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

 
Amendment
001                                                                               Agreement
Number XQ744

THIS AMENDMENT, entered into between the State of Florida, Department of Elder
Affairs, hereinafter referred to as the "Department" and the Wellcare.
hereinafter referred to as the "contractor", amends contract number XQ744.

The purpose of this amendment is to amend ATTACHMENTS I, II, EI, and IV.

1)           ATTACHMENT I is hereby replaced with the revised ATTACHMENT I,
attached hereto.
2)           ATTACHMENT H is hereby replaced with the revised ATTACHMENT H,
attached hereto.
3)           ATTACHMENT m is hereby replaced with the revised ATTACHMENT III,
attached hereto.
4)           ATTACHMENT IV is hereby replaced with the revised ATTACHMENT IV,
attached hereto.

This amendment shall be effective on the last date that the amendment is signed
by both parties.

All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to conform to this amendment.

All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in the contract.

This amendment and all its attachments are hereby made a part of the contract.

IN WITNESS WHEREOF, the parties hereto have caused this 107 page amendment to be
executed by their officials thereunto duly authorized.

CONTRACTOR:   Wellcare
STATE OF FLORIDA, DEPARTMENT OF ELDER AFFAIRS
SIGNED BY:    /s/   Todd Farha
SIGNED BY: /s/  Illegible
for
NAME: Todd Farha
NAME:  E. Douglas Beach, PH.D.
TITLE: President & CEO
TITLE: Secretary
DATE:  12/27/07
DATE:  12/31/07
FEDERAL ID NUMBER: 592583622 FISCAL YEAR END DATE:
 

1

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
 
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT
Table of Contents

SECTION 1
GENERAL CONTRACT REQUIREMENTS
5
1.1
Entire Agreement; Conflict
5
1.2
Misuse of Symbols, Emblems, or Names in Reference to Medicaid
5
1.3
Contractor Qualifications
5
1.4
Contract Management
5
1.5
Insolvency Protection
9
1.6
Surplus Requirements
9
1.7
Bonds
9
1.8
Insurance
10
1.9
Interest and Savings
10
1.10
Third Party Resources
10
1.11
State Ownership
11
1.12
Ownership and Management Disclosure
11
1.13
Independent Provider
13
1.14
Damages from Federal Disallowances
13
1.15
Offer of Gratuities
13
1.16
Attorneys' Fees
13
1.17
Venue
13
1.18
Legal Action Notification
13
1.19
Force Majeure
13
1.20
Sanctions
14
1.21
Additional Applicable Laws and Regulations
15
1.22
Inspection and Audit of Financial Records
15
1.23
Reporting
15
1.24
Fiscal Intermediary
15
1.25
Subcontracts
16
1.26
Subcontractor Terminations
20
1.27
Termination
20
1.28
Assignment
21
SECTION 2
RECIPIENT ELIGIBILITY TO PARTICIPATE IN THE PROJECT
21
2.1
Eligibility Requirements
21
2.2
Eligibility
22
2.3
Persons Not Eligible for Enrollment
22
2.4
Optional State Supplementation (OSS)
22
SECTION 3
EDUCATIONAL MATERIALS AND CHOICE COUNSELING
23
3.1
Educational Materials
23
3.2
Choice Counseling
23
3.3
Prohibited Activities
23
SECTION 4
ENROLLMENT AND DISENROLLMENT
24
4.1
Enrollment Procedures
24
4.2
Effective Date of Enrollment
24
4.3
Transition Care Planning
24
4.4
Orientation
25
4.5
Plan of Care
26
4.6
Integration of Care
28
4.7
Disenrollment
29
4.8
Disputes of Appropriate Enrollments
31
4.9
Medicaid Pending
31
SECTION 5
ENROLLEE RECORDS
32

Attachment I - Page 2

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
SECTION 6
SERVICE PROVISIONS
32
6.1
Genera] Provisions
32
6.2
Long-Term Care Services
34
6.3
Minimum Long-Term Care Service Provider Qualifications
37
6.4
Acute-Care Services
39
6.5
Acute Care Provider Qualifications
40
6.6
Optional Services
40
6.7
Expanded Services
40
6.8
Availability/Accessibility of Services
41
6.9
Staffing Requirements
41
6.10
Emergency Care Requirements
42
6.11
Out of Network Use of Non-Emergency Services
42
6.12
Adult Protective Services
43
SECTION 7
UTILIZATION MANAGEMENT
44
SECTION 8
QUALITY ASSURANCE AND IMPROVEMENT REQUIREMENTS
45
8.1
General
45
8.2
Quality Assurance Program
45
8.3
Quality Assurance Committee
46
8.4
Quality Improvement Activities and Performance Measures
46
8.5
Independent Medical Review
47
8.6
Incident Reporting
47
SECTION 9
GRIEVANCE/APPEALS PROCEDURES
48
9.1
Grievance System Requirements
48
9.2
Appeal Process
49
9.3
Grievance Process
52
9.4
Medicaid Fair Hearing System
52
SECTION 10
PAYMENT
53
10.1
Payment to Contractor
53
10.2
Capitation Rates
53
10.3
Payment in Full
54
10.4
Capitation Payments
54
10.5
Payment Discrepancies
54
SECTION 11
PROGRAM REPORTING REQUIREMENTS
54
11.1
General Requirements
54
11.2
834 Transactions
57
11.3
Disenrollment Summary Report
58
11.4
Encounter Data Report
58
11.5
Grievance/Appeals Report
58
11.6
Updated Provider Network Listing
58
11.7
Minority Business Enterprise Contract Reporting
59
11.8
Emergency Management Plan
59
11.9
Enrollee Satisfaction Reporting
59
11.10
Hospice Services
59
SECTION 12
FINANCIAL REPORTING
59
12.1
General Financial Reporting
59
12.2
Member Payment Liability Protection
59
12.3
Financial Reporting Template
60
12.4
Audited Financial Statements
60
12.5
Unaudited Quarterly Financial Statements
60
12.6
Balance Sheet
61
12.7
Income Statement by Category of Service
65
12.8
Income Statement by Line of Business
74
12.9
Net Worth and Working Capital
75
12.10
Claim Lag Reports & Outstanding Claims Liability (OCL)
76
12.11
Analysis of Total Medical Liability to Actual Claims Paid
76
12.12
Member Months
76
12.13
Notes and Other Information
76

Attachment I - Page 3

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

SECTION 12
FINANCIAL REPORTING (cont)
 
12.14
Ratio Analysis
76
12.15
Footnote Disclosure Requirements
77
SECTION 13
DEFINITIONS
77
EXHIBIT A
MULTIPLE SIGNATURE VERIFICATION AGREEMENT
84
EXHIBITB
DISENROLLMENT SUMMARY REPORT
86
EXHIBIT C
ENCOUNTER DATA REPORTING FORMAT
87
EXHIBIT D
REPORT OF GRIEVANCES/APPEALS
91
EXHIBIT E
MINORITY BUSINESS ENTERPRISE CONTRACT REPORTING
92
EXHIBITF
RECONCILIATION REPORT
93
EXHIBIT G
DISENROLLMENT FORM
94
EXHIBIT H
PROVIDER NETWORK AND STAFF LISTING
96
EXHIBIT I
CAPITATION RATES
98
EXHIBITJ
PUBLIC ENTITY CRIMES
99
EXHIBIT K
DEBARMENT AND SUSPENSION
101
EXHIBIT L
HOSPICE ENROLLMENT REPORT
103

Attachment I - Page 4

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
 
LONG-TERM CARE COMMUNITY DIVERSION PILOT PROJECT SECTION l General Contract
Requirements
1.1          Conflict

Correspondence and project memoranda do not constitute part of this contract.
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.

1.2          Misuse of Symbols, Emblems, or Names in Reference to Medicaid

No person or contractor may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication, or
a broadcast, telecast, or other production, alone or with other words, letters,
symbols or emblems the words "Medicaid," or "Department of Elder Affairs," or
"Agency for Health Care Administration," except as required in the
standard-contract unless prior written approval is obtained from the department.
Specific written authorization from the department is required to reproduce,
reprint, or distribute any department or Agency form, application, or
publication, for a fee. State and local governments are exempt from this
prohibition. A disclaimer that accompanies the inappropriate use of the program
or the department or Agency's terms does not provide a defense. Each piece of
mail or information constitutes a violation.

1.3          Contractor Qualifications

The long-term care community diversion pilot project contractor must:
A.
Have a certificate of authority from the Florida Department of Financial
Services to  operate as a health maintenance organization (HMO) pursuant to
Chapter 641 Part I, F.S.,  and have a health care provider certificate from the
Agency for Health Care  Administration (Agency) pursuant to Section 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 Section 430.703(7), F.S. and;

B.
Have prior experience in providing home and community-based long-term care
services  and;

C.
Have the capacity to integrate the delivery of acute and long-term care services
to  enrollees and;
D.  Meet all the requirements to enroll as a Medicaid provider and;

E.
Meet all other requirements in the remaining provisions of this contract and
its  attachments.

1.4          Contract Management

A.        State Responsibilities
The Department of Elder Affairs (department) in consultation with the Agency for
Health Care Administration (Agency) will oversee contract management
responsibilities. The department will have the right to approve, disapprove, or
require modification of procedures developed by the contractor under the
contract where necessary to assure compliance with department or Agency rules or
the contract.

Attachment I - Page 5

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

A.  Department Responsibilities
1.
Develop or revise policies and procedures for the project in consultation with
the Agency.

2.
Approve, in consultation with the Agency, the contractor's readiness to deliver
services under the contract.

3.
Determine the clinical eligibility of persons applying for Medicaid long-term
care assistance through the Comprehensive Assessment and Review for Long-Term
Care Services (CARES) program.

4.
Provide through the CARES program, information regarding long-term care options
to persons applying for Medicaid long-term care assistance.
5.  Provide policy and contract clarification, in consultation with the Agency.

6.
Monitor with the Agency, the contractor's compliance with the terms of the
contract and impose appropriate corrective and remedial measures as warranted.

7.
Receive all materials that must be submitted by the contractor and forward them
to the appropriate entity except as otherwise stated in the contract.

C.        Contractor Responsibilities
1.
The contractor is responsible for the administration and management of all
contractor functions, including all subcontracts, employees, agents and anyone
acting for or on behalf of the contractor. Any delegation of activities does not
relieve the contractor of this responsibility.

2.
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.

3.
The relationship between management personnel and the governing body must be set
forth in writing, including each person's authority, responsibilities, and
function.

4.
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

5.
The contractor shall comply with applicable department or agency rules and any
Agency handbooks relating to the provision of services set forth in Section 6,
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(a) and (a)(3)(i)-(iii), the contractor must furnish services up to the
limits specified by the Medicaid program. The contractor may exceed these
limits. However, service limitations shall not be more restrictive than the
Medicaid fee-for-service program.

6.
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 health care professionals. d)   Are reviewed and updated
periodically as appropriate.

      
                The contractor shall disseminate the guidelines to all affected
providers and, upon request to enrollees and potential enrollees. The decisions
for utilization

Attachment I - Page 6

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

management, enrollee education, coverage of services, and other areas to
which  the guidelines apply shall be consistent with the guidelines.

  7.          Pursuant to Section 430.705(2)(b)(3), F.S., the contractor, must
have through performance or other documented means, the capacity for prompt
payment of claims as specified under Section 641.3155, F.S.

D. Administrative Polices and Procedures Section
1.  Contractor will have in place polices and procedures relating to
the  following:
a)  Emergency Management Plan
b)  Educational Materials
c)  Initial enrollment and Ongoing Eligibility
d) Transition Care Planning
e) Orientation
f)  Disenrollment
g) Service Provisions
h)  Network Adequacy
i)   Sufficient staff available 24 hours per day
j)   Credentialing and Re-Credentialing
k)  Plan for recruiting and retaining minority health vendors
I)    Integration of Care
m)  Plan of Care
n)  Out of network Use of Non-Emergency Services
o)   Quality Assurance Program
p)  Quality Assurance Committee
q)  Incident Reporting
r)   Utilization Management
s)   Grievance/Appeals
t)   Enrollee Records
u)   Claims
v)   Advance Directives
w)  Payment Discrepancies
x)    Reinstatement
y)    Subcontract
 
2.          Fraud Prevention Polices and Procedures
 
a)
The policies and procedures for fraud prevention shall provide for use of the
HHS Office of the Inspector General List of Excluded Individuals / Entities
Search (http://exclusions.oig.hhs.gov), or its equivalent, to identify excluded
parties during the process of enrolling providers to ensure the contractor
providers are not in a non-payment status or excluded from participation in
federal health care programs under Section 1128 or Section 1128A of the Social
Security Act. The contractor must not employ or contract with excluded providers
and must terminate providers if they become excluded.

b)
The contractor must have written policies and procedures for selection and
retention of providers. These policies and procedures must not discriminate
against particular providers that serve high-risk populations or specialize in
conditions that require costly treatments.

c)
The contractor must develop and maintain written polices and procedures
to  implement the provision of the contract.

Attachment I - Page 7

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

3.  Credentialing and Re-Credentialing Policies and Procedures
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:

1.   The subcontractor's current valid license.
2.   The subcontractor's current valid occupational license, where applicable.

3.   Medicaid provider number, if applicable.
4.   Verification of the following for non-Medicaid providers:

(a)
Evidence of the subcontractor's professional liability claims history.

(b)
Completion of a criminal history background check to determine whether
subcontactor has any history of felony convictions, including adjudication
withheld on a felony, plea of nolo contendere to a felony, or entry into a
pretrial for a felony.
(c)  Any sanctions imposed by Medicare or Medicaid in any state.

(d)
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.

(e)
Any history of loss or limitation of privileges or disciplinary activity.

5.
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).

6.
Verification that all subcontractors and their employees with direct contact
with enrollees have completed Abuse, Neglect, and Exploitation Training.
E. The process for periodic re-credentialing shall include the following:

1.
The procedure for re-credentialing shall be completed at least every three (3)
years.

2.
The contractor shall verify the current licensure of the subcontractor on an
annual basis.

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.

F.
The contractor shall set out in its subcontracts procedures for approval of  new
providers, and for imposition of sanctions, up to termination, of  contract.

G.
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.

H.
 The contractor shall develop and implement an appellate process for sanctions,
restrictions, suspensions and terminations imposed by the contractor against
subcontractors.

Attachment I - Page 8

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

4.          Health Information Systems

The contractor shall maintain a health information system that collects,
analyzes, integrates, and reports data and can achieve the objectives of 42 CFR
438.242 and Health Insurance Portability and Accountability Act (HIPAA)
requirements.

1.5          Insolvency Protection

A.
The contractor must establish and maintain a restricted insolvency protection
account in a  bank or savings and loan association located in the state of
Florida with a balance of at  least $100,000 into which monthly deposits equal
to at least 5 percent of premiums  received under the project are made until the
balance equals 2 percent of the total contract  amount. The account shall be
established with such terms as to ensure that funds may  only be withdrawn with
the signature approval of designated department representatives.  A sample form
(Signature Verification Agreement) can be found in Exhibit A.

B.
If the contractor's authorized representatives do not change from subsequent
contract  years, an attestation statement indicating such must be submitted to
the department.

C.
In the event that a determination is made by the department that the contractor
is  insolvent as defined in Section 13, the department may draw upon the account
solely with  the authorized signatures of representatives of the department and
funds may be  disbursed to meet financial obligations incurred by the contractor
under this contract.  The contractor shall provide a statement of account
balance upon request by the  department.

D.
If the contract is terminated, expired, or not continued, 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.

E.
In the event the contract is terminated or not renewed and the contractor is
insolvent, the  department may draw upon the insolvency protection account to
pay any outstanding  debts the contractor owes the Agency including, but not
limited to, overpayments made  to the contractor, and fines imposed under the
contract or Section 641.52, F.S., for which  a final order has been issued. In
addition, if the contract is terminated or not renewed and  the contractor is
unable to pay all of its outstanding debts to health care 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.

1.6          Surplus Requirements

All contractors shall maintain a surplus of at least $1.5 million as determined
by the department. Each applicant 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.

1.7          Bonds

The contractor must secure and maintain during the life of the contract a
blanket fidelity bond from a company doing business in the State of Florida on
all personnel in its employment and its board of directors. The bond must be
issued in the amount of at least $250,000 per occurrence. Said bond must protect
the department and Agency from any losses sustained through any fraudulent or
dishonest act or acts committed by any employees of the provider and
subcontractors, if any. The contractor must submit proof of coverage within 60
calendar days

Attachment I - Page 9

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

after execution of the contract and prior to the delivery of services. For
fidelity bonds to be acceptable, a surety company must comply with the
provisions of Chapter 624, F.S. The contractor must submit proof of the fidelity
bond annually during the contract renewal period.

1.8          Insurance

A.
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 Section 690-191.069, Florida  Administrative Code, 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 be 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 (Section 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.

B.
The contractor must secure and maintain during the life of the contract,
worker's  compensation insurance for all of its employees connected with the
work under the contract. Such insurance must comply with the Florida Worker's
Compensation Law,  Chapter 440, F.S. Policy declaration pages must be submitted
to the department  annually.

1.9          Interest and Savings

A.
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.

B.
The contractor will retain any savings realized under the contract after all
bills, charges,  and fines are paid.

1.10          Third Party Resources
 
A.
The contractor will 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.  (see Section 409.910, F.S.) The
following standards govern recovery

B.
If the contractor has determined that third party liability exists for part or
all of the  services provided directly by the contractor to an enrollee, the
contractor must make  reasonable efforts to recover from third party liable
sources the value of services  rendered.

C.
If the contractor has determined that third party liability exists for part or
all of the  services provided to an enrollee by a subcontractor or referral
provider, and the third  party is reasonably expected to make payment within 120
calendar days, the contractor  may pay the subcontractor or referral provider
only the amount, if any, by which the  subcontractor's allowable claim exceeds
the amount of the anticipated third party  payment; or, the contractor may
assume full responsibility for third party collections for  service provided
through the subcontractor or referral provider.

D.
The contractor may not withhold payment for services provided to an enrollee if
third  party liability or the amount of liability cannot be determined, or if
payment shall not be

Attachment I - Page 10

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

available within a reasonable time, beyond 120 calendar days from the date of
receipt.
E.
When both the Agency and the contractor have liens against the proceeds of a
third party  resource, the Agency shall prorate the amount due to Medicaid to
satisfy such liens under  Section 409.910, F.S., between the Agency and the
contractor. This prorated amount  shall satisfy both liens in full.
F.  All funds recovered from third parties shall be treated as income for the
contractor.

 
1.11          State Ownership

The department and Agency will have the right to use, disclose, or duplicate,
all information and data developed, derived, documented, or furnished by the
contractor resulting from the contract. Nothing herein will entitle the
department and Agency to disclose to third parties data or information, which
would otherwise be protected from disclosure by state or federal law.

1.12          Ownership and Management Disclosure

A.
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), public
entity crimes (Section  287.133(3)(a), F.S.), and debarment and suspension (52
Fed. Reg., pages 20360-20369,  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 with the initial application and  then resubmitted on an
annual basis. The contractor must disclose any changes in  management as soon as
those 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.
B.   The following definitions apply to ownership disclosure:

1.
A person with an ownership interest or control 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.

Attachment I - Page 11

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

C.
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.
D.
In accordance with Section 409.912(32), F.S., the contractor must annually
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. The
contractor must submit information to the  department for such persons who have
a record of illegal conduct according to the  background check.

1.
In accordance with Section 409.907(8)(a), F.S., contractors must submit, prior
to execution of a contract, complete sets of fingerprints of principals of the
contractor to the department for the purpose of conducting a criminal history
record check.
2.  Principals of the contractor are defined in Section 409.907(8)(a), F.S.

E.
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 Section 435.03,
F.S.

F.
In accordance with Section 409.912(10), F.S., the department and Agency will
not  contract with an entity that has an officer, director, agent, managing
employee, or owner  of stock or beneficial interest in excess of five (5)
percent of the contractor, who has  committed any of the listed offenses as
referenced in Section 435.03, F.S.  In order to  avoid contract termination, the
contractor must submit a corrective action plan, approved  by the department,
that ensures such person is divested of all interest and/or control and  has no
role in the operation and management of the contractor.

G.
The contract is subject to the provisions of Chapter 112 and Section 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.

Attachment I - Page 12

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

1.13          Independent Provider

The contractor and any subcontractors' employees, agents, and officers in the
performance of this contract, shall act in an independent capacity and not as
officers and employees of the department, Agency, or the State of Florida. It is
further expressly agreed that this contract shall not be construed as a
partnership or joint venture between the contractor or any subcontractor and the
department, Agency, or the State of Florida.

1.14          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.

1.15          Offer of Gratuities

By signing this agreement, the contractor signifies that no recipient of or a
delegate of Congress, nor any elected or appointed official or employee of the
State of Florida, the General Accounting Office, Department of Health and Human
Services, Centers for Medicare and Medicaid Services, or any other federal
Department has or will benefit financially or materially from this procurement.
The department may terminate the contract if it is determined that gratuities of
any kind were offered to or received by any officials or employees from the
offeror, his agent, or employees.

1.16          Attorneys' Fees

In the event of a dispute, each party to the contract will be responsible for
attorney's fees except as otherwise provided by law.

1.17          Venue

For purposes of any legal action occurring as a result of or under the contract,
between the contractor and the department or Agency, the place of proper venue
will be Leon County, Florida.

1.18          Legal Action Notification

The contractor must give the department by certified mail immediate 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 or against a subcontractor.

1.19          Force Majeure

The department and Agency will not be liable for any excess cost to the
contractor if the department's or Agency's failure to perform the contract
arises out of causes beyond the control and without the result of fault or
negligence on the part of the department or Agency. In all cases, the failure to
perform must be beyond the control without the fault or negligence of the
department or Agency. The contractor will not be liable for performance of the
duties and responsibilities of the contract when its ability to perform is
prevented by causes beyond its control. These acts must occur without the fault
or negligence of the contractor. These include

Attachment I-Page 13

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

destruction to the facilities due to hurricanes, fires, war, riots, and other
similar acts. Annually by April 30, the contractor must submit to the department
for approval an emergency management plan specifying what actions the contractor
must conduct to ensure the ongoing provisions of health services in a natural
disaster or man-made emergency.

1.20      Sanctions

A.
In accordance with Section 4707 of the Balanced Budget Act of 1997, and
Section  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:
1.   Suspension of the contractor's enrollment.

2.
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 the complainant for
out-of-pocket medically necessary expenses incurred or order the contractor to
pay non-network plan providers who provide medically necessary services.

3.
Imposition of a fine for violation of the contract with the department and
Agency, pursuant to Section 409.912(22), F.S.

4.
Termination pursuant to paragraph IV B (3) 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(f) of the Social
Security Act. 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.

B.
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.

C.
The Agency and/or department may impose intermediate sanctions in accordance
with 42  CFR 438.702, including:
1.   Civil monetary penalties in the amounts specified in Chapter 409.912(22),
F.S.

2.
Appointment of temporary management for the contractor. Rules for temporary
management pursuant to 42 CFR 438.706 are as follows:

a) 
The State may impose temporary management only if it finds (through onsite
survey, enrollee complaints, financial audits, or any other means) that:

(1)
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
(2)  There is substantial risk to enrollees' health; or

(3)
The sanction is necessary to ensure the health of the contractor's  enrollees:
(i)  While improvements are made to remedy violations under 42 CFR  438.700; or
(ii) Until there is an orderly termination or reorganization of the contractor.
b) 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 must also grant

 
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Amendment
001                                                                                    Agreement
Number XQ744

enrollees the right to terminate enrollment without cause, as described in 42
CFR 438.702(a)(3), and must notify the affected enrollees of their right to
terminate enrollment.
c)
The State may not delay imposition of temporary management to provide a hearing
before imposing this sanction.

d)
The State may not terminate temporary management until it determines that the
contractor can ensure that the sanctioned behavior will not recur.

3.
Granting enrollees the right to terminate enrollment without cause and notifying
affected enrollees of their right to disenroll.

4.
Suspension or limitation of all new enrollment, including default enrollment,
after the effective date of the sanction.

5.
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.

6.
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.

7.
Withholding of three (3) percent of the next monthly capitation payment by the
Agency pending receipt of the reports.

1.21          Additional Applicable Laws and Regulations

In addition to the requirements of Section LB. of the Standard Contract, the
contractor agrees to comply with all applicable federal and state laws, rules
and regulations including but not limited to: Title 42 Code of Federal
Regulations (CFR) Chapter IV, Subchapter C; Chapters 409 and 641, F.S.; 42 CFR
431, Subpart F, Chapter 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C.
in regard to the contractor safeguarding information about beneficiaries; Title
VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
applicants for employment; Chapter 641, parts I and III, F.S., in regard to
managed care; Medicare Medicaid Fraud and Abuse Act of 1978; the federal omnibus
budget reconciliation acts; the Newborns' and Mothers' Health Protection Act of
1996; and the Balanced Budget Act of 1997. The contractor is subject to any
changes in federal and state law, rules, or regulations.

1.22          Inspection and Audit of Financial Records

The state and DHHS may inspect and audit any financial records of the contractor
or its providers. Pursuant to section 1903(m)(4)(A) of the Social Security Act
and State Medicaid Manual 2087.6(A-B), non-federally qualified contractors must
report to the state, upon request, and to the Secretary and the Inspector
General of DHHS, a description of certain transactions with parties of interest
as defined in section 1318(b) of the Social Security Act.

1.23          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 when required. 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 time frames specified may result in sanction
in accordance with Section 1.21.

1.24          Fiscal Intermediary

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Amendment
001                                                                                    Agreement
Number XQ744
 
If the contractor utilizes a fiscal intermediary service organization as defined
in Chapter 641.316, F.S., such organization must be licensed to do business as a
fiscal intermediary service organization in the state of Florida. Such
delegation does not relieve the contractor of responsibility for the
administration and management required under this contract.

1.25     Subcontracts

The contractor is responsible for all work performed under this contract, but
may, with the written approval of the department, enter into subcontracts for
the performance of work required under this contract. All subcontracts and
amendments thereto executed by the contractor must meet the requirements listed
in this section. All model provider subcontracts must be approved, in writing,
by the department in advance of implementation and execution of subcontracts.
All subcontractors must be eligible for participation in the Medicaid program;
however, the subcontractor is not required to participate in the Medicaid
program as a provider. Subcontracts are required with all major providers of
services and there shall be no provisions prohibiting service providers from
contracting with other long-term care diversion contractors. All direct service
providers are required to attend and complete Abuse, Neglect & Exploitation
Training. This training can be given by the Department of Children and Families,
the local area agency on aging, the department, and the contractor or be
accommodated through licensing requirements. The contractor's training materials
shall be approved, in advance, by the department.

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. 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 department of Elder Affairs, 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

In all contracts with health care professionals, the contractor must comply with
the requirements specified in 42 CFR 438.214 which includes but is not limited
to selection and retention of providers, credentialing and re-credentialing
requirements, and nondiscrimination.

A.          Identification of conditions and method of payment:
All subcontract and amendments must meet the following requirements:
1.
The contractor agrees to make payment to all providers pursuant to 42 CFR
447.46,42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR
447.45(d)(6). If third party liability exists, payment of claims must be
determined in accordance with Section 1.11, Third Party Resources.
2. Provide for prompt submission of information needed to make payment.

3.
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 contractor's subcontract with the provider in accordance with
Section 1128B(d)(l), 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.

4.
Require an adequate record system be maintained for recording services,
charges,  dates and all other commonly accepted information elements for
services  rendered to recipients under the contract.

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Amendment
001                                                                                    Agreement
Number XQ744

5.
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). All such
arrangements must be submitted to the department for approval, in writing, prior
to use. If any other type of withhold arrangement currently exists, it must be
omitted from all subcontracts.

6.
Specify whether the contractor will assume full responsibility for third party
collections in accordance with Section 1.11, Third Party Resources.

B.          Provisions for monitoring and inspections:
1.
Provide that the department, Agency, and Department of Health and Human Services
(DHHS) may evaluate through inspection or other means the quality,
appropriateness and timeliness of services performed.

2.
Provide for inspections of any records pertinent to the contract by the
department, Agency, and DHHS.

3.
Require that records be maintained for a period not less than five (5) years
from the close of the contract and retained further if the records are under
review or audit until the review or audit is complete. (Prior approval for the
disposition of records must be requested and approved by the provider if the
subcontract is continuous.)

4.
Provide for monitoring and oversight by the contractor of the subcontractor to
provide assurance that all licensed subcontractors are credentialed in
accordance with Section 1.5.D.3, Credentialing and Re-credentialing Policies and
Procedures.
5. Provide for monitoring of services rendered to enrollees- by the
subcontractor.

6.
Require that assisted living facilities and nursing facilities keep a copy of
the plan of care on file in the residents record and available for inspection by
the department, Agency and DHHS.

C.          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.

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Amendment
001                                                                                   Agreement
Number XQ744

D.          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 Section 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 Section 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 Section 641.315(10), contain no provision requiring providers to
contract for more than one long-term care product or otherwise be excluded.

9.
Pursuant to Section 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 contractor
for any reason.

14.
Provisions for nonpayment for goods and services rendered by the subcontractor
to the contractor is not a valid reason for avoiding the 60 day advance notice
of cancellation pursuant to Section 641.315(2)(a)(2), F.S.
15.   Pursuant to Section 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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Amendment
001                                                                                    Agreement
Number XQ744

 

E. The contractor must not discriminate with respect to participation,
reimbursement, or indemnification as to any subcontractor who is acting within
the scope of the provider's license, or certification under applicable state
law, solely on the basis of such license, or certification, in accordance with
Section 4704 of the Balanced Budget Act of 1997. This paragraph shall not be
construed to prohibit a contractor from including subcontractors only to the
extent necessary to meet the needs of the contractor's enrollees or from
establishing any measure designed to maintain quality and control costs
consistent with the responsibilities of the organization. If the contractor
declines to include individual subcontractors or groups of subcontractors in its
network, it must give the affected subcontractors written notice of the reason
for its decision.

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, written notice must be provided 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.

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 enrolled in the Medicare and
Medicaid programs, when it is determined by the department to be in the best
interest of the enrollee(s) to do so. The letter of agreement shall contain
timeframe provisions for the facility. This exception does not apply for initial
network implementation.

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 of the network
for the enrollee, for as long as the contractor is unable to provide them within
the network.

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.

F. Network Expansion

The contractor may expand into new service areas approved by CMS, by providing
the following information to the plan analyst: letter of expansion request,
copies of the first page and signature page of the executed subcontracts,
applicable licenses, 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.

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Amendment
001                                                                                    Agreement
Number XQ744

1.26          Subcontractor Termination

The contractor must make a good faith effort to give written notification of a
contracted provider termination to each enrollee who has been seen by the
terminated provider on a regular basis within 15 days after receipt or issuance
of the termination notice.

1.27          Termination

A.
In conjunction with the Standard Contract, Part TV, section B, titled
"Termination" upon  termination, procedures to ensure services to consumers will
not be interrupted or  suspended by the termination are required (Termination
Plan). Such termination plan  must be approved by the department and Agency
prior to notice of termination, and must  provide for an efficient and timely
transfer and/or relocation of all enrollees.

B.
The party initiating the termination must render written notice of termination
to the  department by certified mail, return receipt requested, or in person.
The notice of  termination required by Part TV, Section B of the Standard
Contract must specify the  nature of termination, the extent to which
performance of work under the contract is  terminated, the date on which such
termination shall become effective, and the terms of  the Termination Plan. In
accordance with section 1932(e)(4), Social Security Act, the  department and
Agency shall provide the contractor with an opportunity for-a hearing  prior to
termination for cause.

C
In the event of a notice of termination and unless a written waiver is executed
by the department or Agency, the contractor must:
1. Continue performance under the terms of the contract until the termination
date. 2. Immediately cease enrollment of new enrollees under the contract. 3.
Immediately perform the duties as specified in the approved Termination Plan.

4.
Assign to the State 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.

5.
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.

6.
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.

7.
Decline any prepaid payments for requests for payment submitted after the
contact 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.

8.
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.

9.
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.

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Amendment
001                                                                                    Agreement
Number XQ744

1.28      Assignment

A.
Except as provided below or with the prior written approval of the department,
which  approval will not be unreasonably withheld, the contract and the monies
which may  become due are not to be assigned, transferred, pledged or
hypothecated in any way by  the contractor, including by way of an asset or
stock purchase of the contractor and will  not be subject to execution,
attachment or similar process by the contractor.
B. Exceptions for HMOs licensed under Chapter 641, F.S., are as follows:

1.
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
Chapter 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.

2.
To be in good standing, a contractor must not have failed accreditation or
committed any material violation of the requirements of Chapter 641.52, F.S.,
and must meet the requirements in this contract.

3.
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.

C.
Exceptions for Other Qualified Providers licensed under Chapter 400 or Chapter
429,  F.S., are as follows:
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.

 

SECTION 2     RECIPIENT ELIGIBILITY TO PARTICIPATE IN THE PROJECT
 
2.1       Eligibility Requirements
Recipients eligible for project enrollment must be:        

A.   65 years of age or older.
B.
Has Medicare Parts A & B as reflected in the Florida Medicaid Management
Information  System (FMMIS) through the Medicaid Eligibility Verification System
(MEVS).
C.  Medicaid eligible with incomes up to the Institutional Care Program level
(ICP). D.  Reside in the project service area.

E.
Determined by CARES to be at risk of nursing home placement and meet one or more
of  the following clinical criteria:
1.  Require some help with five or more activities of daily living (ADLs); or 2.
Require some help with four ADLs plus requiring supervision or administration of
medication; or
3.  Require total help with two or more ADLs; or

4.
Have a diagnosis of Alzheimer's disease or another type of dementia and require
assistance or supervision with three or more ADLs; or

5.
Have a diagnosis of a degenerative or chronic condition requiring daily nursing
services.
F.  Determined by CARES to be a person who, on the effective date of enrollment,
can be safely served with home and community-based services.

Attachment I - Page 21

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

2.2          Eligibility

A.
The Florida Department of Children and Families (DCF) and the federal Social
Security  Administration determine a person's financial and categorical Medicaid
eligibility.  Financial eligibility for the project will be up to the Medicaid
Institutional Care Program  (ICP) income and asset level.

B.
The department's CARES program determines a person's clinical eligibility for
the  project.

C.
The contractor shall assist enrollees to ensure continuous eligibility in the
program. This  includes financial and clinical eligibility as part of the case
management responsibilities  and a systematic process for tracking the
eligibility redetermination dates on a monthly  basis.

D.
Enrollees who lose eligibility and then regain eligibility within 60 days, are
automatically  reinstated to the contractor during the next enrollment cycle.
This possible 60 day period  is considered a break in service. The enrollee's
enrollment eligibility in the plan will  remain the same as if they never left
the plan. The Medicaid fiscal agent will produce two  reinstatement reports -
one during the monthly enrollment cycle and another the first  business day of
the month by 12:00 p.m.

E.
Enrollees who lose eligibility between the second to the last Saturday and the
end of the  month will be identified on the Supplemental HMO Disenrollment
Report. The Medicaid  fiscal agent produces this report on the first business
day of the month by 12:00 p.m.

2.3          Persons Not Eligible for Enrollment
          

A. Persons residing outside the project service area.
B.
Persons residing in a state hospital, intermediate care facility for persons
with  developmental disabilities, or a correctional institution.
C. Persons participating in or enrolled in another Medicaid waiver project.

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

E.
Persons enrolled in any other Medicaid capitated long-term care program or in
a  Medicaid HMO or MediPass program.

2.4          Optional State Supplementation (OSS)

A.
The contractor shall inform and assist enrollees who qualify under Chapter
409.212, F.S.,  with an application for OSS services. OSS is general revenue
cash assistance program.  The purpose of the program is to supplement the
enrollees' income to help pay the cost in  an assisted living facility.

B.
The local Department of Children & Families Economic Self-Sufficiency office or
Audit  Payments Unit will supply the contractor with the forms and income
qualifications.

Attachment I - Page 22

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

SECTION 3     EDUCATIONAL MATERIALS AND CHOICE COUNSELING

3.1          Educational Materials

A.          The contractor may not market to prospective enrollees face-to-face.
B.
The contractor may use mass marketing strategies, approved by the department,
to  communicate information regarding the project to prospective enrollees.

C.
All materials including, but not limited to print and media for potential and
current  enrollees shall be approved by the department.

3.2          Choice Counseling

A.
CARES staff will provide prospective enrollees with information regarding
their  Medicaid long- term care options. These options may include: enrolling in
the project,  participating in another Medicaid home and community-based
services waiver program,  placement in a nursing home, or declining long-term
care assistance.

B.
CARES staff will also perform a choice counseling function for the project. The
choice  counseling function includes providing the prospective enrollee with
contractor prepared,  and department approved, educational materials, and
explaining the following:

1.
The concept of managed care and the integrated delivery of acute and long-term
care.

2.
The advantages to the enrollees of the integration and coordination of acute and
long-term care.
3. The qualifications for enrollment in the project.

4.
That the enrollee has the right to choose any available contractor in the
service area and may change contractors if the enrollee is not satisfied with
his/her initial choice.
5.   The benefits provided under the project. 6.    Pursuant to 42 CFR
438.10(g)(3), the contractor shall provide information on the contractor's
physician incentive plans or on the contractor's structure and operation to any
Medicaid recipient, upon request.

 
3.3          Prohibited Activities

A.
In accordance with 42 CFR 438.104(b)(l)(iv), the entity does not seek to
influence  enrollment in conjunction with the sale or offering of any private
insurance.

B.
In accordance with 42 CFR 438.104(b)(l)(v), the entity does not, directly or
indirectly,  engage in door-to-door, telephone, or other cold-call marketing
activities.

C.
In accordance with 42 CFR 43 8.104(b)(2)(i), the entity does 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 Plan benefits).

D.
In accordance with Section 409.912(2l)(b), F.S., and 42 CFR 438.104(b)(2)(ii),
entity  does not make any inaccurate false or misleading claims that the entity
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.

Attachment I - Page 23

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

SECTION 4    ENROLLMENT AND DISENROLLMENT

4.1          Enrollment Procedures

A.
When a person is determined to be both financially and clinically eligible and
chooses to  enroll in the Long-Term Care Community Diversion Program, CARES
staff will  complete a CARES referral package. CARES staff will forward the
CARES referral  package, with the date of enrollment, to the contractor.
B.  Upon receipt, the contractor will log in and date stamp the CARES referral
package.

C.
The contractor will forward the enrollment information to the Medicaid fiscal
agent in the  HIPAA approved format. This information must be transmitted to the
fiscal agent by the  monthly reporting deadline in order to be effective for the
subsequent month.

D.
The contractor is responsible to check monthly Medicaid eligibility through the
Medicaid  Eligibility Verification System (MEVS). This includes the following:

1.
Recipient address is located in the same county as the contractor's provider
service area
2. Recipient program codes (should be MS, MMS, or MWA) 3.   Residing in a
nursing home 4. Current enrollment in a Medicaid HMO 5. Current enrollment in
the MediPass Program 6. Has presence of Medicare Parts A &B
If a recipient does not have Medicare Parts A & B on MEVS, then the recipient is
not eligible for the program. Once the presence of Medicare Parts A & B is on
MEVS, then the recipient can be submitted for electronic enrollment.

E. The contractor shall not deny enrollment to reinstated enrollees.
F.
The contractor accepts individuals eligible for enrollment in the order in which
they are  received from CARES without restriction (unless authorized by the CMS
Regional  Administrator), up to the limits set under the contract (if
applicable). 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.

4.2          Effective Date of Enrollment

Enrollment is effective at 12:01 a.m. on the first day of the calendar month
that the enrollee's name appears on the report for payment issued by the
Medicaid fiscal agent. Enrollment is in whole months. Retroactive disenrollment
will be considered by the Agency, in consultation with the department for those
enrollees who have moved out of the service area into an area where the
contracted services are unavailable, deceased enrollees prior to the initial
enrollment effective date, and potential enrollees who decided to remain in the
skilled nursing facility for long term care prior to the initial enrollment
effective date.

4.3          Transition Care Planning

A.
Transition care services are those 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  project up until the time the Plan of Care is
implemented. For recipients who are  transferring from another home and
community based service waiver program, the  contractor shall ensure
continuation of needed services during the transition phase.

B.
CARES staff will notify the contractor, the lead agency, and when appropriate,
hospital  discharge planning staff regarding the need for a transition care
plan. CARES staff will

Attachment I - Page 24

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

forward, to each of these entities, any information collected during the
clinical eligibility determination process related to the person's health
status, functional status, caregiver, social support system, living environment
and how current service needs are being met. By the first date of enrollment,
(1) the contractor must provide transition care services in collaboration with
CARES staff and (2) 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.

4.4       Orientation

A.
Prior to or upon enrollment the contractor must provide each new enrollee or
their  representative with a written notice of the effective date of enrollment,
a plan ID card  which includes the contractor's name, address, the member
services telephone number,  an enrollee handbook, and a provider directory.

B.
The contractor must complete face-to-face project orientation within five (5)
business  days of enrollment for those enrollees in a community setting
(document any exceptions  beyond this timeframe). The contractor must complete
face-to-face project orientation  within 7 business days of enrollment for those
enrollees residing in a facility.

C.
The enrollee handbook must be written so it can be read and understood by the
enrollees  or their representatives at or below an eighth grade reading level.
The following items  must be included:
1.   Terms and conditions of 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 Section 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 enrollees obtain access to the services included in their
care plans.
7.  The consequences of obtaining care from out-of-network providers.

8.
Information regarding the enrollee's right to disenroll at any time and
instructions to initiate the disenrollment process. Information must explain
that if voluntary disenrollment is requested prior to the fiscal agent's monthly
processing deadline, disenrollment will be effective the first of the following
month.
9. Information regarding the enrollee's rights and responsibilities. 10.
Grievance and appeals process. 11. Information regarding the confidentiality of
enrollee records.

12.
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 contractor's prescription drug
benefits program.
f) The policies and procedures relating to the confidentiality and disclosure of
the enrollee's medical records. g)  Information that enrollees may obtain from
the contractor regarding quality performance indicators, including aggregate
enrollee satisfaction data

     

Attachment I - Page 25

 
 

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Amendment 001            Agreement Number XQ744
 
13.
Information that interpretation services for all non-English languages and
alternative communication systems are available, free of charge and how to
access these services.

14.
Information that post-stabilization services are provided without prior
authorization and other post-stabilization care services rules set forth in 42
CFR 422.113(c).

15.
Information that services will continue upon appeal of a suspended authorization
and that the enrollee may have to pay in case of an adverse ruling.
16.  Information regarding the health care advanced directives pursuant to
Chapter 765, F.S.. Written information regarding advance directives provided by
the contractor must reflect changes in state law as soon as possible, but no
later than 90 days after the effective date of the change.

17.
The contractor will provide enrollee information in accordance with 42
CFR  438.10(f). 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
obtain  information.

D.
The provider directory must list the providers sorted by county and then by
service, and  contain the following:
1.          Provider name
2.          Service(s) provided
3.          Provider location
4.          Provider telephone number

E.
The contractor shall assure that appropriate non-English language versions of
all  materials are developed and available to members and potential members. The
contractor  shall provide interpreter services in person where practical, but
otherwise by telephone,  for applicants or members whose primary language is not
English. Non-English versions  of materials are required if, as provided
annually by the Agency, the population speaking  a non-English language in a
county is greater than five (5) percent.

F.
All materials including, but not limited to print and media for potential and
current  enrollees shall be approved by the department.

4.5       Plan of Care

A.
The contractor is required to develop an individualized written plan of care, in
a format  approved by the department, for every new enrollee within five (5)
business days of the  effective date of enrollment for those enrollees in a
community setting (document any  exceptions beyond this timeframe). The
contractor must develop an individualized  written plan of care, in a format
approved by the department within seven (7) business  days of enrollment for
those enrollees residing in a facility.

B.
This does not relieve the contractor of its obligation as set forth in Section
4.3 of  Attachment I to this contract.

C.
Services included in the plan of care will be determined by the contractor in
conjunction  with the initial assessment information provided by the CARES
office, in consultation  with the enrollee or their representative and be
necessary to address all health and social  service needs of the enrollee
identified through an assessment.

D.
The plan of care 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 plan of care must clearly identify
barriers to the enrollee and caregivers, if  applicable. The case manager must
discuss barriers and explore potential solutions with

Attachment I - Page 26

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

the enrollee, and caregivers when applicable. The plan of care must detail all
interventions designed to address specific barriers to independent functioning.
The plan may include 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.
E.
The Plan of Care or Plan of Care summary given to the enrollee or the
enrollee's  caregiver must include at minimum the following components as
specified in 42CFR.  441.351(f):

a.          The enrollee's name
b.          The enrollee's Medicaid ID number
c.          Plan of Care effective date
d.          Plan of care review date
e.          Covered services provided including routine medical and HCBS
services
f.          Begin date and end date
g.          Providers
h.          Amount and frequency
i.          Case manager's signature
j.          Enrollee or the enrollee's authorized representative's signature and
date

F.          In developing the plan of care, the contractor must:
1.
Assess the immediacy of the new enrollee's services needs and include a
description of the project participant's condition (e.g., ADL and LADL
limitations, incontinence, cognitive impairment, arthritis, high blood
pressure), as identified through an appropriate comprehensive assessment and a
medical history review.

2.
Identify any existing care plans and service providers and assess the adequacy
of current services.

3.
Provide for continuous care to the new enrollee if the enrollee is receiving
active treatment prior to the effective date of enrollment.

4.
Pursuant to 42 CFR 43 8.208(c)(3) and (c)(4), the contractor must produce a plan
of care that addresses the health, social service, and special health care needs
of the enrollee identified through an assessment. The plan of care must be:

a)
Developed by the enrollee's primary care provider with enrollee participation,
and in consultation with any specialists caring for the enrollee.

b)
Approved by the managed care provider in a timely manner, if the managed care
provider requires an approval.

c)
In accordance with any applicable state quality assurance and utilization review
standards.

5.
Ensure that the care plan contains, at a minimum, 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.

6.
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 plan of care must specify the
long-term care service interventions, and when such services are the
responsibility of the contractor, the medical interventions for the enrollee.

Attachment I - Page 27

 
 

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Amendment 001        Agreement Number XQ744

7.
Ensure that review of the care plan is performed through face-to-face contact
with the enrollee at least every third month to determine the appropriateness
and adequacy of services and to ensure that the services furnished are
consistent with the nature and severity of the enrollee's needs.

8.
Ensure that the care plan is reviewed sooner than the minimum required time
frame if in the opinion of any person or person(s) involved in the care of the
enrollee there is reason to believe significant changes have occurred in the
enrollee's condition or in the services the enrollee receives, or an enrollee or
an enrollee's representative requests another review due to the changes in the
enrollee's physical or mental condition.

9.
Ensure the maintenance or creation of an enrollee's informal network of
caregivers and services providers. Primary caregivers, family, neighbors and
other volunteers will be integrated into an enrollee's plan of care 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 by the enrollee.

10.
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.

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

H.
A copy of the plan of care must be forwarded to the department's CARES office
within ten (10) days of development.

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

J.
Revisions to the plan of care 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 physicians
input regarding plan of care revisions. Changes in service provision resulting
from a plan of care review must be implemented within five (5) business days of
the review date.

K.
The contractor will send a Form 2515 to the local CARES office and DCF informing
them of any changes in an enrollee's address.

4.6           Integration of Care

A.
Project case managers are responsible for long-term care planning and at least
annual  assessments, for developing and carrying out strategies to coordinate
and integrate the  delivery of all acute and long-term care services to
enrollees.

B.
For those persons enrolled in the contractor's Medicare Advantage plan
(where  applicable), 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.

Attachment I - Page 28

 
 

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Amendment 001

Agreement Number XQ744

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. The case manager must actively pursue
coordination with the  enrollee's primary care physician and other care
providers.

D.
In addition, the contractor will be responsible for the following activities to
facilitate care  coordination and continuity of care:

1.
The contractor must implement a systematic process for generating or receiving
referrals and with the enrollee's written consent, sharing clinical and
treatment plan information, including management of medications.

2.
The contractor must implement a systematic process for obtaining consent from
enrollees or their representatives to share confidential medical and
treatment-planning information with providers.

3.
The contractor must implement a systematic process for coordinating care with
organizations which are not part of the contractor's network of providers but
are otherwise important to the health and well being of enrollees.

4.
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.

5.
The contractor must implement a systematic process for tracking the Medicaid
eligibility redetermination dates on a monthly basis to ensure continuity of
care without a break in eligibility.

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

1.
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.

2.
Coordinate the services the contractor furnishes to the enrollee with services
the enrollee receives from any other managed care entity during the same period
of enrollment.

3.
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.

4.
Ensure in the process of coordinating care, each enrollee's privacy is protected
in accordance with the privacy requirements in 45 CFR Part 160 and 164 Subparts
A and E, to the extent that they are applicable.

4.7           Disenrollment

A.
Enrollees must be allowed to voluntarily disenroll at any time. If voluntary
disenrollment  is requested prior to the fiscal agent's monthly processing
deadline, disenrollment will be  effective the first of the following month. If
voluntary disenrollment is requested after  the fiscal agent's monthly
processing deadline, disenrollment will not take place until the  first of the
month subsequent to the next month.

B.
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.  Disenrollment shall be in accordance with 42 CFR
438.56(b)(3) and (d)(3).

C.
Immediately upon receiving a voluntary request for disenrollment, the contractor
must  inform the enrollee of disenrollment procedures.

D.
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.

Attachment I - Page 29

 
 

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Amendment 001        Agreement Number XQ744

The contractor's written disenrollment procedure must list the staff responsible
for this type of assistance.
E.
The contractor must keep a daily log of all verbal and written disenrollment
requests and  the disposition of such requests. The contractor must ensure that
disenrollment request  logs are maintained in an identifiable manner, and
enrollees who wish to file a grievance  are afforded appropriate notice and
opportunity to do so.

F.
The contractor shall assure that appropriate non-English language versions of
all  disenrollment materials are developed and available to members. The
contractor shall  provide interpreter services in person where practical, but
otherwise by telephone, for  members whose primary language is not English.
Non-English language versions of  disenrollment materials are required if, as
provided annually by the Agency, the  population speaking a particular
non-English language in a county is greater than five (5)  percent.
G. 
 Involuntary disenrollments are limited to the following reasons:
1.          Enrollee death.
2.          Ineligibility for Medicaid.
3.          Ineligibility for the project.
4.          Moving outside the contractor's service area.
5.          Fraudulent use of the enrollee's Medicaid ID card.
6.          Incarceration.
7.          Non-cooperation, subject to department approval.

H.
After providing at least one verbal and at least one written warning of the full
implications of failure to follow a recommended plan of care, the contractor may
submit an involuntary disenrollment request to the department for an enrollee
who continues not to comply. The department may approve such a request provided
that a written explanation of reason for disenrollment is given to the enrollee
prior to the effective date and provided that the enrollee's actions are not
related to the enrollee's medical or mental condition. Enrollees must be given a
reasonable opportunity to comply with the plan of care 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
service providers or contractor's staff or representatives. Enrollees who are
disenrolled through this section are not eligible for re-enrollment without the
permission of the contractor.
I.   The contractor may also submit an involuntary disenrollment request for an
enrollee whose behavior is disruptive, unruly, abusive, or uncooperative to the
extent that his or her enrollment with the contractor seriously impairs the
contractor's ability to furnish services to either the enrollee or other
enrollees. The contractor must provide at least one verbal and one written
warning to the enrollee regarding the implications of his or her actions. A
written explanation of the reason for disenrollment must be given to the
enrollee prior to submitting the disenrollment request. The department will
approve, such requests in writing, provided the contractor has documented the
actions described above and the enrollee's actions are not related to the
enrollee's medical or mental condition, involuntary disenrollment documents are
maintained in an identifiable enrollee record, and enrollees who are disenrolled
through this action are not eligible for re-enrollment without the permission of
the contractor. The contractor shall be prohibited from requesting a
disenrollment based on a change in the enrollee's health status pursuant 42 CFR
438.56(b)(2). Involuntary disenrollments without the department's consent will
be considered an express or intentional violation of the contract. Repeated
occurrences will be considered a cause for termination as specified in Section
1.28.

 
J.
Disenrollment request forms must be completed in their entirety whether
completed by the contractor or the enrollee,, and submitted on DOEA Form
LTCD-002, Exhibit G.

Attachment I - Page 30

 
 

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Amendment 001.                                Agreement Number XQ744

K.
All disenrollments, including those subject to prior approval, shall be
completed through the submission of the HIPAA approved format to the Medicaid
fiscal agent.

L.
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. In no event will the contractor submit a
disenrollment with an effective date later than 49 calendar days after the
contractor's receipt of a voluntary disenrollment request.

M.
A copy of the disenrollment form will be sent to the CARES office within 48
hours of receipt and a copy will be placed in the contractor's case management
file.

4.8          Disputes of Appropriate Enrollments

Disputes relating to the appropriateness of enrollments authorized by CARES
staff pursuant to section 2.1 of Attachment I to this contract, will be decided
by the department in consultation with the Agency. This provision excludes
matters brought forth by enrollees. The department must reduce its decision to
writing and serve a copy on the contractor. The decision of the department will
be final and conclusive.

4.9          Medicaid Pending

A.
Section 430.705(5), F.S., designates Medicaid Pending as 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  Department of Children and Families (DCF).

B.
Individuals will be offered the option to receive services under the Medicaid
Pending  initiative.

C.
Contractors may elect to provide the Medicaid Pending option by completing
and  returning Attachment Number IV to the department.

D.
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, 701B Assessment, Level of
Care, 3008, and  Informed Consent.

E.
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.

F.
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 seek reimbursement from the individual in
accordance with the Medicaid  Coverage and Limitations Handbooks and the
associated fee schedules.

G.
The contractor will assist Medicaid Pending individuals in submitting the
ACCESS  Florida Application (on-line or hard copy)f
www.mvflorida.com/accessflorida) to DCF.  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).

H.
Once the individual is determined financially eligible, the contractor must
notify CARES and provide a copy of the Notice of Case Action or verification of
Medicaid eligibility within two (2) business days of receipt.

 
I.
The contractor will submit 834 enrollment transactions for the Medicaid Pending
individuals to the Medicaid fiscal agent one week prior to the monthly
submission date. Additionally, the Florida Medicaid Management Information
System (FMMIS) is designed to process the enrollment date retroactive up to a
maximum of four (4) months prior to the first of the month following the CARES
eligibility determination. If

Attachment I - Page 31

 
 

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Amendment 001        Agreement Number XQ744

circumstances require a determination of Medicaid eligibility by DCF for a
Medicaid Pending individual that exceeds four months, the request for enrollment
must be submitted via the manual enrollment process.

SECTION 5  ENROLLEE RECORDS

A.
The contractor is responsible for a complete long-term care record for each
enrollee.

B.
The contractor must use procedures that promote the development of a
centralized,  comprehensive long-term care record for enrollees. The contractor
must ensure, with  written consent of the enrollee or their representative, all
providers involved in the  enrollee's care have access to the enrollee's record
for the purpose of providing care.

C.
The contractor must maintain an enrollee records system, which is consistent
with  professional standards and permits the prompt retrieval of information.
Each record must  include timely and accurately documented information and must
be readily available to  all appropriate and authorized practitioners involved
in the integration and coordination  of care.

D.
The contractor will ensure all subcontracted long term care providers-properly
document  the care provided to enrollees.

E.
The contractor will ensure enrollee record information is accessible only to
authorized persons in accordance with written consent or an executed
authorization granted by the enrollee or the enrollee's representative and with
all applicable federal and state laws, rules and regulations.

F.
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. Not withstanding
provisions to the contrary, release of  material to the department and Agency
will not be construed as public disclosure of  confidential information.

G.
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 Section 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.

SECTION 6     SERVICE PROVISION

6.1 General Provisions
(a)
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).
Services are to be provided in accordance with an individualized plan of care.
The plan of care is developed by the contractor in consultation with the
enrollee and must include those services that are determined through assessment
to be necessary to address the health and social service needs of the enrollee.

(c)
The contractor must directly provide case management services as listed in
Section 6.2.

(d)
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

Attachment I - Page 32

 
 

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Amendment 001        Agreement Number XQ744

program cost savings and may not be included in encounter data as reported under
Section 11.4.
E.
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.
F.  The contractor must not allow enrollees to be charged for missed
appointments.

G.
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.

H.
All services delivered by the contractor to enrollees, either directly or
through a subcontract, must be guided by the following service delivery
principles:

1.
Services must be individualized as a result of a competent, comprehensive
understanding of an enrollee's multiple needs.

2.
Services must be delivered in a timely fashion in the least restrictive,
cost-effective, and appropriate setting.

3.
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 plan of
care.

4.
Each contractor shall provide the department with documentation of compliance
with access requirements no less frequently than the following:
a)  At the time it enters into a contract with the department.

b)
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.

5.
Long-term care services must be based upon an enrollee's plan of care and
include goals, objectives, and specific treatment strategies. Any limitations on
amount, duration, and scope may be offset by alternative services to address the
health and social services needs of an enrollee.

6.
Services must be coordinated to address comprehensive needs and provide
continuity of care.

7.
Services must be delivered regardless of geographic location within the service
area, level of functioning, cultural heritage, or degree of illness of the
enrollee.

8.
The project's administration and service delivery system must ensure the
participation of the enrollee in care planning and delivery, as appropriate,
allow for the participation of the family, significant others, and caregivers.

9.
The contractor shall provide interpreter services in person where practical, but
otherwise by telephone, for applicants or enrollees whose primary language is
not English. Non-English versions of materials are required if, the population
speaking a particular non-English language in a county is greater than five (5)
percent, as determined annually by the Agency.

10.
Services must be delivered by qualified providers as defined in Sections 6.4,
6.5, 6.6, and 6.7. The contractor must have a credentialing system approved by
an accreditation organization that has been approved by the Agency pursuant to
Chapter 641.512, F.S. The system must include procedures for credentialing
long-term care providers.

11.
The contractor must be approved by an accreditation organization that has been
approved by the Agency pursuant to Chapter 641.512, F.S.

12.
All facilities providing services to enrollees must be accessible to persons
with disabilities, be smoke-free, and have adequate space, supplies, good
sanitation, and fire and safety procedures.

Attachment I - Page 33

 
 

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Amendment 001        Agreement Number XQ744

13.
For contractor performance that is not in compliance with the contract, the
department shall require a corrective action plan. Failure to provide a
corrective action plan within the time specified shall result in penalties or
sanctions as specified by the contract or governing statutes and federal
regulations.

6.2
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.
As required by Section 430.705(2)(b)2., F.S., the contractor shall have at least
two (2) subcontractors for each service as listed below (with the exception of
case management services, which are directly provided by the contractor):

A.
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 incidental to the care and supervision of the enrollee.

B.
Adult Day Health Services: Services provided pursuant to Chapter 429, Part HI,
F.S. 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 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.

C.
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. This service includes 24-hour on-site response  staff to meet
scheduled or unpredictable needs in a way mat promotes maximum dignity  and
independence, and to provide supervision, safety and security. Individualized
care is  furnished to persons who reside in their own living units (which may
include dual  occupied units when both occupants consent to the arrangement)
which may or may not  include kitchenette and/or living rooms and which contain
bedrooms and toilet facilities.  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

 
Attachment I - Page 34

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Amendment 001            Agreement Number XQ744
 

 
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 consumer to facilitate
aging in place. Routines of care provision and service delivery must be
consumer-driven to the maximum extent possible, and treat each person with
dignity and respect. Assisted living services may also include: 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.  Note: Assistive Care Services are
covered under this contract and cannot be billed separately by the Assisted
Living Facility.

D.
Case Management Services: Services which facilitate enrollees gaining access to
other needed medical, social, and educational services regardless of the funding
source for the services, and which contribute to the coordination and
integration of care delivery. Case management services contribute to the
coordination and integration of care delivery through the ongoing monitoring of
services as prescribed in each enrollee's plan of care. The contractor will
provide this service directly and the ratio of enrollees to case managers shall
be appropriate to support the needs of the enrollees.

E.
Chore Services: 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.

F.
Consumable Medical Supply Services: The provision of disposable supplies used by
the enrollee and care giver, 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. 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, and
household items such as detergents, bleach, and paper towels, or prescription
drugs.

G.
Environmental Accessibility Adaptation Services: Physical adaptations to the
home required by the enrollee's plan of care 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.

H.
Escort Services: 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. This service does not
include transportation.

I.
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.

Attachment I - Page 35

 
 

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Amendment 001        Agreement Number XQ744
 
J.
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 coaching and
counseling to enrollees to avoid financial abuse, to maintain and balance
accounts that directly relate to the enrollees living arrangement at home, or to
lessen the risk of nursing home placement due to inappropriate money management.

K.
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, or canned with a satisfactory storage
life. These meals must comply with all federal and state requirements for
procurement, preparation, transportation and storage. Religious preferences in
the selection and preparation of menu items shall be given consideration and
accommodated, if available.

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

M.
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 on food preparation.

N.
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 which are essential to
the health and welfare of the enrollee, rather than the enrollee's family.

O.
Personal Emergency Response Systems (PERS): 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 enrollee's
telephone jack or electrical receptacle 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 tire
day and who would otherwise require extensive supervision.

P.
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, licensed
hospital, nursing facility, or assisted living facility.

Q.
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.

R.
Physical Therapy: Treatment to restore, improve or maintain impaired functions
by using

 
Attachment I - Page 36

 
 

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Amendment 001        Agreement Number XQ744

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.
S.
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.

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

6.3       Minimum Long-Term Care Service Provider Qualifications

The long-term care services authorized in this project must be provided in
accordance with the following requirements.
A.
Adult Companion Services: Providers must be employed by a licensed home
health  agency pursuant to Chapter 400, Part III, F.S., or organizations having
a certificate of  registration issued by the Agency for Health Care
Administration pursuant to Section  400.509, F.S., or be a Community Care for
the Elderly (CCE) provider as defined in  Section 430.203, F.S., and registered
in accordance with Section 400.509, F.S., or  individuals contracted by a nurse
registry pursuant to Sections 400.462(18) and 400.506,  F.S.

B.
Adult Day Health Services: Providers must be licensed by the Agency for Health
Care  Administration as an adult day care center pursuant to Chapter 429, Part
III, F.S., or meet  the adult day care center exemption requirements in Section
429.905, F.S.

C.
Assisted Living Facility Services: Providers must be licensed pursuant to
Chapter 429,  Part I, F.S.

D.
Case Management Services: Case managers must be a registered nurse; or have
a  Bachelor's Degree in Social Work, Sociology, Psychology, Gerontology or a
related  field; or have a Bachelor's Degree in an unrelated field and at least
two (2) years of case  management experience; or be a Licensed Practical Nurse
(LPN) with four (4) years of  geriatric experience. Case managers must attend
and complete the following training  annually: four (4) hours of in-service
training, Abuse, Neglect and Exploitation training,  and Alzheimer's disease and
related disorders continuing education.

E.
Chore Services: Providers must be a lead agency as defined in Section
430.203(9), F.S.;  or a home health agency licensed in accordance with Chapter
400, Part III, F.S.; or a pest  control business licensed pursuant to Section
482.071, F.S.; or a contractor licensed to do  home repair; or a person,
employed by or under the supervision of the contractor, who is  qualified by
training or experience to provide chore services.

Attachment I - Page 37

 
 

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Amendment 001        Agreement Number XQ744

F.
Consumable Medical Supply Services: Providers must be pharmacies permitted
under  Section 465.022, F.S.; or home medical equipment providers licensed
pursuant to  Chapter 400, Part VII, F.S.; or home health agencies licensed
pursuant to Chapter 400,  Part III, F.S.; or be a licensed vendor.

G.
Environmental Accessibility Adaptation Services: Providers must be properly
licensed  pursuant to state and local building requirements, and be confirmed by
the provider to  have knowledge and experience needed to satisfactorily perform
the service.

 
H.
Escort Services: Providers must be a lead agency as defined in Section
430.203(9), F.S.; or home health agencies licensed pursuant to Chapter 400, Part
III, F.S.; or an individual contracted by a nurse registry pursuant to Section
400.506, F.S.; or persons employed by the contractor and trained in the
following areas: communication arid assistance with hearing and visually
impaired patients; emergency procedures; and enrollee confidentiality.

 
I.
Family Training Services: Providers must be a home health agency licensed
pursuant to Chapter 400, Part III, F.S.; or a lead agency as defined in Section
430.203(9), F.S.; or a medical practitioner licensed under Chapter 464 or 491,
F.S., providing training or counseling within the scope of their practice.

 
J.
Financial Assessment/Risk Reduction Services: Providers must be home health
agencies licensed pursuant to Chapter 400, Part III, F.S.; or a lead agency as
defined in Section 430.203(9), F.S.; or persons confirmed to be qualified to
perform the service by experience and training, such as certified financial
planners, bank employees, or individual bookkeepers; or qualified persons
employed or contracted by the contractor.

 
K.
Home Delivered Meal Providers: Providers must be a lead agency as defined in
Section 430.203(9), F.S., with a contract or referral agreement for the
preparation of meals; employed by or under contract with the contractor and meet
the food service standards as defined in Chapters 500 and 509, F.S.; Older
American's Act providers as defined in Chapter 58A-1, Florida Administrative
Code (FAC).

 
L.
Homemaker Service Providers: Services must be provided by a home health agency
licensed pursuant to Chapter 400, Part III, F.S.; or a lead agency as defined in
Section 430.203(9), F.S.; or individuals contracted by a nurse registry pursuant
to Sections 400.462(18) and 400.506, F.S.; or have a certificate of registration
issued by the Agency pursuant to Section 400.509, F.S.

 
M.
Nutritional Assessment Risk Reduction Services: Services must be provided by
Registered Licensed Dietitians or other health professionals functioning in
their legal scope of practice. A dietetic technician (DTR) may, according to the
American Dietetic Association, assist a dietitian and assume full responsibility
under supervision of a Registered Licensed Dietitian for a wide range of duties
including counseling enrollees on specific diets. Nutritional education
materials must be approved by a Registered Licensed Dietitian. Providers may
include lead agencies as defined in Section 430.203(9), F.S.

 
N.
Nursing Facility Services: Providers must be licensed under Chapter 395 or
Chapter 400, F.S.

 
O.
Personal Care Providers: Providers must be lead agencies as defined in Section
430.203(9), F.S.; Certified Nursing Assistants or home health aides contracted
under Nurse Registries licensed pursuant to Section 400.506, F.S.; or home
health agencies licensed pursuant to Chapter 400, Part III, F.S.

 
P.
Respite Care Providers: Providers must be employed by a licensed home health
agency pursuant to Chapter 400, Part III, F.S.; or be a lead agency as defined
in Section 430.203(9), F.S.; or be an Adult Day Care Center licensed pursuant to
Chapter 429, Part HI, F.S.; or be an Assisted Living Facility licensed pursuant
to Chapter 429, Part I, F.S.; or be a Nursing Facility licensed pursuant to
Chapter 400, Part I, F.S.; or be individuals contracted by a nurse registry
pursuant to Section 400.506, F.S.; or be a hospice licensed pursuant to Chapter
400, Part IV, F.S.

 
Attachment I - Page 38

 
 

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Amendment 001        Agreement Number XQ744
 
  Q.   
Occupational, Physical, and Speech Therapy Providers: Providers must be home
health agencies licensed pursuant to Chapter 400, Part III, F.S., or providers
holding current registration, certification, or licenses pursuant to Chapters
455,468, and 486, F.S.

  R. 
Personal Emergency Response System Service Providers: Providers must meet the
requirements as set forth in Section 489.505(15) or (16), F.S.

6.4           Acute-Care Services

The following 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.
A.
Community Mental Health Services: 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.

B.
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.

C.
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. 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.

D.
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.

E.
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.

F.
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.

G.
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.

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Amendment 001        Agreement Number XQ744 
 
H.
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.
L.  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 §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 § 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. J. Vision Services:
Medically necessary eye examinations. 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, and must be provided
by providers licensed under Chapter 484, Part I, or 463, F.S.. K.   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.

 
6.5          Acute Care Provider Qualifications

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

For the acute care services covered under the contract that are not covered by
Medicare, the contractor must meet the provider requirements of the Medicaid
programs except that provider type limitations associated with certain services
will not apply when other provider types can legally perform the service.

6.6          Optional Services

Transportation Services may be rendered within Medicaid guidelines at the option
of the contractor. These services are the arrangement and provision of an
appropriate mode of transportation for enrollees to receive necessary medical
services. Types of transportation services include: ambulance, non-emergency
medical vehicles, public and private transportation vehicles, and air ambulances
as specified in the Medicaid Transportation Coverage and Limitations Handbook.

6.7          Expanded Services

The contractor may offer incentive programs for enrollees. The contractor shall
receive written approval from the department prior to the use of any special
incentives for enrollees. Any incentive program offered must be provided to all
eligible individuals and will not be used to direct individuals to select a
specific contractor.

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Amendment 001        Agreement Number XQ744

6.8          Availability/Accessibility of Services

The contractor must make available and accessible sufficient facilities, service
locations, service sites, and personnel to provide the services. 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.

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.

The contractor must arrange for a 24-hour on-call system for each enrollee. The
system may vary by enrollee and should be reflected in the enrollee's plan of
care. The system should provide for the availability of a qualified person with
information regarding the enrollee's plan of care.

6.9          Staffing Requirements

The contractor is responsible for the following staffing requirements:
A.
A full time administrator designated to be responsible for the administration of
the day-  to-day business activities of the contract.

B.
A licensed physician, with demonstrated experience in geriatric medicine, to
serve as a  medical director to oversee and be responsible for the proper
provisions of covered  services for the contract.

C.
A person, qualified by training, to be responsible for the contract's quality
assurance and  improvement systems.

D.
A person designated to be responsible for the contractor's orientation, outreach
and  educational activities who is qualified by training and experienced in
working with frail  elders.

E.
A person designated to be responsible for the health information and/or the
enrollee  records system.

F.
A person designated to be responsible for the processing and resolution
of  grievances/appeals.

G.
Sufficient support staff to conduct daily business in an orderly manner,
including having  enrollee services staff directly available during business
hours for enrollee services  consultation, as determined through management and
medical reviews.
H. The contractor must maintain sufficient staff available 24 hours per day to
handle care inquiries. I. A person designated to be responsible for the
contractor's utilization control.

 
J.
A person designated to be responsible for case management and qualified case
managers in sufficient numbers to ensure that the case management requirements
are met.

K
A person, graduated from a four-year program, designated on a full-time basis,
to be responsible for the data needs of the program, including but not limited
to, enrollment and disenrollment transactions, HIPAA compliance transactions,
report reconciliations, data collection, and reporting.

 
L.
A plan for recruiting and retaining health care practitioners who are minority
persons as defined in Section 288.703(3), F.S., as required by Section 641.217,
F.S.

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Amendment 001        Agreement Number XQ744

6.10          Emergency Care Requirements

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:
A.
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
pre-approval.

B.
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 except in the circumstances  described above.

6.11          Out of Network Use of Non-Emergency 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. A contractor may
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.

However, in accordance with the Balanced Budget Act of 1997, and pursuant to 42
CFR 422.100(b)(l)(iii), the plan must also cover post-stabilization services
without authorization, regardless of whether the enrollee obtains the service
within or outside the plan's network, for the following situations:
A.
Post-stabilization care services that were pre-approved by the plan; or were not
pre-  approved by the plan because the plan did not respond to the treating
provider's request  for pre-approval within one hour after being requested to
approve such care, or could not  be contacted for pre-approval.

B.
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  plan chooses not to cover out-of-plan except in
the circumstances described above.

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Amendment 001        Agreement Number XQ744

6.12     Adult Protective Services

The Department of Elder Affairs and the Department of Children and Families
(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 Section
430.205 (5)(a), F.S.

A.
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. Individuals
designated "high" risk must  be served within 72 hours after being referred to
the AAA or lead agency, as mandated  by Florida statute.

1.
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 Area Agency on Aging
(AAA) or Community Care for the Elderly (CCE) lead agency.

2.
Reports received on individuals determined to be enrolled in the diversion
program will be referred to the appropriate contractor.

B.
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 your  contract manager at the Department of Elder
Affairs. 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:
1.   Adult Protective Services Referral Form, 2. Adult Safety Assessment of
Safety Factors,

3.
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),
4. Court Order, if services were court ordered,

A.
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.

B.
When contacted by the AAA or CCE lead agency in regard to a high-risk referral,
the contractor will 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), assurance that the crisis will be addressed  must be
provided to the AAA or lead agency within 24 hours. 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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Amendment
001                                                                                    Agreement
Number XQ744

SECTION 7    UTILIZATION MANAGEMENT

The contractor's service authorization systems shall provide authorization
numbers, effective dates for the authorization, and written confirmation to the
contractor of denials, as appropriate. 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
mat 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.

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 Section 13, Definitions, within the time frames for each type of action.
Pursuant to 42 CFR 43 8.404(b) and 42 CFR 438.210(c), the notice must explain:

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.
5.          Procedures for exercising enrollee rights to appeal or grieve.
6.          Circumstances under which expedited resolution is available and how
to request it.
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.

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.

The contractor must mail the notice within the following time frames:
1.
For termination, suspension, or reduction of previously authorized
Medicaid-covered services, within the time frames specified in 42 CFR
431.211,431.213, and 42 CFR 431.214.
2.  For denial of payment, at the time of any action affecting the claim.

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

4.
If the contractor extends the time frame in accordance with 42 CFR
438.210(d)(1), it must:

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

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

5.
For service authorization decisions not reached within the time frames specified
in 42  CFR 438.210(d) (which constitutes a denial and is thus an adverse
action), on the date  that the time frames expire.

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Amendment
001                                                                                    Agreement
Number XQ744

6.          For expedited service authorization decisions, within the time
frames specified in 42 CFR
438.210(d).

SECTION 8    QUALITY ASSURANCE AND IMPROVEMENT REQUIREMENTS

8.1           General

The contractor's quality assurance program must address the needs of enrollees,
promote improved clinical outcomes and quality of life, identify and address
service delivery issues, and monitor the quality and appropriateness of care
furnished to enrollees with special health care needs. The quality assurance
program required by this section must comply with applicable provisions of
Section 409.912(27), F.S., and Section 641.51, F.S., and be incorporated into an
existing quality improvement system.

8.2           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 to 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:
A. A written description of the quality assurance program.
B. Written responsibilities of the governing body for monitoring, evaluating,
and improving  care.

C.  A procedure for quality assurance program supervision.
D. Assurance of adequate resources to carry out the program's specified
activities  effectively.

E. A protocol for provider participation in the quality assurance program.
F. A procedure for delegation of quality assurance responsibilities to
designated personnel.
G. A procedure for credentialing and re-credentialing providers.
H. A procedure for informing enrollees about their rights and responsibilities.
I.  Assurance of availability of and accessibility to services and care.
J.  A procedure to ensure the accessibility and availability of medical and
long-term care records, as well as proper record keeping, and a process for
record review.
K. A procedure for utilization review.
L.  A procedure for quality assurance program documentation.
M.  A procedure for coordination of quality assurance activities with other
management activities.
N. A continuity of care system.
O. An active quality assurance committee.

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Amendment
001                                                                                    Agreement
Number XQ744

8.3          Quality Assurance Committee

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 quality assurance committee must:
A.
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.

B.
Review grievances and appeals identified through the contractor's policies
and  procedures and through external oversight.

C.
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.

D.
Review quality assurance policies, standards, and written procedures to ensure
that the  needs of the enrollees are adequately addressed.
E. Review utilization of services with adverse or unexpected outcomes for
enrollees.

F.
Develop and periodically review written guidelines, procedures and protocols on
areas of  concern in the care of the frail elderly; for example: falls,
incontinence, dementia,  depression, congestive heart failure, inadequate family
care, family caregiver stress,  family conflict, out-of-home placements, alcohol
problems, and problems of compliance  in procedures of medical treatment.

G.
Develop an ethics committee to review ethical questions such as end-of-life
decisions and  advance directives.
H. Develop a system of peer review by physicians and other service providers.

           
8.4          Quality Improvement Activities 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 Section
409.912(27)(b) F.S.

A.         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 collaborative PIP coordinated by the
External Quality Review Organization.

3.
One PIP must be designed to address deficiencies identified by the plan through
monitoring, performance measure results, member satisfaction 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 expected to have a favorable effect on health
outcomes and enrollee satisfaction. Improvement must be measured through
comparison of a baseline measurement and an initial remeasurement
following  application of an intervention. Change must be statistically
significant at the 95% confidence level and must be sustained for a period of
two additional remeasurements. Measurement periods and methodologies shall be
approved in advance by the department prior to initiation of the PIP.

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Amendment 001        Agreement Number XQ744

5.
PIPs that have successfully achieved sustained improvement as defined in A.4 and
as approved by the department shall be considered complete and shall not meet
the requirement for one of the two PIPs, although the contractor may wish to
continue to monitor the performance indicator as part of the overall quality
management program. A new PIP shall be selected and submitted to the department
for approval.

6.
Within 30days of the execution of this amendment and annually within 30 days of
the execution of this contract thereafter, the contractor shall submit to the
department, in writing, a proposal for each planned PIP.  The PIP proposal shall
be submitted using the most recent version of the External Quality Review PIP
Validation Report Form.  Activities 1 through 6 of the Form must be addressed in
the PIP proposal.   Subsequent annual submissions shall be updated to reflect
the contractor's progress. 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.myfloridaeqro.com

7.
The contractor's PEP methodology must comply with the most recent protocol set
forth by the Centers for Medicare and Medicaid Services, Conducting Performance
Improvement Projects. This protocol may be obtained from either of the following
websites: http://www.cms.hhs.gov/MedicaidManagCare/ or www.mvfloridaeqro.com

8.
The contractor's PIPs shall be subject to review and validation by the External
Quality Review Organization. The contractor shall comply with any
recommendations for improvement requested by the External Quality Review
Organization, subject to approval by the department.

9.
The contractor shall submit a quarterly report no less than 45 days following
the last day of the quarter describing the activities that have occurred during
the quarter related to the PIPs.

10.
Populations selected for study under the PIP must be specific to this contract
and shall not include non-Medicaid 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,
PEPs conducted by the separate entity shall not include enrollees for other
health plans served by the entity.

8.5          Independent Medical Review

In accordance with 42 CFR 438.204(d), the Agency shall 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 shall include quality outcomes concerning
timeliness of, and access to, services covered under the contract. The review
shall 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.

8.6          Incident Reporting

The contractor shall implement a systematic process for Incident Reporting in
accordance with Section Q. Incident Reporting of the Standard Agreement.

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Amendment 001        Agreement Number XQ744

The contractor is required to maintain an incident log which shall be submitted
to the department within 30 days of the file closure date via e-mail to
DiversionReports@elderaffairs.org with password protection for HIPAA related
information or via U.S. mail.

SECTION 9    GRIEVANCE/APPEALS PROCEDURES

9.1        Grievance System Requirements

The contractor must have a grievance system in place for enrollees that includes
a grievance process, an appeal process, and access to the Medicaid fair hearing
system. The contractor must develop, implement and maintain a grievance system
mat complies with the requirements in s. 641.511, F.S., and with federal laws
and regulations, including 42 CFR 431.200 and 438, Subpart F, "Grievance
System." The system must include written policies and procedures that are
approved by the department. The contractor shall refer all enrollees and
providers who are dissatisfied with the contractor or its action to the
grievance/appeal coordinator for processing and documentation in accordance with
this contract and the approved policies and procedures. The nature of the
complaint, using the definitions in this contract, determines which of the two
processes the contractor must follow. The grievance process is the procedure for
addressing enrollee grievances, which are expressions of dissatisfaction about
any matter other than an action, as "action" is defined in Section 13,
Definitions. The appeal process is the procedure for addressing enrollee
appeals, which are requests for review of an action, as "action" is defined in
Section 13, Definitions.

The contractor must give enrollees reasonable assistance in completing forms and
other procedural steps, and must provide interpreter services and toll-free
numbers with TTY/TDD and interpreter capability. The contractor must acknowledge
receipt of each grievance and appeal in writing. The contractor must ensure that
decision makers on grievances and appeals were not involved in previous levels
of review or decision-making. The decision makers must be health care
professionals with clinical expertise in treating the enrollee's condition or
disease when deciding any, of the following:
1. An appeal of a denial based on lack of medical necessity.
2. A grievance regarding denial of expedited resolution of an appeal.
3. A grievance or appeal involving clinical issues.

The contractor must provide information on grievance, appeal, and fair hearing,
and its respective policies, procedures, and time frames, to all providers at
the time they enter into a contract. Procedural steps must be clearly specified
in the member handbook for members and the provider manual for providers,
including the address, telephone number, and office hours of the grievance
coordinator. The information must include:

Attachment I - Page 48

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Amendment 001        Agreement Number XQ744

1.   Enrollee rights to Medicaid fair hearing, the method for obtaining a
hearing, the rules that govern representation at the hearing, and the DCF
address for pursuing a fair hearing, which is:

Office of Public Assistance Appeals Hearings
 1317 Winewood Boulevard, Building 5, Room 203
Tallahassee, Florida 32399-0700

2. Enrollee rights to file grievances and appeals, and the requirements and time
frames for filing.
3. The availability of assistance in the filing process.
4. The toll-free numbers to file oral grievances and appeals.
5. Enrollee rights to appeal to the Agency and the Subscriber Assistance Program
(SAP) if enrolled with contractors licensed under 641, F.S.  The contractor's
appeal or grievance process must be exhausted in accordance with s. 408.7056 and
641.511, F.S., with the following exception: a grievance or appeal taken to
Medicaid fair hearing will not be considered by the SAP. The information must
explain that a request for SAP review must be made by the enrollee within one
year of receipt of the final decision letter from the contractor. The
information must explain how to initiate such a review and include the SAP's
address and telephone number as follows:

Agency for Health Care Administration
Bureau of Managed Health Care, Building 1, Room 339
2727 Mahan Drive, Tallahassee, Florida 32308
1-888-419-3456

(6) Notice that the contractor must continue enrollee benefits if:
(a) The appeal is filed timely, meaning on or before the later of the following:
(1) Within ten (10) days of the date on the notice of action (or 15 days if the
notice is sent via U.S. mail).
(2) The intended effective date of the contractor's proposed action.

(b) The appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment;
(c) The services were ordered by an authorized contractor;
(d) The authorization period has not expired; and
(e) The enrollee requests extension of benefits.

The contractor must maintain records of grievances and appeals in accordance
with the terms of this contract.

9.2       Appeal Process

An appeal is a request for review of an "action" as defined in Section 13,
Definitions. An
enrollee may file an appeal, and a provider, acting on behalf of the enrollee
and with the
enrollee's written consent, may file an appeal. The appeal procedure must be the
same for all
enrollees.
A.        Filing Requirements
1.
The enrollee or provider may file an appeal within 30 days of the date of the
notice of action. If the contractor does not issue a written notice of action,
the enrollee or provider may file an appeal within one year of the action.

2.
The enrollee or provider may file an appeal either orally or in writing and must
follow an oral filing with a written? signed appeal. For oral filings, time
frames for resolution begin on the date the contractor receives the oral filing.

B.          Contractor Duties

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Amendment 001

Agreement Number XQ744

The contractor must:
1.
Ensure enrollee oral inquiries seeking to appeal an action are treated as
appeals and confirm those inquiries in writing, unless the enrollee or the
provider requests expedited resolution.

2.
Provide a reasonable opportunity to present evidence and allegations of fact or
law, in person, as well as in writing.

3.
Allow the enrollee and representative an opportunity before and during the
appeals process to examine the enrollee's case file, medical records, and any
other documents and records.

4.
Consider the enrollee, representative, or estate representative of a deceased
enrollee as parties to the appeal.

5.
Resolve each appeal and provide notice, as expeditiously as the enrollee's
health condition requires, within State-established time frames not to exceed 45
days from the day the contractor receives the appeal.
6.  Continue the enrollee's benefits if: a)  The appeal is filed timely on or
before the later of the following:

(1)
Within ten (10) days of the date on the notice of action (or 15 days if the
notice is sent via U.S. mail).
(2) The intended effective date of the contractor's proposed action.

b)
The appeal involves the termination, suspension or reduction of a previously
authorized course of treatment;
c)  The services were ordered by an authorized provider; d)  The authorization
period has not expired; and e) The enrollee requests extension of benefits.

7.
Provide written notice of disposition that includes the results and date of
appeal  resolution, and for decisions not wholly in the enrollee's favor, that
includes:    

a) Notice of the right to request a Medicaid fair hearing.
b) 
Information about how to request a Medicaid fair hearing, including the DCF
address for pursuing a fair hearing, which is:

Office of Public Assistance Appeals Hearings
1317 Winewood Boulevard, BIdg. 5, Room 203,
Tallahassee, Florida 32399-0700
          

c) Notice of the right to continue to receive benefits pending a hearing. d)  
Information about how to request the continuation of benefits.
e)
Notice that if the contractor's action is upheld in a hearing, the enrollee may
be liable for the cost of any continued benefits.

f)
Notice that if the appeal is not resolved to the satisfaction of the enrollee,
the enrollee has one year in which to request review of the contractor's
decision concerning the appeal by the Subscriber Assistance Program, as provided
in Chapter 408.7056, F.S. The notice must explain how to initiate such a review
and must include the addresses and toll-free telephone numbers of the Agency and
the Subscriber Assistance Program.

8.
Provide the department with a copy of the written notice of disposition upon
request.

9.
Ensure punitive action is not taken against a provider who files an appeal on an
enrollee's behalf or supports an enrollee's appeal.

10.
The contractor may extend the resolution time frames by up to 14 calendar days
if the enrollee requests the extension or the contractor documents there is a
need for additional information and the delay is in the enrollee's interest. If
the extension is not requested by the enrollee, the contractor must give the
enrollee written notice of the reason for the delay.
11.  If the contractor continues or reinstates enrollee benefits while the
appeal is

        

Attachment I - Page 50

 
 

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Amendment 001            Agreement Number XQ744

pending, the benefits must be continued until one of following occurs:
a)   The enrollee withdraws the appeal.
b)  Ten days pass from the date of the contractor's adverse contractor decision
and the enrollee has not requested a Medicaid fair hearing with continuation of
benefits until a Medicaid fair hearing decision is reached, (or 15 days if the
notice is sent via U.S. mail.)
c)    A Medicaid fair hearing decision adverse to the enrollee is made.
d)    The authorization expires or authorized service limits are met.

12.
If the final resolution of the appeal is adverse to the enrollee, the contractor
may recover the cost of the services furnished while the appeal was pending, to
the extent that they were furnished solely because of the requirements of this
section.

13.
The contractor must authorize or provide the disputed services promptly, and
as expeditiously as the enrollee's health condition requires, if the services
were not furnished while the appeal was pending and the disposition reverses a
decision to deny, limit, or delay services.

14.
The contractor must pay for disputed services, in accordance with State policy
and regulations, if the services were furnished while the appeal was pending and
the disposition reverses a decision to deny, limit, or delay services.

C.        Expedited Process

Each contractor must establish and maintain an expedited review process for
appeals when the contractor determines or the provider indicates that 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.

The enrollee or provider may file an expedited appeal either orally or in
writing. The contractor must:
1.
Inform the enrollee of the limited time available for the enrollee to present
evidence and allegations of fact or law, in person and in writing.

2.
Resolve each expedited appeal and provide notice, as expeditiously as the
enrollee's health condition requires, within State-established time frames not
to exceed 72 hours after the contractor receives the appeal.
3. Provide written notice of disposition. 4.  Make reasonable efforts to also
provide oral notice of disposition.

5.
Ensure that punitive action is not taken against a provider who requests ah
expedited resolution on the enrollee's behalf or supports an enrollee's request
for expedited resolution.

6.
The contractor may extend the resolution time frames by up to 14 calendar days
if the enrollee requests the extension or the contractor documents that there is
a need for additional information and that the delay is in the enrollee's
interest. If the extension is not requested by the enrollee, the contractor must
give the enrollee written notice of the reason for the delay.

If the contractor denies a request for expedited resolution of an appeal, the
contractor must:

1.
Transfer the appeal to the standard time frame of no longer than 45 days from
the day the contractor receives the appeal with a possible 14-day extension.
2.  Make reasonable efforts to provide prompt oral notice of the denial.

 
Attachment I - Page 51

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

3.          Provide written notice of the denial within two (2) calendar days.
4.          Fulfill all contractor duties listed above.

9.3          Grievance Process

A grievance is an expression of dissatisfaction about any matter other than an
action, as "action" is defined in Section 13, Definitions. A grievance may be
filed by an enrollee or a provider acting on behalf of the enrollee and with the
enrollee's written consent.
 
A.          Filing Requirements
1.
The enrollee or provider may File a grievance within one (1) year after the date
of occurrence that initiated the grievance.

2.
The enrollee or provider may file a grievance either orally or in writing. An
oral request may be followed up with a written request, but the time frame for
resolution begins the date the contractor receives the oral filing.

B.          Contractor Duties
The contractor must:         

1.  Resolve each grievance, and provide notice, as expeditiously as the
enrollee's health condition requires, within State established time frames not
to exceed 90 days from the day the contractor receives the grievance.
2.
Provide written notice of this disposition including the results and date of
grievance resolution.

3.
Provide the department with a copy of the written notice of disposition upon
request.

4.
Ensure punitive action is not taken against a provider who files a grievance on
an enrollee's behalf or supports an enrollee's grievance.

The contractor may extend the resolution time frames by up to 14 calendar days
if the enrollee requests the extension or the contractor documents there is need
for additional information and the delay is in the enrollee's interest. If the
extension is not requested by the enrollee, the contractor must give the
enrollee written notice of the reason for the delay.

9.4          Medicaid Fair Hearing System

The Medicaid fair hearing policy and process is detailed in Rule 65-2.042,
F.A.C. The contractor's grievance system policy and appeal and grievance
processes shall state the enrollee has the right to request a Medicaid fair
hearing at any time, in addition to, pursuing the contractor's grievance
process. A provider-acting on behalf of the enrollee and with the enrollee's
written consent may request a Medicaid fair hearing. Parties to the Medicaid
fair hearing include the contractor, as well as the enrollee and his or her
representative or the representative of a deceased enrollee's estate.

         

A. Request Requirements
1.
The enrollee or provider may request a Medicaid fair hearing within 90 days of
the date of the notice of action.

2.
The enrollee or provider may request a Medicaid fair hearing by contacting DCF
at the Office of Public Assistance Appeals Hearings, 1317 Winewood Boulevard,
Building 5, Room 203, Tallahassee, Florida 32399-0700.

B.
Contractor Duties  The contractor must:
1. Continue the enrollee's benefits while Medicaid fair hearing is pending if:

          

Attachment I - Page 52

 
 

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Amendment 001        Agreement Number XQ744

a)
The Medicaid fair hearing is filed timely on or before the later of
the  following:

(1)
Within 10 days of the date on the notice of action (or 15 days if the notice is
sent via U.S. mail).
(2)    The intended effective date of the plan's proposed action.

b)
The Medicaid fair hearing involves the termination, suspension, or reduction  of
a previously authorized course of treatment;
c) The services were ordered by an authorized provider; d)   The authorization
period has not expired; and e) The enrollee requests extension of benefits. 2. 
Ensure punitive action is not taken against a provider who requests a Medicaid
fair hearing on the enrollee's behalf or supports an enrollee's request for a
Medicaid fair hearing.

C.
If the contractor continues or reinstates enrollee benefits while the Medicaid
fair hearing is pending, the benefits must be continued until one of following
occurs:
1.    The enrollee withdraws the request for Medicaid fair hearing.

2.
Ten days pass from the date of the contractor's adverse decision and the
enrollee has not requested a Medicaid fair hearing with continuation of benefits
until a Medicaid fair hearing decision is reached (or 15 days if the notice is
sent via U.S. mail.)
3.    A Medicaid fair hearing decision adverse to the enrollee is made. 4.   The
authorization expires or authorized service limits are met.

 
The contractor must authorize or provide the disputed services promptly, and as
expeditiously as the enrollee's health condition requires, if the services were
not furnished while the Medicaid fair hearing was pending and the Medicaid fair
hearing officer reverses a decision to deny, limit, or delay services.

The contractor must pay for disputed services, in accordance with State policy
and regulations, if the services were furnished while the Medicaid fair hearing
was pending and the Medicaid fair hearing officer reverses a decision to deny,
limit, or delay services.

SECTION 10   PAYMENT

10.1          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 contract and its
attachments.

10.2          Capitation Rates

A.
The capitation rate paid to the contractor is indicated in Exhibit I. 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. The  contractor shall
have 30 days from the date of the notice to provide written comments to  the
department on the proposed recalculated capitation rate.

B.
The contractor, department, and the Agency acknowledge that the capitation rate
paid  under this contract as specified in Exhibit I of this contract is subject
to approval by the  federal government.

Attachment I - Page 53

 
 

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Amendment 001        Agreement Number XQ744

 
C.        In accordance with 42 CFR 438.6(c)(l)(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.

10.3          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.

10.4          Capitation Payments

A.
Adjustments to funds previously paid and to be paid may be required.
Funds  previously paid will be adjusted when capitation payments) 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.

B.
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.

10.5          Payment Discrepancies

A.
If after an enrollment and disenrollment submission, a discrepancy is discovered
either by  the contractor, the Agency, or the department, the contractor has
five (5) business days to  submit correct detailed information on the
Reconciliation Form (Exhibit F) to the  department.

B.
After receipt of the fiscal agent remittance vouchers, the contractor has ten
(10) business  days to submit correct detailed information on the Reconciliation
Form (Exhibit F) to the  department.

C.
Failure to respond within the above time periods may result in a loss and/or
forfeiture of  any money due the contractor.

SECTION 11   PROGRAM REPORTING REQUIREMENTS

11.1      General Requirements

The contractor is responsible for complying with all reporting requirements
established by the department and Agency. The contractor will be responsible for
assuring the accuracy and completeness of all required reports as well as the
timely submission of each report. The contractor will be furnished with the
appropriate reporting formats, instructions, submission timetables and technical
assistance as required. The contractor shall review all monthly reports, as well
as remittance vouchers, received from the fiscal agent for accuracy and will
notify the department and Agency if discrepancies are found. The discrepancies
shall be reported as specified in Attachment I, Section 10.5.

 
A.        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.

Attachment I - Page 54

 
 

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Amendment
001                                                                                    Agreement
Number XQ744

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.

Example: ABC Health Plan, Medicaid Provider Number 1234567, operates three
locations: ABC of Palm Beach (123456701), ABC of Indian River (123456702), and
ABC of Martin (123456703). A contractor level report would be summarized over
all plans with the seven-digit Medicaid Provider number (1234567). A location
level report would have one report for each nine-digit provider number
(123456701,123456702, and 123456703).

The following table summarizes the required data reporting for the project:

Report Name
Level of Analysis
Reporting Frequency
Submission Method
Reporting Location
834 Transactions
Location
Monthly, by 4:00 PM on the
Wednesday preceding the second to last Saturday.
Secured Internet website supplied by the fiscal agent; file upload and download
on secured website
Fiscal Agent
Supplemental 834 Transaction
Location
Monthly, by 4:00 PM on the
Wednesday prior to 834 transactions
Secured Internet website supplied by the fiscal agent; file upload and download
on secured website
Fiscal Agent
Disenrollment Summary Report
Location
Monthly within 5 calendar days after the
beginning of the reporting month
Electronic Mail (with password protection for HEPAA related information) to
DiversionReports@elderaffairs.org or mail via a compact disk (with password
protection for HEPAA related information)
Department

Attachment I - Page 55

 
 

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Amendment 001        Agreement Number XQ744

Report Name
Level of Analysis
Reporting Frequency
Submission Method
Reporting Location
Encounter Data Report
Individual
Quarterly, within 3 months of the end of reporting calendar quarter
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@elderaffairs.org or mail via a compact disk (with password
protection for HIPAA related information)
Department
Grievance/Appeals Report
Individual
Quarterly within 5 calendar days of end or reporting calendar quarter
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@elderaffairs.org or mail via a compact disk (with password
protection for EQPAA related information)
Department
Updated Provider Network and Staff Listing
Location
Quarterly, within 5 calendar days of end of reporting calendar quarter
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@elderaffairs.org or mail via a compact disk (with password
protection for HIPAA related information)
Department
Minority Business Enterprise Contract Reporting
Contractor
April 15, July 5, October 15, January 15
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@eIderaffairs.org or mail via a compact disk (with password
protection for HIPAA related information)
Department
Financial Statements
Contractor
Quarterly, within 45 days of end of reporting quarter
Agency Supplied Template on Compact Disc, Electronic Mail or Hard Copy
Department
Audited Financial Statement
Contractor
Annually, within 120 days of end ofcontractor's fiscal year
Electronic Mail, Compact Disc or Hard Copy
Department
Emergency Management Plan
Contractor
Annually, April 30
Electronic Mail, Compact Disc, or Hard Copy
Department
Enrollee Satisfaction Survey
Contractor
Annually, May 15
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@eIderaffairs.org or mail via a compact disk (with password
protection for HIPAA related information)
Department

Attachment I - Page 56

 
 

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Amendment 001                                     Agreement Number XQ744

Report Name
Level of Analysis
Reporting Frequency
Submission Method
Reporting Location
Insolvency Fund Statements
Contractor
Monthly Statements
Electronic Mail or Hard Copy
Department
Reconciliation Report
Individual
Within ten (10) days of receipt of remittance vouchers
Electronic Mail (with password protection for HIPAA related information) to
DiversionReports@elderaffairs.org or mail via a compact disk (with password
protection for BDDPAA related information)
Department
Hospice Report
Contractor
15 days after the reporting month
Electronic Mail
Department

11.2      834 Transactions

A.
These reports are to be submitted monthly to the Florida Medicaid fiscal agent.
These  reports shall be transmitted to the Medicaid fiscal agent using the
communications  protocol through the secured Internet site supplied by the
fiscal agent. The contractor is  required to submit the report for every person
who is to be enrolled or disenrolled during  the reporting period.

B.
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  invoice accompanied by a payment
warrant, in hard copy or contract format. The amount  of payment is determined
by the number of enrollees enrolled in each capitation category  and any
adjustments that may apply.

C.
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 ASC X12N 834 Transaction, as well as the ACS/AHCA ANSI ASC XI2N 834
Companion Guide.

A.
The monthly transmission shall be sent to the fiscal agent the Wednesday
preceding the  second to the last Saturday of each month.  The enrollment
transactions will include all  enrollments submitted from the CARES office and
disenrollment requested by enrollees  or their representative. These enrollments
and disenrollments will be effective the first of  the next month.

B.
The supplemental transmission shall be sent to the fiscal agent the Wednesday
prior to  the monthly transaction. The supplemental transactions will include
Medicaid pending,  referrals from the CARES office received after the monthly
cutoff date, and enrollments  that did not process the previous month.

Attachment I - Page 57

 
 

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Amendment 001        Agreement Number XQ744

11.3          Disenrollment Summary Report

This report provides a uniform means of reporting each contractor's monthly
disenrollments. The report is required to assess the reasons for each
disenrollment and to ensure that disenrollments' are in compliance with contract
guidelines.

This report must be provided as a Microsoft Excel spreadsheet in the format
specified in Exhibit B of this contract. Disenrollments shall be numbered, and
information shall be listed in alphabetized ascending order by enrollee last
name, then by enrollee first name. Information shall pertain only to
disenrollments that are effective for the month being reported. A report will be
required if there are no disenrollments filed during the given month. For
example, the November 2002 report of disenrollments would include information on
an enrollee that expired on October 28,2002. October 28, 2002, would be provided
as the Disenrollment Reason Occurrence Date for that enrollee in the
Disenrollment Summary Report.

11.4          Encounter Data Report

The contractor shall provide encounter level service utilization data as
specified in Exhibit C of this contract. The services reported represent the
comprehensive array of services that might be necessary to maintain a member at
home while avoiding nursing home placement, including acute and long-terms care
services.

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.

11.5          Grievance/Appeals Report

This report provides a uniform means of reporting each contractor's quarterly
grievances/appeals, and is needed in order to track the number of
grievances/appeals, as well as the reason and disposition of grievances/appeals.
Grievance/appeals reporting provides a method by which to assess the
contractor's ability to manage formal grievances/appeals through its internal
grievance/appeals process.

The Grievance/Appeals Report must be provided as a Microsoft Excel spreadsheet
in the format specified in Exhibit D of this contract. The Grievance/Appeals
Report shall be submitted by the contractor to report all grievances, appeals or
updates to previously reported grievances, appeals, or to report whether there
have been any new grievances/appeals during the reporting quarter.

11.6          Updated Provider Network and Staff Listing

This updated listing provides current information on the contractor's provider
network and staffing to ensure that adequate resources are available to
enrollees at all times.

The Provider Network and Staff Listing shall be provided electronically in a
format specified by the department. The network listing shall be submitted to
the department via Electronic Mail (with password protection for HIPAA related
information) to DiversionReports@elderaffairs.org or mail via a compact disk
(with password protection for HIPAA related information). The Provider Network
Listing shall be updated to include information on providers who joined the
contractor's provider network, or who were terminated from the contractor's
provider network during the reporting quarter. The terminated providers shall be
indicated by a strikethrough and a termination date. The first page and
signature page of the subcontract will be submitted for each new provider added
to the network.

If the contractor has not added or terminated a subcontract to its provider
network within the

Attachment I - Page 58

 
 

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Amendment 001        Agreement Number XQ744

reporting quarter, a statement to that effect shall be provided to the
department in lieu of an updated Provider Network and Staff Listing.

11.7          Minority Business Enterprise Contract Reporting

This report will be submitted in accordance with the Standard Contract Section
J.3, Equity in Contracting. This format is specified in Exhibit E.

11.8          Emergency Management Plan

The contractor must submit an emergency management plan to the department for
approval specifying what actions the contractor must conduct to ensure the
ongoing provisions of health services in a natural disaster or man-made
emergency. This plan shall also address service delivery post disaster or
emergency, i.e. shelf-stable meals for those affected enrollees whose care plan
includes home delivered meals. This plan is due annually April 30.

11.9          Enrollee Satisfaction Reporting
The contractor shall conduct the enrollee satisfaction survey by March 1st of
each year. A copy of the survey shall be sent to the Department for approval by
November 1st of the state fiscal year. The contractors shall report the survey
results to the department by May 15th of each year. This survey shall be
conducted in English or in an alternative language, if the population speaking a
particular non-English language in a county is greater than five (5) percent.
The sampling for the survey shall be a statistically significant sample for
members having received long term care services during the period reflected in
the report.

The enrollee satisfaction survey results submitted to the department 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 was 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.

11.10     Hospice Services

Hospice Services shall be submitted monthly on the Hospice Enrollment Report
(Exhibit L), indicating enrollees electing hospice services the prior month.

SECTION 12   FINANCIAL REPORTING

12.1          General

The reporting requirements outlined in this section are designed in accordance
with the department and Agency's Medicaid prepaid plan contract financial
reporting requirements.

12.2          Member Payment Liability Protection

The contractor shall not hold members liable for the following in accordance
with Section 1932 (b)(6), Social Security Act (enacted by Section 4704 of the
Balanced Budget Act of 1997):
         

A.  For debts of the contractor, in the event of the contractor's insolvency.
B.
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.

Attachment I - Page 59

 
 

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Amendment 001        Agreement Number XQ744

C.
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.

12.3          Financial Reporting Template

The contractor will be supplied with a template for financial reporting that can
be used with Excel spreadsheet applications. The spreadsheets are to be
completed and either electronically transmitted or on a compact disk mailed to
the department.
A.
Master financial sheet - This is the balance sheet, Income statements and Net
Worth  and Working Capital that reflects four (4) quarters plus the contractor's
fiscal year  totals. Variances have been placed within the quarters to track
fluctuations on a line-  item basis. Ratios have been created to monitor or
detect material weaknesses in the  contractor.

B.
Enrollment sheet - Consists of quarterly summaries of enrollment detailed by
county  penetration. Indicators have been placed to reflect potential over or
under enrolling  practices.

C.
Income Statement By Lines of Business- Contains a sheet to track
individual  performance by commercial, Medicare, and Medicaid product lines.

D.
Balance Sheet Write-ins - This sheet tracks any information recorded on the
balance  sheet, which needs further explanation.

E.
Certification page - Showing the contractor's name, address, telephone number,
and  other elements.

12.4          Audited Financial Statements

The contractor must submit annual audited financial statements prepared by a
certified public accountant that expressly confirm that the contractor satisfies
the surplus requirements as per Section 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 financial statements must be 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 128 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 (CPA)
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 will be for the contractor unless prior
approval is obtained from the department for some other alternative.

If the period covered by this contract is less than six months, the contractor
may request of the department's contract manager, in writing, an exemption from
the requirements of this section for this contract period. The department's
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.

12.5          Unaudited Quarterly Financial Statements

The contractor must submit the following unaudited quarterly financial
statements^ Balance Sheet, Income Statements and Net Worth and Working Capital.

Attachment 1 - Page 60

 
 

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Amendment 001        Agreement Number XQ744

A.
These statements must be filed, on a compact disk or electronically transmitted
using the  supplied spreadsheet template and are due 45 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.

B.
The reporting date, and the name of the provider, roust be plainly written or
stamped on  the certification page, along with the Chief Executive Officer's
(CEO) signature.

C.
Do not leave blanks. If no entry is to be made, write ANONE, @ not applicable
(N/A) or  "-0-" in the space provided. Any item that cannot be readily
classified under one of the  printed items should be entered as an aggregated
item and adequately described.

D.
If additional supporting statements or schedules are added in connection with
providing  information on the financial statement, the additions should be
properly keyed to the item  being answered.

E.          One copy of the financial template is required to be filed with the
quarterly submission.

12.6      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).

A.      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.

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Amendment 001                            Agreement Number XQ744

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.

B.        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.

C.        Property, Plant & Equipment (Net of depreciation)

140- Land
Include:   Real estate owned by the Contractor.

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Amendment 001        Agreement Number XQ744

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
 
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.

D.      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 (D3NR).

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

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Amendment 001        Agreement Number XQ744

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.

E.        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
 
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.

F.          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.

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Amendment 001        Agreement Number XQ744

 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.

12.7     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.

A.        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.

B.        Revenues

302- Capitation Premium
Include:   Revenue recognized on a prepaid basis for eligible enrollees.

Exclude: Premiums and co-payments from enrollees.

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Amendment 001        Agreement Number XQ744

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.

C.
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.

 
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.

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Amendment 001        Agreement Number XQ744
 
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.

D.           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 care
giver, 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. 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, and household items such
as detergents, bleach, and paper towels, or prescription drugs.

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Amendment 001         Agreement Number XQ744

 

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 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.

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

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Amendment 001        Agreement Number XQ744

 
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 plan of
care 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 plan of care 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 avoid financial abuse, to maintain and
balance accounts that directly relate to the

Attachment I - Page 69

 
 

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Amendment 001        Agreement Number XQ744

enrollees living arrangement at home, or to 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
 
Include:   All other long-term care support services that can not be classified
within one of the previous categories of service.

E.      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

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Amendment 001                       Agreement Number XQ744

 
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 § 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 § 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.

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 necessary eye examinations and Eyeglass repairs and
adjustments. Eyeglasses are limited to two pair every 365 days.

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Amendment
001                                                                                    Agreement
Number XQ744

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.

F.         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 D3NR expenses for prior years.

G.         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.

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Amendment
001                                                                                    Agreement
Number XQ744

H.    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.

I.      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.

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Amendment 001        Agreement Number XQ744

12.8      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.

A.        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.

B.        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.

C.        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
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

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Amendment 001        Agreement Number XQ744

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.

D.        Case Management Expense

350- Case Management
 
Include:   Case management expenses, including salaries, benefits, travel and
training expenses for case managers, and case management supervisors.

E.        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.

F.   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.

12.9      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 serves as the
instructions. As indicated on the report, please provide description to any
amounts entered as "other".

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Amendment 001        Agreement Number XQ744
 
12.10           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.

12.11           Analysis of Total Medical Liability to Actual Claims Paid

This report should be completed for the NHD Program ONLY.

Using tire 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.

12.12           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 tire Contractor has received capitation revenue for one month.

12.13           Notes and Other Information

Utilize the Notes and Other Information tab to indicate and provide information
that can not be reported within the main context of the required reports. Please
provide the specific report number and reference of the additional information
being provided.

12.14           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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Amendment 001        Agreement Number XQ744

12.15    Footnote Disclosure Requirements

A.        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 BBNR 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 D3NR and RBUC
balances from the prior quarter. Specifically, address changes in IBNRs and/or
Rubs of more than 10 percent (on an EBNR 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.

SECTION 13   DEFINITIONS

The following terms as used in this contract, shall be construed and/or
interpreted as follows, unless the context otherwise expressly requires a
different construction and/or interpretation.

Action - 42 CFR 438.400 - 1. The denial or limited authorization of a requested
service, including the type or level of service. 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

Attachment I - Page 77

 
 

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Amendment 001        Agreement Number XQ744

manner, as defined by the state. 5. The failure of the plan to act within the
timeframes provided in 42 CFR 438.408(b). 6. For a resident of a rural area with
only one managed care entity, the denial of a Medicaid enrollee's request to
exercise his or her right, under 42 CFR 438.52(b)(2)(h), to obtain services
outside the network

APL - 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.

Advance Directives- refers to oral and written instructions authorizing another
to act as one's agent or attorney regarding future medical care. (Examples:
Living Will and Durable Power of Attorney)

Adverse Determination - Adverse determination means any instance in which
coverage for the requested service is denied, reduced, or terminated. The
contractor's decision to deny, reduce or terminate coverage must be based on the
review of whether an admission, availability of care, continued stay, or other
service required in accordance with this contract meets the contractor's
requirements for medical necessity, appropriateness, health care setting, level
of care, or effectiveness.

Agency - State of Florida, 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 - 42 CFR 438.400 - A request for review of action.

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.

Benefits - a schedule of medical or social services to be delivered to enrollees
covered under this contract.

CMS - Centers for Medicare and Medicaid 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 - See Plan of Care.

CASES - Comprehensive Assessment and Review for Long Term Care Services. A
nursing home pre-admission assessment program, which provides a comprehensive,
on-site assessment of individuals seeking admission to a nursing home under a
state assisted program. The program explores all available options to nursing
home placement and recommends, and may facilitate alternative placements for
individuals who are determined able to remain in the community.

CFR - Code of Federal Regulations.

Cold-call marketing - Any unsolicited personal contact by the contractor or
subcontractors with a potential enrollee for the purpose of marketing.

Complaints - See Grievance

Contractor - the organizational entity serving as the primary contractor and
with whom tins agreement is executed. The term contractor shall include all
employees, subcontractors, agents, volunteers, and anyone acting on behalf of,
in the interest of, or for a contractor.

Covered Services - see Benefits.

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Amendment 001.        Agreement Number XQ744

Department - Department of Elder Affairs.
DCF- Department of Children and Families
DHHS - United States Department of Health and Human Services.
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) means 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 (or, with respect to a pregnant woman, the
health of the woman or  her unborn child) in serious jeopardy.
(2) Serious impairment to bodily functions. (3) Serious dysfunction of any
bodily organ or part.

               
Emergency Services - according to 42 CFR 438.114(a) means covered inpatient and
outpatient services that are as follows:
(1)        Furnished by a provider that is qualified to furnish these services
under this title.
(2)        Needed to evaluate or stabilize an emergency medical condition.

Enrollee - according to 42 CFR 438.10(a) means a Medicaid recipient who is
currently enrolled in a MCO as defined in 42 CFR 438.10(a). See "Member."

Enrollment - the process by which an eligible Medicaid recipient becomes an
enrollee in the Long Term Care Community Diversion Pilot Project.

Existing diversion provider - an entity that is approved by the department on or
before June 30,2007, to provide services to consumers through any Long-Term Care
Community Diversion Pilot Project authorized under Chapter 430.701- 430.709,
F.S..

Extraordinary Reporting - reporting of awareness or discovery of conditions that
may materially affect the contractor's ability to perform services under this
contract.

Facility - any premises (a) owned, leased, used or operated directly or
indirectly by or for the contractor or its affiliates for purposes related to
this contract; or (b) maintained by a sub-contractor to provide services on
behalf of the contractor.

Fair Hearing - the opportunity to present one's case to a reviewing authority in
accordance with the terms and conditions in 42 CFR Part 431, State Organization
and General Administration, Subpart E, and 59G-1.030, Florida Administrative
Code.

Fiscal Agent - any corporation or other legal entity that has contracted with
the Agency to receive, process and adjudicate claims under the Medicaid program.

FMMIS- Florida Medicaid Management Information System, Medicaid fiscal agent
utilizes this system for all Medicaid related data and information.

Furnished - means supplied, given, prescribed, ordered, provided, or directed to
be provided in any manner.

Grievance - means an expression of dissatisfaction about any matter other than
an action, as "action" is defined in this section. The term is also used to
refer to the overall system that includes grievances and appeals handled at the
contractor level and access to the Medicaid fair hearing process. (Possible
subjects for grievances include, but are not limited to, the quality of care or
services provided, and aspects of

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Amendment 001                           Agreement Number XQ744

interpersonal relationships such as rudeness of a contractor or employee, or
failure to respect the enrollee's rights.) (42 CFR 438.2)

Grievance Procedure - the procedure for addressing enrollees' grievances. A
grievance is an enrollee's expression of dissatisfaction with any aspect of
their care other than the appeal of actions (which is an appeal).

Grievance System - the system for reviewing and resolving enrollee grievances or
appeals. Components must include a grievance process, an appeal process, and
access to the Medicaid fair hearing system.

Grievant - an enrollee, subcontractor, or other service provider that files a
grievance with the contractor.

Health Care Professional - means 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.

HMO - Health Maintenance Organization as certified pursuant to Chapter 641,
F.S..

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.

IADL - Instrumental Activities of Daily Living; include making and answering
telephone calls, shopping, transportation ability, preparing meals, laundry,
light housekeeping, heavy chores, taking medication, and managing money.

ICP - The Medicaid Institutional Care Program.

Ineligible Recipient - a Medicaid recipient that does not qualify for enrollment
in the Long Term Care Community Diversion Program.

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 - means 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 plan of care
and documentation of case management activities including efforts to coordinate
and integrate the delivery of all services to the enrollee.

Marketing - any activity conducted by or on behalf of the contractor where
information regarding the services offered by the contractor is disseminated in
order to encourage eligible enrollees to enroll or accept any application for
enrollment in the Long Term Care Community Diversion Program developed under
this contract.

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 there under, as
administered in this state by the Agency under Chapter 409.901 et seq., F.S.

Medicaid HMO - an HMO as defined in the Medicaid State Plan.

Medically Necessary or Medical Necessity - services provided in accordance with
42 CFR 438.210(a)(4) and as defined in Section 59G-1.010(166), F.A.C., to
include that medical or allied care, goods, or services furnished or ordered
must: A. Meet the following conditions:

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Amendment 001        Agreement Number XQ744

1.
Be necessary to protect life, to prevent significant illness or significant
disability, or to alleviate severe pain;

2.
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;

3.
Be consistent with the generally accepted professional medical standards as
determined by the Medicaid program, and not experimental or investigational;

4.
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

5.
Be furnished in a manner not primarily intended for the convenience of the
recipient, the recipient's caretaker, or the contractor.

B.
"Medically necessary" or "medical necessity" for inpatient hospital services
requires that those  services furnished in a hospital on an inpatient basis
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.

C.
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 there
under.

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.

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 who does receive
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.

Plan of Care - 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.

Potential Enrollee - according to 42 CFR 438.10(a) means 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.

Prior Authorization - the act of authorizing specific services before they are
rendered.
 
Project - Long Term Care Community Diversion Program.
 
Protocols - written guidelines or documentation outlining steps to be followed
for handling a

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Amendment 001        Agreement Number XQ744

particular situation, resolving a problem, or implementing a plan of medical,
social, nursing, psycho social, developmental and educational services.

Provider - a person or entity who 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.

Recipient - any individual whom the Department of Children and Families
determines is eligible, pursuant to federal and state law, to receive medical or
allied care, goods, or services for which the Agency may make payments under the
Medicaid program and is enrolled in the Medicaid program.

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 by a contractor 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 control interest in the contractor's
organization.

Subcontractor - any person to which 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 Chapter 641.19(19), F.S..

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Amendment 001        Agreement Number XQ744

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 - an appropriate means of conveyance 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 project until the initial Plan of Care is implemented.

Transition Period - the period of time from the effective date of enrollment
until the initial Plan of Care is effective,

Urgent Grievance - an adverse determination when the standard timeframe of the
grievance procedure would seriously jeopardize the life or health of an
enrollee, or the enrollee's ability to regain maximum function.

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.

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Amendment 001                                    Agreement Number XQ744
 
EXHIBIT A
MULTIPLE SIGNATURE VERIFICATION AGREEMENT  
 
Account Number: _______________________

In consideration of the mutual promises and undertakings expressed herein, this
Agreement is entered into between ______________________________Bank ("Bank")
and_______________Long-Term Care Diversion Provider ("Provider"), effective
as_____________________________of the ________day of ________, 20___.

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,   20.

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 _______________________, at _______________________ Bank, located
at  ____________, Florida, _____________ , 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.

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.

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Amendment 001        Agreement Number XQ744

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:                                       

PROVIDER'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:                                                
Title:                                                

Date of Certification:                                                

[Affix corporate seal]

AUHORIZED SIGNATURES

PROVIDER: _________________________________
DEPARTMENT OF ELDER AFFAIRS
Title Print Name:______________________________
Deputy Secretary Print Name: ______________________________
   
Title Print Name: ______________________________
Chief Financial Officer Print Name: ______________________________
   
Title Print Name: ______________________________
Print Name: ______________________________
 

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Amendment 001         Agreement Number XQ744

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
             

·  
Disenrollment 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 = Subject to DOEA approval
OUT = No longer wish to participate in diversion program
CTY = Moved outside of contractor's service area
S VR = Dissatisfaction with quality and/or quantity of services
JFR = Transfer to another provider

SUMMARY

Total Disenrollments:__________________

Attachment! - Page 86

 
 

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Amendment 001        Agreement Number XQ744

EXHIBIT C

Encounter Data Reporting Format

Service Utilization Reporting

The plan shall provide recipient-specific service utilization data in the
electronic format as specified below. 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.

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 row/record for each
enrollee for each month they receive services. For example, if an enrollee was
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. You
have up to three months after the last month in a specific quarter to submit the
quarterly files. Contractors must also resubmit the Acute Care Services and the
Long-Term Care Services files for the previous quarter with the most-up-to-date
claim data along with the current quarter files.

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).* 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 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 located below.

 FILE 1:   Long-Term Care Services
 
Field Name
Description
Unit of Measurement
Field Length
Start Col.
End Col.
Text/Numeric
SSN
Social Security Number Cleft 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
l=Yes: 2=No
1
38
38
Numeric
MONTH
Report Month
MMYYYY
6
31
44
Numeric
ADMINS
Administrative Costs
Amount Paid
6
«
50
Numeric

* Medicare crossovers are amounts that are billed to Medicaid for those Medicaid
enrollees who are also eligible for Medicare.

Attachment 1 - Page 87
 

 
 

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

 

Amendment 001

Agreement Number XQ744

Field Name
Description
Unit of Measurement
Field Length
Start Col.
End Col.
Text/Numeric
Lone-term care SERVICES
DESCRIPTION
UNIT OF SERVICE/ COST
       
ADCOMP
Adult Companion Services
IS Minute Unit
4
51
H
Numeric
ADCOMPS
Adult Companion Services
Amount Paid
6
55
60
Numeric
ADAYHLTH
Adult Day Health Services
15 Minute Unit
4
16
64
Numeric
ADAYHLS
Adult Day Health Services
Amount Paid
6
65
70
Numeric
ALFSVS
Assisted Living Services
Days
2
71
72
Numeric
ALFSVSSS
Assisted Living Services
Amount Paid
6
73
78
Numeric
ATTCARE
Attendant Care Services
15 Minute Unit
4
79
82
Numeric
ATTCARES
Attendant Care Services
Amount Paid
6
83
88
Numeric
CASEAID
Case Aide
15 Minute Unit
4
89
92
Numeric
CASEAIDS
Case Aide
Amount Paid
6
93
98
Numeric
CASEMGMT
Case Management (Internal)
15 Minute Unit
4
99
102
Numeric
CASEMGTS
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 MH8
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 Equipment
Amount Paid
6
141
146
Numeric
ENVHUA
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
FMM 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
SNFSS
Nursing Facility Services-Long-term
Amount Paid
6
231
236
Numeric
NUTR RRS
Nutritional Assessment/Risk Reduction Services
15 Minute Unit
14
237
240
Numeric
NUTR RRS
Nutritional Assessment/Risk Reduction Services
Amount Paid
6
241
246
Numeric
OT
Occupational Therapy
15 Minute Unit
4
247
250
Numeric
OTS
Occupational Therapy
 
6
251
256
 
PCS
Personal Care Services
15 Minute Unit
4
257
260
Numeric
PCS
Personal Care Services
Amount Paid
6
261
266
 
PERS I
Personal Emergency Response System Installation
Job
2
267
268
Numeric
PERS IS
Personal Emergency Response System
Amount
6
269
274
Numeric

Attachment I - Page 88

 
 

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

 

Amendment 001

Agreement Number XQ744

Field Name
Description
Unit of Measurement
Field Length
Start Col.
End Col.
Text/Numeric
 
Installation
Paid
       
PERS M
Personal Emergency Response System -Maintenance
Day
2
275
276
Numeric
PERS MS
Personal Emergency Response System-Maintenance
Amount Paid
6
277
282
Numeric
PEST I
Pest Control - Initial Visit
Job
2
283
284
Numeric
PEST IS
Pest Control-Initial Visit
Amount Paid
6
285
290
Numeric
PEST M
Pest Control — Maintenance
Month
1
291
291
Numeric
PEST MS
Pest Control- Maintenance
Amount Paid
6
292
297
Numeric
PT
Physical Therapy
15 Minute Unit
4
298
301
Numeric
PTS
Physical Therapy
Amount Paid
6
302
307
Numeric
RISKREDU
Physical Risk Assessment and Reduction
IS Minute Unit
4
308
311
Numeric
RISKREDS
Physical Risk Assessment and Reduction
Amount Paid
6
312
317
Numeric
PRIVNURS
Private Duty Nursing Services
15 Minute Unit
4
318
321
Numeric
PRIVNURS
Private Duty Nursing Services
Amount Paid
6
322
327
Numeric
PT R
Registered Physical Therapist
Visit
2
328
329
Numeric
PT RS
Registered Physical Therapist
Amount Paid
6
330
335
Numeric
RSPTH
Respiratory Therapy
15 Minute Unit
4
336
339
Numeric
RSPTHS
Respiratory Therapy
Amount Paid
6
340
345
Numeric
RESP HM
Respite Care - In Home
15 Minute Unit
4
346
349
Numeric
RESP HMS
Respite Care- In Home
Amount Paid
6
350
355
Numeric
RESP FA€
Respite Care - Facility-Based
Days
2
356
357
Numeric
RESP FAS
Respite Care- Facility-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 Therapy
15 Minute Unit
4
374
377
Numeric
SPTHS
Speech Therapy
Amount Paid
6
378
383
Numeric
TRANSPOR
Transportation Services (not included in Escort or Adult Day Health services)
Trips
3
384
386
Numeric
TRANSPORS
Transportation Services (not included in Escort or Adult Day 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

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
 
CLINICSS
Clinic Services Costs
Amount Paid
6
28
33
Numeric
 
DENTAL
Dental Services
Visit
6
34
39
Numeric
 
DENTALSS
Dental Services Costs
Amount Paid
6
40
45
Numeric
 
DIALYSIS
Dialysis Center
Visit
2
46
47
Numeric
 
DIALYSSS
Dialysis Center Costs
Amount Paid
6
48
53
Numeric
 
ER
Emergency Room Services
Visit
2
54
55
Numeric
 
ER SS
Emergency Room Services Costs
Amount Paid
6
56
61
Numeric
 
FQHC
FQHC Services
Visit
2
62
63
Numeric
 
FQHC SS
FQHC Services Costs
Amount Paid
6
64
69
Numeric

Attachment I - Page 89

 
 

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

 

Amendment
001                                                                                    Agreement
Number XQ744
 

Code
Field Name
Description
Unit of . Measurement
Field Length
Start Col.
End Col.
Text/Numeric
 
HEAR
Hearing Services including hearing aids
Amount Paid
6
70
75
Numeric
 
MPTSVS
Inpatient Hospital Services
Day
3
76
78
Numeric
 
INPTSVSS
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 SS
Nurse Practitioner Services Costs
Amount Paid
6
93
98
Numeric
 
RX SS
Pharmaceuticals
Amount Paid
6
99
104
Numeric
 
PA
Physical Assistant
Visit
2
105
106
Numeric
 
PA S$
Physical Assistant Costs
Amount Paid
6
107
112
Numeric
 
MD
Physician Services
Visit
2
113
114
Numeric
 
MD SS
Physician Services Costs
Amount Paid
6
115
120
Numeric
 
OUTPT
Outpatient Hospital Services
Encounter
3
121
123
Numeric
 
OUTPT SS
Outpatient Hospital Services Costs
Amount Paid
6
124
129
Numeric
 
PODIATRY
Podiatry
Visit
2
130
131
Numeric
 
PODIATSS
Podiatry Costs
Amount Paid
6
132
137
Numeric
 
RURAL
Rural Health Services
Visit
2
138
139
Numeric
 
RURALSS
Rural Health Services Costs
Amount Paid
6
140
145
Numeric
 
SNFREHA
Skilled nursing facility services-rehabilitation
Days
2
146
147
Numeric
 
SNFREHAS
Skilled nursing facility services-rehabilitation**
Amount Paid
6
148
153
Numeric
 
EYE SS
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 SS
Other Acute service not listed (amount)
Amount Paid
6
166
171
Numeric
 
DESCR 1
Description of other Acute service
 
35
172
206
Text
 
DESCR 2
Description of other Acute service
 
35
207
241
Text

*'Medicare Crossovers

Encounter Data Pile 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 YYLTC.txt
*** MON YYACS.txt
Validation Report
*** MON YY LTC DV.pd'f
*** MON YY ACS DV.pdf
Certification File (if applicable)
*** MON YY LTC CERT.doc
*** MON YY ACS CERT.doc
ZIP file *** MON YY.zip *** MON YY.zip
 
 

 
Attachment I - Page 90

 
 

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

 

Amendment 001        Agreement Number XQ744
EXHIBIT D

Report of Grievances/Appeals
 
(Plan Name)
 
(Reporting Quarter)
 
Were any new grievances filed during this reporting quarter?   YES       NO

 
Enrollee's
Last Name
Enrollee's
First Name
Enrollee's Medicaid D>#
Enrollee's Social Security #
Grievance Type*
Grievance Date
Expedited Request? (VorN)
Disposition Type**
Disposition Date
Resolved?
(YorN)
1
                   
2
                   
3
                   
4
                   
5
                   

 
Were any new appeals filed during this reporting quarter?     YES   NO

 
Enrollee's
Last Name
Enrollee's
First Name
Enrollee's Medicaid
Enrollee's
Social Security #
Appeals Type *
Appeals Date
Expedited Request? (YorN)
Disposition
Type **
Disposition Date
Resolved? (YorN)
1
                   
2
                   
3
                   
4
                   
5
                                         

 

 
   * Grievance/Appeals 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 Plan of Care
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 sacs
4    = Changed to Another Provider
10 = In Grievance/Appeal Process
5 = Billing Dispute
11 = Benefits available in plan
5 = Reinstated in Plan
11 = Lost Contact with Enrollee 6 = Contract Interpretation 12 = Other 6 =
Billing Issue Resolved 12 = Other

Attachment I - Page 91

 
 

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Amendment 001         Agreement Number XQ744

 
EXHIBIT E

Minority Business Enterprise Contract Reporting

Vendor Name
 
Quarterly Vendor
 
Expenditure Activity

Reporting Timeframe
Due Date
Quarter 1 (January thru March)
April 15
Quarter 2 (April thru June)
July 05
Quarter 3 (July thru September)
October 15
Quarter 4 (October thru December)
January 15

Subcontractor Name
Subcontractor Address
Subcontractor Telephone #
Subcontractor Federal Identification # or Social Security #
Total Amount Expended With Subcontractor (Current Reporting Quarters Only)
Total Amount Expended With Subcontractor (Prior Reporting Quarters)
                                                                               
   
Completed By:
Telephone  #:
Completion Date:

Attachment I - Page 92

 
 

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

 

Amendment 001

Agreement Number XQ744

Long-Term Care Community Diversion Pilot Project
Reconciliation Report
For (Contractor name) (Month/Year)

EXHIBIT F

 
Last Name
First Name
Medicaid ID Number
Provider Number
Error Code
Comments
1
           
2
           
3
           
4
           
5
           
6
           
7
           
8
           
9
           
10
           

Error Codes
Error Summary Description
Error Codes
Error Summary Description
01
Action Code Invalid
14
Recipient Ineligible
02
HMO Number Invalid
15
Recipient Already enrolled
03
HMO Number Not Found
16
Invalid Recipient AID Cat
04
Recipient ID Not Found
17
Capitation Group Not Covered
05
Recipient ID Not on File
18
Transaction Date Invalid
06
Recipient Date of Birth Invalid
19
Transaction Date Incorrect
07
Recipient Date of Birth Unmatched
20
Outpatient Dollars Invalid
08
Recipient Has Major Medical
21
Inpatient Units Invalid
09
HMO Not A Medicaid Provider
22
Invalid Fiscal Year
10
Recipient Amount Not Met
23
Bad Capitation Update
11
Recipient Not Enrolled
24
Cancelled by Choice Counselor   .
12
Recipient Enrolled In Other HMO
25
Recipient In a Nursing Home
13
Enrollment Error
   

Attachment I - Page 93

 
 

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

 

Amendment 001        Agreement Number XQ744

EXHIBIT G
DEPARTMENT OF ELDER AFFAIRS
LONG-TERM CARE DIVERSION PILOT PROJECT
REQUEST FOR DISENROLLMENT

CURRENT PROVIDER NAME:  COUNTY:

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 All That Apply):
 
□Dissatisfied with services (SVR)
□Moving to out-of-network nursing home (NET)
□Moving to out-of-network ALF
 
□No longer wish to participate in diversion program (OUT)
□Transfer to new provider (TFR)
 

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 All That Apply):
□Death (Date: ____________________) (EXP)
□Not eligible for Medicaid (ELG)
□Not eligible for project (PRJ)
□Moving out of the service area (CTY)
 
□Fraudulent use of Medicaid ID card (FRD)
□Incarceration
□Subject to Department of Elder Affairs approval (SDA)

EFFECTIVE DATE OF DISENROLLMENT:
 
   
Case Manager Signature
 
Date CARES Office Notified
     
Program Administrator Signature
 
CARES Fax Number
 
REQUEST FOR TRANSFER TO NEW PROVIDER
 
NAME OF NEW PROVIDER:  COUNTY: 
 

Attachment I - Page 94

 
 

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

 

Amendment 001        Agreement Number XQ744

DEPARTMENT OF ELDER AFFAIRS

LONG-TERM CARE DIVERSION PILOT PROJECT
SOLICITUD PARA DARSE DE BAJA

Nombre actual del proveedor: 
 
Condado:  

Dirección del proveedor:

Numero de Teléfono: (           )  FAX:(           )

Nombre del Participante:

Numero de Medicaid: Fecha de Nacimiento:   Numero de teléfono: __________

Dirección del Participante:Condado:  

DESEA INFORMAR ACERCA DE ALGUNA QUEJA?[  ] Si[  ] No

VOLUNTARIO (MARQUE LAS QUE SE APLICAN):
 
□No esta satisfecho con el servicio (SVR)
□Se muda a una clínica de reposo fuera del área (NET) 
□Se muda a una residencia de vivienda asistida fuera del área (ALF)
 
□No desea participar en el programa de diversión (OUT)
□Solicita un nuevo proveedor (TFR)
 

COMMENTS:

     
Firma del participante o representante autorizado
 
Fecha
     
Si es represéntate, por favor escribir letras
 
Por favor indicar el relación con el participante
 

PARA USO DEL PROVEEDOR DE DIVERSION
INVOLUNTARIO (Marque las que apliquen)
□Fallecimiento (Fecha: _________) (EXP)
□No es elegible para Medicaid (ELG)
□No es elegible para el programa (PRJ)
□Se mudo fuera del área de servicio
 
□Uso fraudulento de la tarjeta Medicaid (FRD)
□     Encarcelamiento (INC)
□Sujeto a aprobación del departamento de Elder Affairs (SDA)

 
Fecha de desenlistamiento:
   
 
Firma del manejador de caso
 
 
Fecha de notificación a las oficinas de CARES
 
Firma del administrador del programa
 
Numero de fax de la oficina de CARES
 
□SOLICITUD PARA TRANSFERIR A UN NUEVO PROVEEDOR
 
NOMBRE DEL NUEVO PROVEEDOR:   CONDADO: 
 

Attachment I - Page 95

 
 

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

 

Amendment 001        Agreement Number XQ744

EXHIBIT H

Provider Name
 Street Address
City, FL ZIP

Phone:                         Plan Contact:
FAX:                            Email:

List Date x/xx/xx
 
Covered Services
Provider Name
Name of Provider Contact
Phone Number
Street Address
City
State
Zip Code
County Served
Comments
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
                 
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
                 

Attachment I - Page 96

 
 

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

 
Amendment 001        Agreement Number XQ744

 
 
 
 
         
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
                 
Respite Care Services
                 
Respite Care Services
                 
Speech Therapy
                 
Speech Therapy
                 
Vision
                 
Vision
                 
Optional Services
                 
Transportation Services
                 
Expanded Services
                 

Staff Positions
Staff Name
Phone Number
Email
Fax Number
Contract Manager / Plan Administrator
       
Case Management Supervisor
       
Case Manager
       
Data Processing
       
Grievance Coordinator
       
Medical Director
       
Medical Records Coordinator
       
Member Services
       
Quality Assurance Coordinator
       
Training Coordinator
       
Utilization Review
       

Attachment I - Page 97

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
EXHIBIT I

Capitation Rates

Provider ID
Provider Name
County Name
1/1/2008 - 8/31/2008 Diversion Capitation Rate
0150771 00
WellCare
Orange
1,351.22
0150771 01
WellCare
Osceola
1,351.22
0150771 02
WellCare
Seminole
1,351.22
0150771 03
WellCare
Duval
1,410.43

The following table lists the initial rates for prospective expansions.

PSA
Counties
1/1/08-8/31/2008  Diversion Capitation Rate
1
Escambia, Okaloosa Santa Rosa, and Walton
1,514.64
2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Taylor, Wakulla, and Washington
1,514.64
3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lake,
Levy, Marion, Putman, Sumter, Suwannee, and Union
1,544.36
4
Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
1,410.43
5
Pasco and Pinellas
1,568.98
6
Hardee, Highlands, Hillsborough, Manatee, and Polk
1,542.84
7
Brevard, Orange, Osceoia, and Seminole
1,351.22
8
Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
1,529.72
9
Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
1,512.27
10
Broward
1,558.68
11
Miami-Dade and Monroe
1,570.30

Attachment I - Page 98

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
Contract #2007-2008-01
EXHIBIT J

SWORN STATEMENT PURSUANT TO CHAPTER 287.133(3)(a),
FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES

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_____________________(print name
of the public entity) 
by  _________________________(print individual's name and
title)                                                                                                              
for _________________________(print name of entity submitting sworn statement)

whose business address is   _________________________________________

 
and, if applicable, its Federal Employer Identification Number (FEIN) is

If the entity has no FEIN, include the Social Security Number of the individual
signing this sworn statement:
__________________________________________________________________________________

2.
I understand that a "public entity crime" as defined in Paragraph 287.133(l)(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(l)(a),
Florida Statutes, means:

      

a.  A predecessor or successor of a person convicted of a public entity crime;
or
b.
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(l)(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.)

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.

Attachment I - Page 99

 
 

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Amendment
001                                                                                    Agreement
Number XQ744
Contract #2007-2008-01 EXHIBIT J

SWORN STATEMENT PURSUANT TO CHAPTER 287.133(3)(a), FLORIDA STATUTES. ON PUBLIC
ENTITY CRIMES

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 the Florida Department of Elder
Affairs   
 
by   Todd Farha, President and CEO  (print individual's name and title)  
 
for WellCare of Florida, Inc. (print name of entity submitting
sworn  statement)                                              
                                                                                                                  
whose business address is:  8735 Henderson Road Tampa, FL 33634

and, if applicable, its Federal Employer Identification Number (FEIN) is

If the entity has no FEIN, include the Social Security Number of the individual
signing this sworn statement: ______________________________________________

2.
I understand that a "public entity crime" as defined in Paragraph 287,133(l)(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(l)(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(l)(a),
Florida Statutes, means:

 
    

a.   
A predecessor or successor of a person convicted of a public entity crime; or
 
b.
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(l)(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.

Attachment I - Page 99

 
 

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Amendment
001                                                                                Agreement
Number XQ744

 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.

_______ 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 1 AM REQUIRED TO INFORM THE PUBLIC
ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD PROVIDED IN
CHAPTER 287.017, FLORIDA STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE
INFORMATION CONTAINED IN THIS FORM.

 
/s/  Todd S. Farha
(Signature)
 
12/27/07

 

STATE OF FLORIDA

COUNTY OF HILLSBOROUGH

PERSONALLY APPEARD BEFORE ME, the undersigned authority,  Todd S. Farha, who,
after first being sworn by me, affixed his/her signature in the space provided
above on this 27th Day of December, 2007.

/s/  Sara Gallo
Notary Public

My commission expires: 1/29/2010
Jan 2001
Form 102 Sworn State Public Entity Crimes (Jan 2001)                   

Attachment I-Page 100

 
 

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Amendment
001                                                                                    Agreement
Number XQ744 
CONTRACT#2007-2008-0
EXHIBIT K

INSTRUCTIONS                                                                                                         
CERTIFICATION
REGARDING                                                                                                                          
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS

1.
Each recipient or vendor whose contract equals or exceeds $100,000 in federal
monies must sign this debarment certification prior to contract execution.
Independent auditors who audit federal programs regardless of the dollar amount
are required to sign a debarment certification form. Neither the Department of
Elder Affairs nor its contract recipients or vendors can contract with
subrecipients if they are debarred or suspended by the federal government.

2.
This certification is a material representation of fact upon which reliance is
placed when this contract is entered into. If it is later determined that the
signed knowingly rendered an erroneous certification, the Federal Government may
pursue available remedies, including suspension and/or debarment.

3.
The recipient or vendor shall provide immediate written notice to the contract
manager at any time the recipient or vendor learns that its certification was
erroneous when submitted or has become erroneous by reason of changed
circumstances.

4.
The terms "debarred," "suspended," "ineligible," "person," "principal," and
"voluntarily excluded," as used in this certification, have the meanings set out
in the Definitions and Coverage sections of rules implementing Executive Order
12549 and 45 CFR (Code of Federal Regulations), Part 76. You may contact the
contract manager for assistance in obtaining a copy of those regulations.

5.
The recipient or vendor further agrees by submitting this certification that, it
shall not knowingly enter into any subcontract with a person who is debarred,
suspended, declared ineligible, or voluntarily excluded from participation in
this contract unless authorized by the Federal Government.

6.
The recipient or vendor further agrees by submitting this certification that it
will require each subrecipient of this contract whose payment will equal or
exceed $100,000 in federal monies, to submit a signed copy of this certification
with each contract.

7.
The Department of Elder Affairs and its contract recipients or vendor may rely
upon a certification of a recipient/subrecipients that is not debarred,
suspended, ineligible, or voluntarily exclude from contracting/subcontracting
unless it knows that the certification is erroneous.

8.
If the recipient or vendor is an Area Agency on Aging (AAA), the AAA may rely
upon a certification of a recipient/subrecipient or vendor entity that is not
debarred, suspended, ineligible, or voluntarily excluded from
contracting/subcontracting unless the AAA knows that the certification is
erroneous.
 
9. The signed certifications of all subrecipients or vendors shall be kept on
file with recipient.

           

DOEAFORM112A (Revised May 2002)

Attachment I - Page 101

 
 

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Amendment 001        Agreement Number XQ744
Contract 2007-2008-01

INSTRUCTIONS
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY
AND VOLUNTARY EXCLUSION CONTRACTS/SUBCONTRACTS

This certification is required by the regulation implementing Executive Order
12549, Debarment and Suspension, signed February; 18,1986. The guidelines were
published in the May 29, 1987 Federal Register (52 Fed. Reg., pages
20360-20369).

(1)
The prospective recipient or vendor certifies, by signing this certification,
that neither he nor his principals is presently debarred, suspended, proposed
for debarment, declared ineligible, or voluntarily excluded from participation
in contacting with the Department of Elder Affairs by any federal department or
agency.

(2)
Where the prospective recipient or vendor is unable to certify to any of the
statements in this certification, such prospective recipient or vendor shall
attach an explanation to this certification.

 
Signature: /s/ Todd S. Farha

 
Date: 12/27/07

 
Todd S. Farha, President & CEO

Name and Title of Authorized Individual(Print or Type)

 
WellCare of Florida , Inc.

 
Name of Organization

 
DOEA Form 112B

 
(revised May 2002)

 
 

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Amendment 001                                    Agreement Number XQ744

EXHIBIT L

Long-Term Care Diversion Pilot Project Hospice Enrollment Report

Number of Enrollees Electing Hospice Monthly

Month of: __________________________

Contractor: ________________________

 
County
Number of enrollees
For Profit
Not for Profit
1
       
2
       
3
       
4
       
5
       
6
       
7
       
8
       
9
       
10
       
11
       
12
       
13
       
14
       
15
       
16
       
17
       
18
       
19
       
20
       
21
       
22
       
23
       
24
       
25
       

Submitted
by:                                                                                       

Submit to your contract manager by the 15lh day after the reporting month.

Attachment I-Page 103

 
 

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Amendment
001                                                                                 Agreement
Number XQ744

ATTACHMENT II

CERTIFICATION REGARDING LOBBYING

CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENT

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 sub-awards at all tiers (including
subcontracts, sub-grants, and contracts under grants, loans and cooperative
agreements) and that all sub-recipients shall certify and disclose 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 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 and not more than $100,000 for each such failure.

                                                                          

                                                                                                 
                                                                          

/s/  Todd S. Farha
Signature
 
12/27/07
Todd S. Farha
Name of Authorized Individual
 
XQ744
Application or contract number
WellCare of Florida, Inc.  P.O Box 26011, Tampa, FL 33623
Name and Address of Organization
 

DOEA Form 103 (Revised Nov 2002)
ATTACHMENT II - Page 1
 

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Amendment 001        Agreement Number XQ744
ATTACHMENT III

CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR CONTRACTS, GRANTS, LOANS
AND COOPERATIVE AGREEMENTS

The undersigned, an authorized representative of the recipient named in the
contract or agreement to which this form is an attachment, hereby certifies
that:

(1)
The recipient and any sub-recipients 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 contract 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 recipient, sub-recipient(s), or any
outside entity on which the recipient 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, recipient(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-to-date dependent data accurately. All
versions of these products offered by the recipient (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 recipient 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 recipient and any sub-recipient(s) of services under this contact 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 recipient shall require that the language of this certification be included
in all subcontracts, 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 A-l 10.

WellCare of Florida, Inc.  8735 Henderson Road, Tampa, FL 33634
Name and Address of Organization
 
/s/  Todd S. Farha
Signature
 
President & CEO
Title
12/27/07
Date
Todd S. Farha
Name of Authorized Individual
 
       

ATTACHMENT III - Page 1

 
 

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Amendment
001                                                                                Agreement
Number XQ744

ATTACHMENT IV

AGREEMENT TO PROVIDE SERVICES TO INDIVIDUALS IDENTIFIED AS MEDICAID PENDING

……………….. No, contractor does not elect to provide services to individuals
designated as Medicaid Pending.
………………..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/accesssflorida
 

 
d.
Once the individual is determined financially eligible, the contractor must
notify CARES and provide a copy of the Notice of Case Action within two business
days of receipt.
 

 
e.
The contractors will be responsible for submitting 834 enrollment transactions
to the Medicaid fiscal agent one week prior to the regular submission date for
only the Medicaid pending individuals. The enrollment date will be retroactive
to the first of the month following the CARES eligibility determination, not to
exceed four (4) months.
 

 
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.     /s/  Todd S. Farha

Date:   12/27/07

Todd S. Farha
Name and Title of Authorized Individual (Print or type)

ATTACHMENT IV - Page 1

 
 

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