Back to 8-k [form8k.htm]  Exhibit 10.3

 
AHCA CONTRACT NO. FA971
AMENDMENT NO. 2

THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE
ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA,
INC., D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the
"Vendor," or “Health Plan,” is hereby amended as follows:
 
1.
Standard Contract, Section III., Item A., Termination, sub-item 3., Termination
for Breach, first paragraph, the third sentence is hereby amended to now read as
follows:

 
If applicable, the Agency may employ the default provisions in Rule
60A-1.006(3), Florida Administrative Code.
 
2.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, Section B., Population(s) to be Served, Item 1., Population Groups, Table
2, Effective Date: 09/01/12 - 08/31/15 is hereby deleted in its entirety and
replaced with Table 2, Effective Date: 01/01/13 - 08/31/15 as follows:

 
TABLE 2
Effective Date: 01/01/13 – 08/31/15
Non-Reform
Reform
TANF
SSI
Dually Eligible
Frail/ Elderly*
HIV/ AIDS**
TANF
SSI
Dually Eligible
Children with Chronic Conditions***
HIV/ 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 non-Reform HMO that specializes in HIV/AIDS.

***
Enrolled in an Agency-authorized specialty plan for children with chronic
conditions and screened by the Florida Department of Health (DOH) as clinically
eligible for Children’s Medical Services using an Agency-approved screening tool
as specified in Attachment II, Core Contract Provisions, Exhibit 3, Eligibility
and Enrollment.

**** Enrolled in an Agency-authorized specialty plan for recipients with
HIV/AIDS.

3.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, Section B., Population(s) to be Served, Item 2., Age Restrictions, Table
3, Effective Date: September 1, 2012 – August 31, 2015, is hereby deleted in its
entirety and replaced with Table 3, Effective Date: January 1, 2013 – August 31,
2015 as follows:

 
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA971, Amendment No. 2, Page  1 of 25
 
 

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TABLE 3
Effective Date: 01/01/13 – 08/31/15
Age Restriction
Non-Reform
Restricted
Reform Restricted
None
X
X
Only ages 0 up to 21
   
Only ages 21 and over
   

4.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, Section C., Service Level Required, Table 4, Effective Date: September 1,
2012 – August 31, 2015, is hereby deleted in its entirety and replaced with
Table 4, Effective Date: January 1, 2013 – August 31, 2015 as follows:

 
TABLE 4
Effective Date: 01/01/13 – 08/31/15
Non-Reform
Medicaid State Plan
Reform Plan
X
X

5.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, Item D., Services to be Provided, sub-item 1., Covered Medicaid Services,
paragraph b. (3), Table 5 Effective Date: September 1, 2012 – August 31, 2015,
Health Plan Covered Services Chart, is hereby deleted in its entirety and
replaced with Table 5 Effective Date: January 1, 2013 – August 31, 2015, Health
Plan Covered Services Chart, as follows:

 
TABLE 5
Effective Date: 01/01/13 – 08/31/15
Health Plan Covered Services Chart
Non-Reform Covered
Reform 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

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  2 of 25
 
 

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TABLE 5
Effective Date: 01/01/13 – 08/31/15
Health Plan Covered Services Chart
Non-Reform Covered
Reform Covered

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
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 Pediatric Extended Care Services
   
Primary Care Case Management Services
X
X
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

6.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, Section G., Benefit Grid/Customized Benefit Package – Reform Capitated
Plans Only, Benefit Grid(s), Effective September 1, 2012, are hereby deleted in
their entirety and replaced with Section G., Benefit Grid/Customized Benefit
Package – Reform Capitated Plans Only, Benefit Grid(s), Effective January 1,
2013.

 
 
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

 

AHCA Contract No. FA971, Amendment No. 2, Page  3 of 25
 
 

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Benefit Grid(s)

 
  Area 10 Broward- Children and FamiliesEffective
January 1, 2013

 
COVERED SERVICE CATEGORY
Visit/Script Limit
Limit Period (Annual/Monthly)
Dollar Limit
Limit Period (Annual)
Copay Amount
Copay Application
Hospital Inpatient
           
Behavioral Health
       
$
admit
Physical Health
       
$
admit
             
Transplant Services
                         
Outpatient Services
           
Emergency Room
           
Medical/Drug Therapies (Chemo, Dialysis)
           
Ambulatory Surgery – ASC
           
Hospital Outpatient Surgery
       
$
visit
Lab / X-ray
       
$
day
Hospital Outpatient Services NOS
     
Annual
$
visit
Outpatient Therapy (PT/RT)
     
Annual
   
Outpatient Therapy (OT/ST)
                         
Maternity and Family Planning Services
           
Inpatient Hospital
           
Birthing Centers
           
Physician Care
           
Family Planning
           
Pharmacy
                         
Physician and Phys Extender Services (non maternity)
           
EPSDT
           
Primary Care Physician
       
$
visit
Specialty Physician
       
$
visit
ARNP / Physician Assistant
       
$
visit
Clinic (FQHC, RHC)
       
$
visit
Clinic (CHD)
           
Other
                         
Other Outpatient Professional Services
           
Home Health Services
 
Annual
 
Annual
$
visit
Chiropractor
 
Annual
 
Annual
$
visit
Podiatrist
 
Annual
 
Annual
$
visit
Dental Services
   
$
Annual
0%
coinsurance
Vision Services
     
Annual
$
visit
Hearing Services
     
Annual
                 
Outpatient Mental Health
       
$
visit
             
Outpatient Pharmacy
10
Monthly
 
Annual
                 
Other Services
           
Ambulance
           
Non-emergent Transportation
       
$
trip
Durable Medical Equipment
     
Annual
   

 
Expanded benefits
Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies.
 

 

AHCA Contract No. FA971, Amendment No. 2, Page  4 of 25
 
 

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Area 10 Broward- Aged and Disabled

 

 
COVERED SERVICE CATEGORY
Visit/Script Limit
Limit Period (Annual/Monthly)
Dollar Limit
Limit Period (Annual)
Copay Amount
Copay Application
Hospital Inpatient
           
Behavioral Health
       
$
admit
Physical Health
       
$
admit
             
Transplant Services
                         
Outpatient Services
           
Emergency Room
           
Medical/Drug Therapies (Chemo, Dialysis)
           
Ambulatory Surgery – ASC
           
Hospital Outpatient Surgery
       
$
visit
Lab / X-ray
       
$
day
Hospital Outpatient Services NOS
     
Annual
$
visit
Outpatient Therapy (PT/RT)
     
Annual
   
Outpatient Therapy (OT/ST)
                         
Maternity and Family Planning Services
           
Inpatient Hospital
           
Birthing Centers
           
Physician Care
           
Family Planning
           
Pharmacy
                         
Physician and Phys Extender Services (non maternity)
           
EPSDT
           
Primary Care Physician
       
$
visit
Specialty Physician
       
$
visit
ARNP / Physician Assistant
       
$
visit
Clinic (FQHC, RHC)
       
$
visit
Clinic (CHD)
           
Other
                         
Other Outpatient Professional Services
           
Home Health Services
 
Annual
 
Annual
$
visit
Chiropractor
 
Annual
 
Annual
$
visit
Podiatrist
 
Annual
 
Annual
$
visit
Dental Services
   
$
Annual
0%
coinsurance
Vision Services
     
Annual
$
visit
Hearing Services
     
Annual
                 
Outpatient Mental Health
       
$
visit
             
Outpatient Pharmacy
20
Monthly
 
Annual
                 
Other Services
           
Ambulance
           
Non-emergent Transportation
       
$
trip
Durable Medical Equipment
     
Annual
   

 
Expanded benefits
Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies.

 

AHCA Contract No. FA971, Amendment No. 2, Page 5 of 25
 
 

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Area 4- Baker, Clay, Duval & Nassau- Children and Families

 

 
COVERED SERVICE CATEGORY
Visit/Script Limit
Limit Period (Annual/Monthly)
Dollar Limit
Limit Period (Annual)
Copay Amount
Copay Application
Hospital Inpatient
           
Behavioral Health
       
$
admit
Physical Health
       
$
admit
             
Transplant Services
                         
Outpatient Services
           
Emergency Room
           
Medical/Drug Therapies (Chemo, Dialysis)
           
Ambulatory Surgery – ASC
           
Hospital Outpatient Surgery
       
$
visit
Lab / X-ray
       
$
day
Hospital Outpatient Services NOS
     
Annual
$
visit
Outpatient Therapy (PT/RT)
     
Annual
   
Outpatient Therapy (OT/ST)
                         
Maternity and Family Planning Services
           
Inpatient Hospital
           
Birthing Centers
           
Physician Care
           
Family Planning
           
Pharmacy
                                       
Physician and Phys Extender Services (non maternity)
           
EPSDT
           
Primary Care Physician
       
$
visit
Specialty Physician
       
$
visit
ARNP / Physician Assistant
       
$
visit
Clinic (FQHC, RHC)
       
$
visit
Clinic (CHD)
           
Other
                         
Other Outpatient Professional Services
           
Home Health Services
 
Annual
 
Annual
$
visit
Chiropractor
 
Annual
 
Annual
$
visit
Podiatrist
 
Annual
 
Annual
$
visit
Dental Services
   
$
Annual
0%
coinsurance
Vision Services
     
Annual
$
visit
Hearing Services
     
Annual
                 
Outpatient Mental Health
       
$
visit
             
Outpatient Pharmacy
10
Monthly
 
Annual
                 
Other Services
           
Ambulance
           
Non-emergent Transportation
       
$
trip
Durable Medical Equipment
     
Annual
   

 
Expanded benefits
Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies.
 

 

AHCA Contract No. FA971, Amendment No. 2, Page  6 of 25
 
 

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Area 4- Baker, Clay, Duval & Nassau- Aged and Disabled

 

 
COVERED SERVICE CATEGORY
Visit/Script Limit
Limit Period (Annual/Monthly)
Dollar Limit
Limit Period (Annual)
Copay Amount
Copay Application
Hospital Inpatient
           
Behavioral Health
       
$
admit
Physical Health
       
$
admit
             
Transplant Services
                         
Outpatient Services
           
Emergency Room
           
Medical/Drug Therapies (Chemo, Dialysis)
           
Ambulatory Surgery – ASC
           
Hospital Outpatient Surgery
       
$
visit
Lab / X-ray
       
$
day
Hospital Outpatient Services NOS
     
Annual
$
visit
Outpatient Therapy (PT/RT)
     
Annual
   
Outpatient Therapy (OT/ST)
                         
Maternity and Family Planning Services
           
Inpatient Hospital
           
Birthing Centers
           
Physician Care
           
Family Planning
           
Pharmacy
                         
Physician and Phys Extender Services (non maternity)
           
EPSDT
           
Primary Care Physician
       
$
visit
Specialty Physician
       
$
visit
ARNP / Physician Assistant
       
$
visit
Clinic (FQHC, RHC)
       
$
visit
Clinic (CHD)
           
Other
                         
Other Outpatient Professional Services
           
Home Health Services
 
Annual
 
Annual
$
visit
Chiropractor
 
Annual
 
Annual
$
visit
Podiatrist
 
Annual
 
Annual
$
visit
Dental Services
   
$
Annual
0%
coinsurance
Vision Services
     
Annual
$
visit
Hearing Services
     
Annual
                 
Outpatient Mental Health
       
$
visit
             
Outpatient Pharmacy
20
Monthly
 
Annual
                 
Other Services
           
Ambulance
           
Non-emergent Transportation
       
$
trip
Durable Medical Equipment
     
Annual
   

 
Expanded benefits
Up to $25 credit per household each month for selected over the counter drugs
and/or health supplies.

 

AHCA Contract No. FA971, Amendment No. 2, Page  7 of 25
 
 

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7.
Effective January 1, 2013, Attachment I, Scope of Services, Capitated Health
Plans, is hereby amended to include Attachment I, Exhibit 1-B, Maximum
Enrollment Levels, attached hereto and made a part of this Contract. All
references in this Contract to Attachment I, Exhibit 1 and 1-A, shall
hereinafter also refer to Attachment I, Exhibit 1-B, as appropriate.

 
8.
Effective September 1, 2012, Attachment I, Scope of Services, Capitated Health
Plans, Exhibit 2-R, Medicaid Reform HMO Capitation Rates, Effective September 1,
2011 is hereby deleted in its entirety and replaced with Exhibit 2-R, Medicaid
Reform HMO Capitation Rates, Effective September 1, 2012 – August 31, 2013
(90112), attached hereto and made a part of this Contract.

 
9.
Effective September 1, 2012, Attachment I, Scope of Services, Capitated Health
Plans, Exhibit 2-NR, Medicaid Non-Reform Capitation Rates, Effective September
1, 2011, is hereby deleted in its entirety and replaced with Exhibit 2-NR,
Medicaid Non-Reform HMO Capitation Rates, September 1, 2012 – August 31, 2013
(90112), attached hereto and made a part of this Contract.

 
10.
Effective January 1, 2013, Attachment II, Core Contract Provisions, Section V,
Covered Services, Item H., Coverage Provisions is hereby amended to include
sub-item 23. as follows:

 
 
23.
Primary Care Services

 
The Health Plan shall process claims for and, if capitated or are approved by
the Agency to subcapitate for certain covered services, pay certain physicians
who provide Florida Medicaid-covered eligible primary care services in
accordance with the Affordable Care Act and 42 CFR sections 438 and 447, for the
period January 1, 2013, through December 31, 2014. Health Plans that are
approved by the Agency to subcapitate for services shall also pay in accordance
with such requirements
 
11.
Attachment II, Core Contract Provisions, Exhibit 2, General Overview, is hereby
amended to include the following:

 
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.
 
Reform Plans

Section II, General Overview, Item D., General Responsibilities of the Health
Plan
 
 
1.
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

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  8 of 25
 
 

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c.
Individuals diagnosed with developmental disabilities or foster care children,
if approved by the Agency.

 
 
12. Attachment II, Core Contract Provisions, Exhibit 4, Enrollee Services,
Community Outreach and Marketing, is hereby amended to include the following:

 
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 one (1)
year 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.myflorida.com/Medicaid/medicaid_reform/index.shtml#eb.

 
 
(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.myflorida.com/Medicaid/medicaid_reform/index.shtml#eb and must be
submitted to the Health Plan to document participation in healthy behaviors
without a procedure code.

 
 
13. Attachment II, Core Contract Provisions, Exhibit 5, Covered Services, is
hereby amended to include the following:

 
Reform Capitated Health Plans

Section V, Covered Services, Item D., Customized Benefit Packages
 
D.
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.

 
AHCA Contract No. FA971, Amendment No. 2, Page  9 of 25
 
 

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a.
Amount, duration and scope may vary for durable medical supplies (DME) with the
exception of any prosthetic/orthotic supply priced over three-thousand dollars
($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.

 
 
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 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 BMHC. 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;

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  10 of 25
 
 

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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.

 
 
7.
The Health Plan shall submit the Customized Benefit Notifications Report to BMHC
by the fifteenth (15th) calendar day after the end of the reporting month, in
accordance with the Health Plan Report Guide.

 
FFS PSNs 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; Section V, Covered Services, Item B., Optional
Services, as an expanded benefit; and Attachment II, Section VI, Behavioral
Health Care. See Attachment I of this Contract also.
 
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.
 
 
a.
For enrollees under age 21, the Health Plan shall cover diagnostic services,
preventive treatment, 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. The Health Plan shall ensure the
following for active orthodontia:

 
 
(1)
The Health Plan will ensure continuity of care for active orthodontia until
completion of care, regardless of provider network affiliation;

 
 
(2) The Health Plan will ensure reimbursement to providers for active
orthodontia until completion of care, regardless of provider network
affiliation;

 
 
(3)
The Health Plan shall ensure maintenance of written case management continuity
of care protocol(s) that include the following minimum functions:

 
 
(a)
Appropriate referral of and scheduling assistance for enrollees needing
specialty dental care.

 
 
(b)
Documentation of referral services in enrollees' dental records, including
results.

 
 
(c)
Monitoring enrollees with ongoing dental conditions and coordination of services
for high users such that the following functions are addressed as appropriate:
acting as a liaison between the member and providers, ensuring the member is
receiving routine dental care, ensuring that the member has adequate support at
home, and 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.

 
AHCA Contract No. FA971, Amendment No. 2, Page  11 of 25
 
 

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(4)
Documentation in dental records of member emergency encounters with appropriate
indicated follow-up.

 
 
b.
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.

 
 
c.
If the Health Plan is approved to provide dental services through telemedicine,
only the following medically necessary dental services may be provided:

 
 
(1) Oral prophylaxis,

 
 
(2) Topical fluoride application, and

 
 
(3) Oral hygiene instructions.

 
 
d.
The services listed in sub-item 3.c. above performed via telemedicine must be
provided by a Florida-licensed dental hygienist at a spoke site with a
supervising Florida-licensed dentist located at a hub site. For such dental
services, mobile dental units as defined in the Dental Services Coverage and
Limitations Handbook may be used as a spoke site.

 
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 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 CTD. 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, F.A.C.. These standards include
drug and alcohol testing, safety standards, driver accountability, and driver
conduct.

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  12 of 25
 
 

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(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.

 
 
(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;

 
AHCA Contract No. FA971, Amendment No. 2, Page  13 of 25
 
 

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(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 within two (2) business days of the occurrence, 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
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), F.S.) 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 door-through-door

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  14 of 25
 
 

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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; and

 
 
(7)
All vehicles must have working air conditioners and heaters.

 
 
l.
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 submit data on transportation performance measures as
defined by the Agency and as specified in the Agency’s Performance Measures
Specifications Manual. The Health Plan shall report on those measures to the
Agency as specified in Attachment II, Section VIII, Quality Management, Item A.,
Quality Improvement, sub-item 3.d. and Attachment II, Section XII, Reporting
Requirements, and the Health Plan Report Guide.

 
 
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.

 
FFS PSNs 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; Section V, Covered Services, Item B., Optional
Services, as an expanded benefit; and Attachment II, Section VI, Behavioral
Health Care. See Attachment I of this Contract also.
 
 
c.
The Agency may add or delete healthy behaviors with thirty (30) calendar days’
written notice.

 
 
14. Attachment II, Core Contract Provisions, Exhibit 7, Provider Network, is
hereby amended to include the following:

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  15 of 25
 
 

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FFS PSNs and Reform Capitated Health Plans

Section VII, Provider Network, Item I., Provider Services
 
2. Provider Handbook
 
In addition to other requirements specified in Attachment II, Section VII,
Provider Network, Item I., Provider Services, regarding the provider handbook,
the Health Plan shall include the following in its provider handbook:
 
 
1.
If copayments are waived as an expanded benefit (see Attachment I), the provider
must not charge enrollees copayments for covered services; and

 
 
2.
If copayments are not waived as an expanded benefit (see Attachment I), a notice
that the amount paid to providers by the Agency shall be the Medicaid fee
schedule amount less any applicable copayments.

 
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.

 
15.
Attachment II, Core Contract Provisions, Exhibit 8, Quality Management, is
hereby amended to include the following:

 
 
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  16 of 25
 
 

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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
(8th) 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.

 
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://www.ncqa.org/tabid/152/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 November 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 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

 
AHCA Contract No. FA971, Amendment No. 2, Page  17 of 25
 
 

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enrollee’s ability to adhere to a treatment regimen should be monitored in the
plan of treatment as well.

 
16.
Attachment II, Core Contract Provisions, Exhibit 13, CAP-Reform-Method of
Payment, is hereby amended to include the following:

 
NOTE: This exhibit provides Health Plan requirements in addition to Attachment
II of this Contract, unless otherwise specified.
 
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 shall be
eligible for and enrolled as a Medicaid provider with the fiscal agent. Payments
made to the Health Plan resulting from this Contract include monthly capitation
rate payments 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 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
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

 
AHCA Contract No. FA971, Amendment No. 2, Page  18 of 25
 
 

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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 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 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.

 
AHCA Contract No. FA971, Amendment No. 2, Page  19 of 25
 
 

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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 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. 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.

 
 
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.

 
AHCA Contract No. FA971, Amendment No. 2, Page  20 of 25
 
 

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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 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.

 
 
b.
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 FFS 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:

 
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AHCA Contract No. FA971, Amendment No. 2, Page  21 of 25
 
 

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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:

 
 
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
33945
heart transplant with or without recipient cardiectomy
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.
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 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

 
 
AHCA Contract No. FA971, Amendment No. 2, Page  22 of 25
 
 

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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.

 
 
E.
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 E.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:

 

 
(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

 
 
 
AHCA Contract No. FA971, Amendment No. 2, Page  23 of 25
 
 

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

 
 
 
 
the  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.

 
 
F.
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.

 
 
G.
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.

 
Unless otherwise stated, this amendment shall be effective upon execution by
both Parties.
 
All provisions not in conflict with this amendment are still in effect and are
to be performed at the level specified in this Contract.
 
This amendment, and all its attachments, are hereby made part of this Contract.
 
 
AHCA Contract No. FA971, Amendment No. 2, Page  24 of 25
 
 

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

 
 
This amendment cannot be executed unless all previous amendments to this
Contract have been fully executed.
 
IN WITNESS WHEREOF, the Parties hereto have caused this thirty-seven (37) page
amendment (including all attachments) to be executed by their officials
thereunto duly authorized.
 
 
WELLCARE OF FLORIDA, INC.,  
D/B/A STAYWELL HEALTH PLAN OF    
FLORIDA
 
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION
 
                   
SIGNED
BY:
/s/Christina Cooper  
SIGNED
BY:
/s/ Elizabeth Dudek           NAME:  Christina Cooper   NAME:   Elizabeth Dudek
          TITLE:  President   TITLE:  Secretary           DATE:  1/3/13   DATE:
 1/10/13

 
    

List of Attachments/Exhibits included as part of this amendment:

                                                                                   
Specify
Type
Number
Description

Attachment I
Exhibit 1-B
Maximum Enrollment Levels (5 pages)

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

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

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AHCA Contract No. FA971, Amendment No. 2, Page 25 of 25
 
 

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

 

ATTACHMENT I

EXHIBIT 1-B

MAXIMUM ENROLLMENT LEVELS

EFFECTIVE DATE 09/01/12 – 08/31/15

Maximum enrollment levels and Health Plan provider numbers associated with the
counties and populations served as denoted below. Attachment I, Scope of
Services, Exhibits 2-NR and 2-R provide 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

Area1 Counties:  Okaloosa, Walton

Effective Date:  01/01/13
County
Enrollment Level
Provider Number
Okaloosa
12,474
TBD
Walton
3,705
TBD

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

Area 2 Counties:  Franklin, Taylor, Gulf, Holmes, Jackson, Washington

Effective Date:  11/01/12
County
Enrollment Level
Provider Number
Franklin
1,083
015016926
Taylor
2,516
015016935
Effective Date: 01/01/13
Gulf
1,357
TBD
Holmes
2,859
TBD
Jackson
5,554
TBD
Washington
1,083
TBD

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AHCA Contract No. FA971, Attachment I-B, Exhibit 1, Page 1 of 5

 
 

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

 
 
 

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

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

 
Area 3 Counties:
Hernando, Sumter, Columbia, Bradford, Dixie, Gilchrist, Hamilton, Lafayette,
Levy, Suwannee, Union, Alachua

Effective Dates:  09/01/12
County
Enrollment Level
Provider Number
Hernando
15,000
015016901
Sumter
4,500
015016916
Columbia
8,287
015016922
Effective Dates: 11/01/12
Bradford
3,032
015016924
Dixie
1,928
015016925
Gilchrist
1,644
015016927
Hamilton
1,934
015016929
Lafayette
646
015016931
Levy
4,927
015016932
Suwannee
5,346
015016934
Union
1,483
015016936
Effective Dates: 01/01/13
Alachua
19,183
TBD

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

Area 4 Counties:  St. Johns, Flagler

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
St. Johns
8,300
015016920
Flagler
7,400
015016923

 
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AHCA Contract No. FA971, Attachment I-B, Exhibit 1, Page  2 of 5

 
 

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

 
 
 

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

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

Area 5 Counties:  Pasco, Pinellas

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
Pasco
7,000
015016903
Pinellas
15,000
015016904

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

Area 6 Counties:  Hillsborough, Manatee, Polk, Hardee

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
Hillsborough
28,000
015016902
Manatee
12,000
015016912
Polk
25,000
015016905
Hardee
4,100
015016921

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

Area 7 Counties:  Orange, Seminole, Osceola, Brevard

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
Orange
38,000
015016906
Seminole
6,000
015016908
Osceola
12,000
015016907
Brevard
14,000
015016913

 
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AHCA Contract No. FA971, Attachment I-B, Exhibit 1, Page 3 of 5

 
 

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

 
 
 
 

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

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

Area 8 Counties:  DeSoto, Lee, Sarasota, Charlotte, Glades, Hendry, Collier

Effective Dates:  09/01/12
County
Enrollment Level
Provider Number
DeSoto
4,100
015016919
Lee
15,000
015016911
Sarasota
6,000
015016914
Charlotte
27,000
015016917
Effective Dates: 11/01/12
Glades
593
015016928
Hendry
6,048
015016930
Effective Dates: 01/01/13
Collier
22,800
TBD

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

Area 9 Counties:  Palm Beach, St. Lucie, Indian River, Okeechobee

Effective Dates:  09/01/12
County
Enrollment Level
Provider Number
Palm Beach
15,000
015016910
St. Lucie
4,500
015016915
Indian River
10,500
015016918
Effective Dates: 11/01/12
Okeechobee
5,000
015016933

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

Area 10 County:  Broward

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
Broward
25,000
015016900

 
 
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AHCA Contract No. FA971, Attachment I-B, Exhibit 1, Page 4 of 5

 
 

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

 
 
 
 

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

 

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

Area 11 County:  Miami-Dade, Monroe

Effective Date:  09/01/12
County
Enrollment Level
Provider Number
Miami-Dade
25,000
015016909
Effective Date: 01/01/13
Monroe
3,656
TBD

 
B.  Reform

 
See Exhibit 2-R (Baker, Clay, Duval, Nassau)

Agency Area 4

Effective Date:  01/01/13
County
Enrollment Level
Provider Number
Baker
5,000
TBD
Clay
5,000
TBD
Duval
20,000
TBD
Nassau
5,000
TBD

 
See Exhibit 2-R (Broward)

Agency Area 10

Effective Date:  01/01/13
County
Enrollment Level
Provider Number
Broward
10,000
TBD

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AHCA Contract No. FA971, Attachment I-B, Exhibit 1, Page 5 of 5

 
 

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

 
 
 
 

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

 

 
ATTACHMENT I

EXHIBIT 2-R

MEDICAID REFORM HMO CAPITATION RATES

By Area, Age and Eligibility Category/Population

September 1, 2012 – August 31, 2013 (90112)

 
TABLE 1:
COMPREHENSIVE COMPONENT AND CATASTROPHIC COMPONENT CAPITATION RATES

 
Effective September 1, 2012

 
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS

 

 
AREA 4
AREA 10
Eligibility Category: Children and Families
Month 0-2 All
$1383.14
$1,869.81
Month 3-11 All
$218.60
$246.10
1-5 All
$143.45
$135.61
6-13 All
$143.45
$135.61
14-20 Female
$143.45
$135.61
14-20 Male
$143.45
$135.61
21-54 Female
$143.45
$135.61
21-54 Male
$143.45
$135.61
55+ All
$143.45
$135.61
Eligibility Category: Aged and Disabled
Month 0-2 All
$19,057.58
$18,897.54
Month 3-11 All
$4,248.03
$4,190.22
1-5 All
$817.56
$849.41
6-13 All
$817.56
$849.41
14-20 All
$817.56
$849.41
21-54 All
$817.56
$849.41
55+ All
$817.56
$849.41
Eligibility Category: Aged and Disabled with Medicare Parts A & B
Under Age 65
$124.44
$125.20
Age 65 and Over
$104.80
$105.10
Eligibility Category: Aged and Disabled with Medicare Part B Only
All Ages
$421.57
$419.82
Population: HIV/AIDS Specialty Population
No Medicare HIV
$1,879.43
$2,796.49
No Medicare AIDS
$2,712.41
$3,629.28
Medicare HIV
$195.95
$209.22
Medicare AIDS
$172.83
$244.25

 

AHCA Contract No. FA971, Attachment I, Exhibit 2-R, Page 1 of 2

 
 

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

 
 

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

 
 
TABLE 2:
KICK PAYMENT AMOUNTS FOR COVERED OBSTETRICAL DELIVERY SERVICES

 
Effective September 1, 2012

 
CPT Code
Obstetrical Delivery CPT Code Description
Area 4
Area 10
59409
Vaginal delivery only
$4,404.51
$5,112.95
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 inc postpartum care

 
TABLE 3:
KICK PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES

 
Effective September 1, 2012

 
CPT Code
Transplant CPT Code Description
Children/Adolescents or Adult
All Areas
32851
Lung single, without bypass
Children/Adolescents
$320,800.00
32851
Lung single, without bypass
Adult
$238,000.00
32852
Lung single, with bypass
Children/Adolescents
$320,800.00
32852
Lung single, with bypass
Adult
$238,000.00
32853
Lung double, without bypass
Children/Adolescents
$320,800.00
32853
Lung double, without bypass
Adult
$238,000.00
32854
Lung double, with bypass
Children/Adolescents
$320,800.00
32854
Lung double, with bypass
Adult
$238,000.00
33945
Heart transplant with or without recipient cardiectomy
All Age Groups
$162,000.00
47135
Liver, allotransplation, orthotopic, partial or whole from cadaver or living
donor
All Age Groups
$122,600.00
47136
Liver, heterotopic, partial or whole from cadaver or living donor any age
All Age Groups
$122,600.00

 
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AHCA Contract No. FA971, Attachment I, Exhibit 2-R, Page 2 of 2

 
 

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

TABLE 1 

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

TABLE 2

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

 
 
 

 
 
AHCA Contract No. FA971, Attachment I, Exhibit 2-NR, Page 1 of 5
 

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

 

EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
TABLE 3 
General + MH + Dental Rates:
                                                                           
TANF
                 
SSI-N
         
SSI-B
SSI-AB
 
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)  
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13) AGE (14-20)
AGE (21-54)
AGE (55+)
 
AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      01   1,044.18   176.96   101.49   74.61   134.03   77.30  
286.70   135.13   295.93   23,175.56   2,590.20   281.06   194.04   222.64  
804.38   819.27   373.69   110.98   90.72 02   962.33   163.09   95.76   72.29  
126.81   75.04   266.15   126.34   276.24   21,692.26   2,424.43   265.21  
184.33   210.80   753.49   767.67   373.69   104.93   85.77 03   1,132.58  
191.95   114.35   87.70   151.68   91.12   312.29   147.80   323.38   23,983.82
  2,680.55   295.56   206.73   235.69   833.00   848.62   373.69   104.94  
85.78 04   1,224.17   207.47   120.41   89.72   159.24   93.05   337.91   160.09
  350.20   26,645.74   2,978.05   324.64   224.98   257.66   925.96   943.53  
373.69   101.15   82.68 05   1,314.22   222.73   132.37   101.25   175.54  
105.18   362.92   172.02   376.25   26,552.61   2,967.65   326.50   227.96  
260.12   922.47   939.88   373.69   91.44   74.74 06   1,233.38   209.04  
123.44   93.77   163.57   97.37   338.87   159.82   349.94   25,907.97  
2,895.59   317.31   220.83   252.38   899.06   915.65   373.69   90.36   73.86
07   1,189.73   201.64   120.12   92.13   159.35   95.73   327.55   154.80  
338.79   27,627.15   3,087.74   339.32   236.70   270.20   959.00   976.79  
373.69   89.18   72.89 09   1,228.81   208.27   125.84   97.98   167.20   101.90
  338.50   160.06   350.27   28,337.16   3,167.10   349.01   244.00   278.24  
983.98   1,002.36   373.69   99.99   81.73 10   1,087.80   184.36   108.23  
81.68   143.31   84.78   298.21   140.34   307.44   29,961.98   3,348.68  
366.05   254.26   290.86   1,039.64   1,058.79   373.69   103.56   84.65 11  
1,366.02   231.55   139.28   108.79   184.83   110.07   374.98   176.70   386.98
  26,429.18   2,953.83   329.16   230.76   260.96   918.53   935.98   373.69  
117.45   96.01 6B   1,232.85   208.95   123.39   93.73   163.50   97.33   338.73
  159.75   349.80   25,906.33   2,895.41   317.29   220.82   252.36   899.01  
915.59   373.69   90.36   73.86 8A   1,220.32   206.84   127.98   102.09  
170.49   106.32   336.78   159.53   348.99   27,586.45   3,083.20   342.39  
240.83   273.82   958.31   976.35   373.69   101.47   82.95 8B   1,111.97  
188.48   116.21   92.38   154.76   96.19   306.24   144.78   316.84   25,997.16
  2,905.57   321.27   225.21   256.48   902.57   919.37   373.69   97.46   79.66

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

 
 
 

  AHCA Contract No. FA971, Attachment I, Exhibit 2-NR, Page 2 of 5
 

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

 

EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
TABLE 5 

General + Transportation Rates:                                                
                           
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20) AGE (21-54)
AGE (55+)
  AGE (65-)
AGE(65+)
         
Female
Male
Female
Male
                      01   1,050.12   178.84   98.56   61.03   121.62   65.34  
277.81   127.46   289.76   23,219.79   2,623.81   268.90   149.53   187.92  
749.68   809.63   357.57   103.94   82.86 02   967.74   164.80   91.20   58.20  
114.01   62.13   257.70   119.13   268.12   21,731.91   2,454.52   244.94  
122.98   160.95   673.71   747.04   357.57   96.75   77.01 03   1,138.49  
193.82   107.35   68.92   134.54   73.42   303.52   140.34   315.58   24,022.68
  2,710.07   280.38   162.66   200.72   786.28   839.82   357.57   97.16   77.30
04   1,229.86   209.25   115.05   70.04   140.93   74.77   323.99   147.49  
338.21   26,691.09   3,012.51   310.60   177.61   220.51   869.28   932.06  
357.57   94.30   74.90 05   1,318.69   224.12   123.91   78.66   154.50   83.23
  350.26   160.47   364.21   26,589.45   2,995.59   304.35   166.39   209.73  
846.35   919.20   357.57   83.48   66.10 06   1,238.10   210.53   117.36   78.80
  149.97   83.15   333.17   155.15   344.91   25,946.85   2,925.14   304.45  
180.87   221.04   856.67   909.05   357.57   82.62   65.43 07   1,194.60  
203.13   111.19   65.45   134.30   69.90   312.40   140.75   326.87   27,667.61
  3,118.43   315.77   170.03   215.72   876.32   955.41   357.57   80.42   63.67
09   1,234.41   210.01   115.79   71.97   143.09   76.66   326.62   149.44  
340.38   28,377.19   3,197.44   319.94   164.66   212.65   882.61   973.60  
357.57   92.26   73.28 10   1,093.64   186.21   102.96   65.28   128.32   69.65
  290.77   134.08   302.66   30,012.30   3,386.89   344.27   186.93   236.75  
956.60   1,040.20   357.57   96.50   76.75 11   1,370.34   232.86   129.35  
84.93   163.66   89.54   366.68   169.37   380.22   26,465.69   2,981.54  
302.49   164.51   207.78   840.57   914.20   357.57   107.64   85.91 6B  
1,237.58   210.45   117.34   78.97   150.10   83.31   333.20   155.25   344.89  
25,945.21   2,924.96   304.48   181.00   221.14   856.84   909.07   357.57  
82.62   65.43 8A   1,226.11   208.66   115.91   75.97   146.57   80.63   328.30
  152.38   340.71   27,626.22   3,113.41   324.06   192.90   235.47   912.13  
967.46   357.57   90.83   72.25 8B   1,117.89   190.33   105.42   67.67   132.10
  72.11   298.02   137.85   309.90   26,034.80   2,934.14   299.63   166.66  
208.76   835.22   902.83   357.57   89.18   70.82

TABLE 6
General + Dental Rates:
                                                                             
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20) AGE (21-54)
AGE (55+)
  AGE (65-) 
AGE (65+)
         
Female
Male
Female
Male
                      01   1,044.10   176.88   99.25   63.22   122.79   66.06  
276.87   125.30   289.42   23,175.16   2,589.80   262.69   146.20   180.96  
727.05   790.73   356.37   100.73   80.47 02   962.27   163.03   94.08   63.76  
118.39   66.62   258.79   118.98   271.36   21,691.75   2,423.92   241.57  
122.78   157.18   653.99   730.94   356.37   94.68   75.52 03   1,132.51  
191.88   112.47   78.14   142.25   81.69   304.05   139.56   317.92   23,983.48
  2,680.21   279.93   166.03   200.23   767.21   824.34   356.37   94.69   75.53
04   1,224.07   207.37   117.52   75.03   144.74   78.55   325.24   147.42  
341.80   26,645.34   2,977.65   305.98   176.39   215.33   847.41   914.54  
356.37   90.90   72.43 05   1,314.14   222.65   129.99   89.16   163.61   93.25
  352.49   161.59   369.34   26,552.13   2,967.17   304.25   170.01   209.63  
828.79   905.31   356.37   81.19   64.49 06   1,233.33   208.99   122.18   87.33
  157.22   91.02   333.32   154.27   346.26   25,907.65   2,895.27   302.57  
182.44   218.94   837.01   892.75   356.37   80.11   63.61 07   1,189.61  
201.52   116.82   75.31   142.76   79.14   313.04   140.29   329.18   27,626.62
  3,087.21   314.87   173.02   214.73   856.07   938.80   356.37   78.93   62.64
09   1,228.72   208.18   123.27   84.91   154.30   89.00   327.23   148.79  
342.80   28,336.54   3,166.48   320.25   169.12   213.01   862.94   957.69  
356.37   89.74   71.48 10   1,087.73   184.29   106.24   71.56   133.32   74.79
  289.48   131.61   301.65   29,961.42   3,348.12   340.18   186.90   232.18  
930.76   1,018.60   356.37   93.31   74.40 11   1,365.95   231.48   137.44  
99.43   175.59   100.83   366.90   168.62   381.63   26,428.69   2,953.34  
306.59   171.99   209.76   823.52   900.91   356.37   107.20   85.76 6B  
1,232.81   208.91   122.16   87.50   157.35   91.18   333.35   154.37   346.24  
25,906.01   2,895.09   302.60   182.57   219.04   837.18   892.77   356.37  
80.11   63.61 8A   1,220.26   206.78   126.31   93.58   162.10   97.93   329.44
  152.19   344.13   27,586.12   3,082.87   326.89   200.47   238.66   893.08  
952.27   356.37   91.22   72.70 8B   1,111.90   188.41   114.36   82.98   145.48
  86.91   298.13   136.67   311.47   25,996.72   2,905.13   300.84   172.02  
210.14   816.59   887.64   356.37   87.21   69.41

AHCA Contract No. FA971, Attachment I, Exhibit 2-NR, Page 3 of 5 
 

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

 
 
EXHIBIT 2 - NR
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
(MEDICAID Non-Reform HMO CAPITATION RATES)
September 1, 2012 - August 31, 2013 (90112)
By Area , Age and Eligibility Category
 
 
TABLE 7 

 General + Dental + Transportation Rates:                                      
                                     
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
 AGE (14-20)
AGE (21-54)
AGE (55+)
   AGE (65-)
 AGE (65+)
         
Female
Male
Female
Male
                      01   1,050.12   178.85   100.43   64.00   124.38   68.52  
279.56   129.10   292.96   23,219.79   2,623.82   270.84   151.97   190.10  
751.25   811.83   359.98   104.93   83.68 02   967.75   164.82   95.15   64.47  
119.84   68.86   261.24   122.44   274.58   21,731.92   2,454.54   248.90  
127.97   165.40   675.77   749.93   359.98   98.19   78.20 03   1,138.51  
193.85   113.64   78.92   143.84   84.14   306.74   143.35   321.45   24,022.69
  2,710.10   287.09   171.10   208.26   788.47   842.87   359.98   99.09   78.89
04   1,229.87   209.27   118.66   75.78   146.27   80.92   327.83   151.08  
345.22   26,691.10   3,012.53   314.33   182.30   224.70   872.22   936.17  
359.98   96.41   76.64 05   1,318.71   224.15   130.89   89.75   164.82   95.12
  354.54   164.48   372.03   26,589.46   2,995.62   311.06   174.83   217.27  
849.03   922.95   359.98   85.80   68.01 06   1,238.11   210.56   123.12   87.95
  158.48   92.97   335.46   157.29   349.08   25,946.86   2,925.16   309.73  
187.51   226.97   858.27   911.29   359.98   84.20   66.73 07   1,194.62  
203.16   117.80   75.96   144.08   81.18   315.28   143.45   332.13   27,667.62
  3,118.46   322.36   178.32   223.12   878.30   958.18   359.98   82.23   65.16
09   1,234.43   210.05   124.39   85.65   155.81   91.33   329.79   152.40  
346.16   28,377.20   3,197.47   327.67   174.38   221.33   884.98   976.91  
359.98   94.32   74.98 10   1,093.65   186.23   107.40   72.33   134.88   77.21
  292.13   135.35   305.14   30,012.31   3,386.91   349.47   193.48   242.60  
958.35   1,042.65   359.98   97.90   77.90 11   1,370.42   232.94   138.31  
100.01   176.77   102.65   368.90   171.44   384.26   26,465.69   2,981.54  
313.35   176.77   217.33   843.58   918.40   359.98   110.67   88.41 6B  
1,237.59   210.48   123.10   88.12   158.61   93.13   335.49   157.39   349.06  
25,945.22   2,924.98   309.76   187.64   227.07   858.44   911.31   359.98  
84.20   66.73 8A   1,226.14   208.71   127.46   94.34   163.65   100.33   332.07
  155.90   347.59   27,626.24   3,113.45   334.21   205.66   246.87   914.83  
971.23   359.98   93.35   74.33 8B   1,117.92   190.38   115.54   83.76   147.07
  89.37   300.82   140.47   315.01   26,034.81   2,934.17   307.80   176.94  
217.94   837.24   905.65   359.98   90.83   72.18

 
TABLE 8

 General + Mental Health + Dental + Transportation Rates:                      
                                                   
TANF
                 
SSI-N
         
SSI-B
SSI-AB
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20) AGE (21-54)
AGE (55+)
   AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      01   1,050.20   178.93   102.67   75.39   135.62   79.76  
289.39   138.93   299.47   23,220.19   2,624.22   289.21   199.81   231.78  
828.58   840.37   377.30   115.18   93.93 02   967.81   164.88   96.83   73.00  
128.26   77.28   268.60   129.80   279.46   21,732.43   2,455.05   272.54  
189.52   219.02   775.27   786.66   377.30   108.44   88.45 03   1,138.58  
193.92   115.52   88.48   153.27   93.57   314.98   151.59   326.91   24,023.03
  2,710.44   302.72   211.80   243.72   854.26   867.15   377.30   109.34  
89.14 04   1,229.97   209.37   121.55   90.47   160.77   95.42   340.50   163.75
  353.62   26,691.50   3,012.93   332.99   230.89   267.03   950.77   965.16  
377.30   106.66   86.89 05   1,318.79   224.23   133.27   101.84   176.75  
107.05   364.97   174.91   378.94   26,589.94   2,996.10   333.31   232.78  
267.76   942.71   957.52   377.30   96.05   78.26 06   1,238.16   210.61  
124.38   94.39   164.83   99.32   341.01   162.84   352.76   25,947.18  
2,925.48   324.47   225.90   260.41   920.32   934.19   377.30   94.45   76.98
07   1,194.74   203.28   121.10   92.78   160.67   97.77   329.79   157.96  
341.74   27,668.15   3,118.99   346.81   242.00   278.59   981.23   996.17  
377.30   92.48   75.41 09   1,234.52   210.14   126.96   98.72   168.71   104.23
  341.06   163.67   353.63   28,377.82   3,198.09   356.43   249.26   286.56  
1,006.02   1,021.58   377.30   104.57   85.23 10   1,093.72   186.30   109.39  
82.45   144.87   87.20   300.86   144.08   310.93   30,012.87   3,387.47  
375.34   260.84   301.28   1,067.23   1,082.84   377.30   108.15   88.15 11  
1,370.49   233.01   140.15   109.37   186.01   111.89   376.98   179.52   389.61
  26,466.18   2,982.03   335.92   235.54   268.53   938.59   953.47   377.30  
120.92   98.66 6B   1,237.63   210.52   124.33   94.35   164.76   99.28   340.87
  162.77   352.62   25,945.54   2,925.30   324.45   225.89   260.39   920.27  
934.13   377.30   94.45   76.98 8A   1,226.20   208.77   129.13   102.85  
172.04   108.72   339.41   163.24   352.45   27,626.57   3,113.78   349.71  
246.02   282.03   980.06   995.31   377.30   103.60   84.58 8B   1,117.99  
190.45   117.39   93.16   156.35   98.65   308.93   148.58   320.38   26,035.25
  2,934.61   328.23   230.13   264.28   923.22   937.38   377.30   101.08  
82.43

 
AHCA Contract No. FA971, Attachment I, Exhibit 2-NR, Page 4 of 5   

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

 Mental Health Rates:                                                          
                   
TANF
                 
SSI-N
         
SSI-B
SSI-AB
 
Area
BTHMO+2MO
3MO-11MO
AGE (1-5)
AGE (6-13)
AGE (14-20)
AGE (21-54)
 
AGE (55+)
BTHMO+2MO
3MO-11MO
AGE (1-5)
 AGE (6-13)             AGE (14-20)
 AGE (21-54)
AGE (55+)
   AGE (65-)
AGE (65+)
         
Female
Male
Female
Male
                      01   0.08   0.08   2.24   11.39   11.24   11.24   9.83  
9.83   6.51   0.40   0.40   18.37   47.84   41.68   77.33   28.54   17.32  
10.25   10.25 02   0.06   0.06   1.68   8.53   8.42   8.42   7.36   7.36   4.88
  0.51   0.51   23.64   61.55   53.62   99.50   36.73   17.32   10.25   10.25 03
  0.07   0.07   1.88   9.56   9.43   9.43   8.24   8.24   5.46   0.34   0.34  
15.63   40.70   35.46   65.79   24.28   17.32   10.25   10.25 04   0.10   0.10  
2.89   14.69   14.50   14.50   12.67   12.67   8.40   0.40   0.40   18.66  
48.59   42.33   78.55   28.99   17.32   10.25   10.25 05   0.08   0.08   2.38  
12.09   11.93   11.93   10.43   10.43   6.91   0.48   0.48   22.25   57.95  
50.49   93.68   34.57   17.32   10.25   10.25 06   0.05   0.05   1.26   6.44  
6.35   6.35   5.55   5.55   3.68   0.32   0.32   14.74   38.39   33.44   62.05  
22.90   17.32   10.25   10.25 07   0.12   0.12   3.30   16.82   16.59   16.59  
14.51   14.51   9.61   0.53   0.53   24.45   63.68   55.47   102.93   37.99  
17.32   10.25   10.25 09   0.09   0.09   2.57   13.07   12.90   12.90   11.27  
11.27   7.47   0.62   0.62   28.76   74.88   65.23   121.04   44.67   17.32  
10.25   10.25 10   0.07   0.07   1.99   10.12   9.99   9.99   8.73   8.73   5.79
  0.56   0.56   25.87   67.36   58.68   108.88   40.19   17.32   10.25   10.25
11   0.07   0.07   1.84   9.36   9.24   9.24   8.08   8.08   5.35   0.49   0.49
  22.57   58.77   51.20   95.01   35.07   17.32   10.25   10.25 6B   0.04   0.04
  1.23   6.23   6.15   6.15   5.38   5.38   3.56   0.32   0.32   14.69   38.25  
33.32   61.83   22.82   17.32   10.25   10.25 8A   0.06   0.06   1.67   8.51  
8.39   8.39   7.34   7.34   4.86   0.33   0.33   15.50   40.36   35.16   65.23  
24.08   17.32   10.25   10.25 8B   0.07   0.07   1.85   9.40   9.28   9.28  
8.11   8.11   5.37   0.44   0.44   20.43   53.19   46.34   85.98   31.73   17.32
  10.25   10.25

 

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

 
 
 
AHCA Contract No. FA971, Attachment I, Exhibit 2-NR, Page 5 of 5