Exhibit 10.1
Contract No. FA913
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STANDARD CONTRACT
     THIS CONTRACT is entered into between the State of Florida, AGENCY FOR
HEALTH CARE ADMINISTRATION, hereinafter referred to as the “Agency”, whose
address is 2727 Mahan Drive, Tallahassee, Florida 32308, and AMERIGROUP FLORIDA,
INC. D/B/A AMERIGROUP COMMUNITY CARE, hereinafter referred to as the “Vendor” or
the “Health Plan”, whose address is 4425 Corporation Lane, Virginia Beach,
Virginia 23562, a Florida For Profit Corporation, to provide health care
services to eligible Medicaid recipients.
I. THE VENDOR HEREBY AGREES:

  A.   General Provisions

  1.   To provide services according to the terms and conditions set forth in
this Contract, Attachment I and Attachment II, and all other attachments named
herein which are attached hereto and incorporated by reference.     2.   To
perform as an independent vendor and not as an agent, representative, or
employee of the Agency.     3.   To recognize that the State of Florida, by
virtue of its sovereignty, is not required to pay any taxes on the services or
goods purchased under the terms of this Contract.

  B.   Federal Laws and Regulations

  1.   I. This Contract contains federal funds, therefore, the Vendor shall
comply with the provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other
applicable regulations.     2.   This Contract contains federal funding in
excess of $100,000, therefore, the Vendor must, upon Contract execution,
complete the Certification Regarding Lobbying form, Attachment IV. If a
Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may
be obtained from the Agency’s Contract Manager. All disclosure forms as required
by the Certification Regarding Lobbying form must be completed and returned to
the Agency’s Procurement Office.     3.   Pursuant to 45 CFR, Part 76, the
Vendor must, upon Contract execution, complete the Certification Regarding
Debarment, Suspension, ineligibility, and Voluntary Exclusion
Contracts/Subcontracts, Attachment V.

  C.   Audits and Records

  1.   To maintain books, records, and documents (including electronic storage
media) pertinent to performance under this Contract in accordance with generally
accepted accounting procedures and practices which sufficiently and properly
reflect all revenues and expenditures of funds provided by the Agency under this
Contract.

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  2.   To assure that these records shall be subject at all reasonable times to
inspection, review, or audit by state personnel and other personnel duly
authorized by the Agency, as well as by federal personnel.     3.   To maintain
and file with the Agency such progress, fiscal and inventory reports as
specified in Attachment II and other reports as the Agency may require within
the period of this Contract. In addition, access to relevant computer data and
applications which generated such reports should be made available upon request.
    4.   To ensure that all related party transactions are disclosed to the
Agency Contract Manager.     5.   To include these aforementioned audit and
record keeping requirements in all approved subcontracts and assignments.

  D.   Retention of Records

  1.   To retain all financial records, supporting documents, statistical
records, and any other documents (including electronic storage media) pertinent
to performance under this Contract for a period of five (5) years after
termination of this Contract, or if an audit has been initiated and audit
findings have not been resolved at the end of five (5) years, the records shall
be retained until resolution of the audit findings.     2.   Persons duly
authorized by the Agency and federal auditors, pursuant to 45 CFR, Part 74
and/or 45 CFR, Part 92, shall have full access to and the right to examine any
of said records and documents.     3.   The rights of access in this section
must not be limited to the required retention period but shall last as long as
the records are retained.

  E.   Monitoring

  1.   To provide reports as specified in Attachment II. These reports will be
used for monitoring progress or performance of the contractual services as
specified in Attachment I and Attachment II.

  2.   To permit persons duly authorized by the Agency to inspect any records,
papers, documents, facilities, goods and services of the Vendor which are
relevant to this Contract.

  F.   Indemnification         The Vendor shall save and hold harmless and
indemnify the State of Florida and the Agency against any and all liability,
claims, suits, judgments, damages or costs of whatsoever kind and nature
resulting from the use, service, operation or performance of work under the
terms of this Contract, resulting from any act, or failure to act, by the
Vendor, his subcontractor, or any of the employees, agents or representatives of
the Vendor or subcontractor.

  G.   Insurance

  1.   To the extent required by law, the Vendor will be self-insured against,
or will secure and maintain during the life of the Contract, Worker’s
Compensation Insurance for all his employees connected with the work of this
project and, in

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      case any work is subcontracted, the Vendor shall require the subcontractor
similarly to provide Worker’s Compensation Insurance for all of the latter’s
employees unless such employees engaged in work under this Contract are covered
by the Vendor’s self insurance program. Such self insurance or insurance
coverage shall comply with the Florida Worker’s Compensation law. In the event
hazardous work is being performed by the Vendor under this Contract and any
class of employees performing the hazardous work is not protected under Worker’s
Compensation statutes, the Vendor shall provide, and cause each subcontractor to
provide, adequate insurance satisfactory to the Agency, for the protection of
his employees not otherwise protected.     2.   The Vendor shall secure and
maintain Commercial General Liability insurance including bodily injury,
property damage, personal & advertising injury and products and completed
operations. This insurance will provide coverage for all claims that may arise
from the services and/or operations completed under this Contract, whether such
services and/or operations are by the Vendor or anyone directly, or indirectly
employed by him. Such insurance shall include a Hold Harmless Agreement in favor
of the State of Florida and also include the State of Florida as an Additional
Named Insured for the entire length of the Contract. The Vendor is responsible
for determining the minimum limits of liability necessary to provide reasonable
financial protections to the Vendor and the State of Florida under this
Contract.     3.   All insurance policies shall be with insurers licensed or
eligible to transact business in the State of Florida. The Vendor’s current
certificate of insurance shall contain a provision that the insurance will not
be canceled for any reason except after thirty (30) days written notice to the
Agency’s Contract Manager.

  H.   Assignments and Subcontracts         To neither assign the responsibility
of this Contract to another party nor subcontract for any of the work
contemplated under this Contract without prior written approval of the Agency.
No such approval by the Agency of any assignment or subcontract shall be deemed
in any event or in any manner to provide for the incurrence of any obligation of
the Agency in addition to the total dollar amount agreed upon in this Contract.
All such assignments or subcontracts shall be subject to the conditions of this
Contract and to any conditions of approval that the Agency shall deem necessary.
    I.   Return of Funds         To return to the Agency any overpayments due to
unearned funds or funds disallowed pursuant to the terms of this Contract that
were disbursed to the Vendor by the Agency. The Vendor shall return any
overpayment to the Agency within forty (40) calendar days after either discovery
by the Vendor, its independent auditor, or notification by the Agency, of the
overpayment.     J.   Purchasing

  1.   P.R.I.D.E.         It is expressly understood and agreed that any
articles which are the subject of, or required to carry out this Contract shall
be purchased from the corporation identified under Chapter 946, Florida
Statutes, if available, in the same manner and under the same procedures set
forth in Section 946.515(2), (4), Florida Statutes; and for purposes of this
Contract the person, firm or other business

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      entity carrying out the provisions of this Contract shall be deemed to be
substituted for this agency insofar as dealings with such corporation are
concerned.         The “Corporation identified” is PRISON REHABILITATIVE
INDUSTRIES AND DIVERSIFIED ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted
at:         P.R.I.D.E.
2720-G Blair Stone Road
Tallahassee, Florida 32301
(850) 487-3774
Toll Free: 1-800-643-8459
Website: www.pridefl.com

  2.   RESPECT of Florida         It is expressly understood and agreed that any
articles that are the subject of, or required to carry out, this Contract shall
be purchased from a nonprofit agency for the blind or for the severely
handicapped that is qualified pursuant to Chapter 413, Florida Statutes, in the
same manner and under the same procedures set forth in Section 413.036(1) and
(2), Florida Statutes; and for purposes of this Contract the person, firm, or
other business entity carrying out the provisions of this Contract shall be
deemed to be substituted for the state agency insofar as dealings with such
qualified nonprofit agency are concerned.         The “nonprofit agency”
identified is RESPECT of Florida which may be contacted at:

      RESPECT of Florida.
2475 Apalachee Parkway, Suite 205
Tallahassee, Florida 32301-4946
(850) 487-147]
Website: www.respectofflorida.org

  3.   Procurement of Products or Materials with Recycled Content         It is
expressly understood and agreed that any products which are required to carry
out this Contract shall be procured in accordance with the provisions of
Section 403.7065, Florida Statutes.

  K.   Civil Rights Requirements/Vendor Assurance

     The Vendor assures that it will comply with:

  1.   Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
seq., which prohibits discrimination on the basis of race, color, or national
origin.     2.   Section 504 of the Rehabilitation Act of 1973, as amended, 29
U.S.C. 794, which prohibits discrimination on the basis of handicap.     3.  
Title IX of the Education Amendments of 1972, as amended, 20 U.S.C. 1681 et
seq., which prohibits discrimination on the basis of sex.     4.   The Age
Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq., which prohibits
discrimination on the basis of age.

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  5.   Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
42 U.S.C. 9849, which prohibits discrimination on the basis of race, creed,
color, national origin, sex, handicap, political affiliation or beliefs.     6.
  The Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
discrimination on the basis of disability and requires reasonable accommodation
for persons with disabilities.     7.   All regulations, guidelines, and
standards as are now or may be lawfully adopted under the above statutes.

      The Vendor agrees that compliance with this assurance constitutes a
condition of continued receipt of or benefit from funds provided through this
Contract, and that it is binding upon the Vendor, its successors, transferees,
and assignees for the period during which services are provided. The Vendor
further assures that all contractors, subcontractors, subgrantees, or others
with whom it arranges to provide services or benefits to participants or
employees in connection with any of its programs and activities are not
discriminating against those participants or employees in violation of the above
statutes, regulations, guidelines, and standards.     L.   Discrimination      
  An entity or affiliate who has been placed on the discriminatory vendor list
may not submit a bid, proposal, or reply on a contract to provide any goods or
services to a public entity; may not submit a bid, proposal, or reply on a
contract with a public entity for the construction or repair of a public
building or public work; may not submit bids, proposals, or replies on leases of
real property to a public entity; may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity; and may not transact business with any public entity. The Florida
Department of Management Services is responsible for maintaining the
discriminatory vendor list and intends to post the list on its website.
Questions regarding the discriminatory vendor list may be directed to the
Florida Department of Management Services, Office of Supplier Diversity at
(850) 487-0915.     M.   Requirements of Section 287.058, Florida Statutes

  1.   To submit bills for fees or other compensation for services or expenses
in sufficient detail for a proper pre-audit and post-audit thereof.     2.  
Where applicable, to submit bills for any travel expenses in accordance with
Section 112.061, Florida Statutes.     3.   To provide units of deliverables,
including reports, findings, and drafts, in writing and/or in an electronic
format agreeable to both parties, as specified in Attachment II, to be received
and accepted by the Contract Manager prior to payment.     4.   To comply with
the criteria and final date by which such criteria must be met for completion of
this Contract as specified in Section III, Paragraph A. of this Contract.     5.
  To allow public access to all documents, papers, letters, or other material
made or received by the Vendor in conjunction with this Contract, unless the
records are exempt from Section 24(a) of Article I of the State Constitution and
Section 119.07(1), Florida Statutes. It is expressly understood that substantial

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      evidence of the Vendor’s refusal to comply with this provision shall
constitute a breach of Contract.

  N.   Sponsorship         As required by Section 286.25, Florida Statutes, if
the Vendor is a nongovernmental organization which sponsors a program financed
wholly or in part by state funds, including any funds obtained through this
Contract, it shall, in publicizing, advertising or describing the sponsorship of
the program, state:         “Sponsored by AMERIGROUP FLORIDA, INC. D/B/A
AMERIGROUP COMMUNITY CARE and the State of Florida, AGENCY FOR HEALTH CARE
ADMINISTRATION”.         If the sponsorship reference is in written material,
the words “State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION” shall appear
in the same size letters or type as the name of the organization.     O.   Use
Of Funds For Lobbying Prohibited         To comply with the provisions of
Section 216.347, Florida Statutes, which prohibits the expenditure of Contract
funds for the purpose of lobbying the Legislature, the judicial branch or a
state agency.     P.   Public Entity Crime         A person or affiliate who has
been placed on the convicted vendor list following a conviction for a public
entity crime may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public entity, and may
not transact business with any public entity in excess of the threshold amount
provided in Section 287.017, Florida Statutes, for category two, for a period of
36 months from the date of being placed on the convicted vendor list.     Q.  
Health Insurance Portability and Accountability Act         To comply with the
Department of Health and Human Services Privacy Regulations in the Code of
Federal Regulations, Title 45, Sections 160 and 164, regarding disclosure of
protected health information as specified in Attachment III.     R.  
Confidentiality of Information         Not to use or disclose any confidential
information, including social security numbers that may be supplied under this
Contract pursuant to law, and also including the identity or identifying
information concerning a Medicaid recipient or services under this Contract for
any purpose not in conformity with state and federal laws, except upon written
consent of the recipient, or his/her guardian.     S.   Employment         To
comply with Section 274A (e) of the Immigration and Nationality Act. The Agency
shall consider the employment by any contractor of unauthorized aliens a
violation of this Act. If the Vendor knowingly employs unauthorized aliens, such
violation shall be cause for unilateral cancellation of this Contract. The
Vendor

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      shall be responsible for including this provision in all subcontracts with
private organizations issued as a result of this Contract.     T.   Vendor
Performance         Penalties or sanctions for unsatisfactory performance under
this Contract are specified in Attachment II, if applicable.

II. THE AGENCY HEREBY AGREES:

  A.   Contract Amount         To pay for contracted services according to the
conditions of Attachment I and Attachment II in an amount not to exceed
***REDACTED***, subject to the availability of funds. The State of Florida’s
performance and obligation to pay under this Contract is contingent upon an
annual appropriation by the Legislature.     B.   Contract Payment        
Section 215.422, Florida Statutes, provides that agencies have 5 working days to
inspect and approve goods and services, unless bid specifications, Contract or
purchase order specifies otherwise. With the exception of payments to health
care providers for hospital, medical, or other health care services, if payment
is not available within forty (40) days, measured from the latter of the date
the invoice is received or the goods or services are received, inspected and
approved, a separate interest penalty set by the Comptroller pursuant to
Section 55.03, F. S., will be due and payable in addition to the invoice amount.
To obtain the applicable interest rate, please contact the Agency’s Fiscal
Section at (850) 488-5869, or utilize the Department of Financial Services
website at www.dfs.stateRus/interest.html. Payments to health care providers for
hospitals, medical or other health care services, shall be made not more than
35 days from the date of eligibility for payment is determined, and the daily
interest rate is .0003333%. Invoices returned to a vendor due to preparation
errors will result in a payment delay. Invoice payment requirements do not start
until a properly completed invoice is provided to the Agency. A Vendor
Ombudsman, whose duties include acting as an advocate for vendors who may be
experiencing problems in obtaining timely payment(s) from a State agency, may be
contacted at (850) 410-9724 or by calling the State Comptroller’s Hotline,
1-800-848-3792.

III. THE VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

  A.   Effective/End Date         This Contract shall begin upon execution by
both parties on September 1, 2009, (whichever is later) and end August 31, 2012,
inclusive.     B.   Termination

  1.   Termination at Will         This Contract may be terminated by the Agency
upon no less than thirty (30) calendar days written notice, without cause,
unless a lesser time is mutually agreed upon by both parties. Said notice shall
be delivered by certified mail, return receipt requested, or in person with
proof of delivery.

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  2.   Termination Due To Lack of Funds         In the event funds to finance
this Contract become unavailable, the Agency may terminate the Contract upon no
less than twenty-four (24) hours written notice to the Vendor. Said notice shall
be delivered by certified mail, return receipt requested, or in person with
proof of delivery. The Agency shall be the final authority as to the
availability of funds.     3.   Termination for Breach         Unless the
Vendor’s breach is waived by the Agency in writing, the Agency may, by written
notice to the Vendor, terminate this Contract upon no less than twenty-four
(24) hours written notice. Said notice shall be delivered by certified mail,
return receipt requested, or in person with proof of delivery. If applicable,
the Agency may employ the default provisions in Chapter 60A-1.006(4), Florida
Administrative Code.         Waiver of breach of any provisions of this Contract
shall not be deemed to be a waiver of any other breach and shall not be
construed to be a modification of the terms of this Contract. The provisions
herein do not limit the Agency’s right to remedies at law or to damages.

C.   Contract Managers

  1.   The Agency’s Contract Manager’s name, address and telephone number for
this Contract is as follows:         Felicia Wilhelmy
Agency for Health Care
Administration 2727 Mahan Drive,
MS# 50
Tallahassee, FL 32308
(850) 487-2355     2.   The Vendor’s Contract Manager’s name, address and
telephone number for this Contract is as follows:         Chelise Bowery        
AMERIGROUP Florida, Inc. d/b/a
AMERIGROUP CommunityCare
4425 Corporation Lane
Virginia Beach, VA 23562
(757) 473-2737     3.   All matters shall be directed to the Contract Managers
for appropriate action or disposition. A change in Contract Manager by either
party shall be reduced to writing through an amendment to this Contract by the
Agency.

  D.   Renegotiation or Modification

  1.   Modifications of provisions of this Contract shall only be valid when
they have been reduced to writing and duly signed during the term of the
Contract. The parties agree to renegotiate this Contract if federal and/or state
revisions of any applicable laws, or regulations make changes in this Contract
necessary.

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  2.   The rate of payment and the total dollar amount may be adjusted
retroactively to reflect price level increases and changes in the rate of
payment when these have been established through the appropriations process and
subsequently identified in the Agency’s operating budget.

  E.   Name, Mailing and Street Address of Payee

  1.   The name (Vendor name as shown on Page 1 of this Contract) and mailing
address of the official payee to whom the payment shall be made:        
AMERIGROUP Florida, Inc. d/b/a
AMERIGROUP Community
Care 4425 Corporation Lane
Virginia Beach, VA 23562     2.   The name of the contact person and street
address where financial and administrative records are maintained:        
Margaret Mary Roomsberg
AMERIGROUP Florida, Inc. d/b/a
AMERIGROUP Community
Care 4425 Corporation Lane
Virginia Beach, VA 23562

  F.   All Terms and Conditions         This Contract and its attachments as
referenced herein contain all the terms and conditions agreed upon by the
parties.

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     IN WITNESS THEREOF, the parties hereto have caused this two hundred and
ninety (290) page Contract, which includes any referenced attachments, to be
executed by their undersigned officials as duly authorized. This Contract is not
valid until signed and dated by both parties.

     
AMERIGROUP FLORIDA, INC. D/B/A
  STATE OF FLORIDA, AGENCY FOR
AMERIGROUP COMMUNITY CARE
  HEALTH CARE ADMINISTRATION

                 
SIGNED
      SIGNED        
BY:
  /s/ William L. McHugh
 
  BY:   /s/ Holly Benson
 
   
NAME:
  William L. McHugh   NAME:   Holly Benson    
TITLE:
  CEO   TITLE:   Secretary    
DATE:
  8/31/09   DATE:   9/1/09    

FEDERAL ID NUMBER (or SS Number for an individual): 65-0318864
VENDOR FISCAL YEAR ENDING DATE: 12/31
     List of Attachments/Exhibits included as part of this Contract:

             
 
  Attachment   I   Scope of Services (11 Pages)
 
  Exhibits   1-2   Attachment I Exhibits (10 Pages)
 
  Attachment   II   Core Contract Provisions (186 Pages)
 
  Exhibits   1-16   Attachment II Exhibits (68 Pages)
 
  Attachment   III   Business Associate Agreement (3 Pages)
 
  Attachment   IV   Lobbying Certification (1 Page)
 
  Attachment   V   Debarment Certification (1 Page)

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

ATTACHMENT I
SCOPE OF SERVICES
CAPITATED HEALTH PLANS
A. Plan Type
The Vendor (Health Plan) is approved to provide contracted services as the
following health plan type as denoted by “X”:
TABLE 1

                                  Specialty Health   Fee- for-Service      
Specialty Health   Plan for Maintenance   (FFS) Provider       Plan for Children
  Recipients Organization   Service Network       with Chronic   Living with
(HMO)   (PSN)   Capitated PSN   Conditions   HIV/AIDS X                

B. Population(s) to be Served
     1. Population Groups
The Health Plan shall deliver covered services as defined in Attachment II to
the specific population(s) approved below with “X” and as listed in Attachment
II, Section III, Eligibility and Enrollment:
TABLE 2

                                          Non-   Non-               Reform    
Non-   Non-   Reform   Reform           Reform   Children with   Reform Reform  
Reform   Dually   Frail/   Reform   Reform   Dually   Chronic   HIV/ TANF   SSI
  Eligible   Elderly*   TANF   SSI   Eligible   Conditions**   AIDS*** X   X   X
      X   X   X        

  •   Enrollees, who have been determined to be at risk for nursing home
institutionalization by the Comprehensive Assessment and Review for Long Term
Care (CARES) Unit, and are enrolled in an Agency-authorized plan which
participates in the Frail/Elderly Program. **     •   Enrolled in an
Agency-authorized specialty plan for children with chronic conditions and
screened by the Florida Department of Health as clinically eligible for
Children’s Medical Services using an Agency-approved screening tool as specified
in Attachment II, Section III, Eligibility and Enrollment, Exhibit III.     •  
Enrolled in an Agency-authorized specialty plan for recipients with HIV/AIDS.

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

     2. Age Restrictions
The Health Plan’s enrollment is restricted as indicated by “X” below in regard
to the age range for the population groups referenced in Item 1 above that the
Health Plan is authorized by the Agency to serve:
TABLE 3

              Non-Reform   Reform Age Restriction   Restricted   Restricted None
  X   X Only ages 0 up to 21         Only ages 21 and over        

     3. Enrollment Levels and Authorized Counties of Operation
The Agency assigns the Health Plan an authorized maximum enrollment level for
each operational county indicated in Exhibit 1 of this attachment for Reform and
non-Reform populations if those populations are covered in this Contract as
specified in Section B. above. The authorized maximum enrollment level listed is
effective on September 1, 2009, or upon Contract execution, whichever is later.

  a.   The Agency must approve in writing any increase or decrease in the Health
Plan’s maximum enrollment level for each operational county to be served.     b.
  Such approval shall be based upon the Health Plan’s satisfactory performance
of terms of the Contract and upon the Agency’s approval of the Health Plan’s
administrative and service resources, as specified in this Contract, in support
of each enrollment level.

C. Service Level Required
The Health Plan shall deliver Medicaid covered services at the service level(s)
listed below in Table 4 with “X.” In addition, if the Health Plan is listed as
approved to provide both Reform comprehensive component only and Reform
comprehensive and catastrophic components, then the Health Plan is approved to
provide services at the “Reform comprehensive component only” service level only
for the county populations listed below:
TABLE 4

          Non-Reform   Reform Comprehensive   Reform Comprehensive and Medicaid
State Plan   Component Only   Catastrophic Components X       X

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

D. Service(s) to be Provided
     1. Covered Medicaid Services

  a.   The Health Plan shall ensure the provision of the Medicaid services
listed below in Table 5 with “X” and as specified in applicable exhibits to this
attachment and as defined in Attachment II, Section I, Definitions; Section V,
Covered Services; and Section VI, Behavioral Health Care, and as specified in
applicable exhibits to Attachment I.     b.   For non-Reform populations,
Medicaid State Plan dental services and transportation services (notated in
Table 5 with an asterisk and in bold-type font) are considered optional
services, and the Health Plan may request that the Agency allow the Health Plan
to provide these services under this Contract. The denotation of “X” in Table 5
below indicates the Agency has approved the Health Plan to cover these services.
See Attachment II, Exhibit 5, for more information regarding the provision of
these optional benefits. See Item 3., Other Service Requirements, of this
subsection for more information regarding optional services.

  (1)   For optional dental services for the non-Reform population, the Health
Plan is further limited as follows:

  (a)   Dental services include the arrangement and provision of Medicaid State
Plan dental services to the adult and child populations. The Health Plan shall
comply with the limitations and exclusions in the Medicaid Dental Services
Coverage and Limitations & Reimbursement Handbooks.     (b)   In no instance may
the limitations or exclusions imposed by the Health Plan be more stringent than
those specified in the Medicaid Dental Services Coverage and Limitations &
Reimbursement Handbooks.

  (2)   For optional transportation for the non-Reform population, the Health
Plan is further limited as follows:

  (a)   Only certain HMOs are authorized to provide transportation services to
non- Reform populations. The only county for which optional transportation
services may be authorized is Miami Dade County.     (b)   Transportation
services include the arrangement and provision of an appropriate mode of
transportation, including emergency transportation services, for enrollees to
receive medically necessary health care services. The Health Plan shall comply
with the limitations and exclusions in the Medicaid Transportation Coverage and
Limitations Handbook. In no instance may the limitations or exclusions imposed
by the Health Plan be more stringent than those specified in the Medicaid
Transportation Coverage and Limitations Handbook.     (c)   If an “X” is listed
in the non-Reform column, the Agency has authorized the Health Plan to provide
such transportation services in Miami Dade County. See Item 3., Other Service
Requirements, of this subsection for more information regarding optional
services.

AHCA Contract No. FA913, Attachment I, Page 3 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

  (3)   For the optional frail/elderly program for the non-Reform population,
the Health Plan is further limited as follows:

  (a)   Only certain HMOs are authorized to provide frail/elderly services to
non- Reform populations. The only county for which optional frail/elderly
services may be authorized is Miami Dade County.     (b)   Frail/elderly
services include the provision, coordination, and management of services to
prevent or delay placement in a nursing home. A variety of mandatory and
supportive services shall be available to enrollees who meet the eligibility
requirements as set out in Attachment II, Exhibit III, Non-Reform HMO
Frail/Elderly Program.     (c)   If an “X” is listed in the non-Reform column,
the Agency has authorized the Health Plan to provide such frail/elderly services
in Miami Dade County.

TABLE 5

              Non-         Reform   Reform Health Plan Covered Services Chart  
Covered   Covered
Advanced Registered Nurse Practitioner Services
  X   X
Ambulatory Surgical Center Services
  X   X
Birth Center Services
  X   X
Child Health Check-Up Services
  X   X
Chiropractic Services
  X   X
Community Behavioral Health Services
  X   X
County Health Department Services
  X   X
Dental Services*
      X
Durable Medical Equipment and Medical Supplies
  X   X
Dialysis Services
  X   X
Emergency Room Services
  X   X
Family Planning Services
  X   X
Federally Qualified Health Center Services
  X   X
Frail/Elderly Program Services*
       
Freestanding Dialysis Centers
  X   X
Hearing Services
  X   X
Home Health Care Services
  X   X
Hospital Services — Inpatient
  X   X
Hospital Services — Outpatient
  X   X
Immunizations
  X   X
Independent Laboratory Services
  X   X
Licensed Midwife Services
  X   X

AHCA Contract No. FA913, Attachment I, Page 4 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

TABLE 5

              Non-         Reform   Reform Health Plan Covered Services Chart  
Covered   Covered
Optometric Services
  X   X
Physician Services
  X   X
Physician Assistant Services
  X   X
Podiatry Services
  X   X
Portable X-ray Services
  X   X
Prescribed Drugs
  X   X
Prescribed Pediairic Extended Care Services
       
Primary Care Case Management Services
  X   X
Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions
ONLY)
       
Rural Health Clinic Services
  X   X
Targeted Case Management
  X   X
Therapy Services: Occupational
  X   X
Therapy Services: Physical
  X   X
Therapy Services: Respiratory
  X   X
Therapy Services: Speech
  X   X
Transplant Services
  X   X
Transportation Services*
      X
Vision Services
  X   X

     2. Approved Expanded Benefits

  a.   The Health Plan shall provide the following expanded benefits to
non-Reform enrollees as specified below in accordance with Contract provisions
including Attachment I, Section B., Population(s) to be Served, and Attachment
II, Section V, Covered Services, of this Contract.

TABLE 6
Expanded Services
$10 per household, per month OTC drugs and/or health supplies
Enhanced hearing aid benefit — Upgrade from standard, medically necessary,
behind- the-ear hearing aid to digital canal hearing aid up to $500.
Respite Care Annual maximum of not more than an initial home-health visit by RN
@ $65.00 and eight (8) follow-up visits by an aide at $23.00 per visit.
Follow-up visits are four (4) hours in length. Maximum of sixteen (16) hours in
a given month and thirty-two (32) hours per year.

  b.   The Health Plan shall provide the expanded benefits listed in Section G,
Benefit Grid/Customized Benefit Package — Reform Capitated Plans Only, below as
part of the Health Plan’s customized benefit package to Reform enrollees in
accordance

AHCA Contract No. FA913, Attachment I, Page 5 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

      with Contract provisions including Attachment I, Section B., Population(s)
to be Served, and Attachment II, Section V, Covered Services, of this Contract.

     3. Other Service Requirements

  a.   The Health Plan shall meet the minimum service requirements as outlined
and defined in Attachments I and II of this Contract.     b.   Health plans
serving Reform populations agree to provide the services listed in Section G. of
this attachment in accordance with Contract provisions.     c.   The Health Plan
shall submit for approval any changes to the optional services listed in Table 5
and expanded services listed in Table 6 and, for health plans serving Reform
populations, those covered services listed in Section G. below, to the Agency’s
Bureau of Health Systems Development (HSD) by June 15 of each contract year.
These services may be changed on a contract year basis and only if approved by
the Agency in writing.     d.   The Health Plan shall use the following service
provisions for prescribed drug services as allowed in Attachment II, Section V,
Covered Services, and as listed by “X” below.

TABLE 7

      Pharmacy Authorizations   Authorized
The Health Plan shall use a pharmacy benefits manager as specified in Attachment
II, Section V.
  X

  e.   The Health Plan has agreed to and is authorized by the Agency to use the
Medicaid redetermination date data provided in its enrollment files as specified
in Attachment II, Section IV, Enrollee Services, Community Outreach and
Marketing only if listed by “X” below.

TABLE 8

      Medicaid redetermination date data   Authorized
The Health Plan shall use Medicaid redetermination date data as specified in
Attachment II, Section IV, Enrollee Services, Community Outreach and Marketing.
  X

E. Method of Payment
     1. General
This is a fixed price (unit cost) Contract. The Agency will manage this Contract
for the delivery of services to enrollees (service units). The Health Plan will
be paid through the Agency’s Medicaid fiscal agent, in accordance with the terms
of this Contract, a total dollar amount not to exceed ***REDACTED*** subject to
the availability of funds in accordance with Attachment II, Section XIII, Method
of Payment.
AHCA Contract No. FA913, Attachment I, Page 6 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

  a.   The Health Plan shall be paid capitation payments for each Agency service
area, based upon the tables in Exhibit 2 of this attachment.     b.   All
payments made to the Health Plan shall be in accordance with this section and
Attachment II, Section XIII, Method of Payment.

     2. Health Plan Capitation Rates and Reform Kick Payments

  a.   The Health Plan provider numbers associated with the capitation rates
indicated in the Exhibit 2—NR and 2-R tables are provided in Exhibit 1, Maximum
Enrollment Levels, of this attachment.     b.   For health plans serving
non-Reform populations, Attachment I, Exhibit 2-NR table(s) provides the
capitation rates respective to the authorized areas of operation. The capitation
rate payment shall be in accordance with Attachment II, Section XIII, Method of
Payment. These rates are titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS
APPROVED BY CMS.”     c.   For health plans serving Reform populations,
Exhibit 2-R table(s) of this attachment provides the capitation rates and Reform
kick payments respective to the authorized areas of operation. The capitation
rate payment shall be in accordance with Attachment II, Section XIII, Method of
Payment. These rates are titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS
APPROVED BY CMS.”

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AHCA Contract No. FA913, Attachment I, Page 7 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

F. Applicable Exhibits
Any additions or variations from Contract requirements specified in Attachments
I and II are provided in the exhibits to those attachments. Exhibits required
are noted by “X” below depending on health plan type and population served.
There are no additional requirements or changes to the Health Plan’s Contract in
those exhibits marked N/A.
Table 9 — Applicable Exhibits

                                                  Specially   Fee-              
Speciality   HMO             Plan for   for-       Fee-       Plan for   Non-  
          Recipients   Service   Capitated   for-       Children with   Reform  
      HMO   Living with   PSN   PSN   Service   Capitated   Chronic   With
Frail/ Attachment/   HMO   Non-   HIV/AIDS   Non-   Non-   PSN   PSN  
Conditions   Elderly Exhibit*   Reform   Reform   Reform   Reform   Reform  
Reform   Reform   Reform   Program
Att. I. Exh. 1
  X   X   X       X       X       X
Att. I. Exh. 1-FFS
              X       X       X    
Att. I. Exh. 2-NR
      X           X               X
Att. I. Exh. 2-R
  X       X               X        
Att. I. Exh. 2-FFS-NR
              X                    
Att. I. Exh. 2-FFS-R
                      X       X    
Att. II. Exh. 1
          X                        
Att. II. Exh. 2
  X   X   X   X   X   X   X   X   X
Att. 2. Exh. 3
  X       X   X       X   X   X   X
Att. II. Exh. 4
  X       X           X   X   X   X
Att. II. Exh. 5
  X   X   X   X   X   X   X   X   X
Att. II. Exh. 6 HMO&R
  X   X   X           X   X   X   X
Att. II. Exh. 6 PSN-NR
              X   X                
Att. II. Exh. 7
  X       X   X       X   X   X    
Att. II. Exh. 8
  X   X   X   X   X   X   X   X   X
Att. II. Exh. 9
                                   
Att. II. Exh. 10
  X   X   X   X   X   X   X   X   X
Att. II. Exh. 11
  X   X   X   X   X   X   X   X   X
Att. II. Exh. 12
                                   
Att. II. Exh. 13-CAP-R
  X       X           X   X   X    
Att. II. Exh. 13-CAP-NR
      X           X               X
Att. II. Exh. 13-FFS
              X       X            
Att. II. Exh. 14
                                   
Att. II. Exh. 15
  X   X   X   X   X   X   X   X   X
Att. II. Exh. 16
  X   X   X   X   X   X   X   X   X

 

*   Plans offering certain optional coverage also will have additional language
in the exhibits as follows: Exhibits 3, 4, 5, 8 and 13 — Frail/Elderly Program;
Exhibit 5 — dental and transportation. Safety net hospital-based PSNs will have
additional language in the exhibits as follows: — Exhibit 13 — Method of
Payment.

AHCA Contract No. FA913, Attachment I, Page 8 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

G.   Benefit Grid/Customized Benefit Package — Reform Capitated Plans Only      
The benefit grids below describe the Reform Health Plan’s Customized Benefit
Packages (CBP). The CBP comprises all covered services including expanded
services as specified in Attachment I, Scope of Services, Attachment II,
Section V, Covered Services, and Section VI, Behavioral Health Care. The CBP has
been determined to meet actuarial equivalency and sufficiency standards for the
population or populations covered by the CBP. The Health Plan shall provide
these services to all enrollees in accordance with Contract provisions.

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AHCA Contract No. FA913, Attachment I, Page 9 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

Benefit Grid
1. Area 10 Broward- Children and Families
*****REDACTED*****
Benefit Grid
     2. Area 10 Broward- Aged and Disabled
***REDACTED***
AHCA Contract No. FA913, Attachment I, Page 10 of 11

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

ATTACHMENT I
EXHIBIT 1
MAXIMUM ENROLLMENT LEVELS
Maximum enrollment levels and Health Plan provider numbers associated with the
counties and populations served. Exhibit 2-NR provides the capitation rate
tables respective to the areas of operation listed below.
A. Non-Reform
See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 03 Counties: HERNANDO, LAKE

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
HERNANDO
    8,000       015005350  
LAKE
    8,000       015005341  

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 04 Counties: VOLUSIA

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
VOLUSIA
    8,000       015005342  

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 05 Counties: PASCO, PINELLAS

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
PASCO
    15,000       015005304  
PINELLAS
    25,000       015005305  

AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 1 of 10

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 05 Counties: HILLSBOROUGH, MANATEE, POLK

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
HILLSBOROUGH
    40,000       015005300  
MANATEE
    8,000       015005318  
POLK
    30,000       015005307  

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 07 Counties: BREVARD, ORANGE, OSCEOLA, SEMINOLE

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
BREVARD
    8,000       015005336  
ORANGE
    30,000       015005308  
OSCEOLA
    8,500       015005314  
SEMINOLE
    8,000       015005313  

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 08 Counties: LEE, SARASOTA

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
LEE
    18,000       015005302  
SARASOTA
    8,000       015005306  

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates

    Area 10 Counties: BROWARD

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
BROWARD
    14,000       015005311  

AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 2 of 10

 

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AMERIGROUP Florida, Inc.
  Medicaid Non-Reform and Reform
d/b/a AMERIGROUP Community Care
  HMO Contract

See Exhibit 2-NR Table 2, General Capitation Rates plus Mental Health Rates
     Area 11 Counties: DADE

                              Effective Date: 09/01/2009   County   Enrollment
Level   Provider Number
DADE
    25,000       015005312  

B. Reform
See Exhibit 2-R Table 1
     Area 10 Counties: Broward
***REDACTED***
AHCA Contract No. FA913, Attachment I, Exhibit 1, Page 3 of 10

 

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ATTACHMENT I
EXHIBIT 2-NR
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”
MEDICAID Non-Reform HMO CAPITATION RATES
By Area, Age and Eligibility Category
September 1, 2009 — August 31, 2010 HMO RATES
TABLE 1 ***AREA 10 REDACTED***
     General Rates:

                                                                               
                                                                               
                              TANF                                              
            SSI-N                   SSI-B   SSI-AB Area   BTHMO+2MO   JMO-11MO  
AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)   BTHMO + 2MO  
JMO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)      
    AGE (65+)   AGE (65+)                                     Female   Male  
Female   Male                                                                  
                     
01
    1,130.45       171.80       102.22       61.92       136.81       72.25    
  266.35       158.36       341.82       12,166.96       1,661.31       450.32  
    195.11       211.04       684.60       713.62       345.23       81.09      
75.25  
02
    1,130.45       171.80       102.22       61.32       136.81       72.25    
  266.35       158.36       341.82       12,166.98       1,661.31       450.32  
  195.11     211.04       684.60       713.62       345.23       81.01      
75.25  
03
    1,204.98       184.85       110.04       67.83       147.39       78.95    
  288.08       172.19       374.81       12,984.80       1,768.35       485.21  
    215.10       232.17       751.31       786.48       219.92       78.09      
72.84  
04
    1,050.61       162.46       96.93       60.59       129.54       70.25      
254.54       152.86       335.21       12,420.29       1,710.68       467.26    
  210.34       226.43       732.37       768.86       158.79       76.07      
71.40  
05
    1,104.66       182.33       106.66       67.27       145.40       78.31    
  284.72       170.69       372.41       14,030.18       1,934.34       624.96  
    233.58       251.40       814.40       853.04       267.97       63.54      
69.91  
06
    1,085.08       165.73       99.12       62.65       132.43       72.63      
260.83       157.83       347.13       12,740.87       1,765.91       479.44    
  216.29       232.64       751.93       789.61       332.29       65.62      
61.55  
07
    1,094.60       170.03       101.66       64.09       135.85       74.27    
  267.33       161.18       354.76       13.686.78       1,905.44       518.10  
    236.50       253.97       819.80       862.97       278.88       58.32      
64.02  
08
    1,037.09       161.01       96.20       60.62       128.67       70.25      
253.12       162.46       335.67       12,799.17       1,774.58       462.11    
  218.12       234.44       756.47       794.55       315.60       66.83      
62.63  
09
    1.052.10       161.97       96.51       59.97       129.16       69.61      
253.28       151.74       331.35       12,607.35       1.749.I9       475.00    
  215.23       231.33       746.37       783.86       278.68       73.65      
68.76  
10
                                                                               
                                                                       
11
    1,387.45       213.12       126.92       78.43       169.76       91.10    
  332.48       199.01       433.39       16,510.81       2,276.81       618.22  
    275.31       256.69       960.17       1,005.22       380.61       117.49  
    109.41  
6B*
    1,064.96       165.71       99.11       62.64       132.41       72.62      
260.80       157.36       347.08       12,740.29       1,765.81       479.42    
  216.27       232.63       751.89       789.57       332.29       65.62      
61.55  

TABLE 2 ***AREA 10 REDACTED***
General + Mental Health Rates:

                                                                               
                                                                               
                              TANF                                              
            SSI-N                   SSI-B   SSI-AB Area   BTHMO+2MO   3MO-11MO  
AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)   BTHMO+2MO  
3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE(55+)        
  AGE (65-)   AGE (65+)                                     Female   Male  
Female   Male                                                                  
                     
01
    1,130.48       171.83       104.08       74.27       148.20       83.64    
  270.41       162.42       345.39       12,167.05       1,661.36       458.53  
    246.96       257.82       765.70       745.22       353.34       93.65      
87.79  
02
    1,130.47       171.82       103.70       73.65       148.12       83.56    
  271.15       163.16       346.04       12,167.09       1,661.42       462.52  
    271.63       261.47       815.61       764.75       353.34       93.65      
78.79  
03
    1,205.00       184.87       111.59       80.12       159.24       90.80    
  293.11       177.22       379.23       12,964.86       1,788.41       491.02  
    256.66       270.33       822.40       814.16       228.03       90.63      
85.38  
04
    1,050.63       162.48       98.39       72.22       140.75       81.46      
259.29       157.61       339.39       12,420.35       1,720.74       474.10    
  253.25       265.92       805.95       797.55       166.90       88.61      
83.94  
05
    1,184.68       182.35       110.60       82.70       160.27       93.18    
  291.03       175.90       377.96       14,030.25       1,834.41       532.50  
    361.37       295.39       896.35       884.97       266.08       76.08      
72.45  
06
    1,065.10       165.75       100.09       69.11       138.39       78.59    
  262.96       159.61       349.00       12,740.90       1,765.94       483.54  
    242.20       256.02       792.46       805.41       340.40       78.16      
74.09  
07
    1,094.63       170.06       104.05       83.04       154.12       92.54    
  275.08       158.93       361.57       13,685.85       1,905.51       525.43  
    282.49       296.30       898.66       893.70       286.99       80.86      
76.56  
08
    1,037.10       161.02       97.10       68.36       136.14       77.72      
256.29       156.63       336.45       12,799.21       1,774.62       486.19    
  243.72       258.00       800.37       811.65       323.71       79.37      
75.17  
09
    1,062.12       161.99       98.40       74.97       143.62       84.07      
259.41       157.87       336.74       12,607.42       1,749.26       482.36    
  261.41       273.83       825.55       814.71       288.79       86.19      
81.29  
10
                                                                               
                                                                       
11
    1,387.47       213.14       128.49       90.88       181.77       103.11    
  337.67       204.10       437.87       16,510.92       2,276.92       630.84  
    354.52       369.60       1,096.00       1,058.15       386.62       130.03
      121.95  
6B*
    1,064.97       165.72       99.91       68.99       138.53       78.74      
283.40       159.96       349.36       12,740.32       1,765.84       483.29    
  249.54       254.97       793.50       805.79       340.40       78.16      
74.09  

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 4 of 10

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

 

     
ATTACHMENT I
EXHIBIT 2-NR
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”
MEDICAID Non-Reform HMO CAPITATION RATES
By Area, Age and Eligibility Category
September 1, 2009 — August 31, 2010 HMO RATES
TABLE 3***AREA 10 REDACTED***
General + MH + Dental Rates:

                                                                               
                                                                             
TANF                                                                          
SSI-N                                           SSI-B   SSI-AB     Area  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)      
    AGE (55+)   BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)  
AGE (21-54)   AGE (55+)           AGE (65-)   AGE (65+)                        
            Female   Male   Female   Male                                      
                                                 
01
    1,130.49       171.84       105.46       76.79       150.71       85.83    
  271.81       163.93       348.70       12,167.05       1,661.38       459.71  
    248.69       259.34       767.10       747.24       353.34       94.73      
88.76  
02
    1,130.48       171.83       105.08       76.17       150.63       85.75    
  272.65       164.67       349.35       12,167.09       1,661.42       463.70  
    273.37       282.99       817.21       766.77       350.34       94.73      
88.76  
03
    1,205.01       184.89       114.60       85.61       164.70       95.58    
  295.57       179.97       385.26       12,984.86       1,788.42       494.55  
    260.76       273.98       824.81       817.66       229.28       92.53      
87.02  
04
    1,050.64       162.49       100.16       75.46       143.97       84.27    
  261.36       169.84       344.27       12,420.35       1,720.74       475.76  
    255.71       268.06       808.10       800.67       168.79       90.28      
85.30  
05
    1,184.69       182.37       114.20       89.29       166.83       98.92    
  294.84       181.00       386.95       14,000.26       1,934.42       536.45  
    287.10       300.37       899.47       889.49       266.16       79.19      
75.00  
06
    1,065.11       165.77       102.78       74.04       143.29       82.87    
  265.06       161.76       353.94       12,740.90       1,765.95       486.45  
    246.51       259.76       795.04       809.16       343.25       80.33      
75.87  
07
    1,094.64       170.08       106.68       87.86       158.91       96.73    
  276.71       170.68       366.40       13,685.85       1,905.52       528.40  
    286.88       300.12       900.23       895.97       287.74       82.30      
77.75  
08
    1,037.12       161.05       101.81       76.83       144.58       85.09    
  258.91       158.45       344.63       12,799.22       1,774.63       489.94  
    249.27       262.83       802.91       815.32       326.18       81.28      
76.74  
09
    1,062.13       162.01       101.61       80.84       149.46       89.17    
  260.82       159.38       340.05       12,607.42       1,749.27       485.15  
    265.54       277.43       827.10       816.96       292.18       87.67      
82.50  
10
                                                                               
                                                                       
11
    1,387.53       213.20       134.76       98.83       189.24       110.58    
  338.63       250.24       440.36       16,511.00       2,277.00       637.97  
    361.66       375.08       1,097.92       1,060.93       391.98       132.45
      123.94  
6B*
    1,064.98       166.74       102.60       73.92       143.43       83.02    
  263.40       159.96       349.36       12,740.32       1,765.85       486.20  
    244.85       258.71       793.50       806.79       343.25       80.33      
75.87  

TABLE 4***AREA 10 REDACTED***
General + MH + Transportation Rates:

                                                                               
                                                                               
                              TANF                                              
            SSI-N                   SSI-B   SSI-AB     Area   BTHMO+2MO  
3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)     AGE (21-54)   AGE (55+)  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE
(55+)           AGE (65-)   AGE (65+)                                     Female
  Male   Female   Male                                                          
                             
01
    1,135.62       173.12       104.94       74.77       150.36       85.08    
  273.90       165.08       349.30       12,218.57       1,694.83       463.16  
    249.41       263.76       785.58       762.27       361.36       106.87    
  97.94  
02
    1,135.61       173.11       104.56       74.15       150.28       85.00    
  274.64       165.82       349.95       12,218.61       1,694.87       467.15  
    274.09       287.41       835.69       781.80       361.36       106.87    
  97.94  
03
    1,211.17       186.41       112.62       80.72       161.83       92.53    
  297.30       180.41       383.92       13,050.22       1,830.85       497.71  
    259.69       277.86       847.61       835.81       236.63       109.68    
  99.91  
04
    1,054.64       163.49       99.06       72.61       142.43       82.58      
262.02       169.69       342.45       12,468.39       1,751.96       478.42    
  255.66       271.46       824.49       813.45       173.13       103.96      
95.64  
05
    1,188.16       183.22       111.18       83.04       161.73       94.16    
  293.39       178.70       380.61       14,071.98       1,961.61       536.34  
    283.37       300.20       912.65       898.78       272.12       89.99      
83.06  
06
    1,068.60       166.62       100.67       69.45       139.86       79.57    
  265.34       161.32       361.66       12,781.60       1,792.38       487.20  
    244.15       260.70       808.15       818.87       346.35       89.27      
82.67  
07
    1,098.45       171.02       104.67       83.42       165.72       93.60    
  277.67       170.90       364.47       13,731.89       1,935.41       629.58  
    284.70       301.60       916.43       908.94       293.06       92.62      
85.52  
08
    1,042.08       162.27       98.01       68.84       138.22       79.11      
259.67       158.21       342.24       12,849.85       1,807.50       490.75    
  246.16       263.83       819.90       828.40       329.66       93.23      
85.73  
09
    1,057.08       163.23       99.23       76.46       145.70       85.46      
262.78       160.44       340.51       12,659.96       1,783.38       487.10    
  263.94       279.88       845.83       832.09       292.82       101.59      
83.03  
10
                                                                               
                                                                       
11
    1,390.09       213.87       128.97       91.16       183.00       103.93    
  339.56       205.61       440.10       16,547.82       2,300.88       634.16  
    358.30       373.86       1,110.23       1,070.36       394.16       141.29
      130.63  
6B*
    1,068.47       166.59       100.49       69.33       140.00       79.72    
  265.78       161.77       362.02       12,781.02       1,792.28       486.95  
    242.49       259.56       809.19       819.25       346.36       89.27      
82.57  

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 5 of 10

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

 

     
ATTACHMENT I
EXHIBIT 2-NR
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”
MEDICAID Non-Reform HMO CAPITATION RATES
By Area, Age and Eligibility Category
September 1, 2009 — August 31, 2010 HMO RATES
TABLE 5 ***AREA 10 REDACTED***
General + Transportation Rates:

                                                                               
                                                                             
TANF                                                                          
SSI-N                                           SSI-B   SSI-AB Area   BTHMO+2MO
  3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE
(55+)           AGE (65-)   AGE (65+)                                     Female
  Male   Female   Male                                                          
                             
01
    1,135.59       173.09       103.08       62.42       138.97       73.69    
  269.84       161.02       345.73       12,218.50       1,694.76       454.95  
    197.57       216.98       704.48       730.67       353.25       94.33      
85.40  
02
    1,135.59       173.09       103.08       62.42       138.97       73.69    
  269.84       161.02       345.73       12,218.50       1,694.76       454.95  
    197.57       216.98       704.48       730.67       353.25       94.33      
85.40  
03
    1,211.16       186.39       111.07       68.43       149.98       80.68    
  292.27       175.38       379.50       13,050.16       1,830.79       491.10  
    218.23       239.69       776.52       808.11       228.42       97.14      
87.37  
04
    1,054.62       163.47       97.60       60.98       131.22       71.37      
267.27       154.94       338.27       12,468.33       1,751.89       471.58    
  212.66       231.97       760.91       784.78       166.02       91.42      
83.10  
05
    1,188.14       183.20       109.24       67.61       146.86       79.28    
  287.08       172.39       375.06       14,071.91       1,951.44       528.72  
    235.58       256.21       830.50       866.85       264.01       77.45      
70.52  
06
    1,068.58       166.50       99.70       62.99       133.80       73.61      
263.21       159.19       349.79       12,781.57       1,792.35       483.10    
  218.24       237.32       767.62       803.07       338.24       75.73      
70.03  
07
    1,098.42       170.99       102.30       64.47       137.45       75.33    
  269.92       163.16       357.66       13,731.82       1,935.34       522.25  
    238.71       259.27       837.57       878.21       284.95       80.08      
72.98  
08
    1,042.07       162.26       97.03       61.10       130.75       71.64      
236.50       155.04       339.46       12,849.81       1,807.45       486.67    
  220.55       240.27       776.00       811.30       321.56       80.69      
73.19  
09
    1,057.06       163.21       97.34       60.46       131.24       71.00      
256.65       154.31       336.12       12,659.89       1,783.31       479.74    
  217.76       237.38       766.65       801.24       284.71       89.05      
80.49   10
11
    1,390.37       213.85       127.40       78.71       170.99       91.92    
  334.47       200.52       435.62       16,547.71       2,300.77       621.54  
    277.09       300.94       974.40       1,017.43       386.04       128.75  
    117.99  
6B *
    1,058.46       166.58       99.69       62.98       133.88       73.60      
263.18       159.17       349.74       12,780.99       1,792.25       483.08    
  218.22       237.31       767.58       803.03       338.24       76.73      
70.03  

TABLE 6 ***AREA 10 REDACTED***
General + Dental Rates:

                                                                               
                                                                             
TANF                                                                          
SSI-N                                           SSI-B   SSI-AB Area   BTHMO+2MO
  3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE
(55+)           AGE (65-)   AGE (65+)                                     Female
  Male   Female   Male                                                          
                             
01
    1,130.46       171.81       103.60       64.44       139.32       74.44    
  267.75       159.87       346.13       12,166.98       1,661.31       451.50  
    196.85       212.56       686.00       715.64       345.23       82.19      
76.22  
02
    1,130.46       171.81       103.60       64.44       139.32       74.44    
  267.75       159.87       346.13       12,166.98       1,661.31       451.50  
    196.85       212.56       686.00       715.64       345.23       82.19      
76.22  
03
    1,204.99       184.87       113.05       73.32       152.85       83.73    
  290.64       174.94       380.94       12,984.80       1,788.36       488.04  
    219.30       235.82       753.72       789.96       221.17       80.09      
74.48  
04
    1,050.62       162.47       98.70       63.82       132.76       73.06      
256.61       155.09       340.09       12,420.29       1,720.68       468.92    
  212.80       228.57       734.52       772.00       160.58       77.74      
72.76  
05
    1,184.67       182.35       112.26       73.86       151.96       84.05    
  288.53       174.69       381.40       14,030.19       1,934.35       526.83  
    239.31       256.38       817.52       857.56       258.05       66.65      
62.46  
06
    1,065.09       165.75       101.81       67.58       137.13       76.91    
  262.93       159.63       352.07       12,740.87       1,765.92       482.35  
    220.60       236.38       754.51       793.35       335.14       67.79      
63.33  
07
    1,094.61       170.05       104.29       68.91       140.64       78.46    
  268.96       162.93       358.59       13,685.78       1,905.45       521.07  
    240.89       257.79       821.37       965.24       279.63       69.76      
65.21  
08
    1,037.11       161.04       100.83       69.09       137.11       77.62    
  255.74       155.28       341.85       12,799.18       1,774.59       485.86  
    223.67       239.27       759.01       798.22       318.07       68.74      
64.20  
09
    1,052.11       161.99       99.72       65.94       135.00       74.71      
254.69       153.25       334.65       12,607.35       1,749.20       477.79    
  219.36       234.93       747.92       796.11       284.07       75.13      
69.96   10
11
    1,387.51       213.18       133.19       86.38       177.23       98.57    
  333.54       200.15       435.99       16,510.89       2,276.89       625.35  
    282.45       302.17       962.03       1,008.00       383.87       119.91  
    111.40  
6B *
    1,054.97       165.73       101.80       67.57       137.31       76.90    
  260.80       157.36       347.06       12,740.29       1,765.82       482.33  
    220.58       236.37       751.89       789.57       335.14       67.79      
63.33  

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 6 of 10

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

 

     
ATTACHMENT I
EXHIBIT 2-NR
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”
MEDICAID Non-Reform HMO CAPITATION RATES
By Area, Age and Eligibility Category
September 1, 2009 — August 31, 2010 HMO RATES
TABLE 7***AREA 10 REDACTED***
General + Dental + Transportation Rates:

                                                                               
                                                                             
TANF                                                                          
SS1-N                                           SSI-B   SSI-AB Area   BTHMO+2MO
  3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE
(55+)           AGE (65+)   AGE (65+)                                     Female
  Male   Female   Male                                                          
                             
01
    1,135.60       173.10       104.46       64.94       141.48       75.88    
  271.24       162.53       349.04       12,218.50       1,694.76       456.13  
    199.31       218.60       705.88       732.69       353.25       95.51      
86.37  
02
    1,135.60       173.10       104.46       64.94       141.48       75.88    
  271.24       162.53       349.04       12,218.50       1,694.76       456.13  
    199.31       218.60       705.88       732.69       353.25       95.51      
86.37  
03
    1,211.15       186.41       114.08       73.92       155.44       85.46    
  284.83       178.13       385.53       13,050.16       1,830.80       493.93  
    222.43       243.34       778.93       811.59       229.67       99.14      
89.01  
04
    1,054.63       163.48       98.37       64.21       134.44       74.18      
259.34       157.17       343.15       12,468.33       1,751.89       473.24    
  215.11       234.11       753.06       787.90       166.91       93.09      
84.46  
05
    1,188.15       183.22       112.84       74.20       153.42       85.03    
  290.89       176.49       384.05       14,071.92       1,961.45       532.59  
    241.31       261.19       833.62       871.37       264.09       80.56      
73.07  
06
    1,068.69       166.62       102.39       67.92       138.80       77.89    
  265.31       161.44       354.73       12,781.57       1,792.36       486.01  
    222.55       241.06       770.20       806.81       341.09       78.90      
71.81  
07
    1,098.43       171.01       104.93       69.29       142.24       79.52    
  271.55       164.90       361.49       13,731.82       1,936.36       525.22  
    243.10       263.09       839.14       880.48       256.70       81.52      
74.17  
08
    1,042.09       162.29       101.66       69.57       139.19       79.01    
  259.12       157.86       345.64       12,849.82       1,807.47       490.42  
    226.10       245.10       778.54       814.97       324.02       82.60      
74.76  
09
    1,057.07       163.23       100.55       66.33       137.06       76.10    
  258.06       155.82       338.43       12,659.89       1,783.32       482.63  
    221.89       240.98       768.20       803.49       290.10       90.53      
81.70  
10
                                                                               
                                                                       
11
    1,390.43       213.91       133.67       86.66       178.46       99.39    
  335.53       201.66       438.11       16,547.79       2,300.85       628.67  
    284.23       306.42       976.33       1,020.21       389.40       131.17  
    119.98  
6B *
    1,068.47       166.60       102.38       67.91       138.78       77.88    
  263.18       159.17       349.74       12,780.99       1,792.26       485.99  
    222.53       241.05       767.58       803.03       341.09       78.90      
71.81  

TABLE 8***AREA 10 REDACTED***
General + Mental Health + Dental + Transportation Rates:

                                                                               
                                                                             
TANF                                                                          
SS1-N                                           SSI-B   SSI-AB Area   BTHMO+2MO
  3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE (55+)  
BTHMO+2MO   3MO-11MO   AGE (1-5)   AGE (6-13)   AGE (14-20)   AGE (21-54)   AGE
(55+)           AGE (65+)   AGE (65+)                                     Female
  Male   Female   Male                                                          
                             
01
    1,136.63       173.13       106.32       77.29       152.87       87.27    
  275.30       166.59       352.61       12,218.57       1,694.83       464.34  
    251.15       266.28       786.98       764.29       361.36       108.05    
  98.91  
02
    1,135.62       173,12       105.94       76.67       152.79       87.19    
  276.04       167.33       353.26       12,218.61       1.694.87       468.33  
    275.53       288.93       837.09       783.82       361.36       108.05    
  98.91  
03
    1,211,18       186,43       115.63       86.21       167.29       97.31    
  299.86       183.16       389.95       13,050.22       1,830.86       500.54  
    263.89       281.50       850.02       839.29       237.78       111.68    
  101.55  
04
    1,054.65       163.50       100.83       75.84       146.65       85.39    
  264.09       161.92       347.33       12,468.39       1,751.95       480.08  
    255.02       273.60       826.64       815,57       175.02       105.63    
  97.00  
05
    1,188.17       183,24       114.78       89.63       168.29       99.90    
  297.20       182.80       389.60       14.071.99       1,961.52       540.21  
    289.10       305.18       915.57       903.30       272.20       93.10      
85.61  
06
    1,068.61       155.64       103.36       74.38       144.76       83.85    
  267.44       163.57       356.60       12,781.60       1,792.39       490.11  
    248.46       264.44       810.73       822.61       349.20       91.44      
84.35  
07
    1,098.46       171.04       107.32       88.24       160.51       97.79    
  279.30       172.65       368.30       13,731.89       1,936.42       532.55  
    289.09       305.42       918.00       911.21       293.81       94.06      
86.71  
08
    1,042.10       162.30       102.64       77.31       146.66       86.48    
  262.29       161.03       348.42       12,849.56       1,807.51       494.50  
    251.70       268.56       822.44       832.07       332.13       95.14      
87.30  
09
    1,057.09       163.25       102.44       81.33       151.54       90.56    
  264.19       161.95       343.82       12,659.96       1,783.39       489.89  
    268.07       283.48       847.38       834.34       298.21       103.07    
  94.24  
10
                                                                               
                                                                       
11
    1,390.45       213.93       135.24       99.11       190.47       111.40    
  340.62       206.75       442.59       16,547.90       2,300.96       641.29  
    363.44       379.33       1,112.15       1,073.14       397.51       143.71
      132.52  
6B *
    1,068.48       166.61       103.18       74.26       144.90       84.00    
  266.78       161.77       362.02       12,781.02       1,792.29       489.86  
    246.50       263.39       809.19       819.25       349.20       91.44      
84.35  

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 7 of 10

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

 

ATTACHMENT I
EXHIBIT 2-NR
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS”
MEDICAID Non-Reform HMO CAPITATION RATES
By Area, Age and Eligibility Category
September 1, 2009 — August 31, 2010 HMO RATES

     
AREA
  CORRESPONDING COUNTIES
Area 1
  Escambia, Okaloosa, Santa Rosa, Walton
Area 2
  Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jeflerson, Leon,
Liberty, Madison, Taylor, Washington, Wakulla
Area 3
  Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumtor, Suwannee, Union
Area 4
  Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia
Area 5
  Pasco, Pinellas
Area 6
  Hardee, Highlands, Manatee, Polk
Area 6B
  Hills borough
Area 7
  Brevard, Orange, Osceola, Seminole
Area 8
  Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasola
Area 9
  Indian River, Okeechobee, St. Lucle, Martin, Palm Beach
Area 10
  Broward
Area 11
  Dade, Monroe

AHCA Contract No. FA913, Attachment I, Exhibit 2-NR, Page 8 of 10

 

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

 

     
AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

ATTACHMENT I
EXHIBIT 2-R
September 1, 2009 — August 31, 2012 HMO RATES
(MEDICAID Reform HMO CAPITATION RATES)
By Area, Age and Eligibility Category/Population

TABLE 1:   COMPREHENSIVE COMPONENT AND CATASTROPHIC COMPONENT CAPITATION RATES

Effective September 1, 2009
     ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)
***AREA 10 REDACTED***

                      AREA 4   AREA 10 Eligibility Category: Children and
Families
Month 0-2 All
    924.33          
Month 3-11 All
    203.14          
1-5 All
    113.83          
6-13 All
    113.83          
14-20 Female
    113.83          
14-20 Male
    113.83          
21-54 Female
    113.83          
21-54 Male
    113.83          
55+ All
    113.83           Eligibility Category: Aged and Disabled
Month 0-2 All
    14,697.48          
Month 3-11 All
    3,276.14          
1-5 All
    630.52          
6-13All
    630.52          
14-20 All
    630.52          
21-54 All
    630.52          
55+ All
    630.52           Eligibility Category: Aged and Disabled with Medicare Parts
A & B
Month 0-2 All
    14,697.48          
Month 3-11 All
    3,276.14          
1-5 All
    630.52          
6-13 All
    630.52          
14-20 All
    630.52          
21-54 All
    630.52          
55+ All
    630.52           Eligibility Category: Aged and Disabled with Medicare Parts
A & B
Under Age 65
    163.20          
Age 65 and Over
    116.64           Eligibility Category: Aged and Disabled with Medicare Part
B Only
AlI Ages
    337.04          
Population: HIV/AIDS Specialty Population
               
No Medicare HIV
    1,294.05          
No Medicare AIDS
    2,547.50          
Medicare HIV
    175.42          
Medicare AIDS
    187.25          

AHCA Contract No. FA913, Attachment I, Exhibit 2-R, Page 9 of 10

 

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

 

     
AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

TABLE 2:   KICK PAYMENT AMOUNTS FOR COVERED OBSTETRICAL DELIVERY SERVICES

Effective September 1, 2009
***AREA 10 REDACTED***

                          CPT             Code   Obstetrical Delivery CPT Code
Description   Area 4   Area 10   59409    
Vaginal delivery only
                       
 
                  59410    
Vaginal delivery including postpartum care
    4,210.92                  
 
                  59515    
Cesarean delivery including postpartum care
                       
 
                  59612    
Vaginal delivery only, after previous cesarean delivery
                       
 
                  59614    
Vaginal delivery only, after previous cesarean delivery including postpartum
care
                       
 
                  59622    
Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery inc postpartum care
               

TABLE 3:   KICK PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES

                          CPT           Children/Adolescents     Code  
Transplant CPT Code Description   or Adult   All Areas

***REDACTED***
AHCA Contract No. FA913, Attachment I, Exhibit 2-R, Page 10 of 10

 

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

 

     
AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

ATTACHMENT II
CORE CONTRACT PROVISIONS
TABLE OF CONTENTS

         
Section I — Definitions and Acronyms
    6  
A. Definitions
    6  
B. Acronyms
    25  
Section II — General Overview
    29  
A. Background
    29  
B. Purpose
    29  
C. Responsibilities of the State of Florida and the Agency for Health Care
Administration
    29  
D. General Responsibilities of the Health Plan
    31  
Section III — Eligibility and Enrollment
    34  
A. Eligibility
    34  
1. Mandatory Populations
    34  
2. Voluntary Populations
    34  
3. Excluded Populations
    35  
B. Enrollment
    36  
1. General Provisions
    36  
2. Enrollment in a Specialty Plan
    37  
3. Unborn Activation and Newborn Enrollment
    37  
4. Stopping or Limiting Enrollment
    38  
C. Disenrollment
    39  
1. General Provisions
    39  
2. When Disenrollment Can Occur
    39  
3. Cause for Disenrollment
    40  
4. Involuntary Disenrollment Requests
    41  
5. Disenrollment Notice
    42  
Section IV — Enrollee Services, Community Outreach and Marketing
    43  
A. Enrollee Services
    43  
1. General Provisions
    43  
2. Requirements for Written Materials
    44  
3. New Enrollee Materials
    44  
4. Enrollee ID Card
    45  
5. Enrolling with a Primary Care Provider
    45  
6. Enrollee Handbook Requirements
    46  
7. Provider Directory
    50  
8. New Enrollee Procedures
    51  
9. Enrollee Assessments
    52  
10. Enrollee Authorized Representative
    52  
11. Toll-Free Help Line
    52  
12. Translation Services
    53  
13. Preferred Drug List
    54  
14. Incentive Programs
    54  
15. Enhanced Services
    55  
16. Notices of Action
    55  
17. Medicaid Redetermination Notices
    55  

AHCA Contract No. FA913, Attachment II, Page 1 of 186

 

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

 

     
AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

         
B. Community Outreach and Marketing
    58  
1. General Provisions
    58  
2. Prohibited Activities
    59  
3. Permitted Activities
    60  
4. Community Outreach Notification Process
    61  
5. Provider Compliance
    62  
6. Community Outreach Representatives
    62  
Section V — Covered Services
    64  
A. Covered Services
    64  
B. Optional Services
    64  
C. Expanded Services
    64  
D. Customized Benefit Package
    65  
E. Excluded Services
    65  
F. Moral or Religious Objections
    65  
G. Copayments
    66  
H. Coverage Provisions
    66  
1. Requirements
    66  
2. Child Health Check-Up Program
    66  
3. Dental Services
    67  
4. Hearing Services
    67  
5. Vision Services
    67  
6. Diabetes Supplies and Education
    68  
7. Emergency Services
    68  
8. Out-of-Plan Use of Non-Emergency Services
    70  
9. Family Planning Services
    71  
10. Hospital Services — Inpatient
    71  
11. Hospital Services — Outpatient
    74  
12. Hospital Services — Ancillary Services
    75  
13. Hysterectomies, Sterilizations and Abortions
    75  
14. Immunizations
    76  
15. Pregnancy-Related Requirements
    77  
16. Prescription Drug Services
    81  
17. Quality Enhancements
    84  
18. Protective Custody
    86  
19. Therapy Services
    86  
20. Transportation Services
    87  
Section VI — Behavioral Health Care
    88  
A. General Provisions
    88  
Section VII — Provider Network
    90  
A. General Provisions
    90  
B. Network Standards
    91  
1. Primary Care Providers
    91  
2. Specialists and Other Providers
    92  
3. Public Health Providers
    94  
4. Facilities and Ancillary Providers
    95  
C. Network Changes
    96  
D. Provider Contract Requirements
    97  
E. Provider Termination
    101  
F. Appointment Waiting Times and Geographic Access Standards
    101  
G. Continuity of Care
    102  
H. Credentialing and Recredentialing
    103  

AHCA Contract No. FA913, Attachment II, Page 2 of 186

 

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

 

     
AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

         
I. Provider Services
    105  
1. General Provisions
    105  
2. Provider Handbook
    106  
3. Education and Training
    107  
4. Toll-Free Provider Help Line
    107  
5. Provider Complaint System
    108  
J. Medical Records Requirements
    109  
Section VIII — Quality Management
    111  
A. Quality Improvement
    111  
1. General Requirements
    111  
2. Specific Required Components of the QI Program
    111  
3. Health Plan QI Activities
    113  
4. Cultural Competency Plan
    117  
5. EQRO Coordination Requirements
    118  
6. Agency Annual Medical Records Audit
    118  
B. Utilization Management
    118  
1. General Requirements
    118  
2. Care Management
    120  
3. Practice Protocols
    121  
4. Changes to Utilization Management Components
    121  
5. Disease Management
    121  
Section IX — Grievance System
    122  
A. General Requirements
    122  
B. Types of Issues
    123  
C. Notices
    123  
D. Filing Grievances and Appeals
    124  
E. Resolution and Notification
    125  
F. Expedited Appeals
    126  
G. Medicaid Fair Hearings
    126  
H. Continuation of Benefits
    127  
Section X — Administration and Management
    128  
A. General Provisions
    128  
B. Staffing
    128  
C. Claims
    130  
D. Encounter Data
    130  
E. Fraud and Abuse Prevention
    132  
Section XI — Information Management and Systems
    137  
A. General Provisions
    137  
1. General Requirements
    137  
2. Systems Capacity
    137  
3. E-Mail System
    137  
4. Participation in Information Systems Work Groups/Committees
    137  
5. Connectivity to the Agency/State Network and Systems
    137  
B. Data and Document Management Requirements
    137  
1. Adherence to Data and Document Management Standards
    137  
2. Data Model and Accessibility
    138  
3. Data and Document Relationships
    138  
4. Information Retention
    138  
5. Information Ownership
    138  
C. Systems and Data Integration Requirements
    138  
1. Adherence to Standards for Data Exchange
    138  

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

         
2. HIPAA Compliance Checker
    138  
3. Data and Report Validity and Completeness
    139  
4. State/Agency Website/Portal Integration
    139  
5. Functional Redundancy with FMMIS
    139  
6. Data Exchange in Support of the Agency’s Program Integrity and Compliance
Functions
    139  
7. Address Standardization
    139  
8. Eligibility and Enrollment Data Exchange Requirements
    139  
D. Systems Availability, Performance and Problem Management Requirements
    140  
1. Availability of Critical Systems Functions
    140  
2. Availability of Data Exchange Functions
    140  
3. Availability of Other Systems Functions
    140  
4. Problem Notification
    140  
5. Recovery from Unscheduled System Unavailability
    140  
6. Exceptions to System Availability Requirement
    141  
7. Information Systems Corrective Action Plan
    141  
8. Business Continuity-Disaster Recovery (BC-DR) Plan
    141  
E. Systems Testing and Change Management Requirements
    142  
1. Notification and Discussion of Potential System Changes
    142  
2. Response to Agency Reports of Systems Problems not Resulting in System
Unavailability
    142  
3. Valid Window for Certain System Changes
    142  
4. Testing
    142  
F. Information Systems Documentation Requirements
    143  
1. Types of Documentation
    143  
2. Content of System Process and Procedure Manuals
    143  
3. Content of System User Manuals
    143  
4. Changes to Manuals
    143  
5. Availability of/Access to Documentation
    143  
G. Reporting Requirements
    143  
H. Community Health Records/Electronic Medical Records and Related Efforts
    143  
I. Compliance with Standard Coding Schemes
    144  
1. Compliance with HIPAA-Based Code Sets
    144  
2. Compliance with Other Code Sets
    144  
J. Data Exchange and Formats and Methods Application to Health Plans
    145  
1. HIPAA-Based Formatting Standards
    145  
2. Methods for Data Exchange
    145  
3. Agency-Based Formatting Standards and Methods
    145  
Section XII — Reporting Requirements
    146  
A. Health Plan Reporting Requirements
    146  
Table 1 — Summary of Reporting Requirements
    147  
Table 2 — Summary of Submission Requirements
    154  
Section XIII — Method of Payment
    166  
Section XIV — Sanctions
    167  
A. General Provisions
    167  
B. Corrective Action Plans
    167  
C. Specific Sanctions
    168  
D. Intermediate Sanctions
    169  
E. Civil Monetary Penalties
    169  
F. Notice of Sanction
    169  

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

         
Section XV — Financial Requirements
    171  
A. Insolvency Protection
    171  
B. Insolvency Protection Account Waiver
    171  
C. Surplus Start Up Account
    171  
D. Surplus Requirements
    171  
E. Interest
    171  
F. Inspection and Audit of Financial Records
    171  
G. Physician Incentive Plans
    171  
H. Third Party Resources
    172  
I. Fidelity Bonds
    172  
J. Financial Reporting
    172  
Section XVI — Terms and Conditions
    173  
A. Agency Contract Management
    173  
B. Applicable Laws and Regulations
    173  
C. Assignment
    174  
D. Attorney’s Fees
    174  
E. Conflict of Interest
    174  
F. Contract Variation
    175  
G. Court of Jurisdiction or Venue
    175  
H. Damages for Failure to Meet Contract Requirements
    175  
I. Disputes
    175  
J. Force Majeure
    176  
K. Legal Action Notification
    176  
L. Licensing
    176  
M. Misuse of Symbols, Emblems or Names in Reference to Medicaid
    176  
N. Offer of Gratuities
    177  
O. Subcontracts
    177  
P. Hospital Provider Contracts
    181  
Q. Termination Procedures
    181  
R. Waiver
    182  
S. Withdrawing Services from a County
    182  
T. MyFloridaMarketPlace Vendor Registration
    183  
U. MyFloridaMarketPlace Vendor Registration/Transaction Fee Exemption
    183  
V. Ownership and Management Disclosure
    183  
W. Minority Recruitment and Retention Plan
    185  
X. Independent Provider
    185  
Y. General Insurance Requirements
    185  
Z. Workers’ Compensation Insurance
    186  
AA. State Ownership
    186  
BB. Emergency Management Plan
    186  
CC. Indemnification
    186  

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section I
Definitions and Acronyms
A. Definitions (See Attachment II, Exhibit 1, for HIV/AIDS-related definitions)
The following terms as used in this Contract shall be construed and/or
interpreted as follows, unless the Contract otherwise expressly requires a
different construction and/or interpretation. Some defined terms do not appear
in all contracts.
Abandoned Call — A call in which the caller elects an option and is either not
permitted access to that option or disconnects from the system.
Abuse — Provider practices that are inconsistent with generally accepted
business or medical practices and that result in an unnecessary cost to the
Medicaid program or in reimbursement for goods or services that are not
medically necessary or that fail to meet professionally recognized standards for
health care; or recipient practices that result in unnecessary cost to the
Medicaid program.
Action — The denial or limited authorization of a requested service, including
the type or level of service, pursuant to 42 CFR 438.400(b). The reduction,
suspension or termination of a previously authorized service. The denial, in
whole or in part, of payment for a service. The failure to provide services in a
timely manner, as defined by the state. The failure of the Health Plan to act
within ninety (90) days from the date the Health Plan receives a grievance, or
forty-five (45) days from the date the Health Plan receives an appeal. For a
resident of a rural area with only one (1) managed care entity, the denial of an
enrollee’s request to exercise the right to obtain services outside the network.
Advance Directive — A written instruction, such as a living will or durable
power of attorney for health care, recognized under state law (whether statutory
or as recognized by the courts of the state), relating to the provision of
health care when the individual is incapacitated.
Advanced Registered Nurse Practitioner (ARNP) — A licensed advanced registered
nurse practitioner who works in collaboration with a physician according to
protocol, to provide diagnostic and clinical interventions. An ARNP must be
authorized to provide these services by Chapter 464, F.S., and protocols filed
with the Board of Medicine.
Agency — State of Florida, Agency for Health Care Administration.
Agent — A term that refers to certain independent contractors with the state
that perform administrative functions, including but not limited to: fiscal
agent activities; outreach, eligibility and enrollment activities; systems and
technical support. The term as used herein does not create a principal-agent
relationship.
Ancillary Provider — A provider of ancillary medical services who has contracted
with a health plan to serve the health plan’s enrollees.
Appeal - A formal request from an enrollee to seek a review of an action taken
by the Health Plan pursuant to 42 CFR 438.400(b).
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Authoritative Host — A system that contains the master or “authoritative” data
for a particular data type, e.g. enrollee, provider, Health Plan, etc. The
authoritative host may feed data from its master data files to other systems in
real time or in batch mode. Data in an authoritative host is expected to be up
to date and reliable.
Automatic Assignment (or Auto-Assign) — The enrollment of an eligible Medicaid
recipient, for whom enrollment is mandatory, in a Health Plan chosen by the
Agency or its agent, and/or the assignment of a new enrollee to a primary care
provider chosen by the Health Plan.
Baker Act — The Florida Mental Health Act, pursuant to ss. 394.451-394.4789,
F.S.
Behavioral Health Services — Services listed in the Community Behavioral Health
Services Coverage & Limitations Handbook and the Targeted Case Management
Coverage & Limitations Handbook as specified in Attachment II, Section VI,
Behavioral Health Care, Item A., General Provisions.
Behavioral Health Care Case Manager — An individual who provides behavioral
health care case management services directly to or on behalf of an enrollee on
an individual basis in accordance with 65E-15, F.A.C., and the Medicaid Targeted
Case Management Handbook.
Behavioral Health Care Provider — A licensed behavioral health professional,
such as a clinical psychologist, or registered nurse qualified due to training
or competency in behavioral health care, who is responsible for the provision of
behavioral health care to patients, or a physician licensed under Chapters 458
or 459, F.S., who is under contract to provide behavioral health services to
enrollees.
Beneficiary Assistance Program - (PSNs only) — A state external conflict
resolution program authorized under s. 409.91211(3)(q), F.S., similar to the
Subscriber Assistance Program, available to Medicaid participants, that provides
an additional level of appeal if the Health Plan’s process does not resolve the
conflict.
Benefit Maximum - (Reform only) — The point when the cost of covered services
received by a non-pregnant enrollee, age 21 or older, reaches ***REDACTED*** in
a Contract year, based on Medicaid fee-for-service payment levels. Care
coordination services and emergency services and care must continue to be
offered by the Health Plan, but the cost of additional services, excluding
emergency services and care, will not be covered by the Medicaid program for the
remainder of the Contract year in which the benefit maximum is met. In addition,
the Health Plan shall provide benefit reporting in accordance with Attachment
II, Section V, Covered Services, and Section XII, Reporting Requirements.
Benefits — A schedule of health care services to be delivered to enrollees
covered by the Health Plan as set forth in Attachment II, Section V, Covered
Services, and Section VI, Behavioral Health Care.
Blocked Call — A call that cannot be connected immediately because no circuit is
available at the time the call arrives or the telephone system is programmed to
block calls from entering the queue when the queue backs up behind a defined
threshold.
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Business Days — Traditional workdays, which are Monday, Tuesday, Wednesday,
Thursday, and Friday. State holidays are excluded.
Calendar Days — All seven (7) days of the week. Unless otherwise specified, the
term “days” in this attachment refers to calendar days.
Capitation Rate — The per-member/per-month amount, including any adjustments,
that is paid by the Agency to a capitated Health Plan for each Medicaid
recipient enrolled under a Contract for the provision of Medicaid services
during the payment period.
Capitated Health Plan - A health maintenance organization, provider service
network or other health plan that is paid a per-member/per-month fee to cover
the cost of providing health care to its enrollees.
Care Coordination/Case Management — A process that assesses, plans, implements,
coordinates, monitors and evaluates the options and services required to meet an
enrollee’s health needs using communication and all available resources to
promote quality cost- effective outcomes. Proper case management occurs across a
continuum of care, addressing the ongoing individual needs of an enrollee rather
than being restricted to a single practice setting. For purposes of this
Contract, “care coordination” and “case management” are the same.
Catastrophic Component - (Reform Health Plans only) — The amount of financial
risk assumed by a Health Plan or the Agency to provide covered services above
$50,000 per enrollee, based on Medicaid fee-for-service payment levels, and up
to the overall annual benefit maximum.
Catastrophic Component Threshold - (Capitated Reform Health Plans in counties
where no HMO is present and Reform FFS PSNs only) — The point at which the cost
of covered services, based on Medicaid fee-for-service payment levels, reaches
$50,000 for an enrollee in a Contract year. For a Health Plan that accepts the
comprehensive capitation rate only, the Agency begins reimbursing the Health
Plan for the cost of covered services received by the enrollee for the remainder
of the Contract year. This reimbursement is based on a percentage of Medicaid
fee-for-service payment levels.
Cause — Special reasons that allow mandatory enrollees to change their Health
Plan choice outside their open enrollment period. May also be referred to as
“good cause.” (See 59G-8.600, FAC.)
Centers for Medicare & Medicaid Services (CMS) — The agency within the United
States Department of Health & Human Services that provides administration and
funding for Medicare under Title XVIII, Medicaid under Title XIX, and the State
Children’s Health Insurance Program under Title XXI of the Social Security Act.
Certification — The process of determining that a facility, equipment or an
individual meets the requirements of federal or state law, or whether Medicaid
payments are appropriate or shall be made in certain situations.
Child Health Check-Up-Program (CHCUP) — A set of comprehensive and preventive
health examinations provided on a periodic basis to identify and correct medical
conditions
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

in children/adolescents. Policies and procedures are described in the Child
Health Check- Up Services Coverage and Limitations Handbook.
Children/Adolescents — Enrollees under the age of 21. For purposes of the
provision of Behavioral Health Services, excluding inpatient psychiatric
services, adults are persons age 18 and older, and children/adolescents are
persons under age 18, as defined by the Department of Children and Families.
Children & Families, Department of (DCF) — The state agency responsible for
overseeing programs involving behavioral health, childcare, family safety,
domestic violence, economic self-sufficiency, refugee services, homelessness,
and programs that identify and protect abused and neglected children and adults.
Choice Counselor/Enrollment Broker — The state’s contracted or designated entity
that performs functions related to outreach, education, counseling, enrollment,
and disenrollment of potential enrollees into a Health Plan.
Choice Counseling Specialists — Individuals authorized by an Agency-approved
process who provide one-on-one information to Medicaid recipients to help them
choose the health plan that best meets the health care needs of them and their
families.
Claim— (1) A bill for services, (2) a line item of service, or (3) all services
for one (1) recipient within a bill, pursuant to 42 CFR 447.45, in a format
prescribed by the Agency through its Medicaid provider handbooks.
Clean Claim — A claim that can be processed without obtaining additional
information from the provider of the service or from a third party. It does not
include a claim from a provider who is under investigation for fraud or abuse,
or a claim under review for medical necessity, pursuant to 42 CFR 447.45.
Cold Call Marketing — Any unsolicited personal contact with a Medicaid recipient
by the Health Plan, its staff, its volunteers or its vendors with the purpose of
influencing the Medicaid recipient to enroll in the Health Plan or either to not
enroll in, or disenroll from, another health plan.
Commission for the Transportation Disadvantaged (CTD) — An independent
commission housed administratively within the Florida Department of
Transportation. The CTD’s mission is to ensure the availability of efficient,
cost-effective, and quality transportation services for transportation
disadvantaged persons.
Community Living Support Plan — A written document prepared by a behavioral
health resident of an assisted living facility with a limited mental health
license and the resident’s behavioral health case manager in consultation with
the administrator of the facility or the administrator’s designee. A copy must
be provided to the administrator. The plan must include information about the
supports, services, and special needs that enable the resident to live in the
assisted living facility and a method by which facility staff can recognize and
respond to the signs and symptoms particular to that resident that indicate the
need for professional services.
Community Outreach — The provision of health or nutritional information or
information for the benefit and education of, or assistance to, a community in
regard to health-related
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

matters or public awareness that promotes healthy lifestyles. Community outreach
also includes the provision of information about health care services,
preventive techniques and other health care projects and the provision of
information related to health, welfare and social services or social assistance
programs offered by the State of Florida or local communities.
Community Outreach Materials — Materials regarding health or nutritional
information or information for the benefit and education of, or assistance to, a
community on health-related matters or public awareness that promotes healthy
lifestyles. Such materials are meant specifically for the community at large and
may also include information about health care services, preventive techniques
and other health care projects and the provision of information related to
health, welfare, and social services or social assistance programs offered by
the State of Florida or local communities. Community outreach materials are
limited to brochures, fact sheets, billboards, posters, and ad copy for radio,
television, print or the Internet.
Community Outreach Representative — A person who provides health information,
information that promotes healthy lifestyles, information that provides guidance
about social assistance programs, and information that provides culturally and
linguistically appropriate health or nutritional education. Such representatives
must be appropriately trained, certified and/or licensed, including but not
limited to, social workers, nutritionists, physical therapists and other health
care professionals.
Complaint — Any oral or written expression of dissatisfaction by an enrollee
submitted to the Health Plan or to a state agency and resolved by close of
business the following business day. Possible subjects for complaints include,
but are not limited to, the quality of care, the quality of services provided,
aspects of interpersonal relationships such as rudeness of a provider or Health
Plan employee, failure to respect the enrollee’s rights, Health Plan
administration, claims practices or provision of services that relates to the
quality of care rendered by a provider pursuant to the Health Plan’s Contract. A
complaint is an informal component of the grievance system.
Comprehensive Component — (Capitated Reform Health Plans in counties where no
HMOs are present and Reform FFS PSNs only) — The amount of financial risk
assumed by a Health Plan to provide covered service up to ***REDACTED*** per
enrollee based on Medicaid fee for-service payment levels.
Contested Claim — (FFS PSNs only) — A claim that has not been authorized and
forwarded to the Medicaid fiscal agent by the Health Plan because it has a
material defect or impropriety.
Continuous Quality Improvement — A management philosophy that mandates
continually pursuing efforts to improve the quality of products and services
produced by an organization.
Contract — The agreement between the Health Plan and the Agency to provide
Medicaid services to enrollees, comprising the Contract and any addenda,
appendices, attachments, or amendments thereto.
Contract Period — The term of the Contract beginning no earlier than
September 1, 2009, and ending August 31, 2012.
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Contract Year — Each September 1 through August 31 within the Contract period.
Contracting Officer — The Secretary of the Agency or designee.
Cost Effective — The Health Plan’s per-member, per-month costs to the state,
including, but not limited to, FFS costs, administrative costs, and
case-management fees, must be no greater than the state’s costs associated with
capitated health plans. (See s.409.912(44), F.S.)
County Health Department (CHD) — Organizations administered by the Department of
Health to provide health services as defined in Chapter 154, ES., including
promoting public health, controlling and eradicating preventable diseases, and
providing primary health care for special populations.
Coverage & Limitations Handbook (Handbook) — A Florida Medicaid document that
provides information to a Medicaid provider about enrollee eligibility; claims
submission and processing; provider participation; covered care, goods and
services; limitations; procedure codes and fees; and other matters related to
participation in the Medicaid program.
Covered Services — Those services provided by the Health Plan in accordance with
this Contract, and as outlined in Section V, Covered Services, and Section VI,
Behavioral Health Care, and Attachment I.
Crisis Support — Services for persons initially perceived to need emergency
behavioral health services, but upon assessment, do not meet the criteria for
such emergency care. These are acute care services available twenty-four hours a
day, seven days a week (24/7) for intervention. Examples include: mobile crisis,
crisis/emergency screening, crisis hot line and emergency walk-in.
Customized Benefit Package (CBP) — (Reform only) — Covered services, which may
vary in amount, scope and/or duration from those listed in Section V, Covered
Services, and Section VI, Behavioral Health Care. The CBP must meet state
standards for actuarial equivalency and sufficiency. CBP is also referred to as
“benefit grid.”
Direct Ownership Interest — The ownership of stock, equity in capital or any
interest in the profits of a disclosing entity.
Direct Service Behavioral Health Care Provider — An individual qualified by
training or experience to provide direct behavioral health services under the
direction of the Health Plan’s medical director.
Disclosing Entity — A Medicaid provider, other than an individual practitioner
or group of practitioners, or a fiscal agent that furnishes services or arranges
for funding of services under Medicaid, or health-related services under the
social services program.
Disease Management — A system of coordinated health care intervention and
communication for populations with conditions in which patient self-care efforts
are significant. Disease management supports the physician or
practitioner/patient relationship and plan of care; emphasizes prevention of
exacerbations and complications using evidence-based practice guidelines and
patient empowerment strategies, and evaluates
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

clinical, humanistic and economic outcomes on an ongoing basis with the goal of
improving overall health.
Disenrollment — The Agency-approved discontinuance of an enrollee’s
participation in a Health Plan.
Downward Substitution of Care — The use of less restrictive, lower cost services
than otherwise might have been provided, that are considered clinically
acceptable and necessary to meet specified objectives outlined in an enrollee’s
plan of treatment, provided as an alternative to higher cost services.
Durable Medical Equipment (DME) — Medical equipment that can withstand repeated
use, is 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 enrollee’s
home.
Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) — See
Child Health Check-Up Program.
Emergency Behavioral Health Services — Those services required to meet the needs
of an individual who is experiencing an acute crisis, resulting from a mental
illness, which is a level of severity that would meet the requirements for an
involuntary examination (See s. 394.463, F.S.), and in the absence of a suitable
alternative or psychiatric medication, would require hospitalization.
Emergency Medical Condition — (a) A medical condition manifesting itself by
acute symptoms of sufficient severity, which may include severe pain or other
acute symptoms, such that a prudent layperson who possesses an average knowledge
of health and medicine, could reasonably expect that the absence of immediate
medical attention could result in any of the following: (1) serious jeopardy to
the health of a patient, including a pregnant woman or fetus; (2) serious
impairment to bodily functions; (3) serious dysfunction of any bodily organ or
part. (b) With respect to a pregnant woman: (1) that there is inadequate time to
effect safe transfer to another hospital prior to delivery; (2) that a transfer
may pose a threat to the health and safety of the patient or fetus; (3) that
there is evidence of the onset and persistence of uterine contractions or
rupture of the membranes (see s. 395.002. F.S.).
Emergency Services and Care — Medical screening, examination and evaluation by a
physician or, to the extent permitted by applicable laws, by other appropriate
personnel under the supervision of a physician, to determine whether an
emergency medical condition exists. If such a condition exists, emergency
services and care include the care or treatment necessary to relieve or
eliminate the emergency medical condition within the service capability of the
facility.
Emergency Transportation – The provision of emergency transportation services in
accordance with s. 409.908 (13)(c)4., F.S.
Encounter Data – A record of covered services provided to a Health Plan’s
enrollees. An “encounter” is an interaction between a patient and provider
(Health Plan, rendering physician, pharmacy, lab, etc.) who delivers services or
is professionally responsible for services delivered to a patient.
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Enhanced Benefit — (Reform only) — An activity or behavior identified by the
state as beneficial to the health of an individual and designated to earn a
credit in the Enhanced Benefit Program.
Enhanced Benefit Account — (Reform only) — The individual account resulting from
an enrollee’s earning rewards for healthy behaviors under the Enhanced Benefit
Program.
Enhanced Benefit Program — (Reform only) – Also known as Enhanced Benefits
Reward$, a program offered through Medicaid Reform that rewards enrollees for
healthy behaviors.
Enrollee — A Medicaid recipient enrolled in a Health Plan.
Enrollment — The process by which an eligible Medicaid recipient signs up to
participate in a Health Plan.
Expanded Services — A service covered by the Health Plan for which it receives
no direct payment from the Agency.
Expedited Appeal Process — The process by which the appeal of an action is
accelerated because the standard time frame for resolution of the appeal could
seriously jeopardize the enrollee’s life, health or ability to obtain, maintain
or regain maximum function.
External Quality Review (EQR) — The analysis and evaluation by an EQRO of
aggregated information on quality, timeliness, and access to the health care
services that are furnished to Medicaid recipients by a Health Plan.
External Quality Review Organization (EQRO) — An organization that meets the
competence and independence requirements set forth in 42 CFR 438.354, and
performs EQR, other related activities as set forth in federal regulations, or
both.
Federal Fiscal Year – The United States government’s fiscal year starts October
1 and ends on September 30.
Federally Qualified Health Center (FQHC) — An entity that is receiving a grant
under section 330 of the Public Health Service. Act, as amended. (Also see
Section 1905(1)(2)(B) of the Social Security Act.) FQHCs provide primary health
care and related diagnostic services and may provide dental, optometric,
podiatry, chiropractic and behavioral health services.
Fee-for-Service (FFS) — A method of making payment by which the Agency sets
prices for defined medical or allied care, goods or services.
Fiscal Agent — Any corporation, or other legal entity, that enters into a
contract with the Agency to receive, process and adjudicate claims under the
Medicaid program.
Fiscal Year — The State of Florida’s Fiscal Year starts July 1 and ends on
June 30.
Florida Medicaid Management Information System (FMMIS or FL MMIS) — The
information system used to process Florida Medicaid claims and payments to
Health Plans, and to produce management information and reports relating to the
Florida Medicaid
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  HMO Contract

program. This system is used to maintain Medicaid eligibility data and provider
enrollment data.
Florida Mental Health Act — Includes the Baker Act that covers admissions for
persons who are considered to have an emergency mental health condition (a
threat to themselves or others) as specified in ss. 394.451 through 394.4789,
F.S.
Fraud — An intentional deception or misrepresentation made by a person with the
knowledge that the deception results in unauthorized benefit to that person or
another person. The term includes any act that constitutes fraud under
applicable federal or state law.
Full-Time Equivalent Position (FTE) — The equivalent of one (1) full-time
employee who works forty (40) hours per week.
Good Cause — See Cause.
Grievance — An expression of dissatisfaction about any matter other than an
action. Possible subjects for grievances include, but are not limited to, the
quality of care, the quality of services provided and aspects of interpersonal
relationships such as rudeness of a provider or Health Plan employee or failure
to respect the enrollee’s rights.
Grievance Procedure — The procedure for addressing enrollees’ grievances.
Grievance System — The system for reviewing and resolving enrollee complaints,
grievances and appeals. Components must include a complaint process, a grievance
process, an appeal process, access to an applicable review outside the Health
Plan (Subscriber Assistance Program or Beneficiary Assistance Program), and
access to a Medicaid Fair Hearing through the Department of Children and
Families.
Health Assessment — A complete health evaluation combining health history,
physical assessment and the monitoring of physical and psychological growth and
development.
Health Care Professional — A physician or any of the following: 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), a licensed clinical social worker, registered respiratory
therapist and certified respiratory therapy technician.
Health Fair — An event conducted in -a setting that is open to the public or
segment of the public (such as the “elderly” or “schoolchildren”) during which
information about health-care services, facilities, research, preventive
techniques or other health-care subjects is disseminated. At least one
(1) community organization or two (2) health-related organizations that are not
affiliated under common ownership must actively participate in the health fair.
Health Maintenance Organization (HMO) — An organization or entity licensed in
accordance with Chapter 641, F.S., or in accordance with the Florida Medicaid
State Plan definition of an HMO.
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AMERIGROUP Community Care
  HMO Contract

Health Plan — An entity that integrates financing and management with the
delivery of health care services to an enrolled population. It employs or
contracts with an organized system of providers, which delivers services, and
frequently shares financial risk. The term includes health plans contracted with
the Agency to provide Medicaid services under the Florida Medicaid Reform
program as well as 1915(b) managed care waiver (non-Reform) areas, and includes
health maintenance organizations authorized under Chapter 641, F.S., exclusive
provider organizations as defined in Chapter 627, F.S., health insurers
authorized under Chapter 624, F.S., and provider service networks as defined in
s. 409.912, F.S., including the specialty plan for children with chronic
conditions as authorized under Section 409.91211(3)(bb) and (12), F.S.
HEDIS – Healthcare Effectiveness Data and Information Set developed and
published by the National Committee for Quality Assurance. HEDIS includes
technical specifications for the calculation of performance measures.
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.
Hospital Services Agreement — The agreement between the Health Plan and a
hospital to provide medical services to the Health Plan’s enrollees.
Indirect Ownership Interest — Ownership interest in an entity that has direct or
indirect ownership interest in the disclosing entity. The amount of indirect
ownership in the disclosing entity that is held by any other entity is
determined by multiplying the percentage of ownership interest at each level. An
indirect ownership interest must be reported if it equates to an ownership
interest of five percent (5%) or more in the disclosing entity. Example: If “A”
owns ten percent (10%) of the stock in a corporation that owns eighty percent
(80%) of the stock of the disclosing entity, “A’s” interest equates to an eight
percent (8%) indirect ownership and must be reported.
Individuals with Special Health Care Needs — Adults and children/adolescents,
who face physical, mental or environmental challenges daily that place at risk
their health and ability to fully function in society. Factors include
individuals with mental retardation or related conditions; individuals with
serious chronic illnesses, such as human immunodeficiency virus (HIV),
schizophrenia or degenerative neurological disorders; individuals with
disabilities resulting from many years of chronic illness such as arthritis,
emphysema or diabetes; and children/adolescents and adults with certain
environmental risk factors such as homelessness or family problems that lead to
the need for placement in foster care.
Information — (a) Structured Data: Data that adhere to specific properties and
validation criteria that are stored as fields in database records. Structured
queries can be created and run against structured data, where specific data can
be used as criteria for querying a larger data set; (b) Document: Information
that does not meet the definition of structured data includes text files,
spreadsheets, electronic messages and images of forms and pictures.
Information System(s) — A combination of computing hardware and software that is
used in: (a) the capture, storage, manipulation, movement, control, display,
interchange and/or transmission of information, i.e. structured data (which may
include digitized audio and video) and documents; and/or (b) the processing of
such information for the purposes of enabling and/or facilitating a business
process or related transaction.
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AMERIGROUP Community Care
  HMO Contract

Insolvency — 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.
Kick Payment – (Reform only) — The method of reimbursing capitated Health Plans
in the form of a separate one (1) time fixed payment for specific services.
Licensed — A facility, equipment, or an individual that has formally met state,
county, and local requirements, and has been granted a license by a local, state
or federal government entity.
Licensed Practitioner of the Healing Arts — A psychiatric nurse, registered
nurse, advanced registered nurse practitioner, physician assistant, clinical
social worker, mental health counselor, marriage and family therapist, or
psychologist.
List of Excluded Individuals and Entities (LEIE) — A database maintained by the
Department of Health & Human Services, Office of the Inspector General. The LEIE
provides information to the public, health care providers, patients and others
relating to parties excluded from participation in Medicare, Medicaid and all
other federal health care programs.
Managed Behavioral Health Organization (MBHO) — A behavioral health-care
delivery system managing quality, utilization and cost of services.
Additionally, an MBHO measures performance in the area of mental disorders.
Mandatory Assignment — The process the Agency uses to assign enrollees to a
Health Plan. The Agency automatically assigns those enrollees required to be in
a Health Plan who did not voluntarily choose one.
Mandatory Enrollee — The categories of eligible Medicaid recipients who must be
enrolled in a Health Plan or MediPass or, if subject to Reform, must be enrolled
only in a Health Plan.
Mandatory Potential Enrollee — A Medicaid recipient who is required to enroll in
a Health Plan or IVIediPass but has not yet made a choice.
Market Area — The geographic area in which the Health Plan is authorized to
conduct community outreach.
Marketing — Any activity or communication conducted by or on behalf of any
Health Plan with a Medicaid recipient who is not enrolled with the Health Plan,
that can reasonably be interpreted as intended to influence the Medicaid
recipient to enroll in the particular Health Plan.
Medicaid Area — The specific counties designated by the Agency and overseen by
an Agency field office manager.
Medicaid — The medical assistance program authorized by Title XIX of the Social
Security Act, 42 U.S.C. §1396 et seq., and regulations thereunder, as
administered in the State of Florida by the Agency under s. 409.901 et seq.,
F.S.
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AMERIGROUP Community Care
  HMO Contract

Medicaid Fair Hearing – An administrative hearing conducted by the Department of
Children and Families to review an action taken by a Health Plan that limits,
denies, or stops a requested service.
Medicaid Program Integrity (MPI) – The unit of the Agency responsible for
preventing and identifying fraud and abuse in the Medicaid program.
Medicaid Recipient — Any individual whom DCF, or the Social Security
Administration on behalf of DCF, 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 who is enrolled in the
Medicaid program.
Medicaid Reform — The program resulting from s. 409.91211, F.S.
Medical Foster Care Services — Services provided to enable medically-complex
children under the age of 21, whose parents cannot care for them in their own
home, to live and receive care in foster homes rather than in hospitals or other
institutional settings. Medical foster care services are authorized by Title XIX
of the Social Security Act and s. 409.903, F.S., and Chapter 59G, FAC.
Medical Record — Documents corresponding to medical or allied care, goods or
services furnished in any place of business. The records may be on paper,
magnetic material, film or other media. In order to qualify as a basis for
reimbursement, the records must be dated, legible and signed or otherwise
attested to, as appropriate to the media, and meet the requirements of 42 CFR
456.111 and 42 CFR 456.211.
Medically Necessary or Medical Necessity — Services that include medical or
allied care, goods or services furnished or ordered to:

  1.   Meet the following conditions:

  a.   Be necessary to protect life, to prevent significant illness or
significant disability or to alleviate severe pain;     b.   Be individualized,
specific and consistent with symptoms or confirm diagnosis of the illness or
injury under treatment and not in excess of the patient’s needs;     c.   Be
consistent with the generally accepted professional medical standards as
determined by the Medicaid program, and not be experimental or investigational;
    d.   Be reflective of the level of service that can be furnished safely and
for which no equally effective and more conservative or less costly treatment is
available statewide; and     e.   Be furnished in a manner not primarily
intended for the convenience of the enrollee, the enrollee’s caretaker or the
provider.

  2.   For those services furnished in a hospital on an inpatient basis, medical
necessity means that appropriate medical care cannot be effectively furnished
more economically on an outpatient basis or in an inpatient facility of a
different type.

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AMERIGROUP Community Care
  HMO Contract

  3.   The fact that a provider has prescribed, recommended or approved medical
or allied goods or services does not, in itself, make such care, goods or
services medically necessary, a medical necessity or a covered service/benefit.

Medicare — The medical assistance program authorized by Title XVIII of the
Social Security Act.
Medicare Advantage Special Needs Plan - A Medicare plan defined by Section
1859(b)(6) of the Social Security Act and 42 CFR Section 422.2 that exclusively
enrolls or enrolls a disproportionate percentage of special needs individuals as
set forth in 42 CFR Section 422.4(a)(1)(iv).
Meds AD — Individuals who have income up to 88% of federal poverty level and
assets up to $5,000 ($6,000 for a couple) and who do not have Medicare, or who
have Medicare and are receiving institutional care or hospice care, are enrolled
in PACE or an HCBS program, or live in an assisted living facility or adult
family care home licensed to provide assistive care services.
National Provider Identifier (NPI) – An identification number assigned through
the National Plan and Provider Enumerator System of the federal Department of
Health and Human Services. NPIs can be obtained online at
https://nppes.cms.hhs.gov.
Neglect — A failure or omission to provide care, supervision, and services
necessary to maintain enrollee’s physical and mental health, including but not
limited to, food, nutrition, supervision and medical services that are essential
for the well being of the enrollee. Neglect might be a single incident or
repeated conduct that results in, or could reasonably be expected to result in,
serious physical or psychological injury, or a substantial risk of death.
Newborn — A live child born to an enrollee who is a member of the Health Plan.
Non-Covered Service — A service that is not a benefit under either the Medicaid
State Plan or the Health Plan.
Non-Reform Health Plan – An organization that offers health care coverage under
Medicaid as authorized in s. 409.912, F.S., and as defined in the Agency’s
1915(b) managed care waiver.
Nursing Facility — An institutional care facility that furnishes medical or
allied inpatient care and services to individuals needing such services. (See
Chapters 395 and 400, F.S.)
Open Enrollment — The 60-day period before the end of certain enrollees’
enrollment year, during which the enrollee may choose to change health plans for
the following enrollment year.
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 twenty-four (24) hour period, regardless
of the hours of admission, whether or not a bed is used and/or whether or not
the patient remains in the facility past midnight.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Overpayment — Includes any amount that is not authorized to be paid by the
Medicaid program whether paid as a result of inaccurate or improper cost
reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.
Participating Provider – A health care practitioner or entity authorized to do
business in Florida and contracted with the Health Plan to provide services to
the Health Plan’s enrollees.
Participating Specialist — A physician, licensed to practice medicine in the
State of Florida, who contracts with the Health Plan to provide specialized
medical services to the Health Plan’s enrollees.
Peer Review — An evaluation of the professional practices of a provider by the
provider’s peers. It assesses the necessity, appropriateness and quality of care
furnished by comparing it to that customarily furnished by the provider’s peers
and to recognized health care standards.
Penultimate Saturday — The Saturday preceding the last Saturday of the month.
Penultimate Sunday — The Sunday preceding the last Sunday of the month.
Pharmacy Benefits Administrator — An entity contracted to or included in a
Health Plan accepting pharmacy prescription claims for enrollees in the Health
Plan, assuring these claims conform to coverage policy and determining the
allowed payment.
Physician’s Assistant (PA) — A person who is a graduate of an approved program
or its equivalent or meets -standards approved by the Board of Medicine and is
certified to perform medical services delegated by the supervising physician in
accordance with Chapter 458, F.S.
Physicians’ Current Procedural Terminology (CPT) — A systematic listing and
coding of procedures and services published annually by the American Medical
Association.
Plan Factor – (Reform only) — A budget-neutral calculation using a Health Plan’s
available historical enrollee diagnosis data grouped by a health-based risk
assessment model. A Health Plan’s plan factor is developed from the aggregated
individual risk scores of the Health Plan’s prior month’s enrollment. The plan
factor modifies a Health Plan’s monthly capitation payment to reflect the health
status of its enrollees.
Portable X-Ray Equipment — X-ray equipment transported to a setting other than a
hospital, clinic or office of a physician or other licensed practitioner of the
healing arts.
Post-Stabilization Care Services — Covered services related to an emergency
medical condition that are provided after an enrollee is stabilized in order to
maintain, improve or resolve the enrollee’s condition pursuant to 42 CFR
422.113.
Potential Enrollee — Pursuant to 42 CFR 438.10(a), an eligible Medicaid
recipient who is subject to mandatory assignment or one who may voluntarily
elect to enroll in a given health plan, but is not yet actually enrolled in a
health plan.
Pre-Enrollment — The provision of marketing materials to a Medicaid recipient.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Preferred Drug List – A listing of prescription products selected by a
pharmaceutical and therapeutics committee as cost effective choices for
clinician consideration when prescribing for Medicaid recipients.
Prescribed Pediatric Extended Care (PPEC) – A nonresidential health care center
for children who are medically complex or technologically dependent and require
continuous therapeutic intervention or skilled nursing services.
Primary Care — Comprehensive, coordinated and readily-accessible medical care
including: health promotion and maintenance; treatment of illness and injury;
early detection of disease; and referral to specialists when appropriate.
Primary Care Case Management — The provision or arrangement of enrollees’
primary care and the referral of enrollees for other necessary medical services
on a twenty-four hour (24–hour) basis.
Primary Care Provider (PCP) — A Health Plan staff or contracted physician
practicing as a general or family practitioner, internist, pediatrician,
obstetrician, gynecologist, advanced registered nurse practitioner, physician
assistant 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.
Protocols — Written guidelines or documentation outlining steps to be followed
for handling a particular situation, resolving a problem or implementing a plan
of medical, nursing, psychosocial, developmental and educational services.
Provider — A person or entity eligible to provide Medicaid services and that has
a contractual agreement with a Health Plan to provide services. PSN
fee-for-service providers must have an active Medicaid provider agreement. All
other providers must be eligible for a Medicaid provider agreement.
Provider Contract — An agreement between the Health Plan and a health care
provider to serve Health Plan enrollees.
Provider Service Network (PSN) — A network established or organized and operated
by a health care provider, or group of affiliated health care providers that
provides a substantial proportion of the health care items and services under a
contract directly through the provider or affiliated group of providers. The PSN
may make arrangements with physicians or other health care professionals, health
care institutions, or any combination of such individuals or institutions to
assume all or part of the financial risk on a prospective basis for the
provision of basic health services by the physicians, by other health
professionals, or through the institutions. The health care providers must have
a controlling interest in the governing body of the provider service network
organization. (See ss. 409.912(4)(d) and 409.91211(3)(e.), F.S.)
Public Event — An event that is organized or sponsored by an organization for
the benefit and education of or assistance to a community in regard to
health-related matters or public awareness. A Health Plan may sponsor a public
event if the event includes active
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

participation of at least one (1) community organization or two
(2) health-related organizations not affiliated with the Health Plan.
Quality — The degree to which a Health Plan increases the likelihood of desired
health outcomes of its enrollees through its structural and operational
characteristics and through the provision of health services that are consistent
with current professional knowledge.
Quality Enhancements – Certain health-related, community-based services that the
Health Plan must offer and coordinate access to for its enrollees, such as
children’s programs, domestic violence classes, pregnancy prevention, smoking
cessation, or substance abuse programs. Health Plans are not reimbursed by the
Agency for these types of services.
Quality Improvement (QI) — The process of monitoring that the delivery of health
care services is available, accessible, timely, and medically necessary. The
Health Plan must have a quality improvement program (QI program) that includes
standards of excellence. It also must have a written quality improvement plan
(QI plan) that draws on its quality monitoring to improve health care outcomes
for enrollees.
Registered Nurse (RN) — An individual who is licensed to practice professional
nursing in accordance with Chapter 464, F.S.
Remediation – The act or process of correcting a fault or deficiency.
Residential Services — As applied to the Department of Juvenile Justice, refers
to the out of-home placement for use in a level 4, 6, 8 or 10 facility as a
result of a delinquency disposition order. Also referred to as a residential
commitment program.
Risk Adjustment (also Risk-Adjusted) - (Reform only) — A process to adjust
capitation rates to reflect the health conditions relative to the health status
of the enrolled population. This process includes but is not limited to, risk
assessment models, demographics, or population grouping.
Risk Assessment — The process of collecting information from a person about
hereditary, lifestyle and environmental factors to determine specific diseases
or conditions for which the person is at risk.
Rural — An area with a population density of less than 100 individuals per
square mile, or an area defined by the most recent United States Census as
rural, i.e. lacking a metropolitan statistical area (MSA).
Rural Health Clinic (RHC) — A clinic that is located in an area that has a
health-care provider shortage. An RHC provides primary health care and related
diagnostic services and may provide optometric, podiatry, chiropractic and
behavioral health services. An RHC employs, contracts or obtains volunteer
services from licensed. health care practitioners to provide services.
Screen or Screening — Assessment of an enrollee’s physical or mental condition
to determine evidence or indications of problems and need for further evaluation
or services.
Service Area — The designated geographical area within which the Health Plan is
authorized by the Contract to furnish covered services to enrollees.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Service Authorization — The Health Plan’s approval for services to be rendered.
The process of authorization must at least include an enrollee’s or a provider’s
request for the provision of a service.
Service Location — Any location at which an enrollee obtains any health care
service provided by the Health Plan under the terms of the Contract.
Share of Cost-Savings — (FFS PSNs only) — Potential payment to the Health Plan
when amount of the savings pool exceeds the administrative allocation to the
Health Plan as determined through a reconciliation process.
Sick Care — Non-urgent problems that do not substantially restrict normal
activity, but could develop complications if left untreated (e.g., chronic
disease).
Span of Control — Information systems and telecommunications capabilities that
the Health Plan itself operates or for which it is otherwise legally responsible
according to the terms and conditions of this Contract. The span of control also
includes systems and telecommunications capabilities outsourced by the Health
Plan.
Special Supplemental Nutrition Program for Women, Infants & Children (WIC) —
Program administered by the Department of Health that provides nutritional
counseling; nutritional education; breast-feeding promotion and nutritious foods
to pregnant, postpartum and breast-feeding women, infants and children up to the
age of five (5) who are determined to be at nutritional risk and who have a low
to moderate income. An individual who is eligible for Medicaid is automatically
income eligible for WIC benefits. Additionally, WIC income eligibility is
automatically provided to an enrollee’s family that includes a pregnant woman or
infant certified eligible to receive Medicaid.
Specialty Plan – A Health Plan designed for a specific population and whose
enrollees are primarily composed of Medicaid recipients, children with chronic
conditions or for Medicaid Reform recipients who have been diagnosed with the
human immunodeficiency virus or acquired immunodeficiency syndrome (HIV/AIDS). A
Health Plan must be licensed under Chapter 641, F.S., in order to offer a
specialty plan for the Reform population with HIV/AIDS.
State — State of Florida.
Subcontract — An agreement entered into by the Health Plan for provision of
administrative services on its behalf related to this Contract.
Subcontractor — Any person or entity with which the Health Plan has contracted
or delegated some of its functions, services or responsibilities for providing
services under this Contract.
Subscriber Assistance Program – (HMOs only) — The state panel authorized under
s. 408.7056, F.S., that hears appeals from HMO enrollees whose complaints have
not been resolved through the Health Plan’s grievance and appeal process.
Surface Mail — Mail delivery via land, sea, or air, rather than via electronic
transmission.
Surplus — Net worth, i.e., total assets minus total liabilities.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

System Unavailability — As measured within the Health Plan’s information systems
span of control, when a system user does not get the complete, correct
full-screen response to an input command within three (3) minutes after
depressing the “enter” or other function key.
Systems — See Information Systems.
Temporary Assistance to Needy Families (TANF) — Public financial assistance
provided to low-income families through the Department of Children and Families.
Transportation — An appropriate means of conveyance furnished to an enrollee to
obtain Medicaid authorized/covered services.
Unborn Activation — The process by which an unborn child, who has been assigned
a Medicaid ID number, is made Medicaid eligible upon birth.
Urban — An area with a population density of greater than one-hundred (100)
individuals per square mile or an area defined by the most recent United States
Census as urban, i.e. as having a metropolitan statistical area (MSA).
Urgent Behavioral Health Care — Those situations that require immediate
attention and assessment within twenty-three (23) hours even though the enrollee
is not in immediate danger to self or others and is able to cooperate in
treatment.
Urgent Care — Services for conditions, which, though not life-threatening, could
result in serious injury or disability unless medical attention is received
(e.g., high fever, animal bites, fractures, severe pain, etc.) or do
substantially restrict an enrollee’s activity (e.g., infectious illnesses, flu,
respiratory ailments, etc.).
Validation — The review of information, data, and procedures to determine the
extent to which they are accurate, reliable, free from bias and in accord with
standards for data collection and analysis.
Vendor — An entity submitting a proposal to become a Health Plan contractor.
Violation — A determination by the Agency that a Health Plan failed to act as
specified in this Contract or applicable statutes, rules or regulations
governing Medicaid Health Plans. For the purposes of this Contract, each day
that an ongoing violation continues shall be considered to be a separate
violation. In addition, each instance of failing to furnish necessary and/or
required medical services or items to each enrollee shall be considered to be a
separate violation. As well, each day that a Health Plan fails to furnish
necessary and/or required medical services or items to enrollees shall be
considered to be a separate violation.
Voluntary Enrollee — A Medicaid recipient who is not mandated to enroll in a
Health Plan, but chooses to do so.
Voluntary Potential Enrollee — A Medicaid recipient who is not mandated to
enroll in a Health Plan, has expressed a desire to do so, but is not yet
enrolled in a health plan.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Well Care Visit — A routine medical visit for one of the following: CHCUP visit,
family planning, routine follow-up to a previously treated condition or illness,
adult physical or any other routine visit for other than the treatment of an
illness.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

B. Acronyms
ACCESS — Automated Community Connection to Economic Self-Sufficiency, the
Department of Children and Families public assistance service delivery system.
ADL — Activities of Daily Living
AHCA — Agency for Health Care Administration (Agency)
ALF — Assisted Living Facility
APD — Agency for People with Disabilities
ARNP – Advanced Registered Nurse Practitioner
BBA — Balanced Budget Act of 1997
BMHC — Bureau of Managed Health Care
CAP — Corrective Action Plan
CARES — Comprehensive Assessment & Review for Long-Term Care Services
CDC — Centers for Disease Control and Prevention
CFARS — Children’s Functional Assessment Rating Scales
CHD — County Health Department
CMS — Centers for Medicare & Medicaid Services
CFR — Code of Federal Regulations (cites may be searched online at:
www.qpoaccess.qov/cfr/retrieve.qtrril
CHCUP — Child Health Check-Up Program
CPT — Physicians’ Current Procedural Terminology
CTD — Commission for the Transportation Disadvantaged
CWPMHP — Child Welfare Prepaid Mental Health Plan
DCF — Department of Children & Families
DFS — Department of Financial Services
DHHS — United States Department of Health & Human Services
DOH — Department of Health
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

DJJ — Department of Juvenile Justice
DEA — Drug Enforcement Administration
DME — Durable Medical Equipment
EDI — Electronic Data Interchange
ET — Eastern Time
EH — Emotionally Handicapped
EPSDT — Early and Periodic Screening, Diagnosis & Treatment Program
EQR — External Quality Review
EQRO — External Quality Review Organization
EST — Eastern Standard Time
FAC — Florida Administrative Code
FARS — Functional Assessment Rating Scales
FFS — Fee-for-Service
FQHC — Federally Qualified Health Center
F.S. — Florida Statutes
FSFN — Florida Safe Families Network (formerly HomeSafeNet)
FTE — Full-Time Equivalent Position
HCBS — Home and Community Based Services
NEDIS — Healthcare Effectiveness Data and Information Set
HIRAA — Health Insurance Portability & Accountability Act
HMO — Health Maintenance Organization
HSA — Health Savings Account
HSD —Bureau of Health Systems Development
IBNR — Incurred But Not Reported
LEIE — List of Excluded Individuals & Entities
MBHO — Managed Behavioral Health Organization
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

MFCU — Medicaid Fraud Control Unit, Office of the Attorney General
MPI — Medicaid Program Integrity Bureau, Office of the AHCA Inspector General
NMHPA — Newborns and Mothers Health Protection Act
NCQA — National Committee for Quality Assurance
NPI — National Provider Identifier
ODBC — Open Database Connectivity
PA — Physician’s Assistant
PACE — Program of All-Inclusive Care for the Elderly
PCCB — Per Capita Capitation Benchmark
PCP — Primary Care Physician
PPEC — Prescribed Pediatric Extended Care
PDL — Preferred Drug List
PHI — Protected Health Information, as defined in 42 CFR 431.305(b)
PIP — Performance Improvement Plan
PMHP — Prepaid Mental Health Plan
PSN — Provider Service Network
QE — Quality Enhancement
QI — Quality Improvement
RFP — Request for Proposal
RHC — Rural Health Clinic
SAMH — Substance Abuse & Mental Health Office of the Florida Department of
Children & Families
SED — Severely Emotionally Disturbed
SFTP — Secure File Transfer Protocol
SIPP — Statewide Inpatient Psychiatric Program
SNIP — Strategic National Implementation Process
SOBRA — Sixth Omnibus Budget Reconciliation Act
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

     SQL — Structured Query Language
     SSI — Supplemental Security Income
     TANF — Temporary Assistance for Needy Families
     TGCS — Therapeutic Group Care Services
     LIM — Utilization Management
     WEDI — Workgroup for Electronic Data Interchange
     WIC — Special Supplemental Nutrition Program for Women, Infants & Children
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section II
General Overview

A.   Background

  1.   Florida has offered Medicaid services since 1970. In July 2006 a
demonstration pilot, also known as Medicaid Reform, began operating in Broward
and Duval Counties. The pilot was later extended to Nassau, Clay and Baker
Counties.     2.   In addition to its fee-for-service program, Medicaid
contracts with several types of organizations to provide services to recipients.
They are:

  a.   Reform capitated Health Plans (HMOs and PSNs)     b.   Reform
fee-for-service PSNs     c.   Reform specialty plan for children with chronic
conditions     d.   Reform specialty plan for recipients living with HIV/AIDS  
  e.   Non-Reform HMOs     f.   Non-Reform fee-for-service PSNs     g.  
Non-Reform capitated PSNs

B.   Purpose       Medicaid provides health care coverage for income-eligible
children, seniors, disabled adults and pregnant women. It is funded by both the
state and federal governments and includes both capitated health plans as well
as fee-for-service coverage. This attachment describes elements that are common
to all Medicaid Health Plans unless specifically noted otherwise. Provisions
unique to each Health Plan are described in Attachments I and II and their
exhibits.   C.   Responsibilities of the State of Florida (state) and the Agency
for Health Care Administration (Agency) (See Exhibit 2, Attachment II)

  1.   The Agency is responsible for administering the Medicaid program. The
Agency will administer contracts, monitor Health Plan performance, and provide
oversight in all aspects of Health Plan operations.     2.   The state has sole
authority for determining eligibility for Medicaid and whether Medicaid
recipients are required to enroll in, may volunteer to enroll in, may not enroll
in a Medicaid health plan or are subject to annual open enrollment.     3.   The
Agency or its agent will review the Florida Medicaid Management Information
System (FMMIS) file daily and will send written notification and information to
all potential enrollees.     4.   The Agency or its agent will use an
established algorithm to assign mandatory potential enrollees who do not select
a Health Plan during their thirty-day (30-day) choice period. The process may
differ for Reform and non-Reform populations as required by state law and
federally approved waivers.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  5.   Enrollment in a Health Plan, whether chosen or assigned, will be
effective at 12:01 a.m. on the first calendar day of the month following a
selection or assignment that occurs between the first calendar day of the month
and the penultimate Saturday of the month. For those enrollees who choose or are
assigned a Health Plan between the Sunday after the penultimate Saturday and
before the last calendar day of the month, enrollment in a Health Plan will be
effective on the first calendar day of the second month after choice or
assignment.     6.   The Agency or its agent will notify the Health Plan of an
enrollee’s selection or assignment to the Health Plan.     7.   The Agency or
its agent will send written confirmation to enrollees of the chosen or assigned
Health Plan. If the enrollee has not chosen a PCP, the confirmation notice will
advise the enrollee that a PCP will be assigned by the Health Plan. Notice to
the enrollee will be sent by surface mail. Notice to the Health Plan will be by
file transfer.     8.   Conditioned on continued eligibility, mandatory
enrollees have a lock-in period of twelve (12) consecutive months. After an
initial ninety (90) day change period, mandatory enrollees may disenroll from
the Health Plan only for cause. The Agency or its agent will notify enrollees at
least once every twelve (12) months, and for mandatory enrollees at least sixty
(60) calendar days before the lock-in period ends that an open enrollment period
exists giving them an opportunity to change health plans. Mandatory enrollees
who do not make a change during open enrollment will be deemed to have chosen to
remain with the current health plan, unless that health plan no longer
participates. In that case, the enrollee will be assigned to a new health plan.
    9.   The Agency or its agent will automatically re-enroll an enrollee into
the Health Plan in which the person was most recently enrolled if the enrollee
has a temporary loss of eligibility. “Temporary loss” is defined for purposes of
this Contract as less than sixty (60) calendar days for non-Reform enrollees and
less than one-hundred and eighty (180) calendar days for Reform enrollees. In
this instance, for mandatory enrollees, the lock-in period will continue as
though there had been no break in eligibility, keeping the original twelve
(12) month period.     10.   If a temporary loss of eligibility causes the
enrollee to miss the open enrollment period, the Agency or its agent will enroll
the person in the Health Plan in which he or she was enrolled before loss of
eligibility. The enrollee will have ninety (90) calendar days to disenroll
without cause.     11.   The Department of Children and Families (DCF) will
issue a Medicaid identification (ID) number to a newborn upon notification from
the Health Plan, the hospital, or other authorized Medicaid provider, consistent
with the unborn activation process described in Attachment II, Section III,
Eligibility and Enrollment.     12.   The Agency or its agent will notify
enrollees of their right to request disenrollment as described in Attachment II,
Section III, Eligibility and Enrollment, Item C., Disenrollment, sub-item 2.    
13.   The Agency or its agent will process all disenrollments from the Health
Plan. The Agency or its agent will make final determinations about granting
disenrollment requests and will notify the Health Plan by file transfer and the
enrollee by surface mail of any

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      disenrollment decision. Enrollees dissatisfied with an Agency
determination may request a Medicaid Fair Hearing.     14.   When disenrollment
is necessary because an enrollee loses Medicaid eligibility, disenrollment shall
be at the end of the month in which eligibility was lost.     15.   The Agency
and/or its agent shall determine the activities and behaviors that qualify for
contributions to the individual’s enhanced benefit account (Reform enrollees
only).     16.   The Agency will monitor Health Plan operations for compliance
with the provisions of the Contract and applicable federal and state laws and
regulations.

D.   General Responsibilities of the Health Plan (See Attachment I and
Attachment II, Exhibit 2)

  1.   The Health Plan shall comply with all provisions of this Contract,
including all attachments, applicable exhibits, Report Guide requirements and
any amendments and shall act in good faith in the performance of the Contract
provisions. The core provisions in Attachment II apply to all Health Plans
unless otherwise specifically noted. Health Plan specific provisions are in
Attachment I and the exhibits that accompany Attachments I and II. Attachment II
exhibits are numbered to correspond to section numbers.     2.   The Health Plan
shall verify that information it submits to the Agency or its agents is
accurate.     3.   The Health Plan shall develop and maintain written policies
and procedures to implement all provisions of this Contract.     4.   The Health
Plan shall submit all policies and procedures, model provider agreements and
amendments, all subcontracts (including behavioral health, if applicable), and
all other materials related to this Contract to the Bureau of Managed Health
Care (BMHC) for approval before implementation. Likewise, any changes in such
materials must be prior approved by BMHC before they take effect.

  a.   The Health Plan shall provide written materials to BMHC at least
forty-five (45) calendar days before the effective date of the change.     b.  
The Health Plan shall provide written notice of such changes affecting enrollees
to those enrollees at least thirty (30) calendar days before the effective date
of change.

  5.   The Health Plan agrees that failure to comply with all provisions of this
Contract may result in the assessment of sanctions and/or termination of the
Contract, in whole or in part, in accordance with Attachment II, Section XIV,
Sanctions.     6.   The Health Plan shall make enrollee materials, including the
preferred drug list, provider directory and enrollee handbook(s), available
online at the Health Plan’s website without requiring enrollee log-in.     7.  
The Health Plan shall comply with all pertinent Agency rules in effect
throughout the duration of the Contract.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  8.   The Health Plan shall comply with all current Florida Medicaid handbooks
(Handbooks) as noticed in the Florida Administrative Weekly (FAW), or
incorporated by reference in rules relating to the provision of services set
forth in Attachment II, Section V, Covered Services, and Section VI, Behavioral
Health Care, except where the provisions of the Contract alter the requirements
set forth in the Handbooks. In addition, the Health Plan shall comply with the
limitations and exclusions in the Handbooks, unless otherwise specified by this
Contract. In no instance may the limitations or exclusions imposed by the Health
Plan be more stringent than those specified in the Handbooks. The Health Plan
may not arbitrarily deny or reduce the amount, duration or scope of a required
service solely because of the diagnosis, type of illness, or condition. The
Health Plan may exceed these limits by offering expanded services, as described
in the exhibits of Attachment H.     9.   This Contract, including all
attachments and exhibits, represents the entire agreement between the Health
Plan and the Agency and supersedes all other contracts between the parties when
it is executed by duly authorized signatures of the Health Plan and the Agency.
Correspondence and memoranda of understanding do not constitute part of this
Contract. In the event of a conflict of language between the Contract and the
attachments, the provisions of the Contract shall govern, unless otherwise
noted. The Agency reserves the right to clarify any contractual relationship in
writing and such clarification shall govern. Pending final determination of any
dispute over any Agency decision, the Health Plan shall proceed diligently with
the performance of its duties as specified under the Contract and in accordance
with the direction of the Agency’s Division of Medicaid.     10.   The Health
Plan shall have a quality improvement program that ensures enhancement of
quality of care and emphasizes improving the quality of patient outcomes. The
Agency may restrict the Health Plan’s enrollment activities if the Health Plan
does not meet acceptable quality improvement and performance indicators, based
on HEDIS reports and other outcome measures to be determined by the Agency. Such
restrictions may include, but shall not be limited to, the termination of
mandatory assignments.     11.   The Health Plan shall demonstrate that it has
adequate knowledge of Medicaid programs, provision of health care services,
disease management initiatives, medical claims data, and the capability to
design and implement cost savings methodologies. The Health Plan shall
demonstrate the capacity for financial analyses, as necessary to fulfill the
requirements of this Contract. Additionally, the Health Plan shall meet all
requirements for doing business in the State of Florida.     12.   The Health
Plan may be required to provide to the Agency or its agent information or data
relative to this Contract. In such instances, and at the direction of the
Agency, the Health Plan shall fully cooperate with such requests and furnish all
information in a timely manner, in the format in which it is requested. The
Health Plan shall have at least thirty (30) calendar days to fulfill such ad hoc
requests.     13.   A Reform Health Plan shall fully cooperate with, and provide
necessary data to, the Agency and its agent for the design, management,
operations and monitoring of the Enhanced Benefits Program.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  14.   The Health Plan shall provide care management services and monitor
utilization of services through the prior authorization of claims for Medicaid
covered services for its enrollees.     15.   If the Health Plan is capitated by
the Agency for a covered service, then the Health Plan shall enroll all network
providers for such services who are not verified as Medicaid- enrolled providers
with the Agency’s fiscal agent, in the manner and format determined by the
Agency.     16.   The Health Plan shall collect and submit encounter data for
each Contract year in accordance with Attachment II, Section X, Administration
and Management. The Medicaid Encounter Data System Companion Guide is located on
the Medicaid web site http://ahca.mvflorida.com/Medicaid/meds/index.shtml. The
Health Plan shall ensure that its provision of provider information to the
Agency is sufficient to ensure that its providers are recognized as
participating providers of the Health Plan for choice counseling and encounter
data acceptance purposes.     17.   The Health Plan shall provide covered
services to enrollees as required for each enrollee without regard to the
frequency or cost of services relative to the amount paid pursuant to the
Contract. In the event of insolvency, the Health Plan shall cover continuation
of services to enrollees for the duration of the period for which payment has
been made, as well as for inpatient admissions up until discharge.     18.   The
Health Plan shall comply with all requirements of the Health Plan Report Guide
referenced in Attachment II, Section XII, Reporting Requirements.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section III
Eligibility and Enrollment
A. Eligibility (See Attachment II, Exhibit 3)
The following populations represent broad categories that contain multiple
eligibility groups. Certain exceptions may apply within the broad categories and
will be determined by the Agency.

  1.   Mandatory Populations

  a.   The categories of eligible recipients authorized to be enrolled in the
Health Plan are:

  (1)   Low Income Families and Children;     (2)   Sixth Omnibus Budget
Reconciliation Act (SOBRA) Children;     (3)   Supplemental Security Income
(SSI) Medicaid Only,     (4)   Refugees;     (5)   Title XXI MediKids, in
accordance with s. 409.8132, F.S., and     (6)   Medicaid Eligible Designated by
SOBRA/Aged and Disabled population (Meds AD) unless they otherwise meet a
requirement of a voluntary or excluded population.

  b.   Except as otherwise specified in this Contract, Title XXI
MediKids-eligible participants are entitled to the same conditions and services
as currently eligible Title XIX Medicaid recipients.

  2.   Voluntary Populations         The following categories describe
recipients who may enroll in a Health Plan but are not required to do so:

  a.   Foster care children/adolescents, including children/adolescents
receiving medical foster care services or receiving adoption assistance;     b.
  Individuals diagnosed with developmental disabilities, as defined by the
Agency, including those in the Developmental Disabilities Waiver;     c.  
Children with chronic conditions who are eligible to participate in the
Children’s Medical Services Program or a specialty plan for children with
chronic conditions but not enrolled in the program;     d.   Individuals with
Medicare coverage (dual eligible individuals with either Medicare Part B
coverage or Medicare Parts A and B coverage) who are not enrolled in a Medicare
Advantage Plan;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  e.   Children and adolescents who have an open case for services in the
Department of Children and Families’ Florida Safe Families Network
(FSFN) database system (formerly HomeSafenet) unless they otherwise meet a
requirement of a mandatory population or an excluded population;     f.   Women
enrolled in the Health Plan who change eligibility categories to the SOBRA
category due to their pregnancy will remain eligible for enrollment in the
Health Plan or may disenroll;     g.   Individuals who are residents in ALFs and
are not enrolled in an Assisted Living for the Elderly (ALE) waiver program and
are not otherwise in a mandatory population;     h.   For Reform populations,
individuals enrolled in Project AIDS Care (PAC) waiver unless they otherwise
meet a requirement of a mandatory or excluded population; and     i.  
Individuals enrolled in the Channeling Waiver, Aged and Disabled Adult Waiver,
Adult Cystic Fibrosis Waiver, Adult Day Health Care Waiver, Alzheimer’s Disease
Waiver, Traumatic Brain and Spinal Cord Injury Waiver, Familial Dysautonomia
Waiver, Family and Supported Living Waiver, or Model Waiver.

  3.   Excluded Populations         The following categories describe Medicaid
recipients who are not eligible to enroll in a Health Plan:

  a.   Pregnant women who have not enrolled in Medicaid prior to the effective
date of their SOBRA eligibility;     b.   Medicaid recipients who, at the time
of application for enrollment and/or at the time of enrollment, are living in an
institution, including a nursing facility (and have been CARES assessed),
Statewide Inpatient Psychiatric (SIPP) facility for individuals under the age of
21, an Intermediate Care Facility/Developmentally Disabled (ICFDD), a state
mental health hospital or a correctional facility;     c.   Medicaid recipients
whose Medicaid eligibility was determined through the Medically Needy program;  
  d.   Qualified Medicare Beneficiaries (QMBs), Special Low Income Medicare
Beneficiaries (SLMBs), or Qualified Individuals at Level 1 (QI-1s);     e.  
Medicaid recipients who have other creditable health care coverage, such as
TriCare or a private commercial health plan;     f.   Medicaid recipients who
reside in the following:

  (1)   Residential commitment programs/facilities operated through the
Department of Juvenile Justice (DJJ);     (2)   Residential group care operated
by the Family Safety & Preservation Program of Department of Children and
Families (DCF);

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (3)   Children’s residential treatment facilities purchased through the
Substance Abuse & Mental Health District (SAMH) Offices of DCF (also referred to
as Purchased Residential Treatment Services — PRTS);     (4)   SAMH residential
treatment facilities licensed as Level I and Level II facilities; and     (5)  
Residential Level I and Level II substance abuse treatment programs. (See ss.
65D-30.007(2)(a) and (b), F.A.C.);

  g.   Medicaid recipients participating in the Family Planning Waiver;     h.  
Title XXI-funded children with chronic conditions who are enrolled in Children’s
Medical Services Network;     i.   Women eligible for Medicaid due to breast
and/or cervical cancer;     j.   Individuals eligible under a hospice-related
eligibility group or receiving hospice services;     k.   Individuals enrolled
in the Nursing Home Diversion Program or the Program of All Inclusive Care for
the Elderly (PACE);     l.   For non-Reform populations, individuals enrolled in
the PAC Waiver; and     m.   For Reform populations and non-Reform HMO
populations, Medicaid recipients who are members of the Florida Assertive
Community Treatment Team (FACT team) unless they disenroll from the FACT team.
These recipients are allowed to enroll in non-Reform PSNs.

B. Enrollment (See Attachment I and Attachment II, Exhibit 3)

  1.   General Provisions

  a.   Only Medicaid recipients who meet eligibility requirements in Attachment
II and are living in counties with authorized Health Plans are eligible to
enroll and receive services from the Health Plan.     b.   The Agency or its
agent shall be responsible for enrollment, including enrollment into the Health
Plan, disenrollment, and outreach and education activities. The Health Plan
shall coordinate with the Agency and its agent as necessary for all enrollment
and disenrollment functions.     c.   The Health Plan shall accept Medicaid
recipients without restriction and in the order in which they enroll. The Health
Plan shall not discriminate on the basis of religion, gender, race, color, age,
or national origin, health status, pre-existing condition, or need for health
care services and shall not use any policy or practice that has the effect of
such discrimination.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  d.   The Health Plan shall accept new enrollees throughout the Contract period
up to the authorized maximum enrollment levels approved in Attachment I.     e.
  Each month the Health Plan shall review its X12-834 enrollment files to ensure
that all enrollees are residing in the same county in which they were enrolled.
The Health Plan shall update the records for all enrollees who have moved from
one county to another but are still residing in the Health Plan’s service area
and provide those enrollees with a new provider directory for that county, if
necessary or requested.

  2.   Enrollment in a Specialty Plan (See Attachment II, Exhibit 3)     3.  
Unborn Activation and Newborn Enrollment (See Attachment II, Exhibit 3)

  a.   The Health Plan shall use the unborn activation process to facilitate
enrollment and shall be responsible for newborns from the date their enrollment
in the Health Plan is effective. The Health Plan shall comply with all
requirements set forth by the Agency or its agent related to unborn activation.
    b.   Upon unborn activation, during the next enrollment cycle the newborn
shall be enrolled in the mother’s Health Plan. If no unborn eligibility record
exists, the Health Plan shall follow the process described in subparagraph d.
below.     c.   Unborn activation shall occur through the following procedures:

  (1)   Upon identification of an enrollee’s pregnancy through medical history,
examination, testing, claims, or otherwise, the Health Plan shall immediately
notify DCF of the pregnancy and any relevant information known (for example, due
date and gender). The Health Plan must provide this notification by completing
the DCF Excel spreadsheet and submitting it, via electronic mail, to the
appropriate DCF Customer Call Center address and copied to MPI at email:
mcobabvahca.mvflorida.com. The Health Plan shall indicate its name and number as
the entity initiating the referral. The DCF Excel spreadsheet and directions for
completion are located on the Medicaid web site:
http://ahca.myflorida.com/Medicaid/Newborn/index.shtml.     (2)   DCF will
generate a Medicaid ID number for the unborn child. This information will be
transmitted to the Medicaid fiscal agent. The Medicaid ID number will remain
inactive until the child is born and DCF is notified of the birth.     (3)  
Upon notification that a pregnant enrollee has presented to the hospital for
delivery, the Health Plan shall inform the hospital, the pregnant enrollee’s
attending physician and the newborn’s attending and consulting physicians that
the newborn is an enrollee only if the Health Plan has verified that the newborn
has an unborn record on the system that is awaiting activation. At this time the
Health Plan or its designee shall complete and submit the Excel spreadsheet for
unborn activation to DCF, and to IVIPI for its information. (Special provisions
apply to fee-for-service PSNs; see Exhibit 3.)     (4)   E-mail submissions
shall include the password-protected spreadsheet as an attachment, and the
spreadsheet shall contain all pregnancy notifications and

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      newborn births for that Health Plan (or that Health Plan’s designated
subcontractor). Each Health Plan (or Health-Plan-designated subcontractor) shall
send no more than one (1) e-mail submission, per day, to each DCF customer call
center region based on the enrollee’s region of residence. (Refer to the
Medicaid website referenced above for DCF customer call center information.)    
(5)   With regard to participating hospitals, the Health Plan shall include, as
part of its participating hospital contract, a clause that states whether the
Health Plan or the hospital will complete the DCF Excel spreadsheet for unborn
activation (see Attachment II, Section XVI, Terms and Conditions).     (6)   The
Health Plan shall periodically check Medicaid eligibility to determine if the
baby’s Medicaid ID has been activated. Frequent monitoring is recommended.
Monitoring may be done through the following:

  (a)   The Health Plan’s contracted Medicaid Eligibility Vendor System (MEVS);
    (b)   The Medicaid Fiscal Agent’s toll-free provider inquiry line and asking
a representative for assistance;     (c)   The Medicaid Automated Voice Response
System (AVRS); or     (d)   The X12-270 transmission to the Medicaid fiscal
agent.

  (7)   If the unborn activation process is properly completed by the capitated
Health Plan, then the newborn will be enrolled in the Health Plan retroactive to
birth.     (8)   If the unborn activation process is properly completed by the
FFS PSN, the newborn will be enrolled using the process in Attachment II,
Exhibit 3.     (9)   Failure to use the unborn activation process for known
pregnancies per subparagraph(s) c.(1), (3), (5) and (6) above shall result in
sanctions as described in Attachment II, Section XIV, Sanctions.

  d.   If a pregnant enrollee presents for delivery without having an unborn
eligibility record that is awaiting activation, the Health Plan or designee
shall submit the spreadsheet to DCF immediately upon birth of the child. The
newborn will not automatically become a Health Plan enrollee upon birth.

  4.   Stopping or Limiting Enrollment         The Health Plan may ask the
Agency to halt or reduce enrollment temporarily if continued full enrollment
would exceed the Health Plan’s capacity to provide required services under the
Contract. The Agency may also limit Health Plan enrollments when such action is
considered to be in the Agency’s best interest in accordance with the provisions
of this Contract.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

C. Disenrollment (See Attachment II, Exhibit 3)

  1.   General Provisions

  a.   If the Contract is renewed, the enrollment status of all enrollees shall
continue uninterrupted.     b.   The Health Plan shall ensure that it does not
restrict the enrollee’s right to disenroll voluntarily in any way.     c.   The
Health Plan or its agents shall not provide or assist in the completion of a
disenrollment request or assist the Agency’s contracted choice
counselor/enrollment broker in the disenrollment process.     d.   The Health
Plan shall ensure that enrollees that are disenrolled and wish to file an appeal
have the opportunity to do so. All enrollees shall be afforded the right to file
an appeal on disenrollment except for the following reasons:

  (1)   Moving out of the service area;     (2)   Loss of Medicaid eligibility;
    (3)   Determination that an enrollee is in an excluded population, as
defined in Attachment II, Section III, Eligibility and Enrollment, Item A.,
Eligibility, sub-item 3., Excluded Populations; or     (4)   Enrollee death.

  e.   An enrollee subject to open enrollment may submit to the Agency or its
agent a request to disenroll from the Health Plan. This may be done without
cause during the ninety (90) calendar day change period following the date of
the enrollee’s initial enrollment with the Health Plan, or the date the Agency
or its agent sends the enrollee notice of the enrollment, whichever is later. An
enrollee may request disenrollment without cause every twelve (12) months
thereafter during the annual open enrollment period. Those not subject to open
enrollment may disenroll at any time.     f.   The effective date of an approved
disenrollment shall be the last calendar day of the month in which disenrollment
was made effective by the Agency or its agent. In no case shall disenrollment be
later than the first calendar day of the second month following the month in
which the enrollee or the Health Plan files the disenrollment request. If the
Agency or its agent fails to make a disenrollment determination within this
timeframe, the disenrollment is considered approved.

  2.   When Disenrollment Can Occur         An enrollee may request
disenrollment at any time. The Agency or the choice counselor/enrollment broker
performs disenrollment as follows:

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  HMO Contract

  a.   For cause at any time (see below for list of for-cause reasons), or    
b.   Without cause, for enrollees subject to open enrollment, at the following
times:

  (1)   During the ninety (90) days following the enrollee’s initial enrollment,
or the date the Agency or its agent sends the enrollee notice of the enrollment,
whichever is later;     (2)   At least every twelve (12) months;     (3)   If
the temporary loss of Medicaid eligibility has caused the enrollee to miss the
open enrollment period;     (4)   When the Agency or its agent grants the
enrollee the right to terminate enrollment without cause (done on a case-by-case
basis); or     (5)   (Reform Only) If the individual chooses to opt out and
enroll in an employer- sponsored health plan.

  c.   Without cause, for enrollees not subject to open enrollment, at any time.

  3.   Cause for Disenrollment

  a.   A mandatory enrollee may request disenrollment from the Health Plan for
cause at any time. Such request shall be submitted to the Agency or its agent.
The following reasons constitute cause for disenrollment from the Health Plan:

  (1)   The enrollee moves out of the county, or the enrollee’s address is
incorrect and the enrollee does not live in a county where the Health Plan is
authorized to provide services.     (2)   The provider is no longer with the
Health Plan.     (3)   The enrollee is excluded from enrollment.     (4)   A
substantiated marketing or community outreach violation has occurred.     (5)  
The enrollee is prevented from participating in the development of his/her
treatment plan.     (6)   The enrollee has an active relationship with a
provider who is not on the Health Plan’s panel, but is on the panel of another
health plan.     (7)   The enrollee is in the wrong health plan as determined by
the Agency.     (8)   The Health Plan no longer participates in the county.    
(9)   The state has imposed intermediate sanctions upon the Health Plan, as
specified in 42 CFR 438.702(a)(3).

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  HMO Contract

  (10)   The enrollee needs related services to be performed concurrently, but
not all related services are available within the Health Plan network. or the
enrollee’s PCP has determined that receiving the services separately would
subject the enrollee to unnecessary risk.     (11)   The Health Plan does not,
because of moral or religious objections, cover the service the enrollee seeks.
    (12)   The enrollee missed open enrollment due to a temporary loss of
eligibility, defined as sixty (60) days or less for non-Reform populations and
one-hundred and eighty (180) days or less for Reform populations.     (13)  
Other reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor
quality of care; lack of access to services covered under the Contract;
inordinate or inappropriate changes of PCPs; service access impairments due to
significant changes in the geographic location of services; lack of access to
providers experienced in dealing with the enrollee’s health care needs; or
fraudulent enrollment.

  b.   Voluntary enrollees may disenroll from the Health Plan at any time.

  4.   Involuntary Disenrollment Requests (See Attachment II, Exhibit 3)

  a.   With proper written documentation, the following are acceptable reasons
for which the Health Plan may submit involuntary disenrollment requests to the
Agency or its agent:

  (1)   Fraudulent use of the enrollee ID card. In such cases the Health Plan
shall report the event to MPI.     (2)   The enrollee’s behavior is disruptive,
unruly, abusive or uncooperative to the extent that enrollment in the Health
Plan seriously impairs the organization’s ability to furnish services to either
the enrollee or other enrollees.

  (a)   This section does not apply to enrollees with mental health diagnoses if
the enrollee’s behavior is attributable to the mental illness.     (b)   An
involuntary disenrollment request related to enrollee behavior must include
documentation that the Health. Plan:

  (i)   Provided the enrollee at least one (1) oral warning and at least one
(1) written warning of the full implications of the enrollee’s actions;     (ii)
  Attempted to educate the enrollee regarding rights and responsibilities;    
(iii)   Offered assistance through case management that would enable the
enrollee to comply;     (iv)   Determined that the enrollee’s behavior is not
related to the enrollee’s medical or behavioral condition.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  b.   The Health Plan shall promptly submit such disenrollment requests to
BMHC. In no event shall the Health Plan submit a disenrollment request at such a
date as would cause the disenrollment to be effective later than forty-five
(45) calendar days after the Health Plan’s receipt of the reason for involuntary
disenrollment. The Health Plan shall ensure that involuntary disenrollment
documents are maintained in an identifiable enrollee record.     c.   All
requests will be reviewed on a case-by-case basis and subject to the sole
discretion of the Agency. Any request not approved is final and not subject to
Health Plan dispute or appeal.     d.   The Health Plan shall not request
disenrollment of an enrollee due to:

  (1)   Health diagnosis;     (2)   Adverse changes in an enrollee’s health
status;     (3)   Utilization of medical services;     (4)   Diminished mental
capacity;     (5)   Pre-existing medical condition;     (6)   Uncooperative or
disruptive behavior resulting from the enrollee’s special needs (with the
exception of Item C., Disenrollment, sub-item 4.a.(2)(b) above);     (7)  
Attempt to exercise rights under the Health Plan’s grievance system;     (8)  
Request of one (1) PCP to have an enrollee assigned to a different provider out
of the Health Plan.

  e.   When the Health Plan requests an involuntary disenrollment, it shall
notify the enrollee in writing that the Health Plan is requesting disenrollment,
the reason for the request, and an explanation that the Health Plan is
requesting that the enrollee be disenrolled in the next Contract month, or
earlier if necessary. Until the enrollee is disenrolled, the Health Plan shall
be responsible for the provision of services to that enrollee.

  5.   Disenrollment Notice (See Attachment II, Exhibit 3)         Each month
the Health Plan shall review its X12-834 enrollment files to determine which
enrollees were disenrolled due to moving outside the service area. Non-Reform
Health Plans shall send notice of disenrollment to all such recipients with
instructions to contact the choice counselor/enrollment broker to make a plan
choice in the new service area.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section IV
Enrollee Services, Community Outreach and Marketing
A. Enrollee Services

  1.   General Provisions

  a.   The Health Plan shall ensure that enrollees are notified of their rights
and responsibilities, the role of PCPs, how to obtain care, what to do in an
emergency or urgent medical situation, how to pursue a complaint, a grievance,
appeal or Medicaid Fair Hearing, how to report suspected fraud and abuse,
procedures for obtaining required behavioral health services, including any
additional Health Plan telephone numbers to be used for obtaining services, and
all other requirements and benefits of the Health Plan.     b.   The Health Plan
shall have the capability to answer enrollee inquiries through written
materials, telephone, electronic transmission, and face-to-face communication.  
  c.   Mailing envelopes for enrollee materials shall contain a request for
address correction. When enrollee materials are returned to the Health Plan as
undeliverable, the Health Plan shall use and maintain in a file a record of all
of the following methods to contact the enrollee:

  (1)   Telephone contact at the number obtained from the local telephone
directory, directory assistance, city directory, or other directory;     (2)  
Routine checks (at least once a month for the first three (3) months of
enrollment) on services or claims authorized or denied by the Health Plan to
determine if the enrollee has received services, and to locate updated address
and telephone number information.

  d.   New enrollee materials are not required for a former enrollee who was
disenrolled because of the loss of Medicaid eligibility and who regains
eligibility within sixty (60) days for a non-Reform enrollee and one-hundred and
eighty (180) days for a Reform enrollee and is automatically reinstated in the
Health Plan. In addition, unless requested by the enrollee, new enrollee
materials are not required for a former enrollee subject to open enrollment who
was disenrolled because of the loss of Medicaid eligibility, regains eligibility
within the time specified in this paragraph and is reinstated as a Health Plan
enrollee. A notation of the effective date of the reinstatement is to be made on
the most recent application or conspicuously identified in the enrollee’s
administrative file. Enrollees who were previously enrolled in a Health Plan,
and who lose and regain eligibility after the specified number of days for
Reform or non-Reform, will be treated as new enrollees.     e.   The Health Plan
shall notify, in writing, each person who is to be reinstated, of the effective
date of the reinstatement and the assigned primary care physician. The
notifications shall distinguish between enrollees subject to open enrollment and
those who are not and shall include information about change procedures for
cause, or general health plan change procedures through the Agency’s toll-free
choice counselor/enrollment broker telephone number as appropriate. The
notification shall also instruct the enrollee to contact the Health Plan if a
new enrollee card and/or a

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      new enrollee handbook are needed. The Health Plan shall provide such
notice to each affected enrollee by the first calendar day of the month
following the Health Plan’s receipt of the notice of reinstatement or within
five (5) calendar days from receiving the enrollment file, whichever is later.

  2.   Requirements for Written Material

  a.   The Health Plan shall make all written materials available in alternative
formats and in a manner that takes into consideration the enrollee’s special
needs, including those who are visually impaired or have limited reading
proficiency. The Health Plan shall notify all enrollees and, upon request,
potential enrollees that information is available in alternative formats and how
to access those formats.     b.   The Health Plan shall make all written
material available in English, Spanish, and all other appropriate foreign
languages. The appropriate foreign languages comprise all languages in the
Health Plan service area spoken by approximately five percent (5%) or more of
the total population. Upon request, the Health Plan shall provide, free of
charge, interpreters for potential enrollees or enrollees whose primary language
is not English.     c.   The Health Plan shall provide enrollee information in
accordance with 42 CFR 438.10, which addresses information requirements related
to written and oral information provided to enrollees, including: languages;
format; Health Plan features, such as benefits, cost sharing, service area,
provider network and physician incentive plans; enrollment and disenrollment
rights and responsibilities; grievance system; and advance directives. -I-he
Health Plan shall notify enrollees on at least an annual basis of their right to
request and obtain information in accordance with the above requirements.     d.
  All written materials and web sites shall be at or near the fourth (4th) grade
comprehension level. Suggested reference materials to determine whether the
written materials meet this requirement are:

  (1)   Fry Readability Index;     (2)   PROSE The Readability Analyst (software
developed by Education Activities, Inc.);     (3)   Gunning FOG Index;     (4)  
McLaughlin SMOG Index;     (5)   The Flesch-Kincaid Index; and/or     (6)  
Other software approved by the Agency.

  3.   New Enrollee Materials

  a.   By the first day of the assigned enrollee’s enrollment or within five
(5) calendar days following receipt of the enrollment file from Medicaid or its
agent, whichever is later, the Health Plan shall mail to the new enrollee: the
enrollee handbook; the provider directory; the enrollee identification card; and
the following additional materials:

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (1)   The actual date of enrollment and the name, telephone number and address
of the enrollee’s PCP assignment;     (2)   The enrollee’s right to choose a
different PCP;     (3)   An explanation that enrollees may choose to have all
family members served by the same PCP or may choose different PCPs;     (4)  
Procedures for changing PCPs, including notice of the Health Plan’s toll-free
member services telephone number, etc.;     (5)   The enrollees’ right to change
their health plan selections, subject to Medicaid limitations;     (6)   A
request to update the enrollee’s name, address (home and mailing), county of
residence, and telephone number;     (7)   A notice that enrollees who lose
eligibility and are disenrolled shall be automatically re-enrolled in the Health
Plan if eligibility is regained within sixty (60) days for non-Reform
participants and one-hundred and eighty (180) days for Reform participants; and
    (8)   A postage-paid, pre-addressed return envelope.

  b.   Each mailing shall be documented in the Health Plan’s records.     c.  
Materials may be sent in separate mailings.

  4.   Enrollee ID Card         The enrollee ID card shall include, at a
minimum:

  a.   The enrollee’s name and Medicaid ID number;     b.   The Health Plan’s
name, address and enrollee services number; and     c.   A telephone number that
a non-contracted provider may call for billing information.

  5.   Enrollment with a Primary Care Provider (PCP)

  a.   The Health Plan shall offer each enrollee a choice of PCPs. After making
a choice, each enrollee shall have a single or group PCP.     b.   The Health
Plan shall assign a PCP to those enrollees who did not choose a PCP at the time
of health plan selection. The Health Plan shall take into consideration the
enrollee’s last PCP (if the PCP is known and available in the Health Plan’s
network), closest PCP to the enrollee’s ZIP code location, keeping
children/adolescents within the same family together, and age (adults versus
children/adolescents).     c.   The Health Plan shall permit enrollees to
request to change PCPs at any time. If the enrollee request is not received by
the Health Plan’s established monthly cut-off date

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      for system processing, the PCP change will be effective the first day of
the next month.     d.   The Health Plan shall assign all enrollees that are
reinstated after a temporary loss of eligibility to the PCP who was treating
them prior to loss of eligibility, unless the enrollee specifically requests
another PCP, the PCP no longer participates in the Health Plan or is at
capacity, or the enrollee has changed geographic areas.

  6.   Enrollee Handbook Requirements

  a.   The Health Plan shall have separate enrollee handbooks for Reform and
non-Reform populations. The handbooks shall include the following information:

  (1)   Table of contents;     (2)   Terms, conditions and procedures for
enrollment including the reinstatement process and enrollee rights and
protections;     (3)   Description of the ninety (90) day change period and the
open enrollment process (see subparagraph (15), below, for required standardized
language);     (4)   How to change PCPs;     (5)   Description of services
provided, including limitations and general restrictions on provider access,
exclusions and out-of-network use, and any restrictions on enrollee freedom of
choice among network providers;     (6)   Procedures for obtaining required
services, including second opinions, and authorization requirements, including
those services available without prior authorization;     (7)   Information
regarding newborn enrollment, including the mother’s responsibility to notify
the Health Plan and DCF of the pregnancy and the newborn’s birth;     (8)  
Information about how to select the newborn’s PCP;     (9)   Emergency services
and procedures for obtaining services both in and out of the Health Plan’s
service area, including explanation that prior authorization is not required for
emergency or post-stabilization services, the locations of any emergency
settings and other locations at which providers and hospitals furnish emergency
services and post-stabilization care services, use of the 911- telephone system
or its local equivalent, and other post-stabilization requirements in 42 CFR
422.113(c);     (10)   The extent to which, and how, after-hours and emergency
coverage is provided, and that the enrollee has a right to use any hospital or
other setting for emergency care;     (11)   Enrollee rights and
responsibilities, including the extent to which and how enrollees may obtain
services from out-of-network providers; the right to obtain family planning
services from any participating Medicaid provider without prior authorization;
and other provisions in accordance with 42 CFR 438.100;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (12)   Information about the Subscriber Assistance Program (SAP, for HMOs
only) and the Beneficiary Assistance program (BAP, for PSNs only) and the
Medicaid Fair Hearing process, including an explanation that a review by the
SAP/BAP must be requested within one (1) year after the date of the occurrence
that initiated the appeal, how to initiate a review by the SAP/BAP and the
SAP/BAP address and telephone number:         Agency for Health Care
Administration
Subscriber Assistance Program/Beneficiary Assistance Program
Building 1, MS #26
2727 Mahan Drive, Tallahassee, FL 32308
(850) 921-5458
(888) 419-3456 (toll-free)     (13)   Clear specifics on the required procedural
steps in the grievance process, including the address, telephone number and
office hours of the grievance staff. The Health Plan shall specify telephone
numbers to call to present a complaint, grievance, or appeal. Each telephone
number shall be toll-free within the caller’s geographic area and provide
reasonable access to the Health Plan without undue delays;     (14)  
Information that services will continue upon appeal of a denied authorization
and that the enrollee may have to pay in case of an adverse ruling;     (15)  
Enrollee rights and procedures for enrollment and disenrollment, including the
toll-free telephone number for the Agency’s contracted choice
counselor/enrollment broker. The Health Plan shall include the following
language verbatim in the enrollee handbook:

Enrollment:
If you are a mandatory enrollee required to enroll in a plan, once you are
enrolled in [INSERT HEALTH PLAN NAME] or the state enrolls you in a plan, you
will have 90 days from the date of your first enrollment to try the health plan.
During the first 90 days you can change health plans for any reason. After the
90 days, if you are still eligible for Medicaid, you will be enrolled in the
plan for the next nine months. This is called “lock-in.”
Open Enrollment:
If you are a mandatory enrollee, the state will send you a letter 60 days before
the end of your enrollment year telling you that you can change plans if you
want to. This is called “open enrollment.” You do not have to change health
plans. If you choose to change plans during open enrollment, you will begin in
the new plan at the end of your current enrollment year. Whether you pick a new
plan or stay in the same plan, you will be locked into that plan for the next
12 months. Every year you can change health plans during your 60 day open
enrollment period.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Disenrollment:
If you are a mandatory enrollee and you want to change plans after the initial
90 day period ends or after your open enrollment period ends, you must have a
state-approved good cause reason to change plans. The following are state-
approved cause reasons to change health plans: [INSERT CAUSE LIST LANGUAGE
VERBATIM FROM SECTION III, ELIGIBILITY AND ENROLLMENT, ITEM C., DISENROLLMENT,
SUB-ITEM 3.A., CAUSE FOR DISENROLLMENT].

  (16)   Procedures for filing a request for disenrollment for cause. As noted
in subparagraph (15), the state-approved for-cause reasons listed in Attachment
II, Section III, Eligibility and Enrollment, Item C., Disenrollment, sub-item
3.,a. shall be listed verbatim in the disenrollment section of the enrollee
handbook. In addition, the Health Plan shall include the following language
verbatim in the disenrollment section of the enrollee handbook:

Some Medicaid recipients can change health plans whenever they choose, for any
reason. For example, people who are eligible for both Medicaid and Medicare
benefits and children who receive SSI benefits can change plans at any time for
any reason. To find out if you can change plans, call the [INSERT EITHER “CHOICE
COUNSELOR” OR “ENROLLMENT BROKER” AND APPROPRIATE TELEPHONE NUMBER].

  (17)   Information that interpretation services and alternative communication
systems are available, free of charge, including for all foreign languages and
vision and hearing impairment, and how to access these services;     (18)  
Information regarding health care advance directives pursuant to ss. 765.302
through 765.309, F.S., 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128, as follows:

  (a)   The Health Plan shall provide these policies and procedures to all
enrollee’s age 18 and older and shall advise enrollees of:

  (i)   Their rights under state law, including the right to accept or refuse
medical or surgical treatment and the right to formulate advance directives; and
    (ii)   The Health Plan’s written policies respecting the implementation of
those rights, including a statement of any limitation regarding the
implementation of advance directives as a matter of conscience.

  (b)   The information must include a description of state law and must reflect
changes in state law as soon as possible, but no later than ninety (90) calendar
days after the effective change.     (c)   The Health Plan’s information shall
inform enrollees that complaints about non-compliance with advance directive
laws and regulations may be filed with the state’s complaint hotline.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (d)   The Health Plan shall educate enrollees about their ability to direct
their care using this mechanism and shall specifically designate which staff
and/or network providers are responsible for providing this education.

  (19)   Cost sharing for the enrollee, if any;     (20)   How and where to
access any benefits that are available under the Medicaid State Plan but are not
covered under this Contract, including any cost sharing;     (21)   Instructions
explaining how enrollees may obtain information from the Health Plan about how
it rates on performance measures in specific areas of service;     (22)   How to
obtain information from the Health Plan about quality enhancements;     (23)  
Procedures for reporting fraud, abuse and overpayment that includes the
following specific language:

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer
Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and
Abuse Complaint Form, which is available online at
https://ahcaxnet.fdhc.state.fl.us/InspectorGeneral/fraudcomplaintform. aspx;

  (24)   Information regarding HIPAA relative to the enrollee’s personal health
information (PHI);     (25)   Toll-free telephone number of the appropriate Area
Medicaid Office;     (26)   Information to help the enrollee assess a potential
behavioral health problem;     (27)   How to get information about the structure
and operation of the Health Plan and any physician incentive plans, as set forth
in 42 CFR 438.10(g)(3);     (28)   (Reform Health Plans and non-Reform HMOs) A
separate section for behavioral health services that provides the following
information:

  (a)   The extent to which and how after-hours and emergency coverage is
provided and that the enrollee has a right to use any hospital or other setting
for emergency care;     (b)   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);     (c)   A clear statement that the
enrollee may select an alternative behavioral health case manager or direct
service provider within the Health Plan, if one is available;     (d)   A
description of behavioral health services provided, including limitations,
exclusions and out-of-network use;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (e)   A description of emergency behavioral health services procedures both in
and out of the Health Plan’s service area.

  (29)   (Reform Health Plans Only) Information on the enhanced benefit program
and how to access the enrollee’s enhanced benefit account.

  b.   For a counseling or referral service that the Health Plan does not cover
because of moral or religious objections, the Health Plan need not furnish
information on how and where to obtain the service.

  7.   Provider Directory

  a.   The Health Plan shall mail a provider directory to all new enrollees,
including those who reenrolled after the open enrollment period. The Health Plan
shall provide the most recently printed provider directory and append to it a
list of the providers who have left the network and those who have been added
since the directory was printed. In lieu of the appendix to the provider
directory the Health Plan may enclose a letter stating that the most current
listing of providers is available by calling the Health Plan at its toll-free
telephone number and at the Health Plan’s website. The letter shall include the
telephone number and the Internet address that will take the enrollee directly
to the online provider directory.     b.   The provider directory shall include
the names, locations, office hours, telephone numbers of, and non-English
languages spoken by current Health Plan providers. The provider directory shall
include, at a minimum, information relating to PCPs, specialists, pharmacies,
hospitals, certified nurse midwives and licensed midwives, and ancillary
providers. The provider directory also shall identify providers that are not
accepting new patients. The provider directory shall also include information on
how to determine a provider’s hospital affiliations. Such information must be
available online and through customer service.     c.   The Health Plan shall
maintain an online provider directory containing all the information described
in subsection 7.b., above. The Health Plan shall update the online provider
directory at least monthly. The Health Plan shall file an attestation to this
effect with BMHC each month, even if no changes have occurred.     d.   If a
Health Plan elects to use a more restrictive pharmacy network than the network
available to people enrolled in the Medicaid fee-for-service program, then the
provider directory must include the names of the participating pharmacies. If
all pharmacies are part of a chain and all within the Health Plan’s service area
are under contract with the Health Plan, the provider directory need list only
the chain name.     e.   In accordance with s. 1932(b)(3) of the Social Security
Act, the provider directory shall include a statement that some providers may
choose not to perform certain services based on religious or moral beliefs.    
f.   The Health Plan shall arrange the provider directory as follows:

  (1)   Providers listed by name in alphabetical order, showing the provider’s
specialty;     (2)   Providers listed by specialty, in alphabetical order; and

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  HMO Contract

  (3)   (Reform Health Plans and non-Reform HMOs only) Behavioral health
providers listed in a separate section by county and by provider type, where
applicable.

  g.   The Health Plan shall have procedures to inform potential enrollees and
enrollees, upon request, of any changes to service delivery and/or the provider
network including the following:

  (1)   Up-to-date information about any restrictions on access to providers,
including providers who are not taking new patients;     (2)   An explanation to
all potential enrollees that an enrolled family may choose to have all family
members served by the same PCP or they may choose different PCPs based on each
family member’s needs;     (3)   Any restrictions on counseling and referral
services based on moral or religious grounds within ninety (90) days after
adopting the policy with respect to any service.

  8.   New Enrollee Procedures

  a.   The Health Plan shall contact each new enrollee at least twice, if
necessary, within ninety (90) calendar days of the enrollee’s enrollment to
offer to schedule the enrollee’s initial appointment with the PCP, which should
occur within one-hundred and eighty (180) days of enrollment. This appointment
is to obtain a health risk assessment and/or CHCUP screening. For this
subsection “contact” is defined as mailing a notice to or telephoning an
enrollee at the most recent address or telephone number available.     b.  
Within thirty (30) calendar days of enrollment, the Health Plan shall ask the
enrollee to authorize release of the medical and behavioral health records to
the new PCP or other appropriate provider and shall assist by requesting those
records from the enrollee’s previous provider(s).     c.   The Health Plan shall
honor any written documentation of prior authorization of ongoing covered
services for a period of thirty (30) calendar days after the effective date of
enrollment, or until the enrollee’s PCP reviews the enrollee’s treatment plan,
whichever comes first.     d.   For all enrollees, written documentation of
prior authorization of ongoing services includes the following, provided that
the services were prearranged prior to enrollment with the Health Plan:

  (1)   Prior existing orders;     (2)   Provider appointments, e.g. dental
appointments, surgeries, etc.; and     (3)   Prescriptions (including
prescriptions at non-participating pharmacies).

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  HMO Contract

  e.   The Health Plan shall not delay service authorization if written
documentation is not available in a timely manner. However, the Health Plan is
not required to approve claims for which it has received no written
documentation.

  9.   Enrollee Assessments

  a.   Within thirty (30) calendar days of enrollment, the Health Plan shall
notify enrollees of, and ensure the availability of, a screening for all
enrollees known to be pregnant or who advise the Health Plan that they may be
pregnant. The Health Plan shall refer enrollees who are, or may be, pregnant to
a provider to obtain appropriate care.     b.   The Health Plan shall use the
enrollee’s health risk assessments and/or released medical records to identify
enrollees who have not received CHCUP screenings in accordance with the
Agency-approved periodicity schedule.     c.   The Health Plan shall contact,
twice if necessary, any enrollee more than two (2) months behind in the
Agency-approved periodicity screening schedule to urge those enrollees, or their
legal representatives, to make an appointment with the enrollee’s PCP for a
screening visit.     d.   The Health Plan shall take immediate action to address
any identified urgent medical needs. “Urgent medical needs” means any sudden or
unforeseen situation that requires immediate action to prevent hospitalization
or nursing home placement. Examples include hospitalization of spouse or
caregiver or increased impairment of an enrollee living alone who suddenly
cannot manage basic needs without immediate help, hospitalization or nursing
home placement.

  10.   Enrollee Authorized Representative

The enrollee’s guardian, next of kin or legally authorized responsible person is
permitted to act on the enrollee’s behalf in matters relating to the enrollee’s
enrollment, plan of care, and/or provision of services, if the enrollee:

  a.   Was adjudicated incompetent in accordance with the law;     b.   Is found
by the provider to be medically incapable of understanding his or her rights; or
    c.   Exhibits a significant communication barrier.

  11.   Toll-Free Help Line

  a.   The Health Plan shall operate a toll-free telephone help line, which
shall respond to all areas of enrollee inquiry.     b.   If the Health Plan has
authorization requirements for prescribed drug services and is subject to the
Hernandez Settlement Agreement (HSA), the Health Plan may allow the telephone
help line staff to act as Hernandez Ombudsman, pursuant to the terms of the HSA,
so long as the Health Plan maintains a Hernandez Ombudsman log. The Health Plan
may maintain the Hernandez Ombudsman log as part of its telephone help line log,
so long as the Health Plan can access the Hernandez

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AMERIGROUP Community Care
  HMO Contract

      Ombudsman log information separately for reporting purposes. The log shall
contain information as described in Attachment II, Section V, Covered Services,
Item H., Coverage Provisions, sub-item 16, Prescribed Drug Services.     c.  
The Health Plan shall have telephone call policies and procedures that shall
include requirements for staffing, personnel, hours of operation, call response
times, maximum hold times, and maximum abandonment rates, monitoring of calls
via recording or other means, and compliance with performance standards.     d.
  The telephone helpline shall handle calls from non-English speaking enrollees,
as well as calls from enrollees who are hearing impaired.     e.   The telephone
help line shall be fully staffed between the hours of 8:00 a.m. and 7:00 p.m. in
the enrollee’s time zone (Eastern or Central), Monday through Friday, excluding
state holidays. The telephone help line staff shall be trained to respond to
enrollee questions in all areas, including but not limited to, covered services,
provider network, and transportation.     f.   The Health Plan shall develop
performance standards and monitor telephone help line performance by recording
calls and employing other monitoring activities. Such standards shall be
submitted to and approved by BMHC before the Health Plan begins operation. At a
minimum, the standards shall require that, measured on a monthly basis:

  (1)   All calls are answered within four (4) rings (these calls may be placed
in a queue);     (2)   Wait time in the queue shall not exceed three
(3) minutes;     (3)   The blocked call rate does not exceed one percent (1 %);
and     (4)   The rate of abandoned calls does not exceed five percent (5%).

  g.   The Health Plan shall have an automated system available between the
hours of 7:00 p.m. and 8:00 a.m., in the enrollee’s time zone, Monday through
Friday and at all hours on weekends and holidays. This automated system must
provide callers with clear instructions on what to do in case of an emergency
and shall include, at a minimum, a voice mailbox for callers to leave messages.
The Health Plan shall ensure that the voice mailbox has adequate capacity to
receive all messages. A Health Plan representative shall respond to messages on
the next business day.

  12.   Translation Services

The Health Plan is required to provide oral translation services to any enrollee
who speaks any non-English language regardless of whether the enrollee speaks a
language that meets the threshold of a prevalent non-English language. The
Health Plan is required to notify its enrollees of the availability of oral
interpretation services and to inform them of how to access such services. Oral
interpretation services are required for all Health Plan information provided to
enrollees, including notices of adverse action. There shall be no charge to the
enrollee for translation services.
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AMERIGROUP Community Care
  HMO Contract

  13.   Preferred Drug List (PDL) (See Attachment II, Exhibit 4)

If the Health Plan adopts the Agency’s PDL, the Health Plan’s website shall
include an explanation and a link to the Agency’s online PDL. If the Health Plan
uses a pharmacy benefits manager, the Health Plan’s website shall include its
PDL. The Health Plan may update the online PDL by providing thirty (30) calendar
days’ written notice of any changes to the Bureaus of Managed Health Care and
Pharmacy Services.

  14.   Incentive Programs

  a.   The Health Plan may offer incentives for enrollees to receive preventive
care services. The Health Plan shall receive written approval from BMHC before
offering any incentives. The Health Plan shall make all incentives available to
all enrollees and shall not use incentives to direct individuals to select a
particular provider.     b.   The Health Plan may inform enrollees, once they
are enrolled, about the specific incentives available.     c.   The Health Plan
shall not include the provision of gambling, alcohol, tobacco or drugs (except
for over-the-counter drugs) in any of its incentives and shall state on the
incentive award that it may not be used for such purposes.     d.   Incentives
may have some health- or child development-related function (e.g., clothing,
food, books, safety devices, infant care items, subscriptions to publications
that include health-related subjects, membership in clubs advocating educational
advancement and healthy lifestyles, etc.). Incentive dollar values shall be in
proportion to the importance of the health service being incentivized (e.g., a
tee-shirt for attending one (1) prenatal class, but a car seat for completion of
a series of classes).     e.   Incentives shall be limited to a value of $20,
except in the case of incentives for the completion of a series of services,
health education classes or other educational activities, in which case the
incentive shall be limited to a value of $50. The Agency will allow a special
exception to the dollar value relating to infant car seats, strollers, and cloth
baby carriers or slings.     f.   The Health Plan shall not include in the
dollar limits on incentives any money spent on the transportation of enrollees
to services or childcare provided during the delivery of services.     g.   The
Health Plan may offer an Agency-approved program for pregnant women to encourage
beginning prenatal care visits in the first trimester of pregnancy. The prenatal
and postpartum care incentive program must be aimed at promoting early
intervention and prenatal care to decrease infant mortality and low birth weight
and to enhance healthy birth outcomes. The prenatal and postpartum incentives
may include the provision of maternity and health related items and education.  
  h.   The Health Plan’s request for Agency approval of all incentives shall
contain a detailed description of the incentive and its mission.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  15.   Enhanced Services (Reform Only; See Attachment II, Exhibit 4)

  16.   Notices of Action (See 42 CFR 438.210)

  a.   The Health Plan shall notify the provider and give the enrollee written
notice 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.     b.  
For standard authorization decisions, the Health Plan shall provide notice as
expeditiously as the enrollee’s health condition requires and within no more
than fourteen (14) calendar days following receipt of the request for service.  
  c.   The timeframe can be extended up to fourteen (14) additional calendar
days if the enrollee or the provider requests extension or the Health Plan
justifies the need for additional information and how the extension is in the
enrollee’s interest.     d.   Expedited authorization is required when a
provider indicates or the Health Plan determines that following the standard
timeline could seriously jeopardize the enrollee’s life of health or ability to
attain, maintain, or regain maximum function. An expedited decision must be made
no later than three (3) working days after receipt of the request for service.  
  e.   The Health Plan may extend the three (3) working days for expedited cases
by up to fourteen (14) calendar days if the enrollee requests an extension or if
the Health Plan justifies the extension as prescribed in subparagraph 16.c.
above.

  17.   Medicaid Redetermination Notices

The Agency will provide Medicaid recipient redetermination date information to
the Health Plan.

  a.   This information shall be used by the Health Plan only as indicated in
this subsection.     b.   Annually, the Agency will decide whether to continue
to provide this information to the Health Plan and will notify the Health Plan
of its decision by May 1 for the coming Contract year if it decides to stop
providing the information. In addition, the Agency reserves the right to stop at
any time with thirty (30) calendar days’ notice.     c.   By June 1 each year
the Health Plan shall notify BMHC, in writing, if it wants to change the use of
this information for the coming Contract year. The Health Plan’s participation
in using this information is voluntary.

  (1)   If the Health Plan chooses to participate in the use of this
information, it shall provide its policies and procedures regarding this
subsection to MHO for its approval along with its response indicating it will
participate.

  (a)   A Health Plan that chooses to participate in the use of this information
may decide to discontinue using it at any time and must so notify BN/IHC in
writing thirty (30) calendar days prior to the date it will discontinue such
use. The

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AMERIGROUP Community Care
  HMO Contract

      Agency will then delete the Health Plan from the list of health plans
receiving this information for the remainder of the Contract year.     (b)   A
Health Plan that chooses to participate in the use of this information must
train all affected staff, prior to implementation, on its policies and
procedures and the Agency’s requirements regarding this subsection. The Health
Plan must document such training has occurred, including a record of those
trained, for the Agency’s review within five (5) business days after the
Agency’s request.

  (2)   Regardless of whether the Health Plan has declined to participate in the
use of this information, the Health Plan is subject to the sanctioning indicated
in this subsection if the Health Plan misuses the information at any time.

  d.   A Health Plan that chooses to participate in using this information shall
use the redetermination date information only in the methods listed below and
shall use either or both methods to communicate this information.

  (1)   The Health Plan may use redetermination date information in written
notices to be sent to their enrollees reminding them that their Medicaid
eligibility may end soon and to reapply for Medicaid if needed. A Health Plan
that chooses to use this method to provide this information to its enrollees
must adhere to the following requirements:

  (a)   The Health Plan shall mail the redetermination date notice to each
enrollee for whom it has received a redetermination date. The Health Plan may
send one (1) notice to the enrollee’s household when there are multiple
enrollees within a family who have the same Medicaid redetermination date,
provided that these enrollees share the same mailing address.     (b)   The
Health Plan shall use the Agency-provided template for its redetermination date
notices. The Health Plan may put this template on its letterhead for mailing;
however, the Health Plan shall make no other changes, additions or deletions to
the letter text.     (c)   The Health Plan shall mail the redetermination date
notice to each enrollee no more than sixty (60) calendar days and no less than
thirty (30) calendar days before the redetermination date occurs.

  (2)   The Health Plan may use redetermination date information in automated
voice response (AVR) or integrated voice response (IVR) automated messages sent
to enrollees reminding them that their Medicaid eligibility may end soon and to
reapply for Medicaid if needed. A Health Plan that chooses to use this method to
provide this information to its enrollees must adhere to the following
requirements:

  (a)   The Health Plan shall send the redetermination date messages to each
enrollee for whom that Health Plan has received a redetermination date and for
whom the Health Plan has a telephone number. The Health Plan may send an
automated message to the enrollee’s household when there are multiple enrollees
within a family who have the same Medicaid

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      redetermination date provided that these enrollees share the same mailing
address/phone number.     (b)   For the voice messages, the Health Plan shall
use only the language in the Agency’s redetermination date notice template
provided to the Health Plan. The Health Plan may add its name to the message but
shall make no other changes, additions or deletions to the message text.     (c)
  The Health Plan shall make such automated calls to each enrollee no more than
sixty (60) calendar days and no less than thirty (30) calendar days before the
redetermination date occurs.

  (3)   The Health Plan shall not include the redetermination date information
in any file viewable by customer service or community outreach staff. This
information shall be used only in the letter templates and automated scripts
provided by the Agency and cannot be referenced or discussed by the Health Plan
with the enrollees, unless in response to an enrollee inquiry about the letter
received, nor shall it be used at a future time by the Health Plan. If the
Health Plan receives enrollee inquiries about the notices, such inquiries must
be referred to the Department of Children and Families.

  e.   If the Health Plan chooses to participate in using this information, it
shall keep the following information about each mailing made available for the
Agency’s review within five (5) business days after the Agency’s request.

  (1)   For each month of mailings, a dated hard copy or pdf of the monthly
template used for that specific mailing;

  (a)   A list of enrollees to whom a mailing was sent. This list shall include
each enrollee’s name and Medicaid identification number, the address to which
the notice was mailed, and the date of the Agency’s enrollment file used to
create the mailing list;     (b)   A log of returned, undeliverable mail
received for these notices, by month, for each enrollee for whom a returned
notice was received;

  (2)   For each month of automated calls made, a list of enrollees to whom a
call was made, the enrollee’s name, Medicaid identification number, telephone
number to which the call was made, the date each call was made, and the date of
the Agency’s enrollment file used to create the automated call list.

  f.   A Health Plan that chooses to participate in using this information shall
keep up-to- date and approved policies and procedures regarding the use, storage
and securing of this information as well as address all requirements of this
subsection.     g.   A Health Plan that participates in using this information
must submit to the Agency’s BMHC a completed quarterly summary report in
accordance with Attachment II, Section XII, Reporting Requirements.     h.  
Should any complaint or investigation by the Agency result in a finding that the
Health Plan has violated this subsection, the Health Plan will be sanctioned in

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AMERIGROUP Community Care
  HMO Contract

      accordance with Attachment II, Section XIV, Sanctions. In addition to any
other sanctions available in Section XIV, Sanctions, the first such violation
will result in a thirty (30) day suspension of use of Medicaid redetermination
dates; any subsequent violations will result in thirty-day (30-day) incremental
increases in the suspension of use of Medicaid redetermination dates. In the
event of any subsequent violations, additional penalties may be imposed in
accordance with Section XIV, Sanctions. Additional or subsequent violations may
result in the Agency’s rescinding provision of redetermination date information
to the Health Plan.

B. Community Outreach and Marketing

  1.   General Provisions

  a.   The Health Plan’s community outreach representative(s) may provide
community outreach materials at health fairs/public events as noticed by the
Health Plan to the Agency in accordance with sub-item 4, Community Outreach
Notification Process, below. The main purpose of a health fair/public event
shall be to provide community outreach and shall not be for the purpose of
Medicaid Health Plan marketing.     b.   For each new Contract period, the
Health Plan shall submit to BMHC for written approval all community outreach
material no later than sixty (60) calendar days before the start of the next
Contract period, and, for any changes in the community outreach material, no
later than thirty (30) calendar days before implementation. All materials
developed shall be governed by the requirements set forth in this section.    
c.   To announce participation at a specific event (health fair/public event),
the Health Plan shall submit a notice to BMHC in accordance with sub-item B.3.,
Permitted Activities.     d.   The Health Plan shall be responsible for
developing and implementing a written plan designed to control the actions of
its community outreach representatives.     e.   All community outreach policies
set forth in this Contract shall apply to staff, subcontractors, Health Plan
volunteers and all persons acting for or on behalf of the Health Plan.     f.  
The Health Plan is vicariously liable for any outreach and marketing violations
of its employees, agents or subcontractors. In addition to any other sanctions
available in Attachment II, Section XIV, Sanctions, any violations of this
section shall subject the Health Plan to administrative action by the Agency as
determined by the Agency. The Health Plan may dispute any such administrative
action pursuant to Attachment II, Section XVI, Terms and Conditions, Item I.,
Disputes.     g.   Nothing in this section shall preclude the Health Plan from
donating to or sponsoring an event with a community organization where time,
money or expertise is provided for the benefit of the community. If such events
are not health fairs/public events, no community outreach materials or marketing
materials shall be distributed by the Health Plan, but the Health Plan may
engage

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      in brand-awareness activities, including the display of Health Plan or
product logos. Inquiries at such events from prospective enrollees must be
referred to the Health Plan’s member services section or the Agency’s choice
counselor/enrollment broker.

  2.   Prohibited Activities

The Health Plan is prohibited from engaging in the following non-exclusive list
of activities:

  a.   Marketing for enrollment to any potential members or conducting any
pre-enrollment activities not expressly allowed under this Contract;     b.  
Any of the prohibited practices or activities listed in s. 409.912, F.S;     c.
  Engaging in activities not expressly allowed under this Contract for the
purpose of recruitment or enrollment;     d.   Practices that are
discriminatory, including, but not limited to, attempts to discourage enrollment
or re-enrollment on the basis of actual or perceived health status, in
accordance with ss. 409.912 and 409.91211, F.S.;     e.   Direct or indirect
cold call marketing or other solicitation of Medicaid recipients, either by
door-to-door, telephone or other means, in accordance with Section 4707 of the
Balanced Budget Act of 1997 and s. 409.912, F.S.;     f.   Activities that could
mislead or confuse Medicaid recipients or misrepresent the Health Plan, its
community outreach representatives or the Agency, in accordance with s. 409.912,
F.S. No fraudulent, misleading, or misrepresentative information shall be used
in community outreach, including information about other government programs.
Statements that could mislead or confuse include, but are not limited to, any
assertion, statement or claim (whether written or oral) that:

  (1)   The Medicaid recipient must enroll in the Health Plan to obtain Medicaid
or to avoid losing Medicaid benefits;     (2)   The Health Plan is endorsed by
any federal, state or county government, the Agency, CMS, or any other
organization that has not certified its endorsement in writing to the Health
Plan;     (3)   Community outreach representatives are employees or
representatives of the federal, state or county government, or of anyone other
than the Health Plan or the organization by whom they are reimbursed;     (4)  
The state or county recommends that a Medicaid recipient enroll with the Health
Plan; and/or     (5)   A Medicaid recipient will lose benefits under the
Medicaid program or any other health or welfare benefits to which the person is
legally entitled if the recipient does not enroll with the Health Plan.

  g.   Granting or offering any monetary or other valuable consideration for
enrollment;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  h.   Offering insurance, such as but not limited to, accidental death,
dismemberment, disability or life insurance;     i.   Enlisting assistance of
any employee, officer, elected official or agency of the state in recruitment of
Medicaid recipients except as authorized in writing by the Agency;     j.  
Offering material or financial gain to any persons soliciting, referring or
otherwise facilitating Medicaid recipient enrollment. The Health Plan shall
ensure that its staff do not market the Health Plan to Medicaid recipients at
any location including state offices or DCF ACCESS center;     k.   Giving away
promotional items in excess of $5.00 retail value. Items to be given away shall
bear the Health Plan’s name and shall be given away only at health fairs/public
events. In addition, such promotional items must be offered to the general
public and shall not be limited to Medicaid recipients;     I.   Providing any
gift, commission, or any form of compensation to the choice counselor/enrollment
broker, including its full-time, part-time or temporary employees and
subcontractors;     m.   Providing information before enrollment about the
incentives to be offered an enrollee as described in Attachment II, Section IV,
Enrollee Services, Community Outreach and Marketing, Item A., Enrollee Services,
sub-item 14., Incentive Programs. The Health Plan may inform enrollees on or
after their enrollment effective date about the specific incentives or programs
available;     n.   Discussing, explaining or speaking to a potential member
about Health-Plan-specific information other than to refer all Health Plan
inquiries to the member services section of the Health Plan or the Agency’s
choice counselor/enrollment broker;     o.   Distributing any community outreach
materials without prior written notice to BMHC except as otherwise allowed under
Permitted Activities and Provider Compliance subsections;     p.   Distributing
any marketing materials not expressly allowed under this Contract;     q.  
Subcontracting with any brokerage firm or independent agent as defined in
Chapters 624-651, F.S., for purposes of marketing or community outreach;     r.
  Paying commission compensation to community outreach representatives for new
enrollees. The payment of a bonus to a community outreach representative shall
not be considered a commission if such bonus is not related to enrollment or
membership growth; and     s.   All activities included in s. 641.3903, F.S.

  3.   Permitted Activities

The Health Plan may engage in the following activities upon prior written notice
to BMHC:
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  Medicaid Non-Reform and Reform
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  HMO Contract

  a.   The Health Plan may attend health fairs/public events upon request by the
sponsor and after written notification to BMHC as described in sub-item 4.,
Community Outreach Notification Process, below.     b.   The Health Plan may
leave community outreach materials at health fairs/public events at which the
Health Plan participates.     c.   The Health Plan may provide BMHC-approved
community outreach materials. Such materials may include Medicaid enrollment and
eligibility information and information related to other health care projects
and health, welfare and social services provided by the State of Florida or
local communities. The Health Plan staff, including community outreach
representatives, shall refer all Health Plan inquiries to the member services
section of the Health Plan or the Agency’s choice counselor/enrollment broker.
BMHC approval of the script used by the Health Plan’s member services section
must be obtained before usage.     d.   The Health Plan may distribute community
outreach materials to community agencies.

  4.   Community Outreach Notification Process

  a.   The Health Plan shall submit to BMHC a written notice of its intent to
attend and provide community outreach materials at health fairs/public events.
(See sub-items 4.b. and 4.c. below for further notice information.)

  (1)   The Agency requires the following health fair/public event information:

  (a)   The event announcement to be given to the public;     (b)   Date, time
and location of the event;     (c)   Name and type of sponsoring organization;  
  (d)   Event contact person and contact information;     (e)   Health Plan
contact person and contact information; and     (f)   Names of participating
community outreach representatives, their contact information and services they
will provide at the event.

  (2)   In addition to the disclosure information listed in (1) above, if the
Health Plan is the primary organizer of the event, the Health Plan shall submit
in its community outreach health fairs/public events notification report
specified in b., below, to BMHC, complete disclosure information from each
organization participating. Information shall include the name of the
organization, contact person information, and confirmation of participation.    
(3)   In addition to the disclosure information listed in (1) above, if the
Health Plan has been invited by a community organization to be a sponsor or
attendee of an event, the Health Plan shall submit in its community outreach
health fairs/public events notification report specified in b., below, to BMHC,
a copy of the letter of invitation from the event sponsor(s) requesting the
Health Plan’s participation.

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  b.   The Health Plan shall report health fair/public event notices to BMHC by
submitting a community outreach health fairs/public events notification report
by the 20th calendar day of the month prior to the event month. Amendments to
the report are due no later than two weeks prior to the event. See Attachment
II, Section XII, Reporting Requirements.     c.   Notwithstanding the other
notice requirements in this subsection, the monthly and two-week advance notice
requirements are waived in cases of force majeure provided the Health Plan
notices MHO by the time of the event. Force majeure events include destruction
due to hurricanes, fires, war, riots, and other similar acts. When providing the
Agency with notice of attendance at such events, the Health Plan shall include a
description of the force majeure event requiring waiver of notice.     d.   BMHC
will establish a statewide log to track the community outreach notifications
received and may monitor such events.

  5.   Provider Compliance

The Health Plan shall ensure, through provider education and outreach, that its
health care providers are aware of and comply with the following requirements:

  a.   Health care providers may display health-plan-specific materials in their
own offices.     b.   Health care providers cannot orally or in writing compare
benefits or provider networks among health plans, other than to confirm whether
they participate in a Health Plan’s network.     c.   Health care providers may
announce a new affiliation with a Health Plan and give their patients a list of
health plans with which they contract.     d.   Health care providers may
co-sponsor events, such as health fairs and advertise with the Health Plan in
indirect ways; such as television, radio, posters, fliers, and print
advertisement.     e.   Health care providers shall not furnish lists of their
Medicaid patients to the Health Plan with which they contract, or any other
entity, nor can providers furnish other health plans’ membership lists to the
Health Plan, nor can providers assist with Health Plan enrollment.     f.   For
the Health Plan, health care providers may distribute information about
nonhealth-plan-specific health care services and the provision of health,
welfare and social services by the State of Florida or local communities as long
as any inquiries from prospective enrollees are referred to the member services
section of the Health Plan or the Agency’s choice counselor/enrollment broker.

  6.   Community Outreach Representatives

  a.   The Health Plan shall register each community outreach representative
that represents the Health Plan with BMHC as specified below.

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  (1)   The Health Plan shall submit its registration file to BMHC at the
following e-mail address prior to any initial community outreach activity:
MMCDATAahca.myflorida.com. The Agency-supplied template must be used as
specified in Attachment II, Section XII, Reporting Requirements, and in the
Report Guide.     (2)   The Health Plan shall submit changes to the community
outreach representative’s initial registration to BMHC, using the same
Agency-supplied template, immediately upon occurrence, at e-mail
address:MMCDATAahca.mvfiorida.com. The Agency-supplied template shall be used.

  b.   While attending health fairs/public events, community outreach
representatives shall wear picture identification that shows the Health Plan
represented.     c.   If asked, the community outreach representative shall
inform the Medicaid recipient that the representative is not a state employee
and is not a choice counseling specialist but is a representative of the Health
Plan.     d.   The Health Plan shall instruct and provide initial and periodic
training to its community outreach representatives about the outreach and
marketing provisions of this Contract.     e.   The Health Plan shall implement
procedures for background and reference checks for use in hiring community
outreach representatives.     f.   The Health Plan shall report to BMHC any
Health Plan staff or community outreach representative who violates any
requirements of this Contract within fifteen (15) calendar days of knowledge of
such violation.

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  HMO Contract

Section V
Covered Services
(Also See Attachment I and Attachment II, Exhibit 5)
A. Covered Services

  1.   The Health Plan shall ensure the provision of services in sufficient
amount, duration and scope to be reasonably expected to achieve the purpose for
which the services are furnished and shall ensure the provision of the covered
services defined and specified in this Contract. The Health Plan shall not
arbitrarily deny or reduce the amount, duration, or scope of a required service
solely because of the enrollee’s diagnosis, type of illness or condition. The
Health Plan may place appropriate limits on a service on the basis of such
criteria as medical necessity or for utilization control, consistent with the
terms of this Contract, provided the services furnished can be reasonably
expected to achieve their purpose.     2.   The Health Plan is responsible for
ensuring that all providers, service and product standards specified in the
Agency’s Medicaid Services Coverage & Limitations Handbooks and the Health
Plan’s own provider handbooks are incorporated into the Health Plan’s
participation agreements. This includes professional licensure and certification
standards for all service providers. Exceptions exist where different standards
are specified elsewhere in this Contract.     3.   The Health Plan shall require
out-of-network providers to coordinate with respect to payment and must ensure
that cost to the enrollee is no greater than it would be if the covered services
were furnished within the network.     4.   In addition to this section, the
Health Plan shall ensure the provision of the covered services specified in
Attachment I and Attachment II, Exhibit 5.

B. Optional Services (Non-Reform Only, See Attachment I and Attachment II,
Exhibit 5)
C. Expanded Services (See Attachment I)

  1.   The following services are defined as expanded services that may be
offered by the Health Plan. The Health Plan shall define the services
specifically in writing and submit them to HSD for approval before
implementation.

  a.   Services in excess of the amount, duration and scope of those listed in
Attachment II, Section V, Covered Services, and Section VI, Behavioral Health
Care;     b.   Services and benefits not listed in Attachment II, Section V,
Covered Services, or Section VI, Behavioral Health Care;     c.   The Health
Plan may offer, upon written Agency approval, an over-the-counter expanded drug
benefit, not to exceed $25.00 per household, per month. Such benefits shall be
limited to nonprescription drugs containing a national drug code (NDC) number,
first aid supplies and birth control supplies. Such benefits must be offered
directly through the Health Plan’s fulfillment house or through a

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  HMO Contract

      subcontractor. The Health Plan shall make payments for the
over-the-counter drug benefit directly to the subcontractor, if applicable.

  d.   Adult Dental Services — routine preventive services, diagnostic and
restorative services, radiology services and discounts on dental services;    
e.   Adult Vision Services — eye exams, eyeglasses and contact lenses;     f.  
Adult Hearing Services — hearing evaluations, hearing aid devices and hearing
aid repairs.

  2.   The Health Plan’s approved expanded services under this Contract are
listed in Attachment I.

D. Customized Benefit Packages
Some health plans may be authorized by the Agency to offer a customized benefit
package for their Reform enrollees. Refer to Attachment I and Attachment II,
Exhibit 5, for any information applicable to this Contract.
E. Excluded Services

  1.   The Health Plan is not obligated to provide any services not specified in
this Contract. Enrollees who require services available through Medicaid but not
covered by this Contract shall receive the services through the Medicaid
fee-for-service reimbursement system. In such cases, the Health Plan’s
responsibility is limited to case coordination and referral. Therefore, the
Health Plan shall determine the need for the services and refer the enrollee to
the appropriate service provider. The Health Plan may request assistance from
the local Medicaid Area Office for referral to the appropriate service setting.
    2.   The Health Plan shall consult the DCF office to identify appropriate
methods of assessment and referral for enrollees requiring long-term care
institutional services, institutional services for persons with developmental
disabilities or state hospital services. The Health Plan is responsible for
transition and referral of these enrollees to appropriate service providers,
including helping the enrollees obtain an attending physician. The Health Plan
shall disenroll all enrollees requiring these services in accordance with
Attachment II, Section III, Eligibility and Enrollment, Item C., Disenrollment,
sub-item 3.a.(3).

F. Moral or Religious Objections
The Health Plan shall provide or arrange for all covered services. If, during
the course of the Contract period, pursuant to 42 CFR 438.102, the Health Plan
elects not to provide, reimburse for, or provide coverage of a counseling or
referral service because of an objection on moral or religious grounds, the
Health Plan shall notify:

  1.   The Agency within one-hundred and twenty (120) calendar days before
implementing the policy with respect to any service; and

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  HMO Contract

  2.   Enrollees within thirty (30) calendar days before implementing the policy
with respect to any service.

G. Copayments (See Attachment I and Attachment II, Exhibit 5)
H. Coverage Provisions

  1.   Requirements

The Health Plan shall provide the following services in accordance with the
provisions herein, and in accordance with the Florida Medicaid Coverage and
Limitations Handbooks and the Florida Medicaid State Plan unless, for Reform
HMOs, a customized benefit package is certified in the benefit grid in
Attachment I. The Health Plan shall comply with all state and federal laws
pertaining to the provision of such services.

  2.   Child Health Check-Up Program (CHCUP)

  a.   The Health Plan shall provide a health screening evaluation that shall
consist of: comprehensive health and developmental history (including assessment
of past medical history, developmental history and behavioral health status);
comprehensive unclothed physical examination; developmental assessment;
nutritional assessment; appropriate immunizations according to the appropriate
Recommended Childhood Immunization Schedule for the United States; laboratory
testing (including blood lead testing); health education (including anticipatory
guidance); dental screening (including a direct referral to a dentist for
enrollees beginning at age three or earlier as indicated); vision screening,
including objective testing as required; hearing screening, including objective
testing as required; diagnosis and treatment; and referral and follow-up as
appropriate.     b.   For children/adolescents whom the Health Plan identifies
through blood lead screenings as having abnormal levels of lead, the Health Plan
shall provide case management follow-up services as required in Chapter Two of
the Child Health Check-Up Services Coverage and Limitations Handbook. Screening
for lead poisoning is a required component of this Contract. The Health Plan
shall require all providers to screen all enrolled children for lead poisoning
at ages 12 months and 24 months. In addition, children between the ages of
12 months and 72 months must receive a screening blood lead test if there is no
record of a previous test. The Health Plan shall provide additional diagnostic
and treatment services determined to be medically necessary to a
child/adolescent diagnosed with an elevated blood lead level. The Health Plan
shall recommend, but shall not require, the use of paper filter tests as part of
the lead screening requirement.     c.   The Health Plan shall inform enrollees
of all testing/screenings due in accordance with the periodicity schedule
specified in the Medicaid Child Health Check-Up Services Coverage and
Limitations Handbook. The Health Plan shall contact enrollees to encourage them
to obtain health assessment and preventive care.     d.   The Health Ran shall
authorize enrollee referrals to appropriate providers within four (4) weeks of
these examinations for further assessment and treatment of conditions found
during the examination. The Health Plan shall ensure that the referral
appointment is scheduled for a date within six (6) months of the initial
examination,

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  HMO Contract

      or within the time periods set forth in Attachment II, Section VII,
Provider Network, Item F., Appointment Waiting Times and Geographic Access
Standards, as applicable.

  e.   The Health Plan shall cover fluoride treatment by a physician or a
dentist for children/adolescents even if the Health Plan does not provide dental
coverage.     f.   If the Health Plan Contract covers transportation, the Health
Plan shall offer transportation to enrollees in order to assist them to keep,
and travel to, medical appointments. If the Contract does not cover
transportation services, the Health Plan shall offer to help enrollees schedule
transportation.     g.   The CHCUP program includes the maintenance of a
coordinated system to follow the enrollee through the entire range of screening
and treatment, as well as supplying CHCUP training to medical care providers.  
  h.   The Health Plan shall achieve a CHCUP screening rate of at least sixty
percent (60%) for those enrollees who are continuously enrolled for at least
eight (8) months during the federal fiscal year (October 1 — September 30) in
accordance with s. 409.912, F.S. This screening compliance rate shall be based
on the CHCUP screening data reported by the Health Plan and due to the Agency by
January 15 following the end of each federal fiscal year as specified in
Attachment II, Section XII, Reporting Requirements. The data shall be monitored
by the Agency for accuracy, and, if the Health Plan does not achieve the sixty
percent (60%) screening rate for the federal fiscal year reported, the Health
Plan shall file a corrective action plan (CAP) with the Agency no later than
February 15, following the fiscal year reported. Failure to meet the sixty
percent (60%) screening requirement may result in sanctions. Any data reported
by the Health Plan that is found to be inaccurate shall be disallowed by the
Agency, and the Agency shall consider such findings as being in violation of the
Contract and may sanction the Health Plan accordingly. (See Attachment II,
Section XIV, Sanctions)     i.   The Health Plan shall adopt annual screening
and participation goals to achieve at least an eighty percent (80%) CHCUP
screening and participation rates, as required by the Centers for Medicare and
Medicaid Services. For each federal fiscal year that the Health Plan does not
meet the eighty percent (80%) screening and participation rates, it must file a
CAP with the Agency no later than February 15 following the federal fiscal year
being reported. Any data reported by the Health Plan that is found to be
inaccurate shall be disallowed by the Agency, and the Agency shall consider such
findings as being in violation of the Contract and may sanction the Health Plan
accordingly. (See s. 1902(a)(43)(D)(iv) of the Social Security Act.)

  3.   Dental Services (See Attachment I and Attachment II, Exhibit 5)     4.  
Hearing Services (See Attachment I)     5.   Vision Services (See Attachment I)

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  HMO Contract

  6.   Diabetes Supplies and Education

In the same manner as specified in s. 641.31, F.S., the Health Plan shall
provide coverage for medically necessary equipment, supplies, and services used
to treat diabetes, including outpatient self-management training and educational
services, if the enrollee’s PCP, or the physician to whom the enrollee has been
referred who specializes in treating diabetes, certifies that the equipment,
supplies and services are medically necessary.

  7.   Emergency Services (See also Item 10. Hospital Services — Inpatient,
below)

  a.   The Health Plan shall advise all enrollees of the provisions governing
emergency services and care. The Health Plan shall not deny claims for emergency
services and care received at a hospital due to lack of parental consent. In
addition, the Health Plan shall not deny payment for treatment obtained when a
representative of the Health Plan instructs the enrollee to seek emergency
services and care in accordance with s. 743.064, F.S.     b.   The Health Plan
shall not:

  (1)   Require prior authorization for an enrollee to receive pre-hospital
transport or treatment or for emergency services and care;     (2)   Specify or
imply that emergency services and care are covered by the Health Plan only if
secured within a certain period of time;     (3)   Use terms such as “life
threatening” or “bona fide” to qualify the kind of emergency that is covered; or
    (4)   Deny payment based on a failure by the enrollee or the hospital to
notify the Health Plan before, or within a certain period of time after,
emergency services and care were given.

  c.   The Health Plan shall provide pre-hospital and hospital-based trauma
services and emergency services and care to enrollees. See ss. 395.1041,
395.4045 and 401.45, F.S.     d.   When an enrollee presents at a hospital
seeking emergency services and care, the determination that an emergency medical
condition exists shall be made, for the purposes of treatment, by a physician of
the hospital or, to the extent permitted by applicable law, by other appropriate
personnel under the supervision of a hospital physician. See ss. 409.9128,
409.901, F.S. and 641.513, F.S.

  (1)   The physician, or the appropriate personnel, shall indicate on the
enrollee’s chart the results of all screenings, examinations and evaluations.  
  (2)   The Health Plan shall cover all screenings, evaluations and examinations
that are reasonably calculated to assist the provider in arriving at the
determination as to whether the enrollee’s condition is an emergency medical
condition.

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  HMO Contract

  (3)   If the provider determines that an emergency medical condition does not
exist, the Health Plan is not required to cover services rendered subsequent to
the provider’s determination unless authorized by the Health Plan.

  e.   If the provider determines that an emergency medical condition exists,
and the enrollee notifies the hospital or the hospital emergency personnel
otherwise have knowledge that the patient is an enrollee of the Health Plan, the
hospital must make a reasonable attempt to notify:

  (1)   The enrollee’s PCP, if known, or     (2)   The Health Plan, if the
Health Plan has previously requested in writing that it be notified directly of
the existence of the emergency medical condition.

  f.   If the hospital, or any of its affiliated providers, do not know the
enrollee’s PCP, or have been unable to contact the PCP, the hospital must:

  (1)   Notify the Health Plan as soon as possible before discharging the
enrollee from the emergency care area; or     (2)   Notify the Health Plan
within twenty-four (24) hours or on the next business day after the enrollee’s
inpatient admission.

  g.   If the hospital is unable to notify the Health Plan, the hospital must
document its attempts to notify the Health Plan, or the circumstances that
precluded the hospital’s attempts to notify the Health Plan. The Health Plan
shall not deny coverage for emergency services and care based on a hospital’s
failure to comply with the notification requirements of this section.     h.  
If the enrollee’s PCP responds to the hospital’s notification, and the hospital
physician and the PCP discuss the appropriate care and treatment of the
enrollee, the Health Plan may have a member of the hospital staff with whom it
has a participating provider contract participate in the treatment of the
enrollee within the scope of the physician’s hospital staff privileges.     i.  
The Health Plan shall cover any medically necessary duration of stay in a non-
contracted facility, which results from a medical emergency, until such time as
the Health Ran can safely transport the enrollee to a participating facility.
The Health Plan may transfer the enrollee, in accordance with state and federal
law, to a participating hospital that has the service capability to treat the
enrollee’s emergency medical condition. The attending emergency physician, or
the provider actually treating the enrollee, is responsible for determining when
the enrollee is sufficiently stabilized for transfer discharge, and that
determination is binding on the entities identified in 42 CFR 438.114(b) as
responsible for coverage and payment.     j.   Notwithstanding any other state
law, a hospital may request and collect from an enrollee any insurance or
financial information necessary to determine if the patient is an enrollee of
the Health Plan, in accordance with federal law, so long as emergency services
and care are not delayed in the process.

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  HMO Contract

  k.   In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the Health Plan
shall cover post-stabilization care services without authorization, regardless
of whether the enrollee obtains a service within or outside the Health Plan’s
network for the following situations:

  (1)   Post-stabilization care services that were pre-approved by the Health
Plan;     (2)   Post-stabilization care services that were not pre-approved by
the Health Plan because the Health Plan did not respond to the treating
provider’s request for pre-approval within one (1) hour after the treating
provider sent the request;     (3)   The treating provider could not contact the
Health Plan for pre-approval;     (4)   Those post-stabilization care services
that a treating physician viewed as medically necessary after stabilizing an
emergency medical condition are non- emergency services. The Health Plan can
choose not to cover them if they are provided by a non-participating provider,
except in those circumstances detailed in k.(1), (2), and (3) above.

  I.   The Health Plan shall not deny claims for the provision of emergency
services and care submitted by a nonparticipating provider solely based on the
period between the date of service and the date of clean claim submission,
unless that period exceeds three-hundred and sixty-five (365) days.

  m.   For capitated Health Plans, reimbursement for services provided to an
enrollee under this section by a non-participating provider shall be the lesser
of:

  (1)   The non-participating providers charges;     (2)   The usual and
customary provider charges for similar services in the community where the
services were provided;     (3)   The amount mutually agreed to by the Health
Plan and the non-participating provider within sixty (60) calendar days after
the non-participating provider submits a claim; or     (4)   The Florida
Medicaid reimbursement rate established for the hospital or provider.

  n.   Notwithstanding the requirements set forth in this section, the Health
Plan shall approve all claims for emergency services and care by
nonparticipating providers pursuant to the requirements set forth in s.
641.3155, F.S., and 42 CFR 438.114.

  o.   See Attachment II, Section VI, Behavioral Health Care, and Attachment II,
Exhibit 6, for behavioral health emergency care requirements.

  8.   Out-of-Plan Use of Non-Emergency Services

The Health Plan shall provide timely approval or denial of authorization of
out-of-network use through the assignment of a prior authorization number, which
refers to and documents the approval. The Health Plan may not require paper
authorization as a condition of receiving treatment if the Health Plan has an
automated authorization
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  HMO Contract

system. Written follow-up documentation of the approval must be provided to the
out-of-network provider within one (1) business day from the request for
approval. For capitated Health Plan enrollees, the enrollee shall be liable for
the cost of such unauthorized use of covered services from non-participating
providers.

  9.   Family Planning Services

The Health Plan shall provide family planning services to help enrollees make
comprehensive and informed decisions about family size and/or spacing of births.
The Health Plan shall provide the following services: planning and referral,
education and counseling, initial examination, diagnostic procedures and routine
laboratory studies, contraceptive drugs and supplies, and follow-up care in
accordance with the Medicaid Physicians Services Coverage and Limitations
Handbook. Policy requirements include:

  a.   The Health Plan shall furnish services on a voluntary and confidential
basis.     b.   The Health Plan shall allow enrollees freedom of choice of
family planning methods covered under the Medicaid program, including
Medicaid-covered implants, where there are no medical contra-indications.     c.
  The Health Plan shall render the services to enrollees under the age of 18
provided the enrollee is married, a parent, pregnant, has written consent by a
parent or legal guardian, or, in the opinion of a physician, the enrollee may
suffer health hazards if the services are not provided. See s. 390.01114, F.S.  
  d.   The Health Plan shall allow each enrollee to obtain family planning
services from any provider and require no prior authorization for such services.
For capitated Health Plans, if the enrollee receives services from a non-network
Medicaid provider, then the Health Plan shall reimburse at the Medicaid
reimbursement rate, unless another payment rate is negotiated.     e.   The
Health Plan shall make available and encourage all pregnant women and mothers
with infants to receive postpartum visits for the purpose of voluntary family
planning, including discussion of all appropriate methods of contraception,
counseling and services for family planning to all women and their partners. The
Health Plan shall direct providers to maintain documentation in the enrollee’s
medical records to reflect this provision. See s. 409.912, F.S.     f.   The
provisions of this subsection shall not be interpreted so as to prevent a health
care provider or other person from refusing to furnish any contraceptive or
family planning service, supplies or information for medical or religious
reasons. A health care provider or other person shall not be held liable for
such refusal.

  10.   Hospital Services — Inpatient

  a.   Inpatient services are medically necessary services ordinarily furnished
by a state- licensed acute care hospital for the medical care and treatment of
inpatients 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.

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  HMO Contract

  (1)   Inpatient services include, but are not limited to, rehabilitation
hospital care (which are counted as inpatient hospital days), medical supplies,
diagnostic and therapeutic services, use of facilities, drugs and biologicals,
room and board, nursing care and all supplies and equipment necessary to provide
adequate care. See the Medicaid Hospital Services Coverage & Limitations
Handbook.     (2)   Inpatient services also include inpatient care for any
diagnosis including tuberculosis and renal failure when provided by general
acute care hospitals in both emergent and non-emergent conditions.     (3)   The
Health Plan shall cover physical therapy services when medically necessary and
when provided during an enrollee’s inpatient stay.     (4)   The Health Plan
shall provide up to twenty-eight (28) inpatient hospital days in an inpatient
hospital substance abuse treatment program for pregnant substance abusers who
meet ISD Criteria with Florida Medicaid modifications, as specified in InterQual
Level of Care Acute Criteria-Pediatric and/or InterQual Level of Care Acute
Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”), the most current
edition, for use in screening cases admitted to rehabilitative hospitals and
CON-approved rehabilitative units in acute care hospitals.     (5)   In
addition, the Health Plan shall provide inpatient hospital treatment for severe
withdrawal cases exhibiting medical complications that meet the severity of
illness criteria under the alcohol/substance abuse system-specific set which
generally requires treatment on a medical unit where complex medical equipment
is available. Withdrawal cases (not meeting the severity of illness criteria
under the alcohol/substance abuse criteria) and substance abuse rehabilitation
(other than for pregnant women), including court ordered services, are not
covered in the inpatient hospital setting.     (6)   The Health Plan shall
coordinate hospital and institutional discharge planning for substance abuse
detoxification to ensure inclusion of appropriate post-discharge care.     (7)  
The Health Plan shall adhere to the provisions of the Newborns and Mothers
Health Protection Act (NMHPA) of 1996 regarding postpartum coverage for mothers
and their newborns. Therefore, the Health Plan shall provide for no less than a
forty-eight (48) hour hospital length of stay following a normal vaginal
delivery, and at least a ninety-six (96) hour hospital length of stay following
a Cesarean section. In connection with coverage for maternity care, the hospital
length of stay is required to be decided by the attending physician in
consultation with the mother.     (8)   The Health Plan shall prohibit the
following practices:

  (a)   Denying the mother or newborn child eligibility, or continued
eligibility, to enroll or renew coverage under the terms of the Health Plan,
solely for the purpose of avoiding the NMHPA requirements;     (b)   Providing
monetary payments or rebates to mothers to encourage them to accept less than
the minimum protections available under NMHPA;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (c)   Penalizing or otherwise reducing or limiting the reimbursement of an
attending physician because the physician provided care in a manner consistent
with NMHPA;     (d)   Providing incentives (monetary or otherwise) to an
attending physician to induce the physician to provide care in a manner
inconsistent with NMHPA;     (e)   Restricting any portion of the forty-eight
(48) hour, or ninety-six (96) hour, period prescribed by NVIHPA in a manner that
is less favorable than the benefits provided for any preceding portion of the
hospital stay; and

  (9)   The Health Plan shall cover any medically necessary duration of stay in
a non- contracted facility that results from a medical emergency until such time
as the Health Plan can safely transport the enrollee to a Health Plan
participating facility.     (10)   In Reform, for all child/adolescent enrollees
(up to age 21) and pregnant adults, the Health Plan shall be responsible for
providing up to three-hundred and sixty- five (365) days of health-related
inpatient care, including behavioral health (if behavioral health is covered by
the Health Plan as specified in Attachment I), for each state fiscal year. For
all non-pregnant adults in Reform, the Health Plan shall be responsible for up
to forty-five (45) days of inpatient coverage and up to three-hundred and
sixty-five (365) days of emergency inpatient care, including behavioral health
(if behavioral health is covered by the Health Plan as specified in Attachment
I), in accordance with the Medicaid Hospital Services Coverage & Limitations
Handbook, for each state fiscal year. For non-Reform populations, the Health
Plan shall provide up to forty-five (45) days of inpatient coverage per
enrollee, including behavioral health (if behavioral health is covered by the
Health Plan as specified in Attachment I), for each state fiscal year.

  b.   Transplants

The Health Plan shall provide medically necessary transplants and related
services as outlined in the chart below for applicable Reform and non-Reform
populations.

  1.   For transplant services specified with an asterisk, Reform capitated
Health Plans are paid by the Agency through kick payments. See Attachment I and
Attachment II, Section XIII, Method of Payment, for payment details.     2.  
Transplant services specified with two (2) asterisks, as well as pre- and post-
transplant follow-up care, are covered through fee-for-service Medicaid and not
by the Health Plan. If at the conclusion of the transplant evaluation, the
enrollee is listed with the United Network for Organ Sharing (UNOS) as a level
1A, 1B, or 2 candidate for a heart or lung transplant, or with a Model End Stage
Liver Disease (MELD) score of 11-25 for a liver transplant, then the Health Plan
must submit a copy of the UNOS form to BMHC with a request to disenroll the
member from the Health Plan. The recipient cannot re-enroll with the Health Plan
until at least one (1) year post transplant. This re-enrollment is not
automatic.

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  HMO Contract

SUMMARY OF RESPONSIBILITY

                      Reform   Non-Reform     Adult   Pediatric   Adult  
Pediatric     (21 and Over)   (20 and Under)   (21 and Over)   (20 and Under)
Evaluation
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Bone Marrow
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Cornea
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Heart
  Health Plan*   Health Plan*   Medicaid**   Medicaid**
 
               
Intestinal/Multivisceral
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Kidney
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Liver
  Health Plan*   Health Plan*   Medicaid**   Medicaid**
 
               
Lung
  Health Plan*   Health Plan*   Medicaid**   Medicaid**
 
               
Pancreas
  Health Plan   Health Plan   Health Plan   Health Plan
 
               
Pre- and Post-Transplant Care, including Transplants Not Covered by Medicaid
  Health Plan   Health Plan   Health Plan (except
heart, lung, or
liver)   Health Plan (except
heart, lung, or
liver)
 
               
Other Transplants Not
Covered by Medicaid
  Not Covered   Not Covered   Not Covered   Not Covered

  c.   See Attachment II, Section VI, Behavioral Health Care, and Attachment II,
Exhibit 6, for behavioral health inpatient care requirements.

11. Hospital Services — Outpatient
Outpatient hospital services consist of medically necessary preventive,
diagnostic, therapeutic or palliative care under the direction of a physician or
dentist at a licensed
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acute care hospital. Outpatient hospital services include medically necessary
emergency room services, dressings, splints, oxygen and physician-ordered
services and supplies for the clinical treatment of a specific diagnosis or
treatment.

  a.   The Health Plan shall provide emergency services and care without any
specified dollar limitations.     b.   The Health Plan shall have a procedure
for the authorization of dental care and associated ancillary medical services
provided in an outpatient hospital setting if that care meets the following
requirements:

  (1)   Is provided under the direction of a dentist at a licensed hospital; and
    (2)   Although not usually considered medically necessary, is considered
medically necessary to the extent that the outpatient hospital services must be
provided in a hospital due to the enrollee’s disability, behavioral health
condition or abnormal behavior due to emotional instability or a developmental
disability.

12. Hospital Services — Ancillary Services

  a.   The Health Plan shall provide medically necessary ancillary medical
services at the hospital without limitation. Ancillary hospital services
include, but are not limited to, radiology, pathology, neurology, neonatology,
and anesthesiology.

  (1)   When the capitated Health Plan or its authorized physician authorizes
these services (either inpatient or outpatient), the Health Plan shall reimburse
the provider of the service at the Medicaid line item rate, unless the Health
Plan and the hospital have negotiated another reimbursement rate.     (2)   The
Health Plan shall authorize payment for non-network physicians for emergency
ancillary services provided in a hospital setting.

  b.   If the Health Plan covers dental services, as specified in Attachment I,
it shall have a procedure for the authorization of medically necessary dental
care and associated ancillary services provided in licensed ambulatory surgical
center settings if that care is provided under the direction of a dentist as
described in the State Plan.

13. Hysterectomies, Sterilizations and Abortions
The Health Plan shall maintain a log of all hysterectomy, sterilization and
abortion procedures performed for its enrollees. The log shall include, at a
minimum, the enrollee’s name and identifying information, date of procedure, and
type of procedure. The Health Plan shall provide abortions only in the following
situations:

  a.   If the pregnancy is a result of an act of rape or incest; or     b.   The
physician certifies that the woman is in danger of death unless an abortion is
performed.

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  Medicaid Non-Reform and Reform
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  HMO Contract

14. Immunizations
The Health Plan shall:

  a.   Provide immunizations in accordance with the Recommended Childhood
Immunization Schedule for the United States, or when medically necessary for the
enrollee’s health;     b.   Provide for the simultaneous administration of all
vaccines for which an enrollee under the age of 21 is eligible at the time of
each visit;     c.   Follow only contraindications established by the Advisory
Committee on Immunization Practices (ACIP), unless:

  (1)   In making a medical judgment in accordance with accepted medical
practices, such compliance is deemed medically inappropriate; or     (2)   The
particular requirement is not in compliance with Florida law, including Florida
law relating to religious or other exemptions;

  d.   Participate, or direct its providers to participate, in the Vaccines For
Children Program (“VFC”). See s. 1905(r)(1) of the Social Security Act. The VFC
is administered by the Department of Health, Bureau of Immunizations. The VFC
provides vaccines at no charge to physicians and eliminates the need to refer
children to CHDs for immunizations. Title XXI IViediKids enrollees do not
qualify for the VFC program. The Health Plan shall advise providers to bill
Medicaid fee-for-service directly for immunizations provided to Title XXI
MediKids participants;     e.   Provide documentation annually by October 1 of
each Contract year to MOHO that the Health Plan, or its participating providers,
are enrolled in the VFC program;     f.   Provide coverage and reimbursement to
the participating provider for immunizations covered by Medicaid, but not
provided through VFC;     g.   Ensure that providers have a sufficient supply of
vaccines if the Health Plan is enrolled in the VFC program. The Health Plan
shall direct those providers that are directly enrolled in the VFC program to
maintain adequate vaccine supplies;     h.   (Capitated Health Plans only) Pay
no more than the Medicaid program vaccine administration fee of $10 per
administration, unless another rate is negotiated with the participating
provider;     i.   (Capitated Health Plans only) Pay the immunization
administration fee at no less than the Medicaid rate when an enrollee receives
immunizations from a nonparticipating provider so long as:

  (1)   The non-participating provider contacts the Health Plan at the time of
service delivery;

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  (2)   The Health Plan is unable to document to the non-participating provider
that the enrollee has already received the immunization; and     (3)   The
non-participating provider submits a claim for the administration of
immunization services and provides medical records documenting the immunization
to the Health Plan.

  j.   Encourage PCPs to provide immunization information for enrollees
requesting temporary cash assistance from DCF, upon request by DCF and receipt
of the enrollee’s written permission, in order to document that the enrollee has
met the immunization requirements for enrollees receiving temporary cash
assistance.

15. Pregnancy-Related Requirements
The Health Plan shall provide the most appropriate and highest level of quality
care for pregnant enrollees. Required care includes the following:

  a.   Florida’s Healthy Start Prenatal Risk Screening — The Health Plan shall
ensure that the provider offers Florida’s Healthy Start prenatal risk screening
to each pregnant enrollee as part of her first prenatal visit. As required by s.
383.14, F.S., s. 381.004, F.S., and 64C-7.009, F.A.C.

  (1)   The Health Plan shall ensure that the provider uses the DOH prenatal
risk form (DH Form 3134), which can be obtained from the local CHD.     (2)  
The Health Plan shall ensure that the provider keeps a copy of the completed
screening instrument in the enrollee’s medical record and provides a copy to the
enrollee.     (3)   The Health Plan shall ensure that the provider submits the
completed DH Form 3134 to the CHD in the county where the prenatal screen was
completed within ten (10) business days of completion of the screening.     (4)
  The Health Plan shall collaborate with the Healthy Start care coordinator
within the enrollee’s county of residence to assure delivery of risk-appropriate
care.

  b.   Florida’s Healthy Start Infant (Postnatal) Risk Screening Instrument —
The Health Plan shall ensure that the provider completes the Florida Healthy
Start Infant (Postnatal) Risk Screening Instrument (DH Form 3135) with the
Certificate of Live Birth and transmits the documents to the CHD in the county
where the infant was born within ten (10) business days of the birth. The Health
Plan shall ensure that the provider keeps a copy of the completed DH Form 3135
in the enrollee’s medical record and provides a copy to the enrollee.     c.  
Pregnant enrollees or infants who do not score high enough to be eligible for
Healthy Start care coordination may be referred for services, regardless of
their score on the Healthy Start risk screen, in the following ways:

  (1)   If the referral is to be made at the same time the Healthy Start risk
screen is administered, the provider may indicate on the risk screening form
that the enrollee or infant is invited to participate based on factors other
than score; or

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  (2)   If the determination is made subsequent to risk screening, the provider
may refer the enrollee or infant directly to the Healthy Start care coordinator
based on assessment of actual or potential factors associated with high risk,
such as HIV, Hepatitis B, substance abuse or domestic violence.

  d.   The Health Plan shall refer all infants, children up to age five (5), and
pregnant, breast-feeding and postpartum women to the local WIC office.

  (1)   The Health Plan shall ensure providers provide:

  (a)   A completed Florida WIC program medical referral form with the current
height or length and weight (taken within sixty (60) calendar days of the WIC
appointment);     (b)   Hemoglobin or hematocrit; and     (c)   Any identified
medical/nutritional problems.

  (2)   For subsequent WIC certifications, the Health Plan shall ensure that
providers coordinate with the local WIC office to provide the above referral
data from the most recent CHCUP.     (3)   Each time the provider completes a
WIC referral form, the Health Plan shall ensure that the provider gives a copy
of the form to the enrollee and keeps a copy in the enrollee’s medical record.

  e.   The Health Plan shall ensure that providers give all women of
childbearing age HIV counseling and offer them HIV testing. See Chapter 381,
F.S.

  (1)   The Health Plan shall ensure that its providers offer all pregnant women
counseling and HIV testing at the initial prenatal care visit and again at
twenty- eight (28) and thirty-two (32) weeks.     (2)   The. Health Plan shall
ensure that its providers attempt to obtain a signed objection if a pregnant
woman declines an HIV test. See s. 384.31, F.S. and 64D-3.019, F.A.C.     (3)  
The Health Plan shall ensure that all pregnant women who are infected with HIV
are counseled about and offered the latest antiretroviral regimen recommended by
the U.S. Department of Health & Human Services (Public Health Service Task Force
Report entitled Recommendations for the Use of Antiretroviral Drugs in Pregnant
HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal
HIV-1 Transmission in the United States).

  f.   The Health Plan shall ensure that its providers screen all pregnant
enrollees receiving prenatal care for the Hepatitis B surface antigen (HBsAg)
during the first prenatal visit.

  (1)   The Health Plan shall ensure that the providers perform a second HBsAg
test between twenty-eight (28) and thirty-two (32) weeks of pregnancy for all
pregnant

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  HMO Contract

      enrollees who tested negative at the first prenatal visit and are
considered high- risk for Hepatitis B infection. This test shall be performed at
the same time that other routine prenatal screening is ordered.     (2)   All
HBsAg-positive women shall be reported to the local CHD and to Healthy Start,
regardless of their Healthy Start screening score.

  g.   The Health Plan shall ensure that infants born to HBsAg-positive
enrollees receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine
once they are physiologically stable, preferably within twelve (12) hours of
birth, and shall complete the Hepatitis B vaccine series according to the
vaccine schedule established by the Recommended Childhood Immunization Schedule
for the United States.

  (1)   The Health Plan shall ensure that its providers test infants born to
HBsAgpositive enrollees for HBsAg and Hepatitis B surface antibodies (anti-HBs)
six (6) months after the completion of the vaccine series to monitor the success
or failure of the therapy.     (2)   The Health Plan shall ensure that providers
report to the local CHD a positive HBsAg result in any child age 24 months or
less within twenty-four (24) hours of receipt of the positive test results.    
(3)   The Health Plan shall ensure that infants born to enrollees who are
HBsAgpositive are referred to Healthy Start regardless of their Healthy Start
screening score.

  h.   The Health Plan shall report to the Perinatal Hepatitis B Prevention
Coordinator at the local CHD all prenatal or postpartum enrollees who test
HBsAg-positive. The Health Plan also shall report said enrollees’ infants and
contacts to the Perinatal Hepatitis B Prevention Coordinator.

  (1)   The Health Plan shall report the following information — name, date of
birth, race, ethnicity, address, infants, contacts, laboratory test performed,
date the sample was collected, the due date or estimated date of confinement,
whether the enrollee received prenatal care, and immunization dates for infants
and contacts.     (2)   The Health Plan shall use the Perinatal Hepatitis B Case
and Contact Report (DH Form 1876) for reporting purposes.

  i.   The Health Plan shall ensure that the PCP maintains all documentation of
Healthy Start screenings, assessments, findings and referrals in the enrollees’
medical records.

  j.   Prenatal Care — The Health Plan shall:

  (1)   Require a pregnancy test and a nursing assessment with referrals to a
physician, PA or ARNP for comprehensive evaluation;     (2)   Require case
management through the gestational period according to the needs of the
enrollee;

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  (3)   Require any necessary referrals and follow-up;     (4)   Schedule return
prenatal visits at least every four (4) weeks until week thirty-two (32), every
two (2) weeks until week thirty-six (36), and every week thereafter until
delivery, unless the enrollee’s condition requires more frequent visits;     (5)
  Contact those enrollees who fail to keep their prenatal appointments as soon
as possible, and arrange for their continued prenatal care;     (6)   Assist
enrollees in making delivery arrangements, if necessary; and     (7)   Ensure
that all providers screen all pregnant enrollees for tobacco use and make
certain that the providers make available to pregnant enrollees smoking
cessation counseling and appropriate treatment as needed.

  k.   Nutritional Assessment/Counseling — The Health Plan shall ensure that its
providers supply nutritional assessment and counseling to all pregnant
enrollees. The Health Plan shall:

  (1)   Ensure the provision of safe and adequate nutrition for infants by
promoting breast-feeding and the use of breast milk substitutes;     (2)   Offer
a mid-level nutrition assessment;     (3)   Provide individualized diet
counseling and a nutrition care plan by a public health nutritionist, a nurse or
physician following the nutrition assessment; and     (4)   Ensure documentation
of the nutrition care plan in the medical record by the person providing
counseling.

  l.   Obstetrical Delivery — The Health Plan shall develop and use generally
accepted and approved protocols for both low-risk and high-risk deliveries
reflecting the highest standards of the medical profession, including Healthy
Start and prenatal screening, and ensure that all providers use these protocols.

  (1)   The Health Plan shall ensure that all providers document preterm
delivery risk assessments in the enrollee’s medical record by week twenty-eight
(28).     (2)   If the provider determines that the enrollee’s pregnancy is high
risk, the Health Plan shall ensure that the provider’s obstetrical care during
labor and delivery includes preparation by all attendants for symptomatic
evaluation and that the enrollee progresses through the final stages of labor
and immediate postpartum care.

  m.   Newborn Care — The Health Plan shall make certain that its providers
supply the highest level of care for the newborn beginning immediately after
birth. Such level of care shall include, but not be limited to, the following:

  (1)   Instilling of prophylactic eye medications into each eye of the newborn;

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  (2)   When the mother is Rh negative, securing a cord blood sample for type Rh
determination and direct Coombs test;     (3)   Weighing and measuring of the
newborn;     (4)   Inspecting the newborn for abnormalities and/or
complications;     (5)   Administering one half (.5) milligram of vitamin K;    
(6)   APGAR scoring;     (7)   Any other necessary and immediate need for
referral in consultation from a specialty physician, such as the Healthy Start
(postnatal) infant screen; and     (8)   Any necessary newborn and infant
hearing screenings (to be conducted by a licensed audiologist pursuant to
Chapter 468, F.S., a physician licensed under Chapters 458 or 459, F.S., or an
individual who has completed documented training specifically for newborn
hearing screenings and who is directly or indirectly supervised by a licensed
physician or a licensed audiologist).

  n.   Postpartum Care — The Health Plan shall:

  (1)   Provide a postpartum examination for the enrollee within six (6) weeks
after delivery;     (2)   Ensure that its providers supply voluntary family
planning, including a discussion of all methods of contraception, as
appropriate;     (3)   Ensure that continuing care of the newborn is provided
through the CHCUP program component.

16. Prescribed Drug Services

  a.   The Health Plan shall provide those products and services associated with
the dispensing of medicinal drugs pursuant to a valid prescription, as defined
in Chapter 465, F.S. Prescribed drug services generally include all prescription
drugs listed in the Agency’s Preferred Drug List (PDL). See s. 409.91195, F.S.
The Health Plan’s PDL shall include at least two (2) products, when available,
in each therapeutic class. Pursuant to s. 409.912(39), F.S., policy requirements
include, but are not limited to, the following:

  (1)   The Health Plan shall make available those drugs and dosage forms listed
in its PDL.     (2)   The Health Plan shall not arbitrarily deny or reduce the
amount, duration or scope of prescriptions solely based on the enrollee’s
diagnosis, type of illness or condition. The Health Plan may place appropriate
limits on prescriptions based on criteria such as medical necessity, or for the
purpose of utilization control, provided the Health Plan reasonably expects said
limits to achieve the purpose of the prescribed drug services set forth in the
Medicaid State Plan.

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  HMO Contract

  (3)   The Health Plan shall make available those drugs not on its PDL, when
requested and approved, if the drugs on the PDL have been used in a step therapy
sequence or when other medical documentation is provided.     (4)   The Health
Plan shall submit an updated PDL to BMHC and the Bureau of Pharmacy Services by
October 1 of each Contract year, and provide thirty (30) days’ written notice of
any changes. If the Health Plan adopts the Medicaid PDL, the Health Plan shall
be exempt from such reporting. Information on the Health Plan’s use of the PDL
is in Attachment I and Attachment II, Exhibit 5.     (5)   Antiretroviral agents
are not subject to the PDL.

  b.   The Health Plan may delegate any or all functions to one (1) or more
pharmacy benefits administrators (PBA). Before entering into a subcontract, the
Health Plan shall work with the Agency’s fiscal agent.     c.   The Health Plan
shall continue the medication prescribed to the enrollee in a state mental
health treatment facility for at least ninety (90) days after the facility
discharges the enrollee, unless the Health Plan’s prescribing psychiatrist, in
consultation and agreement with the facility’s prescribing physician, determines
that the medications:

  (1)   Are not medically necessary; or     (2)   Are potentially harmful to the
enrollee.

  d.   The Health Plan shall provide to enrollees who want to quit smoking one
(1) course of nicotine replacement therapy, of twelve (12) weeks’ duration, or
the manufacturer’s recommended duration, per year. The Health Plan may use
either nicotine transdermal patches or nicotine gum.     e.   If the Health Plan
has authorization requirements for prescribed drug services, the Health Plan
shall comply with all aspects of the Settlement Agreement to Hernandez, et al v.
Medows (case number 02-20964 Civ-Gold/Simonton) (HSA). An HSA situation arises
when an enrollee attempts to fill a prescription at a participating pharmacy
location and is unable to receive the prescription as a result of:

  (1)   An unreasonable delay in filling the prescription;     (2)   A denial of
the prescription;     (3)   The reduction of a prescribed good or service;
and/or     (4)   The termination of a prescription.

  f.   The Health Plan shall ensure that its enrollees are receiving the
functional equivalent of those goods and services received by fee-for-service
Medicaid recipients in accordance with the HSA.

  (1)   The Health Plan shall maintain a log of all correspondence and
communications from enrollees relating to the HSA ombudsman process. The
ombudsman log

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      shall contain, at a minimum, the enrollee’s name, address and telephone
number and any other contact information, the reason for the participating
pharmacy location’s denial (an unreasonable delay in filling a prescription, a
denial of a prescription and/or the termination of a prescription), the
pharmacy’s name (and store number, if applicable), the date of the call, a
detailed explanation of the final resolution, and the name of the prescribed
good or service. The ombudsman log report shall be submitted quarterly to BMHC,
as required in Attachment II, Section XII, Reporting Requirements.     (2)   The
Health Plan’s enrollees are third party beneficiaries for this section of the
Contract.     (3)   The Health Plan shall conduct annual HSA surveys of no less
than five percent (5%) of all participating pharmacy locations to ensure
compliance with the HSA.

  (a)   The Health Plan may survey less than five percent (5%), with written
approval from the Agency, if the Health Plan can show that the number of
participating pharmacies it surveys is a statistically significant sample that
adequately represents the pharmacies that have contracted with the Health Plan
to provide pharmacy services.     (b)   The Health Plan shall not include in the
HSA survey any participating pharmacy location that the Health Plan found to be
in complete compliance with the HSA requirements within the past twelve
(12) months.     (c)   The Health Plan shall require all participating pharmacy
locations that fail any aspect of the HSA survey to undergo mandatory training
within six (6) months and then be re-evaluated within one (1) month of the
training to ensure that the pharmacy location is in compliance with the HSA.    
(d)   The Health Plan shall ensure that it complies with all aspects and
surveying requirements set forth in Policy Transmittal 06-01, Hernandez
Settlement Requirements, an electronic copy of which can be found at:

http://www.fdhc.state.fl.us/MCHQ/Manaqed Health Care/MHM0/06policv.shtml

  (e)   The Health Plan shall submit a report annually, by August 1 of each
Contract year to BMHC, providing survey results following requirements in
Attachment II, Section XII, Reporting Requirements.

  (4)   The Health Plan shall offer training to all new and existing
participating pharmacy locations about the HSA requirements.

  g.   The Health Plan shall cover the cost of a brand-name drug if the
prescriber:

  (1)   Writes in his/her own handwriting on the valid prescription that the
“Brand Name is Medically Necessary” (pursuant to s. 465.025, F.S.); and     (2)
  Submits a completed “Multisource Drug and Miscellaneous Prior Authorization”
form to the Health Plan indicating that the enrollee has had an adverse reaction

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      to a generic drug or has had, in the prescriber’s medical opinion, better
results when taking the brand-name drug.

  h.   For PSNs, hemophilia factor-related drugs identified by the Agency for
distribution through the Comprehensive Hemophilia Disease Management Program are
reimbursed on a fee-for-service basis. During operation of the Comprehensive
Hemophilia Disease Management Program, the Health Plan shall coordinate the care
of its enrollees with Agency-approved organizations and shall not be responsible
for the distribution of hemophilia-related drugs.     i.   For HMOs, hemophilia
factor-related drugs are reimbursed by Medicaid on a fee-forservice basis. The
HMO shall coordinate the care of its enrollees with hemophilia and shall not be
responsible for the distribution of hemophilia factor-related drugs.     j.  
Capitated Health Plans shall submit pharmacy encounter data, including
behavioral health pharmacy encounter data if behavioral health is a Health Plan
covered service, to the Medicaid Encounter Data System secure file transfer
protocol site in a format supplied by the Agency on an ongoing quarterly
schedule, as specified in Attachment II, Section XII, Reporting Requirements.

17. Quality Enhancements
In addition to the covered services specified in this section, the Health Plan
shall offer quality enhancements (QE) to enrollees as specified below.

  a.   The Health Plan shall offer QEs in community settings accessible to
enrollees.     b.   The Health Plan shall provide information in the enrollee
and provider handbooks on the QEs and how to access related services.     c.  
The Health Plan shall develop and maintain written policies and procedures to
implement QEs.     d.   The Health Plan may cosponsor the annual training of
providers, provided that the training meets the provider training requirements
for the programs listed below. The Health Plan is encouraged to actively
collaborate with community agencies and organizations, including CHDs, local
Early Intervention Programs, Healthy Start Coalitions and local school districts
in offering these services.     e.   If the Health Plan involves the enrollee in
an existing community program for purposes of meeting the QE requirement, the
Health Plan shall ensure documentation in the enrollee’s medical record of
referrals to the community program and follow up on the enrollee’s receipt of
services from the community program.     f.   QE programs shall include, but not
be limited to, the following:

  (1)   Children’s Programs — The Health Plan shall provide regular general
wellness programs targeted specifically toward enrollees from birth to age of
five (5), or the Health Plan shall make a good faith effort to involve enrollees
in existing community children’s programs.

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  (a)   Children’s programs shall promote increased use of prevention and early
intervention services for at-risk enrollees. The Health Plan shall approve
claims for services recommended by the Early Intervention Program when they are
covered services and medically necessary.     (b)   The Health Plan shall offer
annual training to providers that promotes proper nutrition, breast-feeding,
immunizations, CHCUP, wellness, prevention and early intervention services.

  (2)   Domestic Violence — The Health Plan shall ensure that PCPs screen
enrollees for signs of domestic violence and shall offer referral services to
applicable domestic violence prevention community agencies.     (3)   Pregnancy
Prevention — The Health Plan shall conduct regularly scheduled pregnancy
prevention programs, or shall make a good faith effort to involve enrollees in
existing community pregnancy prevention programs, such as the Abstinence
Education Program. The programs shall be targeted towards teen enrollees, but
shall be open to all enrollees, regardless of age, gender, pregnancy status or
parental consent.     (4)   Prenatal/Postpartum Pregnancy Programs — The Health
Plan shall provide regular home visits, conducted by a home health nurse or
aide, and counseling and educational materials to pregnant and postpartum
enrollees who are not in compliance with the Health Plan’s prenatal and
postpartum programs. The Health Plan shall coordinate its efforts with the local
Healthy Start care coordinator to prevent duplication of services.     (5)  
Smoking Cessation — The Health Plan shall conduct regularly scheduled smoking
cessation programs as an option for all enrollees, or the Health Plan shall make
a good faith effort to involve enrollees in existing community smoking cessation
programs. The Health Plan shall provide smoking cessation counseling to
enrollees. The Health Plan shall provide participating PCPs with the Quick
Reference Guide to assist in identifying tobacco users and supporting and
delivering effective smoking cessation interventions. (The health plan can
obtain copies of the guide by contacting the DHHS, Agency for Health Care
Research & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O.
Box 8547, Silver Spring, MD 20907.)     (6)   Substance Abuse — The Health Plan
shall offer annual substance abuse screening training to its providers.

  (a)   The Health Plan shall have all PCPs screen enrollees for signs of
substance abuse as part of prevention evaluation at the following times:

  (i)   Initial contact with a new enrollee;     (ii)   Routine physical
examinations;     (iii)   Initial prenatal contact;

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  (iv)   When the enrollee evidences serious over-utilization of medical,
surgical, trauma or emergency services; and     (v)   When documentation of
emergency room visits suggests the need.

  (b)   The Health Plan shall offer targeted enrollees either community or
Health Plan-sponsored substance abuse programs.

18. Protective Custody

  a.   The Health Plan shall provide a physical screening within seventy-two
(72) hours, or immediately if required, for all enrolled children/adolescents
taken into protective custody, emergency shelter or the foster care program by
DCF. See 65C-29.008, FAC.     b.   The Health Plan shall provide these required
examinations, or, if unable to do so within the required time frames, approve
the out-of-network claim and forward it to the Agency and/or its fiscal agent.  
  c.   For all CHCUP screenings for children/adolescents whose enrollment and
Medicaid eligibility are undetermined at the time of entry into the care and
custody of DCF, and who are later determined to be enrollees at the time the
examinations took place, the Health Plan shall approve the claims and forward
them to the Agency and/or the fiscal agent.

19. Therapy Services
Medicaid therapy services are physical, speech-language (including augmentative
and alternative communication systems), occupational and respiratory therapies.
The Health Plan shall cover therapy services consistent with the Medicaid
Therapy Services Coverage and Limitations Handbook requirements. Therapy
services are limited to children/adolescents under age 21. Adults are covered
for physical and respiratory therapy services under the outpatient hospital
services program. The Agency shall reimburse schools participating in the
certified school match program for school-based therapy services rendered to
enrollees. The provision of school-based therapy services to an enrollee does
not replace, substitute or fulfill a service prescription or doctors’ orders for
therapy services covered by the Health Plan. The Health Plan shall:

  a.   Refer enrollees to appropriate providers for further assessment and
treatment of conditions;     b.   Offer enrollees scheduling assistance in
making treatment appointments and arranging transportation; and     c.   Provide
for care management in order to follow the enrollee’s progress from screening
through the course of treatment

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  HMO Contract

20. Transportation Services (See Attachment I and Attachment II, Exhibit 5)

  a.   Transportation services include the arrangement and provision of an
appropriate mode of transportation for enrollees to receive medical services.  
  b.   Certain health plans are not authorized to provide transportation
services. Some health plans are required to provide them. The transportation
services requirements for this Contract are detailed in Attachment I and in
Attachment II, Exhibit 5. If the Health Plan does provide transportation, it may
do so through its own network of transportation providers or through a
contractual relationship, which may include the Commission for the
Transportation Disadvantaged.     c.   If the Health Plan does not provide
transportation services, it still must assist enrollees in arranging
transportation to and from medical appointments for Medicaid- covered services.

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  HMO Contract

Section VI
Behavioral Health Care
See Attachment I and Attachment II, Exhibit 6

A.   General Provisions

  1.   Specifics of behavioral health coverage for this Contract are in
Attachment II, Exhibit 6.     2.   Provision of Behavioral Health Services When
Not Covered by the Health Plan:

  a.   If the Health Plan determines that an enrollee is in need of behavioral
health services that are not covered under the Contract, the Health Plan shall
refer the enrollee to the appropriate provider. The Health Plan may request the
assistance of the Agency’s local field office or the local DCF SAMH Office for
referral to the appropriate service setting.     b.   Long-term care
institutional services in a nursing facility, an institution for persons with
developmental disabilities, specialized therapeutic foster care, children’s
residential treatment services or state hospital services are not covered by the
Health Plan. For enrollees requiring those services, the Health Plan shall
consult the Medicaid Area Office and/or the local DCF SAMH Office to identify
appropriate methods of assessment and referral.     c.   The Health Plan is
responsible for transition and referral of the enrollee to appropriate
providers.

  3.   Substance Abuse Services — Health Plan enrollees will receive
Medicaid-funded substance abuse services through the fee-for-service system. The
Health Plan shall develop methods of coordinating and integrating mental health
and substance abuse services for enrollees. The Health Plan shall be required to
use the Florida Supplement to the American Society of Addictions Medicine
Patient Placement Criteria for the coordination of mental health treatment with
substance abuse providers as part of the integration effort (Second Edition ASAM
PPC-2, July 1998). The coordination shall be reflected in their individualized
treatment plans for enrollees with co-occurring disorder.

  4.   Drug Utilization Review — The Health Plan shall design and implement a
drug utilization review (DUR) program designed to encourage coordination between
an enrollee’s primary care physician and a prescriber of a psychotropic or
similar prescription drug for behavioral health problems. The Health Plan’s DUR
program shall identify those medications for other serious medical conditions
(such as hypertension, diabetes, neurological disorders, or cardiac problems),
where this is a significant risk to the enrollee posed by potential drug
interactions between drugs for these conditions and behavioral-related drugs.
After the Health Plan identifies the potential for such problems, the Health
Plan’s DUR program shall notify all related prescribers that certain drugs may
be contra-indicated due to the potential for drug interactions and shall
encourage the prescribers to coordinate their care. Notice may be provided
electronically or via mail, or by telephonic or direct consultation, as the
Health Plan deems appropriate.

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  HMO Contract

  5.   Outreach Program — The Health Plan shall have an outreach program
including referral and other resources designed to assist PCPs in the
identification, management and treatment of:

  a.   Enrollees with severe and persistent mental illness;     b.  
Children/adolescents with severe emotional disturbances; and     c.   Enrollees
with clinical depression.

  6.   Release of records — The enrollee or authorized representative shall sign
and date a release form before any psychiatric notes can be released to another
party.

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  HMO Contract

Section VII
Provider Network

A.   General Provisions

  1.   The Health Plan shall have sufficient facilities, service locations and
personnel to provide the covered services described in Attachment II, Section V,
Covered Services, and Section VI, Behavioral Health Care.     2.   The Health
Plan shall provide BMHC, prior to Contract execution and upon request, with
sufficient evidence that the Health Plan has the capacity to provide covered
services to all enrollees up to the maximum enrollment level in each county,
including evidence that the Health Plan:

  a.   Offers an appropriate range of services and accessible preventive and
primary care services to meet the needs of the maximum enrollment level in each
county; and     b.   Maintains a sufficient number, mix and geographic
distribution of providers, including providers who are accepting new Medicaid
patients as specified in s. 1932(b)(7) of the Social Security Act, as enacted by
s. 4704(a) of the Balanced Budget Act of 1997.

  3.   Prior to Contract execution and at least monthly thereafter, the Health
Plan shall submit a file of all network providers to the Agency or its agent in
the manner and format determined by the Agency. See Attachment II, Section XII,
Reporting Requirements, Table 1.     4.   Each provider shall maintain hospital
privileges if hospital privileges are required for the delivery of covered
services. The Health Plan may use admitting panels to comply with this
requirement.     5.   The Health Plan shall not discriminate against particular
providers that serve high-risk populations or specialize in conditions that
require costly treatments.     6.   When establishing and maintaining the
provider network, requesting expansion to other counties, or requesting
enrollment level increases, the Health Plan shall take the following into
consideration as required by 42 CFR 438.206:

  a.   The anticipated number of enrollees;     b.   The expected utilization of
services, taking into consideration the characteristics and health care needs of
specific Medicaid populations represented;     c.   The numbers and types (in
terms of training, experience, and specialization) of providers required to
furnish the covered services;     d.   The numbers of network providers who are
not accepting new enrollees;     e.   The geographic location of providers and
enrollees, considering distance, travel time, the means of transportation
ordinarily used by enrollees and whether the location provides physical access
for Medicaid enrollees with disabilities.

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  7.   If the Health Plan is unable to provide medically necessary services to
an enrollee, the Health Plan shall cover these services in an adequate and
timely manner by using providers and services that are not in the Health Plan’s
network for as long as the Health Plan is unable to provide the medically
necessary services within its network.     8.   The Health Plan shall allow each
enrollee to choose among network providers to the extent possible and
appropriate.     9.   The Health Plan shall require each provider to have a
unique Florida Medicaid provider number. The Health Plan shall require each
provider to have a National Provider Identifier (NPI) in accordance with s.
1173(b) of the Social Security Act, as enacted by s. 4707(a) of the Balanced
Budget Act of 1997. The provider contract shall require providers to submit all
NPIs to the Health Plan within fifteen (15) business days of receipt. The Health
Plan shall report the providers’ NPIs as part of its provider network report to
the Agency or its agent, as set forth in Attachment II, Section XII, Reporting
Requirements. The Health Plan need not obtain an NPI from the following
providers:

  a.   Individuals or organizations that furnish atypical or nontraditional
services that are only indirectly related to the provision of health care
(examples include taxis, home and vehicle modifications, insect control,
habilitation and respite services); and     b.   Individuals or businesses that
only bill or receive payment for, but do not furnish, health care services or
supplies (examples include billing services and repricers).

  10.   The Health Plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider, whether participating or
nonparticipating, 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 s.1932(b) (7) of the Social Security Act (as
enacted by s. 4704[a] of the Balanced Budget Act of 1997). The Health Plan is
not prohibited from including providers only to the extent necessary to meet the
needs of the Health Plan’s enrollees or from establishing any measure designed
to maintain quality and control costs consistent with the responsibilities of
the Health Plan. If the Health Plan declines to include individual providers or
groups of providers in its network, it must give the affected providers written
notice of the reason for its decision.

  11.   The Health Plan shall establish and maintain a formal provider relations
function to timely and adequately respond to inquiries, questions and concerns
from network providers.

B.   Network Standards (See Attachment II, Exhibit 7)

  1.   Primary Care Providers

  a.   The Health Plan shall enter into provider contracts with a sufficient
number of PCPs to ensure adequate accessibility for enrollees of all ages. The
Health Plan shall select and approve its PCPs and ensure they provide the
following:

  (1)   The PCP shall provide, or arrange for coverage of services, consultation
or approval for referrals twenty-four hours per day, seven days per week (24/7)
by

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      Medicaid-enrolled providers who will accept Medicaid reimbursement. This
coverage shall consist of an answering service, call forwarding, provider call
coverage or other customary means approved by the Agency. The chosen method of
24/7 coverage must connect the caller to someone who can render a clinical
decision or reach the PCP for a clinical decision. The after-hours coverage must
be accessible using the medical office’s daytime telephone number; and     (2)  
The PCP shall arrange for coverage of primary care services during absences due
to vacation, illness or other situations that require the PCP to be unable to
provide services. A Medicaid-eligible PCP must provide coverage.

  b.   The Health Plan shall provide the following:

  (1)   At least one (1) FTE PCP per service area including, but not limited to,
the following broad specialty areas:

  (a)   Family Practice;     (b)   General Practice;     (c)   Pediatrics; and  
  (d)   Internal Medicine.

  (2)   At least one (1) FTE PCP per 1,500 enrollees. The Health Plan may
increase the ratio by 750 enrollees for each FTE advanced registered nurse
practitioner (ARNP) or physician’s assistant (PA) affiliated with a PCP.     (3)
  The Health Plan shall allow pregnant enrollees to choose Health Plan
obstetricians as their PCPs to the extent that the obstetrician is willing to
participate as a PCP.

  c.   If the enrollee has not selected a provider for a newborn, the Health
Plan shall assign a pediatrician or other appropriate PCP to all pregnant
enrollees for the care of their newborn babies no later than the beginning of
the last trimester of gestation.

  2.   Specialists and Other Providers (See Attachment II, Exhibit 7)

  a.   In addition to the above requirements, the Health Plan shall assure the
availability of providers in the following specialty areas, as appropriate for
both adults and pediatric enrollees, on at least a referral basis. The Health
Plan shall use participating specialists with pediatric expertise for
children/adolescents when the need for pediatric specialty care is significantly
different from the need for adult specialty care (for example a pediatric
cardiologist for children/adolescents with congenital heart defects).
Specialties below marked with an asterisk (*) require both adult and pediatric
providers.

  (1)   Allergies,     (2)   Anesthesiology,

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  (3)   Cardiology*,     (4)   Chiropractic,     (5)   Dermatology,     (6)  
Endocrinology*,     (7)   Gastroenterology,     (8)   General Surgery,     (9)  
Infectious Diseases,     (10)   Nephrology*,     (11)   Neurology*,     (12)  
Neurosurgery,     (13)   Obstetrics/Gynecology (OB/GYN),     (14)   Oncology,  
  (15)   Ophthalmology,     (16)   Optometry,     (17)   Oral Surgery,     (18)
  Orthopedics*,     (19)   Otolaryngology,     (20)   Pathology,     (21)  
Pediatrics,     (22)   Podiatry,     (23)   Pulmonology,     (24)   Radiology,  
  (25)   Therapy, Physical, Respiratory, Speech and Occupational*,     (26)  
Urology.

  b.   If the infectious disease specialist does not have expertise in HIV and
its treatment and care, then the Health Plan shall have another provider with
such expertise.

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  c.   The Health Plan shall permit female enrollees to have direct access to a
women’s health specialist within the network for covered services necessary to
provide women’s routine and preventive health care services. This is in addition
to an enrollee’s designated PCP, if that provider is not a women’s health
specialist.     d.   In accordance with s. 641.31, F.S., the Health Plan shall
ensure access to certified nurse midwife services or licensed midwife services
for low risk enrollees, licensed in accordance with Chapter 467, F.S.

  3.   Public Health Providers

  a.   The Health Plan shall make a good faith effort to execute memoranda of
agreement with the local CHDs to provide services which may include, but are not
limited to, family planning services, services for the treatment of sexually
transmitted diseases, other public health related diseases, tuberculosis,
immunizations, foster care emergency shelter medical screenings, and services
related to Healthy Start prenatal and post-natal screenings. The Health Plan
shall provide documentation of its good faith effort upon the Agency’s request.
    b.   A capitated Health Plan shall pay, without prior authorization, at the
contracted rate or the Medicaid fee-for-service rate, all valid claims initiated
by any CHD for office visits, prescribed drugs, laboratory services directly
related to DCF emergency shelter medical screening, and tuberculosis. A
capitated Health Plan shall reimburse the CHD when the CHD notifies the Health
Plan and provides the Health Plan with copies of the appropriate medical records
and provides the enrollee’s PCP with the results of any tests and associated
office visits.     c.   The Health Plan shall authorize all claims from a CHD, a
migrant health center funded under Section 329 of the Public Health Services Act
or a community health center funded under Section 330 of the Public Health
Services Act, without prior authorization for the services listed below. Such
providers shall attempt to contact the Health Plan before providing health care
services to enrollees and shall provide the Health Plan with the results of the
office visit, including test results. The Health Plan shall not deny claims for
services delivered by these providers solely based on the period between the
date of service and the date of clean claim submission, unless that period
exceeds three-hundred and sixty-five (365) calendar days, and shall be
reimbursed by the Health Plan at the rate negotiated between the Health Plan and
the public provider or the applicable Medicaid fee-for-service rate.

  (1)   The diagnosis and treatment of sexually transmitted diseases and other
reportable infectious diseases, such as tuberculosis and HIV;     (2)   The
provision of immunizations;     (3)   Family planning services and related
pharmaceuticals;     (4)   School health services listed in a, b and c above,
and for services rendered on an urgent basis by such providers; and,

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  HMO Contract

  (5)   In the event that a vaccine-preventable disease emergency is declared,
the Health Plan shall authorize claims from the CHD for the cost of the
administration of vaccines.

  d.   Other clinic-based services provided by a CHD, migrant health center or
community health center, including well-child care, dental care, and sick care
services not associated with reportable infectious diseases, require prior
authorization from the Health Plan in order to receive reimbursement. If prior
authorization is provided, the Health Plan shall reimburse at the entity’s
cost-based reimbursement rate. If prior authorization for prescription drugs is
given and the drugs are provided, the Health Plan shall reimburse the entity at
Medicaid’s standard pharmacy rate.     e.   The Health Plan shall make a good
faith effort to execute a contract with a Federally Qualified Health Center
(FQHC) and, if applicable, a Rural Health Clinic (RHC).

  (1)   The capitated Health Plan shall reimburse FQHCs and RHCs at rates
comparable to those rates paid for similar services in the FQHC’s or RHC’s
community.     (2)   The capitated Health Plan shall report quarterly to BMHC,
the payment rates and the payment amounts made to FQHCs and RHCs for contractual
services provided by these entities.

  f.   The Health Plan shall make a good faith effort to execute memoranda of
agreement with school districts participating in the certified match program
regarding the coordinated provision of school-based services pursuant to ss.
1011.70 and 409.908(21), F.S.

  4.   Facilities and Ancillary Providers

  a.   Emergency Services and Emergency Services Facilities — The Health Plan
shall ensure the availability of emergency services and care twenty-four hours a
day, seven days a week (24/7).     b.   General Acute Care Hospital — The Health
Plan shall provide at least one (1) fully accredited general acute care hospital
bed per two-hundred and seventy-five (275) enrollees.     c.   Birth Delivery
Facility — The Health Plan shall provide at least one (1) birth delivery
facility, licensed under Chapter 383, F.S., or a hospital with birth delivery
facilities, licensed under Chapter 383, F.S. The birth delivery facility may be
a freestanding facility or part of a hospital. The Health Plan shall also
provide a birthing center, licensed under Chapter 383, F.S. that is accessible
to low-risk enrollees.     d.   Regional Perinatal Intensive Care Centers
(RPICC) — The Health Plan shall assure access for enrollees in one (1) or more
of Florida’s RPICC, see ss. 383.15 through 383.21, F.S., or a hospital licensed
by the Agency for neonatal intensive care unit (NICU) Level III beds.

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  HMO Contract

  e.   Neonatal Intensive Care Unit (NICU) — The Health Plan shall ensure that
care for medically high-risk perinatal enrollees is provided in a facility with
a NICU sufficient to meet the appropriate level of need for the enrollee.     f.
  Pharmacy — If the Health Plan elects to use a more restrictive pharmacy
network than the Medicaid fee-for-service network, the Health Plan shall provide
at least one (1) licensed pharmacy per 2,500 enrollees. The Health Plan shall
ensure that its contracted pharmacies comply with the Settlement Agreement to
Hernandez et a/. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA).

C. Network Changes

  1.   The Health Plan shall submit a request for initial or expansion review,
including submission of its provider network, to HSD when it has met the
standards in this section of the Contract. BMHC will not approve the network
until credentialing and all other network requirements have been met.     2.  
The Health Plan shall provide BMHC and HSD with documentation of compliance with
access requirements at any time there has been a significant change in the
Health Plan’s operations that would affect adequate capacity and services,
including, but not limited to, the following:

  a.   Changes in Health Plan services or service area; and     b.   Enrollment
of a new population in the Health Plan.

  3.   The Health Plan shall notify BMHC within seven (7) business days of any
significant changes to its network. A significant change is defined as:

  a.   A decrease in the total number of PCPs by more than five percent (5%);  
  b.   A loss of all participating specialists in a specialty where another
participating specialist in that specialty is not available within sixty (60)
minutes;     c.   A loss of a hospital in an area where another Health Plan
hospital of equal service ability is not available within thirty (30) minutes;
or     d.   Other adverse changes to the composition of the network that impair
or deny the enrollee’s adequate access to providers.

  4.   The Health Plan shall have procedures to address changes in the Health
Plan network that negatively affect the ability of enrollees to access services,
including access to a culturally diverse provider network. Significant changes
in network composition that negatively impact enrollee access to services may be
grounds for Contract termination or sanctions as determined by the Agency and in
accordance with Attachment II, Section XIV, Sanctions.     5.   If a PCP ceases
participation in the Health Plan’s network, the Health Plan shall send written
notice to BMHC and to the enrollees who have chosen the provider as their PCP.
This notice shall be issued no less than fifteen (15) calendar days after
receipt of the termination notice.

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  a.   If an enrollee is in a prior authorized ongoing course of treatment with
any other provider who becomes unavailable to continue to provide services, the
Health Plan shall notify the enrollee in writing within ten (10) calendar days
from the date the Health Plan becomes aware of such unavailability.     b.  
These requirements to provide notice prior to the effective dates of termination
shall be waived in instances where a provider becomes physically unable to care
for enrollees due to illness, death, or leaving the service area and fails to
notify the Health Plan, or when a provider fails credentialing. Under these
circumstances, notice shall be issued immediately upon the Health Plan’s
becoming aware of the circumstances.

  6.   The Health Plan shall notify BMHC of any new network providers by the 5th
of the month following execution of the provider agreement using the format
provided in the Report Guide referenced in Attachment II, Section XII, Reporting
Requirements.

D.   Provider Contract Requirements

  1.   The Health Plan shall comply with all Agency procedures for provider
contract review and approval submission.

  a.   All provider contracts must comply with 42 CFR 438.230, 42 CFR 455.104,
42 CFR 455.105, and 42 CFR 455.106.     b.   If the Health Plan is capitated, it
shall ensure that all providers are eligible for participation in the Medicaid
program. If a provider was involuntarily terminated from the Florida Medicaid
program, other than for purposes of inactivity, that provider is not considered
an eligible Medicaid provider. If the Health Plan is not capitated, its
providers shall be enrolled as Florida Medicaid providers.     c.   The Health
Plan shall not employ or contract with individuals on the state or federal
exclusions list.     d.   No provider contract that the Health Plan enters into
with respect to performance under this Contract shall in any way relieve the
Health Plan of any responsibility for the provision of services or duties under
this Contract. The Health Plan shall assure that all services and tasks related
to the provider contract are performed in accordance with the terms of this
Contract. The Health Plan shall identify in its provider contract any aspect of
service that may be subcontracted by the provider.

  2.   All provider contracts and amendments executed by the Health Plan shall
be in writing, signed, and dated by the Health Plan and the provider, and shall
meet the following requirements:

  a.   Prohibit the provider from seeking payment from the enrollee for any
covered services provided to the enrollee within the terms of the Contract;    
b.   Require the provider to look solely to the following for compensation for
services rendered, with the exception of nominal cost sharing, pursuant to the
Medicaid State Plan and the Florida Coverage and Limitations Handbooks:

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  HMO Contract

  (1)   If a capitated Health Plan, then to the capitated Health Plan for
compensation;     (2)   If a FFS Health Plan, then to the Agency or its Agent,
unless the service is one for which the Health Plan receives a capitation
payment from the Agency. For such capitated services, the Health Plan shall
require providers to look solely to the Health Plan;

  c.   If there is a Health Plan physician incentive plan, include a statement
that the Health Plan shall make no specific payment directly or indirectly under
a physician incentive plan to a provider as an inducement to reduce or limit,
medically necessary services to an enrollee, and that incentive plans shall not
contain provisions that provide incentives, monetary or otherwise, for
withholding medically necessary care;     d.   Specify that any contracts,
agreements, or subcontracts entered into by the provider for purposes of
carrying out any aspect of this Contract shall include assurances that the
individuals who are signing the contract, agreement or subcontract are so
authorized and that it includes all the requirements of this Contract;     e.  
Require the provider to cooperate with the Health Plan’s peer review, grievance,
QIP and UM activities, and provide for monitoring and oversight, including
monitoring of services rendered to enrollees, by the Health Plan (or its
subcontractor). If the Health Plan has delegated the credentialing to a
subcontractor, the agreement must ensure that all licensed providers are
credentialed in accordance with the Health Plan’s and the Agency’s credentialing
requirements as found in Attachment II, Section VII, Provider Network, Item H.,
Credentialing and Recredentialing;     f.   Include provisions for the immediate
transfer to another PCP or health plan if the enrollee’s health or safety is in
jeopardy;     g.   Not prohibit a provider from discussing treatment or
non-treatment options with enrollees that may not reflect the Health Plan’s
position or may not be covered by the Health Plan;     h.   Not prohibit a
provider from acting within the lawful scope of practice, from advising or
advocating on behalf of an enrollee for the enrollee’s health status, medical
care, or treatment or non-treatment options, including any alternative
treatments that might be self-administered;     i.   Not prohibit a provider
from advocating on behalf of the enrollee in any grievance system or UM process,
or individual authorization process to obtain necessary services;     j.  
Require providers to meet appointment waiting time standards pursuant to this
Contract;     k.   Provide for continuity of treatment in the event a provider
contract terminates during the course of an enrollee’s treatment by that
provider;     l.   Prohibit discrimination with respect to participation,
reimbursement, or indemnification of any provider who is acting within the scope
of his/her license or

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  HMO Contract

      certification under applicable state law, solely on the basis of such
license or certification. This provision shall not be construed as a willing
provider law, as it does not prohibit the Health Plan from limiting provider
participation to the extent necessary to meet the needs of the enrollees. This
provision does not interfere with measures established by the Health Plan that
are designed to maintain quality and control costs;     m.   Prohibit
discrimination against providers serving high-risk populations or those that
specialize in conditions requiring costly treatments;     n.   Require an
adequate record system be maintained for recording services, charges, dates and
all other commonly accepted information elements for services rendered to the
Health Plan;     o.   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
Health Plan if the provider contract is continuous;     p.   Specify that DHHS,
the Agency, MPI and MFCU shall have the right to inspect, evaluate, and audit
all of the following related to this Contract:

  (1)   Pertinent books,     (2)   Financial records,     (3)   Medical records,
and     (4)   Documents, papers, and records of any provider involving financial
transactions;

  q.   Specify covered services and populations to be served under the provider
contract;     r.   Require that providers comply with the Health Plan’s cultural
competency plan;     s.   Require that any community outreach materials related
to this Contract that are displayed by the provider be submitted to the BMHC for
written approval before use;     t.   Provide for submission of all reports and
clinical information required by the Health Plan, including Child Health
Check-Up reporting (if applicable);     u.   Require providers of transitioning
enrollees to cooperate in all respects with providers of other health plans to
assure maximum health outcomes for enrollees;     v.   Require providers to
submit notice of withdrawal from the network at least ninety (90) calendar days
before the effective date of such withdrawal;     w.   Require that all
providers agreeing to participate in the network as PCPs fully accept and agree
to responsibilities and duties associated with the PCP designation;

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AMERIGROUP Community Care
  HMO Contract

  x.   Require all providers to notify the Health Plan in the event of a lapse
in general liability or medical malpractice insurance, or if assets fall below
the amount necessary for licensure under Florida statutes;     y.   Require
providers to offer hours of operation that are no less than the hours of
operation offered to commercial Health Plan members or comparable non-Reform
Medicaid recipients if the provider serves only Medicaid recipients;     z.  
Require safeguarding of information about enrollees according to 42 CFR 438.224;
    aa.   Require compliance with HIPAA privacy and security provisions;     bb.
  Require an exculpatory clause, which survives provider agreement termination,
including breach of provider contract due to insolvency, which assures that
neither Medicaid recipients nor the Agency shall be held liable for any debts of
the provider;     cc.   Require that the provider secure and maintain during the
life of the provider contract worker compensation insurance (complying with the
Florida worker compensation law) for all of its employees connected with the
work under this Contract unless such employees are covered by the protection
afforded by the Health Plan;     dd.   Make provisions for a waiver of those
terms of the provider contract that, as they pertain to Medicaid recipients, are
in conflict with the specifications of this Contract;     ee.   Contain no
provision that in any way prohibits or restricts the provider from entering into
a commercial contract with any other health plan (see s. 641.315, ES.);     ff.
  Contain no provision requiring the provider to contract for more than one
(1) Health Plan product or otherwise be excluded (see s. 641.315, F.S.);     gg.
  Contain no provision that prohibits the provider from providing inpatient
services in a contracted hospital to an enrollee if such services are determined
to be medically necessary and covered services under this Contract;     hh.  
Require providers to cooperate fully in any investigation by the Agency, IV1P1,
MFCU, or other state or federal entity and in any subsequent legal action that
may result from such an investigation involving this Contract; and     ii.  
Require providers to submit timely, complete and accurate encounter data to the
Health Plan in accordance with the requirements of Attachment II, Section X,
Administration and Management, Item D., Encounter Data;     jj.   Contain a
clause indemnifying, defending and holding the Agency and the Health Plan’s
enrollees harmless from and against all claims, damages, causes of action, costs
or expenses, including court costs and reasonable attorney fees, to the extent
proximately caused by any negligent act or other wrongful conduct arising from
the provider agreement. This clause must survive the termination of the
agreement, including breach due to insolvency. The Agency may waive this
requirement for itself, but not Health Plan enrollees, for damages in excess of
the statutory cap on damages for public entities, if the provider is a state
agency or subdivision as defined

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  HMO Contract

      by s. 768.28, F.S., or a public health entity with statutory immunity. All
such waivers shall be approved in writing by the Agency.     kk.   Require
physicians to immediately notify the Health Plan of an enrollee’s pregnancy,
whether identified through medical history, examination, testing, claims, or
otherwise.     ll.   Specify that in addition to any other right to terminate
the provider contract, and notwithstanding any other provision of this Contract,
the Agency or the Health Plan may request immediate termination of a provider
contract if, as determined by the Agency, a provider fails to abide by the terms
and conditions of the provider contract, or in the sole discretion of the
Agency, the provider fails to come into compliance with the provider contract
within fifteen (15) calendar days after receipt of notice from the Health Plan
specifying such failure and requesting such provider abide by the terms and
conditions thereof; and     mm.   Specify that any provider whose participation
is terminated pursuant to the provider contract for any reason shall utilize the
applicable appeals procedures outlined in the provider contract. No additional
or separate right of appeal to the Agendy or the Health Plan is created as a
result of the Health Plan’s act of terminating, or decision to terminate, any
provider under this Contract. Notwithstanding the termination of the provider
contract with respect to any particular provider, this Contract shall remain in
full force and effect with respect to all other providers.

E.   Provider Termination

  1.   The Health Plan shall comply with all state and federal laws regarding
provider termination.     2.   The Health Plan shall notify enrollees in
accordance with the provisions of this Contract regarding provider termination.
    3.   In a case in which a patient’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, notice to both the
provider and BMHC shall be immediate. The Health Plan shall submit a list of
terminated providers to BMHC once a month, in accordance with requirements in
Attachment II, Section XII, Reporting Requirements.     4.   The Health Plan
shall notify the provider, BMHC and enrollees in active care at least sixty
(60) calendar days before the effective date of the suspension or termination of
a provider from the network. If the termination was for “cause,” the Health Plan
shall provide to BMHC the reasons for termination.

F.   Appointment Waiting Times and Geographic Access Standards

  1.   The Health Plan must assure that PCP services and referrals to
participating specialists are available on a timely basis, as follows:

  a.   Urgent Care — within one (1) day,     b.   Routine Sick Patient Care —
within one (1) week, and

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AMERIGROUP Community Care
  HMO Contract

  c.   Well Care Visit — within one (1) month.

  2.   All PCPs, hospital and community mental health services must be available
within an average of thirty (30) minutes’ travel time from an enrollee’s
residence. All participating specialists and ancillary providers must be within
an average of sixty (60) minutes’ travel time from an enrollee’s residence. BMHC
may waive this requirement, in writing, for rural areas and for areas where
there are no PCPs, hospitals or community mental health centers within a thirty
(30) minute average travel time.     3.   The Health Plan shall provide a
designated emergency services facility within an average of thirty (30) minutes’
travel time from an enrollee’s residence, that provides care on a twenty-four
hours a day, seven days a week (24/7) basis. Each designated emergency service
facility shall have one (1) or more physicians and one (1) or more nurses on
duty in the facility at all times. BMHC may waive the travel time requirement,
in writing, in rural areas.     4.   For rural areas, if the Health Plan is
unable to enter into an agreement with specialty or ancillary service providers
within the required sixty (60) minute average travel time, BMHC may waive, in
writing, the requirement.     5.   At least one (1) pediatrician or one (1) CHD,
FQHC or RHC must be available within an average of thirty (30) minutes’ travel
time from an enrollee’s residence, provided that this requirement remains
consistent with the other minimum time requirements of this Contract. In order
to meet this requirement, the pediatrician(s), CHD, FQHC, and/or RHC must
provide access to care on a twenty-four hour a day, seven day a week (24/7)
basis. BMHC may waive this requirement, in writing, for rural areas and where
there are no pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
average travel time.     6.   Annually by February 1 of each Contract year, the
Health Plan shall review a statistically valid sample of PCP offices’ average
appointment wait times to ensure services are in compliance with Attachment II,
Section VII, Provider Network, Item F., Appointment Waiting Times and Geographic
Access Standards, and report the results to BMHC in the format specified, in
accordance with Attachment II, Section XII, Reporting Requirements. (See 42 CFR
438.206(c)(1)(iv),(v) and (vi).)

G. Continuity of Care

  1.   The Health Plan shall allow enrollees in active treatment to continue
care with a terminated treating provider when such care is medically necessary,
through completion of treatment of a condition for which the enrollee was
receiving care at the time of the termination, until the enrollee selects
another treating provider, or during the next open enrollment period. None of
the above may exceed six (6) months after the termination of the providers
contract.     2.   The Health Plan shall allow pregnant enrollees who have
initiated a course of prenatal care, regardless of the trimester in which care
was initiated, to continue care with a terminated treating provider until
completion of postpartum care.     3.   Notwithstanding the provisions in this
subsection, a terminated provider may refuse to continue to provide care to an
enrollee who is abusive or noncompliant.

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  HMO Contract

  4.   For continued care under this subsection, the Health Plan and the
terminated provider shall continue to abide by the same terms and conditions as
existed in the terminated contract.     5.   The requirements set forth in this
subsection shall not apply to providers who have been terminated from the Health
Plan for cause.

H. Credentialing and Recredentialing (See Attachment II, Exhibit 7)

  1.   The Health Plan shall be responsible for the credentialing and
recredentialing of its provider network. Hospital ancillary providers are not
required to be independently credentialed if those providers serve Health Plan
enrollees only through the hospital.     2.   The Health Plan shall establish
and verify credentialing and recredentialing criteria for all professional
providers that, at a minimum, meet the Agency’s Medicaid participation
standards. The Agency’s criteria include:

  a.   A copy of each providers current medical license pursuant to s. 641.495,
F.S.;     b.   No revocation or suspension of the providers state license by the
Division of Medical Quality Assurance, Department of Health;     c.   A
satisfactory background check with the Florida Department of Law Enforcement
(FDLE) for all treating providers not currently enrolled in Medicaid’s
fee-for-service program;

  (1)   If exempt from the criminal background screening requirements, a copy of
the screen print of the provider’s current Department of Health licensure status
with the exemption reason included;     (2)   The Health Plan shall not contract
with any provider who has a record of illegal conduct; i.e., found guilty of,
regardless of adjudication, or who entered a plea of nolo contendere or guilty
to any of the offenses listed in s. 435.03, F.S.;     (3)   Individuals already
screened as Medicaid providers or screened within the past twelve (12) months by
another Florida agency or department are not required to submit fingerprint
cards but shall document the results of the previous screening;     (4)  
Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history
background screening cannot be documented must provide fingerprint cards;

  d.   Disclosure related to ownership and management (42 CFR 455.104), business
transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106);     e.
  Proof of the provider’s medical school graduation, completion of residency and
other postgraduate training. Evidence of board certification shall suffice in
lieu of proof of medical school graduation, residency and other postgraduate
training;     f.   Evidence of specialty board certification, if applicable;

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  Medicaid Non-Reform and Reform
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  HMO Contract

  g.   Evidence of the provider’s professional liability claims history;     h.
  Any sanctions imposed on the provider by Medicare or Medicaid;     i.   The
provider’s Medicaid ID number, Medicaid provider registration number or
documentation of submission of the Medicaid provider registration form.

  3.   If behavioral health is a covered service, the Health Plan’s
credentialing and recredentialing files must document the education, experience,
prior training and ongoing service training for each staff member or provider
rendering behavioral health services.     4.   The Health Plan’s credentialing
and recredentialing policies and procedures shall be in writing and 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 that provides for the
verification of the credentialing and recredentialing criteria required under
this Contract;     e.   Approval of new providers and imposition of sanctions,
termination, suspension and restrictions on existing providers;     f.  
Identification of quality deficiencies that result in the Health Plan’s
restriction, suspension, termination or sanctioning of a provider.

  5.   The credentialing and recredentialing processes must also include
verification of the following additional requirements for physicians and must
ensure compliance with 42 CFR 438.214:

  a.   Good standing of privileges at the hospital designated as the primary
admitting facility by the PCP or if the PCP does not have admitting privileges,
good standing of privileges at the hospital by another provider with whom the
PCP has entered into an arrangement for hospital coverage;     b.   Valid Drug
Enforcement Administration (DEA) certificates, where applicable;     c.  
Attestation that the total active patient load (all populations with Medicaid
FFS, Children’s Medical Services Network, HMO, PSN, Medicare and commercial
coverage) is no more than 3,000 patients per PCP. An active patient is one that
is seen by the provider a minimum of three (3) times per year;     d.   A good
standing report on a site visit survey. For each PCP, documentation in the
Health Plan’s credentialing files regarding the site survey shall include the
following:

  (1)   Evidence that the Health Plan has evaluated the provider’s facilities
using the Health Plan’s organizational standards;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (2)   Evidence that the provider’s office meets criteria for access for
persons with disabilities and that adequate space, supplies, proper sanitation,
smoke-free facilities, and proper fire and safety procedures are in place;    
(3)   Evidence that the Health Plan has evaluated the providers medical record
keeping practices at each site to ensure conformity with the Health Plan’s
organizational standards;     (4)   Evidence that the Health Plan has determined
that the following documents are posted in the provider’s waiting room/reception
area: the Agency’s statewide consumer call center telephone number, including
hours of operation, and a copy of the summary of Florida’s Patient’s Bill of
Rights and Responsibilities, in accordance with s. 381.026, F.S. The provider
must have a complete copy of the Florida Patient’s Bill of Rights and
Responsibilities, available upon request by an enrollee, at each of the
provider’s offices;

  e.   Attestation to the correctness/completeness of the provider’s
application;     f.   Statement regarding any history of loss or limitation of
privileges or disciplinary activity as described in s. 456.039, F.S.;     g.   A
statement from each provider applicant regarding the following:

  (1)   Any physical or mental health problems that may affect the provider’s
ability to provide health care;     (2)   Any history of chemical
dependency/substance abuse;     (3)   Any history of loss of license and/or
felony convictions; and     (4)   The provider is eligible to become a Medicaid
provider;

  h.   Current curriculum vitae, which includes at least five (5) years of work
history.

  6.   The Health Plan shall recredential its providers at least every three
(3) years.     7.   The Health Plan shall develop and implement an appeal
procedure for providers against whom the Health Plan has imposed sanctions,
restrictions, suspensions and/or terminations.

I. Provider Services

  1.   General Provisions

  a.   The Health Plan shall provide sufficient information to all providers in
order to operate in full compliance with this Contract and all applicable
federal and state laws and regulations.

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  Medicaid Non-Reform and Reform
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  HMO Contract

  b.   The Health Plan shall monitor provider knowledge and understanding of
provider requirements, and take corrective actions to ensure compliance with
such requirements.

  2.   Provider Handbooks (See Attachment II, Exhibit 7)

  a.   The Health Plan shall issue a provider handbook to all providers at the
time the provider credentialing is complete. The Health Plan may choose not to
distribute the provider handbook via surface mail, provided it submits a written
notification to all providers that explains how to obtain the handbook from the
Health Plan’s website. This notification shall also detail how the provider can
request a hard copy from the Health Plan at no charge. The Health Plan shall
keep all provider handbooks and bulletins up to date and in compliance with
state and federal laws. The provider handbook shall serve as a source of
information regarding Health Plan covered services, policies and procedures,
statutes, regulations, telephone access and special requirements to ensure all
Contract requirements are met. At a minimum, the provider handbook shall include
the following information:

  (1)   Description of the Medicaid program;     (2)   Covered services;     (3)
  Emergency service responsibilities;     (4)   Child Health Check-Up program
services and standards;     (5)   Policies and procedures that cover the
provider complaint system. This information shall include, but not be limited
to, specific instructions regarding how to contact the Health Plan to file a
provider complaint, including complaints about claims issues, and which
individual(s) has authority to review a provider complaint;     (6)   Required
procedural steps in the enrollee grievance process, including the address,
telephone number and office hours of the grievance staff; the enrollee’s right
to request continuation of benefits while utilizing the grievance system; and
information about the Subscriber Assistance Program (SAP, for HMOs only) and the
Beneficiary Assistance Program (BAP, for PSNs only). The Health Plan shall
specify telephone numbers to call to present a complaint, grievance, or appeal.
Each telephone number shall be toll-free within the caller’s geographic area and
provide reasonable access to the Health Plan without undue delays;     (7)  
Medical necessity standards and practice protocols, including guidelines
pertaining to the treatment of chronic and complex conditions;     (8)   PCP
responsibilities;     (9)   Other provider or subcontractor responsibilities;  
  (10)   Prior authorization and referral procedures, including required forms;
    (11)   Medical records standards;

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  Medicaid Non-Reform and Reform
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  HMO Contract

  (12)   Claims submission protocols and standards, including instructions and
all information necessary for a clean or complete claim;     (13)   Protocols
for submitting encounter data;     (14)   A summary of the Health Plan’s
cultural competency plan and how to get a full copy at no cost to the provider;
    (15)   Information on the Health Plan’s quality enhancement programs;    
(16)   Enrollee rights and responsibilities (see 42 CFR 438.100);     (17)  
Information notifying providers that the Health Plan is authorized to take
whatever steps are necessary to ensure that the provider is recognized by the
state Medicaid program, including its choice counseling/enrollment broker
contractor(s) as a participating provider of the Health Plan and that the
provider’s submission of encounter data is accepted by the Florida MM IS and/or
the state’s encounter data warehouse.

  b.   The Health Plan shall disseminate bulletins as needed to incorporate any
needed changes to the provider handbook.

  3.   Education and Training         The Health Plan shall offer training to
all providers and their staff regarding the requirements of this Contract and
special needs of enrollees. The Health Plan shall conduct initial training
within thirty (30) calendar days of placing a newly contracted provider, or
provider group, on active status. The Health Plan also shall conduct ongoing
training, as deemed necessary by the Health Plan or the Agency, in order to
ensure compliance with program standards and this Contract.     4.   Toll-Free
Provider Help Line

  a.   The Health Plan shall operate a toll-free telephone help line to respond
to provider questions, comments and inquiries.     b.   The Health Plan shall
develop telephone help line policies and procedures that address staffing,
personnel, hours of operation, access and response standards, monitoring of
calls via recording or other means, and compliance with Health Plan standards.  
  c.   The help line shall be staffed twenty-four hours a day, seven days a week
(24/7) to respond to prior authorization requests. This help line shall have
staff to respond to provider questions in all other areas, including the
provider complaint system, provider responsibilities, etc., between the hours of
8 a.m. and 7 p.m. in the provider’s time zone Monday through Friday, excluding
state holidays.     d.   The Health Plan’s call center systems shall have the
capability to track call management metrics identified in Attachment II,
Section IV, Enrollee Services,

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      Community Outreach and Marketing, Item A., General Provisions, sub-item
11., Toll- free Enrollee Help Line.     e.   The Health Plan shall ensure that
after regular business hours the provider services line (not the prior
authorization line) is answered by an automated system with the capability to
provide callers with information about operating hours and instructions about
how to verify enrollment for an enrollee with an emergency or urgent medical
condition. This requirement shall not be construed to mean that the provider
must obtain verification before providing emergency services and care.

  5.   Provider Complaint System

  a.   The Health Plan shall establish and maintain a provider complaint system
that permits a provider to dispute the Health Plan’s policies, procedures, or
any aspect of a Health Plan’s administrative functions, including proposed
actions and claims.     b.   The Health Plan shall include its provider
complaint system policies and procedures in its provider handbook as described
above.     c.   The Health Plan shall also distribute the provider complaint
system policies and procedures, including claims issues, to out-of-network
providers upon request. The Health Plan may distribute a summary of these
policies and procedures, if the summary includes information about how the
provider may access the full policies and procedures on the Health Plan’s
website. This summary shall also detail how the provider can request a hard copy
from the Health Plan at no charge.     d.   As a part of the provider complaint
system, the Health Plan shall:

  (1)   Have dedicated staff for providers to contact via telephone, electronic
mail, regular mail, or in person, to ask questions, file a provider complaint
and resolve problems;     (2)   Identify a staff person specifically designated
to receive and process provider complaints;     (3)   Allow providers forty-five
(45) calendar days to file a written complaint for issues that are not about
claims;     (4)   Thoroughly investigate each provider complaint using
applicable statutory, regulatory, contractual and provider contract provisions,
collecting all pertinent facts from all parties and applying the Health Plan’s
written policies and procedures; and     (5)   Ensure that Health Plan
executives with the authority to require corrective action are involved in the
provider complaint process.

  e.   The Health Plan shall provide a written notice of the outcome of the
review to the provider.

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J. Medical Records Requirements

    The Health Plan shall ensure maintenance of medical records for each
enrollee in accordance with this section and with 42 CFR 456. Medical records
shall include the quality, quantity, appropriateness, and timeliness of services
performed under this Contract.

  1.   The Health Plan shall follow the medical record standards set forth below
for each enrollee’s medical records, as appropriate:

  a.   Include the enrollee’s identifying information, including name, enrollee
identification number, date of birth, sex and legal guardianship (if any);    
b.   Each record shall be legible and maintained in detail;     c.   Include a
summary of significant surgical procedures, past and current diagnoses or
problems, allergies, untoward reactions to drugs and current medications;     d.
  All entries shall be dated and signed by the appropriate party;     e.   All
entries shall indicate the chief complaint or purpose of the visit, the
objective, diagnoses, medical findings or impression of the provider;     f.  
All entries shall indicate studies ordered (e.g., laboratory, x-ray, EKG) and
referral reports;     g.   All entries shall indicate therapies administered and
prescribed;     h.   All entries shall include the name and profession of the
provider rendering services (e.g., MD, DO, OD), including the signature or
initials of the provider;     i.   All entries shall include the disposition,
recommendations, instructions to the enrollee, evidence of whether there was
follow-up and outcome of services;     j.   All records shall contain an
immunization history;     k.   All records shall contain information relating to
the enrollee’s use of tobacco products and alcohol/substance abuse;     l.   All
records shall contain summaries of all emergency services and care and hospital
discharges with appropriate medically indicated follow up;     m.   Document
referral services in enrollees’ medical records;     n.   Include all services
provided. Such services must include, but not necessarily be limited to, family
planning services, preventive services and services for the treatment of
sexually transmitted diseases;     o.   All records shall reflect the primary
language spoken by the enrollee and any translation needs of the enrollee;

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  HMO Contract

  p.   All records shall identify enrollees needing communication assistance in
the delivery of health care services; and     q.   All records shall contain
documentation that the enrollee was provided with written information concerning
the enrollee’s rights regarding advance directives (written instructions for
living will or power of attorney) and whether or not the enrollee has executed
an advance directive. Neither the Health Plan, nor any of its providers shall,
as a condition of treatment, require the enrollee to execute or waive an advance
directive. The Health Plan must maintain written policies and procedures for
advance directives;     r.   Copies of any advance directives executed by the
enrollee.

  2.   Confidentiality of Medical Records

  a.   The Health Plan shall have a policy to ensure the confidentiality of
medical records in accordance with 42 CFR, Part 431, Subpart F. This policy
shall also include confidentiality of a minor’s consultation, examination, and
treatment for a sexually transmissible disease in accordance with s. 384.30(2),
F.S.     b.   The Health Plan shall have a policy to ensure compliance with the
privacy and security provisions of the Health Insurance Portability and
Accountability Act (HIPAA).

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  HMO Contract

Section VIII
Quality Management
A. Quality Improvement

  1.   General Requirements

  a.   The Health Plan shall have an ongoing quality improvement program (QI
program) that objectively and systematically monitors and evaluates the quality
and appropriateness of care and services rendered, thereby promoting quality of
care and quality patient outcomes in service performance to its enrollees. (See
42 CFR 438.204 and 438.240.)     b.   The Health Plan shall develop and submit
to BMHC a written quality improvement plan (QI plan) within thirty (30) calendar
days from execution of the initial Contract and resubmit it annually by April 1
of each Contract year for written approval. The QI plan shall include sections
defining how the QI committee used any of the following programs to develop its
performance improvement projects (PIP): credentialing processes, case
management, utilization review, peer review, review of grievances, and review
and response to adverse events. Any problems/issues identified but not included
in a PIP must be addressed and resolved by the QI committee.     c.   The Health
Plan’s written policies and procedures shall address components of effective
health care management including, but not limited to, anticipation,
identification, monitoring, measurement, evaluation of enrollee’s health care
needs, and effective action to promote quality of care.     d.   The Health Plan
shall define and implement improvements in processes that enhance clinical
efficiency, provide effective utilization, and focus on improved outcome
management achieving the highest level of success.     e.   The Health Plan and
its QI plan shall demonstrate specific interventions in its care management to
better manage the care and promote healthier enrollee outcomes.     f.   The
Health Plan shall cooperate with the Agency and the external quality review
organization (EQRO). The Agency will set methodology and standards for quality
improvement (QI) with advice from the EQRO.     g.   Prior to implementation,
the Agency shall review the Health Plan’s QI plan.

  2.   Specific Required Components of the QI Program

  a.   The Health Plan’s governing body shall oversee and evaluate the QI
program. The role of the Health Plan’s governing body shall include providing
strategic direction to the QI program, as well as ensuring the QI plan is
incorporated into operations throughout the Health Plan. The written QI plan
shall clearly describe the mechanism within the Health Plan for strategic
direction from the governing body to be provided to the QI program and for the
QI program committee to communicate with the governing body.

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  HMO Contract

  b.   The Health Plan shall have a 01 program committee. The Health Plan’s
medical director shall either chair or co-chair the committee. Other committee
representatives shall be selected to meet the needs of the Health Plan but must
include: 1) the quality director; 2) the grievance coordinator; 3) the
utilization review manager; 4) the credentialing manager; 5) the risk
manager/infection control professional (if applicable); 6) the advocate
representative (if applicable); and 7) provider representation, either through
providers serving on the committee or through a provider liaison position, such
as a representative from the network management department. Individual staff
members may serve in multiple roles on the committee if they also serve in
multiple positions within the Health Plan. The Health Plan is encouraged to
include an advocate representative on the 01 program committee. The committee
shall meet no less than quarterly. Its responsibilities shall include the
development and implementation of a written 01 plan, which incorporates the
strategic direction provided by the governing body. The 01 plan shall contain
the following components:

  (1)   The Health Plan’s guiding philosophy for quality management and should
identify any nationally recognized, standardized approach that is used (for
example, PDCA, Rapid Cycle Improvement, FOCUS-PDCA, Six Sigma, etc.). Selection
of performance indicators and sources for benchmarking also shall be described;
    (2)   A description of the Health Plan positions assigned to the 01 program,
including a description of why each position was chosen to serve on the
committee and the roles each position is expected to fulfill. The resumes of 01
program committee members shall be made available upon the Agency’s request;    
(3)   Specific training about quality that will be provided by the Health Plan
to staff serving in the 01 program. At a minimum the training shall include
protocols developed by the Centers for Medicare and Medicaid Services regarding
quality. CMS protocols may be obtained from either:
www.cms.hhs.qov/MedicaidManaqCare or www.myfloridaeqro.com     (4)   The role of
its providers in giving input to the QI program, whether that is by membership
on the committee, its sub-committees, or other means;     (5)   A standard for
how the Health Plan shall assure that QI program activities take place
throughout the Health Plan and document results of QI program activities for
reviewers. Protocols for assigning tasks to individual staff persons and
selection of time standards for completion shall be included;     (6)   A
standard describing the process the QI program will use to review and suggest
new and/or improved QI activities;     (7)   The process for selecting and
directing task forces, committees, or other Health Plan activities to review
areas of concern in the provision of health care services to enrollees;     (8)
  The process for selecting evaluation and study design procedures;

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  HMO Contract

  (9)   The process to report findings to appropriate executive authority,
staff, and departments within the Health Plan as well as relevant stakeholders,
such as network providers. The Q1 plan also shall include how this communication
will be documented for Agency review; and     (10)   The process to direct and
analyze periodic review of enrollee service utilization patterns.

  c.   The Health Plan shall maintain minutes of all QI committee and
sub-committee meetings and make the minutes available for Agency review on
request. The minutes shall demonstrate resolution of items or be brought forward
to the next meeting.     d.   The Health Plan shall have a peer review process
that:

  (1)   Reviews a provider’s practice methods and patterns, morbidity/mortality
rates, and all grievances filed against the provider relating to medical
treatment;     (2)   Evaluates the appropriateness of care rendered by
providers;     (3)   Implements corrective action(s) when the Health Plan deems
it necessary to do so;     (4)   Develops policy recommendations to maintain or
enhance the quality of care provided to enrollees;     (5)   Conducts reviews
that include the appropriateness of diagnosis and subsequent treatment,
maintenance of a provider’s medical records, adherence to standards generally
accepted by a provider’s peers and the process and outcome of a provider’s care;
    (6)   Appoints a peer review committee, as a sub-committee to the QI program
committee, to review provider performance when appropriate. The medical director
or a designee shall chair the peer review committee. Its membership shall be
drawn from the provider network and include peers of the provider being
reviewed;     (7)   Receives and reviews all written and oral allegations of
inappropriate or aberrant service by a provider;     (8)   Educates enrollees
and Health Plan staff about the peer review process, so that enrollees and the
Health Plan staff can notify the peer review authority of situations or problems
relating to providers.

  3.   Health Plan QI Activities (See Attachment II, Exhibit 8)         The
Health Plan 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 peer review, performance improvement projects
(PIP), medical record audits, performance measures, surveys, and related
activities.

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  HMO Contract

  a.   PIPs — Annually, by January 1 of each Contract year, the Agency shall
determine and notify the Health Plan if there are changes in the number and
types of PIPs the Health Plan shall perform for the coming Contract year. The
Health Plan shall perform four (4) Agency-approved performance improvement
projects for each population (Reform and non-Reform). There must at least one
(1) clinical PIP and one (1) non-clinical PIP per population.

  (1)   One (1) of the PIPs shall focus on language and culture, clinical health
care disparities, or culturally and linguistically appropriate services.     (2)
  One (1) of the PIPs shall be the statewide collaborative PIP coordinated by
the EQRO.     (3)   One (1) of the clinical PIPs shall relate to behavioral
health services, if the Health Plan covers those services.     (4)   One (1) PIP
shall be designed to address deficiencies identified by the Health Plan through
monitoring, performance measure results, member satisfaction surveys, or other
similar means.     (5)   Each PIP shall include a statistically significant
sample of enrollees.     (6)   All PIPs shall 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 ninety-five (95%) confidence level and must be
sustained for a period of two (2) additional remeasurements. Measurement periods
and methodologies shall be submitted to BMHC for approval before initiation of
the PIP. PIPs that have successfully achieved sustained improvement, as approved
by the Agency, shall be considered complete and shall not meet the requirement
for one (1) of the four PIPs, although the Health Plan may wish to continue to
monitor the performance indicator as part of its overall 01 program. In this
event, the Health Plan shall select a new PIP and submit it to BMHC for
approval.     (7)   Within ninety (90) calendar days after initial Contract
execution and then on June 1 of each subsequent Contract year, the Health Plan
shall submit to BMHC, in writing, a proposal for each planned PIP. The PIP
proposal shall be submitted using the most recent version of the EQRO PIP
validation form. Activities 1 through 6 of the form must be addressed in the PIP
proposal. Annual submissions for ongoing PIPs shall update the form to reflect
the Health Plan’s progress. In the event the Health Plan elects to modify a
portion of the PIP proposal after initial Agency approval, a written request
must be submitted to the BMHC. The EQRO PIP validation report form may be
obtained from the following web site: www.myfloridaecro.com/. Instructions for
using the form to submit PIP proposals and updates may be obtained from the
BMHC.     (8)   The Health Plan’s PIP methodology must comply with the most
recent protocol set forth by the Centers for Medicare and Medicaid Services,
Conducting

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  HMO Contract

      Performance Improvement Projects, available from the web sites listed in
Item A., sub-item 2.b.(3), above.     (9)   Populations selected for study under
the PIP shall be measured and reported separately for Reform and non-Reform
populations, shall be specific to this Contract and shall exclude non-Medicaid
enrollees or Medicaid recipients from other states. If the Health Plan contracts
with a separate entity for management of particular services, such as behavioral
health or pharmacy, PIPs conducted by the separate entity shall not include
enrollees for other Health Plans served by that entity.     (10)   The Health
Plan’s PIPs shall be subject to review and validation by the EQRO. The Health
Plan shall comply with any recommendations for improvement requested by the
EQRO, subject to approval by the Agency.

  b.   Behavioral Health QI Requirements (See Attachment II, Exhibit 6)     c.  
Performance Measures (PMs)

  (1)   The Health Plan shall collect data on enrollee PMs, as defined by the
Healthcare Effectiveness Data and Information Set (HEDIS) or otherwise defined
by the Agency and as specified in the Agency’s Report Guide and Performance
Measures Specifications Manual. The Performance Measures Specifications Manual
may be found at
http://ahca.mvflorida.com/Medicaid/Qualitvmc/index.shtml.         The Agency may
add or remove reporting requirements with sixty (60) days’ advance notice. By
July 1 of each Contract year, the Health Plan shall deliver to the Bureau of
Medicaid Quality Management (BMQM) a report on performance measure data
(including transportation performance measures if transportation is listed as
covered by the Health Plan in Attachment I of this Contract) and a certification
by an Agency-approved independent auditor that the performance measure data
reported for the previous calendar year are fairly and accurately presented.
(See Attachment II, Section XII, Reporting) The report shall be certified by the
HEDIS auditor, and the auditor must certify the actual file submitted to the
Agency. Extensions to the due date may be granted by the Agency for up to thirty
(30) days and require a written request signed by the Health Plan CEO or
designee. The request must be received by BMQM before the report due date, and
the delay must be due to unforeseen and unforeseeable factors beyond the Health
Plan’s control. Extensions will not be granted on oral requests.     (2)   A
report, certification, or other information required for PM reporting is
incomplete when it does not contain all data required by the Agency or when it
contains inaccurate data. A report or certification is “false” if done or made
with the knowledge of the preparer or a superior of the preparer that it
contains data or information that is not true or not accurate. A report that
contains an “NR” due to bias for any or all measures by the HEDIS auditor, or is
“false,” shall be considered deficient and will be subject to administrative
penalties pursuant to Attachment II, Section XIV, Sanctions.

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  HMO Contract

  (3)   The Health Plan shall meet Agency-specified performance targets for all
PMs. Where applicable, these targets are the equivalent of the seventy-fifth
(75th) percentile of national Medicaid health plan performance as compiled and
reported in the HEDIS national means and percentiles. For Agency-defined
measures the Agency will establish performance targets. The Agency may change
these targets and/or change the timelines associated with meeting the targets.
The Agency shall make these changes with sixty (60) days’ advance notice to the
Health Plan.     (4)   If the Agency determines that the Health Plan performance
relative to the performance targets is not acceptable, the Agency shall require
the Health Plan to submit a performance measure action plan (PMAP) within thirty
(30) calendar days after the notice of the determination in the format
prescribed by the Agency. If the Health Plan fails to provide a PMAP within the
time and format specified by the Agency or fails to adhere to its own PMAP, the
Agency may sanction the Health Plan in accordance with the provisions of
Section XIV, Sanctions, of this attachment. The Health Plan shall submit reports
to the Bureau of Medicaid Quality Management on the progress of all PMAPs as
specified in Attachment II, Section XII, Reporting Requirements.     (5)   If
the Agency-defined or HEDIS PMs indicate that the Health Plan’s performance is
not acceptable, the Agency may sanction the Health Plan in accordance with the
provisions of Attachment II, Section XIV, Sanctions. When considering whether to
impose specific sanctions, such as applying civil monetary penalties or limiting
enrollment activities or automatic assignments, the Agency may consider the
Health Plan’s cumulative performance on all quality and performance measures.

  d.   Consumer Assessment of Health Plans Survey (CAHPS) — The Agency shall
conduct an annual Consumer Assessment of Health Plans Survey (CAHPS). The Health
Plan shall provide an action plan to address the results of the CAHPS survey
within two (2) months of receipt of the written request from the Agency.     e.
  Medical Record Review

  (1)   If the Health Plan is not accredited, the Health Plan shall conduct
reviews of enrollees’ medical records to ensure that PCPs provide high quality
health care that is documented according to established standards, including
subparagraphs (2) through (7) below.     (2)   The standards, which must include
all medical record documentation requirements addressed in this Contract, must
be distributed to all providers.     (3)   The Health Plan shall conduct these
reviews at all PCP sites that serve ten (10) or more enrollees.     (4)  
Practice sites include both individual offices and large group facilities.    
(5)   The Health Plan shall review each practice site at least once every three
years.

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  HMO Contract

  (6)   The Health Plan shall review a reasonable number of records at each site
to determine compliance. Five (5) to ten (10) records per site is a generally-
accepted target, though additional reviews must be completed for large group
practices or when additional data is necessary in specific instances.     (7)  
The Health Plan shall submit to BMHC for written approval, and maintain, a
written strategy for conducting medical record reviews. The strategy must
include, at a minimum, the following:

  (a)   Designated staff to perform this duty;     (b)   The method of case
selection;     (c)   The anticipated number of reviews by practice site;     (d)
  The tool that the Health Plan will use to review each site; and     (e)   How
the Health Plan shall link the information compiled during the review to other
Health Plan functions (e.g., QI, credentialing, peer review, etc.).

  4.   Cultural Competency Plan

  a.   In accordance with 42 CFR 438.206, the Health Plan shall have a
comprehensive written cultural competency plan (CCP) describing the Health
Plan’s program to ensure that services are provided in a culturally competent
manner to all enrollees, including those with limited English proficiency. The
CCP must describe how providers, Health Plan employees, and systems will
effectively provide services to people of all cultures, races, ethnic
backgrounds, and religions in a manner that recognizes, values, affirms, and
respects the worth of the individual enrollees and protects and preserves the
dignity of each. The CCP shall be updated annually and submitted to BMHC by
October 1 for approval for implementation by January 1 of each Contract year.  
  b.   The Health Plan may distribute a summary of the CCP to network providers
if the summary includes information about how the provider may access the full
CCP on the web site. This summary shall also detail how the provider can request
a hard copy of the cultural competency plan from the Health Plan at no charge to
the provider.     c.   The Health Plan shall complete an annual evaluation of
the effectiveness of its CCP. This evaluation may include results from the CAHPS
or other comparative member satisfaction surveys, outcomes for certain cultural
groups, member grievances, member appeals, provider feedback and Health Plan
employee surveys. The Health Plan shall track and trend any issues identified in
the evaluation and shall implement interventions to improve the provision of
services. A description of the evaluation, its results, the analysis of the
results and interventions to be implemented shall be described in the annual CCP
submitted to the Agency.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  5.   EQRO Coordination Requirements

  a.   The Health Plan shall provide all information requested by the EQRO,
including, but not limited to, quality outcomes concerning timeliness of, and
enrollee access to, covered services.     b.   The Health Plan shall cooperate
with the EQRO during the external quality review activities, which may include
independent medical record review.     c.   If the EQRO indicates the Health
Plan’s performance is not acceptable, the Agency may require the Health Plan to
submit a corrective action plan (CAP) and may restrict the Health Plan’s
enrollment activities.

  6.   Agency Annual Medical Record Audit

  a.   The Health Plan shall furnish specific data requested in order for the
Agency to conduct the medical record audit.     b.   If the medical record audit
indicates that quality of care is not acceptable within the terms of this
Contract, the Agency shall sanction the Health Plan, in accordance with the
provisions of Attachment II, Section XIV, Sanctions, and may immediately
terminate all enrollment activities and mandatory assignments, until the Health
Plan attains an acceptable level of quality of care as determined by the Agency.
When considering whether to impose a limitation on enrollment activities or
mandatory assignment, the Agency may take into account the Health Plan’s
cumulative performance on all 01 activities.

B. Utilization Management (UM) (See Attachment II, Exhibit 8)

  1.   General Requirements

  a.   The UM program shall be consistent with 42 CFR 456 and include, but not
be limited to:

  (1)   Procedures for identifying patterns of over-utilization and
under-utilization of services and for addressing potential problems identified
as a result of these analyses.     (2)   Reporting fraud and abuse information
identified through the UM program to the Agency’s MPI as described in Attachment
II, Section X, Administration and Management, and referenced in 42 CFR
455.1(a)(1).     (3)   A procedure for enrollees to obtain a second medical
opinion and for the Health Plan to authorize claims for such services in
accordance with s. 641.51, F.S.     (4)   Protocols for prior authorization and
denial of services; the process used to evaluate prior and concurrent
authorization; mechanisms to ensure consistent application of review criteria
for authorization decisions; consultation with the requesting provider when
appropriate; hospital discharge planning; physician profiling; and a
retrospective review of both inpatient and ambulatory claims,

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      meeting the predefined criteria below. The Health Plan shall be
responsible for ensuring the consistent application of review criteria for
authorization decisions and consulting with the requesting provider when
appropriate.

  (a)   The Health Plan shall obtain written approval from BMHC for its service
authorization protocols and any changes.     (b)   The Health Plan’s service
authorization systems shall provide the authorization number and effective dates
for authorization to providers and non-participating providers.     (c)   The
Health Plan’s service authorization systems shall provide written confirmation
of all denials of authorization to providers (See 42 CFR 438.210(c)).     (d)  
The Health Plan may request to be notified, but shall not deny claims payment
based solely on lack of notification, for the following:

  (i)   Inpatient emergency admissions (within ten (10) calendar days);     (ii)
  Obstetrical care (at first visit);     (iii)   Obstetrical admissions
exceeding forty-eight (48) hours for vaginal delivery and ninety-six (96) hours
for caesarean section; and     (iv)   Transplants.

  (e)   The Health Plan shall ensure that all decisions to deny a service
authorization request, or limit a service in amount, duration, or scope that is
less than requested, are made by health care professionals who have the
appropriate clinical expertise in treating the enrollee’s condition or disease
(see 42 CFR 438.210(b)(3)).     (f)   Only a licensed psychiatrist may authorize
a denial for an initial or concurrent authorization of any request for
behavioral health services. The psychiatrist’s review shall be part of the UM
process and not part of the clinical review, which may be requested by a
provider or the enrollee, after the issuance of a denial.     (g)   The Health
Plan shall provide post authorization to CHDs for emergency shelter medical
screenings provided for DCF clients.     (h)   Health Plans with automated
authorization systems may not require paper authorization as a condition for
providing treatment.     (i)   The Health Plan shall not delay service
authorization if written documentation is not available in a timely manner.
However, the Health Plan is not required to approve claims for which it has
received no written documentation.

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  HMO Contract

  b.   The Health Plan must provide that compensation to individuals or entities
that conduct UM activities is not structured to provide incentives for the
individual or entity to deny, limit, or discontinue medically necessary services
to any enrollee.

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

  a.   Appropriate referral and scheduling assistance for enrollees needing
specialty health care or transportation services, including those identified
through CHCLIP screenings;     b.   Determination of the need for non-covered
services and referral of the enrollee for assessment and referral to the
appropriate service setting (to include referral to WIC and Healthy Start) with
assistance, as needed, by the area Medicaid office;     c.   Case management
follow-up services for children/adolescents whom the Health Plan identifies
through blood screenings as having abnormal levels of lead;     d.   Coordinated
hospital/institutional discharge planning that includes post-discharge care,
including short-term, skilled nursing facility care, as appropriate;     e.   A
mechanism for direct access to specialists for enrollees identified as having
special health care needs, as appropriate for their conditions and identified
needs;     f.   An outreach program and other strategies for identifying every
pregnant enrollee. This shall include case management, claims analysis, and use
of health risk assessment, etc. The Health Plan shall require its participating
providers to notify the plan of any Medicaid enrollee who is identified as being
pregnant;     g.   Documentation of referral services in enrollee medical
records, including reports resulting from the referral;     h.   Monitoring of
enrollees with ongoing medical conditions and coordination of services for high
utilizers to address the following, as appropriate: acting as a liaison between
the enrollee and providers, ensuring the enrollee is receiving routine medical
care, ensuring the enrollee has adequate support at home, assisting enrollees
who are unable to access necessary care due to their medical or emotional
conditions or who do not have adequate community resources to comply with their
care, and assisting the enrollee in developing community resources to manage a
medical condition;     i.   Documentation of emergency care encounters in
enrollee medical records with appropriate medically indicated follow-up;     j.
  Coordination of hospital/institutional discharge planning that includes
post-discharge care, including skilled short-term rehabilitation, and skilled
nursing facility care, as appropriate;

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  HMO Contract

  k.   Sharing with other Health Plans serving the enrollee the results of its
identification and assessment of any enrollee with special health care needs so
that those activities need not be duplicated;     l.   Ensuring that in the
process of coordinating care, each enrollee’s privacy is protected consistent
with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR
Part 164 specifically describes the requirements regarding the privacy of
individually identifiable health information.

  3.   Practice Protocols

  a.   The Health Plan shall adopt practice guidelines that meet the following
requirements:

  (1)   Are based on valid and reliable clinical evidence or a consensus of
health care professionals in a particular field;     (2)   Consider the needs of
the enrollees;     (3)   Are adopted in consultation with providers; and     (4)
  Are reviewed and updated periodically, as appropriate (See 42 CFR 438.236(b)).

  b.   The Health Plan shall disseminate any revised practice guidelines to all
affected providers and, upon request, to enrollees and potential enrollees.    
c.   The Health Plan shall ensure consistency with regard to all decisions
relating to UM, enrollee education, covered services and other areas to which
the practice guidelines apply.

  4.   Changes to Utilization Management Components         The Health Plan
shall provide no less than thirty (30) calendar days’ written notice to BMHC
before making any changes to the administration and/or management procedures
and/or authorization, denial or review procedures, including any delegations, as
described in this section.     5.   Disease Management (See Attachment II,
Exhibit 8)

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AMERIGROUP Community Care
  HMO Contract

Section IX
Grievance System
A. General Requirements

  1.   Federal law requires Medicaid managed care organizations to have internal
grievance procedures under which Medicaid enrollees, or providers acting as
authorized representatives, may challenge denial of coverage of, or payment for,
medical assistance. The Health Plan’s grievance system shall comply with the
requirements set forth in s. 641.511, F.S., if applicable, and with all
applicable federal and state laws and regulations, including 42 CFR 431.200 and
42 CFR Part 438, Subpart F, “Grievance System.”     2.   For purposes of this
Contract, these procedures must include an opportunity to file a complaint, a
grievance, and/or an appeal and to seek a Medicaid Fair Hearing through DCF.    
3.   The Health Plan shall refer all enrollees and/or providers on behalf of the
enrollee (whether participating or non-participating) who are dissatisfied with
the Health Plan or its activities to the Health Plan’s grievance/appeal
coordinator for processing and documentation of the issue.     4.   The Health
Plan shall include all necessary procedural steps for filing complaints,
grievances, appeals and requests for a Medicaid Fair Hearing in the enrollee
handbook.     5.   Where applicable, the Health Plan’s grievance system must
include information for enrollees on seeking a state level appeal through either
the Subscriber Assistance Panel (for HMOs) or the Beneficiary Assistance Panel
(for PSNs).     6.   The Health Plan shall provide information about the
grievance system to all providers and subcontractors in the provider handbook
when they enter into a contract.     7.   The Health Plan must maintain a record
of grievances and appeals and submit reports, as specified in Attachment II,
Section XII, Reporting Requirements, to BMHC.     8.   The Health Plan must keep
a log of complaints that do not become grievances, including date, name, nature
of complaint and disposition. The Health Plan shall submit this report upon
request of the Agency.     9.   The Health Plan shall acknowledge in writing
receipt of each grievance and appeal unless the enrollee requests an expedited
resolution.     10.   The Health Plan shall ensure that decision makers on
grievances and appeals were not involved in previous levels of review or
decision making and that all decision makers are health care professionals with
clinical expertise in treating the enrollee’s condition when deciding the
following:

  a.   Appeal of denial based on lack of medical necessity;     b.   Grievance
of denial of expedited resolution of an appeal; and

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AMERIGROUP Community Care
  HMO Contract

  c.   Grievance or appeal involving clinical issues.

  11.   A Health Plan that covers transportation services through a
subcontractor shall ensure that the subcontractor meets the complaint and
grievance system requirements for problems related to transportation services.

B. Types of Issues

  1.   A complaint is the lowest level of challenge and provides the Health Plan
an opportunity to resolve a problem without its becoming a formal grievance.
Complaints shall be resolved by close of business the day following receipt or
be moved into the grievance system.     2.   A grievance expresses
dissatisfaction about any matter other than an action by the Health Plan.     3.
  An action is any denial, limitation, reduction, suspension, or termination of
service; denial of payment; or failure to act in a timely manner.     4.   An
appeal is a request for review of an action.

C. Notices

  1.   The Health Plan shall provide the enrollee with a written notice of
action that includes the following:

  a.   The action the Health Plan or its contractor has taken or intends to
take;     b.   The reasons for the action;     c.   The enrollee or provider’s
right to file an appeal with the Health Plan;     d.   The enrollee’s right to
request a Medicaid Fair Hearing;     e.   The procedures for exercising the
rights specified in the notice;     f.   The circumstances under which expedited
resolution is available and how to request it;     g.   The enrollee’s right to
have benefits continue pending resolution of the appeal, how to request that
benefits be continued, and the circumstances in which the enrollee must have to
pay the cost of those benefits.

  2.   The Health Plan shall mail the notice as follows:

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

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  HMO Contract

  b.   For denial of payment, at the time of any action affecting the claim;    
c.   For standard service authorization decisions that deny or limit services no
more than fourteen (14) calendar days following the request for service or
within three (3) business days following an expedited service request;     d.  
If the Health Plan extends the timeframe for a service authorization decision,
in which case it shall:

  (1)   Notify the enrollee of the reason for extending the timeframe and
advising of the right to file a grievance if the enrollee disagrees with the
extension of time;     (2)   Issue and carry out its determination as
expeditiously as possible and no later than the date the extension expires;    
(3)   Send notice of the extension to the enrollee within five (5) business days
of determining the need for an extension.

  e.   For service authorization decisions not reached within required
timeframes, on the date the timeframes expire. Such failures constitute a denial
and are, therefore, an adverse action;     f.   For expedited service
authorization decisions within the timeframes specified.

D. Filing Grievances and Appeals

  1.   A grievance may be filed orally or in writing within one (1) year of the
occurrence.     2.   An appeal may be filed orally or in writing within thirty
(30) calendar days of the enrollee’s receipt of the notice of action and, except
when expedited resolution is required, must be followed with a written notice
within ten (10) calendar days of the oral filing. The date of oral notice shall
constitute the date of receipt.     3.   The Health Plan shall provide any
reasonable help to the enrollee in completing forms and following the procedures
for filing a grievance or appeal or requesting a Medicaid Fair Hearing. This
includes interpreter services, toll-free calling, and TTY/TTD capability.     4.
  The Health Plan shall handle grievances and appeals as follows:

  a.   Provide the enrollee a reasonable opportunity to present evidence and
allegations of fact or law in person as well as in writing.     b.   Ensure the
enrollee understands any time limits that may apply.     c.   Provide
opportunity before and during the process for the enrollee or an authorized
representative to examine the case file, including medical records, and any
other material to be considered during the process.     d.   Consider as parties
to the appeal the enrollee or an authorized representative or, if the enrollee
is deceased, the legal representative of the estate.

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AMERIGROUP Community Care
  HMO Contract

E. Resolution and Notification

  1.   The Health Plan shall follow Agency guidelines in resolving grievances
and appeals as expeditiously as possible, observing required timeframes and
taking into account the enrollee’s health condition.     2.   A grievance shall
be reviewed and notice of results sent to the enrollee no later than ninety
(90) calendar days from the date the Health Plan receives it.     3.   An appeal
shall be heard and notice of results sent to the enrollee no later than
forty-five (45) calendar days from the date the Health Plan receives it.     4.
  The timeframe for a grievance or appeal may be extended up to fourteen (14)
calendar days if:

  a.   The enrollee asks for an extension, or the Health Plan documents that
additional information is needed and the delay is in the enrollee’s interest;  
  b.   If the timeframe is extended other than at the enrollee’s request, the
Health Plan shall notify the enrollee within five (5) business days of the
determination, in writing, of the reason for the delay.

  5.   The Health Plan shall complete the grievance process in time to
accommodate an enrollee’s disenrollment effective date, which can be no later
than the first day of the second month after the filing of a request for
disenrollment.     6.   The Health Plan shall provide written notice of
disposition of an appeal. In the case of an expedited appeal, the Health Plan
also shall provide oral notice by close of business the day of disposition.    
7.   Content of notice — The written notice of resolution shall include:

  a.   The results of the resolution process and the date it was completed;    
b.   If not decided in the enrollee’s favor, information on the right to request
a Medicaid Fair Hearing and how to do so; the right to request to receive
benefits while the hearing is pending, and how to make the request;     c.   The
right to appeal an adverse decision on an appeal to the Subscriber Assistance
Program (SAP) for HMOs or the Beneficiary Assistance Program (BAP) for PSNs,
including how to initiate such a review and the following;

  (1)   Before filing with the SAP or BAP, the enrollee must complete the Health
Plan’s appeal process.     (3)   The enrollee must submit the appeal to the SAP
or BAP within one (1) year after receipt of the final decision letter from the
Health Plan;     (4)   Neither the SAP nor the BAP will consider an appeal that
has already been to a Medicaid Fair Hearing.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (5)   The address and toll-free telephone numbers of the SAP/BAP:        
Agency for Health Care Administration
Subscriber Assistance Program / Beneficiary Assistance Program
Building 1, MS #26
2727 Mahan Drive
Tallahassee, Florida 32308
(850) 921-5458
(888) 419-3456 (toll-free)

  d.   That the enrollee may have to pay for the cost of those benefits if the
Medicaid Fair Hearing upholds the Health Plan’s action.

F. Expedited Appeals

  1.   The Health Plan shall have an expedited review process for appeals for
use when taking the time for a standard resolution could seriously jeopardize
the enrollee’s life or health or ability to attain, maintain or regain maximum
function.     2.   The Health Plan shall resolve each expedited appeal and
provide notice to the enrollee, as quickly as the enrollee’s health condition
requires, within state established time frames not to exceed seventy-two
(72) hours after the Health Plan receives the appeal request, whether the appeal
was made orally or in writing.     3.   The Health Plan shall ensure that no
punitive action is taken against a provider who requests or supports a request
for an expedited appeal.     4.   If the Health Plan denies the request for
expedited appeal, it shall immediately transfer the appeal to the timeframe for
standard resolution and so notify the enrollee.

G. Medicaid Fair Hearings (see 65-2.042-2.069, FAC)

  1.   An enrollee may seek a Medicaid Fair Hearing without having first
exhausted the Health Plan’s grievance and appeal process.     2.   An enrollee
who chooses to exhaust the Health Plan’s grievance and appeal process may still
file for a Medicaid Fair Hearing within ninety (90) calendar days of receipt of
the Health Plan’s notice of resolution.     3.   An enrollee who chooses to seek
a Medicaid Fair Hearing without pursuing the Health Plan’s process must do so
within ninety (90) days of receipt of the Health Plan’s notice of action.     4.
  Parties to the Medicaid Fair Hearing include the Health Plan as well as the
enrollee or that person’s authorized representative.     5.   The address at DCF
for the Medicaid Fair Hearing office is:
Office of Public Assistance Appeals Hearings
1317 Winewood Boulevard, Building 5, Room 203
Tallahassee, FL 32399-0700

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

H. Continuation of Benefits

  1.   The Health Plan shall continue the enrollee’s benefits if:

  a.   The enrollee or the enrollee’s authorized representative files an appeal
with the Health Plan regarding the Health Plan’s decision:

  (1)   Within ten (10) business days after the notice of the adverse action is
mailed or     (2)   Within ten (10) business days after the intended effective
date of the action, whichever is later;

  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 original period covered by the original
authorization has not expired; and     e.   The enrollee requests extension of
benefits.

  2.   If, at the enrollee’s request, the Health Plan continues or reinstates
the benefits while the appeal is pending, benefits must continue until one
(1) of the following occurs:

  a.   The enrollee withdraws the appeal;     b.   Ten (10) business days pass
after the Health Plan sends the enrollee the notice of resolution of the appeal
against the enrollee, unless the enrollee within those ten (10) days has
requested a Medicaid Fair Hearing with continuation of benefits;     c.   The
Medicaid Fair Hearing office issues a hearing decision adverse to the enrollee;
    d.   The time period or service limits of a previously authorized service
have been met.

  3.   If the final resolution of the appeal is adverse to the enrollee and the
Health Plan’s action is upheld, the Health Plan may recover the cost of services
furnished to the enrollee while the appeal was pending to the extent they were
furnished solely because of the continuation of benefits requirement.     4.  
If the Medicaid Fair Hearing officer reverses the Health Plan’s action and
services were not furnished while the appeal was pending, the Health Plan shall
authorize or provide the disputed services promptly.     5.   If the Medicaid
Fair Hearing officer reverses the Health Plan’s action and the enrollee received
the disputed services while the appeal was pending, the Health Plan shall pay
for those services in accordance with this Contract.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section X
Administration and Management
A. General Provisions

  1.   The Health Plan’s governing body shall set forth policy and has overall
responsibility for the organization of the Health Plan.     2.   The Health Plan
shall be responsible for the administration and management of all aspects of
this Contract, including, but not limited to, delivery of services, provider
network, provider education, claims resolution and assistance, and all
subcontracts, employees, agents and services performed by anyone acting for or
on behalf of the Health Plan.     3.   The Health Plan shall have a centralized
executive administration, which shall serve as the contact point for the Agency,
except as otherwise specified in this Contract.

B. Staffing

  1.   The Health Plan shall educate its staff about its policies and procedures
and all applicable provisions of this Contract, including advance directives,
situations in which advance directives may be of benefit to enrollees, and their
responsibility to educate enrollees about this tool and assist them in making
use of it.     2.   Minimum Staffing Requirements — The positions described
below represent the minimum management staff required for the Health Plan.
Within five (5) working days of any changes in staffing, the Health Plan shall
report such changes to BMHC and HSD.

  a.   Contract Manager: The Health Plan shall designate a Contract Manager to
work directly with the Agency. The Contract Manager shall be a full-time
employee of the Health Plan with authority to revise processes or procedures and
assign additional resources as needed to maximize the efficiency and
effectiveness of services required under the Contract. The Health Plan shall
meet in person, or by telephone, at the request of Agency representatives to
discuss the status of the Contract, Health Plan performance, benefits to the
state, necessary revisions, reviews, reports and planning.     b.   Full-Time
Administrator: The Health Plan shall have a full-time administrator specifically
identified to administer the day-to-day business activities of this Contract.
The Health Plan may designate the same person as the Contract Manager, the full-
time administrator, or the medical director, but such person cannot be
designated to any other position in this section, including in other lines of
business within the Health Plan, unless otherwise approved by BMHC.     c.  
Medical and Professional Support Staff: The Health Plan shall have medical and
professional support staff sufficient 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. The Health Plan shall maintain sufficient
medical staff, available twenty-four hours a day, seven days a week (24/7), to
handle emergency services and care

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AMERIGROUP Community Care
  HMO Contract

      inquiries. The Health Plan shall maintain sufficient medical and
professional support staff during non-business hours, unless the Health Plan’s
computer system automatically approves all emergency services and care claims
relating to screening and treatment.     d.   Medical Director: The Health Plan
shall have a full-time physician with an active unencumbered license in
accordance with Chapter 458 or 459, F.S., to serve as medical director to
oversee and be responsible for the proper provision of covered services to
enrollees, the quality management program and the grievance system. The medical
director cannot be designated to serve in any other non-administrative position.
    e.   Medical Records Review Coordinator: The Health Plan shall have a
designated person, qualified by training and experience, to ensure compliance
with the medical records requirements as described in this Contract. The medical
records review coordinator shall maintain medical record standards and direct
medical record reviews according to the terms of this Contract.     f.   Data
Processing and Data Reporting Coordinator: The Health Plan shall have a person
trained and experienced in data processing, data reporting, and claims
resolution, as required, to ensure that computer system reports the Health Plan
provides to the Agency and its agents are accurate, and that computer systems
operate in an accurate and timely manner.     g.   Community Outreach Oversight
Coordinator: If the Health Plan engages in community outreach, it shall have a
designated person, qualified by training and experience, to ensure the Health
Plan adheres to the community outreach and marketing requirements of this
Contract.     h.   QI and UM Professional: The Health Plan shall have a
designated person, qualified by training and experience in QI and UM and who
holds the appropriate clinical certification and/or license.     i.   Grievance
System Coordinator: The Health Plan shall have a designated person, qualified by
training and experience, to process and resolve complaints, grievances and
appeals, be responsible for the grievance system.     j.   Compliance Officer:
The Health Plan shall have a designated person qualified by training and
experience in health care or risk management, to oversee a fraud and abuse
program to prevent and detect potential fraud and abuse activities pursuant to
state and federal rules and regulations, and carry out the provisions of the
compliance plan, including fraud and abuse policies and procedures,
investigating unusual incidents and implementing corrective action.     k.  
Case Management Staff: The Health Plan shall have sufficient case management
staff, qualified by training, experience and certification/licensure to conduct
the Health Plan’s case management functions.     l.   Claims/Encounter Manager:
The Health Plan shall have a designated person qualified by training and
experience to oversee claims and encounter submittal and

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      processing, where applicable, and to ensure the accuracy, timeliness and
completeness of processing payment and reporting.

C. Claims (See Attachment II, Exhibits 10 and 13)

  1.   The Health Plan shall have performance metrics, including those for
quality, accuracy and timeliness, and include a process for measurement and
monitoring, and for the development and implementation of interventions for
improvement in regards to claims processing and claims payment. The Health Plan
shall keep documentation of the above and have these available for Agency
review.     2.   The Health Plan shall be able to accept
electronically-transmitted claims from providers in HIPAA compliant formats.    
3.   For purposes of this subsection, electronic transmission of claims, HIPAA
compliant transactions, notices, documents, forms, and payments shall be used to
the greatest extent possible by the Health Plan.     4.   The Health Plan shall
ensure that claims are processed and comply with the federal and state
requirements set forth in 42 CFR 447.45 and 447.46 and Chapter 641, F.S.,
whichever is more stringent.     5.   The Health Plan shall have a process for
handling and addressing the resolution of provider complaints concerning claims
issues. The process shall be in compliance with s. 641.3155 F.S.     6.   The
Health Plan shall not deny claims submitted by an out-of-network provider,
including provision of emergency services and care, solely based on the period
between the date of service and the date of clean claim submission, unless that
period exceeds three- hundred and sixty-five (365) days.     7.   Each quarter
the Health Plan shall submit an aging claims summary in accordance with
Attachment II, Section XII, Reporting Requirements, Attachment II.

D. Encounter Data

  1.   Encounter data collection and submission is required from all capitated
Health Plans for all health care services rendered to their enrollees (services
for which the Health Plan is reimbursed by the Agency on a capitated basis) and
from all fee-for-service PSNs for all capitated services. The Health Plan shall
submit encounter data that meets established Agency data quality standards as
defined herein. These standards are defined by the Agency to ensure receipt of
complete and accurate data for program administration and are closely monitored
and enforced. The Agency will revise and amend these standards with ninety
(90) calendar days’ advance notice to the Health Plan to ensure continuous
quality improvement. The Health Plan shall make changes or corrections to any
systems, processes or data transmission formats as needed to comply with Agency
data quality standards as originally defined or subsequently amended.     2.  
The encounter data submission standards required to support encounter data
collection and submission are defined by the Agency in the Medicaid Encounter
Data System

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      (MEDS) Companion Guide and this section. In addition, the Agency will post
encounter data reporting requirements on its MEDS website:
http://ahca.myflorida.com/Medicaid/meds/.     3.   The Health Plan shall adhere
to the following requirements for the encounter data submission process:

  a.   In accordance with the Health Plan’s submission schedule approved by the
Agency, the Health Plan shall submit by October 31, 2009, the historical
encounters for all typical and atypical services with Health Plan paid dates of
January 1, 2007, for Reform populations, and July 1, 2008, for non-Reform
populations, up to the submission start date. The Health Plan shall retain
submitted historical encounter data for a period not less than five (5) years as
specified in the Standard Contract, Section I., Item D., Retention of Records.  
  b.   The Health Plan shall submit encounters for all typical and atypical
services with Health Plan paid dates on or after the submission start date on an
ongoing basis within sixty (60) calendar days following the end of the month in
which the Health Plan paid the claims for services.     c.   For all encounters
submitted after the submission start date, including historical and ongoing
claims, if the Agency or its fiscal agent notifies the Health Plan of encounters
failing X12 electronic data interface (EDI) compliance edits or FMMIS threshold
and repairable compliance edits, the Health Han shall remediate all such
encounters within sixty (60) calendar days after such notice.     d.   There
will be no requirement to submit encounters for Health Plan paid dates prior to
January 1, 2007, for Reform populations, and July 1, 2008, for non-Reform
populations.

  4.   The Health Plan shall have a comprehensive automated and integrated
encounter data system capable of meeting the requirements below:

  a.   All Health Plan encounters shall be submitted to the Agency in the
standard HIPAA transaction formats, namely the ANSI X12N 837 transaction formats
(P — Professional; I — Institutional; D — Dental), and, for pharmacy services,
in the National Council for Prescription Drug Programs (NCPDP) format. Health
Plan paid amounts shall be provided for non-capitated network providers.     b.
  The Health Plan shall collect, and submit to the Agency’s fiscal agent,
enrollee service level encounter data for all covered services. The Health Plan
shall be held responsible for errors or noncompliance resulting from their own
actions or the actions of an agent authorized to act on their behalf.     c.  
The Health Plan shall convert all information that enters its claims system via
hard copy paper claims or other proprietary formats to encounter data to be
submitted in the appropriate HIPAA-compliant formats.     d.   The Health Plan
shall provide complete and accurate encounters to the Agency. The Health Plan
shall implement review procedures to validate encounter data submitted by
providers.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (1)   Complete: A Health Plan submitting encounters that represent at least
ninety-five (95%) of the covered services provided by Health Plan providers and
non-participating providers. The Health Plan shall strive to achieve a
one-hundred percent (100%) complete submission rate.     (2)   Accurate (X12):
ninety-five (95%) of the records in a Health Plan’s encounter batch submission
pass X12 EDI compliance edits and the FMNIIS threshold and repairable compliance
edits. The X12 EDI compliance edits are established through SNIP levels 1
through 4. FMMIS threshold and repairable edits that report exceptions are
defined in the MEDS X12 Companion Guide.     (3)   Accurate (NCPDP): ninety-five
(95%) of the records in a Health Plan’s encounter batch submission pass NCPDP
compliance edits and the pharmacy benefits system threshold and repairable
compliance edits. The NCPDP compliance edits are described in the National
Council for Prescription Drug Programs Telecommunications Standard Guides.
Pharmacy benefits system threshold and repairable edits that report exceptions
are defined in the MEDS Pharmacy Claims Companion Guide.

  5.   The Health Plan shall designate sufficient IT and staffing resources to
perform these encounter functions as determined by generally accepted best
industry practices.     6.   Where a Health Plan has entered into capitation
reimbursement arrangements with providers, the Health Plan shall comply with
sub-item 4 of this section, above. The Health Plan shall require timely
submissions from its providers as a condition of the capitation payment.     7.
  The Health Plan shall participate in Agency-sponsored workgroups directed at
continuous improvements in encounter data quality and operations.     8.   If
the Agency determines that the Health Plan’s MEDS performance is not acceptable,
the Agency shall require the Health Plan to submit a corrective action plan
(CAP). When considering whether to impose a sanction, the Agency will take into
account the Health Plan’s cumulative performance on all NIEDS activities,
including progress toward completeness and accuracy of encounter data, as
defined in Item D., Encounter Data, above.     9.   Encounter data submission
time frames specified in this section do not affect time frames specified in
Attachment II, Section XII, Reporting Requirements, for either pharmacy data
encounter reporting, for risk adjustment, or behavioral health encounters
(including pharmacy reporting).

E. Fraud and Abuse Prevention

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

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   The Health Plan shall have adequate staffing and resources to enable the
compliance officer to investigate unusual incidents and develop and implement
corrective action plans relating to fraud and abuse. The compliance officer
shall have unrestricted access to the Health Plan’s governing body for
compliance reporting, including fraud and abuse.     3.   The Health Plan’s
written fraud and abuse prevention program shall have internal controls and
policies and procedures in place that are designed to prevent, reduce, detect,
correct and report known or suspected fraud and abuse activities.     4.   The
Health Plan shall submit its compliance plan and its fraud and abuse policies
and procedures to the Bureau of Medicaid Program Integrity (NIPI) for written
approval before those procedures are implemented.

  a.   At a minimum the compliance plan must include:

  (1)   Written policies, procedures and standards of conduct that articulate
the Health Plan’s commitment to comply with all applicable federal and state
standards;     (2)   The designation of a compliance officer and a compliance
committee accountable to senior management;     (3)   Effective training and
education of the compliance officer and the Health Plan’s employees;     (4)  
Effective lines of communication between the compliance officer and the Health
Plan’s employees;     (5)   Enforcement of standards through well-publicized
disciplinary guidelines;     (6)   Provision for internal monitoring and
auditing; and     (7)   Provisions for prompt response to detected offenses and
for development of corrective action initiatives.

  b.   At a minimum, the Health Plan’s fraud and abuse policies and procedures
shall:

  (1)   Ensure that all officers, directors, managers and employees know and
understand the provisions of the Health Plan’s fraud and abuse policies and
procedures;     (2)   Include procedures designed to prevent and detect
potential or suspected fraud and abuse in the administration and delivery of
services under this Contract. Nothing in this Contract shall require that the
Health Plan assure that nonparticipating providers are compliant with this
Contract or state and/or federal law, but the Health Plan is responsible for
reporting suspected fraud and abuse by non-participating providers when
detected;     (3)   Describe the Health Plan’s organizational arrangement of
anti-fraud personnel, their roles and responsibilities, including a description
of the internal investigational methodology and reporting protocols;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (4)   Incorporate a description of the specific controls in place for
prevention and detection of potential or suspected fraud and abuse, including,
but not limited to:

  (a)   Claims edits;     (b)   Post-processing review of claims;     (c)  
Provider profiling, credentialing, and recredentialing, including a review
process for claims and encounters that shall include providers and
non-participating providers:

  (i)   Who demonstrate a pattern of submitting falsified encounter data or
service reports;     (ii)   Who demonstrate a pattern of overstated reports or
up-coded levels of service;     (iii)   Who alter, falsify or destroy clinical
record documentation;     (iv)   Who make false statements relating to
credentials;     (v)   Who misrepresent medical information to justify enrollee
referrals;     (vi)   Who fail to render medically necessary covered services
they are obligated to provide according to their provider contracts; and    
(vii)   Who charge enrollees for covered services.

  (d)   Prior authorization;     (e)   Utilization management;     (f)  
Subcontract and provider contract provisions;     (g)   Provisions from the
provider and the enrollee handbooks; and     (h)   Standards for a code of
conduct;

  (5)   Contain provisions pursuant to this section for the confidential
reporting of Health Plan violations to MPI and other agencies as required by
law;     (6)   Include provisions for the investigation and follow-up of any
reports;     (7)   Ensure that the identities are protected for individuals
reporting in good faith alleged acts of fraud and abuse;     (8)   Require all
suspected or confirmed instances of provider or enrollee fraud and abuse under
state and/or federal law be reported to MPI within fifteen (15) calendar days of
detection. Additionally, any final resolution reached by the Health Plan shall
include a written statement that provides notice to the provider

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      or enrollee that the resolution in no way binds the State of Florida nor
precludes the State of Florida from taking further action for the circumstances
that brought rise to the matter;     (9)   Ensure that the Health Plan and all
providers and subcontractors, upon request and as required by state and/or
federal law, shall:

  (a)   Make available to all authorized federal and state oversight agencies
and their agents, including but not limited to the Agency and the Florida
Attorney General, any and all administrative, financial and medical records and
data relating to the delivery of items or services for which Medicaid monies are
expended; and     (b)   Allow access to all authorized federal and state
oversight agencies and their agents, including but not limited to the Agency and
the Florida Attorney General, to any place of business and all medical records
and data, as required by state and/or federal law. Access shall be during normal
business hours, except under special circumstances when the Agency and the
Florida Attorney General shall have after-hours admission. The Agency and the
Florida Attorney General shall determine the need for special circumstances.

  (10)   Ensure that the Health Plan shall cooperate fully in any investigation
by federal and state oversight agencies and any subsequent legal action that may
result from such an investigation.     (11)   Ensure that the Health Plan does
not retaliate against any individual who reports violations of the Health Plan’s
fraud and abuse policies and procedures or suspected fraud and abuse.     (12)  
Not knowingly have affiliations with individuals debarred or excluded by federal
agencies under ss. 1128 and 1128A of the Social Security Act and 42 CFR 438.610.
    (13)   Use the federal List of Excluded Individuals and Entities (LEIE), or
its equivalent, to identify excluded parties during the process of engaging the
services of new employees, subcontractors and providers and during renewal of
agreements and recredentialing. The Health Plan shall not engage the services of
an entity that is in nonpayment status or is excluded from participation in
federal health care programs under ss. 1128 and 1128A of the Social Security
Act.     (14)   Provide details and educate employees, subcontractors and
providers about the following as required by s. 6032 of the federal Deficit
Reduction Act of 2005:

  (a)   The False Claim Act;     (b)   The penalties for submitting false claims
and statements;     (c)   Whistleblower protections;     (d)   The law’s role in
preventing and detecting fraud, waste and abuse;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (e)   Each person’s responsibility relating to detection and prevention; and  
  (f)   The toll-free state telephone numbers for reporting fraud and abuse.

  5.   The Health Plan shall query its potential non-provider subcontractors
before contracting to determine whether the subcontractor has any existing or
pending contract(s) with the Agency and, if any, notify MPI.     6.   In
accordance with s. 6032 of the federal Deficit Reduction Act of 2005, the Health
Plan shall make available written fraud and abuse policies to all employees. If
the Health Plan has an employee handbook, the Health Plan shall include specific
information about s. 6032, the Health Plan’s policies, and the rights of
employees to be protected as whistleblowers.     7.   The Health Plan shall
comply with all reporting requirements as set forth in Attachment II,
Section XII, Reporting Requirements.     8.   The Health Plan shall meet with
the Agency periodically, at the Agency’s request, to discuss fraud, abuse,
neglect and overpayment issues.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XI
Information Management and Systems
A. General Provisions

  1.   Systems Functions. The Health Plan shall have information management
processes and information systems that enable it to meet Agency and federal
reporting requirements, other Contract requirements, and all applicable state
and federal laws, rules and regulations, including HIPAA.     2.   Systems
Capacity. The Health Plan’s system(s) shall possess capacity sufficient to
handle the workload projected for the begin date of operations and will be
scaleable and flexible so they can be adapted as needed, within negotiated
timeframes, in response to changes in Contract requirements, increases in
enrollment estimates, etc.     3.   E-Mail System. The Health Plan shall provide
a continuously available electronic mail communication link (e-mail system) with
the Agency. This system shall be:

  a.   Available from the workstations of the designated Health Plan contacts;
and     b.   Capable of attaching and sending documents created using software
products other than the Health Plan’s systems, including the Agency’s currently
installed version of Microsoft Office and any subsequent upgrades as adopted.

  4.   Participation in Information Systems Work Groups/Committees. The Health
Plan shall meet as requested by the Agency, to coordinate activities and develop
cohesive systems strategies across vendors and agencies.     5.   Connectivity
to the Agency/State Network and Systems. The Health Plan shall be responsible
for establishing connectivity to the Agency’s/state’s wide area data
communications network, and the relevant information systems attached to this
network, in accordance with all applicable Agency and/or state policies,
standards and guidelines.

B. Data and Document Management Requirements

  1.   Adherence to Data and Document Management Standards

  a.   The Health Plan’s systems shall conform to the standard transaction code
sets specified in the Contract.     b.   The Health Plan’s systems shall conform
to HIPAA standards for data and document management.     c.   The Health Plan
shall partner with the Agency in the management of standard transaction code
sets specific to the Agency. Furthermore, the Health Plan shall partner with the
Agency in the development and implementation planning of future standard code
sets not specific to HIPAA or other federal efforts and shall conform to these
standards as stipulated in the plan to implement the standards.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   Data Model and Accessibility. Health Plan systems shall be structured
query language (SQL) and/or open database connectivity (ODBC) compliant.
Alternatively, the Health Plan’s systems shall employ a relational data model in
the architecture of its databases in addition to a relational database
management system (RDBMS) to operate and maintain them.     3.   Data and
Document Relationships. The Health Plan shall house indexed images of documents
used by enrollees and providers to transact with the Health Plan in the
appropriate database(s) and document management systems so as to maintain the
logical relationships between certain documents and certain data.     4.  
Information Retention. Information in the Health Plan’s systems shall be
maintained in electronic form for three (3) years in live systems and, for audit
and reporting purposes, for five (5) years in live and/or archival systems.    
5.   Information Ownership. All information, whether data or documents, and
reports that contain or make references to said Information, involving or
arising out of this Contract is owned by the Agency. The Health Plan is
expressly prohibited from sharing or publishing the Agency information and
reports without the prior written consent of the Agency. In the event of a
dispute regarding the sharing or publishing of information and reports, the
Agency’s decision on this matter shall be final and not subject to change.

C. System and Data Integration Requirements

  1.   Adherence to Standards for Data Exchange

  a.   The Health Plan’s systems shall be able to transmit, receive and process
data in HIPAA-compliant formats that are in use as of the Contract execution
date.     b.   The Health Plan’s systems shall be able to transmit, receive and
process data in the Agency-specific formats and/or methods that are in use on
the Contract execution date.     c.   Health Plan systems shall conform to
future federal and/or Agency-specific standards for data exchange within
one-hundred and twenty (120) calendar days of the standard’s effective date or,
if earlier, the date stipulated by CMS or the Agency. The Health Plan shall
partner with the Agency in the management of current and future data exchange
formats and methods and in the development and implementation planning of future
data exchange methods not specific to HIPAA or other federal effort.
Furthermore, the Health Plan shall conform to these standards as stipulated in
the Agency agreed-upon-plan to implement such standards.

  2.   HIPAA Compliance Checker

All HIPAA-conforming exchanges of data between the Agency and the Health Plan
shall be subjected to the highest level of compliance as measured using an
industry-standard HIPAA compliance checker application.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  3.   Data and Report Validity and Completeness

The Health Plan shall institute processes to ensure the validity and
completeness of the data, including reports, it submits to the Agency. At its
discretion, the Agency will conduct general data validity and completeness
audits using industry-accepted statistical sampling methods. Data elements that
will be audited include but are not limited to: enrollee ID, date of service,
assigned Medicaid provider ID, category and subcategory (if applicable) of
service, diagnosis codes, procedure codes, revenue codes, date of claim
processing, and (if and when applicable) date of claim payment. Control totals
shall also be reviewed and verified.

  4.   State/Agency Website/Portal Integration

Where deemed that the Health Plan’s web presence will be incorporated to any
degree to the Agency’s or the state’s web presence (also known as a portal), the
Health Plan shall conform to any applicable Agency or state standard for website
structure, coding and presentation.

  5.   Functional Redundancy with FMMIS

The Health Plan’s systems shall be able to transmit and receive transaction data
to and from FMMIS as required for the appropriate processing of claims and any
other transaction that could be performed by either system.

  6.   Data Exchange in Support of the Agency’s Program Integrity and Compliance
Functions

The Health Plan’s systems shall be capable of generating files in the prescribed
formats for upload into Agency systems used specifically for program integrity
and compliance purposes.

  7.   Address Standardization

The Health Plan’s system(s) shall possess mailing address standardization
functionality in accordance with US Postal Service conventions.

  8.   Eligibility and Enrollment Data Exchange Requirements

  a.   The Health Plan shall receive, process and update enrollment files sent
daily by the Agency or its agent.     b.   The Health Plan shall update its
eligibility/enrollment databases within twenty-four (24) hours after receipt of
said files.     c.   The Health Plan shall transmit to the Agency or its agent,
in a periodicity schedule, format and data exchange method to be determined by
the Agency, specific data it may garner from an enrollee including third party
liability data.     d.   The Health Plan shall be capable of uniquely
identifying a distinct Medicaid recipient across multiple systems within its
span of control.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

D. Systems Availability, Performance and Problem Management Requirements

  1.   Availability of Critical Systems Functions

The Health Plan shall ensure that critical systems functions available to
enrollees and providers, functions that if unavailable would have an immediate
detrimental impact on enrollees and providers, are available twenty-four hours a
day, seven days a week (24/7), except during periods of scheduled system
unavailability agreed upon by the Agency and the Health Plan. Unavailability
caused by events outside of a Health Plan’s span of control is outside the scope
of this requirement. The Health Plan shall make the Agency aware of the nature
and availability of these functions prior to extending access to these functions
to enrollees and/or providers.

  2.   Availability of Data Exchange Functions

The Health Plan shall ensure that the systems and processes within its span of
control associated with its data exchanges with the Agency and/or its agent(s)
are available and operational according to specifications and the data exchange
schedule.

  3.   Availability of Other Systems Functions

The Health Plan shall ensure that at a minimum all other system functions and
information are available to the applicable system users between the hours of
7:00 a.m. and 7:00 p.m., in the time zone where the user is located, Monday
through Friday.

  4.   Problem Notification

  a.   Upon discovery of any problem within its span of control that may
jeopardize or is jeopardizing the availability and performance of all systems
functions and the availability of information in said systems, including any
problems affecting scheduled exchanges of data between the Health Plan and the
Agency and/or its agent(s), the Health Plan shall notify the applicable Agency
staff via phone, fax and/or electronic mail within one (1) hour of such
discovery. In its notification the Health Plan shall explain in detail the
impact to critical path processes such as enrollment management and claims
submission processes.

  b.   The Health Plan shall provide to appropriate Agency staff information on
system unavailability events, as well as status updates on problem resolution.
At a minimum these updates shall be provided on an hourly basis and made
available via electronic mail and/or telephone.

  5.   Recovery from Unscheduled System Unavailability

Unscheduled system unavailability caused by the failure of systems and
telecommunications technologies within the Health Plan’s span of control will be
resolved, and the restoration of services implemented, within forty-eight
(48) hours of the official declaration of system unavailability.
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  6.   Exceptions to System Availability Requirement

The Health Plan shall not be responsible for the availability and performance of
systems and IT infrastructure technologies outside of the Health Plan’s span of
control.

  7.   Information Systems Corrective Action Plan

If at any point there is a problem with a critical systems function, at the
request of the Agency, the Health Plan shall provide to the Agency full written
documentation that includes a corrective action plan (CAP) that describes how
problems with critical systems functions will be prevented from occurring again.
The CAP shall be delivered to the Agency within five (5) business days of the
problem’s occurrence. Failure to submit a CAP and to show progress in
implementing the CAP shall make the Health Plan subject to sanctions, in
accordance with Attachment II, Section XIV, Sanctions.

  8.   Business Continuity-Disaster Recovery (BC-DR) Plan

  a.   Regardless of the architecture of its systems, the Health Plan shall
develop, and be continually ready to invoke, a business continuity and disaster
recovery (BC-DR) plan that is reviewed and prior-approved by BMHC.

  b.   At a minimum the Health Plan’s BC-DR plan shall address the following
scenarios: (1) the central computer installation and resident software are
destroyed or damaged; (2) system interruption or failure resulting from network,
operating hardware, software, or operational errors that compromise the
integrity of transactions that are active in a live system at the time of the
outage; (3) system interruption or failure resulting from network, operating
hardware, software or operational errors that compromise the integrity of data
maintained in a live or archival system; (4) system interruption or failure
resulting from network, operating hardware, software or operational errors that
do not compromise the integrity of transactions or data maintained in a live or
archival system, but do prevent access to the system, i.e., cause unscheduled
system unavailability.

  c.   The Health Plan shall periodically, but no less than annually, by
April 30 of each Contract year, perform comprehensive tests of its BC-DR plan
through simulated disasters and lower level failures in order to demonstrate to
the Agency that it can restore system functions per the standards outlined in
the Contract.

  d.   In the event that the Health Plan fails to demonstrate in the tests of
its BC-DR plan that it can restore system functions per the standards outlined
in this Contract, the Health Plan shall be required to submit to the Agency a
corrective action plan in accordance with Attachment II, Section XIV, Sanctions,
that describes how the failure will be resolved. The corrective action plan
shall be delivered within ten (10) business days of the conclusion of the test.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

E. System Testing and Change Management Requirements

  1.   Notification and Discussion of Potential System Changes

The Health Plan shall notify HSD of the following changes to systems within its
span of control at least ninety (90) calendar days before the projected date of
the change. If so directed by the Agency, the Health Plan shall discuss the
proposed change with the applicable Agency staff. This includes: (1) software
release updates of core transaction systems: claims processing, eligibility and
enrollment processing, service authorization management, provider enrollment and
data management; (2) conversions of core transaction management systems.

  2.   Response to Agency Reports of Systems Problems not Resulting in System
Unavailability

The Health Plan shall respond to Agency reports of system problems not resulting
in system unavailability according to the following timeframes:

  a.   Within seven (7) calendar days of receipt, the Health Plan shall respond
in writing to notices of system problems.     b.   Within twenty (20) calendar
days, the correction shall be made or a requirements analysis and specifications
document will be due.     c.   The Health Plan shall correct the deficiency by
an effective date to be determined by the Agency.

  3.   Valid Window for Certain System Changes

Unless otherwise agreed to in advance by the Agency as part of the activities
described in this section, scheduled system unavailability to perform system
maintenance, repair and/or upgrade activities shall not take place during hours
that could compromise or prevent critical business operations.

  4.   Testing

  a.   The Health Plan shall work with the Agency pertaining to any testing
initiative as required by the Agency.     b.   Upon the Agency’s written
request, the Health Plan shall provide details of the test regions and
environments of its core production information systems, including a live
demonstration, to enable the Agency to corroborate the readiness of the Health
Plan’s information systems.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

F. Information Systems Documentation Requirements

  1.   Types of Documentation

The Health Plan shall develop, prepare, print, maintain, produce, and distribute
distinct system process and procedure manuals, user manuals and quick-reference
guides, and any updates thereafter, for the Agency and other applicable Agency
staff.

  2.   Content of System Process and Procedure Manuals

The Health Plan shall ensure that written system process and procedure manuals
document and describe all manual and automated system procedures for its
information management processes and information systems.

  3.   Content of System User Manuals

The system user manuals shall contain information about, and instructions for,
using applicable system functions and accessing applicable system data.

  4.   Changes to Manuals

  a.   When a system change is subject to the Agency’s written approval, the
Health Plan shall draft revisions to the appropriate manuals prior to Agency
approval of the change.     b.   Updates to the electronic version of these
manuals shall occur in real time; updates to the printed version of these
manuals shall occur within ten (10) business days of the update’s taking effect.

  5.   Availability of/Access to Documentation

All of the aforementioned manuals and reference guides shall be available in
printed form and/or on-line. If so prescribed, the manuals will be published in
accordance with the appropriate Agency and/or state standard.
G. Reporting Requirements
The Health Plan shall extract and upload data sets, upon request, to a secure
FTP site to enable authorized Agency personnel, or the Agency’s agent, on a
secure and read-only basis, to build and generate reports for management use.
The Agency and the Health Plan shall arrange technical specifications for each
data set as required for completion of the request.
H. Community Health Record/Electronic Medical Record and Related Efforts

  1.   At such times that the Agency requires, the Health Plan shall participate
and cooperate with the Agency to implement, within a reasonable timeframe,
secure, web-accessible, community health records for enrollees.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   The design of the vehicle(s) for accessing the community health record,
the health record format and design shall comply with all HIPAA and related
regulations.     3.   The Health Plan shall also cooperate with the Agency in
the continuing development of the state’s health care data site
(www.FloridaHealthFinder.com).

I. Compliance with Standard Coding Schemes

  1.   Compliance with HIPAA-Based Code Sets

Health Plan systems that are required to or otherwise contain the applicable
data type shall conform to the following HIPAA-based standard code sets; the
processes through which the data are generated should conform to the same
standards as needed:

  a.   Logical Observation Identifier Names and Codes (LOINC);     b.   Health
Care Financing Administration Common Procedural Coding System (HCPCS);     c.  
Home Infusion EDI Coalition (HEIC) Product Codes;     d.   National Drug Code
(NDC);     e.   National Council for Prescription Drug Programs (NCPDP);     f.
  International Classification of Diseases (ICD-9);     g.   Diagnosis Related
Group (DRG);     h.   Claim Adjustment Reason Codes; and     i.   Remittance
Remarks Codes.

  2.   Compliance with Other Code Sets

Health Plan systems that are required to or otherwise contain the applicable
data type shall conform to the following non-HIPAA-based standard code sets:

  a.   As described in all Agency Medicaid reimbursement handbooks, for all
“covered entities,” as defined under HIPAA, and which submit transactions in
paper format (non-electronic format).     b.   As described in all Agency
Medicaid reimbursement handbooks for all “non-covered entities,” as defined
under HIPAA.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

J. Data Exchange and Formats and Methods Applicable to Health Plans

  1.   HIPAA-Based Formatting Standards

Health Plan systems shall conform to the following HIPAA-compliant standards for
information exchange effective the first day of operations in the applicable
service region:

  a.   Batch transaction types

  (1)   ASC X12N 834 Enrollment and Audit Transaction     (2)   ASC X12N 835
Claims Payment Remittance Advice Transaction     (3)   ASC X12N 8371
Institutional Claim/Encounter Transaction     (4)   ASC X12N 837P Professional
Claim/Encounter Transaction     (5)   ASC X12N 837D Dental Claim/Encounter
Transaction     (6)   NCPDP 1.1 Pharmacy Claim/Encounter Transaction

  b.   Online transaction types

  (1)   ASC X12N 270/271 Eligibility/Benefit Inquiry/Response     (2)   ASC X12N
276 Claims Status Inquiry     (3)   ASC X12N 277 Claims Status Response     (4)
  ASC X12N 278/279 Utilization Review Inquiry/Response     (5)   NCPDP 5.1
Pharmacy Claim/Encounter Transaction

  2.   Methods for Data Exchange

The Health Plan and the Agency and/or its agent shall make predominant use of
secure file transfer protocol (SFTP) and electronic data interchange (EDI) in
their exchanges of data.

  3.   Agency-Based Formatting Standards and Methods

Health Plan systems shall exchange the following data with the Agency and/or its
agent in a format to be jointly agreed upon by the Health Plan and the Agency:

  a.   Provider network data;     b.   Case management fees, if applicable; and
    c.   Payments.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XII
Reporting Requirements
A. Health Plan Reporting Requirements

  1.   The Health Plan shall comply with all reporting requirements set forth by
the Agency in this Contract. These requirements are summarized in Table 1 in
this section.

  a.   The Health Plan is responsible for assuring the accuracy, completeness,
and timely submission of each report.     b.   The Health Plan’s chief executive
officer (CEO), chief financial officer (CFO), or an individual who reports to
the CEO or CFO and who has delegated authority to certify the Health Plan’s
reports, shall attest, based on his/her best knowledge, information, and belief,
that all data submitted in conjunction with the reports and all documents
requested by the Agency are accurate, truthful, and complete (see 42 CFR
438.606(a) and (b)).     c.   The Health Plan shall submit its certification at
the same time it submits the certified data reports (see 42 CFR 438.606(c)). The
certification page shall be scanned and submitted electronically.     d.  
Deadlines for report submission referred to in this Contract specify the actual
time of receipt at the Agency bureau or location listed in Table 1 of this
section, not the date the file was postmarked or transmitted.     e.   If a
reporting due date falls on a weekend or state holiday, the report shall be due
to the Agency on the following business day.     f.   All reports filed on a
quarterly basis shall be filed on a calendar year quarter.

  2.   The Health Plan shall use the Health Plan Report Guide in submitting
required reports, including the report formats, templates, instructions, data
specifications, submission timetables and locations, and other materials
contained in the guide posted on the Agency’s web site at:
http://ahca.myflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml. The Agency
shall furnish the Health Plan with appropriate technical assistance in using the
Report Guide.     3.   Unless otherwise specified, all reports are to be
submitted electronically, as prescribed in the reporting guidelines.     4.  
The Agency reserves the right to modify the reporting requirements, with a
ninety (90) calendar day notice to allow the Health Plan to complete
implementation, unless otherwise required by law.     5.   The Agency shall
provide the Health Plan with written notification of any modifications to the
reporting requirements.

AHCA Contract No. FA913, Attachment II, Page 146 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  6.   If the Health Plan fails to submit the required reports accurately and
within the timeframes specified, the Agency shall fine or otherwise sanction the
Health Plan in accordance with Attachment II, Section XIV, Sanctions, and
59A-12.0073, FAC.     7.   Reports are to be transmitted as described below:

  a.   If hard copies are required, mail to the following address:

Agency for Health Care Administration
Bureau of Managed Health Care
2727 Mahan Drive, MS #26
Tallahassee, FL 32308
Or
Transmit electronically to the Agency at the addresses in Table 1.

  b.   PHI information must be submitted to the Agency SFTP sites.

  8.   Health Plan reports required by the Agency are as follows as indicated by
plan type/ population served. These reports must be submitted as indicated in
Table 1 and as specified in the Health Plan Report Guide.

Table 1
SUMMARY OF REPORTING REQUIREMENTS

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section II
  Benefit Maximum Report   Ref HMO;
Ref FFS PSN;
Ref Cap PSN;   Monthly, fifteen (15) days after end of reporting month once
$450,000 in enrollee costs is reached   HSD Contract Manager once $450,000 is
reached, and to BMHC that initial month and monthly thereafter through end of
state fiscal year
 
               
Section III
  Newborn Enrollment Report   NR FFS PSN;
Ref FFS PSN;
CCC   Weekly, on Wednesday   Medicaid Area Office

AHCA Contract No. FA913, Attachment II, Page 147 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section III
  Involuntary Disenrollment Report   Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Monthly, first Thursday of month   Choice Counseling Vendor
 
               
Section IV
  Medicaid Redetermination Notice Summary Report   All Plans that participate
per Attachment I   Quarterly, forty-five (45) days after end of reporting
quarter   BMHC
 
               
Section IV
  Community Outreach Health Fairs/Public Events Notification   All Plans  
Monthly, no later than 20th day of month before event month; amendments two
weeks before event   BMHC
 
               
Section IV
  Community Outreach Representative Report   All Plans   Two ( 2) weeks before
activity   BMHC
 
               
 
          Quarterly, forty-five (45) days after end of reporting quarter    
 
               
Section V
  Customized Benefit Notifications Report   Ref HMO; Ref Cap PSN   Monthly,
fifteen (15) days after end of reporting month   BMHC
 
               
Section V
  CHCUP (CMS-416) & FL 60% Screening (Child Health Check Up report)   All Plans
  Annually, unaudited by January 15th for prior federal fiscal year; Annually,
audited report by October 1st   BMHC

AHCA Contract No. FA913, Attachment II, Page 148 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section V
  Inpatient Discharge Report   NR Ref HMO;
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS   Quarterly, thirty (30) calendar days after end of reporting quarter  
BMHC
 
               
Section V
  Hernandez Settlement Ombudsman Log   NR HMO;
NR FFS PSN*;
NR Cap PSN;
Ref HMO;
Ref FFS PSN*;
Ref Cap PSN;
CCC*;
HIV/AIDS   Quarterly, fifteen (15) days after end of reporting quarter   BMHC
 
               
 
      * If the FFS Health Plan has authorization requirements for prescribed
drug services        
 
               
Section V
  Hernandez Settlement Agreement Survey   NR HMO;
NR FFS PSN*;
NR Cap PSN;
Ref HMO;
Ref FFS PSN*;
Ref Cap PSN;   Annually, on August 1st   BMHC
 
      CCC*;
HIV/AIDS        
 
               
 
      * If the FFS Health Plan has authorization requirements for prescribed
drug services        
 
               
Section V
  Quarterly Pharmacy (RX Quarterly) Encounter Data Submissions   NR HMO;
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS   Quarterly, 30 calendar days after end of reporting quarter   MEDS
Team
 
               
Section V
  Behavioral Health – Pharmacy Encounter Data Report   NR HMO; Ref HMO; Ref Cap
PSN; HIV/AIDS   Quarterly, forty-five (45) days after end of reporting quarter  
BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section V
  Pharmacy Navigator Report   Ref HMO;
Ref Cap PSN;
HIV/AIDS   Annually, by December 1st   Choice Counseling Vendor
 
               
Section V and Exhibit 4
  Enhanced Benefits Report   Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Monthly, ten (10) days after end of reporting month   BMHC
 
               
Section VI, Exhibit 6
  Behavioral Health Annual 80/20 Expenditure Report   NR HMO   Annually, by
April 1st   BMHC
 
               
Section VI, Exhibit 6
  Behavioral Health Critical Incident Report-Individual   NR HMO;
Ref-HMO;
Ref. FFS PSN;
Ref Cap. PSN;
CCC;
HIV/AIDS   Immediately, no later than twenty -four (24) hours after occurrence
or knowledge of incident   BMHC
 
               
Section VI, Exhibit 6
  Behavioral Health Critical Incident Report-Summary   NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Monthly, on the 15th   BMHC
 
               
Section VI, Exhibit 6
  Behavioral Health-Required Staff /Providers Report   NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Quarterly, forty-five (45) days after end of reporting quarter for
Health Plans operating less than one (1) year;   BMHC
 
               
 
          Annually, by August 15th, for all other Health Plans    
 
               
Section VI, Exhibit 6
  Behavioral Health-FARS/CFARS   NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Semi-Annually, August 15th and February 15th   BMHC

AHCA Contract No. FA913, Attachment II, Page 150 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section VI, Exhibit 6
  Behavioral Health- Enrollee Satisfaction Survey Summary   NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Annually by March 1st   BMHC behavioral health analyst
 
               
Section VI, Exhibit 6
  Behavioral Health-Stakeholders’ Satisfaction Survey-Summary   NR HMO;
Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Annually, by March 1st   BMHC
 
               
Section VI, Exhibit 6
  Behavioral Health-Encounter Data Report   NR HMO;
Ref HMO;
Ref Cap PSN;
HIV/AIDS   Quarterly, forty-five (45) days after end of reporting quarter   BMHC
 
               
Section VII
  Provider Network File   All Plans   Monthly, First Thursday of month (optional
weekly submissions each Thursday for remainder of month)   AHCA Choice
Counseling Vendor for Reform;

For non-Reform, to Medicaid fiscal agent and BMHC
 
               
Section VII
  Provider Termination and New Provider Notification Report   All Plans  
Monthly, by fifth calendar day of the month following the reporting month   BMHC
 
               
Section VII
  PCP Wait Times Report   ALL Plans   Annually, by February 1st   BMHC
 
               
Section VIII
  Cultural Competency Plan (and Annual Evaluation)   All Plans   Annually,
October 1st   BMHC
 
               
Section IX
  Complaints, Grievance, and Appeals Report   All Plans   Quarterly, fifteen
(15) days after end of quarter   BMHC
 
               
Section X
  Performance Measures   All Plans   Annually, on July 1st   BMQM

AHCA Contract No. FA913, Attachment II, Page 151 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section X
  MPI — Quarterly Fraud&Abuse Activity Report   All Plans   Quarterly, fifteen
(15) days after the end of reporting quarter   MPI
 
               
Section X
  MPI — Suspected/Confirmed Fraud & Abuse Reporting   All Plans   Within fifteen
(15) days of detection   MPI
 
               
Section XI
  Claims Aging Report & Supplemental Filing Report   All Plans   Quarterly,
forty-five (45) days after end of reporting quarter,   BMHC
 
               
 
          Capitated Plans, optional supplemental filing-one-hundred and five
(105) calendar days after end of reporting quarter    
 
               
Section XIII
  Madicaid Reform Supplemental HIV/AIDS Report   Ref HMO;
Ref FFS PSN;
Ref Cap PSN;
CCC;
HIV/AIDS   Monthly, by second Thursday of month   BMHC
 
               
Section XIII
  Catastrophic Component Threshold Report   Ref HMO;
Ref FFS PSN;
Ref Cap PSN   Monthly, fifteen (15) days after end of reporting month   BMHC
 
               
Section XV
  Insolvency Protection Multiple Signatures Agreement Form   NR HMO;
NR Cap PSN;
Ref HMO;
Ref Cap PSN;
HIV/AIDS   Annually, by April 1st;

Thirty (30) days after any change   BMHC
 
               
Section XV
  Audited Annual and Unaudited Quarterly Financial Reports   All Plans except
CCC   Audited-Annually April 1st for calendar year;   BMHC
 
               
 
          Unaudited-Quarterly, forty-five (45) calendar days after end of
reporting quarter    

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Report Name   Plan Type  
Frequency   Submit To
Section XVI
  Minority Participation Report   All Plans   Monthly, fifteen (15) days after
month being reported   BMHC
 
               

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

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

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Attachment I, Section B., Item3.a.
  Increase in enrollment levels   Capitated Health Plans & FFS PSNs   Before
increases occur   BMHC and HSD
 
               
Attachment I, Section D., Item 3.c.
  Changes to optional or expanded services   Capitated Health Plans & FFS PSNs  
Annually, by June 15th   HSD
 
                Subsequent references are to Attachment II and its Exhibits

 
               
Section II, Item D.4.
  Policies, procedures, model provider agreements & amendments, subcontracts,
All materials related to Contract for distribution to enrollees, providers,
public   All   Before beginning use; whenever changes occur   BMHC
 
               
Section II, Item D.4.a.
  Written materials   All   Forty-five (45) calendar days before effective date
  BMHC
 
               
Section II, Item D.4.b
  Written notice of change to enrollees   All   Thirty (30) calendar days before
effective date   Enrollees affected by change
 
               
Section II, Item D.6.
  Enrollee materials, PDL, provider & enrollee handbooks   All   Available on
Health Plan’s web site without log-in   Plan web site

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section III, Item B.3.c.(1)
  Enrollee pregnancy   All   Upon confirmation   DCF & MPI
 
               
Section III,
ltem B.3.c.(3)
  Unborn activation notice   All   Presentation for delivery   DCF & MPI
 
               
Section III, Item B.3.d.
  Birth information if no unborn activation   All   Upon delivery   DCF
 
               
Section III, Item C.4.b.
  Involuntary disenrollment request   All   Forty-five (45) calendar days before
effective date   BMHC
 
               
Section III, Item C.4.e.
  Notice that Health Plan is requesting disenrollment in next Contract month  
All   Before effective date   Enrollee affected
 
               
Section IV, Item A. 1.e.
  Notice of reinstatement of enrollee   All   By 1st calendar day of month after
learning of reinstatement or within five (5) calendar days from receipt of
enrollment file, whichever is later   Person being reinstated
 
               
Section IV, Item A.2.a. and Item A.6.a.(17); Section VIII, Item A.4.
  How to get Health Plan information in alternative formats   All   Include in
cultural competency plan and enrollee handbook, and upon request   Enrolles &
potential enrollees
 
               
Section IV, Item A.2.c.
  Right to get information about Health Plan   All   Annually   Enrollees
 
               
Section IV, Item A.7.c.
  Provider directory online file   All   Update monthly & submit attestation  
BMHC
 
               
Section IV, Item A.9.a.
  Enrollee assessments   All   Within thirty (30) days of enrollment notify
about pregnancy screening   Enrollees

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section IV,
Item A.9.c.
  Enrollees more than 2 months behind in periodicity screening   All   Contact
twice, if needed   Enrollees who meet criteria
 
               
Section IV,
Item A.11.f.
  Toll-free help line performance standards   All   Get approval before
beginning operation   BMHC
 
               
Section IV, Item A. 12. and Item A.,6.a.(17); Section VIII, Item A.4.
  How to access translation services   All   Include in cultural competence plan
and enrollee handbook   Enrollees
 
               
Section IV, Item A.14.a.
  Incentive program   All   Get approval before offering   BMHC
 
               
Section IV,
Item A.14.g.
  Pre-natal care programs   All   Before implementation   BMHC
 
               
Section IV,
Item A.17.c.
  Notice of change in participation in redetermination notices   All   If Change
in participation, annually, by June 1st   BMHC
 
               
Section IV, Item A.17.c.(1)
  Redetermination policies & procedures   All   When Health Plan agrees to
participate   BMHC
 
               
Section IV, Item A.17.c.(1)(a)
  Notice in writing to discontinue Medicaid redetermination date data use   All
  Thirty (30) calendar days before stopping   BMHC
 
               
Section IV, Item B.3.c.
  Member services phone script responding to community outreach calls and
outreach materials   All   Before use   BMHC
 
               
Section IV, Item B.4.c.
  In case of force majeure, notice of participation in health fair or other
public event   All   By day of event   BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section IV, Item B.6.f.
  Report of staff or community outreach rep. Violations   All   Within fifteen
(15) calendar days of knowledge   BMHC
 
               
Section V, Item C.1.
  Written details of expanded services   All   Before implementation   HSD
 
               
Section V, Item F.
  Decision to not offer a service on moral/religious grounds   All   One-hundred
and twenty (120) Calendar days before implementation   BMHC
 
               
 
          Thirty (30) calendar days before implementation   Enrollees
 
               
Section V, Item H.10.b.2.
  UNOS form & disenrollment request for specified transplants   All   When
enrollee listed   BMHC
 
               
Section V, Item H.14.e.
  Notice that Health Plan or providers enrolled in VFC program   All   Annually,
by October 1st   BMHC
 
               
Section V, Item H.16.a.(4)
  PDL update   All   Annually, by October 1st plus thirty-day (30—day) written
change notice   BMHC and Bureau of Madicaid Pharmacy Services
Section VII, Item A.2.
  Capacity to provide covered services   All   Before taking enrollment   BMHC
 
               
Section VII, Item A.3. and Section XII, Table 1
  Network provider file   All   Before enrollment and monthly update   BMHC
 
               
Section VII, Item C.1.
  Request for initial or expansion review   All   When requesting initial
enrollment or expansion into a county.   BMHC and HSD

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section VII, Item C.2.
  Compliance with access requirements following significant changes in service
area or new populations   All   Before expansion   BMHC and HSD
 
               
Section VII, Item C.3.
  Significant network changes   All   Within seven (7) business days   BMHC
 
               
Section VII, Item C.5.
  When PCP leaves network   All   Within fifteen (15) calendar days of knowledge
  BMHC & affected enrollees
 
               
Section VII,
ltem D.2.jj.
  Waiver of provider agreement indemnifying clause   All   Approval before use  
BMHC
 
               
Section VII, Item E.3.
  Notice of terminated providers due to imminent danger/impairment   All  
Immediate   BMHC
 
               
Section VII,
ltem E.4.
  Termination or suspension of providers: for “for cause” terminations, include
reasons for termination   All   Sixty (60) calendar days before termination
effective date   BMHC, affected enrollees, & provider
 
               
Section VIII, Item A.1.b.
  Written Quality Improvement Plan   All   Within thirty (30) calendar days of
initial Contract execution; Thereafter, Annually by April 1st   BMHC
 
               
Section Vlll, Item A.3.a.(6)
  Measurement periods and methodologies   All   Any new PIPs before initiation  
BMHC
 
               
Section VIII, Item A.3.a.(7)
  Proposal for each planned PIP   All   Ninety (90) calendar days after Contract
execution; Thereafter, Annually by June 1st   BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section VIII, Item A.3.c.(1)
  Performance measure data and auditor certification   All   Annually by July
1st   BMQM
 
               
Section VIII,
ltem A.3.c.(4)
  Performance measure action plan   All   Within thirty (30) calendar days of
determination of unacceptable performance   BMQM
 
               
Section VIII,
ltem A.3.e.(7)
  Written strategies for medical record review   All   Before use   BMHC
 
               
Section VIII, Item A.4.a.
  Update cultural competency plan & prior year evaluation   All   Annually, By
October 1 for January 1 implementation   BMHC
 
               
Section VIII, Item B.1.a.(4)(a)
  Service authorization protocols & any changes   All   Before use   BMHC
 
               
Section VIII, Item B.4.
  Changes to UM component   All   Thirty (30) calendar days before effective
date   BMHC
 
               
Section IX, Item A.8.
  Complaint log   All   Upon request   BMHC
 
               
Section X, Item B.2.
  Changes in staffing   All   Five (5) business days of any change   BMHC & HSD
 
               
Section X,
Item B.2.b.
  Full-Time Administrator   All   Before designating duties of any other
position   BMHC
 
               
Section X,
Item D.3.a.
  Reform and non-Reform historical encounter data for all typical and atypical
services   All   According to Agency-approved schedules and no later than
10/31/09   MEDS team & Fiscal Agent

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section X, Item D.3.b.
  Encounter data for all typical and atypical services   All   Within sixty
(60) calendar days following end of month in which Health Plan paid claims for
services, and as specified in MEDS Companion Guide   MEDS Team & Agency Fiscal
Agent
 
               
Section X,
Item E.4.
  Fraud & abuse compliance plan & policies & procedures   All   Before
implementation   MPI
 
               
Section XI, Item D.4.a.
  Any problem that threatens system performance   All   Within one (1) hour  
Applicable Agency staff
 
               
Section XI, Item D.8.a. & Section XVI, Item BB.
  Business Continuity-Disaster Recovery Plan   All   Before beginning operation
and by May 31 annually thereafter   BMHC
 
               
Section XI, Item E.1.
  System changes   All   Ninety (90) calendar days before change   HSD
 
               
Section XIV, Item A.1.a.
  Corrective action plan   All   Within ten (10) business days of notice of
violation or non-compliance with Contract   BMHC or MPI if related to
fraud/abuse
 
               
Section XIV, Item A.1.(b)
  Performance measure action plan   All   Within thirty (30) calendar days of
notice of failure to meet a performance standard   BMHC
 
               
Section XV, Item C.
  Proof of working capital   All   Before enrollment   BMHC
 
               
Section XV, Item G.2.
  Physician incentive plan   All   Written description before use   BMHC

AHCA Contract No. FA913, Attachment II, Page 160 of 186

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan type  
Frequency   Submit To
Section XV, Item H.
  Third party coverage identified   All   As soon as known   Medicaid Third
Party Liability Vendor
 
               
Section XV,
Item I.
  Proof of fidelity bond coverage   All   Within sixty (60) calendar days of
Contract execution & before delivering health care   HSD Contract manager
 
               
Section XVI, Item C.1.
  Assignment of Contract in approved merger/acquisition   All   Ninety (90) days
before effective date   BMHC & HSD
 
               
Section XVI, Item M.
  Use of “Medicaid” or “AHCA”   All   Before use   BMHC
 
               
Section XVI, Item O.
  All subcontracts for Agency approval   All   Before effective date   BMHC
 
               
Section XVI,
Item O.1.f.
  Subcontract monitoring schedule   All   Annually, by December 1   BMHC
 
               
Section XVI, Item V.1.
  Ownership & management disclosure forms   All   With initial application; and
then annually by September 1   HSD — for initial application; BMHC & HSD for
annual
 
               
Section XVI, Item V.1.
  Changes in ownership & control   All   Within five (5) calendar days of
knowledge & sixty (60) days before effective date   BMHC & HSD
 
               
Section XVI, Item V.4.
  Fingerprints for principals   All   Before Contract execution; Thereafter,
annually by September 1   HSD
 
               
Section XVI,
Item V.4.c.
  Fingerprints of newly hired principals   All   Within thirty (30) days of hire
date   HSD
 
               
Section XVI, Item V. 5.
  Information about offenses listed in 435.03   All   Within five (5) business
days of knowledge   HSD

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Section XVI, Item V.6.
  Corrective action plan related to principals committing offenses under 435.03
  All   As prescribed by the Agency   HSD
 
               
Section XVI, Item Y.
  General insurance policy declaration pages   All   Annually upon renewal  
BMHC
 
               
Section XVI, Item Z.
  Workers’ compensation insurance declaration page   All   Annually upon renewal
  BMHC
 
               
Exhibit 2, Section II, Item D.4.c.
  Policies & procedures for screening for clinical eligibility & any changes to
them   Specialty Plan for Children with Chronic Conditions   Before
implementation   BMHC
 
               
Exhibit 3, Section III, Item C.5.
  Disenrollment notice   Specialty Plan for Children with Chronic Conditions  
Get template approved before use

At least two (2) months before anticipated effective date of involuntary
disenrollment   BMHC

Enrollee
 
               
Exhibit 5, Section V, Item A.6.
  Letters about exhaustion of benefits under customized benefit package   Reform
capitated Health Plans   Before use   BMHC
 
               
Exhibit 5, Section V, Item H.20.g.
  Transportation subcontract   NR HMO offering transportation; Reform Health
Plans   Before execution   BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Exhibit 5, Section V, Item H.20.h.
  Transportation policies & procedures   NR HMO offering transportation; Reform
Health Plans   Before use   BMHC
 
               
Exhibit 5, Section V, Item H.20.I.
  Transportation adverse incidents   NR HMO offering transportation; Reform
Health Plans   Within twenty-four (24) hours of occurrence   BMHC & MPI if
related to fraud/abuse
 
               
Exhibit 5,
Section V, Item H.20.p.
  Performance measures   NR HMO offering transportation; Reform Health Plans  
By end of 1st month of Contract; Thereafter, annually by August 15   BMQM
 
               
Exhibit 5, Section V, Item H.20.q. & r.
  Attestation that Health Plan complies with transportation policies &
procedures & drivers pass background checks & meet
qualifications   NR HMO offering transportation; Reform Health Plans   Annually
by January 1   BMHC
 
               
Exhibit 6,
Item A.3.
  Review & approval of behavioral health services staff & sub-contractors for
licensure compliance   Reform Health Plans
& NR HMOs   Before providing services   BMHC
 
               
Exhibit 6,
Item B.9.
  Model agreement with community mental health centers   Reform Health Plans &
NR HMOs   Before agreement is executed   BMHC
 
               
Exhibit 6,
Item M.
  Optional services   Plans covering behavioral health   Before offering   BMHC
 
               
Exhibit 6,
Item R.3.a.
  Schedule for administrative and program monitoring and clinical record review
  Plans covering behavioral health   Annually by July 1   BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

                  Contract                 Section   Submission   Plan Type  
Frequency   Submit To
Exhibit 6.
Item B.12.
  Behavioral health staffing
information   Health Plans
covering behavioral
health   Annually, by August 151, if Health Plan has been operating twelve
(12) months or more;   BMHC
 
               
 
          Quarterly if Health Plan has been operating less than twelve
(12) months, due forty-five (45) days after end of quarter    
 
               
Exhibit 6,
Item C.3.e.
  Denied appeals from providers for
emergency services claims   Plans covering
behavioral health   Within ten (10) days after Health Plan’s final denial   BMHC
 
               
Exhibit 6,
Item C.5.a.(3)
  Medical necessity criteria
for community mental health services   Plans covering
behavioral health   Before use and before changes implemented   BMHC
 
               
Exhibit 6,
Item L.2.
  MBHO staff psychiatrist and model contracts for each specialty type   Plans
covering
behavioral health   Before execution   BMHC
 
               
Exhibit 6,
Item M.
  Optional services   Plans covering
behavioral health   Before offering   BMHC
 
               
Exhibit 6,
Item R.3.a.
  Schedule for administrative and program monitoring and clinical record review
  Plans covering
behavioral health   Annually by July 1   BMHC

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

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

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XIII
Method of Payment
See Exhibit 13
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XIV
Sanctions
A. General Provisions

  1.   The Health Plan shall comply with all requirements and performance
standards set forth in this Contract.

  (a)   In the event the Agency identifies a violation of or other
non-compliance with this Contract, the Health Plan shall submit a corrective
action plan (CAP) within ten (10) business days of the date of receiving
notification of the violation or non-compliance from the Agency.     (b)   If
the Agency determines that the Health Plan has not met its performance
standards, the Health Plan shall submit a performance measure action plan (PMAP)
within thirty (30) calendar days of receiving notice from the Agency.     (c)  
In addition to a CAP or PMAP, the Agency may impose sanctions for failure to
follow provisions of this Contract.

  2.   As allowed in Attachment II, Section XVI, Terms and Conditions, Item I.,
Disputes, the Health Plan may appeal any notice of sanction to the Deputy
Secretary for Medicaid (Deputy Secretary) but must do so within twenty-one
(21) calendar days from receipt of the notice of sanction.     3.   If monetary
sanctions are imposed, they are due from the Health Plan within twenty-one
(21) calendar days from receipt of the notice of sanction and within thirty
(30) days from the date of a final decision rendered by the Deputy Secretary
upholding the sanction.     4.   If the Health Plan fails to carry out the
substantive terms of the Contract or fails to meet applicable requirements in
ss. 1932 and 1903(m) of the Social Security Act, the Agency has the authority to
terminate the Contract in accordance with 42 CFR 438.708 and may terminate the
Contract for violations of 42 CFR 438.700 in addition to imposing intermediate
sanctions.

B. Corrective Action Plans (CAP)

  1.   The Agency will either approve or disapprove the CAP. If the CAP is
disapproved, the Health Plan shall submit a new CAP within ten (10) business
days that addresses the concerns identified by the Agency.     2.   Upon
receiving approval of the CAP, the Health Plan shall implement the action steps
set forth in the CAP within the time frames specified by the Agency.     3.   If
the Health Plan’s CHCUP screening and participation rates are below the eighty
percent (80%) federal goal, the Health Plan shall implement an Agency- accepted
CAP that meets federal requirements. If the Health Plan does not meet the
standard established in the CAP during the time period indicated in the CAP, the
Agency may impose sanctions in accordance with this section.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  4.   If the Health Plan’s state-mandated CHCUP screening rate is below sixty
percent (60%), it must implement an Agency-accepted CAP. If the Health Plan does
not meet the standard established in the CAP during the time period indicated in
the CAP, the Agency may impose sanctions in accordance with this section.     5.
  The Agency shall impose a monetary sanction of $100 per day on the Health Plan
for each calendar day that the approved CAP is not implemented to the
satisfaction of the Agency.

C. Specific Sanctions

  1.   In accordance with 42 CFR 438.700, the Agency may impose intermediate
sanctions against a Health Plan if it determines that a Health Plan has violated
any provision of this Contract, or any applicable statutes. The Agency may base
its determinations on findings from onsite surveys, enrollee or other
complaints, financial status, or any other source.     2.   The Agency
determines whether the Health Plan acts or fails to act as follows:

  a.   Fails substantially to provide medically necessary services the Health
Plan is required to provide, under law or its Contract with the Agency, to an
enrollee covered under the Contract.     b.   Imposes on enrollees’ premiums or
charges that exceed the premiums or charges permitted under the Medicaid
program.     c.   Acts to discriminate among enrollees on the basis of health
status or need for health care services. This includes termination of enrollment
or refusal to re-enroll a recipient, except as permitted by the Agency, or any
practice that would reasonably be expected to discourage enrollment by a
recipient whose medical condition or history indicates probable need for
substantial future medical services.     d.   Misrepresents or falsifies
information it furnishes to federal or state officials.     e.   Misrepresents
or falsifies information it furnishes to an enrollee, potential enrollee, or
provider.     f.   Fails to comply with the requirements for physician incentive
plans.     g.   Distributes directly or indirectly through any agent or
independent contractor, marketing materials that have not been approved by the
Agency or contain false or materially misleading information.     h.   Violates
any of the other requirements of federal or state law and any implementing
regulations. For a violation under this subparagraph, only the sanctions
specified in Item D., Intermediate Sanctions, sub-items 3., 4., or 5., may be
imposed.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

D. Intermediate Sanctions
The Agency may impose the following types of intermediate sanctions in
accordance with 42 CRF 438.702 for the above violations, including but not
limited to:

  1.   Civil money penalties in the amounts specified below.     2.  
Appointment of temporary management for the Health Plan in accordance with 42
CFR 438.706.     3.   Granting enrollees the right to terminate enrollment
without cause and notifying the affected enrollees of their right to disenroll.
    4.   Suspension or limitation of all new enrollments, including mandatory
enrollments, after the effective date of the sanction.     5.   Suspension of
payment for recipients enrolled after the effective date of the sanction and
until CMS or the Agency is satisfied that the reason for imposing the sanction
no longer exists and is not likely to recur.

E. Civil Monetary Penalties
In accordance with 42 CFR 438.704, the Agency may impose the following civil
monetary penalties:

  1.   For a nonwillful violation, the fine shall not exceed $2,500 per
violation and shall not exceed an aggregate of $10,000 for all nonwillful
violations arising out of the same action.     2.   For a willful violation, the
Agency may impose a fine not to exceed $20,000 for each violation not to exceed
an aggregate of $100,000 for all knowing and willful violations arising out of
the same action.     3.   For purposes of this section, violations involving
individual, unrelated recipients shall not be considered arising out of the same
action.     4.   For failure to timely and accurately submit data to the Agency
as required in this Contract, the penalty shall be $200 a day beginning on the
first day following the due date. (See 59A-12.0073, FAC.)

F. Notice of Sanction

  1.   Except as noted in Item D., Intermediate Sanctions, sub-item 2., above,
before imposing any of the sanctions specified in this section, the Agency shall
give the Health Plan timely written notice that explains the basis and nature of
the sanction and applicable due process provisions.     2.   Before terminating
the Health Plan’s Contract for cause, the Agency shall provide a pre-termination
hearing as follows:

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  a.   Provide written notice of intent to terminate, the reason, and the time
and place of the hearing;     b.   After the hearing, provide written notice of
the decision affirming or reversing the proposed termination of the Contract
and, for an affirming decision, the effective date of termination; and     c.  
For an affirming decision, notify Health Plan enrollees of the termination along
with information on their options for receiving services following Contract
termination.

  3.   Unless the duration of a sanction is specified, a sanction shall remain
in effect until the Agency is satisfied that the basis for imposing the sanction
has been corrected and is not likely to recur.     4.   For FFS PSNs, the Agency
reserves the right to withhold all or a portion of the Health Plan’s monthly
administrative allocation for any amount owed pursuant to this section.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XV
Financial Requirements
A. Insolvency Protection — See Attachment II, Exhibit 15
B. Insolvency Protection Account Waiver — See Attachment II, Exhibit 15
C. Surplus Start Up Account
All new private entity capitated Health Plans, after initial Contract execution
but before initial enrollment, shall submit to BMHC proof of working capital in
the form of cash or liquid assets excluding revenues from Medicaid payments
equal to at least the first three (3) months of operating expenses or $200,000,
whichever is greater. This provision shall not apply to Health Plans that have
been providing services to enrollees for a period exceeding three (3) continuous
months.
D. Surplus Requirement
In accordance with s. 409.912, F.S., a capitated Health Plan shall maintain at
all times a surplus amount equal to the greater of $1.5 million, ten percent
(10%) of total liabilities, or two percent (2%) of the annualized amount of the
Health Plan’s prepaid revenues. In the event that the Health Plan’s surplus (as
defined in Attachment II, Section I, Definitions and Acronyms) falls below the
amount specified in this paragraph, the Agency shall prohibit the Health Plan
from engaging in community outreach activities, shall cease to process new
enrollments until the required balance is achieved, or may terminate the Health
Plan’s Contract.
E. Interest
Interest generated through investments made by the Health Plan under this
Contract shall be the property of the Health Plan and shall be used at the
Health Plan’s discretion.
F. Inspection and Audit of Financial Records
The state, CMS, and DHHS may inspect and audit any financial records of the
Health Plan or its subcontractors. Pursuant to s. 1903(m)(4)(A) of the Social
Security Act and state Medicaid Manual 2087.6(A-B), non-federally qualified
Health Plans shall 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 s. 1318(b) of the Social Security Act.
G. Physician Incentive Plans

  1.   Physician incentive plans shall comply with 42 CFR 417.479, 42 CFR
438.6(h), 42 CFR 422.208 and 42 CFR 422.210 and shall not contain provisions
that provide incentives for withholding medically necessary care.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   The Health Plan shall disclose information on physician 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 shall be submitted to BMHC for
approval, in writing, prior to use. If any other type of withhold arrangement
currently exists, it must be omitted from all provider contracts.

H. Third Party Resources — See Attachment II, Exhibit 15
The Health Plan shall make every reasonable effort to determine the legal
liability of third parties to pay for services rendered to enrollees under this
Contract and notify the Agency’s third party liability vendor of any third party
creditable coverage discovered.
I. Fidelity Bonds — See Attachment II, Exhibit 15
The Health Plan shall secure and maintain during the life of this Contract a
blanket fidelity bond from a company doing business in the State of Florida on
all personnel in its employment. The bond shall be issued in the amount of at
least $250,000 per occurrence. Said bond shall protect the Agency from any
losses sustained through any fraudulent or dishonest act or acts committed by
any employees of the Health Plan and subcontractors, if any. Proof of coverage
shall be submitted to the Agency’s Contract Manager within sixty (60) calendar
days after execution of the Contract and prior to the delivery of health care.
To be acceptable to the Agency for fidelity bonds, a surety company shall comply
with the provisions of Chapter 624, F.S.
J. Financial Reporting — Excludes the Specialty Plan for Children with Chronic
Conditions
The Health Plan shall submit to BMHC an annual financial report and quarterly
unaudited financial statements in accordance with Attachment II, Section XII,
Reporting Requirements, and with any modification specified in Attachment II,
Exhibit 15.

  1.   The Health Plan shall submit to BMHC the audited financial statements no
later than three (3) calendar months after the end of the Health Plan’s fiscal
year, and submit the quarterly statements no later than forty-five (45) calendar
days after each calendar quarter and shall use generally accepted accounting
principles in preparing the statements.     2.   The Health Plan shall submit
annual and quarterly financial statements that are specific to the operations of
the Health Plan rather than to a parent or umbrella organization.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section XVI
Terms and Conditions
A. Agency Contract Management

  1.   The Agency’s Division of Medicaid (Division) shall be responsible for
management of the Contract. The Division shall make all statewide policy
decisions or Contract interpretation. In addition, the Division shall be
responsible for the interpretation of all federal and state laws, rules and
regulations governing, or in any way affecting, this Contract. Contract
management shall be conducted in good faith, with the best interest of the state
and the Medicaid recipients it serves being the prime consideration. The Agency
shall provide final interpretation of general Medicaid policy. When
interpretations are required, the Health Plan shall submit written requests to
the Agency’s Contract Manager.     2.   The terms of this Contract do not limit
or waive the ability, authority or obligation of the Office of Inspector
General, MPI, its contractors, or other duly constituted government units (state
or federal) to audit or investigate matters related to, or arising out of this
Contract.     3.   The Contract shall be amended only as follows:

  a.   The parties cannot amend or alter the terms of this Contract without a
written amendment and/or change order to the Contract.     b.   The Agency and
the Health Plan understand that any such written amendment to amend or alter the
terms of this Contract shall be executed by an officer of each party, who is
duly authorized to bind the Agency and the Health Plan.

B. Applicable Laws and Regulations

  1.   The Health Plan shall comply with all applicable federal and state laws,
rules and regulations including but not limited to: Title 42 CFR Chapter IV,
Subchapter C; Title 45 CFR Part 74, General Grants Administration Requirements;
Chapters 409 and 641, F.S.; all applicable standards, orders, or regulations
issued pursuant to the Clean Air Act of 1970 as amended (42 USC 1857, et seq.);
Title VI of the Civil Rights Act of 1964 (42 USC 2000d) in regard to persons
served; Title IX of the education amendments of 1972 (regarding education
programs and activities); 42 CFR 431, Subpart F; s. 409.907(3)(d), F.S., and
Rule 59G-8.100 (24)(b), F.A.C. in regard to the Contractor safeguarding
information about enrollees; Title VII of the Civil Rights Act of 1964 (42 USC
2000e) in regard to employees or applicants for employment; Rule 59G-8.100,
F.A.C.; Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794
(which prohibits discrimination on the basis of handicap in programs and
activities receiving or benefiting from federal financial assistance); the Age
Discrimination Act of 1975, as amended, 42 USC 6101 et. seq. (which prohibits
discrimination on the basis of age in programs or activities receiving or
benefiting from federal financial assistance); the Omnibus Budget Reconciliation
Act of 1981, P.L. 97-35, which prohibits discrimination on the basis of sex and
religion in programs and activities

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      receiving or benefiting from federal financial assistance; Medicare —
Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget Reconciliation
Acts; Americans with Disabilities Act (42 USC 12101, et seq.); the Newborns’ and
Mothers’ Health Protection Act of 1996, the Balanced Budget Act of 1997, and the
Health Insurance Portability and Accountability Act of 1996.     2.   The Health
Plan is subject to any changes in federal and state law, rules, or regulations.

C. Assignment
Except as provided below, or with the prior written approval of the Agency, this
Contract and the monies which may become due are not to be assigned,
transferred, pledged or hypothecated in any way by the Health Plan, including by
way of an asset or stock purchase of the Health Plan, and shall not be subject
to execution, attachment or similar process by the Health Plan.

  1.   When a merger or acquisition of a Health Plan has been approved, the
Agency shall approve the assignment or transfer of the appropriate Medicaid
Health Plan Contract upon the request of the surviving entity of the merger or
acquisition if the Health Plan and the surviving entity have been in good
standing with the Agency for the most recent twelve month (12-month) period,
unless the Agency determines that the assignment or transfer would be
detrimental to Medicaid recipients or the Medicaid program (see s. 409.912,
F.S.). The entity requesting the assignment or transfer shall notify the Agency
of the request ninety (90) days before the anticipated effective date.     2.  
Entities regulated by the Department of Financial Services, Office of Insurance
Regulation (OIR), must comply with provisions of s. 628.4615, F.S., and receive
OIR approval before a merger or acquisition can occur.     3.   For the purposes
of this section, a merger or acquisition means a change in controlling interest
of a Health Plan, including an asset or stock purchase.     4.   To be in good
standing, a Health Plan shall not have failed accreditation or committed any
material violation of the requirements of s. 641.52, F.S., and shall meet the
Medicaid Contract requirements.

D. Attorney’s Fees
In the event of a dispute, each party to the Contract shall be responsible for
its own attorneys’ fees, except as otherwise provided by law.
E. Conflict of Interest
This Contract is subject to the provisions of Chapter 112, F.S. The Health Plan
shall disclose to HSD within ten (10) business days of discovery the name of any
officer, director, or agent who is an employee of the State of Florida, or any
of its agencies. Further, the Health Plan shall disclose the name of any state
employee who owns, directly or indirectly, an interest of five percent (5%) or
more in the Health Plan or any of its affiliates. The Health Plan covenants that
it presently has no interest and
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AMERIGROUP Community Care
  HMO Contract

shall not acquire any interest, direct or indirect, which would conflict in any
manner or degree with the performance of the services hereunder. The Health Plan
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 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 shall, prior to completion of this
Contract, voluntarily acquire any personal interest, direct or indirect, in this
Contract or proposed Contract.
F. Contract Variation
If any provision of the Contract (including items incorporated by reference) is
declared or found to be illegal, unenforceable, or void, then both the Agency
and the Health Plan shall be relieved of all obligations arising under such
provisions. If the remainder of the Contract is capable of performance, it shall
not be affected by such declaration or finding and shall be fully performed. In
addition, if the laws or regulations governing this Contract should be amended
or judicially interpreted as to render the fulfillment of the Contract
impossible or economically infeasible, both the Agency and the Health Plan shall
be discharged from further obligations created under the terms of the Contract.
However, such declaration or finding shall not affect any rights or obligations
of either party to the extent that such rights or obligations arise from acts
performed or events occurring prior to the effective date of such declaration or
finding.
G. Court of Jurisdiction or Venue
For purposes of any legal action occurring as a result of, or under, this
Contract, between the Health Plan and the Agency, the place of proper venue
shall be Leon County.
H. Damages for Failure to Meet Contract Requirements
In addition to remedies available through this Contract, in law or equity, the
Health Plan shall reimburse the Agency for any federal disallowances or
sanctions imposed on the Agency as a result of the Health Plan’s failure.
I. Disputes

  1.   The Health Plan may request in writing an interpretation of the Contract
from the Contract Manager. In the event the Health Plan disputes the
interpretation or any sanction imposed by the Agency, the Health Plan shall
request that the dispute be decided by the Deputy Secretary for Medicaid (Deputy
Secretary). The Health Plan shall submit, within twenty-one (21) days of said
interpretation or sanction, a written request disputing the interpretation or
sanction directly to the Deputy Secretary. The ability to dispute an
interpretation does not apply to language in the Contract that is based on
federal or state statute, regulation or case law.     2.   The Deputy Secretary
shall reduce the decision to writing and serve a copy to the Health Plan. The
written decision of the Deputy Secretary shall be final. The Deputy Secretary
will render the final decision based upon the written

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AMERIGROUP Community Care
  HMO Contract

      submission of the Health Plan and the Agency, unless, at the sole
discretion of the Deputy Secretary, the Deputy Secretary allows an oral
presentation by the Health Plan and the Agency. If such a presentation is
allowed, the information presented will be considered in rendering the decision.
    3.   In the event the Health Plan challenges the decision of the Deputy
Secretary, the Agency action shall not be stayed except by order of the court.  
  4.   Without limiting the foregoing, the exclusive venue of any legal or
equitable action that arises out of or relates to the Contract, including an
appeal of the final decision of the Deputy Secretary, shall be the appropriate
state court in Leon County, Florida; in any such action, Florida law shall apply
and the parties waive any right to a jury trial.     5.   Pending final
determination of any dispute over an Agency decision, the Health Plan shall
proceed diligently with the performance of the Contract and in accordance with
the direction of the Agency.

J. Force Majeure
The Agency shall not be liable for any excess cost to the Health Plan if the
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 Agency. In all
cases, the failure to perform must be beyond the control without the fault or
negligence of the Agency. The Health Plan shall 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 Health Plan. These include destruction to the facilities
due to hurricanes, fires, war, riots, and other similar acts.
K. Legal Action Notification
The Health Plan shall give HSD, by certified mail, immediate written
notification (no later than thirty (30) calendar days after service of process)
of any action or suit filed or of any claim made against the Health Plan by any
subcontractor, vendor, or other party that results in litigation related to this
Contract for disputes or damages exceeding the amount of $50,000. In addition,
the Health Plan shall immediately advise HSD of the insolvency of a
subcontractor or of the filing of a petition in bankruptcy by or against a
principal subcontractor.
L. Licensing (See Attachment II, Exhibit 16)
M. Misuse of Symbols, Emblems, or Names in Reference to Medicaid
No person or Health Plan 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 “Agency for Health Care
Administration,” except as required in the Agency’s Standard Contract,
Section I., Item N., Sponsorship, unless prior written approval is obtained from
the Agency. Specific written authorization from the Agency is required to
reproduce, reprint, or distribute
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AMERIGROUP Community Care
  HMO Contract

any 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 program or Agency terms does not provide a defense. Each
piece of mail or information constitutes a violation.
N. Offer of Gratuities
By signing this agreement, the Health Plan signifies that no member of, or a
delegate of, Congress, nor any elected or appointed official or employee of the
State of Florida, the Government Accountability Office, DHHS, CMS, or any other
federal agency has or shall benefit financially or materially from this
procurement. This Contract may be terminated by the Agency if it is determined
that gratuities of any kind were offered to, or received by, any officials or
employees from the state, its agents, or employees.
O. Subcontracts (See Attachment II, Exhibit 16)
The Health Plan shall be responsible for all work performed under this Contract,
but may, with the prior written approval of the Agency, enter into subcontracts
for the performance of work required under this Contract.

  1.   All subcontracts must comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR
455.105 and 42 CFR 455.106. All subcontracts and amendments executed by the
Health Plan shall meet the following requirements.

  a.   If the Health Plan is capitated, 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.     b.   If a
subcontractor was involuntarily terminated from the Medicaid program other than
for purposes of inactivity, that entity is not considered an eligible
subcontractor.     c.   The Agency encourages use of minority business
enterprise subcontractors. See Attachment II, Section VII, Provider Network,
Item D., Provider Contract Requirements, for provisions and requirements
specific to provider contracts. See Attachment II, Section XVI, Terms and
Conditions, Item W., Minority Recruitment and Retention Plan, for other minority
recruitment and retention plan requirements. The Health Plan shall provide a
monthly Minority Participation Report (See Attachment II, Section XII, Reporting
Requirements, Table 1), to BMHC summarizing the business it does with minority
subcontractors or vendors.

  (1)   The Agency will use this information for assessment and evaluation of
the Agency’s Minority Business Utilization Plan. During the term of the
Contract, the Health Plan shall provide this information monthly by the
fifteenth (15th) day after the reporting month.     (2)   The Agency may waive
this requirement, in writing, if at least one of the following is true:

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AMERIGROUP Community Care
  HMO Contract

  (a)   The Health Plan demonstrates that it is at least fifty-one percent (51%)
minority-owned;     (b)   At least fifty-one percent (51 %) of its board of
directors belong to a minority;     (c)   At least fifty-one percent (51%) of
its officers belong to a minority; or     (d)   The Health Plan is a
not-for-profit corporation and at least fifty-one percent (51 %) of the
population it serves belong to a minority.

  (3)   If the Health Plan has been approved by the Agency for a waiver of this
report requirement, it must submit a request for waiver renewal annually, in
writing, to HSD by September 1 of each Contract year.     (4)   If this report
requirement has not been waived in writing by the Agency, the Health Plan shall
submit a monthly Minority Participation Report to the BMHC and to the designated
HSD Minority Participation Report contact person by the fifteenth (15th) day of
the month following the month being reported.

  d.   Subcontractors are subject to background checks. The Health Plan shall
consider the nature of the work a subcontractor or agent will perform in
determining the level and scope of the background checks.     e.   The Health
Plan shall document compliance certification (business-to-business) testing of
transaction compliance with HIPAA for any subcontractor receiving enrollee data.
    f.   No subcontract that the Health Plan enters into with respect to
performance under the Contract shall, in any way, relieve the Health Plan of any
responsibility for the performance of duties under this Contract. The Health
Plan shall assure that all tasks related to the subcontract are performed in
accordance with the terms of this Contract and shall provide BMHC with its
monitoring schedule annually by December 1 of each Contract year. The Health
Plan shall identify in its subcontracts any aspect of service that may be
further subcontracted by the subcontractor.

  2.   All model and executed subcontracts and amendments used by the Health
Plan under this Contract shall be in writing, signed, and dated by the Health
Plan and the subcontractor and meet the following requirements:

a. Identification of conditions and method of payment:

  (1)   The Health Plan agrees to make payment to all subcontractors pursuant to
all state and federal laws, rules and regulations, specifically, s. 641.3155,
F.S., 42 CFR 447.46, and 42 CFR 447.45(d)(2), (3), (d)(5) and (d)(6);     (2)  
Provide for prompt submission of information needed to make payment;

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AMERIGROUP Community Care
  HMO Contract

  (3)   Provide for full disclosure of the method and amount of compensation or
other consideration to be received from the Health Plan;     (4)   Require an
adequate record system be maintained for recording services, charges, dates and
all other commonly accepted information elements for services rendered to the
Health Plan; and     (5)   Specify that the Health Plan shall assume
responsibility for cost avoidance measures for third party collections in
accordance with Attachment II, Section XV, Financial Requirements.

b. Provisions for monitoring and inspections:

  (1)   Provide that the Agency and 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
Agency and DHHS;     (3)   Require that records be maintained for a period not
less than five 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
Health Plan if the subcontract is continuous.);     (4)   Provide for monitoring
and oversight by the Health Plan and the subcontractor to provide assurance that
all licensed medical professionals are credentialed in accordance with the
Health Plan’s and the Agency’s credentialing requirements as found in Attachment
II, Section VII, Provider Network, Item H., Credentialing and Recredentialing,
if the Health Plan has delegated the credentialing to a subcontractor; and    
(5)   Provide for monitoring of services rendered to Health Plan enrollees
through the subcontractor.

c. Specification of functions of the subcontractor:

  (1)   Identify the population covered by the subcontract;     (2)   Provide
for submission of all reports and clinical information required by the Health
Plan, including CHCUP reporting (if applicable); and     (3)   Provide for the
participation in any internal and external quality improvement, utilization
review, peer review, and grievance procedures established by the Health Plan.

d. Protective clauses:

  (1)   Require safeguarding of information about enrollees according to 42 CFR,
Part 438.224.

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  HMO Contract

  (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, which assures that Medicaid recipients
or the Agency will not be held liable for any debts of the subcontractor.    
(4)   If there is a Health Plan physician incentive plan, include a statement
that the Health Plan shall make no specific payment directly or indirectly under
a physician incentive plan to a subcontractor as an inducement to reduce or
limit medically necessary services to an enrollee, and affirmatively state that
all incentive plans do not provide incentives, monetary or otherwise, for the
withholding of medically necessary care;     (5)   Require full cooperation in
any investigation by the Agency, MPI, MFCU or other state or federal entity or
any subsequent legal action that may result from such an investigation;     (6)
  Contain a clause indemnifying, defending and holding the Agency and the Health
Plan’s enrollees harmless from and against all claims, damages, causes of
action, costs or expenses, including court costs and reasonable attorney fees,
to the extent proximately caused by any negligent act or other wrongful conduct
arising from the subcontract agreement. This clause must survive the termination
of the subcontract, including breach due to insolvency. The Agency may waive
this requirement for itself, but not Health Plan enrollees, for damages in
excess of the statutory cap on damages for public entities, if the subcontractor
is a state agency or subdivision as defined by s. 768.28, F.S., or a public
health entity with statutory immunity. All such waivers must be approved in
writing by the Agency;     (7)   Require that the subcontractor secure and
maintain, during the life of the subcontract, workers’ 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 Health Plan. Such
insurance shall comply with Florida’s Workers’ Compensation Law;     (8)  
Specify that if the subcontractor delegates or subcontracts any functions of the
Health Plan, that the subcontract or delegation includes all the requirements of
this Contract;     (9)   Make provisions for a waiver of those terms of the
subcontract, which, as they pertain to Medicaid recipients, are in conflict with
the specifications of this Contract;     (10)   Provide for revoking delegation,
or imposing other sanctions, if the subcontractor’s performance is inadequate;  
  (11)   Provide that compensation to individuals or entities that conduct
utilization management activities is not structured so as to provide incentives
for the

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AMERIGROUP Community Care
  HMO Contract

      individual or entity to deny, limit, or discontinue medically necessary
services to any enrollee; and     (12)   Provide details about the following as
required by Section 6032 of the federal Deficit Reduction Act of 2005:

  (a)   The False Claim Act;     (b)   The penalties for submitted false claims
and statements;     (c)   Whistleblower protections; and     (d)   The law’s
role in preventing and detecting fraud, waste and abuse, and each person’s
responsibility relating to detection and prevention.

P. Hospital Provider Contracts
All hospital provider contracts must meet the requirements outlined in
Attachment II, Section VII, Provider Network D., Provider Contract Requirements.
In addition, hospital provider contracts shall require that the hospitals notify
the Health Plan of enrollee pregnancies and births where the mother is a Health
Plan enrollee. The hospital provider contract must also specify which entity
(Health Plan or hospital) is responsible for completing the DCF Excel
spreadsheet and submitting it to the appropriate DCF Customer Call Center. The
hospital provider contract must also indicate that the Health Plan’s name shall
be indicated as the referring agency when the DCF Excel spreadsheet is
completed. (See Attachment II, Section III, Eligibility and Enrollment)
Q. Termination Procedures

  1.   In conjunction with the Standard Contract, Section III., Item B.,
Termination, all provider contracts and subcontracts shall contain termination
procedures. The Health Plan agrees to extend the thirty (30) calendar-day notice
found in the Standard Contract, Section III., Item B.1., Termination at Will, to
one-hundred and twenty (120) calendar days’ notice. The Health Plan will work
with the Agency to create a transition plan, including the orderly and
reasonable transfer of enrollee care and progress whether or not they are
hospitalized. Depending on the volume of Health Plan enrollees affected, the
Agency may require an extension of the termination date. The party initiating
the termination shall render written notice of termination to the other party by
certified mail, return receipt requested, or in person with proof of delivery,
or by facsimile letter followed by certified mail, return receipt requested. The
notice of termination shall specify the nature of termination, the extent to
which performance of work under the Contract is terminated, and the date on
which such termination shall become effective. In accordance with s. 1932(e)(4),
Social Security Act, the Agency shall provide the Health Plan with an
opportunity for a hearing prior to termination for cause. This does not preclude
the Agency from terminating without cause.     2.   Upon receipt of final notice
of termination, on the date and to the extent specified in the notice of
termination, the Health Plan shall:

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  a.   Continue work under the Contract until the termination date unless
otherwise required by the Agency;     b.   Cease enrollment of new enrollees
under the Contract;     c.   Terminate all community outreach activities and
subcontracts relating to community outreach;     d.   Assign to the state those
subcontracts as directed by the Agency’s contracting officer including all the
rights, title and interest of the Health Plan for performance of those
subcontracts;     e.   In the event the Agency has terminated this Contract in
one or more Agency areas of the state, complete the performance of this Contract
in all other areas in which the Health Plan’s Contract was not terminated;    
f.   Take such action as may be necessary, or as the Agency’s contracting
officer may direct, for the protection of property related to the Contract that
is in the possession of the Health Plan and in which the Agency has been granted
or may acquire an interest;     g.   Not accept any payment after the Contract
ends, unless the payment is for the time period covered under the Contract. Any
payments due under the terms of this Contract may be withheld until the Agency
receives from the Health Plan all written and properly executed documents as
required by the written instructions of the Agency;     h.   At least sixty
(60) calendar days before the termination effective date, provide written
notification to all enrollees of the following information: the date on which
the Health Plan will no longer participate in the state’s Medicaid program and
instructions on contacting the Agency’s choice counselor/enrollment broker help
line to obtain information on enrollment options and to request a change in
health plans.

R. Waiver
No covenant, condition, duty, obligation, or undertaking contained in or made a
part of the Contract shall be waived except by written agreement of the parties,
and forbearance or indulgence in any other form or manner by either party in any
regard whatsoever shall not constitute a waiver of the covenant, condition,
duty, obligation, or undertaking to be kept, performed, or discharged by the
party to which the same may apply. Until complete performance or satisfaction of
all such covenants, conditions, duties, obligations, or undertakings, the other
party shall have the right to invoke any remedy available under law or equity
notwithstanding any such forbearance or indulgence.
S. Withdrawing Services from a County
If the Health Plan intends to withdraw services from a county, the Health Plan
shall provide the Agency with one-hundred and twenty (120) calendar days’ notice
and work with the Agency to develop a transition plan. The Health Plan shall
provide
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AMERIGROUP Community Care
  HMO Contract

written notice to all enrollees in that county at least sixty (60) calendar days
before the last day of service. The notice shall contain the same information as
required for a notice of termination according to Attachment II, Section XVI,
Terms and Conditions, Item Q., Termination Procedures. The Health Plan shall
also provide written notice of the withdrawal to all providers and
subcontractors in the county.
T. MyFloridaMarketPlace Vendor Registration
The Health Plan is exempt under Rule 60A-1.030(3)d(ii), FAC, from being required
to register in MyFloridaMarketPlace for this Contract.
U. MyFloridaMarketPlace Vendor Registration and Transaction Fee Exemption
The Health Plan is exempt from paying the one percent (1%) transaction fee per
60A-1.032(1)(g), FAC, for this Contract.
V. Ownership and Management Disclosure
The Health Plan shall fully disclose ownership, management and control of
disclosing entities in accordance with state and federal law.

  1.   Disclosure shall be made on forms prescribed by the Agency for the areas
of ownership and control interest (42 CFR 455.104, Form CMS 1513); business
transactions (42 CFR 455.105); conviction of crimes (42 CFR 455.106); public
entity crimes (s. 287.133(3)(a), F.S.); and disbarment and suspension (52 Fed.
Reg., pages 20360-20369, and Section 4707 of the Balanced Budget Act of 1997).
The forms are available through the Agency and are to be submitted to HSD with
the initial application for a Medicaid Health Plan and annually to HSD and BMHC
by September 1 of each Contract year thereafter. In addition, the Health Plan
shall submit to the BMHC and HSD full disclosure of ownership and control of the
Health Plan and any changes in management within five calendar days of knowing
the change will occur and at least sixty (60) calendar days before any change in
the Health Plan’s ownership or control takes effect.     2.   The following
definitions apply to ownership disclosure:

  a.   A person with an ownership interest or control interest means a person or
corporation that:

  (1)   Owns, indirectly or directly, five percent (5%) or more of the Health
Plan’s capital or stock, or receives five percent (5%) or more of its profits;  
  (2)   Has an interest in any mortgage, deed of trust, note, or other
obligation secured in whole or in part by the Health Plan or by its property or
assets and that interest is equal to or exceeds five percent of the total
property or assets; or     (3)   Is an officer or director of the Health Plan,
if organized as a corporation, or is a partner in the Health Plan, if organized
as a partnership.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  b.   The percentage of direct ownership or control is calculated by
multiplying the percent of interest that a person owns by the percent of the
Health Plan’s assets used to secure the obligation. Thus, if a person owns ten
percent (10%) of a note secured by sixty percent (60%) of the Health Plan’s
assets, the person owns six percent (6%) of the Health Plan.     c.   The
percent of indirect ownership or control is calculated by multiplying the
percentage of ownership in each organization. Thus, if a person owns ten percent
(10%) of the stock in a corporation, which owns eighty percent (80%) of the
Health Plan’s stock, the person owns eight percent (8%) of the Health Plan.

  3.   The following definitions apply to management disclosure:

  a.   Changes in management are defined as any change in the management control
of the Health Plan. Examples of such changes are those listed below and in
Section X, Attachment II, or equivalent positions by another title.     b.  
Changes in the board of directors or officers of the Health Plan, medical
director, chief executive officer, administrator, and chief financial officer.  
  c.   Changes in the management of the Health Plan where the Health Plan has
decided to contract out the operation of the Health Plan to a management
corporation. The Health Plan shall disclose such changes in management control
and provide a copy of the contract to the Agency for approval at least sixty
(60) calendar days prior to the management contract start date.

  4.   By September 1 of each Contract Year, the Health Plan shall conduct an
annual background check with the Florida Department of Law Enforcement on all
persons with five percent (5%) or more ownership interest in the Health Plan, or
who have executive management responsibility for the Health Plan, or have the
ability to exercise effective control of the Health Plan (see ss. 409.912 and
435.03, F.S.).

  a.   The Health Plan shall submit, prior to execution of this Contract,
complete sets of fingerprints of principals of the Health Plan to HSD for the
purpose of conducting a criminal history record check (see s. 409.907, F.S.).  
  b.   Principals of the Health Plan shall be as defined in s. 409.907, F.S.    
c.   The Health Plan shall submit to the Agency Contract Manager complete sets
of fingerprints of newly hired principals (officers, directors, agents, and
managing employees) within thirty (30) days of the hire date.

  5.   The Health Plan shall submit to the Agency, within five (5) business
days, any information on any officer, director, agent, managing employee, or
owner of stock or beneficial interest in excess of five percent of the Health
Plan who has been found guilty of, regardless of adjudication, or who entered a
plea of nolo contendere or guilty to, any of the offenses listed in s. 435.03,
F.S. The Health Plan shall submit information to HSD for such persons who have a
record of

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      illegal conduct according to the background check. The Health Plan shall
keep a record of all background checks to be available for Agency review upon
request.     6.   The Agency shall not contract with a Health Plan that has an
officer, director, agent, managing employee, or owner of stock or beneficial
interest in excess of five percent (5%) of the Health Plan, who has committed
any of the above listed offenses (see ss. 409.912 and 435.03, F.S.). In order to
avoid termination, the Health Plan shall submit a corrective action plan,
acceptable to the Agency, which ensures that such person is divested of all
interest and/or control and has no role in the operation and/or management of
the Health Plan.

W.   Minority Recruitment and Retention Plan (See Item 0. Subcontracts, sub-item
1.c., above, for other requirements)       The Health Plan shall implement and
maintain a minority recruitment and retention plan in accordance with s.
641.217, F.S. The Health Plan shall have policies and procedures for the
implementation and maintenance of such a plan. The minority recruitment and
retention plan may be company-wide for all product lines.   X.   Independent
Provider       It is expressly agreed that the Health Plan and any agents,
officers, and/or employees of the Health Plan or any subcontractors, in the
performance of this Contract shall act in an independent capacity and not as
officers and employees of the 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 Health Plan or any subcontractor and the Agency and
the State of Florida.   Y.   General Insurance Requirements       The Health
Plan shall obtain and maintain the same adequate insurance coverage including
general liability insurance, professional liability and malpractice insurance,
fire and property insurance, and directors’ omission and error insurance. All
insurance coverage for the Health Plan must comply with the provisions set forth
for HMOs in Rule 690-191.069, F.A.C.; excepting that the reporting,
administrative, and approval requirements shall be to the Agency rather than to
the Department of Financial Services, Office of Insurance Regulation (OIR). All
insurance policies must be written by insurers licensed to do business in the
State of Florida and in good standing with OIR. All policy declaration pages
must be submitted to BMHC annually upon renewal. Each certificate of insurance
shall provide for notification to the Agency in the event of termination of the
policy.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Z.   Workers’ Compensation Insurance       The Health Plan shall secure and
maintain during the life of the Contract, workers’ compensation insurance for
all of its employees connected with the work under this Contract. Such insurance
shall comply with the Florida Workers’ Compensation Law (see Chapter 440, F.S.).
Policy declaration pages shall be submitted to BMHC annually upon renewal.   AA.
  State Ownership       The Agency shall have the right to use, disclose, or
duplicate all information and data developed, derived, documented, or furnished
by the Health Plan resulting from this Contract. Nothing herein shall entitle
the Agency to disclose to third parties data or information that would otherwise
be protected from disclosure by state or federal law.   BB.   Emergency
Management Plan       Annually by May 31 of each Contract year, the Health Plan
shall submit to BMHC for approval an emergency management plan specifying what
actions the Health Plan shall conduct to ensure the ongoing provision of health
services in a disaster or manmade emergency including, but not limited to,
localized acts of nature, accidents, and technological and/or attack-related
emergencies. If the emergency management plan is unchanged from the previous
year, the Health Plan shall submit a certification to BMHC that the prior year’s
plan is still in place.   CC.   Indemnification (See Attachment H, Exhibit 16;
Standard Contract applies unless indicated otherwise in Exhibit 16)

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 1
Definitions and Acronyms
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
II of this Contract, unless otherwise specified.
N/A
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 2
General Overview
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
II of this Contract, unless otherwise specified.

  1.   All Health Plans Except Reform HMOs

Section II, General Overview, Item D., General Responsibilities of the Health
Plan
A Health Plan shall furnish services in an amount, duration and scope that are
no more restrictive than the services provided in the Medicaid fee-for-service
program and may reasonably be expected to achieve the purpose for which the
services are furnished.

  2.   All Capitated Reform Health Plans

Section II, General Overview, Item D., General Responsibilities of the Health
Plan
The Health Plan shall comply with all current Florida Medicaid Handbooks
(Handbooks) pursuant to Attachment II, Section II, General Overview, unless a
customized benefit package has been certified by the Agency. In no instance may
the limitations or exclusions imposed by the Health Plan be more stringent than
those specified in the Handbooks, unless authorized in the customized benefit
package by the Agency. The Health Plan may exceed limits in the Handbooks by
offering expanded services, as described elsewhere in this Contract or through
its approved customized benefit package.

  3.   Capitated Reform Health Plans and FFS PSNs where there is no HMO

Section II, General Overview, Item D., General Responsibilities of the Health
Plan
A Health Plan that accepts only the comprehensive component of the capitation
rate shall continue to provide all covered services to each enrollee who reaches
the catastrophic component threshold. The Health Plan shall continue to apply
its QM and UM program components, as well as other administrative policies and
protocols to the delivery of care and services to the enrollees who meet the
threshold. The Health Plan shall submit documentation for reimbursement for
covered services costs as outlined in Attachment II, Exhibit 13.

  4.   Reform Plans

Section II, General Overview, Item D., General Responsibilities of the Health
Plan

  1.   When the cost of an enrollee’s covered services reaches the benefit
maximum of $550,000 in a fiscal year, the Health Plan shall assist the enrollee
in obtaining necessary health care services in the community. The Health Plan
shall continue to coordinate the care received by the enrollee in the community,
and the Health Plan shall continue to be responsible for emergency services and
care. In addition, the Health Plan shall provide benefit reporting to BMHC,
monthly, and HSD in accordance with Attachment II, Section XII, Reporting
Requirements, once the cost of covered services reaches $450,000.

AHCA Contract No. FA913, Attachment II, Exhibit 2, Page 2 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   The Health Plan may choose to offer a specialty plan only for Medicaid
Recipients who are:

  a.   Children with chronic conditions;     b.   Persons diagnosed with
HIV/AIDS (HMOs only); or     c.   Individuals diagnoses with developmental
disabilities or foster care children, if approved by the Agency.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 3
Eligibility and Enrollment
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1.   All Reform Health Plans

Section III, Eligibility and Enrollment, Item C.4., Disenrollment

  4.   Involuntary Disenrollment Requests

      The Reform Health Plan shall submit involuntary disenrollment requests for
the following reasons to the Agency’s choice counselor/enrollment broker as
specified in the Health Plan Report Guide. In no event shall the Health Plan
submit a disenrollment request at such a date as would cause the disenrollment
to be effective later than forty-five (45) calendar days after the Health Plan’s
receipt of the reason for involuntary disenrollment. The Health Plan shall
ensure that involuntary disenrollment documents are maintained in an
identifiable enrollee record.

  a.   Moved out of Reform Health Plan service area;     b.   Enrollee death;
and     c.   Enrollee ineligible for Health Plan enrollment.

  5.   Disenrollment Notice         The Health Plan shall notify enrollees who
will be involuntarily disenrolled due to the reasons above of the following at
least two (2) months before the anticipated effective date of the involuntary
disenrollment. The template for such notice must be submitted to and approved by
BMHC before use.

  a.   The reason for involuntary disenrollment;     b.   The telephone number
of the choice counselor/enrollment broker; and     c.   Transition information.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   Voluntary Populations         In order to be eligible for the
frail/elderly program, enrollees must be:

  a.   Assessed by CARES as having met a nursing home level of care and in need
of services to live in their homes or in the homes of relatives or caregivers,
as an alternative to being placed in a nursing home facility;     b.  
Twenty-one (21) years of age or older;     c.   An SSI beneficiary including
dually-eligible Individuals with Medicare coverage (dual eligible with either
Medicare Part B coverage or Medicare Parts A and B coverage) who are not
enrolled in a Medicare Advantage Plan or a Medicare Advantage Special Needs Plan
and not otherwise ineligible under the terms of this Contract; and     d.   Not
ineligible as listed in Section III, Eligibility and Enrollment, Item A.3.
below.

  3.   Excluded Populations         A TANF beneficiary or Medicaid recipient in
the following programs may not enroll in a frail/elderly component of a Medicaid
HMO:

  a.   An Aged and Adult disabled Waiver;     b.   The Channeling Waiver;     c.
  Developmental Disabilities Waiver; or     d.   The Assisted Living for the
Elderly Waiver Section

Section III, Eligibility and Enrollment, Item B., Enrollment
Enrollment in the Frail/Elderly Program. This provision replaces Attachment II,
Section III, Eligibility and Enrollment, Item B.3.b. as follows:
In order for enrollment to occur, the Health Plan must maintain and document the
following information on file and provide it at the Agency’s request:

  (1)   A current CARES assessment completed within the past twelve (12) months.
    (2)   An agreement in writing from the recipient’s Medicare or Medicaid PCP,
whichever is applicable, that the provider would participate as part of the
multidisciplinary treatment team and would provide input, review, data etc.
related to the care of the recipient.     (3)   A voluntary consent form signed
by the recipient documenting the recipients request to enroll in the
frail/elderly program. This form must be approved by BMHC prior to use

AHCA Contract No. FA913, Attachment II, Exhibit 3, Page 5 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Section III, Eligibility and Enrollment, Item C., Disenrollment
The disenrollment requirements listed below must be met in addition to those
specified in Attachment II, Section III, Eligibility and Enrollment, unless
otherwise noted below.

  a.   The Health Plan may request the Agency to disenroll an enrollee if the
enrollee is institutionalized in a long term nursing facility at the conclusion
of the state fiscal year and the Health Plan furnishes written documentation
based upon a CARES assessment or written assurance from the enrollee’s PCP or
the administrator of the nursing facility where the enrollee is placed that the
nursing home placement is permanent and not temporary.     b.   All
disenrollments for institutionalized enrollees must have prior written approval
by the Agency and be submitted as involuntary disenrollments on the first
available transmission to the fiscal agent after receiving Agency approval of
the request.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 4
Enrollee Services, Community Outreach and Marketing
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1.   All Reform Health Plans

Section IV, Enrollee Services, Community Outreach and Marketing, Item A.,
Enrollee Services

15.   Enhanced Benefit Program

  a.   The Agency has identified a combination of covered and non-covered
services as healthy behaviors that will earn credits for an enrollee. The Agency
shall assign a specific credit to an enrollee’s account for each healthy
behavior service received and notify each enrollee of the availability of the
credits in the account. The credits in the enrollee’s account shall be available
if the enrollee enrolls in a different health plan and for a period of up to
three (3) years after loss of Medicaid eligibility.     b.   The Agency shall
administer the program with assistance from the Health Plan.

  (1)   For covered services identified as healthy behaviors, the Health Plan
shall submit a monthly report to the Medicaid Bureau of Contract Management
(MCM) by the tenth calendar day of the month for the previous month’s paid
claims. See Attachment II, Section XII, Reporting Requirements. A list of
procedure codes and healthy behaviors will be provided in the Agency Report
Guide posted on the Agency’s website at
http://ahca.mvflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml.     (2)   For
non-Medicaid services, the Health Plan shall assist the enrollee in obtaining
and submitting documentation to MCM to verify participation in a healthy
behavior without a procedure code. A universal form shall be available with the
Agency’s website at
http://ahca.mvflorida.com/MCHQ/ManaqedHealthCare/MHMO/index.shtml and must be
submitted to the Health Plan to document participation in healthy behaviors
without a procedure code.

  c.   The Agency may add or delete healthy behaviors with thirty (30) calendar
days’ written notice.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 5
Covered Services
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Reform Capitated Health Plans
Section V, Covered Services, Item A., Covered Services
Customized Benefit Packages (See Attachment I)

  1.   The capitated Health Plan shall submit a customized benefit package
(CBP), which may vary the co-pays or the amount, duration and scope of the
following services for non-pregnant adults: hospital outpatient not otherwise
specified (NOS) and hospital outpatient physical, occupational, respiratory, and
speech therapy services; and home health, dental, pharmacy, chiropractic,
podiatry, vision, hearing and durable medical equipment as specified below.

  a.   Amount, duration and scope may vary for durable medical supplies
(DME) with the exception of any prosthetic/orthotic supply priced over $3,000 on
the Medicaid fee schedule and except for motorized wheelchairs, which must be
covered up to the Medicaid State Plan (State Plan) limit.     b.   Dialysis
services, contraceptives, and chemotherapy-related medical and pharmaceutical
services must be covered up to the State Plan limit.     c.   Hearing services
for non-pregnant adults may vary in amount, duration and scope except for
hearing aid services, which must be covered up to the State Plan limit.     d.  
The Health Plan shall provide all medically necessary services up to the State
Plan limit in accordance with the Medicaid Handbook requirements for pregnant
women, children/adolescents, and enrollees with a HIV/AIDS diagnoses as
identified by the Agency.

  2.   Approved CBPs must comply with the benefit grid plan evaluation tool and
instructions available from HSD. The Agency shall test the Health Plan’s CBP for
actuarial equivalency and sufficiency of benefits, before approving the CBP.
Actuarial equivalency is tested by using a benefit plan evaluation tool that:

  a.   Compares the value of the level of benefits in the proposed package to
the value of the current Medicaid State Plan package for the average member of
the covered population; and     b.   Ensures that the overall level of benefits
is appropriate.

  3.   Sufficiency is tested by comparing the proposed CBP to state-established
standards. The standards are based on the covered population’s historical use of
Medicaid State Plan services. These standards are used to ensure that the
proposed CBP is adequate to cover the needs of the vast majority of the
enrollees.     4.   If, in its CBP, the Health Plan limits a service to a
maximum annual dollar value, the Health Plan must calculate the dollar value of
the service using the Medicaid fee schedule.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 8 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  5.   The CBPs may change on a Contract year basis and only if approved by the
Agency in writing. The Health Plan shall submit to HSD its CBP for
recertification of actuarial equivalency and sufficiency standards no later than
June 15"' of each year. See Attachment I of this Contract.     6.   The Health
Plan shall incorporate a requirement into its policies and procedures stating
that it will send letters of notification to enrollees regarding exhaustion of
benefits for services restricted by unit amount if the amount is more
restrictive than Medicaid for the following services: pharmacy; DME; hospital
outpatient services not otherwise specified (NOS) and hospital outpatient
physical, occupational, respiratory, and speech therapy services; hearing
services; vision services; chiropractic; podiatry; and home health services. The
Health Plan shall send an exhaustion of benefits letter for any service
restricted by a dollar amount. The Health Plan shall implement said letters upon
the written approval of the Agency. The letters of notification include the
following:

  a.   A letter notifying an enrollee when he/she has reached fifty percent
(50%) of any maximum annual dollar limit established by the Health Plan for a
benefit;     b.   A follow-up letter notifying the enrollee when he/she has
reached seventy-five (75%) of any maximum annual dollar limit established by the
Health Plan for a benefit; and     c.   A final letter notifying the enrollee
that he/she has reached the maximum dollar limit established by the Health Plan
for a benefit.

2. Non-Reform Capitated Health Plans
Section V, Covered Services, Item G., Copayments

  1.   The Health Plan shall not require a copayment or cost sharing for
services listed in Attachment I or Attachment II, Section V, Covered Services,
Item A., Covered Services, including optional services, and Attachment II,
Section V, Covered Services, Item B., Optional Services, and Attachment II,
Section V, Covered Services, Item C., Expanded Services, nor may the Health Plan
charge enrollees for missed appointments. The Health Plan agrees that the cost
of the services and deliverables specified in Section V, Covered Services,
represent the total cost to the state and the Agency for the contracted services
and deliverables and that no additional charges, fees, or costs may be added to
this amount or sought from the state, the Agency or the enrollees.     2.   For
non-Reform HMOs, paragraph 1. above also applies to covered services listed in
Attachment II, Section VI, Behavioral Health Care.

3. Fee-for-Service PSN and Reform Capitated Health Plans
Section V, Covered Services, Item G., Copayments
The Health Plan may offer to waive copayments or cost sharing for services
listed in Attachment II, Section V, Covered Services, Item A., Covered Services,
including optional services, and Section V, Covered Services, Item B., Optional
Services, as an expanded benefit. See Attachment I of this Contract also.
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

4. Non-Reform Health Plans covering dental as an optional service and Reform
Health Plans
Section V, Covered Services, Item H., Coverage Provisions, sub-item 3., Dental
Services
Dental services are defined in the Medicaid Dental Services Coverage and
Limitations Handbook. For enrollees under age 21, the Health Plan shall cover
diagnostic services, preventive treatment, CHCUP dental screening (including a
direct referral to a dentist for enrollees beginning at three years of age or
earlier as indicated); restorative treatment, endodontic treatment, periodontal
treatment, surgical procedures and/or extractions, orthodontic treatment,
complete and partial dentures, complete and partial denture relines and repairs,
and adjunctive and emergency services. Adult services include adult full and
partial denture services and medically necessary emergency dental procedures to
alleviate pain or infection. Emergency dental care shall be limited to emergency
oral examinations, necessary x-rays, extractions, and incision and drainage of
abscess.

5. All Capitated Health Plans
Section V, Covered Services, Item H., Coverage Provisions, sub-item 8.,
Out-of-Plan Use of Non-Emergency Services

a.   Unless otherwise specified in this Contract, where an enrollee uses
non-emergency services available under the Health Plan from a non-participating
provider, the Health Plan shall not be liable for the cost of such services
unless the Health Plan referred the enrollee to the nonparticipating provider or
authorized the out-of-network service.   b.   In accordance with s. 409.912,
F.S., the Health Plan shall reimburse any hospital or physician that is outside
the Health Plan’s authorized service area for health-plan-authorized services at
a rate negotiated with the hospital or physician or according to the lesser of
the following:

  (1)   The usual and customary charge made to the general public by the
hospital or provider; or     (2)   The Florida Medicaid reimbursement rate
established for the hospital or provider.

c.   The Health Plan shall reimburse all out-of-network providers as described
in s. 641.3155, F.S.

6. Capitated Health Plans
Section V, Covered Services, Item H., Coverage Provisions, sub-item 10.,
Hospital Services — Inpatient
The Health Plan may provide services in a nursing home as downward substitution
for inpatient services. Such services shall not be counted as inpatient hospital
days.

7. Non-Reform Health Plans not covering transportation as an optional service
Section V, Covered Services, Item H., Coverage Provisions, sub-item 20.,
Transportation Services
The Health Plan shall refer enrollees needing transportation to the Agency’s
contracted CTD provider in order to assist them to keep and travel to medical
appointments.
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8. Non-Reform HMOs covering transportation as an optional service and Reform
Health Plans
Section V, Covered Services, Item H., Coverage Provisions, sub-item 20.,
Transportation Services
The Health Plan shall provide transportation services, including emergency
transportation, for its enrollees who have no other means of transportation
available to any Medicaid-compensable, medically necessary service, including
Medicaid services not covered by this Contract such as prescribed pediatric
extended care (this example does not apply to the specialty plan for children
with chronic conditions).

a.   The Health Plan shall comply with provisions of the Medicaid Transportation
Services Coverage and Limitations Handbooks. In any instance when compliance
conflicts with the terms of this Contract, the Contract prevails. In no instance
may the limitations or exclusions imposed by the Health Plan be more stringent
than those in the Medicaid Transportation Services Coverage and Limitations
Handbooks.   b.   The Health Plan is not obligated to follow the requirements of
the Commission for the Transportation Disadvantaged (CTD) or the Transportation
Coordinating Boards as set forth in Chapter 427, F.S., unless the Health Plan
has chosen to coordinate services with the CTD.   c.   The Health Plan may
provide transportation services directly through its own network of
transportation providers or through a provider contract relationship, which may
include the Commission for the Transportation Disadvantaged. In either case, the
Health Plan is responsible for monitoring provision of services to its
enrollees.   d.   The Health Plan shall:

  (1)   Ensure that all transportation providers comply with standards set forth
in Chapter 427, F.S., and Rules 41-2 and 14-90, FAC. These standards include
drug and alcohol testing, safety standards, driver accountability, and driver
conduct.     (2)   Ensure that all transportation providers maintain vehicles
and equipment in accordance with state and federal safety standards and the
manufacturers’ mechanical operating and maintenance standards for any and all
vehicles used for transportation of Medicaid recipients.     (3)   Ensure that
all transportation providers comply with applicable state and federal laws,
including, but not limited to, the Americans with Disabilities Act (ADA) and the
Federal Transit Administration (FTA) regulations.     (4)   Ensure that
transportation providers immediately remove from service any vehicle that does
not meet the Florida Department of Highway Safety and Motor Vehicles licensing
requirements, safety standards, ADA regulations, or Contract requirements and
re-inspect the vehicle before it is eligible to provide transportation services
for Medicaid recipients under this Contract. Vehicles shall not carry more
passengers than the vehicle was designed to carry. All lift-equipped vehicles
must comply with ADA regulations.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 11 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (5)   Ensure transportation services meet the needs of its enrollees including
use of multiload vehicles, public transportation, wheelchair vehicles, stretcher
vehicles, private volunteer transport, over-the-road bus service, or, where
applicable, commercial air carrier transport.     (6)   Collect and submit
encounter data, as required elsewhere in this Contract;     (7)   Ensure a
transportation network of sufficient size so that failure of any one component
will not impede the ability to provide the services required in this Contract;  
  (8)   Ensure that any subcontracts for transportation services meet the
subcontracting requirements detailed in Attachment II, Section XVI, Terms and
Conditions;     (9)   Maintain policies and procedures, consistent with 42 CFR
438.12 to ensure there is no discrimination in serving high-risk populations or
people with conditions that require costly transportation;     (10)   Ensure all
transportation providers maintain sufficient liability insurance to meet
requirements of Florida law.

  e.   The Health Plan shall be responsible for the cost of transporting an
enrollee from a nonparticipating facility or hospital to a participating
facility or hospital if the reason for transport is solely for the Health Plan’s
convenience.     f.   The Health Plan shall approve and process claims for
transportation services in accordance with the requirements set forth in this
Contract.     g.   If the Health Plan subcontracts for transportation services,
it shall provide a copy of the model subcontract to BMHC for approval before
use.     h.   Before providing transportation services, the Health Plan shall
provide BMHC a copy of its policies and procedures for approval relating to the
following:

  (1)   How the Health Plan will determine eligibility for each enrollee and
what type of transportation to provide that enrollee;     (2)   The Health
Plan’s procedure for providing prior authorization to enrollees requesting
transportation services;     (3)   How the Health Plan will review
transportation providers to prevent and/or identify those who falsify encounter
or service reports, overstate reports or upcode service levels, or commit any
form of fraud or abuse as defined in s. 409.913, F.S.;     (4)   How the Health
Plan will deal with providers who alter, falsify or destroy records before the
end of the retention period; make false statements about credentials;
misrepresent medical information to justify referrals; fail to provide scheduled
transportation; or charge enrollees for covered services;     (5)   How the
Health Plan will provide transportation services outside its service area.

  i.   The Health Plan shall report immediately, in writing to BMHC, any
transportation-related adverse or untoward incident (see s. 641.55, F.S.). The
Health Plan shall also report, immediately upon identification, in writing to
MPI, all instances of suspected enrollee or

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 12 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      transportation services provider fraud or abuse. (As defined in s.
409.913, F.S. See also Attachment II, Section X, Administration and Management,
on fraud and abuse.)     j.   The Health Plan shall ensure compliance with the
minimum liability insurance requirement of $100,000 per person and $200,000 per
incident for all transportation services purchased or provided for the
transportation disadvantaged through the Health Plan. (See s. 768.28(5), ES.)
The Health Plan shall indemnify and hold harmless the local, state, and federal
governments and their entities and the Agency from any liabilities arising out
of or due to an accident or negligence on the part of the Health Plan and/or all
transportation providers under contract to the Health Plan.     k.   The Health
Plan shall ensure adequate seating for paratransit services for each enrollee
and escort, child, or personal care attendant, and shall ensure that the vehicle
meets the following requirements and does not transport more passengers than the
registered passenger seating capacity in a vehicle at any time:

  (1)   Enrollee property that can be carried by the passenger and/or driver,
and can be stowed safely on the vehicle, shall be transported with the passenger
at no additional charge. The driver shall provide transportation of the
following items, as applicable, within the capabilities of the vehicle:

  (a)   Wheelchairs;     (b)   Child seats;     (c)   Stretchers;     (d)  
Secured oxygen;     (e)   Personal assistive devices; and/or     (f)  
Intravenous devices.

  (2)   Each vehicle shall have posted inside the Health Plan’s toll-free
telephone number for enrollee complaints;     (3)   The interior of all vehicles
shall be free from dirt, grime, oil, trash, torn upholstery, damaged or broken
seats, protruding metal or other objects or materials which could soil items
placed in the vehicle or cause discomfort to enrollees;     (4)   The
transportation provider shall provide the enrollee with boarding assistance, if
necessary or requested, to the seating portion of the vehicle. Such assistance
shall include, but not be limited to, opening the vehicle door, fastening the
seat belt or wheelchair securing devices, storage of mobility assistive devices
and closing the vehicle door. In the doorthrough-door paratransit service
category, the driver shall open and close doors to buildings, except in
situations in which assistance in opening and/or closing building doors would
not be safe for passengers remaining in the vehicle. The driver shall provide
assisted access in a dignified manner.     (5)   Smoking, eating and drinking
are prohibited in any vehicle, except in cases in which, as a medical necessity,
the enrollee requires fluids or sustenance during transport;     (6)   All
vehicles must be equipped with two-way communications, in good working order and
audible to the driver at all times, by which to communicate with the
transportation services hub or base of operations;     (7)   All vehicles must
have working air conditioners and heaters.

AHCA Contract No. FA913, Attachment II, Exhibit 5, Page 13 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  I.   Vehicle transfer points shall provide shelter, security, and safety of
enrollees.     m.   The transportation provider shall maintain a passenger/trip
database for each enrollee it transports.     n.   The Health Plan shall
establish a minimum twenty-four (24) hour advance notification policy to obtain
transportation services, and the Health Plan shall communicate that policy to
its enrollees and transportation providers.     o.   The Health Plan shall
establish enrollee pick-up windows and communicate those timeframes to enrollees
and transportation providers.     p.   The Health Plan shall establish
performance measures to evaluate the safety, quality, timeliness, and adequacy
of its transportation services. The transportation performance measures shall be
submitted to the Medicaid Bureau of Quality Management for approval by the end
of the first month of the Contract term and report on those measures to the
Agency as specified in Attachment II, Section VIII, Quality Management, Item A.,
Quality Improvement, sub-item 3.c.     q.   The Health Plan shall provide an
annual attestation to BMHC by January 1 of each Contract year that it is in full
compliance with the policies and procedures relating to transportation services,
and that all vehicles used for transportation services have received annual
safety inspections.     r.   The Health Plan shall provide an annual attestation
to BMHC by January 1 of each Contract Year that all drivers providing
transportation services have passed background checks and meet all
qualifications specified in law and in rule.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 6
HMOs & Reform Health Plans
Behavioral Health Care
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Reform Health Plans and Non-Reform HMOs
A. General Provisions

  1.   The Health Plan shall name a staff member employed by the Health Plan
with a behavioral health-related license or training and experience in
behavioral health to maintain oversight responsibility for behavioral health
services and to act as liaison to the Agency.     2.   The Health Plan’s medical
director shall appoint a board-certified or board-eligible Florida- licensed
psychiatrist (staff psychiatrist) to oversee the provision of behavioral health
services to enrollees. The Health Plan may delegate this duty to a third party
by a written subcontract.     3.   The Agency shall review and approve the
Health Plan’s behavioral health services staff and any subcontracted behavioral
health care providers in order to determine the Health Plan’s compliance with
all licensure requirements.     4.   The Health Plan shall provide a full range
of medically necessary behavioral health services authorized under the State
Plan and specified by this Contract for all enrollees.

  a.   Nothing in this Contract shall be construed as preventing the plan from
substituting additional services supported by nationally recognized,
evidence-based clinical guidelines for those provided in the Medicaid handbooks
described below or from using different or alternative services, based on
nationally recognized, evidence-based practices, methods, or approaches to
assist individual enrollees, provided that the net effect of this substitution
and these alternatives is that the overall benefits available to the enrollee
are at least equivalent to those described in the applicable handbooks.     b.  
Provision of substitution or alternate services shall not supplant or relieve
the Health Plan from providing covered services if needed.

  5.   The Health Plan shall provide the following services as described in the
Mental Health Targeted Case Management Coverage & Limitations Handbook and the
Community Behavioral Health Services Coverage & Limitations Handbook (the
Handbooks). The Health Plan shall not alter the amount, duration and scope of
such services from that specified in the Handbooks. The Health Plan shall not
establish service limitations that are lower than, or inconsistent with, the
Handbooks.

  a.   Inpatient hospital services for psychiatric conditions (ICD-9-CM codes
290 through 290.43, 290.8, 290.9, 293.0 through 298.9, 300 through 301.9, 302.7,
306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
315.9);     b.   Outpatient hospital services for psychiatric conditions
(ICD-9-CM codes 290 through 290.43, 290.8, 290.9, 293 through 298.9, 300 through
301.9, 302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31,
315.5, 315.8, and 315.9);

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AMERIGROUP Community Care
  HMO Contract

  c.   Psychiatric physician services (for psychiatric specialty codes 42, 43,
44 and ICD-9-CM codes 290 through 290.43, 290.8, 290.9, 293.0 through 298.9, 300
through 301.9, 302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3,
315.31, 315.5, 315.8, and 315.9);     d.   Community mental health services
(ICD-9-CM codes 290 through 290.43, 290.8, 290.9, 293.0 through 298.9, 300
through 301.9, 302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3,
315.31, 315.5, 315.8, and 315.9); and for these procedure codes H0001, H0001HN;
H0001HO, H0001TS; H0031; H0031H0; H0031HN; H0031TS; H0032; H0032TS; H0046;
H0047; H2000; H2000HO; H2000HP; H2010H0; H2010HE; H2010HF; H2010HQ; H2012;
H2O12HF; H2017; H2019; H2O19HM; H2O19HN; H2019H0; H2O19HQ; H2O19HR; T1007;
T1007TS; T1015; T1015HE; T1015HF; T1023HE; or T1023HF;     e.   Mental Health
Targeted Case Management (Children: T1017HA; Adults: T1017); and     f.   Mental
Health Intensive Targeted Case Management (Adults: T1017HK).

  6.   Non-Covered Services

  a.   The following services are not covered by the Health Plan:

  (1)   Specialized therapeutic foster care;     (2)   Therapeutic group care
services;     (3)   Behavioral health overlay services;     (4)   Community
substance abuse services, except as required by this Contract;     (5)  
Residential care;     (6)   Statewide Inpatient Psychiatric Program
(SIPP) services;     (7)   Clubhouse services; and     (8)   Comprehensive
behavioral assessment.

  b.   The Health Plan shall not be responsible for the provision of behavioral
health services to enrollees assigned to a FACT team by the DCF Substance Abuse
and Mental Health Program (SAMH) Office.     c.   The Health Plan is not
responsible for behavioral health services for enrollees who are enrolled in the
Child Welfare Prepaid Mental Health Plan (CWPMHP) with the exception of CWPMHP
enrollees residing in Area 1 and the following counties in Area 6: Hardee,
Highlands, Manatee and Polk. In Area 1 and the above listed Area 6 counties, the
Health Plan is responsible for providing behavioral health care services,
provided it is approved to cover those counties as specified in Attachment I of
this Contract.

  7.   If an enrollee makes a request for behavioral health services to the
Health Plan, the Health Plan shall provide the enrollee with the name (or names)
of qualified behavioral health care

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      providers, and if requested, assist the enrollee with making an
appointment with the provider that is within the required access times indicated
in Attachment II, Section VII, Provider Network, Item F., Appointment Waiting
Times and Geographic Access Standards, and Attachment II, Section VI, Behavioral
Health Care.     8.   Services available under the Health Plan shall represent a
comprehensive range of appropriate services for both children/adolescents and
adults who experience impairments ranging from mild to severe and persistent.
This section outlines the Agency’s expectations and requirements related to each
of the categories of service.

  a.   (Capitated Health Plans only) — The Health Plan may provide expanded
services under the Contract as a substitution of care or downward substitution.
    b.   (Capitated Health Plans only) — When the Health Plan intends to provide
a service as a downward substitution, the provider must use clinical rationale
for determining the benefit of the service for the enrollee.

B. Provider Network

  1.   The Health Plan shall have at least one (1) certified adult psychiatrist
and at least one (1) board-certified child psychiatrist (or one (1) child
psychiatrist who meets all education and training criteria for board
certification) that is available within thirty (30) minutes’ average travel time
for urban areas and sixty (60) minutes’ average travel time for rural areas of
all enrollees.     2.   For rural areas, if the Health Plan does not have a
provider with the necessary experience, BMHC may waive, in writing, the travel
time requirements of paragraph B.1., above.     3.   The Health Plan shall
ensure that outpatient staff includes at least one (1) FTE direct service
behavioral health provider per 1,500 enrollees. The Agency expects the Health
Plan’s staffing pattern for direct service providers to reflect the ethnic and
racial composition of the community.     4.   The Health Plan’s array of direct
service behavioral health providers for children under age 18 and adults shall
include, but not be limited to, providers that are licensed or eligible for
licensure, and demonstrate two (2) years of clinical experience in the following
specialty areas or with the following populations:

  a.   Adoption/attachment issues;     b.   Post traumatic stress syndrome;    
c.   Dual diagnosis (mental illness/developmental disability);     d.  
Co-occurring diagnosis (mental illness/substance abuse);     e.   Gender/sexual
issues;     f.   Geriatric/aging issues;     g.   Eating disorders;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  h.   Adolescent/children’s issues;     i.   Sexual/physical abuse (adult);    
j.   Sexual/physical abuse (children/adolescents);     k.   Separation, grief
and loss;     I.   Domestic violence/adult;     m.   Non-clinical specialties:

  (1)   Behavioral analysis;     (2)   Behavior management/alternative therapies
for children/adolescents;     (3)   Court-ordered mental health evaluations;    
(4)   Expert witness testimony;     (5)   Child protection or foster care; and  
  (6)   Bi-lingual (English/Spanish, for example).

  5.   Mental health targeted case managers shall not be counted as direct
service behavioral health providers.     6.   The Health Plan shall have access
to no fewer than one (1) fully accredited psychiatric community hospital bed per
2,000 enrollees, as appropriate, for both children/adolescents and adults.
Specialty psychiatric hospital beds may be used to count toward this requirement
when psychiatric community hospital beds are not available within a particular
community. Additionally, the Health Plan shall have access to sufficient numbers
of accredited hospital beds on a medical/surgical unit to meet the need for
medical detoxification treatment.     7.   The Health Plan’s facilities must be
licensed, as required by law and rule, accessible to the handicapped, in
compliance with federal Americans with Disabilities Act guidelines, and have
adequate space, supplies, good sanitation, and fire, safety, and disaster
preparedness and recovery procedures in operation.     8.   The Health Plan
shall ensure that it has providers that are qualified to serve enrollees and
experienced in serving severely emotionally disturbed children/adolescents and
severely and persistently mentally ill adults. The Health Plan shall maintain
documentation of its providers’ experience in the providers’ credentialing
files. See Section VII, Provider Network, Item H. Credentialing and
Recredentialing, for additional requirements.     9.   Before beginning
behavioral health services, the Health Plan shall enter into agreements for
coordination of care and treatment of enrollees, jointly or sequentially served,
with community mental health care center(s) that are not a part of the Health
Plan’s provider network. The Health Plan shall enter into similar agreements
with agencies funded pursuant to Chapter 394, F.S. The Agency shall approve all
model agreements between the Health Plan and community mental health
center(s)/agencies before the Health’ Plan enters into the agreement. This
requirement shall not apply if the Health Plan provides the

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  Medicaid Non-Reform and Reform HMO Contract

      Agency with documentation that shows the Health Plan has made a good faith
effort to contract with the center(s)/agencies but could not reach agreement.  
  10.   The Health Plan shall request current behavioral health care provider
information from all new enrollees upon enrollment. The Health Plan shall
solicit these providers to participate in the Health Plan’s network. The Health
Plan may request in writing that the Agency grant exemption to a Health Plan
from soliciting a specific behavioral health services provider on a case-by-case
basis.     11.   Pursuant to s. 409.912(4)(b)(7), F.S., the Health Plan shall
make a good faith effort to contract for the provision of behavioral health
services with all local community mental health providers designated by the
Agency and DCF unless waived by the Agency.     12.   The Health Plan shall
submit contracted and subcontracted behavioral health staffing information to
BMHC as follows:

  a.   Annually for Health Plans providing Medicaid behavioral health services
for more than twelve (12) months. Reports are due no later than August 15th and
shall reflect staffing in the month of June;     b.   Quarterly for Health Plans
providing Medicaid behavioral health services for twelve (12) months or less.
Reports are due forty-five (45) calendar days following the end of the quarter
and shall reflect staffing for the last month of the quarter.

C. Service Requirements

  1.   Inpatient Hospital Services

  a.   Inpatient hospital services are medically necessary behavioral health
services provided in a hospital setting. (See Section V, Covered Services, Item
H., Coverage Provisions, sub-item 10., Hospital Services — Inpatient.) The
inpatient care and treatment services that an enrollee receives must be under
the direction of a licensed physician with the appropriate medical specialty
requirements. Capitated Health Plans may provide inpatient hospital services in
a general hospital psychiatric unit or in a specialty hospital.     b.   A
hospital’s per diem (daily rate) for inpatient mental health hospital care and
treatment covers all services and items furnished during a twenty-four (24) hour
period. The facilities, supplies, appliances, and equipment furnished by the
hospital during the inpatient stay are included in the per diem as well as the
related nursing, social, and other services furnished by the hospital during the
inpatient stay.     c.   For all child/adolescent enrollees (up to age 21) and
pregnant adults in Reform, the Health Plan shall be responsible for the
provision of up to three-hundred and sixty-five (365) days of behavioral
health-related hospital inpatient care for each state fiscal year. For all
non-pregnant adults in Reform, the Health Plan shall be responsible for up to
forty-five (45) days of behavioral health-related inpatient coverage and up to
three- hundred and sixty-five (365) days of behavioral health-related emergency
inpatient care, for each state fiscal year. For non-reform, the Health Plan
shall be responsible for providing up to forty-five (45) days of behavioral
health-related hospital inpatient care for each state fiscal year for all
enrollees.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  d.   For all enrollees, the Health Plan shall pay for inpatient mental
health-related hospital days determined medically necessary by the Health Plan’s
medical director or designee, up to the maximum number of days required under
the Contract.     e.   If an enrollee is admitted to a hospital for a
non-psychiatric diagnosis and during the same hospitalization transfers to a
psychiatric unit or receives treatment for a psychiatric diagnosis, the Health
Plan is at risk for the medically necessary behavioral health treatment
inpatient days up to the maximum number of days required under this Contract.  
  f.   The Health Plan shall cover the cost of all enrollees’ medically
necessary stays resulting from a mental health emergency, until such time as the
Health Plan can safely transport the enrollee to a designated facility.     g.  
Capitated Health Plans only — Crisis stabilization units (CSU) may be used as a
downward substitution for inpatient psychiatric hospital care when determined
medically appropriate. These bed days are calculated on a two-for-one basis.
Beds funded by the DCF SAMH cannot be used for enrollees if there are non-funded
clients in need of the beds. If CSU beds are at capacity, and some of the beds
are occupied by enrollees, and a non-funded client presents in need of services,
the enrollees must be transferred to an appropriate facility to allow the
admission of the non-funded client. Therefore, the Health Plan shall demonstrate
adequate capacity for inpatient hospital care in anticipation of such transfers.
    h.   The Health Plan shall coordinate hospital discharge planning for
psychiatric admissions and substance abuse detoxification to ensure inclusion of
appropriate post-discharge care. This provision does not apply to admissions to
residential settings not covered by the Health Plan.

  (1)   Enrollees admitted to an acute care facility (inpatient hospital or CSU)
shall receive appropriate services upon discharge from the acute care facility.
    (2)   The Health Plan shall have follow-up services available to enrollees
within twenty- four (24) hours of discharge from an acute care facility,
provided the acute care facility notified the Health Plan it had provided
services to the enrollees.

  i.   BMHC shall sanction the Health Plan, as described in Attachment II,
Section XIV, Sanctions, for any inappropriate over-utilization of state mental
health treatment facility services for its enrollees.

  2.   Outpatient Hospital Services         Outpatient hospital services are
medically necessary behavioral health services provided in a hospital setting.
The outpatient care and treatment services that an enrollee receives must be
under the direction of a licensed physician with the appropriate specialty.

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     3. Emergency Services — Behavioral Health Services

  a.   Crisis Intervention Mental Health Services and Post-Stabilization Care
Services

  (1)   Crisis intervention services include intervention activities of less
than twenty-four (24) hour duration (within a twenty-four (24) hour period)
designed to stabilize an enrollee in a psychiatric emergency.     (2)  
Post-stabilization care services include any of the mandatory services that a
treating physician views as medically necessary, that are provided after an
enrollee is stabilized from an emergency mental health condition in order to
maintain the stabilized condition, or under the circumstances described in 42
CFR 438.114(e) to improve or resolve the enrollee’s condition.

  b.   An out-of-area, non-participating provider shall notify the Health Plan
within twenty-four (24) hours of the enrollee’s presenting for emergency
behavioral health services. In cases in which the enrollee has no
identification, or is unable to orally identify himself/herself when presenting
for behavioral health services, the out-of-area, nonparticipating provider shall
notify the Health Plan within twenty-four (24) hours of learning the enrollee’s
identity. The out-of-area, non-participating provider shall deliver to the
Health Plan the medical records that document that the identity of the enrollee
could not be ascertained at the time the enrollee presented for emergency
behavioral health services due to the enrollee’s condition.     c.   If the
out-of-area, non-participating provider fails to provide the Health Plan with an
accounting of the enrollee’s presence and status within twenty-four (24) hours
after the enrollee presents for treatment and provides identification, the
Health Plan shall approve claims only for the time period required for treatment
of the enrollee’s emergency behavioral health services, as documented by the
enrollee’s medical record.     d.   The Health Plan shall review and approve or
disapprove all out-of-plan emergency behavioral health service claims within the
time frames specified for emergency claims payment in Attachment II, Section V,
Covered Services, Item H., Coverage Provisions, sub-item 7., Emergency Services.
    e.   The Health Plan shall submit to BMHC for review and final determination
all denied appeals from behavioral health care providers and out-of-plan,
non-participating behavioral health care providers for denied emergency
behavioral health service claims. The provider, whether a participating provider
or not, must submit the denied appeal to the BMHC within ten (10) calendar days
after receiving notice of the Health Plan’s final appeal determination.     f.  
The Health Plan shall not deny emergency services for enrollees presenting at
participating or non-participating receiving facilities for involuntary
examination under the Baker Act. The Health Plan shall evaluate the need for and
authorize or deny any additional services within three (3) hours of being
notified by telephone from the receiving facility.

  (1)   The receiving facility must notify the Health Plan within four (4) hours
of the enrollee’s presenting. If the receiving facility fails to notify the
Health Plan of the

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      enrollee’s presence and status within four (4) hours, the Health Plan
shall pay for only the first four (4) hours of the enrollee’s treatment, subject
to medical necessity.

  (2)   If the receiving facility is a non-participating receiving facility and
documents in the medical record that it is unable, after a good faith effort, to
identify the enrollee and, therefore, fails to notify the Health Plan of the
enrollee’s presence, the Health Plan shall cover medical stabilization lasting
no more than three (3) calendar days from the date the enrollee presented at the
receiving facility, as documented by the enrollee’s medical record and subject
to medical necessity, unless there is irrefutable evidence in the medical record
that a longer period was required to treat the enrollee.

  g.   Fee-for-service Health Plans shall follow provisions of subparagraph f.
above for receiving facilities that are not CSUs.

     4. Physician Services

  a.   Physician services are those services rendered by a licensed physician
who possesses the appropriate medical specialty requirements, when applicable. A
psychiatrist must be Florida licensed and certified as a psychiatrist by the
American Board of Psychiatry and Neurology or the American Osteopathic Board of
Neurology and Psychiatry, or have completed a psychiatry residency accredited by
the Accreditation Council for Graduate Medical Education (ACGME) or the Royal
College of Physicians and Surgeons of Canada.     b.   Physician services
include specialty consultations for evaluations. A physician consultation shall
include an examination and evaluation of the enrollee with information from
family member(s) or significant others as appropriate. The consultation shall
include written documentation on an exchange of information with the attending
provider. The components of the evaluation and management procedure code and
diagnosis code must be documented in the enrollee’s medical record. A hospital
visit to an enrollee in an acute care hospital for a behavioral health diagnosis
shall be documented with a behavioral health procedure code and behavioral
health diagnosis code. All procedures with a minimum time requirement shall be
documented in the enrollee’s medical record to show the time spent providing the
service to the enrollee. The Health Plan shall be responsive to requests for
consultations made by the PCP.     c.   Physicians are required to coordinate
medically necessary behavioral health services with the PCP and other providers
involved with the enrollee’s care. The Health Plan shall draft and implement a
set of protocols that indicate when such coordination is required.

     5. Community Mental Health Services

  a.   General Provisions

  (1)   Community mental health services include behavioral health services that
are provided for the maximum reduction of the enrollee’s behavioral health
disability and restoration to the best possible functional level. Such services
can reasonably be expected to improve the enrollee’s condition or prevent
further regression. The Health Plan shall provide medically necessary community
mental health services rendered or recommended by a physician or psychiatrist
and included in a treatment

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    plan. Services must be provided to enrollees of all ages. Services should
emphasize the value of early intervention, be age appropriate and be sensitive
to the enrollee’s developmental level. The term “community” is not intended to
suggest that the services must be provided by state-funded facilities or to
preclude state-funded centers from providing these services.

  (2)   Services shall meet the intent of those covered in the Florida Medicaid
Community Mental Health Services Coverage and Limitations Handbook. Although the
Health Plan can provide flexible services, the service limits and medical
necessity criteria cannot be more restrictive than those in Medicaid policy as
stated in Medicaid Mental Health Targeted Case Management Coverage & Limitations
Handbook and the Community Behavioral Health Services Coverage & Limitations
Handbook (Handbooks) and this Contract.     (3)   The Health Plan shall
establish medical necessity criteria, including those for admission, continuing
stay, and discharge, for all mandatory and optional services. Criteria must be
specific to enrollee ages and diagnoses and must account for orders for
involuntary outpatient placement pursuant to s. 394.4655, F.S. These criteria
shall be submitted to BMHC for review and approval when developed and/or when
changed.

  b.   Treatment Plan Development and Modification:

  (1)   Treatment planning includes working with the enrollee, the enrollee’s
natural support system, and all involved treating providers to develop an
individualized plan for addressing identified clinical needs. A behavioral
health care provider must complete a face-to-face interview with the enrollee
during the development of the plan.     (2)   In addition to the Handbook
requirements, the individualized treatment plan shall:

  (a)   Be recovery-oriented and promote resiliency;     (b)   Be
enrollee-directed;     (c)   Accurately reflect the presenting problems of the
enrollee;     (d)   Be based on the strengths of the enrollee, family, and other
natural support systems;     (e)   Provide outcome-oriented objectives for the
enrollee;     (f)   Include an outcome-oriented schedule of services that will
be provided to meet the enrollee’s needs;     (g)   Include the coordination of
services not covered by the Health Plan such as school-based services,
vocational rehabilitation, housing supports, Medicaid feefor-service substance
abuse treatment, and physical health care; and     (h)   For enrollees in the
child welfare system the individual treatment plans shall be coordinated with
and complement the goals of the child welfare case plan.

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  Medicaid Non-Reform and Reform
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  HMO Contract

  (3)   Individualized treatment plan reviews shall be conducted at six
(6) month intervals to assure that the services being provided are effective and
remain appropriate for addressing individual enrollee needs. Additionally, a
review is expected whenever clinically significant events occur or when
treatment is not meeting the enrollee’s needs. The provider is expected to use
the individualized treatment plan review process in the utilization management
of medically necessary services. For further guidance see the most recent
Community Behavioral Health Services and Coverage Handbook.

  c.   Evaluation and Assessment Services

  (1)   Evaluation and testing services include psychological testing
(standardized tests) and evaluations that assess the enrollee’s functioning in
all areas. Evaluations completed prior to provision of treatment shall include a
holistic view of factors that underlie or may have contributed to the need for
behavioral health services. Diagnostic evaluations are included in this
category. Diagnostic evaluations shall be comprehensive and must be used in the
development of an individualized treatment plan. All evaluations shall be
appropriate to the age, developmental level and functioning of the enrollee. All
evaluations shall include a clinical summary that integrates all the information
gathered and identifies the enrollee’s needs. The evaluation shall prioritize
the clinical needs, evaluate the effectiveness of any prior treatment, and
include recommendations for interventions and mental health services to be
provided. All new enrollees who appear for treatment services shall receive an
evaluation unless there is sufficient collateral information that a new
evaluation would not be necessary.     (2)   Evaluation services, when
determined medically necessary, shall include assessment of mutual status,
functional capacity, strengths and service needs by trained mental health staff.
    (3)   Before receiving any community mental health services, children ages
0-5 shall have a current assessment (within one (1) year) of presenting symptoms
and behaviors; developmental and medical history; family psychosocial and
medical history; assessment of family functioning; a clinical interview with the
primary caretaker and an observation of the child’s interaction with the
caretaker; and an observation of the child’s language, cognitive, sensory,
motor, self-care, and social functioning.

  d.   Medical and Psychiatric Services

  (1)   These services include medically necessary interventions that require
the skills and expertise of a psychiatrist, psychiatric ARNP, or physician.    
(2)   Medical psychiatric interventions include the prescribing and management
of medications, monitoring side effects associated with prescribed medications,
individual or group medical psychotherapy, psychiatric evaluation (for
diagnostic purposes and for initiating treatment), psychiatric review of
treatment records for diagnostic purposes, and psychiatric consultation with an
enrollee’s family or significant others, PCPs, and other treatment providers.  
  (3)   Interventions related to specimen collections, taking vital signs and
administering injections are also a covered service.

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  (4)   Treatment services are distinguished from the physician services
outlined above in that they are provided through a community mental health
provider. Psychiatric or physician services must be at sites where substantial
amounts of community mental health services are provided.

  e.   Behavioral Health Therapy Services

  (1)   Therapy services include individual and family therapy, group therapy
and behavioral health day services. These services may include psychotherapy or
supportive counseling focused on assisting enrollees with the problems or
symptoms identified in an assessment. The focus should be on identifying and
utilizing the strengths of the enrollee, family, and other natural support
systems. Therapy services shall be geared to the individual needs of the
enrollee and shall be sensitive to the age, developmental level, and functional
level of the enrollee.     (2)   Family and marital therapy are also included in
this category. Examples of interventions include those that focus on resolution
of a life crisis or an adjustment reaction to an external stressor or
developmental challenge.     (3)   Behavioral health day services are designed
to enable enrollees to function successfully in the community in the least
restrictive environment and to restore or enhance ability for social and
pre-vocational life management services. The primary functions of behavioral
health day services are stabilization of the symptoms related to a behavioral
health disorder to reduce or eliminate the need for more intensive levels of
care, to provide transitional treatment after an acute episode, or to provide a
level of therapeutic intensity not possible in a traditional outpatient setting.

  f.   Community Support and Rehabilitative Services

  (1)   These services include psychosocial rehabilitation services and
clubhouse services. Clubhouse services are excluded from the Health Plan’s
coverage but are covered under fee-for-service Medicaid. Psychosocial
rehabilitation services may be provided in a facility, home, or community
setting. These services assist enrollees in functioning within the limits of a
disability or disabilities resulting from a mental illness. Services focus on
restoration of a previous level of functioning or improving the level of
functioning. Services must be individualized and directly related to goals for
improving functioning within a major life domain.     (2)   The coverage must
include a range of social, educational, vocational, behavioral, and cognitive
interventions to improve enrollees’ potential for social relationships,
occupational/educational achievement and living skills development. Skills
training development is also included in this category and includes activities
aimed toward restoration of enrollees’ skills/abilities that are essential for
managing their illness, actively participating in treatment, and conducting the
requirements of daily independent living. Providers must offer the services in a
setting best suited for desired outcomes, i.e., home or community-based
settings.     (3)   Psychosocial rehabilitative services may also be provided to
assist enrollees in finding or maintaining appropriate housing arrangements or
to maintain employment. Interventions should focus on the restoration of
skills/abilities that are adversely affected by the mental illness and supports
required to manage the enrollee’s housing or employment needs. The provider must
be knowledgeable

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      about TANF and is responsible for medically necessary mental health
services that will assist the individual in finding and maintaining employment.

  g.   Therapeutic Behavioral On-Site Services (TBOS) for Children and
Adolescents

  (1)   TBOS services are community services and natural supports for
children/adolescents with serious emotional disturbances. Clinical services
include provision of a professional level therapeutic service that may include
teaching problem solving skills, behavioral strategies, normalization activities
and other treatment modalities that are determined to be medically necessary.
These services shall be designed to maximize strengths and reduce behavior
problems or functional deficits stemming from the existence of a mental health
disorder. Social services include interventions designed for the restoration,
modification, and maintenance of social, personal adjustment and basic living
skills.     (2)   TBOS services are intended to maintain the child/adolescent in
the home and to prevent reliance upon a more intensive, restrictive, and costly
mental health placement. They are also focused on helping the child/adolescent
possess the physical, emotional, and intellectual skills to live, learn and work
in the home community. Coverage shall include the provision of these services
outside of the traditional office setting. The services shall be provided where
they are needed, in the home, school, childcare centers or other community
sites.

  h.   Day Treatment Services

  (1)   Adult day treatment services include therapy, rehabilitation, social
interactions, and other therapeutic services that are designed to redevelop,
maintain, or restore skills that are necessary for enrollees to function in the
community. The provider must have an array of available services designed to
meet the individualized needs of the enrollee, and which address the following
primary functions:

  (a)   Stabilize symptoms related to a behavioral health disorder to reduce or
eliminate the need for more intensive levels of care;     (b)   Provide a level
of therapeutic intensity between traditional outpatient and an inpatient or
partial hospital setting;     (c)   Provide a level of treatment that will
assist enrollees in transitioning from an acute care or institutional settings;
    (d)   Assist enrollees in redeveloping the skills required to maintain a
living environment, use community resources, and conduct activities of daily
living and/or live independently in the community.

  (2)   Children/adolescent day treatment services include therapy,
rehabilitation and social interactions, and other therapeutic services that are
designed to redevelop, maintain, or restore skills that are necessary for
children/adolescents to function in their community. The approach shall take
into consideration developmental levels and delays in development due to
emotional disorders. If the child/adolescent is school age, the services shall
be coordinated with the school system. All therapeutic day treatment
interventions for children/adolescents shall have a component that addresses
caregiver participation and involvement. Services for all

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      children/adolescents should be coordinated with home care to the greatest
extent possible. Day treatment services shall include an array of programs with
the following functions:

  (a)   Stabilize the symptoms related to a behavioral health disorder to reduce
or eliminate the need for more intensive levels of care;     (b)   Provide
transitional treatment after an acute episode, admission to an inpatient
program, or discharge from a residential treatment setting;     (c)   Provide a
therapeutic intensity not possible in a traditional outpatient setting; and    
(d)   Assist the child/adolescent in redeveloping age-appropriate skills
required to conduct activities of everyday living in the community.

  (3)   Staff providing adult or children/adolescent day treatment services must
have appropriate training and experience. Behavioral health care providers shall
be available to provide clinical services when necessary.

  i.   Services for Children Ages 0 through 5 Years

  (1)   Services include behavioral health day services and therapeutic
behavioral on-site services for children ages 0 through 5 years.     (2)   Prior
to receiving these services, the enrollees in this age group must have an
assessment that meets the criteria in the Medicaid Community Behavioral Health
Services Coverage and Limitations Handbook.

     6. Behavioral Health Targeted Case Management

  a.   The Health Plan shall provide targeted case management services to
children/adolescents with serious emotional disturbances and adults with a
severe and persistent mental illness as defined below. The Health Plan shall
either develop its own targeted case management certification program or approve
a provider training program that meets the criteria in the Medicaid Targeted
Case Management Coverage and Limitations Handbook.

  (1)   The Health Plan shall meet the intent of the services and ensure the
qualification and certification of providers as outlined below and in the
Medicaid Targeted Case Management Coverage and Limitations Handbook.     (2)  
The Health Plan shall set criteria and clinical guidelines for case management
services. Service limits and criteria developed cannot be more restrictive than
those in Medicaid policy.     (3)   At a minimum, case management services are
to incorporate the principles of a strengths-based approach. Strengths-based
case management services are an alternative service modality for working with
individuals and families. This method stresses building on the strengths of
individuals that can be used to resolve current problems and issues, countering
more traditional approaches that focus almost exclusively on individual’s
deficits or needs.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  b.   Target Populations

  (1)   Behavioral health targeted case management services shall be available
to all enrollees:

  (a)   Who require numerous services from different providers and also require
advocacy and coordination to implement or access services;     (b)   Who would
be unable to access or maintain consistent care within the service delivery
system without case management services;     (c)   Who do not possess the
strengths, skills, or support system to allow them to access or coordinate
services;     (d)   Who may benefit from case management but lack the skills or
knowledge necessary to access services; or     (e)   Who do not meet these
criteria but may still be eligible for limited targeted case management services
by meeting exception criteria contained in the Medicaid Targeted Case Management
Coverage and Limitations Handbook.

  (2)   The Health Plan also shall have case management services available to
children/adolescents who have a serious emotional disturbance, which is: a
defined mental disorder; a level of functioning which requires two or more
coordinated behavioral health services to be able to live in the community; and
at imminent risk of out-of-home behavioral health treatment placement.     (3)  
The Health Plan shall also have case management services available for adults
with a severe and persistent mental illness or who have been denied admission to
a long-term mental health institution or residential treatment facility or have
been discharged from a long-term mental health institution or residential
treatment facility.

  c.   The Health Plan will not be required to seek approval from the SAMH
Program Office for client eligibility or behavioral health targeted case
management agency or individual provider certification.     d.   Required
Services

  (1)   Behavioral health targeted case management services include working with
the enrollee and the enrollee’s natural support system to develop and promote a
service plan. The service plan reflects the services or supports needed to meet
the needs identified in an individualized assessment of the following areas:
education or employment, physical health, mental health, substance abuse, social
skills, independent living skills, and support system status. The approach used
shall identify and utilize the strengths, abilities, cultural characteristics,
and informal supports of the enrollee, family, and other natural support
systems. Targeted case managers focus on overcoming barriers by collaborating
and coordinating with providers and the enrollee to assist in the attainment of
service plan goals. The targeted case manager takes the lead in both
coordinating services/treatment and assessing the effectiveness of the services
provided.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (2)   When targeted case management recipients enrolled in the Health Plan are
hospitalized in an acute care setting or held in a county jail or juvenile
detention facility, the Health Plan shall document efforts to ensure that
contact is maintained with the enrollee and shall participate actively in the
discharge planning processes.     (3)   Case managers are also responsible for
coordination and collaboration with the parents or guardians of
children/adolescents who receive mental health targeted case management
services. The Health Plan shall monitor case management activities to assure
that case managers routinely include the parents or guardians of enrollees in
the process of providing targeted case management services. Integration of the
parent’s input and involvement with the case manager and other providers shall
be reflected in medical record documentation and monitored through the Health
Plan’s quality of care monitoring activities. Involvement with the
child/adolescent’s school and/or childcare center must also be a component of
case management with children/adolescents.     (4)   The Health Plan shall
provide behavioral health targeted case management services to
children/adolescents in the care or custody of the state who need them. The
Health Plan shall document efforts to develop a cooperative agreement with DCF,
or its provider of community-based services, to address how to minimize
duplication of case management services and to promote the establishment of one
case manager for the child/adolescent and family whenever possible.

  e.   Additional Requirements for Targeted Case Management         The Health
Plan shall have a case management program, including guidelines and protocols
that address:

  (1)   Caseloads set to achieve the desired results. Size limitations must
clearly state the ratio of enrollees to each individual case manager. The limits
shall be specified for children/adolescents and adults, with a description of
the clinical rationale for determining each limitation. If the Health Plan
permits “mixed” caseloads, i.e., children/adolescents and adults, a separate
limitation is expected along with the rationale for the determination. Ratios
must be no greater than the requirements set forth in the Medicaid Mental Health
Targeted Case Management Coverage and Limitations Handbook;     (2)   A system
to manage caseloads when positions become vacant;     (3)   A description of the
modality of service provision and the location that services will be provided;  
  (4)   The expected frequency, duration and intensity of the service with
service limits and criteria no more restrictive than those in Medicaid policy;  
  (5)   Issues related to recovery and self-care, including services to help
enrollees gain independence from the behavioral health and case management
system;     (6)   Services based on individual needs of the enrollees receiving
the service. The service system shall also address the changing needs and
abilities of enrollees; and

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (7)   Case management staff with expertise and training necessary to
competently and promptly assist enrollees in working with Social Security
Administration or Disability Determination in maintaining benefits from SSI and
SSDI. For enrollees who wish to work, case management staff must have the
expertise and training necessary to help enrollees access Social Security Work
Incentives.

     7. Intensive Case Management

  a.   Intensive case management is intended for highly recidivistic adults who
have a severe and persistent mental illness. The service is intended to help
enrollees remain in the community and avoid institutional care. Care criteria
for this level of case management shall address the same elements required
above, as well as expanded elements related to access and twenty-four (24) hour
coverage as described below. Additionally, the intensive case management team
composition shall be expanded to include members selected specifically to assist
with the special needs of this population.     b.   The Health Plan shall
provide this service for all enrollees for whom it is determined to be medically
necessary, to include any enrollee who meets the following criteria:

  (1)   Has resided in a state mental health treatment facility for at least six
(6) of the past thirty-six (36) months;     (2)   Resides in the community and
has had two (2) or more admissions to a state mental health treatment facility
in the past thirty-six (36) months;     (3)   Resides in the community and has
had three (3) or more admissions to a crisis stabilization unit, short-term
residential facility, inpatient psychiatric unit, or any combination of these
facilities within the past twelve (12) months; or     (4)   Resides in the
community and, due to a mental illness, exhibits behavior or symptoms that could
result in long-term hospitalization if frequent interventions for an extended
period of time were not provided.

  c.   Intensive case management services are frequent and intense and focus on
helping the enrollee attain skills and supports needed for independent living.
Case management services are provided primarily in the enrollee’s residence and
include community- based interventions.     d.   The Health Plan shall provide
this service in the least restrictive setting with the goal of improving the
enrollee’s level of functioning, and providing ample opportunities for
rehabilitation, recovery, and self-sufficiency. Intensive case management
services shall be accessible twenty-four (24) hours per day, seven (7) days per
week. The Health Plan shall demonstrate adequate capacity to provide this
service for the targeted population within the guidelines outlined.

     8. Community Treatment of Patients Discharged from State Mental Health
Treatment Facilities

  a.   The Health Plan shall provide medically necessary behavioral health
services to enrollees who have been discharged from any state mental health
treatment facility, including, but not limited to, follow-up services and care.
All enrollees who have

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      previously received services at a state mental health treatment facility
must receive follow-up care.

  b.   The plan of care shall be aimed at encouraging enrollees to achieve a
high quality of life while living in the community in the least restrictive
environment that is medically appropriate and reducing the likelihood that the
enrollees will be readmitted to a state mental health treatment facility.     c.
  The Health Plan shall follow the progress of all enrollees enrolled in the
Health Plan prior to admission to a state mental health treatment facility until
the thirtieth day after admission or until disenrollment from the Health Plan.
The Health Plan shall use behavioral health targeted case managers to follow the
progress of enrollees.     d.   If the enrollee remains in the state facility
more than thirty (30) calendar days and is disenrolled, the Health Plan shall
cooperate with DCF and the enrollee to ensure that the enrollee is assigned a
DCF-funded case management provider who will bear the responsibility of ongoing
monthly follow-up care and discharge planning until such time that the enrollee
is again eligible for, and enrolled in, a health plan.     e.   The Health Plan
shall document efforts to develop a cooperative agreement with the behavioral
health care facility.

     9. Community Services for Medicaid Recipients Involved with the Justice
System
The Health Plan shall make every effort as follows to provide medically
necessary community-based services for Health Plan enrollees who have justice
system involvement:

  a.   Ensure a linkage to pre-booking sites for assessment, screening or
diversion related to behavioral health services;     b.   Provide psychiatric
services within twenty-four (24) hours of release from jail, juvenile detention
facility, or other justice facility to assure that prescribed medications are
available for all enrollees;     c.   Ensure a linkage to post-booking sites for
discharge planning and assuring that prior Health Plan enrollees receive
necessary services upon release from the facility. Health Plan enrollees shall
be linked to services and receive routine care within seven (7) calendar days
from the date they are released;     d.   Provide outreach to homeless and other
populations of Health Plan enrollees at risk of justice system involvement, as
well as those Health Plan enrollees currently involved in this system, to assure
that services are accessible and provided when necessary. This activity shall be
oriented toward preventive measures to assess behavioral health needs and
provide services that can potentially prevent the need for future inpatient
services or possible deeper involvement in the forensic or justice system;    
e.   The Health Plan or its designee shall document efforts to develop a
cooperative agreement with justice facilities to enable the Health Plan to
anticipate enrollees who were Health Plan enrollees prior to incarceration who
will be released from these institutions. The cooperative agreement must address
arrangement for persons who are to be released, but for whom re-enrollment may
not take effect immediately. All enrollees who were Health Plan enrollees prior
to incarceration and Medicaid recipients

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      who are likely to enroll in the Health Plan upon return to the community
must receive a community behavioral health service within twenty-four (24) hours
of discharge from the corrections facility.

     10. Treatment and Coordination of Care for Enrollees with Medically Complex
Conditions

  a.   The Health Plan shall ensure that appropriate resources are available to
address the treatment of complex conditions that reflect both mental health and
physical health involvement. The following conditions must be addressed:

  (1)   Mental health disorders due to or involving a general medical condition,
specifically ICD-9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89, and 310.1;
and     (2)   Eating disorders — ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
307.52.

  b.   The Health Plan shall provide medically necessary community mental health
services to enrollees who exhibit the above diagnoses and shall develop a plan
of care that includes all appropriate collateral providers necessary to address
the complex medical issues involved. Clinical care criteria shall address
modalities of treatment that are effective for each diagnosis. The Health Plan’s
provider network must include appropriate treatment resources necessary for
effective treatment of each diagnosis within the required access time periods.

     11. Coordination of Children’s Services

  a.   The delivery and coordination of child/adolescent mental health services
shall be provided for all who exhibit the symptoms and behaviors of an emotional
disturbance. The delivery of services must address the needs of any
child/adolescent served in an SED (severely emotionally disturbed) or EH
(emotionally handicapped) school program. Developmentally appropriate early
childhood mental health services must be available to children from birth to
five(5) years and their families.     b.   The Health Plan shall deliver
services for all children/adolescents within a strengths- based, culturally
competent service design. The service design shall recognize and ensure that
services are family-driven and include the participation of family, significant
others, informal support systems, school personnel, and any state entities or
other service providers involved in the child/adolescent’s life.     c.   For
all children/adolescents receiving services from the Health Plan, the provider
shall work with the parents, guardians, or other responsible parties to monitor
the results of services and determine whether progress is occurring. Active
monitoring of the child/adolescent’s status shall occur to detect potential risk
situations and emerging needs or problems.     d.   When the court mandates a
parental behavioral health assessment, and the parent is an enrollee, the
provider must complete an assessment of the parent’s mental health status and
the effects on the child. Time frames for completion of this service shall be
determined by the mandates issued by the courts.     e.   Evaluation and
Treatment Services for Enrolled Children/Adolescents

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (1)   The Health Plan shall provide all medically necessary evaluations,
psychological testing and treatment services for children/adolescents referred
to the Health Plan by DCF, DJJ and by schools (elementary, middle, and secondary
schools).     (2)   The Health Plan shall provide court-ordered evaluation and
treatment required for children/adolescents who are enrollees. See
specifications in the Medicaid Community Behavioral Health Services Coverage &
Limitations Handbook.     (3)   The Health Plan or designee shall participate in
all DCF or school staffings that may result in the provision of behavioral
health services to an enrolled child/adolescent.     (4)   The Health Plan shall
refer children/adolescents to DCF when residential treatment is medically
necessary.

D. Transition Plan

  1.   A transition plan is a detailed description of the process of
transferring enrollees from nonparticipating providers to the Health Plan’s
behavioral health care provider network to ensure optimal continuity of care.
The transition plan shall include, but not be limited to, a timeline for
transferring enrollees, description of provider clinical record transfers,
scheduling of appointments, and proposed prescription drug protocols and claims
approval for existing providers during the transition period. The Health Plan
shall document its efforts relating to the transition plan in the enrollee’s
clinical records.     2.   The Health Plan shall minimize the disruption to the
enrollee as a result of any change in behavioral health care providers or case
managers that occurs as a result of this Contract. For enrollees who have
received behavioral health services from a behavioral health care provider,
whether the provider is in the Health Plan’s network or not, the Health Plan
shall continue to authorize all valid claims until the Health Plan has:

  a.   Reviewed the enrollee’s treatment plan;     b.   Developed an appropriate
written transition plan; and     c.   Implemented the written transition plan.

  3.   During the first three (3) months that the enrollee receives behavioral
health services under this Contract, the Health Plan shall not deny requests for
behavioral health services outside the network under the following conditions:

  a.   The enrollee is a patient at a community behavioral health center and the
center has discussed the enrollee’s care with the Health Plan;     b.   If,
following contact with the Health Plan, there is no behavioral health care
provider readily available and the enrollee’s condition would not permit a delay
in treatment.

  4.   If the previous treating provider is unable to allow the Health Plan
access to the enrollee’s clinical records because the enrollee refuses to
release the records, then the Health Plan shall approve the provider’s claims
for:

  a.   Four (4) sessions of outpatient behavioral health counseling or therapy;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  b.   One (1) outpatient psychiatric physician session;     c.   Two
(2) one-hour (1-hour) therapeutic behavioral health on-site sessions; or     d.
  Six (6) days of behavioral health day services.

  5.   Any disputes related to coverage of services necessary for the transition
of enrollees from their current behavioral health care provider to a behavioral
health care provider shall follow the process set forth in Attachment II,
Section IX, Grievance System.     6.   The Health Plan shall approve claims from
providers for authorized out-of-plan non- emergency services, provided such
claims are submitted within twelve (12) months of the date of service. The
Health Plan shall process such claims within the time period specified in s.
641.3155, F.S.

E.   Psychiatric Evaluations for Enrollees Applying for Nursing Home Admission

The Health Plan shall, upon request from the SAMH offices, promptly arrange for
and authorize psychiatric evaluations for enrollees who are applying for
admission to a nursing facility pursuant to OBRA 1987, and who, on the basis of
a screening conducted by Comprehensive Assessment and Review for Long term Care
(CARES) workers, are thought to need mental health treatment. The examination
shall be adequate to determine the need for “specialized treatment” under OBRA.
Evaluations must be completed within five (5) working days from the time the
request from the DCF SAMH office is received. Regulations have been interpreted
by the state to permit any of the mental health professionals listed in s.
394.455, F.S., to make the observations preparatory to the evaluation, although
a psychiatrist must sign such evaluations. The Health Plan will not be
responsible for resident reviews or for providing services as a result of a
pre-admission screening and resident review (PASRR) evaluation.

F.   Assessment and Treatment of Mental Health Residents Who Reside in Assisted
Living Facilities (ALF) that hold a Limited Mental Health License

  1.   The provider must develop and implement a plan to ensure compliance with
s, 394.4574, F.S., related to services provided to residents of licensed
assisted living facilities that hold a limited mental health license. A
cooperative agreement, as defined in s. 429.02, F.S., must be developed by the
ALF with the enrollee’s Health Plan if an enrollee is a resident of an ALF. The
provider must ensure that appropriate assessment services are provided to
enrollees and that medically necessary behavioral health services are available
to all enrollees who reside in this type of setting.     2.   A community living
support plan, as defined in Attachment II, Section I, Definitions and Acronyms,
shall be developed for each enrollee who is a resident of an ALF, and it must be
updated annually. The Health Plan or its designee’s behavioral health care case
manager is responsible for ensuring that the community living support plan is
implemented as written.     3.   Upon request from an ALF, the Health Plan shall
provide procedures for the ALF to follow should an emergent condition arise with
an enrollee that resides at the ALF (see s. 409.912(36), F.S.).

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

G.   Individuals with Special Health Care Needs

  1.   The Health Plan shall implement mechanisms for identifying, assessing and
ensuring the existence of an individualized treatment plan for individuals with
special health care needs, as defined in Attachment II, Section I, Definitions
and Acronyms. Mechanisms shall include evaluation of risk assessments, claims
data, and CPT/ICD-9 codes. Additionally, the Health Plan shall implement a
process for receiving and considering provider and enrollee input.     2.   In
accordance with this Contract and 42 CFR 438.208(c)(3), an individualized
treatment plan for an enrollee determined to need a course of treatment or
regular care monitoring must be:

  (a)   Developed by the enrollee’s direct service mental health care
professional with enrollee participation and in consultation with any
specialists caring for the enrollee;     (b)   Approved by the Health Plan in a
timely manner if this approval is required; and     (c)   Developed in
accordance with any applicable Agency quality assurance and utilization review
standards.

  3.   Pursuant to 42 CFR 438.208(c)(4), for enrollees with special health care
needs determined through an assessment by appropriate mental health care
professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of
treatment or regular care monitoring, the Health Plan shall have a mechanism in
place to allow enrollees to directly access a mental health care specialist (for
example, through a standing referral or an approved number of visits) as
appropriate for the enrollee’s condition and identified needs.

H.   Crisis Support/Emergency Services

  1.   The Health Plan shall operate, as part of its crisis support/emergency
services, a crisis emergency hotline available to all enrollees twenty-four
hours a day, seven days a week, (24/7).     2.   For each county it serves, the
Health Plan shall designate an emergency service facility that operates
twenty-four hours a day, seven days a week, (24/7) with Registered Nurse
coverage and on-call coverage by a behavioral health specialist.

I.   Behavioral Health Services Care Coordination and Management

The Health Plan shall be responsible for the coordination and management of
behavioral health services and continuity of care for all enrollees. At a
minimum, the Health Plan shall provide the following services to its enrollees:

  1.   Document all emergency behavioral health services received by an
enrollee, along with any follow-up services, in the enrollee’s behavioral health
medical records. The Health Plan shall also assure the PCP receives the
information about the emergency behavioral health services for filing in the
PCP’s medical record.     2.   Document all referral services in the enrollees’
behavioral health clinical records.

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  HMO Contract

  3.   Provide appropriate referral of the enrollee for non-covered services to
the appropriate service setting. The Health Plan shall request referral
assistance, as needed, from the Medicaid Area Office. The Health Plan is
encouraged to use the Florida Supplement to the American Society of Addictions
Medicine Patient Placement Criteria for coordination and treatment of substance
abuse related disorders with substance abuse providers. The Health Plan shall
provide coordination of care with community-based substance abuse agencies as
part of its policies and procedures developed for continuity of care for
enrollees who are diagnosed with mental illness and substance abuse or
dependency.     4.   Where a SAMH planning process exists, the Health Plan shall
participate (see s. 394.75, F.S.).

J.   Discharge Planning       Discharge planning is the evaluation of an
enrollee’s medical care needs, including behavioral health service needs,
substance abuse service needs, or both, in order to arrange for appropriate care
after discharge from one level of care to another. The Health Plan shall:

  1.   Monitor all enrollee discharge plans from behavioral health inpatient
admissions to ensure that they incorporate the enrollee’s needs for continuity
in existing behavioral health therapeutic relationships;     2.   Ensure that
enrollees’ family members, guardians, outpatient individual practitioners and
other identified supports are given the opportunity to participate in enrollee
treatment to the maximum extent practicable and appropriate, including
behavioral health treatment team meetings and developing the discharge plan. For
adult enrollees, family members and other identified supports may be involved in
the development of the discharge plan only if the enrollee consents to their
involvement;     3.   Designate staff members who are responsible for
identifying enrollees who remain in the hospital for non-clinical reasons (i.e.,
absence of appropriate treatment setting availability, high demand for
appropriate treatment setting, high-risk enrollees and enrollees with multiple
agency involvement);     4.   Develop and implement a plan that monitors and
ensures that clinically indicated behavioral health services are offered and
available to enrollees within twenty-four (24) hours of discharge from an
inpatient setting;     5.   Ensure that a behavioral health program clinician
provides medication management to enrollees requiring medication monitoring
within twenty-four (24) hours of discharge from a behavioral health program
inpatient setting. The Health Plan shall ensure that the behavioral health
program clinician is duly qualified and licensed to provide medication
management;     6.   Upon the admission of an enrollee, the Health Plan shall
make its best efforts to ensure the enrollee’s smooth transition to the next
service or to the community and shall require that behavioral health care
providers:

  a.   Assign a behavioral health care case manager to oversee the care given to
the enrollee;

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  b.   Develop an individualized discharge plan, in collaboration with the
enrollee where appropriate, for the next service or program or the enrollee’s
discharge, anticipating the enrollee’s movement along a continuum of services;
and     c.   Document all significant efforts related to these activities,
including the enrollee’s active participation in discharge planning.

K.   Functional Assessments

  1.   The Health Plan shall ensure that all behavioral health care providers
administer functional assessments using the functional assessment rating scales
(FARS) for all enrollees over the age of 18 and child functional assessment
rating scale (CFARS) for all enrollees age 18 and under.     2.   The Health
Plan shall ensure that all behavioral health care providers administer and
maintain the FARS and CFARS for all enrollees receiving behavioral health
services and upon termination of providing such services, as required in the
FARS and CFARS manuals and report templates provided by the Agency.     3.   The
results of the FARS and CFARS assessments shall be maintained in each enrollee’s
clinical record, including a chart trending the results of the functional
assessments.     4.   The Health Plan shall submit the FARS/CFARS reports to
BMHC as required in Attachment II, Section XII, Reporting Requirements.

L.   Behavioral Health Provider Contracts

  1.   If the Health Plan subcontracts with a managed behavioral health
organization (MBHO) for the provision of behavioral health services, the MBHO
must be accredited by at least one of the recognized national accreditation
organizations.     2.   The Health Plan shall submit to the BMHC the staff
psychiatrist employment contract, if any, and the model provider contracts for
each behavioral health services specialist type or facility.     3.   All
subcontracts and provider contracts must adhere to the requirements set forth in
this Contract.

M.   Optional Services       The Health Plan is encouraged to provide additional
services that will enhance its covered services. To the degree possible, the
Health Plan shall use existing community resources. Optional services represent
a downward substitution for services in the Community Behavioral Health Services
Coverage and Limitations Handbook and are not an expansion of behavioral health
services. The Health Plan shall make information on optional services available
to enrollees and require documentation of enrollee agreement before implementing
such services. The Health Plan shall not require an enrollee to choose an
optional service over a Community Behavioral Health Services Coverage and
Limitations Handbook service. Optional services must be prior approved by BMHC.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

N.   Community Coordination and Collaboration

The Health Plan shall make every effort to ensure that its providers become a
vital part of the community services and support system. It shall actively
participate with and support community programs and coalitions that promote
school readiness, that assist persons to return to work and provide for
prevention programs. The Health Plan shall have linkages with numerous community
programs that will assist enrollees in obtaining housing, economic assistance
and other supports.

0.   Behavioral Health Managed Care Local Advisory Forum

  1.   There will be one designated Medicaid behavioral health care advisory
forum in each Medicaid Area where managed care organizations are operating. Each
forum shall convene no less than quarterly and report to the Agency on advocacy
and programmatic concerns related to delivery of Medicaid-funded behavioral
health services. The local forum is responsible for gathering information and
reporting to the Agency on the provision of managed behavioral health care
services. The forum functions solely as a fact-finder or information gatherer
with no decision-making authority. The forum shall be conducted as an open
public meeting designed to promote the coordination, integration, quality, and
efficiency of the behavioral health system of care.     2.   Information is to
be presented to keep participants up to date on activities and contractual
responsibilities of each managed care plan. Meeting minutes related to
discussion and activities must be kept and distributed to participants. The
local forum is to be coordinated by Agency staff.     3.   The forum is to be
facilitated by a volunteer chairperson and vice-chairperson or two (2) co-
chairpersons. Representatives from the Health Plan, behavioral health service
provider agencies or state employees may not hold these voluntary positions.    
4.   This public forum provides opportunities for beneficiaries, providers, and
community stakeholders to discuss ideas and pose questions to Health Plans and
Agency representatives. Health Plan behavioral health representatives shall
attend the forums in person, participate, and respond to participant questions
and inquiries for information related to Medicaid-funded behavioral health
services. Agency representatives also shall be present and participate
appropriately in responding to concerns related to service delivery, oversight,
access, and best practices.     5.   Health Plans shall follow up on identified
issues of concern related to Medicaid services or Health Plan administration. On
request, Health Plans shall provide pertinent information about quality
improvement findings, access, outreach activities, and best practices.

P.   Community Behavioral Health Services Annual 80/20 Expenditure Report (HMOs
serving non-Reform populations only)       By April 1st of each Contract year,
HMOs shall provide a breakdown of expenditures related to the provision of
community behavioral health services to non-Reform populations using the
spreadsheet template provided by the Agency (see Attachment II, Section XII,
Reporting Requirements). For non-Reform HMOs, in accordance with s. 409.912,
F.S., 80% of the capitation rate paid to the Health Plan by the Agency shall be
expended for the direct provision of community behavioral health services. In
the event the Health Plan expends less

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

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

  1.   For reporting purposes in accordance with this section, “community
behavioral health services” are defined as those services that the Health Plan
is required to provide as listed in the Community Mental Health Services
Coverage and Limitations Handbook and the Mental Health Targeted Case Management
Coverage and Limitations Handbook.     2.   For reporting purposes in accordance
with this section “expended” means the total amount, in dollars, paid directly
or indirectly to community behavioral health services providers solely for the
provision of community behavioral health services, not including administrative
expenses or overhead of the Health Plan. If the report indicates that a portion
of the capitation payment is to be returned to the Agency, the Health Plan shall
submit a check for that amount with the Behavioral Health Services Annual 80/20
Expenditure Report that the Health Plan provides to BMHC. See Attachment II,
Section XII, Reporting Requirements, and the Agency’s Report Guide.

Q.   Behavioral Health Clinical Records       The Health Plan shall maintain a
behavioral health clinical record of services for each enrollee. Each enrollee’s
behavioral health clinical record shall:

  1.   Include documentation sufficient to disclose the quality, quantity,
appropriateness and timeliness of behavioral health services performed;     2.  
Be legible and maintained in detail consistent with the clinical and
professional practice that facilitates effective internal and external peer
review, medical audit and adequate follow-up treatment; and     3.   For each
service provided, clearly identify:

  a.   The physician or other service provider;     b.   Date of service;     c.
  The units of service provided; and     d.   The type of service provided.

R.   Behavioral Health Quality Improvement (QI) Requirements

  1.   The Health Plan’s QI plan shall include a behavioral health component in
order to monitor and assure that the Health Plan’s behavioral health services
are sufficient in quantity, of acceptable quality and meet the needs of the
enrollees.     2.   Treatment plans must:

  a.   Identify reasonable and appropriate objectives;     b.   Provide
necessary services to meet the identified objectives; and

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  c.   Include retrospective reviews that confirm that the care provided, and
its outcomes, were consistent with the approved treatment plans and appropriate
for enrollee needs.

  3.   In determining if behavioral health services are acceptable according to
current treatment standards, the Health Plan shall:

  a.   Submit the annual Contract year schedule for administrative/programmatic
monitoring and clinical record review for approval to BMHC by July 1 St each
Contract year.

  (1)   A Health Plan that has been in operation less than twelve (12) months
shall perform quarterly administrative monitoring and quarterly review of a
random selection of ten percent (10%) or fifty (50) clinical records, whichever
is less, of enrollees receiving behavioral health services during the previous
quarter.     (2)   A Health Plan that has been in operation twelve (12) months
or more shall perform an annual review of a random selection of ten percent
(10%) or seventy-five (75) clinical records, whichever is less, of enrollees who
received behavioral health services during the previous Contract year.

  b.   Elements of these reviews shall include, but not be limited to:

  (1)   Management of specific diagnoses;     (2)   Appropriateness and
timeliness of care;     (3)   Comprehensiveness of, and compliance with, the
plan of care;     (4)   Evidence of special screening for high risk enrollees
and/or conditions;     (5)   Evidence of appropriate coordination of care; and  
  (6)   Evidence of compliance with applicable Medicaid Mental Health Targeted
Case Management Coverage & Limitations Handbook and the Community Behavioral
Health Services Coverage & Limitations Handbook.

S.   Behavioral Health Reporting Requirements       Behavioral health reporting
requirements are also listed in Attachment II, Section XII, Reporting
Requirements and must be submitted as required in the Health Plan Report Guide.

T.   Enrollee Satisfaction Survey

  1.   In all service areas in which the Health Plan provides behavioral health
services, the Health Plan shall annually conduct a behavioral health services
enrollee satisfaction survey in both English and Spanish.     2.   The Health
Plan shall submit the survey tool for approval to BMHC prior to

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  HMO Contract

    use. Any revisions to the tool must also be submitted to BMHC prior to use.

U.   Stakeholder Satisfaction Survey

  1.   In all service areas in which the Health Plan provides behavioral health
services, the Health Plan shall annually conduct a behavioral health services
stakeholder satisfaction survey in both English and Spanish.     2.   The Health
Plan shall submit the survey tool for approval to BMHC prior to use. Any
revisions to the tool must also be submitted to BMHC prior to use.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 7
Provider Network
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
II of this Contract, unless otherwise specified.

1. All Reform Health Plans
Section VII Provider Network, Item B., Network Standards

    In addition to the requirements in Attachment II, Section VII, Provider
Network, Item B. Network Standards, a Health Plan that offers a specialty plan
shall ensure that its provider network meets the following requirements:

  1.   The provider network will be integrated and consist of PCPs and
specialists who are trained to provide services for a particular condition or
population;     2.   If the Health Plan has been developed for individuals with
a particular disease state, the network will contain a sufficient number of
board certified specialists in the care and management of the disease. Because
individuals have multiple diagnoses, there should be a sufficient number of
specialists to manage different diagnoses as well;     3.   A defined network of
facilities used for inpatient care shall be included with accredited tertiary
hospitals and hospitals that have been designated for specific conditions,
appropriate for the Health Plan population (e.g., end stage renal disease
centers, comprehensive hemophilia centers);     4.   Specialty pharmacies when
appropriate; and     5.   A range of community-based care options as
alternatives to hospitalization and institutionalization.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 8
Quality Management
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. All Reform Health Plans
Section VIII, Quality Management, Item A., Quality Improvement, sub-item 3.,
Health Plan QI Activities

  f.   Provider Satisfaction Survey — The Health Plan shall submit a provider
satisfaction survey plan to BMHC for written approval by the end of the eighth
month of this Contract. The plan shall include the questions to be asked. The
Health Plan shall conduct the survey at the end of the first year of this
Contract. The results of the survey shall be reported to BMHC within four
(4) months of the beginning of the second year of this Contract.

2. All Reform Health Plans Except the HIV/AIDS Specialty Plan
Section VIII, Quality Management, Item B. Utilization Management, sub-item 5.,
Disease Management

  a.   The Health Plan shall develop and implement disease management programs
for Reform enrollees living with chronic conditions. The disease management
initiatives shall include, but are not limited to, asthma, HIV/AIDS, diabetes,
congestive heart failure and hypertension. The Health Plan may develop and
implement additional disease management programs for its enrollees.     b.  
Each disease management program shall have policies and procedures that follow
the National Committee for Quality Assurance’s (NCQA’s) most recent Disease
Management Standards and Guidelines, which may be accessed online at
http://web.ncqa.orq/tabid/381/Default.aspx. In addition to policies and
procedures, the Health Plan shall have a disease management program description
for each disease state that describes how the program fulfills the principles
and functions of each of the NCQA Disease Management Standards and Guidelines
categories. Each program description should also describe how enrollees are
identified for eligibility and stratified by severity and risk level. The Health
Plan shall submit a copy of its policies and procedures and program description
for each of its disease management programs to BMHC by April 1 of each Contract
year.     c.   The Health Plan shall have a policy and procedure regarding the
transition of enrollees from disease management services outside the Health Plan
to the Health Plan’s disease management program. This policy and procedure shall
include coordination with the disease management organization (DMO) that
provided services to the enrollee before enrollment in the Health Plan.
Additionally, the Health Plan shall request that the enrollee sign a limited
release of information to aid the Health Plan in accessing the DMO’s information
for the enrollee.     d.   The Health Plan shall develop and use a plan of
treatment for chronic disease follow-up care that is tailored to the individual
enrollee. The purpose of the plan of treatment is to

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      assure appropriate ongoing treatment reflecting the highest standards of
medical care designed to minimize further deterioration and complications. The
plan of treatment shall be on file for each enrollee with a chronic disease and
shall contain sufficient information to explain the progress of treatment.
Medication management, the review of medications that an enrollee is currently
taking, should be an ongoing part of the plan of treatment to ensure that the
enrollee does not suffer adverse effects or interactions from contra-indicated
medications. The enrollee’s ability to adhere to a treatment regimen should be
monitored in the plan of treatment as well.

3. Non-Reform Health Plans
Section VIII, Quality Management, Item B., Utilization Management

  5.   Disease Management — The Agency encourages the Health Plan to develop and
implement disease management programs for enrollees living with chronic
conditions.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 9
Grievance System
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.
N/A
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AMERIGROUP Community Care
  HMO Contract

Exhibit 10
Administration and Management
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. All Capitated Health Plans
Section X, Administration and Management, Item C., Claims Payment

  1.   The date of claim receipt is the date the Health Plan receives the claim
at its designated claims receipt location.     2.   The date of Health Plan
claim payment is the date of the check or other form of payment.     3.   For
all electronically submitted claims for capitated services, the Health Plan
shall:

  a.   Within twenty-four (24) hours after the beginning of the next business
day after receipt of the claim, provide electronic acknowledgment of the receipt
of the claim to the electronic source submitting the claim.     b.   Within
twenty (20) calendar days after receipt of the claim, pay the claim or notify
the provider or designee that the claim is denied or contested. The notification
to the provider of a contested claim shall include an itemized list of
additional information or documents necessary to process the claim.     c.   Pay
or deny the claim within ninety (90) calendar days after receipt of the claim.
Failure to pay or deny the claim within one hundred and twenty (120) calendar
days after receipt of the claim creates an uncontestable obligation for the
Health Plan to pay the claim.

  4.   For all non-electronically submitted claims for capitated services, the
Health Plan shall:

  a.   Within fifteen (15) calendar days after receipt of the claim, provide
acknowledgment of receipt of the claim to the provider or designee or provide
the provider or designee with electronic access to the status of a submitted
claim.     b.   Within forty (40) calendar days after receipt of the claim, pay
the claim or notify the provider or designee that the claim is denied or
contested. The notification to the provider of a contested claim shall include
an itemized list of additional information or documents necessary to process the
claim.     c.   Pay or deny the claim within one hundred and twenty
(120) calendar days after receipt of the claim. Failure to pay or deny the claim
within one hundred and forty (140) calendar days after receipt of the claim
creates an uncontestable obligation for the Health Plan to pay the claim.

  5.   The Health Plan shall reimburse providers for the delivery of authorized
services as described in s. 641.3155, F.S., including, but not limited to:

  a.   The provider must mail or electronically transfer (submit) the claim to
the Health Plan within six (6) months after:

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AMERIGROUP Community Care
  HMO Contract

  (1)   The date of service or discharge from an inpatient setting; or     (2)  
The date that the provider was furnished with the correct name and address of
the Health Plan.

  b.   When the Health Plan is the secondary payer, the provider must submit the
claim to the Health Plan within ninety (90) calendar days after the final
determination of the primary payer.

  6.   In accordance with s. 409.912, F.S., the Health Plan shall reimburse any
hospital or physician that is outside the Health Plan’s authorized geographic
service area for Health Plan authorized services provided by the hospital or
physician to enrollees:

  a.   At a rate negotiated with the hospital or physician; or     b.   The
lesser of the following:

  (1)   The usual and customary charge made to the general public by the
hospital or physician; or     (2)   The Florida Medicaid reimbursement rate
established for the hospital or physician.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 11
Information Management and Systems
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
II of this Contract, unless otherwise specified.
N/A
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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 12
Reporting Requirements
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.
N/A
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AMERIGROUP Community Care
  HMO Contract

Exhibit 13
CAP-Reform
Method of Payment
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Capitated Reform Health Plans

A.   Payment Overview       This is a fixed price (unit cost) Contract. The
Agency will manage this fixed price Contract for the delivery of covered
services to enrollees. The Agency or its fiscal agent shall make payment to the
Health Plan on a monthly basis for the Health Plan’s satisfactory performance of
its duties and responsibilities as set forth in this Contract. To accommodate
payments, the Health Plan is enrolled as a Medicaid provider with the fiscal
agent. Payments made to the Health Plan resulting from this Contract include
monthly capitation rate payments for either a comprehensive component or a
comprehensive component and catastrophic component, both of which contain risk
adjustments, and were developed for particular Medicaid populations, and may
contain an adjustment to collect amounts for the enhanced benefit accounts fund.
The Agency may also pay Health Plans for obstetrical delivery and transplant
services through kick payments; for covered services that are over the
catastrophic component threshold, if the Health Plan has contracted for the
comprehensive component only; and for CHCUP incentive payments, if any, as
specified below.   B.   Capitation Rate Payments 1. The Agency’s capitation rate
payments shall meet the following requirements:

  a.   Medicaid Reform capitation rates will begin with the September 1, 2009,
capitation rate payments.

  (1)   For SSI Medicare Part B-only enrollees and SSI Medicare Parts A and B
enrollees, the capitation rates are based on non-Reform capitation rate
methodology for the age groups listed in Attachment I.     (2)   The capitation
rates for all other enrollees are fully risk-adjusted.

  (a)   The Agency will pay the Health Plan the HIV/AIDS capitation rate only
for those enrollees who have been identified and verified as having an HIV/AIDS
diagnosis. The HIV/AIDS capitation rate is provided in Attachment I.

  (i)   The Agency will pay the HIV/AIDS capitation rate for those enrollees who
have been identified as having an HIV/AIDS diagnosis, regardless of whether or
not the Health Plan is a specialty plan.     (ii)   Enrollees with an HIV/AIDS
diagnosis may be identified by either the Agency or the Health Plan. For the
Health Plan to identify that an enrollee has an

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  HMO Contract

      HIV/AIDS diagnosis, the Health Plan must have completed lab testing as
interpreted by a licensed physician prior to reporting the enrollee to the
Agency as an identified enrollee with an HIV/AIDS diagnosis. The Health Plan
shall provide the Agency with such enrollee’s test results upon request.    
(iii)   The Health Plan shall submit enrollees identified with an HIV/AIDS
diagnosis to BMHC in a format and transmittal method approved by the Agency as
specified in the Agency’s Report Guide. See Attachment II, Section XII,
Reporting Requirements, of this Contract.     (iv)   The Agency shall not pay
the HIV/AIDS capitation rate for any enrollee who was not identified as HIV/AIDS
prior to enrollment processing for the month for which the capitation payment is
made, nor shall the Agency make a retroactive capitation payment at the HIV/AIDS
capitation rate if the enrollee was identified as HIV/AIDS after enrollment
processing.

  (b)   The Agency will pay the Health Plan the capitation rate for children
with chronic conditions only if the enrollee meets the requirements for children
with chronic conditions, as identified by the Agency, and the enrollee is
enrolled in a specialty plan for children with chronic conditions based on the
rates specified in Attachment I.

  b.   For each eligibility category indicated, and for each age group
indicated, the Agency will make a capitation payment for enrollees as provided
for in the capitation rate tables in Attachment I as follows:

  (1)   Enrollees who are in the Children and Families and the Aged and Disabled
eligibility categories, not identified as diagnosed with HIV/AIDS and not
enrolled in a specialty plan as identified children with chronic conditions;    
(2)   Enrollees who are in the SSI Medicare Part B-only and the SSI Medicare
Parts A and B eligibility categories, and who are not identified as diagnosed
with HIV/AIDS or enrolled in a specialty plan as identified children with
chronic conditions enrollees;     (3)   Enrollees who are identified as
diagnosed with HIV/AIDS.

  c.   HIV/AIDS specialty plan enrollees who are family members of enrollees
identified as diagnosed with HIV/AIDS, and who are not identified as diagnosed
with HIV/AIDS, will receive a capitation rate based on their respective
eligibility categories in capitation rate tables in Attachment I. In developing
the capitation rates for these family members, a plan factor of 1.0 will be
assigned until the Agency determines that the Health Plan has enough population
of such enrollees to warrant its own plan factor.     d.   The capitation rates
for enrollees who are in the children with chronic conditions specialty plan are
provided in Attachment I. Sibling enrollees who are enrolled in the children
with chronic conditions specialty plan, and are not identified as children with
chronic conditions, will receive a capitation rate based on their respective
eligibility

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      categories in capitation rate tables in Attachment I. In developing the
capitation rates for these family members, a plan factor of 1.0 will be assigned
until the Agency determines that the Health Plan has enough population of such
enrollees to warrant its own plan factor.     e.   The risk-adjusted capitation
rates paid by the Agency are either for the comprehensive component or
comprehensive component and catastrophic component as specified below.

  (1)   Health Plans are required to provide the comprehensive component and the
catastrophic component to enrollees in the following manner:

  (a)   For Contracts serving Broward County and/or Duval County, Health Plans
that are not capitated PSNs are required to provide both the comprehensive
component and catastrophic component. This means that the Health Plan is
responsible for the cost of providing covered services up to the benefit maximum
determined by the Agency for the Contract year.     (b)   For Contracts serving
Broward County and/or Duval County, Health Plans that are capitated PSNs must
provide the comprehensive component and may choose to provide the catastrophic
component. The capitated PSN’s choice shall be documented in Attachment I.

  i.   If the capitated PSN has chosen to provide both the comprehensive
component and the catastrophic component, the Health Plan is responsible for the
cost of providing covered services up to the benefit maximum determined by the
Agency for the Contract year.     ii.   If the capitated PSN has chosen to
provide the comprehensive component only, the Health Plan shall be responsible
for the cost of providing covered services up to the catastrophic component
threshold by the Agency for the Contract year. Such a Health Plan will receive
reimbursement from the Agency for its costs beyond the catastrophic threshold up
to the benefit maximum. This reimbursement shall be based on a percentage of
Medicaid fee-for-service payment levels.

  (c)   For Contracts serving Baker County, Clay County and/or Nassau County,
the Health Plan is required to provide the comprehensive component and may
choose to provide the catastrophic component to its enrollees in those counties.

  i.   If, by this Contract, as specified in Attachment I, the Health Plan has
agreed to provide both the comprehensive component and the catastrophic
component, then the Health Plan is responsible for the cost of providing the
enrollee with covered services up to the benefit maximum determined by the
Agency for the Contract year.     ii.   If, by this Contract, as specified in
Attachment I, the Health Plan has agreed to provide the comprehensive component
only, then the Health Plan is

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      financially responsible for the provision of covered services up to the
catastrophic component threshold determined by the Agency for the Contract year.

  (2)   For purposes of calculating whether an enrollee has met the catastrophic
component threshold and the benefit maximum, a Health Plan’s costs shall be
converted to the Medicaid fee-for-service payment levels. For services covered
by the Health Plan for which there is no Medicaid fee, the Agency will use the
amount the Health Plan paid for the service. Upon the Agency’s request, the
Health Plan shall provide documentation to validate payment and services
rendered. In addition, if the Health Plan receives payment from the Agency for
kick payment services, the kick payment made by the Agency will be included
toward the catastrophic component threshold and toward the benefit maximum.    
(3)   Health Plans will be paid capitation rates for the comprehensive component
and the catastrophic component or for the comprehensive component only, in
accordance with whether the Health Plan agreed, by this Contract, to provide
both the comprehensive component and catastrophic component or to provide only
the comprehensive component.

  2.   The Agency’s capitation rates are included as Attachment I, titled
“ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

  a.   The Agency may use, or may amend and use these rates, only after
certification by its actuary and approval by the Centers for Medicare and
Medicaid Services. Inclusion of these rates is not intended to convey or imply
any rights, duties or obligations of either party, nor is it intended to
restrict, restrain or control the rights of either party that may have existed
independently of this section of the Contract.     b.   By signature on this
Contract, the parties explicitly agree that this section shall not independently
convey any inherent rights, responsibilities or obligations of either party,
relative to these rates, and shall not itself be the basis for any cause of
administrative, legal or equitable action brought by either party. In the event
that the rates certified by the actuary and approved by CMS are different from
the rates included in this Contract, the Health Plan agrees to accept a
reconciliation performed by the Agency to bring payments to the Health Plan in
line with the approved rates. The Agency may amend and use the CMS-approved
rates by notice to the Health Plan through an amendment to the Contract.

  3.   The Agency shall pay the applicable capitation rate for each eligible
enrollee whose name appears on the HIPAA-compliant X12-820 file for each month,
except that the Agency shall not pay for, and, in accordance with subsections F.
and G. of this exhibit, shall recoup payment for, any part of the total
enrollment that exceeds the maximum authorized enrollment level(s) expressed in
this Contract in Attachment I. The total payment amount to the Health Plan shall
depend on the number of enrollees in each eligibility category and each rate
group, and whether the Health Plan is providing the comprehensive component only
or the comprehensive component and the catastrophic component, and at a rate
that has been risk-adjusted pursuant to this Contract, or as adjusted pursuant
to the Contract, where necessary in accordance with subsection F. of this
exhibit.

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  a.   The Health Plan is obligated to provide services pursuant to the terms of
this Contract for all enrollees for whom the Health Plan has received capitation
payment or for whom the Agency has assured the Health Plan that the capitation
payment is forthcoming.     b.   To ensure a seamless health care delivery
system for the enrollee, if the Health Plan contracts for the comprehensive
component only, the Health Plan continues to be responsible for coordinating,
managing, and delivering all enrollee care up to the benefit maximum regardless
of whether the cost of the enrollee’s covered services is above and beyond the
catastrophic component threshold.     c.   Regardless of whether the Health Plan
is at risk for the comprehensive component only or for both the comprehensive
component and the catastrophic component, the Health Plan shall continue to be
responsible for coordinating and managing all enrollee care even if the cost of
the enrollee’s covered services is above and beyond the benefit maximum.

  4.   The capitation rates to be paid specific to the Health Plan shall be as
indicated in the payment tables in Attachment I, and adjusted monthly based on
the Health Plan’s plan factor.     5.   Unless otherwise specified in this
Contract, the Health Plan shall accept the capitation payment received each
month as payment in full by the Agency for all services provided to enrollees
covered under this Contract and the administrative costs incurred by the Health
Plan in providing or arranging for such services. Any and all costs incurred by
the Health Plan in excess of the capitation payment shall be borne in total by
the Health Plan.     6.   The Agency shall pay a retroactive capitation rate for
each newborn enrolled in the Health Plan for up to the first three (3) months of
life provided the newborn was enrolled through the unborn activation process.

  a.   The Health Plan shall use the unborn activation process to enroll all
babies born to pregnant enrollees as specified in Attachment II, Section III,
Eligibility and Enrollment.     b.   The Health Plan is responsible for payment
of all covered services provided to newborns enrolled through the unborn
activation process.

C. Kick Payments

  1.   The Agency shall pay the Health Plan one kick payment for the following
covered services for enrollees who are not also eligible for Medicare:

  a.   Each obstetrical delivery, and     b.   Each covered transplant.

  2.   The Agency shall make kick payments in the amounts indicated in
Attachment I.

  a.   For Health Plans that provide only the comprehensive component, kick
payment services will be counted toward the catastrophic component threshold.
Once the threshold has been met, the Agency will continue to reimburse the
Health Plan any kick

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      payment services delivered by the Health Plan at the kick payment amounts
specified in Attachment I of this Contract.     b.   For kick payment purposes,
an obstetrical delivery includes all births resulting from the delivery;
therefore, if an obstetrical delivery results in multiple births, the Agency
will make only one kick payment. This includes still births as specified in the
Medicaid Physicians Services Handbook.     c.   For Health Plans under Contract
as specialty plans, reimbursement for kick payment services will be counted
toward the enrollee’s benefit maximum.

  3.   To receive a kick payment, the Health Plan must adhere to the specific
requirements listed in subsections 4. and 5. below and adhere to the following
requirements:

  a.   The Health Plan must have provided the covered kick payment service while
the recipient was enrolled in the Health Plan; and     b.   The Health Plan
shall submit any required documentation to the Agency upon its request in order
to receive the kick payment applicable to the covered service provided.

  4.   In addition to subsection 3. above, to receive a kick payment for covered
transplants provided to an enrollee without Medicare, the Health Plan shall also
comply with the following requirements:

  a.   For each transplant provided, the Health Plan shall submit an accurate
and complete CMS-1500 claim form (CMS-1500) and operative report to the fiscal
agent within the required Medicaid fee-for-service claims submittal timeframes  
  b.   The Health Plan shall list itself as both the pay-to and the treating
provider on the CMS- 1500; and     c.   The Health Plan shall use the following
list of transplant procedure codes relative to the type of transplant performed
when completing Field 24 D on the CMS-1500:

      CPT     Code   Transplant CPT Code Description
32851
  lung single, without bypass
 
   
32852
  lung single, with bypass
 
   
32853
  lung double, without bypass
 
   
32854
  lung double, with bypass
 
   
33945
  heart transplant with or without recipient cardiectomy
 
   
47135
  liver, allotransplantation, orthotopic, partial or whole from cadaver or
living donor
 
   
47136
  liver, heterotopic, partial or whole from cadaver or living donor any age

  5.   In addition to subsection 3. above, to receive a kick payment for the
covered obstetrical delivery provided to an enrollee, the Health Plan shall also
comply with the following requirements:

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  a.   The Health Plan shall submit an accurate and complete claim form in
sufficient time to be received by the fiscal agent within nine months following
the date of service delivery. The Health Plan shall submit the claim
electronically in a HIPAA compliant X12 837P format;

  b.   The Health Plan shall list itself as both the pay-to and the treating
provider; and

  c.   The Health Plan shall use the following list of delivery procedure codes
relative to the type of delivery performed when submitting the X12 837P
transaction:

      CPT     Code   Obstetrical Delivery CPT Code Description
59409
  Vaginal delivery only
 
   
59410
  Vaginal delivery including postpartum care
 
   
59515
  Cesarean delivery including postpartum care
 
   
59612
  Vaginal delivery only, after previous cesarean delivery
 
   
59614
  Vaginal delivery only, after previous cesarean delivery including postpartum
care
 
   
59622
  Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery including postpartum care

D. Claims Payment for Health Plans Accepting Financial Risk for the
Comprehensive Component Only

  1.   In order for Health Plans accepting financial risk for only the
comprehensive component to receive reimbursement from the Agency for incurred
expenditures for covered services for an enrollee who has reached the annual
catastrophic component threshold, the Health Plan shall adhere to the following
requirements:

  a.   The Health Plan shall notify BMHC in writing, in an Agency-specified
format as specified in Attachment II, Section XII, Reporting Requirements, when
expenditures it has paid for an enrollee’s covered services exceed $25,000 prior
to the end of a Contract year.     b.   For enrollee’s whose Health Plan
expenditures for covered services costs exceed $25,000, the Health Plan shall
update BMHC in writing, as specified in Section XII, Reporting Requirements,
Attachment II, and on a monthly basis, of the Health Plan’s additional
expenditures for covered services for the enrollee until the enrollee has
exceeded the catastrophic component threshold or for the remainder of the
Contract year, whichever occurs first;     c.   Once the Agency has reviewed the
covered services expenditure information provided by the Health Plan and has
determined that a Health Plan’s expenditures for an enrollee have exceeded the
catastrophic component threshold for the Medicaid covered services received
based on Florida Medicaid’s fee schedules and as indicated in subsection
B.1.c.(2) of this exhibit, and the Health Plan has received Agency notification
that the enrollee has met the catastrophic component threshold, the Health

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      Plan shall submit the following to the Agency, or its fiscal agent, in
order to receive reimbursement for covered services provided:

  (1)   An accurate and fully completed claim form in the Agency’s designated
format and within the Medicaid FFS time frames for claims submission. The Health
Plan shall list itself as both the pay-to and treating provider.     (2)   Any
specified data requested by the Agency regarding treating providers unknown to
FMMIS.     (3)   Health Plan claims data, for an Agency-specified data set in an
Agency-specified format and transmittal method, that documents that the Health
Plan’s expenditures, after conversion to the appropriate Medicaid fee (as
applicable) are an amount equal to the catastrophic component threshold.

  2.   For Health Plans providing the comprehensive component only, the Agency
will be responsible for payment to the Health Plan for Medicaid-covered services
provided in excess of the catastrophic component threshold up to the enrollee’s
benefit maximum.

  a.   With the exception of kick payment services, such payment will be made at
ninety-five percent (95%) of the Medicaid FFS payment rate, less co-payment or
coinsurance required under the Medicaid fee schedule, for the respective
Medicaid-covered service provided and paid for by the Health Plan.     b.   For
kick payment services provided by the Health Plan, the Agency’s payment to the
Health Plan will be the kick payment amount specified in Attachment I.     c.  
For covered services provided by the Health Ran for which there is not a
Medicaid payment rate, the Agency will pay the actual amount the Health Plan
paid to the provider less five percent (5%).     d.   If the Health Plan submits
claims to the Agency, or its fiscal agent, for covered services that are not in
excess of the catastrophic component threshold, or claims for covered services
beyond the benefit maximum, and the Agency reimburses the Health Plan for those
claims, the Agency will recoup such reimbursement or the Health Plan will be
responsible for repayment in accordance with the payment assessments and errors
subsections below.

E. Child Health Check-Up (CHCUP) Incentive Payments
Health Plans will be eligible to participate in the CHCUP incentive program when
the Health Plan has exceeded both the sixty percent (60%) state screening rate
and the federal eighty percent (80%) participation and screening ratio goals as
outlined in Attachment II, Section V, Covered Services. The Agency will
determine which Health Plans will participate based upon the audited CHCUP
reports submitted.

  1.   The amount of the incentive payment shall be calculated as follows: the
ratio of a qualified Health Plan’s screenings to the total of all health plans’
screenings will be multiplied by the total amount in the fund for the incentive
payment. The ratios will be based on the Health Plans’ audited CHCUP reports.
The total amount in the fund will be determined at the

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  2.   Pursuant to 42 CFR 438.6, (5)(iii), the payment to any one health plan
shall not be in excess of five percent (5%) of the capitation amount paid to all
health plans for CHCUP services provided pursuant to this Contract.

F. Payment Assessments

  1.   Choice Counseling/Enrollment and Disenrollment

In accordance with s 409.912 (29), F.S., at such time as the Agency receives
legislative direction to assess health plans for enrollment and disenrollment
services costs, the Agency shall apply assessments, in quarterly installments
each year, against the Health Plan’s next capitation payment to pay for the
enrollment and disenrollment services costs of the choice counselor/enrollment
broker as follows:

  a.   July 1, for costs estimated for the enrollment and disenrollment services
rendered by the choice counselor/enrollment broker for July and the following
two (2) months;     b.   October 1, for costs related to the enrollment and
disenrollment services rendered by the choice counselor/enrollment broker for
October and the following two (2) months;     c.   January 1, for costs related
to the enrollment and disenrollment services rendered by the choice
counselor/enrollment broker for January and the following two (2) months; and  
  d.   April 1, for costs related to maintaining the third party enrollment and
disenrollment services contract for April and the following two (2) months.

  2.   Rate Adjustments

The Health Plan and the Agency acknowledge that the capitation rates paid under
this Contract, as specified in Attachment I of this Contract, are subject to
approval by the federal government.

  a.   Adjustments to funds previously paid and to be paid may be required.
Funds previously paid shall be adjusted when capitation rate calculations are
determined to have been in error, or when capitation payments have been made for
Medicaid recipients who are determined to be ineligible for Health Plan
enrollment during the period for which the capitation payments were made. In
such events, the Health Plan agrees to refund any overpayment and the Agency
agrees to pay any underpayment.     b.   If the Agency receives legislative
direction as specified in subsection F.1., Payment Assessments, Choice
Counseling, respectively, the Agency shall annually, or more frequently,
determine the actual expenditures for enrollment and disenrollment services
rendered by the choice counselor/enrollment broker. The Agency will compare
capitation rate assessments to the actual expenditures for such enrollment and
disenrollment services. The following factors will enter into the cost
settlement process:

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  (1)   If the amount of capitation rate assessments is less than the actual
cost of providing enrollment and disenrollment services rendered by the choice
counselor/enrollment broker, the Health Plan shall pay the difference to the
Agency within thirty (30) calendar days of settlement.     (2)   If the amount
of capitation assessments exceeds the actual cost of providing enrollment, and
disenrollment services, the Agency will pay the difference to the Health Plan
within thirty (30) calendar days of the settlement.

  c.   As the Agency adjusts the plan factor based on updated historical data,
the Health Plan’s capitation rates will be adjusted according to the methodology
indicated in the capitation rate tables.     d.   The Agency may adjust the
Health Plan’s capitation rates if the percentage deducted for the enhanced
benefit accounts fund is modified due to program needs.

G. Errors

  1.   The Health Plan shall carefully prepare all reports and monthly payment
requests for submission to the Agency.     2.   If after preparation and
electronic submission, either the Health Plan or the Agency discover an error,
including but not limited to errors resulting in incorrect kick payments, errors
resulting in incorrect identification of enrollees (including but not limited to
specific identification of enrollees with HIV/AIDS diagnoses), errors resulting
in incorrect claims payments, and errors resulting in capitation rate payments
above the Health Plan’s authorized enrollment levels, the Health Plan has thirty
(30) calendar days after its discovery of the error, or from its receipt of
Agency notice of the error, to correct the error and re-submit accurate reports
and/or invoices. Failure to respond within the thirty (30) calendar day period
shall result in a loss of any money due the Health Plan for such errors and/or a
sanction against the Health Plan pursuant to Attachment II, Section XIV,
Sanctions.

H. Member Payment Liability Protection
Pursuant to s. 1932 (b)(6), Social Security Act (as enacted by section 4704 of
the Balanced Budget Act of 1997), the Health Plan shall not hold members liable
for the following:

  1.   For debts of the Health Plan, in the event of the Health Plan’s
insolvency;     2.   For payment of covered services provided by the Health Plan
if the Health Plan has not received payment from the Agency for the covered
services, or if the provider, under contract or other arrangement with the
Health Plan, fails to receive payment from the Agency or the Health Plan; and/or
    3.   For payments to a provider, including referral providers, that
furnished covered services under a contract, or other arrangements with the
Health Plan, that are in excess of the amount that normally would be paid by the
enrollee if the covered services had been received directly from the Health
Plan.

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Exhibit 13
CAP-Non-Reform
Method of Payment
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Non-Reform Capitated Health Plans
A. Fixed Price Unit Contract
This is a fixed price (unit cost) Contract. The Agency or its appointed fiscal
agent shall make payment to the Health Plan on a monthly basis for the Health
Plan’s satisfactory performance of its duties and responsibilities as set forth
in this Contract. To accommodate payments, the Health Plan is capitated with the
fiscal agent.
B. Child Health Check-Up (CHCUP) Incentive Program
Health Plans will be eligible to participate in the CHCUP incentive program when
the Health Plan has exceeded both the sixty percent (60%) state screening rate
and the federal eighty percent (80%) participation and screening ratio goals as
outlined in Attachment II, Section V, Covered Services. The Agency will
determine which health plans will participate based upon the audited CHCUP
reports submitted each October as set forth in Attachment II, Section XII,
Reporting Requirements.

  1.   The amount of the incentive payment shall be calculated as follows: The
ratio of a qualified Health Plan’s screenings to the total of all health plans’
screenings will be multiplied by the total amount in the fund for the incentive
payment. The ratios will be based on the Health Plans’ audited CHCUP reports.
The total amount in the fund will be determined at the discretion of the Agency.
In no event shall the total monies allotted to the incentive program exceed the
incentive payment fund.     2.   Pursuant to 42 CFR 438.6, (c)(5)(iii), the
payment to any one health plan shall not be in excess of five percent (5%) of
the capitation amount paid to all health plans for CHCUP services provided
pursuant to this Contract.

C. Capitation Rates
The Agency shall pay the applicable capitation rate for each eligible enrollee
whose name appears on the HIPAA-compliant X12 820 file for each month, except
that the Agency shall not pay for, and shall recoup, any part of the total
enrollment that exceeds the maximum authorized enrollment level(s) expressed in
Attachment I. The total payment amount to the Health Plan shall depend upon the
number of enrollees in each eligibility category and each rate group, as
provided for by this Contract, or as adjusted pursuant to the Contract when
necessary. The Health Plan is obligated to provide services pursuant to the
terms of this Contract for all enrollees for whom the Health Plan has received
capitation payment and for whom the Agency has assured the Health Plan that
capitation payment is forthcoming.

  1.   The Agency’s capitation rates are developed using historical rates paid
by Medicaid fee-forservice for similar services in the same service area,
adjusted for inflation, where applicable, in accordance with 42 CFR 438.6(c).
These rates are included as Attachment I,

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  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”

  a.   The Agency may use, or may amend and use these rates, only after
certification by its actuary and approval by the Centers for Medicare and
Medicaid Services. Inclusion of these rates is not intended to convey or imply
any rights, duties or obligations of either party, nor is it intended to
restrict, restrain or control the rights of either party that may have existed
independently of this section of the Contract.     b.   By signature on this
Contract, the parties explicitly agree that this section shall not independently
convey any inherent rights, responsibilities or obligations of either party,
relative to these rates, and shall not itself be the basis for any cause of
administrative, legal or equitable action brought by either party. In the event
that the rates certified by the actuary and approved by CMS are different from
the rates included in this Contract, the Health Plan agrees to accept a
reconciliation performed by the Agency to bring payments to the Health Plan in
line with the approved rates. The Agency may amend and use the CMS-approved
rates by notice to the Health Plan through an amendment to the Contract.

  2.   The capitation rates to be paid specific to the Health Plan shall be as
indicated in Attachment I, which indicates the initial and maximum authorized
enrollment levels and capitation rates applicable to each authorized eligibility
category.     3.   At such time as the Agency receives legislative direction to
assess Health Plans for enrollment and disenrollment services costs, the Agency
shall apply assessments, in quarterly installments each Contract year, against
the Health Plan’s next capitation payment to pay for the enrollment and
disenrollment services contractor as follows:

  a.   July 1, for costs estimated for the Agency’s enrollment and disenrollment
services contractor system and Contract for July and the following two
(2) months.     b.   October 1, for costs related to the third party enrollment
and disenrollment services Contract for October and the following two
(2) months.     c.   January 1, for costs related to maintaining the third party
enrollment and services Contract for January and the following two (2) months.  
  d.   April 1, for costs related to maintaining the third party enrollment and
disenrollment services contract for April and the following two (2) months.

  4.   Unless otherwise specified in this Contract, the Health Plan shall accept
the capitation payment received each month as payment in full by the Agency for
all services provided to enrollees covered under this Contract and the
administrative costs incurred by the Health Plan in providing or arranging for
such services. Any and all costs incurred by the Health Plan in excess of the
capitation payment shall be borne in total by the Health Plan.     5.   The
Agency shall pay a retroactive capitation rate for each newborn enrolled in the
Health Plan for up to the first three (3) months of life, provided the newborn
was enrolled through the unborn activation process.

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

  a.   The Health Plan shall use the unborn activation process to enroll all
babies born to pregnant enrollees as specified in Section III, Eligibility and
Enrollment, B.3, Unborn Activation and Newborn Enrollment.     b.   The Health
Plan is responsible for payment of all covered services provided to newborns
enrolled through the unborn activation process.

D. Rate Adjustments and Payment Assessments

  1   The Health Plan and the Agency acknowledge that the capitation rates paid
under this Contract are subject to approval by the federal government.     2.  
The Health Plan and the Agency acknowledge that adjustments to funds previously
paid, and to funds yet to be paid, may be required. Funds previously paid shall
be adjusted when capitation rate calculations are determined to have been in
error, or when capitation rate payments have been made for enrollees who are
determined not to have been eligible for Health Plan membership during the
period for which the capitation rate payments were made. In such events, the
Health Plan agrees to refund any overpayment and the Agency agrees to pay any
underpayment.     3.   The Agency agrees to adjust capitation rates to reflect
budgetary 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 shall take effect on the dates specified
in the legislation.     4.   At such time the Agency receives the appropriate
legislative direction as specified above, the Agency shall annually, or more
frequently, determine the actual expenditures for enrollment and disenrollment
services. The Agency will compare capitation rate assessments to the actual
costs for enrollment and disenrollment services. The following factors will
enter into any cost settlement process:

  a.   If the amount of capitation rate assessments are less than the actual
cost of providing enrollment and disenrollment services, the Health Plan will
return the difference to the Agency within thirty (30) calendar days of
settlement.     b.   If the amount of capitation rate assessments exceeds the
actual cost of providing enrollment and disenrollment services, the Agency will
make up the difference to the Health Plan within thirty (30) calendar days of
the settlement.

E. Errors
The Health Plan shall carefully prepare all reports and monthly payment requests
for submission to the Agency. If after preparation and electronic submission,
the Health Plan discovers an error, including, but not limited to, errors
resulting in capitated payments above the Health Plan’s authorized levels,
either by the Health Plan or the Agency, the Health Plan has thirty
(30) calendar days from its discovery of the error, or thirty (30) calendar days
after receipt of notice by the Agency, to correct the error and re-submit
accurate reports and/or invoices. Failure to respond within the thirty
(30) calendar day period shall result in a loss of any money due to the Health
Plan for such errors and/or sanctions against the Health Plan pursuant to
Attachment II, Section XIV, Sanctions.
AHCA Contract No. FA913, Attachment II, Exhibit 13-NR, Page 62 of 68

 

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F. Member Payment Liability Protection
Pursuant to s. 1932 (b)(6), Social Security Act (as enacted by section 4704 of
the Balanced Budget Act of 1997), the Health Plan shall not hold members liable
for the following:

  1.   For debts of the Health Plan, in the event of the Health Plan’s
insolvency;     2.   For payment of covered services provided by the Health Plan
if the Health Plan has not received payment from the Agency for the covered
services, or if the provider, under contract or other arrangement with the
Health Plan, fails to receive payment from the Agency or the Health Plan; and/or
    3.   For payments to a provider, including referral providers, that
furnished covered services under a contract, or other arrangements with the
Health Plan, that are in excess of the amount that normally would be paid by the
enrollee if the covered services had been received directly from the Health
Plan.

G. Transition to Medicaid Reform (Non-Reform Health Plans)

  1.   The Health Plan understands that the state began Medicaid Reform in
Broward County and Duval County on September 1, 2006, with Baker, Clay, and
Nassau Counties added September 1, 2007, as authorized by the state. As a
result, in all areas in which the state implements Medicaid Reform, the Health
Plan’s enrollment will transition from coverage under this Contract to the
Medicaid Reform Contract in accordance with the Agency’s implementation
schedule.     2.   When the state authorizes expansion of Medicaid Reform into a
new county in which the Health Plan is currently providing, or will provide,
Medicaid services, the Health Plan acknowledges that it must request an
amendment for an expansion of service under the Contract in order to continue to
provide benefits in the new Medicaid Reform county. Upon implementation of
Medicaid Reform, the Health Plan:

  a.   Shall not engage in marketing or community outreach activities with
regard to the services and/or benefits provided under this Contract; and     b.
  Shall receive voluntary or mandatory enrollees for the Medicaid Reform county
under this Contract.

H. Cost Effectiveness
The Agency shall ensure that the Health Plan is cost-effective (see s.
409.912(44), F.S.). The Agency may not renew this Contract if it is not
cost-effective.
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 14
Sanctions
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.
N/A
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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

Exhibit 15
Financial Requirements
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Non-Reform Capitated Health Plans and Reform HMOs
Section XV, Financial Requirements, Item A., Insolvency Protection

  1.   The Health Plan shall establish a restricted insolvency protection
account with a federally guaranteed financial institution licensed to do
business in Florida in accordance with s. 1903(m)(1) of the Social Security Act
(amended by s. 4706 of the Balanced Budget Act of 1997), and s. 409.912, F.S.,
and, for capitated PSNs, the solvency requirements established in approved
federal waivers. The Health Plan shall deposit into that account five percent
(5%) of the capitation payments made by the Agency each month until a maximum
total of two percent (2%) of the annualized total current Contract amount is
reached and maintained. No interest may be withdrawn from this account until the
maximum Contract amount is reached and withdrawal of the interest will not cause
the balance to fall below the required maximum amount. This provision shall
remain in effect as long as the Health Plan continues to contract with the
Agency.     2.   The restricted Insolvency protection account may be drawn upon
with the authorized signatures of two (2) persons designated by the Health Plan
and two (2) representatives of the Agency. The Multiple Signature Agreement Form
shall be resubmitted to BMHC within thirty (30) calendar days of Contract
execution and resubmitted within thirty (30) calendar days after a change in
authorized Health Plan personnel occurs. If the authorized persons remain the
same, the Health Plan shall submit an attestation to this effect annually by
April 1 of each Contract year to BMHC along with a copy of the latest bank
statement. The Health Plan may obtain a sample Multiple Signature Verification
Agreement form from the Agency or its agent or download from the BMHC website
at: http://ahca.myflorida.com/MCHQ/Manaqed Health Care/MHMO/med prov.shtml All
such agreements or other signature cards shall be approved in advance by BMHC.  
  3.   In the event that a determination is made by the Agency that the Health
Plan is insolvent, as defined in Attachment II, Section I, Definitions, the
Agency may draw upon the amount solely with the two (2) authorized signatures of
representatives of the Agency and funds may be disbursed to meet financial
obligations incurred by the Health Plan under this Contract. A statement of
account balance shall be provided by the Health Plan within fifteen
(15) calendar days of request of the Agency.     4.   If the Contract is
terminated, expired, or not continued, the account balance shall be released by
the Agency to the Health Plan upon receipt of proof of satisfaction of all
outstanding obligations incurred under this Contract.     5.   In the event the
Contract is terminated or not renewed and the Health Plan is insolvent, the
Agency may draw upon the insolvency protection account to pay any outstanding
debts the Health Plan owes the Agency including, but not limited to,
overpayments made to the Health Plan, and fines imposed under the Contract or,
for HMOs, s. 641.52, F.S., for which a final order has been issued. In addition,
if the Contract is terminated or not renewed and the Health Plan is unable to
pay all of its outstanding debts to health care providers, the

AHCA Contract No. FA913, Attachment II, Exhibit 15, Page 65 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      Agency and the Health Plan agree to the court appointment of an impartial
receiver for the purpose of administering and distributing the funds contained
in the Insolvency protection account. An appointed receiver shall give
outstanding debts owed to the Agency priority over other claims.

2. Reform Capitated PSNs
Section XV, Financial Requirements, Item B., Insolvency Protection Account
Waiver

  1.   A capitated Health Plan is required to assume responsibility for
comprehensive coverage and meet the following financial reserve requirements:

  a.   The capitated Health Plan shall maintain a minimum surplus in an amount
that is the greater of $1 million or one and one half percent (1.5%) of
projected annual premiums.     b.   In lieu of the requirements above, the
Agency may consider the following:

  (1)   If the organization is a public entity, the Agency may take under
advisement a statement from the public entity that a county supports the Health
Plan with the county’s full faith and credit. In order to qualify for the
Agency’s consideration, the county must own, operate, manage, administer, or
oversee the Health Plan, either partly or wholly, through a county department or
agency;     (2)   The state guarantees the solvency of the organization;     (3)
  The organization is a federally qualified health center or is controlled by
one (1) or more federally qualified health centers and meets the solvency
standards established by the state for such organization pursuant to s.
409.912(4)(c), F.S.; or     (4)   The entity meets the financial standards for
federally approved provider-sponsored organizations as defined in 42CFR 422.380
— 422.390 and the solvency requirements established in approved federal waivers.

  2.   Capitated PSNs have the option to assume responsibility for catastrophic
coverage, but will be required to meet more stringent financial standards
consistent with licensed HMOs in Chapter 641, F.S. and s. 409.912, F.S. At a
minimum, the capitated Health Plan shall at all times maintain a minimum surplus
in an amount that is the greater $1,500,000, or ten percent (10%) of total
liabilities, or two percent (2%) of total Contract amount.

3. All Capitated Health Plans
Section XV, Financial Requirements, Item H., Third Party Resources

  1.   The Health Plan shall specify whether it will assume full responsibility
for third party collections in accordance with this section.     2.   The Health
Plan has the same rights to recovery of the full value of services as the Agency
(See s. 409.910, F.S.) The following standards govern recovery:

  a.   If the Health Plan has determined that third party liability exists for
part or all of the services provided directly by the Health Plan to an enrollee,
the Health Plan shall make

AHCA Contract No. FA913, Attachment II, Exhibit 15, Page 66 of 68

 

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AMERIGROUP Florida, Inc. d/b/a
  Medicaid Non-Reform and Reform
AMERIGROUP Community Care
  HMO Contract

      reasonable efforts to recover from third party liable sources the value of
services rendered.     b.   If the Health Plan 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 one-hundred and twenty (120) calendar days, the Health
Plan 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 Health Plan may assume full responsibility for
third party collections for service provided through the subcontractor or
referral provider.     c.   The Health Plan 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 available within a
reasonable time, beyond one-hundred and twenty (120) calendar days from the date
of receipt.     d.   When both the Agency and the Health Plan have liens against
the proceeds of a third party resource, the Agency shall prorate the amount due
to Medicaid to satisfy such liens under s. 409.910, F.S., between the Agency and
the Health Plan. This prorated amount shall satisfy both liens in full.     e.  
The Agency may, at its sole discretion, offer to provide third party recovery
services to the Health Plan. If the Health Plan elects to authorize the Agency
to recover on its behalf, the Health Plan shall be required to provide the
necessary data for recovery in the format prescribed by the Agency. All
recoveries, less the Agency’s cost to recover, shall be income to the Health
Plan. The cost to recover shall be expressed as a percentage of recoveries and
shall be fixed at the time the Health Plan elects to authorize the Agency to
recover on its behalf.     f.   All funds recovered from third parties shall be
treated as income for the Health Plan.

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Exhibit 16
Terms and Conditions
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
ll of this Contract, unless otherwise specified.

1. Reform and Non-Reform HMOs
Section XVI, Term and Conditions, Item L., Licensing
In accordance with s. 409.912, F.S., all entities that provide Medicaid health
care services must be commercially licensed in accordance with the provisions of
Part I and Part III of Chapter 641, F.S.
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ATTACHMENT III
BUSINESS ASSOCIATE AGREEMENT
The parties to this Attachment agree that the following provisions constitute a
business associate agreement for purposes of complying with the requirements of
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This
Attachment is applicable if the Vendor is a business associate within the
meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.
The Vendor certifies and agrees as to abide by the following:

1.   Definitions. Unless specifically stated in this Attachment, the definition
of the terms contained herein shall have the same meaning and effect as defined
in 45 C.F.R. 160 and 164.

  1.a.   Protected Health Information. For purposes of this Attachment,
protected health information shall have the same meaning and effect as defined
in 45 C.F.R. 160 and 164, limited to the information created, received,
maintained or transmitted by the Vendor from, or on behalf of, the Agency.    
1.b.   Security Incident. For purposes of this Attachment, security incident
shall mean any event resulting in computer systems, networks, or data being
viewed, manipulated, damaged, destroyed or made inaccessible by an unauthorized
activity. See National Institute of Standards and Technology (NIST) Special
Publication 800-61, “Computer Security Incident Handling Guide,” for more
information.

2.   Use and Disclosure of Protected Health Information. The Vendor shall not
use or disclose protected health information other than as permitted by this
Contract or by federal and state law. The Vendor will use appropriate safeguards
to prevent the use or disclosure of protected health information for any purpose
not in conformity with this Contract and federal and state law. The Vendor will
implement administrative, physical, and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity, and availability of
electronic protected health information the Vendor creates, receives, maintains,
or transmits on behalf of the Agency.   3.   Use and Disclosure of information
for Management, Administration, and Legal Responsibilities. The Vendor is
permitted to use and disclose protected health information received from the
Agency for the proper management and administration of the Vendor or to carry
out the legal responsibilities of the Vendor, in accordance with 45 C.F.R.
164.504(e)(4). Such disclosure is only permissible where required by law, or
where the Vendor obtains reasonable assurances from the person to whom the
protected health information is disclosed that: (1) the protected health
information will be held confidentially, (2) the protected health information
will be used or further disclosed only as required by law or for the purposes
for which it was disclosed to the person, and (3) the person notifies the Vendor
of any instance of which it is aware in which the confidentiality of the
protected health information has been breached.

AHCA Contract No. FA913, Attachment III, Page 1 of 3

 

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4.   Disclosure to Third Parties. The Vendor will not divulge, disclose, or
communicate protected health information to any third party for any purpose not
in conformity with this Contract without prior written approval from the Agency.
The Vendor shall ensure that any agent, including a subcontractor, to whom it
provides protected health information received from, or created or received by
the Vendor on behalf of, the Agency agrees to the same terms, conditions, and
restrictions that apply to the Vendor with respect to protected health
information.   5.   Access to Information. The Vendor shall make protected
health information available in accordance with federal and state law, including
providing a right of access to persons who are the subjects of the protected
health information in accordance with 45 C.F.R. 164.524.   6.   Amendment and
Incorporation of Amendments. The Vendor shall make protected health information
available for amendment and to incorporate any amendments to the protected
health information in accordance with 45 C.F.R. § 164.526.   7.   Accounting for
Disclosures. The Vendor shall make protected health information available as
required to provide an accounting of disclosures in accordance with 45 C.F.R. §
164.528. The Vendor shall document all disclosures of protected health
information as needed for the Agency to respond to a request for an accounting
of disclosures in accordance with 45 C.F.R. § 164.528.   8.   Access to Books
and Records. The Vendor shall make its internal practices, books, and records
relating to the use and disclosure of protected health information received
from, or created or received by the Vendor on behalf of the Agency, available to
the Secretary of the Department of Health and Human Services or the Secretary’s
designee for purposes of determining compliance with the Department of Health
and Human Services Privacy Regulations.   9.   Reporting. The Vendor shall make
a good faith effort to identify any use or disclosure of protected health
information not provided for in this Contract. The Vendor will report to the
Agency, within ten (10) business days of discovery, any use or disclosure of
protected health information not provided for in this Contract of which the
Vendor is aware. The Vendor will report to the Agency, within twenty-four
(24) hours of discovery, any security incident of which the Vendor is aware. A
violation of this paragraph shall be a material violation of this Contract.  
10.   Termination. Upon the Agency’s discovery of a material breach of this
Attachment, the Agency shall have the right to terminate this Contract.

  10.a.   Effect of Termination. At the termination of this Contract, the Vendor
shall return all protected health information that the Vendor still maintains in
any form, including any copies or hybrid or merged databases made by the Vendor;
or with prior written approval of the Agency, the protected health information
may be destroyed by the Vendor after its use. If the protected health
information is destroyed pursuant to the Agency’s prior written approval, the
Vendor must provide a written confirmation of

MICA Contract No. FA913, Attachment III, Page 2 of 3

 

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      such destruction to the Agency. If return or destruction of the protected
health information is determined not feasible by the Agency, the Vendor agrees
to protect the protected health information and treat it as strictly
confidential.

The Vendor has caused this Attachment to be signed and delivered by its duly
authorized representative, as of the date set forth below.
Vendor Name:

             
/s/ William L. McHugh
 
Signature
      8/31/09
 
Date    
 
           
William L. McHugh, CEO
 
Name and Title of Authorized Signer
           

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ATTACHMENT IV
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:

(1)   No federal appropriated funds have been paid or will be paid, by or on
behalf of the undersigned, to any person for influencing or attempting to
influence an officer or employee of any agency, a member of congress, an officer
or employee of congress, or an employee of a member of congress in connection
with the awarding of any federal contract, the making 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/ William L. McHugh
 
Signature
                      8/31/09
 
                    Date    
 
       
William L. McHugh
 
Name of Authorized Individual
   
 
                    Application or Contract Number    
 
        AMERIGROUP FL, Inc 4200 W. Cypress St. Tampa, FL 33607          
Name and Address of Organization
       

AHCA Contract No. PA913, Attachment IV, Page 1 of 1

 

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ATTACHMENT V
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS
This certification is required by the regulations 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).
INSTRUCTIONS

1.   Each Vendor whose contract/subcontract equals or exceeds $25,000 In federal
monies must sign this certification prior to execution of each
contract/subcontract. Additionally, Vendors who audit federal programs must also
sign, regardless of the contract amount. The Agency for Health Care
Administration cannot contract with these types of Vendors 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/subcontract is entered into. If it is later determined that the signer
knowingly rendered an erroneous certification, the Federal Government may pursue
available remedies, including suspension and/or debarment.   3.   The Vendor
shall provide immediate written notice to the contract manager at any time the
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. You may contact
the contract manager for assistance in obtaining a copy of those regulations.  
5.   The Vendor 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/subcontract unless authorized by the Federal Government.   6.   The
Vendor further agrees by submitting this certification that it will require each
subcontractor of this contract/subcontract, whose payment will equal or exceed
$25,000 in federal monies, to submit a signed copy of this certification.   7.  
The Agency for Health Care Administration may rely upon a certification of a
Vendor that it is not debarred, suspended, ineligible, or voluntarily excluded
from contracting/subcontracting unless it knows that the certification is
erroneous.   8.   This signed certification must be kept in the contract
managers contract file. Subcontractor’s certifications must be kept at the
contractors business location.

CERTIFICATION

(1)   The prospective 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
this contract/subcontract by any federal department or agency.   (2)   Where the
prospective Vendor is unable to certify to any of the statements in this
certification, such prospective Vendor shall attar an explanation to this
certification.

             
/s/ William L. McHugh
 
Signature
      8/31/09
 
Date    
 
           
William L. McHugh, CEO
                 
Name and Title of Authorized Signer
           

AHCA Contract No. FA913, Attachment V, Page 1 of 1