exv10w27w2w1



 





Exhibit 10.27.2.1


Medicaid HMO Contract




			
	Amerigroup Florida, Inc.
	 	
	d/b/a Amerigroup Community Care	 	 






AHCA CONTRACT NO. FA614

AMENDMENT NO. 4



THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
hereinafter referred to as the “Agency” and AMERIGROUP FLORIDA, INC. D/B/A AMERIGROUP COMMUNITY
CARE, hereinafter referred to as the “Vendor” or “Health Plan”, is hereby amended as follows:




1. Attachment I, Scope of Services, is hereby amended to include Exhibit II-D, Fourth Revised
Capitation Rates, attached hereto and made a part of the Contract. All references in the
Contract to Exhibit II-C, Third Revised Capitation Rates, shall hereinafter also refer to
Exhibit II-D, Fourth Revised Capitation Rates, as appropriate.



2. Attachment I, Scope of Services, is hereby amended to include Exhibit III-A, September 1,
2007-August 31, 2008 Medicaid Non-Reform HMO Capitation Rates, attached hereto and made a part
of the Contract. All references in the Contract to Exhibit III, September 1, 2006 — August 31,
2007 HMO Rates, shall hereinafter also refer to Exhibit III-A, September 1, 2007- August 31,
2008 Medicaid Non-Reform HMO Capitation Rates, as appropriate.



3. Attachment II, Medicaid Prepaid Health Plan Model Contract, Section V, Covered Services, Item
C, Expanded Services, sub-item 2 is hereby deleted in its entirety and replaced with the
following:




	 	2.	 	The following is a list of the Health Plan’s Expanded Services:






	 	a.	 	Adult basic dental benefits, such as cleanings, simple fillings, and/or
extractions.
	 
	 	b.	 	Up to $25 credit per household each month for selected
over-the-counter drugs and/or health supplies.
	 
	 	c.	 	Respite Care services — Annual maximum of not more than
an initial home health visit by an R.N. and eight (8) follow-up visits by an
aide. Follow-up visits are four (4) hours in length. Maximum of sixteen (16)
hours in a given month and thirty-two (32) hours per year.
	 
	 	d.	 	Circumcisions for newborns (routine newborn circumcision
up to twelve (12) weeks of age).






	4.	 	This Amendment shall have an effective date of September 1, 2007, or the date on which both
parties execute the Amendment, whichever is later.





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



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



This Amendment and all its attachments are hereby made a part of the Contract.



This Amendment cannot be executed unless all previous amendments to this Contract have been
fully executed.


 
	 	 
	AHCA Form 2100-0002 (Rev. NOV03)	AHCA Contract No. FA614, Amendment No. 4, Page 1 of 2







 









 








			
	Amerigroup Florida, Inc. 

d/b/a Amerigroup Community Care
	 	Medicaid HMO Contract






     IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which
includes all attachments hereto) to be executed by their officials thereunto duly authorized.



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

	 	 
	 	 	 	 
	 
	 	 	 	 	 	 
	NAME:

	 	William McHugh
	 	NAME:
	 	Andrew C. Agwunobi, M.D
	 
	 	 	 	 	 	 
	TITLE:

	 	CEO
	 	TITLE:
	 	Secretary
	 
	 	 	 	 	 	 
	DATE:

	 	 	 	DATE:	 	 
	 

	 	 
	 	 	 	 






List of attachments included as part of this Amendment:




	 	 	 	 	 
	Specify	 	Letter/	 	 
	Type	 	Number	 	Description
	Exhibit

	 	II-D
	 	Fourth Revised Capitation
Rates (1 Page)
	 
	Exhibit

	 	III-A
	 	September 1, 2007- August 31,
2008 Medicaid Non-Reform HMO
Capitation Rates (5 Pages)






REMAINDER OF PAGE INTENTIONALLY LEFT BLANK




 
	 	 
	AHCA
Contract No. FA614, Amendment No. 4, Page 2 of 2	AHCA Form
2100-0002 (Rev. NOV03)





  









 








			
	Amerigroup Florida, Inc. 

d/b/a Amerigroup Community Care
	 	Medicaid HMO Contract






EXHIBIT II-D

FOURTH REVISED CAPITATION RATES




Table 4 — General Capitation Rates plus Mental Health Rates plus Transportation:




	 	 	 	 	 
	Area 3 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Hernando

	 	 	015005350	 
	Lake

	 	 	015005341	 
	 
	 	 	 	 
	Area 5 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Pasco

	 	 	015005304	 
	Pinellas

	 	 	015005305	 
	 
	 	 	 	 
	Area 6 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Hillsborough

	 	 	015005300	 
	Polk

	 	 	015005307	 
	Manatee

	 	 	015005318	 
	 
	 	 	 	 
	Area 7 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Orange

	 	 	015005308	 
	Seminole

	 	 	015005313	 
	Osceola

	 	 	015005314	 
	Brevard

	 	 	015005336	 
	 
	 	 	 	 
	Area 8 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Lee

	 	 	015005302	 
	Sarasota

	 	 	015005306	 
	 
	 	 	 	 
	Area 9 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Palm Beach

	 	 	015005310	 
	 
	 	 	 	 
	Area 10 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Broward

	 	 	015005311	 
	 
	 	 	 	 
	Area 11 Counties:
	 	 	 	 
	County:

	 	 	Provider Number:

	Miami-Dade

	 	 	015005312	 






 
	 	 
	AHCA
Form 2100-0002 (Rev. NOV03)	AHCA Contract No. FA614, Exhibit II-D, Page 1 of 1








 









 








     




EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)




TABLE 1

General Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	SSI-B	 	SSI-AB
	Area	 	BTHM0+2M0 3M0.11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21.54)	 	AGE (55+)	 	BTHMO+2M0   3M0-11MO	 	AGE (1-5)	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)	 	 	 	AGE (65-)	 	AGE (65+)
	 

	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




TABLE 2

General + Mental Health Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	SSI-B	 	SSI-AB
	Area	 	BTHM0+2M0 3M0.11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21.54)	 	AGE (55+)	 	BTHMO+2M0   3M0-11MO	 	AGE (1-5)	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)	 	 	 	AGE (65-)	 	AGE (65+)
	 

	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****



AHCA Contract No. FA614, Exhibit III-A, Page 1 of 5



HMO CapRates_200709-200608 08/10/2007




 









 





      





EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area, Age and Eligibility Category

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)




TABLE 3

General + MH + Dental Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	SSI-B	 	SSI-AB
	Area	 	BTHM0+2M0 3M0.11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21.54)	 	AGE (55+)	 	BTHMO+2M0 3M0-11MO	 	AGE (1-5)	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)	 	 	 	AGE (65-)	 	AGE (65+)
	 

	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




TABLE 4

General + MH + Transportation Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	SSI-N	 	SSI-B	 	SSI-AB
	Area	 	BTHM0+2M0 3M0.11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+) 	 	BTHMO+2M0 3M0-11MO	 	AGE (1-5)	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)	 	 	 	AGE (65-)	 	AGE (65+)
	 

	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




 
	 	 
	AHCA Contract No. FA614, Exhibit III-A, Page 2 of 5	HMO CapRates_200709-200808 08/10/2007











 











 




     



EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area, Age and Eligibility Category

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)




TABLE 5

General + Transportation Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	SSI-B
	 	SSI-AB
	Area

	 	BTHM0+2M0
	 	3M0.11MO
	 	AGE (1-5)
	 	AGE (6-13)
	 	AGE (14-20)
	 	 	 	AGE (21.54)
	 	 	 	AGE (55+)
	 	BTHMO+2M0 3M0-11MO
	 	AGE (1-5)
	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)
	 	 	 	AGE (65-)
	 	AGE (65+)
	 

	 	 	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




TABLE 6

General + Dental Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	SSI-B
	 	SSI-AB	 	 
	Area

	 	BTHM0+2M0
	 	3M0.11MO
	 	AGE (1-5)
	 	AGE (6-13)
	 	AGE (14-20)
	 	 	 	AGE (21-54)
	 	 	 	AGE (55+)
	 	BTHMO+2M0 3M0-11MO
	 	AGE (1-5)
	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)
	 	 	 	AGE (65-)
	 	 AGE (65+)
	 

	 	 	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****



 
	 	 
	AHCA Contract No. FA614, Exhibit III-A, Page 3 of 5	HMO CapRates_200709-200808 08/10/2007





 









 






     




EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)




TABLE 7

General + Dental + Transportation Rates:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	SSI-B
	 	SSI-AB
	Area

	 	BTHM0+2M0
	 	3M0.11MO
	 	AGE (1-5)
	 	AGE (6-13)
	 	AGE (14-20)
	 	 	 	AGE (21.54)
	 	 	 	AGE (55+)
	 	BTHMO+2M0 3M0-11MO
	 	AGE (1-5)
	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)
	 	 	 	AGE (65-)
	 	AGE (65+)
	 

	 	 	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




TABLE 8

General + Mental Health + Dental + Transportation Rates:







	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	TANF
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-N
	 	 	 	 	 	SSI-B
	 	SSI-AB
	Area

	 	BTHM0+2M0
	 	3M0.11MO
	 	AGE (1-5)
	 	AGE (6-13)
	 	AGE (14-20)
	 	 	 	AGE (21-54)
	 	 	 	AGE (55+)
	 	BTHMO+2M0 3M0-11MO
	 	AGE (1-5)
	 	AGE (6-13) AGE (14-20) AGE (21-54) AGE (55+)
	 	 	 	AGE (65-)
	 	AGE (65+)
	 

	 	 	 	 	 	 	 	 	 	Female
	 	Male
	 	Female
	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 






**** REDACTED****




 
	 	 
	AHCA Contract No. FA614, Exhibit III-A, Page 4 of 5	HMO CapRates_200709-200808 08/10/2007





 











 





EXHIBIT III-A

September 1, 2007- August 31, 2008

Medicaid Non-Reform HMO Capitation Rates

By Area , Age and Eligibility Category

ESTIMATED HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)




	 	 	 
	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, Hemando, 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, Hillsborough, Manatee, Polk
	Area 7

	 	Brevard, Orange, Osceola, Seminole
	Area 8

	 	Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota
	Area 9

	 	Indian River, Okeechobee, St. Lucie, Martin, Palm Beach
	Area 10

	 	Broward
	Area 11

	 	Dade, Monroe






Created on August 10, 2007



 
	 	 
	AHCA Contract No. FA614, Exhibit III-A, Page 5 of 5	HMO CapRates_200709-200808 08/10/2007





 









 





			
	Amerigroup Florida, Inc. 

d/b/a Amerigroup Community Care
	 	Medicaid HMO Contract






     IN WITNESS WHEREOF, the parties hereto have caused this eight (8) page Amendment (which
includes all attachments hereto) to be executed by their officials thereunto duly authorized.



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

	 /S/ William McHugh	 	 	 		SIGNED BY:	 	 
	 	 	 	 	 	 
	 
	 	 	 	 		 	 	 
	NAME: William McHugh	 		NAME: Andrew C. Agwunobi, M.D
	 							 	 
	 
	 	 	 	 		 	 	 
	TITLE:. CEO	 		TITLE: Secretary
	 								 
	 
	 	 	 	 		 	 	 
	DATE: 8-31-07	 		DATE:	 	 
	 	 		 	 
	 
	 	 	 	 		 	 	 
	List of attachments included as part of this Amendment:		 	 	 
	 
	 	 	 	 		 	 	 






	 	 	 	 	 
	Specify

	 	Letter/	 	 
	Type

	 	Number
	 	Descnption		 
	 
	Exhibit	 	II-D	 	Fourth Revised Capitation Rates (1 Page)
	 
	Exhibit	 	III-A	 	September 1, 2007- August 31, 2008 Medicaid Non-Reform HMO Capitation Rates (5 Pages)






REMAINDER OF PAGE INTENTIONALLY LEFT BLANK



 
	 	 
	AHCA Contract No. FA614, Amendment No. 4, Page 2 of 2	AHCA Form 2100-0002 (Rev. NOV03)