contractor upon
receipt of proof of satisfaction of all outstanding obligations incurred under
this contract.

 

 
(5) 
If this contract is terminated or not renewed and the Contractor is unable to
pay all of its outstanding debts to providers; the Department, Agency, and the
Contractor agree to the court appointment of an impartial receiver for the
purpose of administering and distributing the funds contained in the insolvency
protection account. A receiver must give outstanding debts owed to the Agency
priority over other claims.

 

 
(6) 
If the Contractor has a change in authorized personnel listed on the Multiple
Signature Verification Agreement, the Contractor shall resubmit a revised
Attachment IX to the Department within thirty (30) days of the change in
personnel. If there is no change to the authorized signatory personnel, the
Contractor shall submit an attestation or a new Attachment IX upon renewal of
the contract.

 
2.9.2         Surplus Requirements
 
Pursuant to s. 430.705(b)(5) F.S., all contractors shall maintain a surplus of
at least $1,500,000.00 as  determined by the Department. Each applicant (the
Contractor) and each provider shall furnish to the Department initial and annual
unqualified audited financial statements prepared by a certified public
accountant that expressly confirm that the applicant or provider satisfies this
surplus requirement.

 
2.9.3          Insurance

 
(1)  
The Contractor must obtain and maintain, at all times, adequate insurance
coverage including general liability insurance, professional liability and
malpractice insurance, fire and property insurance, and director’s omission and
error insurance. All insurance coverage must comply with the provisions set
forth in Rule 69O-191.069, F.A.C., except that the reporting, administrative,
and approval requirements will be submitted to the Department in addition to the
Department of Financial Services. All insurance policies must be written by
insurers licensed to do business in the State of Florida and in good standing
with the Department of Financial Services, unless coverage is not procurable
from authorized insurers, in which case the provisions of the Surplus Lines Law
(s. 626.913 - 626.937, F.S.) shall apply. The Contractor must submit all policy
declaration pages annually or whenever there is a change in insurer or policy
provisions to the Contract Manager. Each certificate of insurance must provide
for notification to the Department in the event of termination of the policy.

 

 
(2)
The Contractor must secure and maintain worker’s compensation insurance during
the life of the contract for all of its employees and provide verification of
coverage to the Department annually, in compliance with Chapter 440, F.S. The
Contractor and all its subcontractors must comply with Workers Compensation
Chapter 440, F.S.

 
2.9.4          Interest and Savings

 
(1) 
Interest generated through investments made by the Contractor of funds provided
to the Contractor pursuant to this contract will be the property of the
Contractor and will be used at the Contractor’s discretion.

 
(2) 
The Contractor shall retain any savings realized under this contract after all
bills, charges, and fines are

 
 
 
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paid.

 
2.9.5          Third Party Resources
                   Pursuant to s. 409.910, F.S, the Contractor shall be
responsible for making every reasonable effort to determine the legal liability
of third parties to pay for services rendered to enrollees under this contract.
The Contractor has the same rights to recovery of the full value of services as
the Agency.
 
2.10   FINANCIAL REPORTING
 
2.10.1       Enrollee Payment Liability Protection
                  The Contractor shall not hold enrollees liable for the
following in accordance with s. §1932 (b)(6), (42 USC 1396u-2) Social Security
Act, as enacted by Section 4704 of the Balanced Budget Act of 1997:

 
(1) 
For debts of the Contractor, in the event of the Contractor’s insolvency.

 

 
(2) 
For payment of covered services provided by the Contractor if the Contractor has
not received payment from the Agency for the services, or if the provider under
contract or other arrangement with the Contractor fails to receive payment from
the Agency or the Contractor.

 

 
(3) 
For payments to the providers that furnished covered services under a contract
or other arrangement with the Contractor that are in excess of the amount that
normally would be paid by the member if the service had been received directly
from the Contractor.

 
2.10.2        Audited Financial Statements

 
(1)  
The Contractor must submit annual unqualified audited financial statements
prepared by a certified public accountant that confirm that the Contractor
satisfies the surplus requirements as per s. 430.705(b)(5) and summarizes the
Contractor’s financial activities for the contract period. In addition, the
Contractor must annually send a statement, signed by the president of the
organization, attesting that no assets of the Contractor have been pledged to
secure personal loans. The Contractor shall submit the financial statements
submitted to the Department no later than four calendar months after the end of
the Contractor’s fiscal year and must be prepared by an independent certified
public accountant on the accrual basis of accounting in accordance with
generally accepted accounting principles as established by the American
Institute of Certified Public Accountants (AICPA). Audits performed to meet the
requirements of OMB Circular A-133 satisfy this requirement. For government
owned and operated facilities operating on a cash method of accounting, data
based on such a method of accounting will be acceptable. The certified public
accountant preparing the financial statements must sign statements as the
preparer and in a separate letter state the scope of his work and opinion in
conformity with generally accepted auditing standards and AICPA statements on
auditing standards. The annual audited report is for the Contractor unless prior
approval is obtained from the Department for some other alternative.

 

 
(2) 
If the period covered by this contract is less than six months, the Contractor
may request of the Contract Manager, in writing, an exemption from the
requirements of this section for this contract period. The Contract Manager will
grant the exception provided that all other performance measures are
satisfactory and the Contractor provides a complete set of financial statements
accompanied by an attestation of accuracy signed by a corporate officer.

 
2.10.3       Unaudited Quarterly Financial Statements
 
The Contractor will be supplied with a template for financial reporting that
shall be used with Excel spreadsheet applications. The Financial Reporting
Package is found in EXHIBIT K. The Contractor must complete the spreadsheets and
electronically transmit them or mail them on a compact disk to the Department.
The unaudited quarterly financial statements must meet the following conditions:

 

 
(1) 
These statements must be filed on a compact disc or electronically transmitted
using the supplied spreadsheet template and received by the Department within 60
days after the end of each quarter in a Contractor’s fiscal year. Quarterly
financial reports are to be specific to the operation of the Contractor rather
than to a parent or umbrella organization;

 
(2) 
The reporting date and the name of the provider must be plainly written or
stamped on the certification

 
 
 
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page, along with the Chief Executive Officer’s (CEO) signature, and

 

 
(3)  
The Contractor shall file one copy of the financial template with the quarterly
submission.

 
2.11          CONTRACT MANAGEMENT
                  The Department will oversee contract management
responsibilities. The Department has the right to approve, disapprove, or
require modification of procedures developed by the Contractor.
 
2.11.1        Independent Medical Review
 
In accordance with 42 CFR 438.204(d), the Agency will provide for an independent
review of all Medicaid services provided or arranged by the Contractor. The
Contractor shall provide information necessary for the review based upon the
requirements of the Agency or the Agency’s independent peer review contractor.
The information will include quality outcomes concerning timeliness of, and
access to, services covered under the contract. The review will be performed at
least annually by an entity outside state government. If the medical audit
indicates that quality of care is unacceptable pursuant to contractual
requirements, the Agency and the Department may restrict the Contractor’s
enrollment activities pending attainment of acceptable quality of care.

 
2.12          CONTRACTOR RESPONSIBILITIES
 
2.12.1       Contractor Qualifications
 
The Contractor must have the following qualifications:

 

 
(1)
Have a certificate of authority from the Florida Department of Financial
Services to operate as a HMO pursuant to Chapter 641 Part I, F.S., and have a
health care provider certificate from the Agency pursuant to s. 641.49, F.S.,
for those counties in the service area in which the applicant will apply to
provide services or; have a license issued pursuant to Chapter 400 or Chapter
429, F.S., and meet the provisions of an “other qualified provider” set forth in
s. 430.703(7), F.S.;

 

 
(2) 
Have prior experience in providing home and community-based long-term care
services;

 

 
(3) 
Have the capacity to integrate the delivery of acute and long-term care services
to enrollees;

 

 
(4) 
Enroll as a Medicaid provider; and

 

 
(5) 
Meet all other requirements in the remaining provisions of this contract and its
attachments.

 
2.12.2       Contractor Tasks

 
(1) 
Pursuant to 42 CFR 447.45(d)(2)(3)(5)(6) and 42 CFR 447.46, the Contractor shall
ensure that all subcontracts provide for the timely processing of claims for
payments. If third party liability exists, payment of claims must be determined
in accordance with this ATTACHMENT I, section 2.9.5, Third Party Resources.

 

 
(2) 
The Contractor shall ensure that all subcontracts specify whether the Contractor
shall assume full responsibility for third party collections in accordance with
this ATTACHMENT I, section 2.9.5, Third Party Resources.

 

 
(3) 
The Contractor shall provide for monitoring of services rendered to enrollees by
the subcontractor.

 

 
(4) 
The Contractor shall include a provision in its subcontract with assisted living
facilities that requires a copy of the current care plan to be maintained in the
enrollee’s record for inspection by state and federal agencies.

 

 
(5) 
Pursuant to 42 CFR 438.12(a)(1), if a Contractor declines to include individual
or groups of providers in its network, it must give the affected providers
written notice of the reason for its decision.

 

 
(6) 
Physician incentive plans must comply with 42 CFR 417.479. The Contractor shall
make no specific payment directly or indirectly under a physician incentive plan
to a physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an individual enrollee. Incentive plans must not
contain provisions that provide incentives, monetary or otherwise, for the
withholding of medically necessary care. The Contractor must disclose
information on provider incentive plans listed in 42 CFR 417.479(h)(1) and 42
CFR 417.479(i) at the times indicated in 42 CFR 417.479(d)-(g). The

 
 
 
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Contractor shall submit all such arrangements in writing to the Department for
approval prior to use. If any other type of withhold arrangement currently
exists, such arrangement must be omitted from all subcontracts.

 

 
(7)
If the Contractor delegates administrative and management functions to a third
party administrator (TPA), the TPA must be licensed to do business as a TPA in
Florida. Such delegation to a TPA does not relieve the Contractor of
responsibility for the administration and management required under this
contract.

 

 
(8) 
The relationship between management personnel and the governing body must be set
forth in writing, including each person’s authority, responsibilities, and
function.

 

 
(9) 
The Contractor’s governing body shall set policy and has overall responsibility
for the organization. Pursuant to 42 CFR 438.210(b)(2), the Contractor is
responsible for ensuring consistent application of review criteria for
authorization decisions and consulting with the requesting subcontractor when
appropriate.

 

 
(10)
The Contractor shall comply with applicable Department or Agency rules and any
Agency handbooks relating to the provision of services set forth in this
ATTACHMENT I, Section II, Manner of Service Provisions, except where the
provisions of the contract alter the requirements set forth in the handbooks
where applicable. Pursuant to 42 CFR 438.210, the Contractor must furnish
services up to the limits specified by the Medicaid program. The Contractor may
exceed these limits. Service limitations must not be more restrictive than the
Medicaid fee-for-service program.

 

 
(11) 
Pursuant to 42 CFR 438.236(b), the Contractor shall adopt practice guidelines
that meet the following requirements:

 

 
a.  
Are based on valid and reliable clinical evidence or a consensus of healthcare
professionals in the particular field.

 

 
b.  
Consider the needs of the enrollees.

 

 
c.  
Are adopted in consultation with contracting heal care professionals.

 

 
d.  
Are reviewed and updated periodically as appropriate.

 

 
(12) 
The Contractor shall disseminate the guidelines to all affected providers, and
upon request, to enrollees and potential enrollees. The decisions for
utilization management, enrollee education, coverage of services, and other
areas to which the guidelines apply must be consistent with the guidelines.

 

 
(13) 
The Contractor shall maintain accreditation pursuant to Chapter 641.512, F.S.,
if applicable. Other Qualified Providers shall be accredited as appropriate for
their programs and the accreditation organization shall be approved by the
Department in advance.

 

 
(14) 
Pursuant to s. 430.705(2)(b)(3), F.S., the Contractor must demonstrate, through
performance or other documented means, the capacity for prompt payment of claims
as specified under s. 641.3155, F.S.

 

 
(15) 
In addition to section 33 of the Standard Contract, the Contractor must submit
an emergency management plan to the Department specifying what actions the
Contractor and subcontractors shall take to ensure the ongoing provision of all
services in a natural disaster or man-made emergency. This plan must also
address service delivery both pre and post disaster or emergency. The Emergency
Management Plan is due either electronically or hard copy to the Department by
April 30 of each contract year.

 

 
a.  
For any management functions delegated by the Contractor to a TPA, the
Contractor shall submit a copy of the TPA’s emergency management plan at the
same time.

 

 
(16) 
The Contractor shall conduct an enrollee satisfaction survey between January 1st
and April 30th of each year. The sampling for the survey must be a statistically
significant sample for members having received long term care services during
the period reflected in the report.

 

 
a.  
The Contractor shall send a copy of the survey to the Department for approval by
November 1st of each year. The survey shall include, but is not limited to, the
questions listed in EXHIBIT F.

 

 
b.  
The Contractor shall report the survey results to the Department by May 15th of
each year. The

 
 
 
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Contractor shall submit the enrollee satisfaction survey results to the
Department, and the Contractor shall include an attestation statement signed by
an authorized representative that addresses the validity, reliability, and
unbiasedness of the survey. The attestation must describe how the validity and
reliability were statistically or otherwise established. The attestation of
unbiasedness must include the measures the provider took to ensure the
independence of the survey and the trust of the respondent.

 

 
(17)  
The Contractor shall provide encounter data that is recipient-specific service
utilization data in the electronic format as specified in EXHIBIT C. The service
utilization data reported represents the comprehensive array of services that
might be necessary to maintain a member at home while avoiding nursing home
placement, including acute and long-term care services.

 

 
a.  
The Contractors shall use the data validation software provided by the
Department to generate data validation reports for long-term care and acute care
services. All “red flag” items on the data validation reports must be corrected
or certified by the Contractor. The Contractor shall submit one password
protected zipped file that includes the long-term and acute care services data
files, validation report files, and if applicable, certification files. The
Contractor shall adhere to the file- naming format in EXHIBIT C.

 

 
b.  
The Contractor shall begin preparing its information systems for the Medicaid
Encounter Data System (MEDS). The information the Contractor is required to
report and submit will be defined in the MEDS Companion Guide and MEDS
Operational Manual found on the following Web site:
http://ahca.myflorida.com/Medicaid/meds/information.shtml. The Department will
provide the beginning submission date for the Medicaid Encounter Data
submission. The Contractor must be ready to submit encounter data within thirty
days from the beginning submission date in the format outlined in the MEDS
Companion Guide and MEDS Operations Manual. When the Medicaid Encounter Data
System is operational, the Contractor shall submit encounter data in the
standard HIPAA transaction format, namely the ANSI X 12N 837 Transaction format.

 

 
(18)  
The Contractor shall remain in good standing with Medicaid, Medicare, AHCA,
Department of Management Services, Office of Insurance Regulation in Florida,
and regulatory authorities in any other state. If the Contractor is not in good
standing, then the Contractor may be subject to sanctions as listed in this
ATTACHMENT I,section 2.12.13. To be in good standing, the Contractor must not
have failed accreditation or committed any material statutory violation, and
must meet Medicaid and if applicable, Medicare contract requirements. If the
Contractor is notified of sanctions and/or enrollment restrictions by the Agency
for Health Care Administration or Centers for Medicare and Medicaid Services,
the Contractor must notify the Department within 72 hours of the receipt of the
notice. The Department may suspend new enrollments associated with this contract
until such time as the Department has reviewed the sanction and/or suspension
and determined that no violation of this contract has occurred.

 
2.12.3        Reporting
 
The Contractor  is responsible for complying with all the reporting and
monitoring requirements in accordance with the contract. The Department will
provide the Contractor with the appropriate reporting formats, instructions,
submission timetables, and technical assistance. A list of required reports is
found in APPENDIX 3. The Department reserves the right to modify the reporting
and monitoring requirements to which the Contractor must adhere. Failure of the
Contractor to submit the required reports accurately and within the timeframes
specified may result in sanction.

 

 
(1)
Disenrollment Summary Report
The Contractor shall provide the Disenrollment Summary Report as a Microsoft
Excel spreadsheet in the format specified in EXHIBIT B of this contract. The
Contractor shall number disenrollments and list information in alphabetized
ascending order by enrollee last name, then by enrollee first name. Information
will pertain only to disenrollments that are effective for the month being
reported.

 
(2)
Grievance/Appeals/Complaints Report
The Contractor shall provide the Grievance/Appeals/Complaints Report as a
Microsoft Excel spreadsheet in the format specified in EXHIBIT D of this
contract. The report shall be submitted by the Contractor to report all
grievances, appeals or updates to previously reported grievances, appeals as
well as new

 
 
 
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grievances and appeals during the reporting quarter.

 

 
(3) 
Provider Network and Staffing Report

 
The Contractor shall provide the Provider Network and Staffing Report a
Microsoft Excel spreadsheet in the format specified in EXHIBIT E of this
contract. The Contractor must indicate terminated providers by a strikethrough
and a termination date in the comments column and indicate all new provider by
blue cells. The Contractor must submit the first page and signature page of the
subcontract and the confirmation letter (Exhibit G) for each new provider added
to the network. In addition, all Contractors must conduct and report a 100%
review of new and existing subcontractors to ensure that they are appropriately
qualified, per Appendix 4.

 

 
(4) 
Enrollee Roster Report

 
The Contractor shall provide a monthly Enrollee Roster Report to the Department
by the 8th day of each month detailing the enrollees for that month. Said report
shall conform to the template provided in APPENDIX 5.

 

 
(5) 
Subcontractor Training Attestation Report

  The Contractor shall provide the Subcontractor Training Attestation Report as
a Microsoft Excel spreadsheet in the format specified in EXHIBIT J of this
contract. The Contractor shall submit said report annually to the Department
indicating that the Contractor has verified that all its subcontractors have
staff that is mandated as reporters of abuse, neglect, and exploitation, and the
Contractor attests that its subcontractor’s staff has received the appropriate
training. The Contractor shall submit said report to the Department no later
than July 5 th.

 
2.12.4        Provider Relations and Subcontracts

 
(1) 
All subcontracts executed by the Contractor must be appropriate to the services
or activities delegated under the contract and fulfill all state and federal
requirements as specifically provided in 42 CFR 438. The Contractor is
responsible for evaluating the prospective subcontractor’s ability to perform
these activities. All subcontract templates must be approved in writing, by the
Department in advance of implementation and execution. The Contractor shall
ensure that all providers are eligible for participation in the Medicaid
program; however, the subcontractor is not required to participate in the
Medicaid program as a provider. In addition, if a provider was suspended or
terminated from the Florida Medicaid program by contract or sanction, a
termination other than for purposes of inactivity or withdraw, that provider is
not considered an eligible Medicaid provider. Subcontracts are required with all
major providers of services and shall not prohibit service providers from
contracting with other Long-Term Care Diversion Contractors.

 

 
(2) 
The Department may waive the use of the model subcontract and permit the
Contractor to enter into a letter of agreement with certain facilities, licensed
under Chapter 400 and Chapter 429, F.S. and eligible for participation in the
Medicaid program, when it is determined by the Department to be in the best
interest of the enrollee(s) to do so. The letter of agreement must contain
timeframe provisions for the facility. This exception does not apply for initial
network implementation.

 

 
(3) 
All subcontractors must comply with the regulations of section 19.2 of the
Standard Contract. The Contractor shall ensure that all its subcontractors
verify that their staff mandated to report abuse, neglect and exploitation have
received appropriate training in reporting abuse, neglect and exploitation.

 

 
(4) 
If the Contractor wishes to terminate a subcontract with an assisted living
facility or a Nursing Facility in which any of its project enrollees are
currently residing, the Contractor shall provide a written notice to the
Department at least ten (10) calendar days prior to notifying the subcontractor
of its intent to terminate. This requirement is waived if the facility’s license
has been revoked or the Department, in consultation with the Agency, waives the
notice period.

 

 
(5) 
The Contractor shall place procedures in its subcontracts from approval of new
providers up to termination of contract. The Contractor shall include imposition
of sanctions in its subcontracts. The Contractor’s selection policies and
procedures cannot discriminate against particular providers that serve high-risk
populations or specialize in conditions that require costly treatment.

 

 
(6) 
In addition, the Contractor must monitor the subcontractor’s performance on an
ongoing basis and subject the subcontractor to formal reviews according to a
periodic schedule established by the State,

 
 
 
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consistent with industry standards or State MCO laws and regulations. The
Contractor shall identify deficiencies or areas for improvement, the Contractor
and the subcontractor must take corrective action where deficiencies or areas
for improvement are found.

 
2.12.4.1    Credentialing

 
(1) 
Pursuant to 42 CFR 438.214(a), (b)(1), and (b)(2), the Contractor must have
written policies and procedures and a description of its policies and procedures
for selection and retention of providers following the State’s policy for
credentialing and re-credentialing. Contractors may not discriminate for the
participation, reimbursement, or indemnification of any provider who is acting
within the scope of his or her license or certification under applicable state
law, solely on the basis of that license. The Contractor must not contract with
and must terminate providers who do not meet credentialing standards.

 

 
(2)  
The Contractor’s credentialing and re-credentialing policies and procedures
shall include the following:

 

 
a.  
Formal delegations and approvals of the credentialing process;

 

 
b.  
 A designated credentialing committee;

 

 
c.  
Identification of providers who fall under its scope of authority;

 

 
d.  
A process which provides for verification of the following core credential
information and the subcontractor’s work history;

 

 
e.  
The subcontractor’s current valid license;

 

 
f.  
The subcontractor’s current valid local occupational license or authority to do
business, where applicable;

 

 
g.  
Medicaid provider number if applicable;

 

 
h.  
Medicaid Encounter Data System (MEDS) number if applicable; and

 

 
i.  
Verification of the following:

 

 
i.  
Evidence of the subcontractor’s professional liability claims history.

 

 
ii.  
Determination of whether the subcontractor, employees or volunteers of the
subcontractor meet the definition of “direct service provider” as defined in
section 8.1 of the Standard Contract and completion of a Level 2 criminal
history background screening on each direct service provider to determine
whether any have disqualifying offenses as provided for in s. 430.0402 F.S. and
s. 435.04, F.S. Any subcontractor, employee or volunteer of the subcontractor
meeting the definition of “direct service provider” who has a disqualifying
offense is prohibited from providing services to the elderly as set forth in s.
430.0402, F.S.

 

 
1.  
The Contractor must maintain a signed affidavit from each subcontractor
attesting to their compliance with this requirement; or with the requirements of
their licensing agency if it requires Level 2 screening of direct services
providers.

 

 
2.  
The Contractor must include compliance with this requirement in its subcontracts
and verify compliance as part of its subcontractor monitoring activity.

 

 
iii.  
Any sanctions imposed or denied enrollment by Medicare or Medicaid in any state.

 

 
iv.  
Any sanctions imposed or denied enrollment by Medicare or Medicaid in any state.

 

 
v.  
Any disciplinary action taken against any business or professional license held
in this or any other state or surrendered a license in this or any state.

 

 
vi.  
Any history of loss or limitation of privileges or disciplinary action.

    

 
vii.  
Verification that the Contractor obtained information about the subcontractor on
the HHS Office of the Inspector General’s exclusion website
(http://exclusions.oig.hhs.gov).

 

 
viii.  
The subcontractor shall include an attestation as to the
correctness/completeness of the subcontractor’s application.

 

 
ix.  
Verification of the Contractors reviews of AHCA’s Florida Health Finder website
at

 
 
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http://www.floridahealthfinder.gov/facilitylocator/facloc.aspx.

 
2.12.4.2
Re-Credentialing

 
The process for periodic re-credentialing will include the following:

 

 
(1)  
The Contractor shall complete the procedure for re-credentialing at least every
three (3) years.

 

 
(2) 
The Contractor shall verify the current licensure of the subcontractor on an
annual basis or as required by licensure.

 

 
(3) 
The Contractor shall verify Medicare and Medicaid exclusions on the
subcontractor on the HHS Office of the Inspector General’s website on an annual
basis.

 

 
(4) 
The Contractor shall develop and implement a mechanism for identifying quality
deficiencies that result in the Contractor’s restriction, suspension,
termination, or sanctioning of a subcontractor, including reviewing AHCA’s
Florida Health Finder website.

 
2.12.4.3
Delegated Credentialing

 
(1) 
For Contractors who delegate credentialing, the credentialing subcontractor must
meet the requirements of this ATTACHMENT I, sections 2.12.4.1 and 2.12.4.2.

 

 
(2)  
The Contractors Credentialing Committee must review and approve or disapprove
providers submitted by the delegated credentialing provider.

 

 
(3) 
The Contractor shall monitor the delegated credentialing provider at least
annually to ensure compliance with this ATTACHMENT I, sections 2.12.4.1 and
2.12.4.2.

 
2.12.4.4
Identification of Conditions and Method of Payment

 
All subcontracts must meet the following requirements:

 

 
(1)  
Provide for prompt submission of information needed to make payment.

 

 
(2) 
Make full disclosure of the method and amount of compensation or other
consideration to be received from the Contractor. The provider must not charge
for any service provided to the recipient at a rate in excess of the rates
established by the contract in accordance with Section 1128B(d)(1), Social
Security Act (enacted by Section 4704 of the Balanced Budget Act of 1997). The
provider may not bill the recipient any amount greater than would be owed if the
entity provided the services directly.

 

 
(3) 
Require an adequate record system be maintained for recording services, charges,
dates and all other commonly accepted information elements for services rendered
to recipients.

 
2.12.5
Provisions for Monitoring and Inspections

 
All subcontracts must meet the following requirements:

 

 
(1) 
Provide for the state and federal government to evaluate through inspection or
other means the quality, appropriateness and timeliness of services performed.

 

 
(2)  
Comply with the provisions of section 10 and its subparagraphs as set forth in
the Standard Contract.

 

 
(3) 
Provide for monitoring and oversight by the Contractor of the subcontractor to
provide assurance that all licensed subcontractors are credentialed in
accordance with this ATTACHMENT I, section 2.12.4, Credentialing and
Re-credentialing Policies and Procedures.

 

 
(4)  
Comply with the provisions set forth in APPENDIX 1.

 
2.12.6
Subcontractor Termination

                  The Contractor must give written notification to all enrollees
served by the terminated subcontractor within 15 days after issuance of a
termination notice to the subcontractor.
 
2.12.7
Ownership and Management Disclosure

 
(1)  
Federal and state laws require full disclosure of ownership, management and
control of managed care organizations, including other qualified providers.
Disclosure must be made on forms prescribed by the Department for the areas of
ownership and control interest business transactions (42 CFR 455.104),

 
 
 
 
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public entity crimes (s. 287.133(3)(a), F.S.), and debarment and suspension (52
Fed. Reg., pages 20360­20369, and Chapter 4707 of the Balanced Budget Act of
1997). The forms are available through the Department and are to be submitted to
the Department on an annual basis. The Contractor must disclose any changes in
management as soon as they occur. In addition, the Contractor must submit to the
Department full disclosure of ownership and control at least 60 calendar days
before any change in the Contractor's ownership or control occurs.

 

 
(2) 
In accordance with s. 409.912(32), F.S., the Contractor must conduct a
background check with the Florida Department of Law Enforcement on all persons
with five (5) percent or more ownership interest in the Contractor, or who have
executive management responsibility for the managed care plan, or have the
ability to exercise effective control of the Contractor at least once each
contract year.

 

 
(3) 
Contractors must submit complete sets of fingerprints of its principals as
defined in s. 409.907(8)(a), F.S., to the Agency for Health Care Administration
for the purpose of conducting a criminal history record check as provided in s.
409.907(8).

 

 
(4) 
The Contractor must submit to the Department, within five (5) working days, any
information on any officer, director, agent, managing employee, or owner of
stock or beneficial interest in excess of five (5) percent of the Contractor who
has been found guilty of, regardless of adjudication, or who entered a plea of
nolo contendere or guilty to, any of the offenses listed in s. 435.03, F.S.

 
2.12.8       Damages from Federal Disallowances

 
In addition to any remedies available through the contract, in law or equity,
the Contractor must reimburse the Agency for any federal disallowances or
sanctions imposed on the Department or Agency as a result of the Contractor's
failure to abide by the terms of the contract.

 
2.12.9       Legal Action Notification

 
The Contractor must give the Department written notification no later than 30
calendar days after service of process of any action or suit filed or of any
claim made against the Contractor by any subcontractor, vendor, or other party
which results in litigation related to this contract for disputes or damages. In
addition, the Contractor must immediately advise the Department of the
insolvency of a subcontractor or of the filing of a petition in bankruptcy by a
subcontractor.

 
2.12.10    Conflict
                  Pending final determination of any dispute, the Contractor
must proceed diligently with the performance of the contract and in accordance
with the Department’s direction.
 
2.12.11    Prospective Enrollee Materials

 
(1) 
Marketing Materials means materials that are produced in any medium, by or on
behalf of an MCO that can be reasonably interpreted as intended to market to
potential enrollees.

 

 
(2) 
The Contractor may not market to prospective enrollees face-to-face.

 

 
(3) 
The Contractor may use mass marketing strategies, approved by the Department, to
communicate information regarding the project to prospective enrollees.

 

 
(4) 
All materials including, but not limited to, print and media for potential and
current enrollees shall be approved by the Department annually.

 
2.12.12    Prohibited Activities

 
(1) 
In accordance with 42 CFR 438.104(b)(1)(iv), the Contractor and its
subcontractors shall not seek to influence enrollment in conjunction with the
sale or offering of any private insurance.

 

 
(2)  
In accordance with 42 CFR 438.104(b)(1)(v), the Contractor and its
subcontractors shall not, directly or indirectly, engage in door-to-door,
telephone, or other cold-call marketing activities.

 

 
(3)
In accordance with 42 CFR 438.104(b)(2)(i), the Contractor and its
subcontractors shall not make any assertion or statement (whether written or
oral) that the beneficiary must enroll with the Contractor in order to obtain
benefits (Medicaid State Plan benefits) or in order to not lose benefits
(Medicaid State

 
 
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Plan benefits).

 

 
(4) 
In accordance with s. 409.912(21)(b), F.S., and 42 CFR 438. 104(b)(2)(ii), the
Contractor and its subcontractors shall not make any inaccurate false or
misleading claims that the Contractor is recommended or endorsed by any federal,
state or county government, the Agency, CMS, Department, or any other
organization which has not certified its endorsement in writing to the
Contractor.

 
2.12.13    Sanctions

 
(1) 
In accordance with s. 1932(a) of the Balanced Budget Act of 1997, as enacted by
s. 4707, and s. 409.912(22), F.S., the following sanctions may be imposed
against the Contractor if it is determined that the Contractor has violated any
provision of this contract, or the applicable statutes or rules governing
Medicaid HMOs:

 

 
a.  
Suspension of the Contractor’s enrollment.

 

 
b.  
Suspension or revocation of payments to the plan for Medicaid recipients
enrolled during the sanction period. If the Contractor has violated the
contract, the Contractor may be ordered to reimburse for out- of-pocket
medically necessary expenses incurred, or the Contractor may be ordered to pay
non-network plan providers who provide medically necessary services.

 

 
c.  
Imposition of a fine for violation of the contract with the Department and
Agency, pursuant to s. 409.912(22), F.S.

 

 
d.  
Termination pursuant to section 49.4 of the Standard Contract. If the Contractor
fails to carry out substantive terms of its contract or fails to meet applicable
requirements in sections 1932, 1903(m) and 1905(t) of the Social Security Act,
the Department may terminate the contract. After the Department, in consultation
with the Agency, notifies the Contractor that it intends to terminate the
contract, the Department, in consultation with the Agency, may give the
Contractor’s enrollees written notice of the State's intent to terminate the
contract and allow the enrollees to disenroll immediately without cause.

 

 
(2) 
Unless the duration of a sanction is specified, a sanction will remain in effect
until the Department is satisfied that the basis for imposing the sanction has
been corrected and is not likely to recur.

 

 
(3) 
The Department may impose intermediate sanctions in accordance with 42 CFR
438.702, and s. 409.912, F.S., including the following:

 

 
a. 
Civil monetary penalties in the amounts specified in s. 409.912(22), F.S.

 

 
b.
Appointment of temporary management for the Contractor. Rules for temporary
management pursuant to 42 CFR 438.706 are as follows:

 

 
 1)
The State may impose temporary management only if it finds through onsite
survey, enrollee complaints, financial audits, or any other means that meet the
following conditions:

 

 
i.  
There is continued egregious behavior by the Contractor, including but not
limited to, behavior that is described in 42 CFR 438.700, or that is contrary to
any requirements of sections 1903(m) and 1932 of the Social Security Act; or

 

 
ii.  
There is substantial risk to enrollees' health; or

 
 
iii.  
The sanction is necessary to ensure the health of the Contractor’s enrollees:

 

 
(a) 
While improvements are made to remedy violations under 42 CFR 438.700; or

 

 
(b) 
Untilthere is an orderly termination or reorganization of the Contractor.

 

 
 2)
The State must impose temporary management (regardless of any other sanction
that may be imposed) if it finds that a Contractor has repeatedly failed to meet
substantive requirements in section 1903(m) or section 1932 of the Social
Security Act or 42 CFR 438.706. The State will also grant enrollees the right to
terminate enrollment without cause, as described in 42 CFR 438.702(a)(3), and
will notify the affected enrollees of their right to terminate enrollment.

 

 
 3)
The State will not delay imposition of temporary management to provide a hearing
before imposing this sanction.

 
 
 
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4)
The State will not terminate temporary management until it determines that the
Contractor can ensure that the sanctioned behavior will not recur.

 

 
c.  
Granting enrollees the right to terminate enrollment without cause and notifying
affected enrollees of their right to disenroll.

 

 
d.  
Suspension or limitation of all new enrollment, including default enrollment,
after the effective date of the sanction.

 

 
e.  
Suspension of payment for beneficiaries enrolled after the effective date of the
sanction and until CMS, the Department, or the Agency is satisfied that the
reason for imposition of the sanction no longer exists and is not likely to
recur.

 

 
f.  
Denial of payments provided for under the contract for new enrollees when, and
for so long as, payment for those enrollees is denied by CMS in accordance with
42 CFR 438.730. Before imposing any intermediate sanctions, the state must give
the Contractor timely notice according to 42 CFR 438.710.

 

 
g.  
Withholding of three (3) percent of the next monthly capitation payment by the
Agency pending receipt of the reports.

 
2.12.14    Assignment of Contract

 
(1)  
Notwithstanding sections 23 through 23.3 of the Standard Contract, the following
are exceptions for HMOs licensed under Chapter 641, F.S:

 
a.  
As provided by Chapter 409.912(20), F.S., when a merger or acquisition of a
Contractor has been approved by the Office of Insurance Regulation pursuant to
s. 628.4615, F.S., the Office of Insurance Regulation shall approve the
assignment or transfer of the appropriate Medicaid HMO contract upon the request
of the surviving entity of the merger or acquisition if the Contractor and the
surviving entity have been in good standing with the Department and Agency for
the most recent 12 month period, unless the Department determines that the
assignment or transfer would be detrimental to the Medicaid recipients or the
Medicaid program.

 
b.  
To be in good standing, a Contractor must not have failed accreditation or
committed any material violation of the requirements of s. 641.52, F.S., and
must meet the requirements in this contract.

 
c.  
For the purposes of this section, a merger or acquisition means a change in
controlling interest of a Contractor, including an asset or stock purchase.

 

 
(2) 
Notwithstanding sections 23 through 23.3 of the Standard Contract, the following
are exceptions for Other Qualified Providers licensed under Chapter 400 or
Chapter 429, F.S.:

 

 
a.  
In determining whether to approve an assignment, the Department will consider
whether the Contractor and the surviving entity have been in good standing with
the Department and Agency for the most recent 12 month period and will not
approve an assignment or transfer that would be detrimental to the project
enrollees or the Medicaid program.

 
2.12.15    Contract Termination

 
(1)  
The Contractor must provide a termination plan that will ensure that services to
consumers will not be interrupted or suspended by the termination and provide
for an efficient and timely transfer or relocation of all enrollees. Any
termination plan must be approved by the Department prior to notice of
termination.

 

 
(2)  
The party initiating the termination must render written notice of termination
to the Department by certified mail, return receipt requested, or in person no
less than 60 calendar days unless the parties agree to an earlier or later
termination by a separate written agreement. The notice of termination must
specify the nature of the termination, the extent to which performance is
terminated, the date on which such termination shall become effective, and the
terms of the Termination Plan. In accordance with s. 1932(e)(4), Social Security
Act, the Department will provide the Contractor with an opportunity for a
hearing prior to termination for cause.

 

 
(3) 
In the event of a notice of termination and unless a written waiver is executed
by the Department, the

 
 
 
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Contractor must take the following actions:

 

 
a. 
Continue performance under the terms of the contract until the termination date.

 

 
b. 
Immediately cease enrollment of new enrollees under the contract.

 

 
c. 
Immediately perform the duties as specified in the approved Termination Plan.

 

 
d. 
Assign to the Department those subcontracts as directed by the Department’s
contracting officer including all the rights, title and interest of the
Contractor for performance of those contracts.

 

 
e. 
At least 60 calendar days prior to the effective date of the termination,
provide written notification to all enrollees of the date on which the
Contractor will no longer participate in the State’s Medicaid program and
instructions on how to contact the Department’s CARES office for information on
their long-term care options.

 

 
f. 
Take such action as may be necessary, or as the Department, in consultation with
the Agency may direct, to protect property related to the contract, which is in
the possession of the provider, and in which the Department and Agency have or
may acquire an interest.

 

 
g.
Decline any prepaid payments or requests for payment submitted after the
contract ends. Any payments due under the terms of the contract may be withheld
until the Department receives from the Contractor all documents as required by
the written instructions of the Department.

 

 
h.
Continue to serve or arrange for provision of services to the enrollees pursuant
to the contract on a fee-for-service basis for up to 45 days from the
notification of termination date.

 

 
i. 
In the event the Department has terminated this contract in only one or more
counties of the state, complete the performance of this contract in all other
areas in which the Contractor’s duties have not been terminated.

 
SECTION III: METHOD OF PAYMENT
 
3.1            REQUEST FOR PAYMENT
 
3.1.1         Payment to Contractor

 
The Agency, through the Medicaid fiscal agent, will make a payment to the
Contractor on a monthly basis for the Contractor’s satisfactory performance of
its duties and responsibilities as set forth in this attachment. This Section
III supersedes section 26 of the Standard Contract and related sections to the
extent that they require the Contractor to submit bills or invoices directly to
the Department.

 
3.2            METHOD OF PAYMENT
                  Notwithstanding section 7.2.1 of the Standard Contract, the
Contractor will be paid in accordance with the manner expressed in this section.
 
3.2.1        Capitation Rates

 
(1)  
The capitation rate paid to the Contractor is indicated in EXHIBIT A. The Agency
and Department, working in conjunction with a licensed actuary, shall review
and, if necessary, recalculate the capitation rate. Legislatively mandated
changes in Medicaid services will also be considered in reviewing the capitation
rate. If as a result of the review, the capitation rate is recalculated, notice
shall be provided to the Contractor.

 

 
(2) 
The Contractor, Department, and the Agency acknowledge that the capitation rate
paid under this contract as specified in EXHIBIT A of this contract is subject
to approval by the federal government.

 

 
(3)  
In accordance with 42 CFR 438.6(c)(1)(i), capitation rates are to be developed
and certified as actuarially sound, appropriate for the populations to be
covered, and the services to be furnished under the contract.

 
3.2.2        834 Transactions

 
(1)  
The Contractor shall submit the electronic 834 transactions monthly to the
Florida Medicaid fiscal agent. The Contractor shall transmit the electronic 834
transactions to the Medicaid fiscal agent using the

 
 
 
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 communications protocol through the secured internet site supplied by the
fiscal agent. The Contractor is required to submit the electronic 834
transactions for every person who is to be enrolled or disenrolled during the
reporting period.

 

 
(2)  
The fiscal agent is authorized to process the enrollment input data as an
electronic transaction in which payment is generated for each enrollee according
to the established capitation rate. On specified dates each month, the
Contractor will receive the remittance report accompanied by a payment warrant,
check or electronic funds transfer statement. The amount of payment is
determined by the number of enrollees enrolled in each capitation category and
any adjustments that may apply.

 

 
(3)  
Contractors must comply with all the federal requirements of administrative
simplification, as documented in the National Electronic Data Interchange
Transaction Set Implementation Guide for the Benefit Enrollment and Maintenance
EDS X12N 834 Transaction, as well as the EDS/AHCA ANSI ASC X12N 834 Companion
Guide.

 

 
(4)  
The Contractor shall transmit the electronic 834 transactions monthly to the
fiscal agent by the Wednesday preceding the second to the last Saturday of each
month. The electronic 834 transactions must include all enrollments submitted
from the CARES office, including “Medicaid Pending”, enrollments that did not
process from the previous month and disenrollments requested by enrollees or
their representative. These enrollments and disenrollments will be effective the
first of the next month.

 
3.2.3         Payment in Full
 
The Contractor must accept the capitation payment received each month as payment
in full for all services provided to enrollees covered under this contract and
the administrative costs incurred by the Contractor in providing or arranging
for such services..

 
3.2.4         Capitation Payments

 
(1)  
Adjustments to funds previously paid and to be paid may be required. Funds
previously paid will be adjusted when capitation payment(s) are determined to
have been in error, or an error is made in enrolling an ineligible person. In
such events, the Contractor agrees to refund any overpayment and the Agency
agrees to pay any underpayment.

 

 
(2) 
The Agency agrees to reflect changes in the Medicaid fee-for-service program.
The rate of payment and total dollar amount may be adjusted with a properly
executed amendment when Medicaid fee-for-service expenditure changes have been
established through the appropriations process and subsequently identified in
the Agency’s operating budget. Legislatively mandated changes will take effect
on the dates specified in the legislation.

 
3.2.5         Payment Discrepancies

 
(1)  
If after an enrollment and disenrollment submission or receipt of the fiscal
agent remittance voucher, a discrepancy is discovered either by the Contractor,
the Agency, or the Department, the Contractor has ten (10) business days to
submit correct detailed information on the Reconciliation Form (EXHIBIT H) to
the Department.

 

 
(2) 
Failure to respond within the above time periods will result in a loss and/or
forfeiture of any money due the Contractor.

 
 
 
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   July 2012   Contract XT220               ATTACHMENT II         CERTIFICATION
REGARDING LOBBYING      CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND    
 AGREEMENTS  

 
The undersigned certifies, to the best of his or her knowledge and belief, that:

 
(1)  
No federal appropriated funds have been paid or will be paid, by or on behalf of
the undersigned, to any person for influencing or attempting to influence an
officer or employee of any state or federal agency, a member of congress, an
officer or employee of congress, an employee of a member of congress, or an
officer or employee of the state legislator, in connection with the awarding of
any federal grant, the making of any federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any federal contract, grant, loan, or cooperative agreement.

 
(2)  
If any funds other than federal appropriated funds have been paid or will be
paid to any person for influencing or attempting to influence an officer or
employee of any agency, a member of congress, an officer or employee of
congress, or an employee of a member of congress in connection with this federal
contract, grant, loan, or cooperative agreement, the undersigned shall complete
and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in
accordance with its instructions.

 
(3)  
The undersigned shall require that the language of this certification be
included in the award documents for all sub­awards at all tiers (including
subcontracts, sub-grants, and contracts under grants, loans and cooperative
agreements) and that all sub-contractors shall certify and disclose accordingly.

 
(3)  
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the
required certification shall be subject to a civil penalty of not less than
$10,000.00 and not more than $100,000.00 for each such failure.

 
 
 

 /s/Christina Cooper    6/26/2012    Signature    Date                          
 Christina Cooper    XT220    Name of Authorize Individual    Appliation or
Agreement Number                            WellCare of Florida, Inc. dba
HealthEase        Name and Address of Organization                              
         DOEA form 103       (Revised Nov 2002)      

 
 
 
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   July 2012   Contract XT220               ATTACHMENT III    FINANCIAL AND
COMPLIANCE AUDIT  

 
The administration of resources awarded by DOEA to the provider may be subject
to audits and/or monitoring by DOEA, as described in this section.
 
MONITORING
 
In addition to reviews of audits conducted in accordance with OMB Circular
A-133, as revised, and Section 215.97, F.S., (see “AUDITS” below), monitoring
procedures may include, but not be limited to, on-site visits by the Department
of staff, limited scope audits as defined by OMB Circular A-133, as revised,
and/or other procedures. By entering into this agreement, the provider agrees to
comply and cooperate with any monitoring procedures/processes deemed appropriate
by DOEA. In the event the Department of Elder Affairs determines that a limited
scope audit of the provider is appropriate, the provider agrees to comply with
any additional instructions provided by the Department of Elder Affairs to the
provider regarding such audit. The provider further agrees to comply and
cooperate with any inspections, reviews, investigations, or audits deemed
necessary by the Chief Financial Officer (CFO) or Auditor General.
 
AUDITS
 
PART I: FEDERALLY FUNDED
 
This part is applicable if the provider is a State or local government or a
non-profit organization as defined in OMB Circular A-133, as revised.
 
In the event that the provider expends $500,000.00 or more in Federal awards
during its fiscal year, the provider must have a single or program-specific
audit conducted in accordance with the provisions of OMB Circular A-133, as
revised. EXHIBIT 1 to this agreement indicates Federal resources awarded through
the Department of Elder Affairs by this agreement. In determining the Federal
awards expended in its fiscal year, the provider shall consider all sources of
Federal awards, including Federal resources received from the Department of
Elder Affairs. The determination of amounts of Federal awards expended should be
in accordance with the guidelines established by OMB Circular A-133, as revised.
An audit of the provider conducted by the Auditor General in accordance with the
provisions of OMB Circular A-133, as revised, will meet the requirements of this
part.
 
In connection with the audit requirements addressed in Part I, paragraph 1, the
provider shall fulfill the requirements relative to auditee responsibilities as
provided in Subpart C of OMB Circular A-133, as revised.
 
If the provider expends less than $500,000.00 in Federal awards in its fiscal
year, an audit conducted in accordance with the provisions of OMB Circular
A-133, as revised, is not required. In the event that the provider expends less
than $500,000.00 in Federal awards in its fiscal year and elects to have an
audit conducted in accordance with the provisions of OMB Circular A-133, as
revised, the cost of the audit must be paid from non-Federal resources (i.e.,
the cost of such audit must be paid from provider resources obtained from other
than Federal entities.)
 
An audit conducted in accordance with this part shall cover the entire
organization for the organization’s fiscal year. Compliance findings related to
agreements with the Department of Elder Affairs shall be based on the
agreement’s requirements, including any rules, regulations, or statutes
referenced in the agreement. The financial statements shall disclose whether or
not the matching requirement was met for each applicable agreement. All
questioned costs and liabilities due to the Department of Elder Affairs shall be
fully disclosed in the audit report with reference to the Department of Elder
Affairs agreement involved. If not otherwise disclosed as required by Section
.310(b)(2) of OMB Circular A-133, as revised, the schedule of expenditures of
Federal awards shall identify expenditures by agreement number for each
agreement with the Department of Elder Affairs in effect during the audit
period. Financial reporting packages required under this part must be submitted
within the earlier of 30 days after receipt of the audit report or 9 months
after the end of the provider’s fiscal year end.
 
 
 
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PART II: STATE FUNDED
 
This part is applicable if the provider is a nonstate entity as defined by
Section 215.97(2), Florida Statutes.
 
In the event that the provider expends a total amount of state financial
assistance equal to or in excess of $500,000.00 in any fiscal year of such
provider (for fiscal years ending September 30, 2004 or thereafter), the
provider must have a State single or project-specific audit for such fiscal year
in accordance with Section 215.97, Florida Statutes; applicable rules of the
Department of Financial Services; and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for- profit organizations), Rules of the
Auditor General. EXHIBIT I to this agreement indicates state financial
assistance awarded through the Department of Elder Affairs by this agreement. In
determining the state financial assistance expended in its fiscal year, the
provider shall consider all sources of state financial assistance, including
state financial assistance received from the Department of Elder Affairs, other
state agencies, and other nonstate entities. State financial assistance does not
include Federal direct or pass-through awards and resources received by a
nonstate entity for Federal program matching requirements.
 
In connection with the audit requirements addressed in Part II, paragraph 1, the
provider shall ensure that the audit complies with the requirements of Section
215.97(8), Florida Statutes. This includes submission of a financial reporting
package as defined by Section 215.97(2), Florida Statutes, and Chapter 10.550
(local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General.
 
If the provider expends less than $500,000.00 in state financial assistance in
its fiscal year (for fiscal years ending September 30, 2004 or thereafter), an
audit conducted in accordance with the provisions of Section 215.97, Florida
Statutes, is not required. In the event that the provider expends less than
$500,000.00 in state financial assistance in its fiscal year and elects to have
an audit conducted in accordance with the provisions of Section 215.97, Florida
Statutes, the cost of the audit must be paid from the nonstate entity’s
resources (i.e., the cost of such an audit must be paid from the provider
resources obtained from other than State entities).
 
An audit conducted in accordance with this part shall cover the entire
organization for the organization’s fiscal year. Compliance findings related to
agreements with the Department of Elder Affairs shall be based on the
agreement’s requirements, including any applicable rules, regulations, or
statutes. The financial statements shall disclose whether or not the matching
requirement was met for each applicable agreement. All questioned costs and
liabilities due to the Department of Elder Affairs shall be fully disclosed in
the audit report with reference to the Department of Elder Affairs agreement
involved. If not otherwise disclosed as required by Rule 69I-5.003, Fla. Admin.
Code, the schedule of expenditures of state financial assistance shall identify
expenditures by agreement number for each agreement with the Department of Elder
Affairs in effect during the audit period. Financial reporting packages required
under this part must be submitted within 45 days after delivery of the audit
report, but no later than 12 months after the provider’s fiscal year end for
local governmental entities. Non-profit or for-profit organizations are required
to be submitted within 45 days after delivery of the audit report, but no later
than 9 months after the provider’s fiscal year end. Notwithstanding the
applicability of this portion, the Department of Elder Affairs retains all right
and obligation to monitor and oversee the performance of this agreement as
outlined throughout this document and pursuant to law.
 
PART III: REPORT SUBMISSION
 
Copies of reporting packages for audits conducted in accordance with OMB
Circular A-133, as revised, and required by PART I of this agreement shall be
submitted, when required by Section .320 (d), OMB Circular A-133, as revised, by
or on behalf of the provider directly to each of the following:
 
The Department of Elder Affairs at each of the following addresses:
 
Department of Elder Affairs
Attn: Nicole Trainor
 4040 Esplanade Way Office, Suite 360C
Tallahassee, FL 32399-7000
 
 
 
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The Federal Audit Clearinghouse designated in OMB Circular A-133, as revised
(the number of copies required by Sections .320 (d)(1) and (2), OMB Circular
A-133, as revised, should be submitted to the Federal Audit Clearinghouse), at
the following address:
 
Federal Audit Clearinghouse
 Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
 
Other Federal agencies and pass-through entities in accordance with Sections
.320 (e) and (f), OMB Circular A-133, as revised.
 
Pursuant to Sections .320(f), OMB Circular A-133, as revised, the provider shall
submit a copy of the reporting package described in Section .320(c), OMB
Circular A-133, as revised, and any management letter issued by the auditor, to
the Department of Elder Affairs at each of the following addresses:
 
Department of Elder Affairs
Attn: Nicole Training
4040 Esplanade Way Office, Suite 360C
Tallahassee, FL 32399-7000
 
Additionally, copies of financial reporting packages required by Part II of this
agreement shall be submitted by or on behalf of the provider directly to each of
the following:
 
The Department of Elder Affairs at each of the following addresses:
 
Department of Elder Affairs
Attn: Nicole Training
4040 Esplanade Way Office, Suite 360C
Tallahassee, FL 32399-7000
 
The Auditor General’s Office at the following address:
 
State of Florida Auditor General
Claude Pepper Building, Room 574
111 West Madison Street
Tallahassee, Florida 32399-1450
 
Any reports, management letter, or other information required to be submitted to
the Department of Elder Affairs pursuant to this agreement shall be submitted
timely in accordance with OMB Circular A-133, Florida Statutes, and Chapters
10.550 (local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General, as applicable.
 
Providers, when submitting financial reporting packages to the Department of
Elder Affairs for audits done in accordance with OMB Circular A-133 or Chapters
10.550 (local governmental entities) or 10.650 (nonprofit and for-profit
organizations), Rules of the Auditor General, should indicate the date that the
reporting package was delivered to the provider in correspondence accompanying
the reporting package.
 
PART IV: RECORD RETENTION
 
The provider shall retain sufficient records demonstrating its compliance with
the terms of this agreement for a period of six years from the date the audit
report is issued, and shall allow the Department of Elder Affairs or its
designee, the CFO or Auditor General access to such records upon request. The
provider shall ensure that audit working papers are made available to the
Department of Elder Affairs, or its designee, CFO, or Auditor General upon
request for a period of six years from the date the audit report is issued,
unless extended in writing by the Department of Elder Affairs.
 
 
 
 
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   July 2012   Contract XT220               ATTACHMENT III     EXHIBIT - 1 

 
1.  
FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS AGREEMENT CONSIST
OF THE FOLLOWING:

 
PROGRAM TITLE
FUNDING SOURCE
CFDA
AMOUNT
                                       
TOTAL FEDERAL AWARD
$0.00

 
COMPLIANCE REQUIREMENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED PURSUANT TO
THIS AGREEMENT ARE AS FOLLOWS:
 
2.  
STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT CONSIST OF
THE FOLLOWING:

 
MATCHING RESOURCES FOR FEDERAL PROGRAMS
PROGRAM TITLE
FUNDING SOURCE
CFDA
AMOUNT
Long Term Community Diversion Pilot Project
General Revenue-Match
93.777  
&
93.778
$60,000,000.00
                               
TOTAL STATE AWARD
$60,000,000.00

 
STATE FINANCIAL ASSISTANCE SUBJECT TO Sec. 215.97, F.S.
PROGRAM TITLE
FUNDING SOURCE
CSFA
AMOUNT
                                       
TOTAL AWARD
$0.00

 
COMPLIANCE REQUIREMENTS APPLICABLE TO STATE RESOURCES AWARDED PURSUANT TO THIS
AGREEMENT ARE AS FOLLOWS:
 
 
 
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   July 2012   Contract XT220               ATTACHMENT III  
PART I: AUDIT RELATIONSHIP DETERMINATION
EXHIBIT - 2 

  
Providers who receive state or federal resources may or may not be subject to
the audit requirements of OMB Circular A-133, as revised, and/or Section 215.97,
Fla. Stat. Providers who are determined to be recipients or subrecipients of
federal awards and/or state financial assistance may be subject to the audit
requirements if the audit threshold requirements set forth in Part I and/or Part
II of Exhibit 1 are met. Providers who have been determined to be vendors are
not subject to the audit requirements of OMB Circular A- 133, as revised, and/or
Section 215.97, Fla. Stat. Regardless of whether the audit requirements are met,
providers who have been determined to be recipients or subrecipients of federal
awards and/or state financial assistance, must comply with applicable
programmatic and fiscal compliance requirements.
 

 In accordance with Sec. 210 of OMB Circular A-133 and/or Rule 691-5.006, FAC,
provider has been determined to be:  X  Vendor or exempt entity and not subject
to OMB Circular A-133 and/or Section 215.97, F.S.    Recipient/subrecipient
subject to OMG Circular A-133 and/or Section 215.97, F.S.

 
NOTE:  If a provider is determined to be a recipient /subrecipient of federal
and/or state financial assistance and has been approved by the Department to
subcontract, they must comply with Section 215.97(7), F.S., and Rule
69I-.006(2), FAC [state financial assistance] and Section _ .400 OMB Circular
A-133 [federal awards].
 
PART II: FISCAL COMPLIANCE REQUIREMENTS
 
FEDERAL AWARDS OR STATE MATCHING FUNDS ON FEDERAL AWARDS. Providers who receive
federal awards or state matching funds on Federal awards and who are determined
to be a subrecipient, must comply with the following fiscal laws, rules and
regulations:
 
  STATES, LOCAL GOVERNMENTS AND INDIAN TRIBES MUST FOLLOW:
2 CFR Part 225 Cost Principles for State, Local and Indian Tribal Governments
(Formerly OMB Circular A-87)*
OMB Circular A-102 - Administrative Requirements OMB Circular A-133 - Audit
Requirements Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
  NON-PROFIT ORGANIZATIONS MUST FOLLOW:
2 CFR Part 230 Cost Principles for Non-Profit Organizations (Formerly OMB
Circular A-122 - Cost Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-110 -
Administrative Requirements) Requirements)
OMB Circular A-133 - Audit Requirements Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
  EDUCATIONAL INSTITUTIONS (EVEN IF A PART OF A STATE OR LOCAL GOVERNMENT) MUST
FOLLOW:
2 CFR Part 220 Cost Principles for Educational Institutions OMB (Formerly
Circular A-21 - Cost Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-110 -
Administrative Requirements)
OMB Circular A-133 - Audit Requirements Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
 
  *Some federal programs may be exempted from compliance with the Cost
Principles Circulars as noted in the OMB Circular A-133 Compliance Supplement,
Appendix 1.
 
              STATE FINANCIAL ASSISTANCE.   Providers who receive state
financial assistance and who are determined to be a recipient/subrecipient, must
comply with the following fiscal laws, rules and regulations:
 
  Section 215.97, Fla. Stat.
  Chapter 69I-5, Fla. Admin. Code State Projects Compliance Supplement Reference
Guide for State Expenditures
  Other fiscal requirements set forth in program laws, rules and regulations
 
 
 
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   July 2012   Contract XT220               ATTACHMENT IV   CERTIFICATION
REGARDNIG DATA INTEGRITY COMPLIANCE      FOR AGREEMENTS, GRANST, LOANS AND    
 COOPERATIVE AGREEMENTS  

 
The undersigned, an authorized representative of the Contractor named in the
contract or agreement to which this form is an attachment, hereby certifies
that:
 
(1)  
The Contractor and any sub-contractors of services under this contract have
financial management systems capable of providing certain information,
including: (1) accurate, current, and complete disclosure of the financial
results of each grant-funded project or program in accordance with the
prescribed reporting requirements; (2) the source and application of funds for
all agreement supported activities; and (3) the comparison of outlays with
budgeted amounts for each award. The inability to process information in
accordance with these requirements could result in a return of grant funds that
have not been accounted for properly.

 
(2)  
Management Information Systems used by the Contractor, sub-contractor(s), or any
outside entity on which the Contractor is dependent for data that is to be
reported, transmitted or calculated, have been assessed and verified to be
capable of processing data accurately, including year-date dependent data. For
those systems identified to be non- compliant, Contractor(s) will take immediate
action to assure data integrity.

 
(3)  
If this contract includes the provision of hardware, software, firmware,
microcode or imbedded chip technology, the undersigned warrants that these
products are capable of processing year-date dependent data accurately. All
versions of these products offered by the Contractor (represented by the
undersigned) and purchased by the State will be verified for accuracy and
integrity of data prior to transfer.

 
In the event of any decrease in functionality related to time and date related
codes and internal subroutines that impede the hardware or software programs
from operating properly, the Contractor agrees to immediately make required
corrections to restore hardware and software programs to the same level of
functionality as warranted herein, at no charge to the State, and without
interruption to the ongoing business of the state, time being of the essence.
 
(4)  
The Contractor and any sub-contractor(s) of services under this contract warrant
their policies and procedures include a disaster plan to provide for service
delivery to continue in case of an emergency including emergencies arising from
data integrity compliance issues.

 
The Contractor shall require that the language of this certification be included
in all subagreements, subgrants, and other agreements and that all
sub-contractors shall certify compliance accordingly.
 
This certification is a material representation of fact upon which reliance was
placed when this transaction was made or entered into. Submission of this
certification is a prerequisite for making or entering into this transaction
imposed by OMB Circulars A-102 and 2 CFR Part 215 (formerly OMB Circular A-110).
 
 

WellCare of Florida, Inc. dba HealthEase            Name and Address of
Contractor                                    /s/Christina Cooper    President,
FL & HI Division    6/26/2012    Signature    Title    Date                    
       Christina Cooper            Name of Authorized Signer                    
               (Revised June 2008)          

 
 
 
 
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   July 2012   Contract XT220               ATTACHMENT V  
CERTIFICATION REGARDNIG DEBARMENT, SUSPENSION,
INELIGIBILITY AND
VOLUNTARY EXCLUSION FOR LOWER TIER COVERED
TRANSACTIONS
 

 
(1)  
The Contractor certifies, by signing this certification, neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from participation in this transaction by
any federal department or agency.

 
(2)
Where the Contractor is unable to certify to any of the statements in this
certification, the Contractor shall attach an explanation to this certification.

 
 

 /s/Christina Cooper    6/26/2012    Signature    Date            President, FL
& HI Division    WellCare of florida, Inc. dba HealthEase   Title   
 Agency/Organization    (Certification signature should be same as Contract
signature.)      

 
Instructions for Certification
 
1. 
The terms "covered transaction," "debarred," "suspended," "ineligible," "lower
tier covered transaction," "person," "primary covered transaction," and
"voluntarily excluded," as used herein, have the meanings set out in the
sections of rules implementing Executive Order 12549. (2 CFR 180.5-180.1020, as
supplemented by 2 CFR 376.10-376.995). You may contact the Contract Manager for
assistance in obtaining a copy of those regulations.

2.  
This certification is a material representation of facts upon which reliance was
placed when the parties entered into this transaction. If it is later determined
that the Contractor knowingly rendered an erroneous certification, in addition
to other remedies available to the federal government, the Department may pursue
available remedies, including suspension and/or debarment.

3.  
The Contractor will provide immediate written notice to the Contract Manager if
at any time the Contractor learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances. The
Contractor may decide the method and frequency by which it determines the
eligibility of its principals. Each participant to a lower tier covered
transaction may, but is not required to, check the Excluded Parties List System
(EPLS).

4.  
The Contractor will include a "Certification Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion - Lower Tier Covered Transaction” in all
its lower tier covered transactions and in all solicitations for lower tier
covered transactions.

5.  
The Contractor agrees that it shall not knowingly enter into any lower tier
covered transaction with a person who is debarred, suspended, determined
ineligible or voluntarily excluded from participation, unless otherwise
authorized by the federal government.

6.  
If the Contractor knowingly enters into a lower tier covered transaction with a
person who is suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to
the federal government, the Department may pursue available remedies, including
suspension, and/or debarment.

7.  
The Contractor may rely upon a certification of a prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible,
or voluntarily excluded from the covered transaction, unless it knows that the
certification is erroneous.

 
(Revised June 2008)
 
 
 
 
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   July 2012   Contract XT220               ATTACHMENT VI  
ASSURANCES-NON-CONSTRUCTION PROGRAMS  

 
 

Public reporting burden for this collection of information is estimated to
average 45 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed and
completing and reviewing the collection of information. Send comments regarding
the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and
Budget. Paperwork Reduction Project (0348-0043), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET,

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

 
Note: Certain of these assurances may not be applicable to your project or
program. If you have questions please contact the awarding agency. Further,
certain federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.

 
1.  
Has the legal authority to apply for federal assistance, and the institutional,
managerial and financial capability (including funds sufficient to pay the
non-federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.

 
2.  
Will give the awarding agency, the Comptroller General of the United States, and
if appropriate, the State, through any authorized representative, access to and
the right to examine all records, books, papers, or documents related to the
award; and will establish a proper accounting system in accordance with
generally accepted accounting standards or agency directives.

 
3.  
Will establish safeguards to prohibit employees from using their positions for a
purpose that constitutes or presents the appearance of personal or
organizational conflict of interest, or personal gain.

 
4.  
Will initiate and complete the work within the applicable timeframe after
receipt of approval of the awarding agency.

 
5.  
Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C..
4728-4763) relating to prescribed standards for merit systems for programs
funded under one of the 19 statutes or regulations specified in Appendix A of
OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900,
Subpart F).

 
6.  
Will comply with all federal statutes relating to nondiscrimination. These
include but are not limited to: (a) Title VI of the Civil Rights Act of 1964
(P.L. 88-352) which prohibits discrimination on the basis of race, color or
national origin; (b) Title IX of the Education Amendments of 1972, as amended
(20 U.S.C.. 1681-1683, and 1685-1686), which prohibits discrimination on the
basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29
U.S.C.. 794), which prohibits discrimination on the basis of handicaps; (d) the
Age Discrimination Act of 1975, as amended (42 U.S.C.. 6101-6107), which
prohibits discrimination on the basis of age; (e) the Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination
on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended,
relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g)
523 and 527 of the Public Health Service Act of 1912 (42 U.S.C.. 290 dd-3 and
290 ee 3), as amended, relating to confidentiality of alcohol and drug abuse
patient records; (h) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. .
3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or
financing of housing; (i) any other nondiscrimination provisions in the specific
statute(s) under which application for federal assistance is being made; and (j)
the requirements of any other nondiscrimination statute(s) which may apply to
the application.

 
7.  
Will comply, or has already complied, with the requirements of Titles II and III
of the uniform Relocation Assistance and Real Property Acquisition Policies Act
of 1970 (P.L. 91-646) which provide for fair and equitable treatment of persons
displaced or whose property is acquired as a result of federal or federally
assisted programs. These requirements apply to all interests in real property
acquired for project purposes regardless of federal participation in purchases.

 
8.  
Will comply, as applicable, with the provisions of the Hatch Act (5 U.S.C..
1501-1508 and 7324-7328), which limit the political activities of employees
whose principal employment activities are funded in whole or in part with
federal funds.

 
9.  
Will comply, as applicable, with the provisions of the Davis-Bacon Act (40
U.S.C.. 276a to 276a-7), the Copeland Act (40 U.S.C. 276c and 18 U.S.C.. 874)
and the Contract Work Hours and Safety Standards Act (40 U.S.C.. 327-333),
regarding labor standards for federally assisted construction subagreements.

 
10.  
Will comply, if applicable, with flood insurance purchase requirements of
Section 102(a) of the Flood Disaster Protection Act of 1973 (P.L. 93-234) which
requires recipients in a special flood hazard area to participate in the program
and to purchase flood insurance if the total cost of insurable construction and
acquisition is $10,000.00 or more.

 
 
 
 
 
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   July 2012   Contract XT220   

 
11.  
Will comply with environmental standards which may be prescribed pursuant to the
following: (a) institution of environmental quality control measures under the
National Environmental Policy Act of 1969 (P.L. 91-190) and Executive Order (EO)
11514 (b) notification of violating facilities pursuant to EO 11738; (c)
protection of wetlands pursuant to EO 11990; (d) evaluation of flood hazards in
floodplains in accordance with EO 11988; (e) assurance of project consistency
with the approved State management program developed under the Coastal Zone
Management Act of 1972 (16 U.S.C. . 1451 et seq.); (f) conformity of federal
actions to State (Clear Air) Implementation Plans under Section 176(c) of the
Clear Air Act of 1955, as amended (42 U.S.C.. 7401 et seq.); (g) protection of
underground sources of drinking water under the Safe Drinking Water Act of 1974,
as amended, (P.L. 93-523); and (h) protection of endangered species under the
Endangered Species Act of 1973, as amended, (P.L. 93-205).

 
12.
Will comply with the Wild and Scenic Rivers Act of 1968 (16 U.S.C.. 1721 et
seq.) related to protecting components or potential components of the national
wild and scenic rivers system.

 
13.  
Will assist the awarding agency in assuring compliance with Section 106 of the
National Historic Preservation Act of 1966, as amended (16 U.S.C. . 470), EO
11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C.. 469a-1 et
seq.).

 
14.  
Will comply with P.L. 93-348 regarding the protection of human subjects involved
in research, development, and related activities supported by this award of
assistance.

 
15.  
Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as
amended, 7 U.S.C.. 2131 et seq.) pertaining to the care, handling, and treatment
of warm blooded animals held for research, teaching, or other activities
supported by this award of assistance.

 
16.  
Will comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C.. 4801
et seq.), which prohibits the use of lead- based paint in construction or
rehabilitation of residence structures.

 
17.  
Will cause to be performed the required financial and compliance audits in
accordance with the Single Audit Act Amendments of 1996 and OMB Circular No.
A-133, Audits of States, Local Governments, and Non-Profit Organizations.

 
18.  
Will comply with all applicable requirements of all other federal laws,
executive orders, regulations and policies governing this program.

 
 
 SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
 
 
/s/Christina Cooper
 TITLE
 
 
President, FL & HI Division

 APPLICANT ORGANIZATION
 
 
WellCare of Florida, Inc. dba HealthEase
 DATE SUBMITTED
 
 
6/26/2012

 
 
 
 
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   July 2012   Contract XT220               ATTACHMENT VI     INSTRUCTIONS FOR
COMPLETING DISCLOSURE OF         OWNERSHIP AND CONTROL INTEREST STATEMENT    

 
Return the original and a copy to the Department of Elder Affairs retain a copy
for your files. This form is to be completed annually. Any substantial delay in
completing the form should be reported to the Department of Elder Affairs.
 
General Instructions
 
Please answer all questions as of the current date. If the yes block for any
item is checked, list requested additional information under the Remarks section
on page 2, referencing the item number to be continued. If additional space is
needed use an attached sheet. Return the original and two original copies to the
Department of Elder Affairs. This form is to be completed annually. Any
substantial delay in completing the form should be reported to the Department of
Elder Affairs.
 
DETAILED INSTRUCTIONS
 
These instructions are designed to clarify certain questions on the form.
Instructions are listed in question order for easy reference. No instructions
have been given for questions considered self-explanatory.
 
IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT
ALL INFORMATION BE CURRENT.
 
Item I Under identifying information specify in what capacity the entity is
doing business as (DBA), example, name of trade or corporation.
 
Item II - Self-explanatory.
 
Item III - List the names of all individuals and organizations having direct or
indirect ownership interests, or controlling interest separately or in
combination amounting to an ownership interest of 5 percent or more in the
disclosing entity.
 
Direct ownership interest is defined as the possession of stock, equity in
capital or any interest in the profits of the disclosing entity. A disclosing
entity is defined as a Medicare provider or supplier, or other entity that
furnishes services or arranges for furnishing services under Medicaid or the
Maternal and Child Health program, or health related services under the social
services program.
 
Indirect ownership interest is defined as ownership interest in an entity that
has direct or indirect ownership interest in the disclosing entity. The amount
of indirect ownership in the disclosing entity that is held by any other entity
is determined by multiplying the percentage of ownership interest at each level.
An indirect ownership interest must be reported if it equates to an ownership
interest of 5 percent or mo re in the disclosing entity. Example: if A owns 10
percent of the stock in a corporation that owns 80 percent of the stock of the
disclosing entity, A's interest equates to an 8 percent indirect ownership and
must be reported.
 
Controlling interest is defined as the operational direction or management of a
disclosing entity which may be maintained by any or all of the following
devices: the ability or authority, expressed or reserved, to amend or change the
corporate identity (i.e., joint venture agreement, unincorporated business
status) of the disclosing entity; the ability or authority to nominate or name
members of the Board of Directors or Trustees of the disclosing entity; the
ability or authority, expressed or reserved, to amend or change the by-laws,
constitution, or other operating or management direction of the disclosing
entity; the right to control any or all of the assets or other property of the
disclosing entity upon the sale or dissolution of that entity; the ability or
authority, expressed or reserved, to control the sale of any or all of the
assets, to encumber such assets by way of mortgage or other indebtedness, to
dissolve the entity, or to arrange for the sale or transfer of the disclosing
entity to new ownership or control.
 
Items IV - VII - Changes in Provider Status
 
Change in provider status is defined as any change in management control.
Examples of such changes would include: a change in Medical or Nursing Director,
a new Administrator, contracting the operation of the facility to a management
corporation, a change in the composition of the owning partnership which under
applicable State law is not considered a change in ownership, or the hiring or
dismissing of any employees with 5 percent or more financial interest in the
facility or in an owning corporation, or any change of ownership. For Items IV -
VII, if the yes box is checked, list additional information requested under
Remarks. Clearly identify which item is being continued.
 
Item IV - (a & b) If there has been a change in ownership within the last year
or if you anticipate a change, indicate the date in the appropriate space.
 
Item V - If the answer is yes, list name of the management firm and employer
identification number (EIN), or the name of the leasing organization. A
management company is defined as any organization that operates and manages a
business on behalf of the owner of that business, with the owner retaining
ultimate legal responsibility for operation of the facility.
 
Item VI - If the answer is yes, identify which has changed (Administrator,
Medical Director, or Director of Nursing) and the date the change was made. Be
sure to include name of the new Administrator, Director of Nursing or Medical
Director, as appropriate.
 
Item VII - A chain affiliate is any free-standing health care facility that is
either owned, controlled, or operated under lease or contract by an organization
consisting of two or more free-standing health care facilities organized within
or across State lines which is under the ownership or through any other device,
control and direction of a common party. Chain affiliates include such
facilities whether public, private, charitable or proprietary. They also include
subsidiary organizations and holding corporations. Provider-based facilities,
such as hospital-based home health agencies, are not considered to be chain
affiliates.
 
Item VIII - If yes, list the actual number of beds in the facility now and the
previous number.
 
 
 
 
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   July 2012   Contract XT220   

 
 
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT

  Indentifying Information

 
 

 (a) Name of Entity                                                 D/B/A  
 Telephone No.            WellCare of Florida, Inc.           HealthEase  
 (800) 960-2530                    Street Address  City, County, State  Zip Code
           8735 Henderson Road  Tampa, Hillsborough County, FL  33634          
       

  II. Answer the following questions by checking "Yes" or "No."  If any of the
questions are answered "Yes," list names and addresses of individuals or
corporations under Remarks on page 2.  Identify each item number to be
continued.    

 
(a) Are there any individuals or organizations having a direct or indirect
ownership or control interest of 5 percent or more in the institution,
organizations, or agency that have been convicted of a criminal offense related
to the involvement of such persons, or organizations in any of the programs
established by titles XVIII, XIX, or XX?
(   )Yes                                 ( x ) No

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

(b) Are there any directors, officers, agents, or managing employees of the
institution, agency or organization who have ever been convicted of a criminal
offense related to their involvement in such programs established by titles
XVIII, XIX, or XX?
(   ) Yes                                 ( x ) No

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

(c) Are there any individuals currently employed by the institution, agency, or
organization in a managerial, accounting, auditing, or similar capacity who were
employed by the institution's, organization's, or agency's fiscal intermediary
or carrier within the previous 12 months? (Title XVIII providers only)
(   ) Yes                                 (   ) No     N/A - no fiscal
intermediary

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

III.   (a) List names, addresses for individuals, or the EIN for organizations
having direct or indirect ownership or a controlling interest in the entity.
(See instructions for definition of ownership and controlling interest.) List
any additional names and addresses under "Remarks" on page 2. If more than one
individual is reported and any of these persons are related to each other, this
must be reported under Remarks.
 
Name
Address
EIN
 
The WellCare Management Group, Inc.
  8735 Henderson Road, Tampa, FL 33634   14-1647239
 
WCG Health Management, Inc.
  8735 Henderson Road, Tampa, FL 33634   04-3669698
 
WellCare Health Plans, Inc.
  8735 Henderson Road, Tampa, FL 33634   47-0937650
 
 
Please also see attached Schedule to Disclosrue of Ownership and control
Interest Statemetn for discussion regarding holders of the publicly-traded
common stock of WellCare Health Plans, Inc.  
 
 
   

 
 

        (b) Type of Entity:              (    )Sole Proprietorship  (    )
Partnership  ( x ) Corporation  (    ) Unicorporated Associates Other (Specify  
           (c) If the disclosing    entity is a corporation, list names,
addresses of the Directors, and EINs  for corporations under Remarks            
                 

Check appropriate box for each of the following questions:
(d) Are any owners of the disclosing entity also owners of other
Medicare/Medicaid facilities? (Example: sole proprietor, partnership or members
of Board of Directors.) If yes, list names, addresses of individuals and
provider numbers.
( x ) Yes                                (   ) No
Name
Address
Provider Number
 
 
Please see Schedule to Disclosure of Ownership and Control Interest Statement
 

 
 

 
 
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   July 2012   Contract XT220   

 
 
 

         IV. (a) Has there been a change in ownership or control within the last
year?        If yes, give date_________________  (    ) Yes  ( x ) No          
 (b) Do you anticipate any change of ownership or control within the year?     
   If yes, when? _________________  (    ) Yes  ( x ) No            (c) Do you
anticipate filing for bankruptcy within the year?        If yes, when?
_________________  (    ) Yes  ( x ) No            V. Is this facility operated
by a management company, or leased in whole or party by another organization?  
 If yes, give date of change in operations _________________  (    ) Yes  (    )
No     N/A - not a facility (managed care plan)            VII. (a) Is this
facility chain affiliated? (If yes, list name, address of Corporation, and EIN)
     Name:  EIN #  ( x ) Yes  (    ) No     Dr. Kirk Cianciolo is the Medical
Director for WellCare of Florida, Inc.                            Address      
                         VII. (b) If the answer to Question VII.a. is No, was
the facility every affiliated with a chain?      Name  EIN #  (    ) Yes   (   
) No     N/A - not a facility (managed care plan)                          
 Address                                VIII. Have you increased your bed
capacity by 10 percent or more or by 10 beds, whichever is greater, within the
last 2 years?      (    ) Yes   (    ) No     N/A - not a facility (managed care
plan)    If yes, give year of change ______________          Current beds
______________  Prior beds__________________            WHOEVER KNOWINGLY AND
WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS
STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS.  IN
ADDITION, KNOWINGLY AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THE
INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE
THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS CONTRACT WITH THE
DEPARTMENT OF ELDERS AFFAIRS.  Name of Authorized Representative (Typed)    
 Title          Thomas L. Tran      Chief Financial Officer         Signature  
             /s/ Thomas L. Tran      June 26, 2012          Remarks            
   Please see Schedule to Disclosure of Ownership and Control Interest Statement
     

 
 
 
 
 
 
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SCHEDULE
to Disclosure of Ownership and Control Interest Statement

WellCare of Florida, Inc. d/b/a HealthEase
As of June 26, 2012

Remarks to Section III(a)
 
The disclosing entity, WellCare of Florida, Inc. d/b/a HealthEase, is an
indirect wholly owned subsidiary of WellCare Health Plans, Inc. (“WCG”).  The
ownership path is as follows:

 
WellCare Health Plans, Inc.
8735 Henderson Road
Tampa, FL 33634
EIN:  14-1647239
 

↓
                                                                         100%
 
WCG Health Management, Inc.
8735 Henderson Road
Tampa, FL 33634
EIN:  04-3669698
 

↓
                                                                         100%
 
The WellCare Management Group, Inc.
8735 Henderson Road
Tampa, FL 33634
EIN:  47-0937650
 

↓
                                                                         100%
 
WellCare of Florida, Inc.
d/b/a HealthEase
8735 Henderson Road
Tampa, FL 33634
EIN:  59-2583622
 

 
The stock of WCG is publicly traded on the New York Stock Exchange under the
symbol “WCG.”  Information regarding holders of 5% or more of WCG’s publicly
traded stock is available in WCG’s Proxy Statement, Schedule 14A, as filed with
the U.S. Securities and
 
 
 
 
1

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

 
 
 
Exchange Commission (the “SEC”) on April 10, 2012, as well as on Schedules 13G
filed by such investors with the SEC with respect to WCG’s stock.
 
Please note that a person is only eligible to file a Schedule 13G with respect
to an issuer’s securities if such person has acquired the securities in the
ordinary course of business and not for the purpose nor with the effect of
changing or influencing the control of the issuer.

The directors and officers (controlling persons) of the disclosing entity are:

Name
Title(s)
Business Address
Christina C. Cooper
Director,
President, Florida and Hawaii Division
WellCare of Florida,
8735 Henderson Road
Tampa, FL 33634
Alec Cunningham
Director,
President,
Chief Executive Officer
WellCare of Florida,
8735 Henderson Road
Tampa, FL 33634
Maurice Hebert
Director,
Assistant Treasurer,
Chief Accounting Officer
WellCare of Florida,
8735 Henderson Road
Tampa, FL 33634
Lisa G. Iglesias
Director,
Secretary
WellCare of Florida,
8735 Henderson Road
Tampa, FL 33634
Thomas L. Tran
Director,
Chief Financial Officer,
Treasurer
WellCare of Florida,
8735 Henderson Road
Tampa, FL 33634

Remarks to Section III(c)

The disclosing entity’s EIN is 59-2583622.  The directors of the disclosing
entity are set forth above under the remarks to Section III(a) and are
incorporated in this section by reference.

Remarks to Section III(d)

The disclosing entity is not a facility; it is a company that offers health
plans.  The owners of the disclosing entity own one pharmacy, Exactus Pharmacy
Solutions, Inc. (f/k/a WellCare Specialty Pharmacy, Inc.).  They also own other
companies that offer Medicare and/or Medicaid health plans.  The names and
addresses of the other companies offering health plans and of Exactus Pharmacy
Solutions, Inc. (f/k/a WellCare Specialty Pharmacy, Inc.) are set forth
below.  Except where indicated, these companies are owned by The WellCare
Management Group, Inc.
 
 
 
 
2

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

 

Name
Address
Exactus Pharmacy Solutions, Inc.
(f/k/a WellCare Specialty Pharmacy, Inc.)
(owned by WellCare Pharmacy Benefits Management, Inc., which is in turn owned by
The WellCare Management Group, Inc.)
4110 George Road
Suite 100
Tampa, FL 33634
Harmony Health Plan of Illinois, Inc,
(owned by Harmony Health Systems, Inc., which is in turn owned by The WellCare
Management Group, Inc.)
200 W. Adams Street, Suite 800
Chicago, IL 60606
HealthEase of Florida, Inc.
8735 Henderson Road
Tampa, FL 33634
WellCare Health Insurance of Arizona, Inc. d/b/a ‘Ohana Health Plan
8735 Henderson Road
Tampa, FL 33634
WellCare Health Insurance of Illinois, Inc. d/b/a WellCare of Kentucky
200 W. Adams Street, Suite 800
Chicago, IL 60606
WellCare Health Plans of New Jersey, Inc.
33 Washington Street, 1st floor
Newark, NJ 07102
WellCare of Connecticut, Inc.
(owned by WellCare of New York, Inc.)
127 Washington Street, 4th floor
North Haven, CT 06473
WellCare of Georgia, Inc.
211 Perimeter Center Parkway, Suite 800
Atlanta, GA 30346
WellCare of Louisiana, Inc.
11603 Southfork
Baton Rouge, LA 70816
WellCare of New York, Inc.
110 Fifth Avenue, 3rd floor
New York, NY 10111
WellCare of Ohio, Inc.
Spectrum Building,
6060 Rockside Woods Blvd., Suite #300
Independence, OH 44131
WellCare of Texas, Inc.
2211 Norfolk Street, Suite 300
Houston, TX 77098
WellCare Prescription Insurance, Inc.
8735 Henderson Road
Tampa, FL 33634

Remarks to Section IV(b)

There is no anticipated change in ownership with respect to the disclosing
entity, WellCare of Florida, Inc. d/b/a HealthEase (“WCFL”). However, in the
interest of full disclosure, HealthEase of Florida, Inc., an affiliate of WCFL,
will be merged into WCFL as of July 1, 2012.

-  -
  3
 

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   July 2012   Contract XT220               ATTACHMENT VIII    SWORN STATEMENT
PURSUANT TO SECTION 287.133(3)(a),    
 
 

 
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
 

 1.  This sworn statement is submitted to  Department of Elder Affairs      
 (print name of the public entity)  by  Christina Cooper, President, FL & HI
Division                                         (print individual's name and
title)  for  WellCare of Florida, Inc. dba HealthEase  
                                      (print name of entity submitting sworn
statement)    whose business address is    8725 Henderson Road    
                    Tampa, FL 33634    and, if applicable, its Federal Employer
Identification Number (FEIN) is 59-2583622        If the entity has no FEIN,
include Social Security Number of the individual signing this sworn      
 statement:        

                                                
2.  
I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g),
Florida Statutes, means a violation of any state or federal law by a person with
respect to and directly related to the transaction of business with any public
entity or with an agency or political subdivision of any other state or of the
United States, including, but not limited to, any bid or contract for goods or
services to be provided to any public entity or an agency or political
subdivision of any other state or of the United States and involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material
representation.

 
3.
I understand that "convicted" or "conviction" as defined in Paragraph
287.133(1)(b), Florida Statutes, means a finding of guilt or a conviction of a
public entity crime, with or without an adjudication of guilt, in any federal or
state trial court of record relating to charges brought by indictment or
information after July 1, 1989, as a result of a jury verdict, non-jury trial,
or entry of a plea of guilty or nolo contendere.

 

 
4.  
I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida
Statutes, means:

 

 
1.  
A predecessor or successor of a person convicted of a public entity crime; or

 
2.  
An entity under the control of any natural person who is active in the
management of the entity and who has been convicted of a public entity crime.
The term "affiliate" includes those officers, directors, executives, partners,
shareholders, employees, members, and agents who are active in the management of
the affiliate. The ownership by one person of shares constituting a controlling
interest in another person, or a pooling of equipment or income among persons
when not for fair market value under an arm's length agreement, shall be a prima
facie case that one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted of a public
entity crime in Florida during the preceding 36 months shall be considered an
affiliate.

 
5.  
I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida
Statutes, means any natural person or entity organized under the laws of any
state or of the United States with the legal power to enter into a binding
contract and which bids or applies to bid on contracts for the provision of
goods or services let by a public entity, or which otherwise transacts or
applies to transact business with a public entity. The term "person" includes
those officers, directors, executives, partners, shareholders, employees,
members, and agents who are active in management of an entity.

 
6.  
Based on information and belief, the statement which I have marked below is true
in relation to the entity submitting this sworn statement. (Indicate which
statement applies.)

 

 
    X    
Neither the entity submitting this sworn statement, nor any of its officers,
directors, executives, partners, shareholders, employees, members, or agents who
are active in the management of the entity, nor any affiliate of the entity has
been charged with and convicted of a public entity crime subsequent to July 1,
1989.

 
_____
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, or agents who
are active in the management of the entity, or an affiliate of the entity has
been charged with and convicted of a public entity subsequent to July 1, 1989.

 
 
 
 
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   July 2012   Contract XT220   

 
 

 
_____
The entity submitting this sworn statement, or one or more of its officers,
directors, executives, partners, shareholders, employees, members, or agents who
are active in the management of the entity, or an affiliate of the entity has
been charged with and convicted of a public entity subsequent to July 1, 1989.
However, there has been a subsequent proceeding before a Hearing Officer of the
State of Florida, Division of Administrative Hearings and the Final Order
entered by the Hearing Officer determined that it was not in the public interest
to place the entry submitting this sworn statement on the convicted vendor list.
(Attach a copy of the final order.)

 
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN
WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC
ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD PROVIDED IN
SECTION 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE
INFORMATION CONTAINED IN THIS FORM.
 
 
 
 

       (signature)                        (date)

 
 
 

  STATE OF  FLORIDA             COUNTY OF  HILLSBOROUGH              PERSONALLY
APPEARED BEFORE ME, the undersigned authority            Christina Cooper  who,
after first being sworn by me, affixed his/her signature in the    (name of
individual signing)            space provided above this       26th          day
of          June          , 19   2012               [NOTARY PUBLIC]          
 Emily A. Merlin  /s/Emily Merlin    MY COMMISSION #DD 868288  NOTARY PUBLIC  
 EXPIRES: April 23, 2012    My commission expires: _____________________  Bonded
Thru Notary Public Underwriters    Jan2001      Form 102 Sworn Statement Public
Entity Crimes                

 
 
 
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   July 2012   Contract XT220          ATTACHMENT IX      MULTIPLE SIGNATURE
VERIFICATION AGREEMENT    

 
Account Number: _____________________________
 
In consideration of the mutual promises and undertakings expressed herein, this
Agreement is entered into between                US Bank                     
Bank (“Bank”) and             HEFL              Long-Term Care Diversion
Provider (“Provider”), effective as of the     15     day of        
September       , 2011.
 
1.  Provider is opening the Bank business investment account referenced by
number above (“the Account”), pursuant to the conditions contained in the
agreement entered between Provider and the Office of the Secretary of the
Department of Elder Affairs, State of Florida Department of Elder Affairs
(“DOEA”) dated September 1, 2011.
 
2.  Pursuant to its agreement with DOEA, Provider desires, and Bank agrees to
provide, a “hold” on the account so that withdrawals may be made only by
properly authorized written request, and upon manual examination of the
requests, which service shall be subject to the terms and restrictions set forth
below.
 
3.  Bank will only honor written requests for withdrawals that bear the
signatures of two authorized representatives of DOEA and two signatures of
authorized representatives of Provider. DOEA and Provider will provide to Bank
examples of the signatures of the authorized representatives.
 
4.  Provider will present the written, properly executed requests for withdrawal
to    Glenda D. Webb         , at Bank, located at  225 Water Street, Ste. 700,
Jacksonville, Florida, 32202, between the hours of 8:00 am and 4:00 pm, EST,
during banking business days. The request will contain the Account number, the
amount of the funds to be withdrawn, a description of the payee who shall
receive the funds, and the signatures of two authorized representatives of DOEA
and two signatures of authorized representatives of Provider.
 
5.  Bank agrees to review the requests; draft the Account for the amount of the
requested withdrawal, and prepare a Bank Official Check in the withdrawn amount,
in accordance with the terms of the request. Bank agrees to undertake the above
and make the Check available to Provider no later than the close of the banking
day following the banking day in which the request was presented to Bank in
accordance with Paragraph 4, above. [Optional language: Provider agrees to pay
to Bank a fee of $5.00 for each Official Bank Check issued.]
 
6.  Bank shall return to Provider any request that does not meet the
above-described requirements. Bank shall have the sole discretion to determine
whether the requirements have been met.
 
7.  Pursuant to its agreement with DOEA, Provider agrees that in the event that
DOEA determines Provider to be insolvent and notifies Bank of its determination,
DOEA may make withdrawals on the account by two authorized representatives of
DOEA, without authorized signatures from Provider. Bank shall not be responsible
or liable for determining insolvency. Bank shall not be required to permit
withdrawals upon the sole order of DOEA until written notification is received
from DOEA at the address described in Paragraph 4, and Bank has had a reasonable
time to act thereon but in no event later than two (2) business days.
 
8.  Except to the extent that Bank is negligent in performing its duties under
this Agreement, Provider shall indemnify and hold Bank harmless against any
claim, loss, liability, damage, cost or expense (including reasonable attorneys’
fees incurred by Bank) arising out of or in any way relating to Bank’s
compliance with the terms of this Agreement.
 
9.  This Agreement shall supplement the Bank Deposit Agreement, any corporate or
other resolution of Provider relating to the Account, and any other agreements
or terms affecting the Account. All legal rights and obligations of Provider and
Bank under such other documents and pursuant to any applicable laws and banking
regulations shall remain in effect, except as expressly modified by this
Agreement.
 
 
 
 
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   July 2012   Contract XT220   

 
10.    This Agreement shall be executed by all currently authorized signers on
the Account, and it shall continue in effect notwithstanding any subsequent
change of authorized signers, and without any requirement that it be re-executed
or amended.
 
11.   This Agreement may be terminated at any time by Bank or Provider, provided
Provider provides Bank written approval from DOEA, and provided that the
indemnification provision of paragraph 7 above shall continue in effect after
any such termination with respect to any withdrawals or requests handled by Bank
prior to such termination. This Agreement shall be binding upon and shall inure
to the benefit of any successors and assigns of Provider, DOEA, and Bank.
 
The undersigned parties have executed this Agreement through their duly
authorized representatives as of the date shown above.
 
 
 

 BANK        By:      Title:         PROVIDER          By:       Title:        
  PROVIDERS'S CERTIFICATION OF AUTHORITY     The undersigned hereby certifies
that: (1) (s)he is the Secretary of ____________________________ Provider; and
(2) the foregoing Agreement is consistent with any corporate or other
resolution(s) of Provider previously or contemporaneously provided to Bank.    
    

 By:  Lisa G. Iglesias /s/ Lisa Iglesias    Title:  Secretary  

 Date of Certification          [Affix corporate seal]  

 
AUHORIZED SIGNATURES
 
PROVIDER
 
DEPARTMENT OF ELDER AFFAIRS
 /s/ Thomas L.
Tran                                                                                                                                            
 ______________________________________________________________________
Title    SVP and Chief Financial Office
Print Name:  Thomas L.
Tran                                                                                                                        
Deputy Secretary
Print Name:____________________________________________________________
  /s/Goran Jankovic
 
_______________________________________________________________________
Title              VP Treasury
Print Name: Goran
Jankovic                                                                                                                         
Chief Financial Officer
Print Name:_____________________________________________________________
 
____________________________________________________________________________
 
________________________________________________________________________
Title
Print Name:_________________________________________________________________
 
Print Name:______________________________________________________________
   

 
 
 
 
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   July 2012   Contract XT220               ATTACHMENT X

 
AGREEMENT TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID PENDING
 

     No, Contractor does not elect to provide services to individuals designated
as Medicaid Pending.  X    Yes, Contractor elects to provide services to
individuals designated as Medicaid Pending.

 
By checking YES above, Contractor agrees to provide services to individuals
referred to them by CARES who have been designated as Medicaid Pending in
accordance with Section 430.705(5), Florida Statutes. The Contractor will meet
all conditions of this contract and the following:
 

   a.   The Contractor is responsible for compliance with all pertinent
insurance laws and regulations prior to providing services to Medicaid Pending
individuals.    b.   CARES staff will refer individuals, identified as Medicaid
pending and who choose to receive Medicaid Pending services, to the chosen
Contractor. Included with the referral will be the Freedom of Choice form, 701 B
Assessment, 3008, Informed Consent, and the Level of Care.    c.  The Contractor
may assist Medicaid pending individuals through the Medicaid financial
eligibility process by submitting the ACCESS Florida Application (online or
hardcopy) to the Department of Children and Families and when contacted by DCF,
forward at a minimum the following documentation:  Financial Release (CF ES
2613), CARES’ level of care decision (Form 603) and the Certification of
Enrollment Status (HCBS) (CF-AA 2515). Applications may be completed and
submitted online at the following website: www.myflorida.com/accessflorida    d.
Once the individual is determined financially eligible or ineligible by DCF, the
Contractor must notify CARES and provide a copy of the Notice of Case Action
within (2) two business days of receipt.    e.  The Contractors will be
responsible for submitting 834 enrollment transactions to the Medicaid fiscal
agent on the regular submission date for Medicaid pending individuals. The
enrollment date will be retroactive to the first of the month following the
CARES eligibility determination.    f.  Services must be in place on the first
of the month following the CARES eligibility determination.    g.  The
Contractor will be paid the capitation rate for services rendered retroactive to
the first of the month following the CARES eligibility determination. The
Contractor shall make available, on request from the Department, proof of
services, which meet the timeframes listed above.    h.  Payment will be made
once full financial eligibility has been determined.    i.  In the event the
individual is determined not to be financially eligible by the Department of
Children & Families, the Contractor must notify CARES and can seek reimbursement
from the individual in accordance with the Medicaid Coverage and Limitations
Handbooks and the associated fee schedules.

 
 

  Signature  Christina Cooper      Date  6/26/2012      Christina Cooper   Name
and Title of Authorized Individual (Print or type) 

 
 
 
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   July 2012   Contract XT220               ATTACHMENT B

 
STATE OF FLORIDA DEPARTMENT OF ELDER AFFAIRS
CIVIL RIGHTS COMPLIANCE CHECKLIST
Program/Facility Name
 
County
AAA/Contractor
Address
 
Completed By
City, State, Zip Code
 
Date
Telephone

 
            PART I. READ THE ATTACHED INSTRUCTIONS FOR ILLUSTRATIVE INFORMATION
WHICH WILL HELP YOU IN THE COMPLETION OF THIS FORM.

 

1. Briefly describe the geographic area served by the program/facility and the
type of service provided:        

 
 
 

2.      POPULATION OF AREA SERVED. Source of data:

Total #
 
% White
% Black
% Hispanic
% Other
% Female
   

3.      STAFF CURRENTLY EMPLOYED. Effective date:
Total #
 
% White
% Black
% Hispanic
% Other
% Female
% Disabled
 

4.     CLIENTS CURRENTLY ENROLLED OR REGISTERED. Effective date:
Total #
 
% White
% Black
% Hispanic
% Other
% Female
% Disabled
% Over 40

5.     ADVISORY OR GOVERNING BOARD, IF APPLICABLE.
Total #
 
% White
% Black
% Hispanic
% Other
% Female
% Disabled
 

PART II. USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE
SPACE.

6.      Is an Assurance of Compliance on file with DOEA? If NA or NO explain.

 
NA
YES
NO
                               

7.      Compare staff composition to the population. Is staff representative of
the population? If NA or NO Explain.

 
NA
YES
NO
                               

 
8.      Compare the client composition to the population. Are race and sex
characteristics representative of the population? If NA or NO, explain.

 
NA
YES
NO
                               

9.      Are eligibility requirements for services applied to clients and
applicants without regard to race, color, national origin, sex, age, religion or
disability? If NA or NO, explain.

 
NA
YES
NO
                               

 
10.    Are all benefits, services and facilities available to applicants and
participants in an equally effective manner regardless of race, sex, color, age,
national origin, religion or disability? If NA or NO, explain.

 
NA
YES
NO
                               

 
11.    For in-patient services, are room assignments made without regard to
race, color, national origin or disability? If NA or NO, explain.

 
NA
YES
NO
                               

 
Revised May 2008, Page 1 of 2
 
 
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   July 2012   Contract XT220         

 
12.    Is the program/facility accessible to non-English speaking clients?  If
NA or NO, explain.

 
NA
YES
NO
               

13.    Are employees, applicants and participants informed of their protection
against discrimination?
         If YES, how? Verbal ____ Written ____ Poster ____ If NA or NO, explain.

 
NA
YES
NO
               

14.    Give the number and current status of any discrimination complaints
regarding services or employment filed against the program/facility.

 
NA
NUMBER
           

 
15.    Is the program/facility physically accessible to mobility, hearing and
sight-impaired individuals? If NA or NO, explain.

 
NA
YES
NO
               

 
 
PART III. THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR
MORE EMPLOYEES.

 
16.    Has a self-evaluation been conducted to dentify any barriers to serving
disabled individuals, and to make any necessary modifications? If NO, explain.

 
 
YES
NO
               

17.    Is there an established grievane procedure that incorporates due process
in the resolution of complaints? If NO, explain

 
 
YES
NO
               

 
18.    Has a person been designated to coordinate Section 504 compliance
activities?  If NO, explain.

 
 
YES
NO
               

 
19.    Do recruitment and notification materials advise applicants, employees
and participatns to nondiscrimination on the basis of disabilty?  If NO,
explain.

 
 
YES
NO
               

 
20.    Are auxilary aids available to assure accessibility of services to
hearing and sight-impaired individuals?  If NO, explain.

 
 
YES
NO
               

 
PART IV. FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL
CONTRACTS OF $50,000.00 OR MORE.

21.    Do you have a written affirmation action plan?  If NO, explain.

 
 
YES
NO
               

 
 
 
DOEA USE ONLY
Reviewed By
 
In Compliance: YES NO
Program Office
 
*Notice of Corrective Action Sent
Date
 
Telephone
Response Due         /         /          
On-Site Desk Review
 
Response Received         /         /         

 
Revised May 2008, Page 2 of 2
 
 
 
 
 
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   July 2012   Contract XT220         

 
 

INSTRUCTIONS FOR THE CIVIL RIGHTS COMPLIANCE CHECKLIST
 
1.  
Describe the geographic service area such as a district, county, city or other
locality. If the program/facility serves a specific target population such as
adolescents, describe the target population. Also, define the type of service
provided.

 
2.  
Enter the percent of the population served by race and sex. The population
served includes persons in the geographical area for which services are provided
such as a city, county or other regional area. Population statistics can be
obtained from local chambers of commerce, libraries, or any publication from the
1980 Census containing Florida population statistics. Include the source of your
population statistics. (“Other” races include Asian/Pacific Islanders and
American Indian/Alaskan Natives.)

 
3.  
Enter the total number of full-time staff and their percent by race, sex and
disability. Include the effective date of your summary.

 
4.  
Enter the total number of clients who are enrolled, registered or currently
served by the program or facility, and list their percent by race, sex and
disability. Include the date that enrollment was counted.

 
5.  
Enter the total number of advisory board members and their percent by race, sex,
and disability. If there is no advisory or governing board, leave this section
blank.

 
6.  
Each recipient of federal financial assistance must have on file an assurance
that the program will be conducted in compliance with all nondiscriminatory
provisions as required in 45 CFR 80. This is usually a standard part of the
contract language for DOEA recipients and their sub-grantees, 45 CFR 80.4 (a).

 
7.  
Is the race, sex, and national origin of the staff reflective of the general
population? For example, if 10% of the population is Hispanic, is there a
comparable percentage of Hispanic staff?

 
8.  
Where there is a significant variation between the race, sex or ethnic
composition of the clients and their availability in the population, the
program/facility has the responsibility to determine the reasons for such
variation and take whatever action may be necessary to correct any
discrimination. Some legitimate disparities may exist when programs are
sanctioned to serve target populations such as elderly or disabled persons, 45
CFR 80.3 (b) (6).

 
9.  
Do eligibility requirements unlawfully exclude persons in protected groups from
the provision of services or employment? Evidence of such may be indicated in
staff and client representation (Questions 3 and 4) and also through on-site
record analysis of persons who applied but were denied services or employment,
45 CFR 80.3 (a) and 45 CFR 80.1 (b) (2).

 
10.  
Participants or clients must be provided services such as medical, nursing and
dental care, laboratory services, physical and recreational therapies,
counseling and social services without regard to race, sex, color, national
origin, religion, age or disability. Courtesy titles, appointment scheduling and
accuracy of record keeping must be applied uniformly and without regard to race,
sex, color, national origin, religion, age or disability. Entrances, waiting
rooms, reception areas, restrooms and other facilities must also be equally
available to all clients, 45 CFR 80.3 (b).

 
11.  
For in-patient services, residents must be assigned to rooms, wards, etc.,
without regard to race, color, national origin or disability. Also, residents
must not be asked whether they are willing to share accommodations with persons
of a different race, color, national origin, or disability, 45 CFR 80.3 (a).

 
12.  
The program/facility and all services must be accessible to participants and
applicants, including those persons who may not speak English. In geographic
areas where a significant population of non-English speaking people live,
program accessibility may include the employment of bilingual staff. In other
areas, it is sufficient to have a policy or plan for service, such as a current
list of names and telephone numbers of bilingual individuals who will assist in
the provision of services, 45 CFR 80.3 (a).

 
 
 
 
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   July 2012   Contract XT220   

 
13.  
Programs/facilities must make information regarding the nondiscriminatory
provisions of Title VI available to their participants, beneficiaries or any
other interested parties. This should include information on their right to file
a complaint of discrimination with either the Florida Department of Elder
Affairs or the U.S. Department of HHS. The information may be supplied verbally
or in writing to every individual, or may be supplied through the use of an
equal opportunity policy poster displayed in a public area of the facility, 45
CFR 80.6 (d).

 
14.  
Report number of discrimination complaints filed against the program/facility.
Indicate the basis, e.g., race, color, creed, sex, age, national origin,
disability, retaliation; the issues involved, e.g., services or employment,
placement, termination, etc. Indicate the civil rights law or policy alleged to
have been violated along with the name and address of the local, state or
federal agency with whom the complaint has been filed. Indicate the current
status, e.g., settled, no reasonable cause found, failure to conciliate, failure
to cooperate, under review, etc.

 
15.  
The program/facility must be physically accessible to disabled individuals.
Physical accessibility includes designated parking areas, curb cuts or level
approaches, ramps and adequate widths to entrances. The lobby, public telephone,
restroom facilities, water fountains, information and admission offices should
be accessible. Door widths and traffic areas of administrative offices,
cafeterias, restrooms, recreation areas, counters and serving lines should be
observed for accessibility. Elevators should be observed for door width and
Braille or raised numbers. Switches and controls for light, heat, ventilation,
fire alarms, and other essentials should be installed at an appropriate height
for mobility-impaired individuals.

 
16.  
Section 504 of the Rehabilitation Act of 1973 requires that a recipient of
federal financial assistance conduct a self-evaluation to identify any
accessibility barriers. Self-evaluation is a four step process:

 
a.  
With the assistance of a disabled individual/organization, evaluate current
practices and policies which do not comply with Section 504.

 
b.  
Modify policies and practices that do not meet Section 504 requirements.

 
c.  
Take remedial steps to eliminate any discrimination that has been identified.

 
d.  
Maintain self-evaluation on file. (This checklist may be used to satisfy this
requirement if these four steps have been followed.), 45 CFR 84.6.

 
17.  
Programs or facilities that employ 15 or more persons must adopt grievance
procedures that incorporate appropriate due process standards and provide for
the prompt and equitable resolution of complaints alleging any action prohibited
by Section 504.45 CFR 84.7 (b).

 
18.  
Programs or facilities that employ 15 or more persons must designate at least
one person to coordinate efforts to comply with Section 504.45 CFR 84.7 (a).

 
19.  
Continuing steps must be taken to notify employees and the public of the
program/facility’s policy of nondiscrimination on the basis of disability. This
includes recruitment material, notices for hearings, newspaper ads, and other
appropriate written communication, 45 CFR 84.8 (a).

 
20.  
Programs/facilities that employ 15 or more persons must provide appropriate
auxiliary aids to persons with impaired sensory, manual or speaking skills where
necessary. Auxiliary aids may include, but are not limited to, interpreters for
hearing impaired individuals, taped or Braille materials, or any alternative
resources that can be used to provide equally effective services, (45 CFR 84.52
(d).

 
21.  
Programs/facilities with 50 or more employees and $50,000.00 in federal
contracts must develop, implement and maintain a written affirmative action
compliance program in accordance with Executive Order 11246. 41 CFR 60 and Title
VI of the Civil Rights Act of 1964, as amended.

 
DOEA Form 101-B, Revised May 2008
 
 
 
 
 
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   July 2012   Contract XT220          ATTACHMENT D

 
 
Provider's State Contracts List
 

PROVIDER INFORMATION:        REPORT PERIOD:                  FROM           TO  
 Name:      Phone #:                  Address:      Email:                
 FEID:      Contact:                

 

   
Contract #
Contract/Program Name
State
Agency/Program
Start
Date
End
Date
Description of Contract
Purpose/Types of Services
Contract
Manager
Phone #
Contract
Amount
  1                        
2
                  $ -     3                   $ -     4                   $ -  
  5                   $ -     6                   $ -     7                   $
-     8                   $ -     9                   $ -     10                
  $ -     11                   $ -     12                   $ -     13          
        $ -     14                   $ -     15                   $ -     16    
              $ -     17                   $ -     18                   $ -    
19                   $ -     20                        
Total
     

 

 

   SIGNATURE:      DATE:                      TITLE:          

 
 
 
 
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   July 2012   Contract XT220          ATTACHMENT G

 
[logo_deptelderaffairs.jpg]
 BACKGROUND SCREENING
   Affidavit of Compliance

 
 

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

 AUTHORITY: This form is required annually of all employers to comply with the
attestation requirements set forth in section 435.05(3), Florida Statutes.

 
 
 
 
>  
The term "employer" means any person or entity required by law to conduct
background screening, including but not limited to. Area Agencies on Aging,
Aging Resource Centers, Aging and Disability Resource Centers, Lead Agencies,
Long-Term Care Ombudsman Program, Service Providers, Diversion Providers, and
any other person or entity which hires employees or has volunteers in service
who meet the definition of a direct service provider. See §§ 435.02, 430.0402,
Fla. Stat.

 
>  
A direct service provider is a person at least 18 years of age who, pursuant to
a program to provide services to the elderly, has direct face-to-face contact
with a client while providing services, or has access to the client's living
area, funds, or personal property.  A direct service provider also includes
coordinators, managers, and supervisors of residential facilties; and
volunteers. § 430.0402, Fla. Stat. 

 
ATTESTATION:
 
As the duly authorized representative of
WellCare of Florida, Inc. dba HealthEase

                         Employer Name
 
located at
  8725
HendersonRd                     Tampa                                  FL                                33634

Street
Address                                                         City                                                            State                                         Zipcode
 

I,  Christina Cooper
do hereby affirm under penalty of perjury, that level 2 background screening has
been conducted in compliance with the provisions of Chapter 435 and section
430.0402, Florida Statutes.

Name of Representative
 
 

   /s/Christina Cooper      Signature of Representative        6/26/12      Date

 
 
 

 STATE OF FLORIDA COUNT OF HILLSBOROUGH                          Sworn to or
affirmed) and subscribed before me this 26th day of June     , 2012, by  
 Christina
Cooper                                                                                         (Name
of Representative) who is personally known    to me or produced
_________________________________________________________ as proof of
identification.    
[Notary Stamp]
EMILY A. MERLIN
MY COMMISSION #DD 868288
EXPIRES: April 23, 2013
Bonded Thru Notary Public Underwriters
 /s/Emily A. Merlin                                             Print, Type, or
Stamp Commissioned Name of Notary Public  Notary Public      DOEA Form 235,
Affidavit of Compliane, Effective 9-1-11  Section 435.05(3), F.S.      Form
available at: http://elderaffairs.state.fl.us/english/backgroundscreening.php  

 
 
 
 
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   July 2012   Contract XT220          ATTACHMENT H

 
CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS
 
 
The undersigned, an authorized representative of the Contractor named in the
contract or agreement to which this form is an attachment, hereby certifies
that:
 
(1)  
The Contractor understands that pursuant to s. 287.135 F.S., any company at the
time of bidding or submitting a proposal for a new contract or renewal of an
existing contract, that is on the “Scrutinized Companies with Activities in
Sudan List” or the “Scrutinized Companies with Activities in the Iran Petroleum
Sector List (collectively, “the Lists”) is ineligible for, and may not bid on,
submit a proposal for, or enter into or renew a contract with the Department of
Elder Affairs (Department) for goods or services of $1 million or more.

 
(2)  
The Contractor understands that, pursuant to s. 287.135 F.S., any company that
submits a false certification to the Department is subject to civil penalties,
attorney’s fees and costs and any costs for investigations that led to the
finding of false certification.

 
(3)  
The Contractor understands that the contract to which this form is an attachment
may be terminated by the Department if the Contractor submits a false
certification or has been placed on the Lists.

 
This certification, required by Florida law, is a material representation of
fact upon which reliance was placed when this transaction was made or entered
into. Submission of this certification is a prerequisite for making or entering
into this transaction.
 
 

 /s/Christina Cooper    6/26/2012   Signature        Date  (Same as contract
signature)                        President, FL & HI Division     Ttitle        
               WellCare of Florida, Inc. dba HealthEase      Company Name      
         

 
 
 
 
 
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   July 2012   Contract XT220          ATTACHMENT J

 
 
 
VERIFICATION OF EMPLOYMENT STATUS CERTIFICATION
 
As a condition of contracting with the Department of Elder Affairs, WellCare of
Florida, Inc. dba HealthEase, hereby referred to as Contractor certifies the use
of the U.S. Department of Homeland Security’s E-Verify system to verify
employment eligibility of (a) all persons employed during the contract term to
perform employment duties within the State of Florida and (b) all persons
(including subcontractors) assigned by the Contractor to perform work pursuant
to the contract with the Department of Elder Affairs.
 

 Christina Cooper    6/26/2012   Signature        Date  (Same as contract
signature)                        President, FL & HI Division     Ttitle        
               WellCare of Florida, Inc. dba HealthEase      Company Name      
         

 
 
 
 
 
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   July 2012   Contract XT220          EXHIBIT A

 
 
CAPITATION RATES
Provider ID
Provider Name
County
Name
9/1/2011-8/31/2012
Diversion Capitation
Rate
0055758-00
WellCare of Florida, Inc.dba HealthEase
Escambia
$1,646.24
0055758-01
WellCare of Florida, Inc.dba HealthEase
Santa Rosa
$1,646.24

                      The following table lists the initial rates for
prospective expansions.
PSA
Counties
9/1/2011-8/31/2012
Diversion Capitation
Rate
     
1
Escambia, Okaloosa Santa Rosa, and Walton
$1,646.24
2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Taylor, Wakulla, and Washington
$1,430.59
3
    Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lake, Levy, Marion, Putman, Sumter, Suwannee, and Union
$1,448.38
4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
$1,347.32
5
Pasco and Pinellas
$1,459.66
6
Hardee, Highlands, Hillsborough, Manatee, and Polk
$1,427.22
7
Brevard, Orange, Osceola, and Seminole
$1,290.18
8
Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
$1,522.48
9
Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
$1,434.39
10
Broward
$1,423.05
11
Miami-Dade and Monroe
$1,553.55

 

 
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   July 2012   Contract XT220          EXHIBIT B

 
Long-Term Care Community Diversion Pilot Project
Disenrollment Summary Report
 
(Plan Name)
 
(Reporting Month)
 
 
    Were any disenrollments filed during this reporting month?
    YES □         NO □
 
  DISENROLLMENT 

 
Last Name
First Name
Medicaid
ID#
County
Name
Provider
Number
Disenrollment
Reason Code*
Disenrollment Reason
Occurrence Date
1
             
2
             
3
             
4
             
5
             

   *Disenrollement Reason Codes:

 EXP = Death    FRD = Fraudulent use of Medicaid or plan ID card    NET = Moved
to an out-of-network nursing home                ELG = Lost Medicaid eligibility
   INC = Incarceration    ALF = Moved to an out-of-network ALF              
 PRJ = Lost project eligibility    SDA = Dissatisfaction with quality and/or
quantity of services    OUT = No longer wish to participate in diversion program
               CTY = Moved outside of Contractor's service area        TFR =
Transfer to another provider                SUMMARY            Total
Disenrollments:                                                                
     

 

 
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   July 2012   Contract XT220          EXHIBIT C

 

Encounter Data Report
 
These data must be provided as reported quarterly in two ASCII fixed-length text
files. One file will contain long-term care services and a separate file will
contain acute care services. Each file will contain one (1) row/record for each
enrollee for each month they receive services. For example, if an enrollee were
enrolled for an entire quarter, you would include three separate rows/records in
each of the two files submitted for the quarter, where each row represents
services received during the one-month period. The acute care services would be
recorded in one file and long-term care services would be reported in the other.
These two files, the Long-Term Care Services file and the Acute Care Services
file, must be submitted once every quarter to your DOEA contract manager. The
Contractor has up to three months after the last month in a specific quarter to
submit the quarterly files (initial submission). Contractor resubmissions are
due no later than February of each year for the prior year’s initial
submissions.
 
If no units of service are provided in a particular category or if the category
is not applicable to you, fill that field with the specified number of spaces
(using the spacebar) that match that particular field length. Right justify all
fields unless noted otherwise. For amount paid, include the sum of Medicaid and
Medicare crossover claims (deductibles and co-payments for Medicare claims).
Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
enrollees who are also eligible for Medicare. If you have questions about the
definitions of these services please reference the appropriate Medicaid coverage
and limitations handbook for Medicaid State Plan Services. Note: Please do not
use commas between fields and round currency to the nearest dollar amount.
 
For individuals designated “Medicaid Pending” who do not yet have a Medicaid ID,
the Medicaid ID field must be set to “PENDING”.
 
The Encounter Data Report shall be submitted by the Contractor electronically to
the Department within three (3) months of the end of the reporting calendar
quarter.
 
The Contractor shall resubmit files with more current data during the subsequent
reporting quarter to replace the data previously submitted. The previously
submitted data will be discarded, and the more recent data will be utilized.
 
    FILE 1: Long-Term Care Services
Field Name
Description
Unit of Measurement
Field
Length
Start
Col.
End
Col.
Text/
Numeric
SSN
Social Security Number (left justify)
000000000
9
1
9
Numeric
MEDICAID
Medicaid ID Number
0000000000
10
10
19
Numeric
ENROLL
Initial Date of Program Enrollment
MMYYYY
6
20
25
Numeric
DISENROL
Date of Disenrollment, if Applicable
MMYYYY
6
26
31
Numeric
REINST
Reinstate date
MMYYYY
6
32
37
Numeric
ALF
ALF Resident Indicator
1=Yes; 2=No
1
38
38
Numeric
MONTH
Report Month
MMYYYY
6
39
44
Numeric
ADMINS
Administrative Costs
Amount Paid
6
45
50
Numeric
LONG-TERM
CARE
SERVICES
DESCRIPTION
UNIT OF SERVICE/ COST
       
ADCOMP
Adult Companion Services
15 Minute Unit
4
51
54
Numeric
ADCOMPS
Adult Companion Services
Amount Paid
6
55
60
Numeric
ADAYHLTH
Adult Dav Health Services
15 Minute Unit
4
61
64
Numeric
ADAYHL$
Adult Dav Health Services
Amount Paid
6
65
70
Numeric
ALFSVS
Assisted Living Services
Davs
2
71
72
Numeric
ALFSVS$$
Assisted Living Services
Amount Paid
6
73
78
Numeric
ATTCARE
Attendant Care Services
15 Minute
4
79
82
Numeric

 
 
 
 
 
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   July 2012   Contract XT220   

 
Field Name
Description
Unit of Measurement
Field
Length
Start
Col.
End
Col.
Text/
Numeric
   
Unit
       
ATTCARE$
Attendant Care Services
Amount Paid
6
83
88
Numeric
CASEAID
Case Aide
15 Minute Unit
4
89
92
Numeric
CASEAID$
Case Aide
Amount Paid
6
93
98
Numeric
CASEMGMT
Case Management (Internal)
15 Minute Unit
4
99
102
Numeric
CASEMGT$
Case Management (Internal)
Amount Paid
6
103
108
Numeric
CHORE
Chore Services
15 Minute Unit
2
109
110
Numeric
CHORES
Chore Services
Amount Paid
6
111
116
Numeric
COM MH
Community Mental Health
Visit
2
117
118
Numeric
COM MHS
Community Mental Health
Amount Paid
6
119
124
Numeric
CNMS SS
Consumable Medical Supplies
Amount Paid
6
125
130
Numeric
COUNSEL
Counseling
15 Minute Unit
4
131
134
Numeric
COUNSELS
 
Amount Paid
6
135
140
Numeric
DME SS
Durable Medical Eauipment
Amount Paid
6
141
146
Numeric
ENVIRAA
Environmental Accessibility Adaptations
Job
2
147
148
Numeric
ENVIRRAAS
Environmental Accessibility Adaptations
Amount Paid
6
149
154
Numeric
ESCORT
Escort Services
15 Minute Unit
4
155
158
Numeric
ESCORTS
Escort Services
Amount Paid
6
159
164
Numeric
FAMT I
Family Training Services (Individual)
15 Minute Unit
2
165
166
Numeric
FAMT IS
Family Training Services (Individual)
Amount Paid
6
167
172
Numeric
FAMT G
Family Training Services (Group)
15 Minute Unit
2
173
174
Numeric
FAMT GS
Family Training Services (Group)
Amount Paid
6
175
180
Numeric
FINARRS
Financial Assessment/Risk Reduction Services
15 Minute Unit
4
181
184
Numeric
FINARRS
Financial Assessment/Risk Reduction Services
Amount Paid
6
185
190
Numeric
FINM RRS
Financial Maintenance/Risk Reduction Services
15 Minute Unit
4
191
194
Numeric
FINM RRS
Financial Maintenance/Risk
Reduction
Services
Amount Paid
6
195
200
Numeric
HDMEAL
Home Delivered Meals
Meal
2
201
202
Numeric
HDMEALS
Home Delivered Meals
Amount Paid
6
203
208
Numeric
HOMESRVS
Homemaker Services
15 Minute Unit
4
209
212
Numeric
HOMESRVCS
Homemaker Services
Amount Paid
6
213
218
Numeric
MH CM
Mental Health Case Management
15 Minute Unit
4
219
222
Numeric
MH CMS
Mental Health Case Management
Amount Paid
6
223
228
Numeric
SNF
Nursing Facility Services- Long-term
Days
2
229
230
Numeric
SNF SS
Nursing Facility Services-Long-term
Amount Paid
6
231
236
Numeric
NUTR RRS
Nutritional Assessment/Risk Reduction Services
15 Minute Unit
4
237
240
Numeric
NUTR RRS
Nutritional Assessment/Risk
Reduction
Services
Amount Paid
6
241
246
Numeric
OT
Occupational Therapy
15 Minute
4
247
250
Numeric

 
 
 
 
 
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   July 2012   Contract XT220   

 
 
Field Name
Description
Unit of Measurement
Field
Length
Start
Col.
End
Col.
Text/
Numeric
   
Unit
       
OT$
Occupational Therapv
 
6
251
256
 
PCS
Personal Care Services
15 Minute Unit
4
257
260
Numeric
PC$
Personal Care Services
Amount Paid
6
261
266
 
PERS I
Personal Emergency Response Svstem Installation
Job
2
267
268
Numeric
PERS I$
Personal Emergencv Response Svstem Installation
Amount Paid
6
269
274
Numeric
PERS M
Personal Emergencv Response Svstem - Maintenance
Dav
2
275
276
Numeric
PERS M$
Personal Emergencv Response
Svstem-
Maintenance
Amount Paid
6
277
282
Numeric
PEST I
Pest Control - Initial Visit
Job
2
283
284
Numeric
PEST I$
Pest Control-Initial Visit
Amount Paid
6
285
290
Numeric
PEST M
Pest Control - Maintenance
Month
1
291
291
Numeric
PEST M$
Pest Control- Maintenance
Amount Paid
6
292
297
Numeric
PT
Phvsical Therapv
15 Minute Unit
4
298
301
Numeric
PT$
Phvsical Therapv
Amount Paid
6
302
307
Numeric
RISKREDU
Phvsical Risk Assessment and Reduction
15 Minute Unit
4
308
311
Numeric
RISKRED$
Phvsical Risk Assessment and Reduction
Amount Paid
6
312
317
Numeric
PRIVNURS
Private Dutv Nursing Services
15 Minute Unit
4
318
321
Numeric
PRIVNUR$
Private Dutv Nursing Services
Amount Paid
6
322
327
Numeric
PT R
Registered Phvsical Therapist
Visit
2
328
329
Numeric
PT R$
Registered Phvsical Therapist
Amount Paid
6
330
335
Numeric
RSPTH
Respiratorv Therapv
15 Minute Unit
4
336
339
Numeric
RSPTH$
Respiratorv Therapv
Amount Paid
6
340
345
Numeric
RESP HM
Respite Care - In Home
15 Minute Unit
4
346
349
Numeric
RESP HM$
Respite Care- In Home
Amount Paid
6
350
355
Numeric
RESP FAC
Respite Care - Facilitv-Based
Davs
2
356
357
Numeric
RESP FA$
Respite Care- Facilitv-Based
Amount Paid
6
358
363
Numeric
NURSE
Skilled Nursing
Visit
4
364
367
Numeric
NURSES
Skilled Nursing
Amount Paid
6
368
373
Numeric
SPTH
Speech Therapv
15 Minute Unit
4
374
377
Numeric
SPTHS
Speech Therapv
Amount Paid
6
378
383
Numeric
TRANSPOR
Transportation Services (not included in Escort or Adult Dav Health services)
Trips
3
384
386
Numeric
TRANSPORS
Transportation Services (not included in Escort or Adult Dav Health services)
Amount Paid
6
387
392
Numeric
OTH UNIT
Other LTC Service not listed (unit)
Unit/ Visit
6
393
398
Numeric
DESCR 1
Description of other LTC service
 
35
399
433
Text
OTH SS
Other LTC service not listed (amount)
Amount Paid
6
434
439
Numeric
DESCR 2
Description of other LTC service
 
35
440
474
Text

 
 
 
 
 
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   July 2012   Contract XT220   

 
 
    File 2: Acute Care Services
Code
Field Name
Description
Unit of
 Measurement
Field
Length
Start
Col.
End
Col.
Text/
Numeric
 
ACUTE
SERVICES
DESCRIPTION
UNITS OF
SERVICE/ COST
         
SSN
Social Security Number (left justify)
000000000 9 1 9
Numeric
 
MEDICAID
Medicaid ID Number
0000000000 10 10 19
Numeric
 
MONTH
Report Month
MMYYYY
6 20 25
Numeric
 
CLINIC
Clinic Services
Visit
2 26 27
Numeric
 
CLINIC$$
Clinic Services Costs
Amount Paid
6 28 33
Numeric
 
DENTAL
Dental Services
Visit
6 34 39
Numeric
 
DENTAL$$
Dental Services Costs
Amount Paid
6 40 45
Numeric
 
DIALYSIS
Dialysis Center
Visit
2 46 47
Numeric
 
DIALYS$$
Dialysis Center Costs
Amount Paid
6 48 53
Numeric
 
ER
Emergency Room Services
Visit
2 54 55
Numeric
 
ER_$$
Emergency Room Services Costs
Amount Paid
6 56 61
Numeric
 
FQHC
FQHC Services
Visit
2 62 63
Numeric
 
FQHC_$$
FQHC Services Costs
Amount Paid
6 64 69
Numeric
 
HEAR
Hearing Services including hearing aids
Amount Paid
6 70 75
Numeric
 
INPTSVS
Inpatient Hospital Services
Day
3 76 78
Numeric
 
INPTSV$$
Inpatient Hospital Services Costs
Amount Paid
6 79 84
Numeric
 
LAB
Independent Laboratory or Portable X-ray Services
Amount Paid
6 85 90
Numeric
 
ARNP
Nurse Practitioner Services
Visit
2 91 92
Numeric
 
ARNP_$$
Nurse Practitioner Services Costs
Amount Paid
6 93 98
Numeric
 
RX_$$
Pharmaceuticals
Amount Paid
6 99 104
Numeric
 
PA
Physical Assistant
Visit
2 105 106
Numeric
 
PA_$$
Physical Assistant Costs
Amount Paid
6 107 112
Numeric
 
MD
Physician Services
Visit
2 113 114
Numeric
 
MD_$$
Physician Services Costs
Amount Paid
6 115 120
Numeric
 
OUTPT
Outpatient Hospital Services
Encounter
3 121 123
Numeric
 
OUTPT_$$
Outpatient Hospital Services Costs
Amount Paid
6 124 129
Numeric
 
PODIATRY
Podiatry
Visit
2 130 131
Numeric
 
PODIAT$$
Podiatry Costs
Amount Paid
6 132 137
Numeric
 
RURAL
Rural Health Services
Visit
2 138 139
Numeric
 
RURAL$$
Rural Health Services Costs
Amount Paid
6 140 145
Numeric
 
SNFREHA
Skilled nursing facility services- rehabilitation
Days
2 146 147
Numeric
 
SNFREHA$
Skilled nursing facility services- rehabilitation**
Amount Paid
6 148 153
Numeric
 
EYE_$$
Visual Services including eyeglasses
Amount Paid
6 154 159
Numeric
 
OTH_UNIT
Other Acute Service not listed (unit)
Unit/ Visit
6 160 165
Numeric
 
OTH_$$
Other Acute service not listed (amount)
Amount Paid
6 166 171
Numeric
 
DESCR_1
Description of other Acute service
  35 172 206
Text

 
 
 
 
 
 
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   July 2012   Contract XT220   

 
 
Code
Field Name
Description
Unit of
Measurement
Field
Length
Start
Col.
End
Col.
Text/
Numeric
 
DESCR_2
Description of other Acute service
  35 207 241
Text

 
**Medicare Crossovers
 
 
Encounter Data File Naming Format
Replace *** with the Contractor’s prearranged 3-character file code, MON with
the beginning month of the reporting quarter and YY with the reporting year.
 

 
Long-Term Care Services
Acute Care Services
Data File
*** MON YY LTC.txt
*** MON YY ACS.txt
Validation Report
*** MON YY LTC DV.pdf
*** MON YY ACS DV.pdf
Certification File (if applicable)
*** MON YY LTC CERT.doc
*** MON YY ACS CERT.doc
ZIP file
*** MON YY.zip

 
 
 
 
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   July 2012   Contract XT220          EXHIBIT D

 

Report of Grievances/Appeals/Complaints
(Plan Name)
(Reporting Quarter)
Were any new grievances filed during this reporting quarter?  YES o   NO o
 

 
Enrollee’s
Last Name
Enrollee’s
First Name
Enrollee’s
Medicaid ID#
Grievance
Type *
Grievance
Date
Expedited
Request?
(Y or N)
Disposition
 Type **
Disposition
Date
Resolved?
(Y or N)
 1                    2                    3                    4              
     5                  

 
 
Were any new grievances filed during this reporting quarter?  YES o   NO o
 

 
Enrollee’s
Last Name
Enrollee’s
First Name
Enrollee’s
Medicaid ID#
Appeals
Type *
Appeals
Date
Expedited
Request?
(Y or N)
Disposition
 Type **
Disposition
Date
Resolved?
(Y or N)
 1                    2                    3                    4              
     5                  

 
 
Were any new grievances filed during this reporting quarter?  YES o   NO o
 

 
Enrollee’s
Last Name
Enrollee’s
First Name
Enrollee’s
Medicaid ID#
Complaints
Type *
Complaints
Date
Elevated to a
Grievance ?
(Y or N)
Disposition
 Type **
Disposition
Date
Resolved?
(Y or N)
 1                    2                    3                    4              
     5                  

 
 

 *Grievance/Appeals/Complaint Type    ** Disposition Type                1 =
Quality of Care      7 = Enrollment/Disenrollment    1 = Reassigned Case Manager
   7 = Disenrolled Self                2 = Access to Care      8 = Termination
of Contract    2 = Service Added to Care Plan    8 = Disenrolled by plan        
       3 = Not Medically Necessary svcs      9 = Unauthorized out of plan    3 =
Service Increased    9 = In QA Review                4 = Excluded Benefit    10
= Unauthorized in-plan svcs    4 = Changed to Another Provider    10 = In
Grievance / Appeal Process                5 = Billing Dispute    11 = Benefits
available in plan    5 = Reenrolled in Plan    11 = Lost Contact with Enrollee  
                 12 = Medicare Issue        12 = Referred to Medicare  6 =
Contract Interpretation                  13 = Other (If used must be described)
   6 = Billing Issue Resolved    13 = Other (if used must be described)

 
 
 
 
 
 
 
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   July 2012   Contract XT220          EXHIBIT E

 
Provider Network and Staffing Report
 

Plan Name   Street   City, FL ZIP   Phone:   FAX:      County of Service: Plan
Contact Person:   Email:    Date Revised:  

(A)
(B)
(C)
(D)
(E)
(F)
(G)
(H)
(I)
(J)
(K)
(L)
(M)
(N)
Covered Services
Number of
Qualified Service Providers per county
(EXPANSIONS
ONLY)
Provider
Name (as it appears on license)
Type of License
Held (ex: HHA)
Travel
Time / Approx #
miles*
(EXPANSIONS
ONLY; ONLY
SERVICES
PROVIDED
OUTSIDE OF
HOME)
 
Name of
Provider
Contact
Phone
Number
Street Address
City
State
Zip
Code
License
Number(if
not
applicable
put N/A)
Tax I.D.
Number or
SSN
 
 
 
Is this
provider
qualified to provide
services according to Appendix 4 of
the NHD contract?
(Y/N)
 
 
Adult Companion Services
                         
Adult Companion Services
                         
Adult Day Health Services
                         
Adult Day Health Services
                         
Assisted Living Services
                         
Assisted Living Services
                         
Case Management Services
                         
Chore Services
                         
Chore Services
                         
Consumable Medical Supply Services
                         
Consumable Medical Supply Services
                         
Dental
                         
Dental
                         

 

 
 
 
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   July 2012   Contract XT220   

 
Environmental Accessibility Adaptation Services
                         
Environmental Accessibility Adaptation Services
                         
Escort Services
                         
Escort Services
                         
Family Training Services
                         
Family Training Services
                         
Financial Assessment/Risk Reduction Services
                         
Financial Assessment/Risk Reduction Services
                         
Hearing
                         
Hearing
                         
Home Delivered Meals
                         
Home Delivered Meals
                          Homemaker Services                           Homemaker
Services                          
Nursing Facility Services
                         
Nursing Facility Services
                          Nutritional Assessment/Risk Reduction Services        
                  Nutritional Assessment/Risk Reduction Services                
          Occupational Therapy                           Occupational Therapy  
                        Personal Care Services                          
Personal Care Services                           Personal Emergency Response
Systems (PERS):                           Personal Emergency Response Systems
(PERS):                           Physical Therapy                          
Physical Therapy                           Respiratory Therapy                  
        Respiratory Therapy                           Respite Care Services    
                      Respite Care Services                           Speech
Therapy                           Speech Therapy                          
Vision                           Vision                          
Optional Services
                                                      Expanded Services        
                 

 
 
 
 
 
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   July 2012   Contract XT220   

 
Staff Positions
Staff Name
Contact Phone Number
Fax Number
Email
Administrator
       
Medical Director
       
Health Information System Director
       
Quality Review Director
       
Utilization Review Director
       
Data Management Director
       
Grievance and Appeals Director
       
Case Management Supervisor
                 

Note:    A strikethrough and a termination date shall indicate the terminated
providers. All new provider cells shall be blue. The first page and Signature
page of the subcontract, copy of current license and the confirmation letter
will be submitted for each new provider added to the network.

 
*This column applies to expansions into underserved counties, when enrollees
must travel outside county lines to receive services. Distance should be
measured from the county line to the service provider’s location.

 
 
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   July 2012   Contract XT220          EXHIBIT F

 
ENROLEE SATISFACTION SURVEY
 
 

Confirm Enrollment in Program
 
1.  
Our records show that you are now in «PLAN NAME»’s Diversion Program. Is that
right?

 

1 o  Yes 2 o  No

 

Assess Enrollment Duration
 
2.  
How many months or years in a row have you been in the Diversion Program?

 

1 o  Less than 6 months 2 o  At least 6 months but less than 1 year 3 o  At
least 1 year but less than 2 years 4 o  At least 2 years but less than 5 years 5
o  5 or more years

 
Assess Care Manager

 
3.  
When you first enrolled with «PLAN NAME»’s Diversion Program, did your Care
Manager contact you prior to your effective date?

 

1 o  Yes 2 o  No

 
 
4.  
Since you joined «PLAN NAME»’s Diversion Program, how much of a problem, if any,
was it to get in contact with your Care Manager?

 

1 o Very easy 2 o Easy 3 o Somewhat easy 4 o A little difficult 5 o Very
difficult

 
5.  
Using any number from 0 to 10 where 0 is the worst Care Manager possible and 10
is the best Care Manager possible, what number would you use to rate your Care
Manager?

 

0 o 0    Worst Care Manager possible 1 o 1 2 o 2 3 o 3 4 o 4 5 o 5 6 o 6  7 o 7
 8 o 8  9 o 9  10 o 10    Best Care Manager possible

 

 
 
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   July 2012   Contract XT220   

 
Assess Assisted Living Facility
 
6.  
In the last 6 months, have you received services in an Assisted Living Facility
that were provided by «PLAN NAME»’s Diversion Program?

 

1 o  Yes      →      Go to Question 7 2 o  No        →  Go to Question 9

 
7.  
Where the Assisted Living Facility services you received delivered in a timely
manner?

 

1 o  Yes 2 o  No

 
 
8.  
Using any number from 0 to 10 where 0 is the worst quality of services possible
and 10 is the best quality of services possible, what number would you use to
rate the quality of the Assisted Living Facility services you received through
«PLAN NAME»’s Diversion Program?

 

0 o 0    Worst Quality of Servies possible 1 o 1 2 o 2 3 o 3 4 o 4 5 o 5 6 o 6
 7 o 7  8 o 8  9 o 9  10 o 10    Best Quality of Services possible

 

 
9.  
In the last 6 months, did you try to get information or help from «PLAN NAME»’s
customer service?

 

1 o  Yes      →      Go to Question 10 2 o  No      →  Go to Question 11

 
10.  
In the last 6 months, how often did «PLAN NAME»’s customer service give you the
information or help you needed?

 

1 o Never 2 o Sometimes 3 o Usually 4 o Always

 
 
 
 
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   July 2012   Contract XT220   

 
 
11.  
Using any number from 0 to 10 where 0 is the worst program possible and 10 is
the best program possible, what number would you use to rate «PLAN NAME»’s
Nursing Home Diversion Program?

 

0 o 0    Worst Program possible 1 o 1 2 o 2 3 o 3 4 o 4 5 o 5 6 o 6  7 o 7  8 o
8  9 o 9  10 o 10    Best Program possible

 
About the Member
 
12.  
In general, how would you rate your overall health?

 

1 o Excellent 2 o Very Good 3 o Good 4 o Fair 5 o Poor

 
13.  
After joining «PLAN NAME»’s Diversion Program, how much has your quality of life
improved?

 

1 o Not improved 2 o Improved a little 3 o Improved a lot

 
Survey completed by
 

1 o Person to whome the survey was addressed 2 o Family member or relative of
person to whom the survey was addressed 3 o Friend of person to whom the survey
was addressed 4 o Professional caregiver of person to whom the survey was
addressed

 
 
 
 
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   July 2012   Contract XT220          EXHIBIT G

 
 
 
 
 
 Insert Contractor Letterhead
 

Long-Term Care Community Diversion Expansion Request Subcontractor Confirmation
Letter
 
I,____________________________________(insert signatory’s name), hereby verify
that__________________________________________________________________________________________________(insert
subcontractor’s entity name/dba name if applicable) is a subcontracted
entity/participant in the Long-Term Care Community Diversion Pilot Project
provider network
for_________________________________________________________________________________________________
insert PLAN name) in the following county (ies) of service:
 
 
 

 o  Alachua  o  Baker  o  Bay  o  Bradford  o  Brevard  o  Broward  o  Calhoun
 o  Charlotte o  Citrus o  Clay  o  Collier  o  Columbia  o  DeSoto  o  Dixie o
 Duval  o  Escambia  o  Flager  o  Franklin  o  Gadsden  o  Gilchrist o  Glades
 o  Gulf  o  Hamilton  o  Hardee  o  Hendry  o  Hernando o  Highlands  o
 Hillsborough  o  Holmes  o  Indian River  o  Jackson  o  Jefferson o  Lafayette
 o  Lake  o  Lee  o  Leon  o  Levy  o  Liberty o  Madison  o  Manatee  o  Marion
 o  Martin  o  Miami-Dade  o  Monroe o  Nassau  o  Okaloosa  o  Okeechobee  o
 Orange o  Osceola  o  Palm Beach o  Pasco  o  Pinellas  o  Polk  o  Putnam  o
 St. Lucie  o  St. Johns o  Santa Rosa  o  Sarasota  o  Seminole  o  Sumter o
 Suwannee  o  Union o  Volusia  o  Wakulla  o  Walton  o  Washington

 
    I confirm that the above-named entity will be providd the service(s)
indicated below for enrollees in the Long-Term Care Community Diversion Pilot
Project on behalf of
___________________________________________________________________(insert
PLAN's name).
 
 

 o Adult Companion Services o  Adult Day Health Services o  Assisted Living
Services  o  Chore Services o  Consumable Medical Supplies o  Dental Services  o
 Environmental Accessibility Adaptation o  Escort Services o  Family Training
Services  o  Financial Assessment/Risk Management o  Hearing Services o  Home
Delivered Meals  o  Homemaker Services o  Nursing Facility Services o
 Nutrition/Risk Reduction  o  Occupational Therapy o  Personal Care Services o
 PERS  o  Physical Therapy o  Respite Care Services o  Speech Therapy  o  Vision
Services o  Respiratory Therapy o
 Other

 
 
 

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

(Print Name)                (Sign Name)                   (Position
Title)             (Date)
 
 
 

Subcontractor Information (as it appears on license) Entity Name: DBA: Address:
City:                                         FL                         Zip
Business Telephone Number: (xxx) xxx-xxxx                         Ext. Alternate
Telephone Number: (xxx)
xxx-xxxx                        o cell     o business     o other Service
County:                                                 License Exp Date:
xx/xx/xxxx

 
 
 
 
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   July 2012   Contract XT220          EXHIBIT H

 
                                                           
Long-Term Care Communitv Diversion Pilot Project
Reconciliation Report
For (Contractor name) (Month/Year)
 

 
Medicaid ID
Number
First Name
Last Name
Provider
Number
Beginning to
Ending Months
Error
Comments
1
             
2
             
3
             
4
             
5
             
6
             
7
             
8
             
9
             
10
             

 
 
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   July 2012   Contract XT220          EXHIBIT I

 

DEPARTMENT OF ELDER AFFAIRS
LONG-TERM CARE DIVERSION PILOT PROJECT
REQUEST FOR DISENROLLMENT
 
 

     COUNTY:      CURRENT PROVIDER NAME:                    PROVIDER ADDRESS:  
               TELEPHONE NUMBER:  (           )  FAX:  (              )        
   

 

 PARTICIPANT NAME:                  MEDICAID #:    DOB:    TELEPHONE NUMBER:
(          )                  PARTICIPANT ADDRESS:                    COUNTY:  
   

 
  Does enrollee wish to file a grievance?     [ ] Yes [ ] No
VOLUNTARY (Check one):
       
□
Dissatisfied with services (SVR)
 
   □     No longer wish to participate in diversion program (OUT)
□
Moving to out-of-network nursing home
   □     Moving to out-of-network ALF (ALF)
 
(NET)
   

 
□
Transfer to a new provider.
   
Name of new provider if
known:_______________________________________________________
County:____________________________________________
     

 
COMMENTS:
 
__________________________________________________________                                   
_________________________________
Signature of Participant or Authorized
Representative                                                                           Date
 
__________________________________________________________                                  ________________________________________________________________
If representative, please print
name                                                                                   Please
state relationship to participant
 
 

 

FOR DIVERSION PROVIDER USE ONLY
 
INVOLUNTARY (Check one):
□
Death (Date: __________________________________________) (EXP)
□      Fraudulent use of Medicaid ID card (FRD)
□
Not eligible for Medicaid (ELG)
□      Incarceration (INC)
□
Not eligible for project (PRJ)
□      Subject to Department of Elder Affairs approval
□
Moving out of the service area (CTY)
(SDA)

 
 

 EFFECTIVE DATE OF DISENROLLMENT:             Case Manager Signature     Date
CARES Office Notifed                     Program Administrator Signature    
CARES Fax Number

 
 
 
 
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   July 2012   Contract XT220   

  
DEPARTMENT OF ELDER AFFAIRS
LONG-TERM CARE DIVERSION PILOT PROJECT
SOLICITUD PARA DARSE DE BAJA
 
 

     Condado:      Nombre actual del proveedor:                    Dirección del
proveedor:                  Número de teléfono:  (           )  FAX:
 (              )            

 
 

 Nombre del participante:                  Número del Medicaid:    Fecha de
nacimiento:    Número de teléfono: (          )                  Dirección del
participante:                    Condado:      

 
  ¿DESEA COMUNICAR ALGUNA QUEJA?     [ ] Sí [ ] No
 
VOLUNTARY (Marque las que se aplican):
       
□
No está satisfecho con el servicio (SVR)
 
   □     No desea participar en el programa de cuidado a largo plazo o Nursing
Home Diviersion (OUT)
□
Se muda a una clínica de reposo fuera del área
   □     Se muda a una residencia de vivienda asistida fuera del área (ALF)
 
(NET)
   

 
□
Transfererido a un proveedor diferente.
   
Por favor indique el nombre del nuevo
proveedor:_______________________________________________________
Condado:____________________________________________
     

 
COMMENTS:
 
__________________________________________________________                                   
_________________________________
firma del participante o representante
autorizado                                                                                Fecha
__________________________________________________________                                  ________________________________________________________________
Si es representante, por favor escriba su nombre en letra de
molde                                                     Por favor indique su
relación con el participante
 

 

PARA USO DEL PROVEEDOR DE CUIDADO A LARGO PLAZO (NHD)
 
INVOUNTARIO (MARQUE LAS QUE APLIQUEN):
□
Fallecimiento (Fecha: __________________________________________) (EXP)
□      Uso fraudulento de la tarjeta de Medicaid (FRD)
□
No es elegible para Medicaid (ELG)
□      Encarcelamiento (INC)
□
No es elegible para el programa (PRJ)
□      Sujeto a aprobación del Departamento de Asuntos de las Personas Mayores o
Elder Affairs (SDA)
□
Se mudó fuera del área de servicio (CTY)
 

 
 

 Fecha de desenlistamiento:             Firma del manejador de caso     Fecha de
notificación a las oficinas de CARES                     Firma del administrador
del programa     Número de fax de la oficina de CARES

 
 
 
 
 
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   July 2012   Contract XT220          EXHIBIT J

 

 

Subcontractor Abuse, Neglect, and Exploitation Training Attestation Report
Type of Service
Provider
Name
Name of
Provider
Contact
Phone
Number
Street
Address
City
State
Zip
Code
Received Attestation Confirming all Mandated Reporters have Received Abuse,
Neglect, and Exploitation Training (Y/N and Date Received)
                                                                               
                                         

 
 
 
 
 
 
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   July 2012   Contract XT220          EXHIBIT K

 
FLORIDA NURSING HOME DIVERSION PROGRAM

 
 
 
 
 
 
[logo_deptelderaffairs.jpg]
 
 
 
 
FINANCIAL REPORTING PACKAGE FOR
FLORIDA NURSING HOME DIVERSION CONTRACTORS
 
 
 
 
 
 
 
 
 
 
Revision Date:  September 2007
 
 
 
 
 
 
 
 
 
 
 
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TABLE OF CONTENTS
 
 
GENERAL INFORMATION
 

 1.01  Purpose, Objective, and General Instructions  3  2.0  INSTRUCTIONS FOR
COMPLETION OF REPORTING FORMS    2.01  contractor Information and Certification
statement  4  2.02  Report 1 Balance Sheet  4  2.03  Report 2 NHD Specific
Income Statement by Category of Service  8  2.04  Report 2A Income Statement by
Line of Business  16  2.05  Report 3 Net Worth and Working Capital  17  2.06
 Report 4 NHD Only Claims Lag Reports and Outstanding Claim Liability  18  2.07
 Report 5 NHD Analysis of Total Medical Liability to Actual Claims Paid  18
 2.08  Report 6 Enrollment/Member Months  18  2.09  Notes and other Information
 18  2.10  Ratio Analysis  18  3.0  FOOTNOTE DISCLOSURE REQUIRMENTS    3.01
 Footnote Disclosures  19

 
 
 
 
 
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 1.0   GENERAL INFORMATION        1.01   Purpose, Objective and General
Instructions of the Financial Reporting Guide           The purpose of the
Financial Reporting Guide (Guide) for the Florida Nursing Home Diversion Program
(NHD) is to set forth the financial reporting requirements for Program
Contractors (Contractors). The primary objective of the Guide is to establish
consistency and uniformity in financial reporting. This Guide is neither
intended to limit the scope of audit procedures to be performed during the
Contractor’s annual certified audit, nor to replace the independent Certified
Public Accountant's judgment as to the work to be performed.          
The Department of Elder Affairs (Department) and the Florida Agency for Health
Care Administration (Agency) will use these reports to monitor the financial
health of the Contractors as well as the results of their operations. The
Department reserves the right to audit these reports in part, or whole, at the
Department’s discretion.
         
If there are any inconsistencies between the Guide and any contract provisions,
the contract provisions shall prevail. This Guide is not intended nor should it
be construed as an all-inclusive manual. The format and content of the required
reports are subject to change.
         
Contractors are required to utilize the Financial Statement Reporting Templates
provided with these instructions. The reports that must be completed are
contained with the appendix to this package. The reports must be completed in an
excel format and submitted to the Department.
         
These reports are to be completed quarterly (on a calendar year basis) and are
due within 60 days of the end of the quarter. Resubmissions may be filed with
approval from the Department. The Contractor shall also submit the audited
financial reports within 6 months of the end of the fiscal year to the
Department.
         
Report line titles and column headings are detailed in the report specific
paragraphs later in this Guide. Utilize the predefined categories or
classifications before reporting an amount as "Other". For any amounts included
in the "Other" categories, provide details and explanations on the appropriate
“Write- ins” page.
         
If information is not available, or applicable, leave the space provided blank.
All amounts are to be reported in whole dollars. Only cells highlighted in
yellow should be completed by the Contractor. Cells highlighted in blue are
automatically calculated within the report.
         
Utilize the Notes and Other Information tab to indicate and provide information
that cannot be reported within the main context of the required reports. Please
provide the specific report number and reference of the additional information
being provided.

 

2.0   INSTRUCTIONS FOR COMPLETION OF REPORTING FORMS        1.01   Contractor
Information and Certification Statement          
The purpose of the Contractor Information is to identify the reporting entity
and reporting period of the submitted reports. In addition, general information
such as a list of Officers and Directors along with the filing status of the
Contractor is requested to provide background on the Contractor.
         
The purpose of the certification statement is to attest that the information
submitted in the reports is current, complete and accurate. The statement should
be signed and dated by the Contractor’s Chief Executive Officer/President and
the Contractor’s Chief Financial Officer. This certification must be signed with
the Contractor Information that includes the Contractor name, address, reporting
period ending, and Contractor fiscal year ending.

 
 
 
 
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 2.02
Report 1 Balance Sheet

 
 
The balance sheet is to report all assets and liabilities of the Contractor in
total and does not relate to the NHD Program specifically. This is a Contractor
wide Balance Sheet (i.e. should represent the entire legal reporting entity).

 

 
CURRENT ASSETS

 
Assets that can be converted into cash or consumed within one year from the
balance sheet date. Restricted assets are not to be included as current assets.

 
 
 
100 - Cash and Cash Equivalents

  Include:    
Cash and cash equivalents, available for current use. Cash equivalents are
investments maturing 90 days or less from the date of purchase.

 
  Exclude:    
Restricted cash (and equivalents) and any cash (and equivalents) pledged by the
Contractor to satisfy insolvency and surplus requirements.

 
 
102 - Short-term Investments

  Include:    
Investments that are readily marketable or that are to be redeemed or sold
within one year of the balance sheet date.

 
  Exclude:    
Investments maturing 90 days or less from the date of purchase and restricted
securities. Also exclude investments pledged by the Contractor to satisfy
insolvency and surplus requirements.

 
 
104 - Premium/Capitation Receivable

  Include:    
Net amounts receivable for premiums and capitation payments as of the balance
sheet date.

 
 
106 - Interest Receivable

  Include:    
Interest income earned but not yet received from cash equivalents, investments,
on-balance sheet performance bonds, and short and long-term investments.

 
 
108 - Other Receivables

  Include:    
Any amount due to Contractor not included in accounts 104 or 106.

 
 
110 - Prepaid Expenses

  Include:    
Any amount paid by the Contractor in advance for expenses not yet incurred.

 
 
112 - Other Aggregate Write-Ins

  Include:    
Other current assets that are not accounted for elsewhere in accounts 100, 102,
104, 106, 108, or 110. These other current assets should be recorded in Tab 1-
Balance Sheet Write-ins. Due from Affiliates, Provider Advances/Receivables, and
Tax Receivables are accounted for in this line item. Provider
Advances/Receivables should be accounted for in this line item, and should not
be netted against Claims Payables and/or IBNRs. Please provide a detail
description of other write-ins for those that comprise at least 5 percent of
total current assets.

 
  Exclude:    
Amounts due to affiliates.

 
 
 
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OTHER ASSETS
 
 
120 - Restricted Funds (NHD Surplus)

  Include:    
All cash and investments pledged to meet the NHD Surplus requirement.

 
          122 - Restricted Funds (NHD Insolvency)
 
Include:     All cash and investments pledged to meet the NHD Insolvency
requirement.

 
           124 - All Other Restricted Funds
 
Include:      Cash, securities, receivables, etc., whose use is restricted.

 
           126 - Long-term Investments
 
Include:      Investments that are to be held longer than one year.

 
 
Exclude:      Investments pledged by the Contractor to satisfy insolvency and
surplus requirements

 
                           128 - Intangibles/Goodwill
 
Include:      The net amount of intangible assets and/or goodwill.

 
           130 - Other Aggregate Write-ins
  Include:     
Other assets that are not accounted for elsewhere in accounts 120, 122, 124,
126, and 128. These other assets should be recorded in Tab 1-Balance Sheet
Write-ins. Security Deposits, Due from Affiliates, and Tax Receivables are
accounted for in this line item. Please provide a detail description of other
write-ins for those that comprise at least 5 percent of total other assets.

 
PROPERTY, PLANT & EQUIPMENT (NET OF DEPRECIATION)
 
           140 - Land
 
Include:      Real estate owned by the Contractor.

 
           142 - Buildings & Improvements (Net of Depreciation)
 
Include:     Buildings owned by the Contractor, including buildings under a
capital lease, and improvements to buildings owned by the Contractor. All
amounts are reported net of accumulated depreciation.

 
 
Exclude:     Improvements made to leased or rented buildings or offices.

 
           144 - Construction in Progress (Net of Depreciation)
 
Include:     All building and other major construction projects not completed.
All amounts are reported net of accumulated depreciation.

 
           146 - Furniture & Equipment (Net of Depreciation)
 
Include:     Medical equipment, office equipment, data processing hardware and
software (where permitted), and furniture owned by the Contractor, as well as
similar assets held under capital leases. All amounts are reported net of
accumulated depreciation.

 
           148 - Leasehold Improvements (Net of Depreciation)
 
Include:     Capitalized improvements made to facilities not owned by the
Contractor.

 
           150 - Other Aggregate Write-ins
 
 
 
 
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  Include:    
All other tangible assets that are not accounted for elsewhere in accounts 140,
142, 144, 146, and 148. These assets should be recorded in Tab 1-Balance Sheet
Write-ins. Computer Software and Vehicles are accounted for in this line item.
Please provide a detail description of other write-ins for those that comprise
at least 5 percent of total Property, Plant & Equipment.

 
CURRENT LIABILITIES
Obligations that are reasonably expected to be paid within one year from the
balance sheet date.
 
           200 - Accounts Payable
 
Include:     Amounts due to creditors for the acquisition of goods and services
(trade and administrative vendors) on a credit basis.

 
 
Exclude:    Amounts due to providers related to the delivery of health care
services.

 
           202 - Outstanding Claims Liability (OCL)
  Include:    
The total amount of received but unpaid claims of the Contractor. This
represents the claims that have been received by the Contractor but as of the
date of the report have not been paid. In addition, this includes all estimated
amounts for claims incurred by the Contractor that have not been reported
(IBNR).

 
           204 - Accrued Provider Incentive Pool
 
Include:     The estimated payable to providers for incentives that have been
earned by the providers but not yet paid.

 
           206 - Capitation Payable
 
Include:     Net amounts owed to providers for monthly capitation.

 
 
Exclude:     Capitation amounts payable as a result of an underpayment or
unearned premiums.

 
           208 - Unearned Premiums
 
Include:     The total portion of premiums received by the Contractor for which
the revenue will be recorded/earned in a subsequent period.

 
           210 - Current Portion of Loans & Notes Payable
 
Include:     The total current portion from the principal amount on loans,
notes, and capital lease obligations due within one year of the balance sheet
date.

 
 
Exclude:     Long-term portion of and accrued interest on loans, notes, and
capital lease obligations.

 
           212 - Other Aggregate Write-ins
  Include:    
All other current liabilities that are not accounted for elsewhere in accounts
200, 202, 204, 206, 208, 210, and 212. These current liabilities should be
recorded in Tab 1-Balance Sheet Write-ins. Accrued Salaries, Taxes Payable, and
due to Affiliates are accounted for in this line item. Please provide a detail
description of other write-ins for those that comprise at least 5 percent of
total current liabilities.

 
OTHER LIABILITIES
Obligations that are reasonably expected to be paid more than one year from the
date of the balance sheet.
 
           220 - Long-Term Portion of Loans & Notes Payable
 
 
 
 
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Include:     The total non-current portion of the principal on loans, notes, and
capital lease obligations.

 
 
Exclude:     Current portion of long-term debt and accrued interest on loans,
notes, and the current portion of capital lease obligations.

 
           222 - Statutory Liabilities
 
Include:     The total amount of any Statutory Liabilities.

 
           224 - Other Aggregate Write-Ins
  Include:    
All other liabilities that are not accounted for elsewhere in accounts 220 and
222. These liabilities should be recorded in Tab 1-Balance Sheet Write-ins. Due
to Affiliates and Other Contingencies are accounted for in this line item.
Please provide a detail description of other write-ins for those that comprise
at least 5 percent of total other liabilities.

 
EQUITY/NET ASSETS (LIABILITIES)
Includes preferred stock, common stock, treasury stock, additional paid-in
capital, contributed capital, restricted net assets, unrestricted net assets,
unrealized gains and losses on investments, and retained earnings/fund balance.
 
           300 - Contributed Capital
 
Include:     Capital paid or donated to the Contractor.

 
           302 - Common Stock
 
Include:     Total par value of Common Stock or in the case of no-par shares,
the stated or liquidation value.

 
           304 - Preferred Stock
 
Include:     Total par value of Preferred Stock or in the case of no-par shares,
the stated or liquidation value.

 
           306 - Paid in Surplus
 
Include:     Amounts paid and contributed in excess of the par or stated value
of shares issued.

 
           308 - Surplus Notes
 
Include:     Amounts designated as Surplus Notes to the Contractor.

 
           310 - Unassigned Surplus-Retained Earnings
 
Include:     Accumulated earnings of the Contractor.

 
           312 - Other Aggregate Write-Ins
  Include:    
All equity items that are not accounted for elsewhere in accounts 300, 302, 304,
306, 308, and 310. These items should be recorded in Tab 1-Balance Sheet
Write-ins. Non-Admitted Assets are accounted for in this line item. Please
provide a detail description of other write-ins for those that comprise at least
5 percent of total Equity.

 
 2.03
Report 2 NHD Specific Income Statement by Category of Service

 

 
Report 2 should be reported at the NHD Program level by applicable Category of
Service. All medical expenses must be reported net of Medicare/Other Payor
reimbursement. The medical expenses should be reported in the applicable
Category of Service for the NHD Program only. This report is not a
Contractor-wide Income Statement. In addition to completing this report, a
Contractor-wide Income Statement by Line of Business will be completed in Report
2A.

 

 
 
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                           MEMBER MONTHS
 
                       300 - Nursing Home Diversion Member Months
  Include:    
All member months for the Nursing Home Diversion Program. The total reported
here will be consistent with the total reported on Report 6 Member Months. A
member month is equivalent to one person for whom the Contractor has received
capitation revenue for one month.

 
                       REVENUES
 
                       302 - Capitation Premium
 
Include:     Revenue recognized on a prepaid basis for eligible enrollees.

 
 
Exclude:     Premiums and co-payments from enrollees.

 
                       304 - Other Premiums
 
Include:     Premiums received by the Contractor that are paid for by the
Contractor’s enrollees.

 
 
Exclude:     Co-payments from enrollees.

 
                       306 - Co-payments
 
Include:     The revenue earned from co-payments paid by the Contractor’s
enrollees to receive covered services. Only include co-payments actually
received by the Contractor.

 
 
Exclude:     Co-payments collected by contracted providers from enrollees to
receive covered services.

 
                       308 - Investment/Interest Income
 
Include:     All investment income earned during the period. Interest income and
interest expense should not be netted together.

 
                       310- Net Reinsurance Recovery/Expense
 
Include:     The net amount of reinsurance earned over premiums (or premiums
over reinsurance earned) as of the statement date.

 
                       312- Third Party Liability/Coordination of Benefits
Recoveries
 
Include:     Revenue from the settlement of accident claims or other third party
sources.

 
 
Exclude:     TPL/COB recoveries collected by the contracted providers. These
amounts should be netted against claims expenses.

 
                       314- Other Income
 
Include:     Revenue from sources not identified in other revenue categories for
NHD Program only.

 
                       FACILITY CARE EXPENSES
                       Report expenses for Facility Care Services. Expense must
be reported net of patient SOC contributions, if collected by the nursing
facilities. Included in these expenses are therapeutic leave and bed hold days.
 
                       400- Skilled Nursing Facility
 
Include:     Services furnished in a health care facility licensed under Chapter
395 or Chapter 400, Florida Statutes.

 
 
 
 
 
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Exclude:     Non-SNF services delivered in the SNF, such as physician services
etc

 
                           402- Bed Holds
  Include:    
Expenses incurred for therapeutic leave and bed hold days in a skilled nursing
facility. Medicaid limits bed holds due to hospitalization to 8 days per
occurrence and therapeutic leave for family setting visits to 16 days per state
fiscal year. Due to hospitalization policy, Florida Medicaid has no upper limit
per year for bed holds. Nursing facilities must have less than 95 percent
occupancy in Medicaid certified beds on the date claimed for the bed hold to be
reimbursed for bed holds.

 
                           404- Assisted Living Facility Services
  Include:    
Personal care services, homemaker services, chore services, attendant care,
companion services, medication oversight, and therapeutic social and
recreational programming provided in a home-like environment in an assisted
living facility licensed pursuant to Chapter 429 Part I, Florida Statutes, in
conjunction with living in the facility. This service does not include the cost
of room and board furnished in conjunction with residing in the facility. This
service includes 24-hour on-site response staff to meet scheduled or
unpredictable needs in a way that promotes maximum dignity and independence, and
to provide supervision, safety and security.

 
                  LONG-TERM CARE SUPPORT SERVICES
 
                           410- Hospice
 
Include: Expenses incurred for palliative and support care for terminally ill
members and their family, or caregivers.

 
                           412- Occupational/Physical/Other Therapies
 
Include:     Physical, occupational, respiratory, audiology and speech therapy
expenses incurred for outpatient services.

 
                           414- Respite Care Services
  Include:    
Services provided to enrollees unable to care for themselves furnished on a
short-term basis due to the absence or need for relief of persons normally
providing the care. Respite care does not substitute for the care usually
provided by a registered nurse, a licensed practical nurse or a therapist.
Respite care is provided in the home/place of residence, Medicaid licensed
hospital, nursing facility, or assisted living facility.

 
                           416- Personal Care Services
  Include:    
Assistance with eating, bathing, dressing, personal hygiene, and other
activities of daily living. This service includes assistance with preparation of
meals, but does not include the cost of the meals. This service may also include
housekeeping chores such as bed making, dusting and vacuuming, which is
incidental to the care furnished or which are essential to the health and
welfare of the enrollee, rather than the enrollee's family.

 
                           418- Homemaker Services
 
Include:     General household activities (meal preparation and routine
household care) provided by a trained homemaker.

 
                           420- Consumable Medical Supplies

Include:    
The provision of disposable supplies used by the enrollee and caregiver, which
are essential to adequately care for the needs of the enrollee. These supplies

 
 
 
 
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enable the enrollee to perform activities of daily living or stabilize or
monitor a health condition. Consumable medical supplies include adult disposable
diapers, tubes of ointment, cotton balls and alcohol for use with injections,
medicated bandages, gauze and tape, colostomy and catheter supplies, and other
consumable supplies. Not included are items covered under the Medicaid home
health service; personal toiletries; household items such as detergents, bleach,
and paper towels; or prescription drugs.

 
 
                           422- Adult Day Health Services

Include:    
Services provided pursuant to Chapter 400, Part V, Florida Statutes. For
example, services furnished in an outpatient setting, encompassing both the
health and social services needed to ensure optimal functioning of an enrollee,
including social services to help with personal and family problems, and planned
group therapeutic activities. Adult day health services include nutritional
meals. Meals are included as a part of this service when the patient is at the
center during meal times. Adult day health care provides medical screening
emphasizing prevention and continuity of care including routine blood pressure
checks and diabetic maintenance checks. Physical, occupational and speech
therapies indicated in the enrollee's care plan are furnished as components of
this service. Nursing services which include periodic evaluation, medical
supervision and supervision of self-care services directed toward activities of
daily living and personal hygiene are also a component of this service. The
inclusion of physical, occupational and speech therapy services and nursing
services as components of adult day health services does not require the
Contractor to contract with the adult day health provider to deliver these
services when they are included in an enrollee’s care plan. The Contractor may
contract with the adult day health provider for the delivery of these services
or the Contractor may contract with other providers qualified to deliver these
services pursuant to the terms of this contract.

 
                           424- Adult Companion Services

Include:    
Non-medical care, supervision and socialization provided to a functionally
impaired adult. Companions assist or supervise the enrollee with tasks such as
meal preparation or laundry and shopping, but do not perform these activities as
discreet services. The provision of companion services does not entail hands-on
nursing care. This service includes light housekeeping tasks incidental to the
care and supervision of the enrollee.

 
                           426- Home Delivered Meals
  Include:    
Nutritionally sound meals to be delivered to the residence of an enrollee who
has difficulty shopping for or preparing food without assistance. Each meal is
designed to provide 1/3 of the Recommended Dietary Allowance (RDA). Home
delivered meals may be hot, cold, frozen, dried, canned or a combination of hot,
cold, frozen, dried, canned with a satisfactory storage life.

 
                           428- Chore Services
  Include:    
Services needed to maintain the home as a clean, sanitary and safe living
environment. This service includes heavy household chores such as washing
floors, windows and walls; tacking down loose rugs and tiles; and moving heavy
items of furniture in order to provide safe entry and exit.

 
                           430- Environmental Accessibility/Adaptation Services
  Include:    
Physical adaptations to the home required by the enrollee's care plan which are
necessary to ensure the health, welfare and safety of the enrollee or which
enable the enrollee to function with greater independence in the home and
without which the enrollee would require institutionalization. Such

 
 
 
 
 
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 Physical adaptations to the home required by the enrollee's care plan which are
necessary to ensure the health, welfare and safety of the enrollee or which
enable the enrollee to function with greater independence in the home and
without which the enrollee would require institutionalization. Such adaptations
may include the installation of ramps and grab-bars, widening of doorways,
modification of bathroom facilities, or installation of specialized electric and
plumbing systems to accommodate the medical equipment and supplies which are
necessary for the welfare of the enrollee. Excluded are those adaptations or
improvements to the home that are of general utility and are not of direct
medical or remedial benefit to the enrollee, such as carpeting, roof repair, or
central air conditioning. Adaptations which add to the total square footage of
the home are not included in this benefit. All services must be provided in
accordance with applicable state and local building codes.

 
                           432- Escort Services
    Include:    
Personal escort for Enrollees to and from service Providers. An escort may
provide language interpretation for people who have hearing or speech
impairments or who speak a language different from that of the Provider. Escort
Providers assist Enrollees in gaining access to services.

 
                           434- Family Training Services
  Include:    
Training and counseling services for the families of enrollees served under this
contract. For purposes of this service, "family" is defined as the individuals
who live with or provide care to a person served by the Contractor and may
include a parent, spouse, children, relatives, foster family, or in-laws.
"Family" does not include persons who are employed to care for the enrollee.
Training includes instruction and updates about treatment regimens and use of
equipment specified in the care plan to safely maintain the enrollee at home.

 
                           436- Financial Assessment/Risk Reduction Services
  Include:    
Assessment and guidance to the caregiver and enrollee with respect to financial
activities. This service provides instruction for and/or actual performance of
routine, necessary, monetary tasks for financial management such as budgeting
and bill paying. In addition, this service also provides financial assessment to
prevent exploitation by sorting through financial papers and insurance policies
and organizing them in a usable manner. This service provides coaching and
counseling to enrollees to: (1) avoid financial abuse; (2) maintain and balance
accounts that directly relate to the enrollees living arrangement at home; or
(3) lessen the risk of nursing home placement due to inappropriate money
management.

 
                           438- Nutritional Assessment/Risk Reduction Services
  Include:    
An assessment, hands-on care, and guidance to caregivers and enrollees with
respect to nutrition. This service teaches caregivers and enrollees to follow
dietary specifications that are essential to the enrollee’s health and physical
functioning, to prepare and eat nutritionally appropriate meals and promote
better health through improved nutrition. This service may include instructions
on shopping for quality food and on food preparation.

 
                           440- Personal Emergency Response Systems (PERS)
  Include:    
The installation and service of an electronic device which enables enrollees at
high risk of institutionalization to secure help in an emergency. The PERS is
connected to the person's phone and programmed to signal a response center once
a "help" button is activated. The enrollee may also wear a portable "help"
button to allow for mobility. PERS services are generally limited to those
enrollees who live alone or who are alone for significant parts of the day and
who would otherwise require extensive supervision.

 
                           442- Other Long-Term Care Support Services
 
 
 
 
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  Include:    
All other long-term care support services that cannot be classified within one
of the previous categories of service.

 
                  ACUTE CARE SERVICES
 
                           444- Inpatient Hospital Services (Hospitalization)
  Include:    
Medically necessary services, including ancillary services, furnished to
inpatient enrollees, provided under the direction of a physician or dentist, in
a hospital maintained primarily for the care and treatment of patients.

 
  Exclude:    
Services provided in a facility by a separate registered provider such as a
physician.

 
                           446- Outpatient Facility Services
  Include:    
Outpatient facility expenses incurred for outpatient services, including
ambulatory surgical centers.

 
  Exclude:    
Services provided in a facility by a separate registered provider such as a
physician.

 
                           448- Emergency Services
  Include:    
Those expenses relating to emergency room services provided on an outpatient
basis, including any facility fee.

 
  Exclude:    
Services provided in a facility by a separate registered provider such as a
physician.

 
                           450- Primary Care/Physician Services
  Include:    
All forms of compensation for primary care delivery, including salary,
capitation, and fee-for-service.

 
                           452- Referral/Specialty Physician Services
  Include:    
All forms of compensation paid for referral (specialist) physician services.

 
                           454- Other Professional Services
  Include:    
All forms of compensation paid for non-physician professional services,
including advanced registered nurse practitioner services, chiropractic
services, physician assistant services, registered nurse first assistant
services, etc.

 
                           456- Prescription Drug
  Include:    
Prescribed drug services for dual eligible Medicaid beneficiaries are covered
per the Medicare Modernization Act (MMA). However, Section 103(c) of the MMA
added s.1935(d)(2) to the Social Security Act to allow State Medicaid programs
to continue to provide and receive Federal Financial Participation (FFP) for
certain drugs not included in the Medicare Prescription Drug benefit (Part D).
Drugs excluded from Part D coverage are listed in s.1927(d)(2) of the Act.
Contractors shall provide certain drugs not included in Part D as described in
the Medicaid Prescribed Drugs Services and Limitations Handbook.

 
                           458- Independent Lab/Radiology/X-Ray
  Include:    
Medically necessary and appropriate diagnostic laboratory procedures and
portable x-rays ordered by a physician or other licensed practitioner of the
healing arts as specified in the Independent Laboratory and Portable X-ray
Services Coverage and Limitations Handbook.

 
 
 
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                           460- Community Mental Health Services
  Include:    
Community-based rehabilitative services, which are psychiatric in
nature, recommended or provided by a psychiatrist or other physician. Such
services must be provided in accordance with the policy and service provisions
specified in the Medicaid Community Mental Health Coverage and Limitations
Handbook except that the provider need not be a community mental health center.

 
  Exclude:    
Inpatient behavioral health expenses, lab, radiology and psychotropic
medications and monitoring.

 
                           462- Home Health Care Services
  Include:    
Intermittent or part-time nursing services provided by a registered nurse or
licensed practical nurse, or personal care services provided by a licensed home
health aide, with accompanying necessary medical supplies, appliances, and
durable medical equipment.

 
                           464- Vision/Optometric Services
  Include:    
Medically needy eye examinations and Eyeglass repairs and adjustments.
Eyeglasses are limited to two pair every 365 days. Such services must be
provided in accordance with the policy and service provisions specified in the
Medicaid Vision Services Coverage and Limitations Handbook.

 
                           466- Durable Medical Equipment & Supplies
  Include:    
Medical supplies, medical equipment, prosthetic devices, and oxygen expenses
incurred for outpatient services.

 
                           468- Dialysis
  Include:    
All expenses incurred for the provision of dialysis services.

 
                           470- Transportation
  Include:    
Medically necessary transportation expenses incurred for inpatient and
outpatient services.

 
                           472- Dental Services
  Include:    
Dental expenses incurred for outpatient services, including outpatient surgery,
prescription drugs, lab, and radiology specifically related to a dental
diagnosis.

 
                           474- Hearing Services
  Include:    
Hearing expenses incurred for outpatient services, including outpatient surgery,
hearing exams, corrective hearing devices, and other services related to hearing
services.

 
                           476- Home Health Services
  Include:    
Expenses incurred for medically supervised and physician ordered intermittent
health maintenance, continued treatment or monitoring of a health condition and
supporting care with activities of daily living in a home and community based
setting.

 
                           478- Home Diversion Provider Services
  Include:    
Expanded services paid by the Contractor on a case-by-case basis.

 
                           480- Other Acute Services
  Include:    
Those outpatient expenses not specifically identified in one of the categories
defined above.

 
 
 
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              PRIOR YEAR OCL ADJUSTMENTS IN CURRENT YEAR
 
       482- Prior Year OCL Adjustments in Current Year (Prior Period Claim
Liability Adjustment)
  Include:    
Adjustments made within the current year’s medical expense for over/under
estimation of IBNR expenses for prior years.

 
              CASE MANAGEMENT EXPENSE
 
        490 - Case Management
  Include:    
Services which facilitate enrollees gaining access to other needed services
regardless of the funding source for the services, and which contribute to the
coordination and integration of care delivery.

 
              ADMINISTRATIVE EXPENSE
       Those costs associated with the overall management and operation of the
Contractor.
 
       500 - Compensation
  Include:    
All forms of compensation, including employee benefits and taxes, to
administrative personnel. This includes medical director compensation, whether
on salary or contract.

 
  Exclude:    
Compensation classified as case management and of any physician or contracted
provider that bills independently for services.

 
       502 - Data Processing
  Include:    
Costs for outside data processing services during the period as well as internal
data processing expenses, other than compensation.

 
  Exclude:    
Compensation for any internal data processing personnel as this is reported in
500-Compensation.

 
       504- Management Fees
  Include:    
Management fees paid or payable by the Contractor for the current period to a
parent or an outside management company.

 
       506 - Interest Expense
  Include:    
Interest expense incurred on outstanding debt during the period. Interest income
and interest expense should not be netted together.

 
       508 - Occupancy
  Include:    
Occupancy expenses incurred, such as rent and utilities, on facilities that are
not used to deliver health care services to members.

 
       510- Marketing
  Include:    
Those activities whose intent is to increase membership. This requirement also
applies to any marketing costs included in an allocation from a parent or other
related corporation.

 
       512 - Depreciation
  Include:    
Depreciation on those assets that are not used to deliver health care services
to members.

 
       514 - Other Administration
  Include:    
Administration expenses not specifically identified in the categories above.

 
 
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                  OTHER ITEMS
 
           520- Non-operating Income (Loss)
  Include:    
Gains and losses on sale of investments and fixed assets during the period and
any other non-operating income or loss.

 
           530- Provision for Income Taxes and/or Premium Taxes
  Include:    
Income taxes (Federal and State) and premium taxes for the period.

 
2.04
Report 2A Income Statement by Line of Business

 
   
Report 2A Income Statement by Line of Business Report 2A should be reported by
each of the requested lines of business: Nursing Home Diversion, All Other
Medicaid, Medicare, and All Other. This report is a Contractor-wide Income
Statement.

 
                           MEMBER MONTHS
 
           300 - Member Months
  Include:    
All member months for each line of business. A member month is equivalent to one
person for whom the Contractor has received capitation revenue for one month.

 
           REVENUES
 
           310 - Net Capitation and Premium Revenue
  Include:    
Revenue recognized on a prepaid basis for eligible enrollees and premiums paid
by, or for, eligible members for covered services.

 
           312 - Fee-For-Service Revenue
  Include:    
Revenue received by the Contractor that are paid for by enrollees or others on a
fee-for-service basis.

 
           314 - Other Health Care Related Revenue
  Include:    
Revenue received by the Contractor for the provision of health care services
that has not been included in Net Capitation and Premium Revenue or Fee-
For-Service Revenue.

           316- Net Reinsurance Recovery/Expense
  Include:    
The net amount of reinsurance earned over premiums (or premiums over reinsurance
earned) as of the statement date.

 
           318 - Investment/Interest Income
  Include:    
All investment income earned during the period. Interest income and interest
expense should not be netted together.

 
           320- All Other Income and Revenue
  Include:     
Revenue from sources not identified in other revenue categories.

 
           MEDICAL EXPENSE
 
           330- Inpatient and Outpatient Facility Expense
  Include:    
All forms of compensation for hospital inpatient, as well as outpatient facility
expenses incurred for outpatient services, including ambulatory surgical
centers.

 
           332- Professional Services
 
 
 
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  Include:    
All forms of compensation for primary care/physician services, referral
(specialist) physician services, an all forms of compensation paid for
professional services, including advanced registered nurse practitioner
services, chiropractic services, physician assistant services, registered nurse
first assistant services, etc

 
           334- Emergency Room
  Include:    
Those expenses relating to emergency room services provided on an outpatient
basis, including any facility fee.

 
           336- Prescription Drug
  Include:    
Retail and mail order pharmacy expenses incurred for outpatient services.

 
           338- Long-Term Care Services
  Include:    
All services designated as Long-Term Care in Report 2.

 
           340- Other Medical Expense
  Include:    
Those medical expenses that are not specifically identified in one of the
categories defined above.

 
              CASE MANAGEMENT EXPENSE
 
           350 - Case Management
  Include:    
Case management expenses, including salaries, benefits, travel and training
expenses for case managers, and case management supervisors.

 
              ADMINISTRATIVE EXPENSE
 
           360 - Administration
  Include:    
All costs associated with the overall management and operation of the Contractor
including: compensation, data processing, management fees, interest expenses,
occupancy, marketing, depreciation, and other administration expenses.

 
              OTHER ITEMS
 
           372- Non-operating Income (Loss)
  Include:    
Gains and losses on sale of investments and fixed assets during the period and
any other non-operating income or loss.

 
           374- Provision for Income Taxes and/or Premium Taxes
  Include:    
Income taxes (Federal and State) and premium taxes for the period.

 
2.05
Report 3 Net Worth and Working Capital

 
   
The Net Worth (Changes to Equity/Net Assets) Report shows changes to the
Contractor’s net assets on a quarterly and annual basis. This report is
completed on a Contractor-Wide basis and not NHD Program Specific. The design of
the report is self-explanatory and serves as the instructions. As indicated on
the report, please provide description to any amounts entered as “other”.

 
   
The Working Capital Analysis section reports the entity’s cash flows during the
reporting period. This report is completed on a Contractor-Wide basis and not
NHD Program Specific. The Working Capital Analysis is segregated by sources and
uses of funds. The design of the report is self-explanatory and

 
 
 
 
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   July 2012   Contract XT220   

 
   
serves as the instructions. As indicated on the report, please provide
description to any amounts entered as “other”.

 
2.06
Report 4 NHD Only Claims Lag Reports & Outstanding Claims Liability (OCL)

 
   
This report should be completed for the NHD Program ONLY.

 
   
The schedules are arranged with dates of service horizontally and quarter of
payment vertically. Therefore, payments made during the current quarter for
services rendered during the current quarter are reported on row 1, column 3,
while payments made during the current quarter for services rendered in prior
quarters are reported on row 1, columns 4 through 9. Do not include risk pool
distributions or sub-capitation as payments in this schedule. Include these
payments in row 12.

 
   
Payments and expenses should be reported in this Report consistent with the
major expense categories in Report 2 (Facility Care Expenses, Long-Term Care
Support Services, and Acute Care Services). For example, Facility Care payments
and expenses should include all payments and expenses adjustments for Report 2
account 400 (Skilled Nursing Facility), account 402 (Bed Holds), and account 404
(Assisted Living Facility Services). As a result the total expense reported for
Facility Care Expenses, row 14, for a given quarter should tie to the expense
reported on Report 2 as Total Facility Care Expenses.

 
   
The schedules allow for the inclusion of an adjustment (e.g., for provider
refunds) amount to the lag schedule. A general explanation of any adjustments
should be included in the footnotes as well as additional detail if any
adjustment is greater than 10 percent of total medical claims payable.
 

 
 
2.07
Report 5 NHD Analysis of total Medical Liability to Actual Claims Paid

 
   
This report should be completed for the NHD Program ONLY.

 
   
Using the Contractor’s Lag Reports from Report 4, complete the schedule for the
current and previous seven quarters. The report is arranged to illustrate the
difference between the original OCL at the end of the quarter to the claims
subsequently paid for that quarter.

 
2.08
Report 6 Member Months

 
   
This report details the member months associated with the NHD Program and All
Other Lines of Business by county. Provide total member months by county for the
NHD Program column and the All Other column (include all other
lines-of-business) for the current quarter and contract year-to-date. The total
column will calculate automatically. A member month is equivalent to one person
for whom the Contractor has received capitation revenue for one month.

 
2.09
Notes and Other Information

 
   
Utilize the Notes and Other Information tab to indicate and provide information
that cannot be reported within the main context of the required reports. Please
provide the specific report number and reference of the additional information
being provided.

 
2.10
Ratio Analysis

 
   
This report summarizes specific ratios utilized by the State to monitor the
Contractor. All information is automatically calculated and no input is required
by the Contractor. The information will not calculate for all ratios if the
Contractor is not required to complete all reports.

 
 
 
 
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3.0
FOOTNOTE DISCLOSURE REQUIREMENTS

 
3.1
Footnote Disclosures

 
   
Footnote disclosures are required in order to supplement the financial reporting
template. The following list represents expected items that should be disclosed
and included in the Notes and Other Information tab, but is not intended to be
all-inclusive.

 
1)  Contractor’s Organizational Structure: Discuss changes in the organization
structure and/or location of its headquarters.
 
2)  Summary of Significant Accounting Policies: Discuss changes in accounting
policies relating to significant balance sheet line items such as, but not
limited to, cash and cash equivalents, investments and medical claims payable.
 
3)  Pledges/Assignments and Guarantees: Describe any pledges, assignments, or
collateralized assets and any guaranteed liabilities not disclosed on the
balance sheet.
 
4)  Material Adjustments: Disclose and describe any material adjustments made
during the current reporting period, including those adjustments that may relate
to a prior period, specifically IBNR adjustments, that affect the financial
statements.
 
5)  Claims Payable Analysis: Explain large fluctuations and/or revisions in
estimates and the factors that contributed to the change in IBNR and RBUC
balances from the prior quarter. Specifically, address changes in IBNRs and/or
RBUCs of more than 10 percent (on an IBNR or RBUC per  member basis).
Explanations should detail the amount of the adjustments by quarter and by
county.
 
6)  Contingent Liabilities: Provide details of any malpractice or other claims
asserted against the Contractor, as well as the status of the case, potential
financial exposure and expected resolution.
 
7)  Due from/to Affiliates (Current and Non-current): Describe, in detail, the
composition of the due to/from affiliates including the name of the affiliate, a
description of the affiliation, amount due to/from the affiliate and a
description of any significant changes to the line item.
 
8)  Equity Activity: Disclose all activity in equity, other than net income or
net loss.
 
9)  Prior Period Adjustments: Disclose and describe any adjustments made to
previously submitted financial statements including those adjustments that
affect the current quarter’s financial statements.
 
 
 
 
 
 
 
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   July 2012   Contract XT220          EXHIBIT  L

LEVEL OF CARE (LOC) REDETERMINATION
 
 
 
 

 Contractors Logo                  Requester's Org:
_________________________________________________    Request Date:
______________________________________              Requester's Name:
_______________________________________________    Requester's Phone:
__________________________________              CARES Office:
__________________________________________________  
 Mailed:____________    Faxed:____________ (check one)  

 
LOC
Deadline
First Name
Last Name
Date of Birth
County of
Residence
Program Currently
Enrolled In
                                                                               
                                                                               
                                                                   

 
LOC Deadline - Enter the date by which the LOC redetermination is needed
 
Received By: ____________________________________________
Received On: ____________________________________________
 
 
 
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   July 2012   Contract XT220          EXHIBIT  M

External Quality Review Organization (HSAG) Due Dates
 
Quality Improvement Measurers
 
Date Due
Report or Document
September 7, 2011
Last day HSAG will provide the Contractor with notification and instructions for
submitting the two PIPs for annual notification.
October 2011- February 2012
All PIPs are reviewed by HSAG
March 14, 2012
The Contractor will receive the final draft validation report for review and
comment regarding any needed corrections.
April 2012
HSAG will send to the Contractor the final report.
June 1, 2012
Submit current performance improvement projects (PIP) to the Department.

 
Performance Measures for reporting period calendar year 2011
 
Due Date
Report or document
September 27, 2011
The Contractor will submit to HSAG the completed ISCAT, attachments, source code
and performance measures (using the performance measure rate reporting template)
for Q1 (January through March) and Q2 (April through June).
October 8, 2011-November 4, 2012
HSAG will schedule with the contract compliance audits within this time period.
February 13, 2012
Q3 (May through August) and Q4 (September through December) performance measures
rates and annual roll-up are due to HSAG.
Mid- April 2012
Final reports will be available.

 
 
 
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   July 2012   Contract XT220               APPENDIX 1          Additional
Subcontract Requirements  

 
Specification of functions of the subcontractor:
 
1.  
Identify the population covered by the subcontract and the counties served.

2.  
Specify the amount, duration and scope of services to be provided by the
subcontractor, including a requirement that the subcontractor continue to
provide services through the term of the capitation period for which the Agency
has paid the Contractor.

3.  
Provide for timely access to appointments and services.

4.  
Provide for submission of all reports and clinical information required by the
Contractor.

5.  
Provide for the participation in any internal and external quality improvement,
utilization review, peer review, and grievance procedures established by the
Contractor.

6.  
Facility and Home Health providers will provide notice to the Contractor within
24 hours when an enrollee dies, leaves the facility, or moves to a new
residence.

 

Protective clauses:
 
1.  
Require safeguarding of information about enrollees in accordance with 42 CFR
438.224.

2.  
Require compliance with HIPAA privacy and security provisions.

3.  
Require an exculpatory clause, which survives subcontract termination including
breach of subcontract due to insolvency, that assures the enrollees, Department,
Agency, or DHHS may not be held liable for any debts of the subcontractor in
accordance with 42 CFR 447.15. In addition, the recipient is not liable to the
subcontractor for any services for which the Contractor is liable as specified
in s. 641.3154, F.S.

4.  
Contain a clause indemnifying, defending and holding the Department, Agency,
DHHS, and the Contractor’s enrollees harmless from and against all claims,
damages, causes of action, costs or expense, including court costs and
reasonable attorney fees arising from the subcontract agreement. This clause
must survive the termination of the subcontract, including breach due to
insolvency. The Department may waive this requirement for itself, but not the
Contractor’s enrollees, for damages in excess of the statutory cap on damages
for public entities if the subcontractor is a public health entity with
statutory immunity. The Department must approve all such waivers in writing.

5.  
Require that the subcontractor secure and maintain during the life of the
subcontract worker’s compensation insurance for all of its employees connected
with the work under this contract unless such employees are covered by the
protection afforded by the Contractor. Such insurance must comply with the
Florida’s Worker’s Compensation Law.

6.  
Pursuant to s. 641.315(9), F.S., contain no provision that prohibits a physician
from providing inpatient services in a contracted hospital to an enrollee if
such services are determined by the organization to be medically necessary and
covered services under the organization’s contract with the contract holder.

7.  
Contain no provision restricting the subcontractor’s ability to communicate
information to the subcontractor’s patient regarding medical care or treatment
options for the patient when the subcontractor deems knowledge of such
information by the patient to be in the best interest of the health of the
patient.

8.  
Pursuant to s. 641.315(10), F.S., contain no provision requiring providers to
contract for more than one long-term care product or otherwise be excluded.

9.  
Pursuant to s. 641.315(6), F.S., contain no provision that in any way prohibits
or restricts the health care provider from entering into a commercial contract
with any other contractor.

10.  
Specify that if the subcontractor delegates or subcontracts any functions of the
Contractor, that the subcontract or delegation include all the requirements of
this section.

11.  
Make provisions for a waiver of those terms of the subcontract that, as they
pertain to Medicaid recipients, are in conflict with the specifications of this
contract.

12.  
Specify procedures and criteria for extension, renegotiation, and termination of
the subcontract.

13.  
Specify that the Contractor must give 60 days advance written notice to the
subcontractor, and Department, before canceling the contract with the
subcontractor for any reason.

 
 
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14.  
Provisions for nonpayment for goods and services rendered by the subcontractor
to the Contractor are not a valid reason for avoiding the 60-day advance notice
of cancellation pursuant to s. 641.315(2)(a)(2), F.S.

15.  
Pursuant to s. 641.315(2)(b), F.S., specify that the Contractor will provide 60
days advance written notice to the subcontractor and the Department before
canceling, without cause, the contract with the subcontractor. However, in a
case in which an enrollee’s health is subject to imminent danger or a
physician’s ability to practice medicine is effectively impaired by an action by
the Board of Medicine or other governmental agency, notification must be
provided to the Department immediately.

 
 
 
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   July 2012   Contract XT220               APPENDIX 2          Additional
Ownership and Management Requirements  

 
  
The following definitions apply to ownership disclosure:
1.  
A person with an ownership interest or controlling interest means a person or
corporation that:

a)  
Owns, indirectly or directly, five (5) percent or more of the Contractor's
capital or stock, or receives five (5) percent or more of its profits;

b)  
Has an interest in any mortgage, deed of trust, note, or other obligation
secured in whole or in part by the Contractor or by its property or assets and
that interest is equal to or exceeds five (5) percent of the total property or
assets; or

c)  
Is an officer or director of the Contractor if organized as a corporation, or is
a partner in the Contractor if organized as a partnership.

 
2.  
The percentage of direct ownership or control is calculated by multiplying the
percent of interest that a person owns by the percent of the Contractor's assets
used to secure the obligation. Thus, if a person owns 10 percent of a note
secured by 60 percent of the Contractor's assets, the person owns six (6)
percent of the Contractor.

 
3.  
The percent of indirect ownership or control is calculated by multiplying the
percentage of ownership in each organization. Thus, if a person owns 10 percent
of the stock in a corporation that owns 80 percent of the Contractor’s stock,
the person owns eight (8) percent of the Contractor.

 
Changes in management are defined as any change in the management control of the
Contractor. Examples of such changes are those listed below or equivalent
positions by another title.
1.  
Changes in the Board of Directors or Officers of the Contractor, Medical
Director, Chief Executive Officer, Administrator, and Chief Financial Officer;

2.  
Changes in the management of the Contractor where the Contractor has decided to
contract out the operation of the Contractor to a management corporation.

 
The Contractor must disclose such changes in management control and provide a
copy of the contract agreement to the Contract Manager for approval at least 60
calendar days prior to the management contract start date.
 
The contract is subject to the provisions of Chapter 112 and s. 435.03, F.S. The
Contractor must disclose the name of any officer, director, or agent who is an
employee of the State of Florida, or any of its agencies. Further, the
Contractor must disclose the name of any state employee who owns, directly or
indirectly, an interest of five (5) percent or more in the offeror's firm or any
of its branches. The Contractor covenants that it presently has no interest and
shall not acquire any interest, direct or indirect, which would conflict in any
manner or degree with the performance of the services hereunder. The Contractor
further covenants that in the performance of the contract no person having any
such known interest shall be employed. No official or employee of the Department
or Agency and no other public official of the State of Florida or the federal
government who exercises any functions or responsibilities in the review or
approval of the undertaking of carrying out the contract must, prior to
completion of this contract, voluntarily acquire any personal interest, direct
or indirect, in this contract.
 
 
 
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   July 2012   Contract XT220               APPENDIX 3          Programmatic
Reports  

 
 
 
All reports containing PHI will be password protected, zipped and encrypted
using WinZip version 9.0 or higher. Use standard passwords for both the WinZip
file as well as the report files. Unless otherwise indicated, electronic reports
will be sent to DiversionReports@elderaffairs.org and a copy to the Contract
Manager.
 
 
Level of Analysis: The following levels of analysis will be used, as indicated,
for the required reports:

1.  
Individual Level - One report is required for each enrollee, e.g., one grievance
record for each grievance, one record per long-term care service.

2.  
Location Level - One report required for each nine-digit Medicaid provider
number the Contractor has under contract.

3.  
Contractor Level - One report is required for each seven-digit Medicaid provider
number the Contractor has under contract.

 
Report Name
Level of Analysis
Reporting
Frequency
Submission
Method
Reporting
Location
File Type
File Name
834 Transactions
Individual
Monthly the Wednesday preceding the second to last Saturday for enrollments and
for disenrollments the prior day
Secured Web site supplied by the fiscal agent, file upload and download`
Fiscal agent
834 format Prescribed by the Fiscal Agent
Prescribed by the Fiscal Agent
Disenrollment Summary Report
Location
Monthly within 15 calendar days after the beginning of the reporting month
Electronic Mail
Department
Excel (template in contract)
Plan_Report Name_Date
Encounter Data Report
Individual
Quarterly, within 3 months of the end of reporting calendar quarter
FTP Site
Department
PDF/text file see contract
Plan_Report Name_Quarter #_Year
Grievance, Appeals, Complaints Report
Individual
Quarterly, within 5 calendar days of end or reporting calendar quarter
Electronic Mail
Department
Excel (template in contract)
Plan_Report Name_Quarter #_ Year
Provider Network and Staff Listing
Location
Quarterly, within 5 calendar days of end of reporting calendar quarter
Electronic Mail
Department
Excel (template in contract)
Plan_Report Name_ Quarter #_ Year
Performance Measures Report
Location
Annually, March 1
Electronic Mail
Department
Word
Plan_Report Name_Date
Emergency Management Plan
Contractor
Annually, April 30
Electronic Mail
Department
Word/PDF
Plan_Report Name_Date

 
 
 
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Emergency Management Plan
Verification
Contractor
Verification of plan within 30 days of execution of contract
Electronic Mail
Department
Word/ PDF
Plan_Report Name_Date
Report Name
Level of Analysis
Reporting
Frequency
Submission
Method
Reporting
Location
File Type
File Name
Enrollee Satisfaction Survey
Contractor
Annually, May 15
Electronic
Mail
Department
Word/PDF (template in contract)
Plan_Report Name_Date
Reconciliation Report
Individual
Within 10 days of receipt of remittance vouchers
Electronic
Mail
Department
Excel
Plan_Report Name_Date
Insolvency Fund Statements
Contractor
Monthly Statements
Electronic Mail or Hard Copy
Department
PDF copy
Plan_Report Name_Date
Audited Financial Statement
Contractor
Annually, within 120 days of end of Contractor’s fiscal year (4 months)
Electronic Mail, Compact Disc or Hard Copy
Department
Word/PDF
Plan_Report Name_Date
Performance Measures
Contractor
Report to HSAG
Electronic Mail to HSAG
HSAG
Format prescribed by HSAG
Plan_Report Name_Date
Unaudited Financial Statements
Contractor
Quarterly, within 60 days of end of reporting quarter (2 months)
Electronic Mail on Department supplied template
Department
Excel
Plan_Report
Name_Quarter#_Year
Performance Improvement Measures
Contractor
Report to HSAG
Electronic Mail to HSAG
HSAG
Format prescribed by HSAG
Plan_Report Name_Date
Staff Changes
 
 
 
Subcontractor Training Attestation
Individual
 
 
 
Subcontractor
As Needed
 
 
 
Annually, July 5
Electronic Mail, hard copy or compact disk
 
 
 
Electronic Mail
Department
 
 
 
Department
Word
 
 
 
Excel
Plan_Report Name_Date
 
 
 
Plan_Report Name_Date

 
 
 
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  July 2012   Contract XT220         APPENDIX 4          Service Provider
Qualifications  

 
Service Title
 
Provider Qualifications
 
Provider Type
License
Certificate
Other Standard (Specify)
Case Management
Contractor ONLY
   
Case managers must be qualified in one of the following ways: (a) have a
Bachelor’s Degree in Social Work, Sociology, Psychology, Gerontology or related
field, (b) be a Registered Nurse, licensed to practice in the state, (c) have a
Bachelor's Degree in an unrelated field and at least two (2) years of geriatric
experience, or (d) be a Licensed Practical Nurse (LPN) with four (4) years of
geriatric experience. All case managers must have at least 2 years of geriatric
experience and 4 hours of in-service training annually and the Abuse and Neglect
Exploitation training (which shall be approved in advance by the Department).
Homemaker
Home Health Agency Part III
Licensed under Ch. 400, Part IV, F.S.
 
Optional to meet Federal Conditions of Participation under 42 CFR 484.
CCE Providers Chapter 400.509
As defined in 430.203, F.S. Registration in accordance with Ch. 400.509, F.S.
Homemaker/Companion Agency Chapter 400.509
Registration in accordance with Ch. 400.509, F.S.
Nurse Registry*
Chapter 400.506 F.S.
   

 
 
 
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Respite
Home Health Agency
Ch 400, Part IIIF.S.
 
Federal Conditions of Participation (42 CFR 484)
Homemaker/Companion Agency Chapter 400.509
   
Registration in accordance with Ch 400.509 F.S.
Adult Day Care Center
Ch 429, Part III, F.S.
   
Assisted Living Facility
Ch 429, Part I,F.S.
   
Nursing Facility
Ch 400, Part II, F.S.
   
Nurse Registry
Ch 400.506, F.S.
   
CCE Providers
Chapter 430.203
   
Personal Care
Home Health Agency
Ch 400, Part III, F.S.
 
Optional to meet Federal Conditions of Participation under 42 CFR 484.
CCE Providers
Chapter 430.203
 
As defined in 430.203, F.S.
Nurse Registry
Ch 400.506, F.S.
   
Adult Day Health
Adult Day Care Center
Ch. 429, Part III,
   
Assisted Living Facility
Chapter 429, Part I, F.S.
   
Adult Companion
Home Health Agency
Ch 400, Part III, F.S.
 
Optional to meet Federal Conditions of Participation under 42 CFR 484.
CCE Providers
Chapter 430.203 Chapter 400.509
 
As defined in 430.203, F.S.. Registration in accordance with Ch 400.509, F.S.
Homemaker/Companion Agency
Nurse Registry*
Chapter 400.506, F.S.
   
Assisted Living Services
Assisted Living Facility
Licensed under Chapter 429, Part I, F.S.
   

 
 
 
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Chore Services
Pest Control Business
Licensed under Chapter 482.071, F.S.
   
General Contractor
Licensed under Chapter 489, Part I, F.S.
   
CCE Provider
Chapter 430.203
   
Commercial Cleaning Companies*
   
Applicable local business license or certificate required
Home Health Agency
Ch 400, Part III, F.S.
   
Consumable
Medical Supplies
Home Health Agency
Ch 400, Part III, F.S.
 
Optional to meet Federal Conditions of Participation under 42 CFR 484
Pharmacy
Ch 465, F.S..
 
Permit under Ch 465, F.S.
Home Medical Equipment Provider
Ch 400, Part X, F.S.
   
Prescription Drug Wholesale Distributor*
   
Appropriate Department of Health Licensure Required or applicable local business
license
Assisted Living Facility*
Licensed under Chapter 429, Part I, F.S.
   
Environmental Accessibility
Adaptations
Independent providers
Licensed pursuant to state and local building codes or other licensure
appropriate for task(s) performed. (Ch 205, F.S.)
   
General Contractor
Licensed pursuant to Ch. 489.131, F.S.
   

 
 
 
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Escort Services
Home Health Agency
Ch 400, Part III, F.S.
 
Optional to meet Federal Conditions of Participation under 42 CFR 484
CCE providers
Chapter 400.509
 
As defined in 430.203, F.S.
Nurse Registry*
Chapter 400.506
   
Family Training
Registered Nurse, Licensed Practical Nurse
Ch 464, F.S.
   
Clinical Social Worker, Mental Health Counselor
Ch 491, F.S.
   
CCE provider
Chapter 430.203
   
Financial Assessment and
Risk Reduction
CCE provider
Chapter 430.203
 
As defined in 430.203, F.S.
Independent Contractors*
   
Confirmed to be qualified to perform the service by training and experience.
Independent contractors may include the following designations or occupations:
Certified Financial Analyst, Certified Financial Planner, Certified Financial
Advisor, Insurance Agent, Individual with 4 yr degree in finance, accounting
and/or 4 yr working experience within the finance or banking industry and Pass a
Level II background screening
Certified Public Accountants
Licensed under Chapter 473, F.S.
   
Banks
Licensed under Chapter 658, F.S.
   
Home-Delivered
Meals
Food Service Establishment
Ch 509.241, F.S.
   
Food Establishment
   
Permit under Ch. 500.12, F.S.
CCE Providers
Chapter 430.203
 
As defined in 430.203, F.S.
Older American's Act Providers
   
As defined in Ch 58A-1, Florida Administrative Code (FAC)
Nutritional Assessment and
Risk Reduction
Dietician/Nutritionist, Nutrition Counselor
Ch. 468, Part X, F.S.
   
CCE Providers
Chapter 430.203
 
As defined in 430.203, F.S.
Other Health Professionals
   
Must practice within the legal scope of their practice.
Nurse Registry*
Chapter 400.506
   

 
 
 
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Personal Emergency Response Systems (PERS)
Alarm System Contractor
 
Certified under Ch. 489, Part II, F.S.
 
Low-Voltage Contractors and Electrical Contractors1
   
Exempt from licensure in accordance with Section 489.503(15)(a-d) and Section
489.503(16), F.S
Physical Therapy
Physical Therapist
Ch. 486, F.S.
   
Home Health Agency
Licensed under Chapter 400, Part III, F.S.
 
Option to meet Federal Conditions of Participation.
Speech Therapy
Speech-language
Pathologist
Ch. 468, Part I, F.S.
   
Home Health Agency
Licensed under Chapter 400, Part III, F.S.
   
Occupational
Therapy
Occupational Therapist
Licensed under Chapter 468, Part III, F.S.
   
Occupational Therapist Aide
Licensed under Chapter 468, Part III, F.S.
   
Home Health Agency
Licensed under Chapter 400, Part III, F.S.
 
Meet Federal Conditions of Participation.
Respiratory
Therapy
Home Health Agency*
Licensed under Chapter 400, Part III, F.S.
   
Respiratory Therapist*
Licensed under 468, F.S.
   

 
*Effective upon aproval in this programs renewal Application for a §1915(c) Home
and Community-Based Services Waiver & related amendments (first submitted to CMS
in March 18, 2011).
 
 
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 APPENDEIX 5   those facilities without enrollees, enter “00000” for all fields
except the Physical Address, City / Zip code, County, Type of Facility, and Name
of Facility fields.  Enrollee and Facility Roster Instructions        
The report will be submitted to the DOEA via the FTP site by the 8th of each
month. Each month you will need to refresh the roster by deleting disenrolled
individuals and adding new enrollees to the report.
The Excel file report due pursuant to Appendix 5 shall identify the entire
enrollee population, including members categorized as Medicaid Pending. In
addition, this report requires that the Contractor’s current facility network be
included on the spreadsheet, regardless of whether or not enrollees currently
reside in the subcontracted facility. The Excel file, (which includes formulas,
tied to the ACCESS Florida Medicaid financial eligibility application submitted
to DCF) should be obtained from the Department.          
Enrollee Roster Instructions:
         
Individuals referred as Medicaid Pending that change their status using Form 606
(status change to receive assistance with financial eligibility but no services)
should be identified as described herein.
          The roster will include a column for Medicaid Pending that will be
denoted by a 0/1 system to calculate the total number of Medicaid Pending
individuals and other information.             - Enter a 1 for Medicaid pending
individuals.       - Enter a 0 for Non-Medicaid pending individual.       -
Enter a 606 for individuals referred as Medicaid Pending that change their
status using Form 606 (status change to receive assistance with financial
eligibility but not services)          
Enter the date the ACCESS Florida Medicaid financial eligibility application was
submitted to DCF.
         
Facility Roster Instructions
         
For the purposes of reporting your current facility network on a monthly basis,
which the Department intends to publish on the DOEA website, the Excel file
should include a list of each facility in your network, even for those that
currently have no enrollees as residents. For
   

 
 
 
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                                                   DOEA USE    ONLY            
                               

 
 
 
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  July 2012   Contract XT220               APPENDIX 6    Incident Reporting Log
 

 
Plan Name:
 
Address of Incident:
 
County:
 
Facility Yes/ No:
 
Facility Name (if applicable):
 

 
Member’s Name
 
Member I.D. #
 
Date of Incident
__ /__ /__
Incident/ Occurrence Details:
 
Corrective Action Plan CAP (Include timeframes for CAP implementation):
 
Incident Resolved?
Yes/No: if unresolved, explain how it will be resolved
 
Date Resolved
__ /__ /__

 
 
 
 
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