fa905ahcacontractamend2.htm


    Back to Form 10-K 

    Exhibit
10.55.2

    
       

      
        	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


      

       

      
        AHCA
CONTRACT NO. FA905

        AMENDMENT
NO. 2

      

      
         

        THIS CONTRACT, entered into
between the STATE OF FLORIDA,
AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter
referred to as the "Agency"
and HEALTHEASE OF
FLORIDA, INC., hereinafter referred to as the "Vendor" or "Health Plan", is hereby
amended as follows:

      

      
         

        
          	
                  1.

                	
                  Attachment
      I, Scope of Services, Capitated Health Plans, Section B. Population(s) to
      be Served, Item 1., the
      third paragraph is hereby amended to now read as
      follows:

                


        

         

      

      
        
          	
                    
       ** 

                	
                  Enrolled
      in an Agency-authorized specialty plan for children with chronic
      conditions and screened by the Florida Department of Health as clinically
      eligible for Children's  Medical Services using an Agency-approved
      screening tool as specified in Attachment II, Section III, Eligibility and
      Enrollment, Exhibit 3.

                


        

      

      
         

        
          	
                  2.

                	
                  Attachment
      I, Scope of Services,  Capitated Health Plans, Section F.,
      Applicable Exhibits, Table 9, Applicable
      Exhibits, is hereby deleted in its entirety and replaced with the
      following:

                


        

         

      

      
        	
                 Table
      9-A 

                Revised
      Applicable Exhibits

              
	
                
                  Attachment/
      

                  Exhibit*

                

              	
                
                  HMO
      

                  Reform

                

              	
                
                  HMO
      

                  Non-

                  Reform

                

              	
                
                  Specialty

                  Plan
      for

                  Recipients

                  Living
      with

                  HIV/AIDS

                  Reform

                

              	
                
                  Fee-

                  for-

                  Service
      

                  PSN
      

                  Non-

                  Reform

                

              	
                
                  Capitated
      

                  PSN
      

                  Non-

                  Reform

                

              	
                
                  Fee-

                

                
                  for-

                  Service

                  PSN
      

                  Reform

                

              	
                
                  Capitated

                

                
                  PSN
      

                  Reform

                

              	
                
                  Specialty

                  Plan
      for

                  Children
      with

                  Chronic

                  Conditions

                  Reform

                

              	
                
                  HMO
      

                  Non-

                  Reform
      

                  with
      Frail/ 

                  Elderly
      

                  Program

                

              
	
                
                  Att.
      1, Exh. 1

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              
	
                
                  Att.
      I, Exh. 1-

                  FFS

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              
	
                
                  Att.
      I, Exh. 

                  2-NR

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              
	
                
                  Att.
      I, Exh. 2-R

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              
	
                
                  Att.
      I, Exh. 

                  2-FFS-NR

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              
	
                
                  Att.
      I, Exh. 

                  2-FFS-R

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh. 1

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh. 2

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      2, Exh. 3

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh. 4

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh. 5

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh. 6-

                  HMO&R

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh. 6-

                  PSN-NR

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh. 7

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh. 8

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh. 9

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh. 10

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              	
                
                  X

                

              
	
                
                  Att.
      II, Exh.
11

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              
	
                
                  Att.
      II, Exh.
12

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              	
                
                  N/A

                

              


      

      
         

        AHCA
Contract No. FA905, Amendment No. 2, Page 1 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

          

        

      

      
        
          
                                                                                                                                         

          

        

      

      
        	
                 Table
      9-A 

                Revised
      Applicable Exhibits

              
	
                
                  Attachment/
      

                  Exhibit*

                

              	
                
                  HMO
      

                  Reform

                

              	
                
                  HMO

                  Non-

                  Reform

                

              	
                
                  Specialty

                  Plan
      for

                  Recipients

                  Living
      with

                  HIV/AIDS

                  Reform

                

              	
                
                  Fee-

                

                
                  for-Service

                

                
                  PSN

                

                
                  Non-

                  Reform

                

              	
                
                  Capitated
      

                  PSN
      

                  Non-

                  Reform

                

              	
                
                  Fee-

                  for-

                  Service
      

                  PSN

                  Reform

                

              	
                
                  Capitated

                

                
                  PSN
      

                  Reform

                

              	
                
                  Specialty

                  Plan
      for

                  Children
      with

                  Chronic

                  Conditions

                  Reform

                

              	
                
                  HMO

                  Non-

                  Reform

                  with
      Frail/

                  Elderly

                  Program

                

              
	
                
                  Att.
      II, Exh. 

                  13-CAP-R

                

              	X	N/A	X	N/A	N/A	X	X	N/A	N/A
	
                
                  Att.
      II, Exh. 

                  13-CAP-NR

                

              	N/A	X	N/A	N/A	X	N/A	N/A	N/A	X
	
                
                  Att.
      II, Exh. 

                  13-FFS

                

              	N/A	N/A	N/A	X	N/A	X	N/A	X	N/A
	
                
                  Att.
      II, Exh. 14

                

              	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	
                
                  Att.
      II, Exh. 15

                

              	X	X	X	X	X	X	X	X	X
	
                
                  Att.
      II, Exh. 16

                

              	X	X	X	X	X	X	X	X	X


      

      
         

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

      

      
         

        
          	
                  3.  

                	
                  Effective
      November 1, 2009, Attachment I, Scope of Services, Capitated Health Plans,
      is hereby amended to include Exhibit 2-NR-A, Medicaid Non-Reform HMO
      Capitation Rates, Effective November 1, 2009 - August 31, 2012, attached
      hereto and made a part of this Contract. All references to Exhibit 2-NR,
      Medicaid Non-Reform HMO Capitation Rates, September 1, 2009 - August 31,
      2010, shall hereinafter also refer to Exhibit 2-NR-A, as
      appropriate.

                


        

      

      
         

        
          	
                  4.  

                	
                  Attachment
      II, Core Contract Provisions, Section I, Definitions and Acronyms, Item
      A., Definitions, the following definitions are hereby amended to now read
      as follows:

                


        

      

      
         

        Catastrophic
Component Threshold - (Capitated Reform
Health Plans in counties where no HMO is present, Reform FFS PSNs, and the
Specialty Plan for Children with Chronic Conditions only) - The point at which
the cost of covered services, based on Medicaid fee-for-service payment levels,
reaches $50,000 for an enrollee in a Contract year. For a Health Plan that
accepts the comprehensive capitation rate only, the Agency begins reimbursing
the Health Plan for the cost of covered services received by the enrollee for
the remainder of the Contract year. This reimbursement is based on a percentage
of Medicaid fee-for-service payment levels.

      

      
         

        Comprehensive
Component -
(Capitated Reform Health Plans in counties where no HMOs are present, Reform FFS
PSNs, and the Specialty Plan for Children with Chronic Conditions only) - The
amount of financial risk assumed by a Health Plan to provide covered service up
to $50,000 per enrollee based on Medicaid fee-for-service payment
levels.

      

      
         

        Contested
Claim - (FFS
PSNs and the Specialty Plan for Children with Chronic Conditions only) - A claim
that has not been authorized and forwarded to the Medicaid fiscal agent by the
Health Plan because it has a material defect or impropriety.

      

      
         

        Federally
Qualified Health Center (FQHC) - An entity that is
receiving a grant under section 330 of the Public Health Service Act, as
amended. (Also see Section 1905(I)(2)(B) of the Social Security Act.) FQHCs
provide primary health care and related diagnostic services and may provide
dental, optometric, podiatry, chiropractic and behavioral health
services.

      

      
         

        Share of
Cost-Savings - (FFS PSNs and the
Specialty Plan for Children with Chronic Conditions only) -Potential payment to
the Health Plan when amount of the savings pool exceeds the administrative
allocation to the Health Plan as determined through a reconciliation
process.

      

      
         

        AHCA
Contract No. FA905, Amendment No. 2, Page 2 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

      
        
          	
                  5.

                	
                  Attachment
      II, Core Contract Provisions, Section I, Definitions and Acronyms, Item
      B., Acronyms, the following
      acronym is hereby amended to now read as
  follows:

                


        

         

        
        

      

      
        APD — Agency for Persons with
Disabilities

      

      
         

        
          	
                  6.

                	
                  Attachment
      II, Core Contract Provisions, Section II, General Overview, Item D.,
      General Responsibilities of the
      Health Plan, sub-item 1., the first sentence is hereby amended to now read
      as follows:

                


        

         

        
        

      

      
        The
Health Plan shall comply with all provisions of this Contract, including all
attachments, applicable exhibits, Health Plan Report Guide (Report Guide)
requirements and any amendments and shall act in good faith in the performance
of the Contract provisions.

      

      
         

        
          	
                  7.

                	
                  Attachment
      II, Core Contract Provisions, Section III, Eligibility and Enrollment,
      Item B., Enrollment, sub-item
      3.c.(3), the third sentence is hereby amended to now read as
      follows:

                


        

         

        
        

      

      
        (Special
provisions apply to fee-for-service PSNs and the Specialty Plan for Children
with Chronic Conditions; see Exhibit 3.)

      

      
         

        
          	
                  8.

                	
                  Attachment
      II, Core Contract Provisions, Section III, Eligibility and Enrollment,
      Item B., Enrollment, sub-item
      3.c.(8) is hereby amended to now read as
  follows:

                


        

         

      

      
        
          	
                   
      

                	
                   (8)
      

                	If
      the unborn activation process is properly completed by the FFS PSN and the
      Specialty Plan for Children with Chronic Conditions, the newborn will be
      enrolled using the process in Attachment II, Exhibit
  3.


        

      

      
         

        
          	
                  9.

                	
                  Attachment
      II, Core Contract Provisions, Section IV, Enrollee Services, Community
      Outreach and Marketing,
      Item A., Enrollee Services, sub-item 1.c. is hereby amended to now read as
      follows:

                


        

         

      

      
        
          	
                   
      

                	
                   c.

                	
                  The
      Health Plan shall mail all enrollee materials to the enrollee's payee
      address provided by the Agency on the Health Plan's monthly enrollment
      file. Mailing envelopes for enrollee materials shall contain a request for
      address correction. When enrollee materials are returned to the Health
      Plan as undeliverable, the Health Plan shall remail the materials to the
      enrollee residence address provided by the Agency if that address is
      different from the payee address. The Health Plan shall use and maintain
      in a file a record of all of the following methods to contact the
      enrollee:

                


        

      

      
         

        
          	
                  (1)  

                	
                  Routine
      checks of the Agency enrollment reports for changes of address and/or
      presence of the enrollee's residence address, maintaining a record of
      returned mail and attempts to remail to either a new payee address or
      residence address as provided by the
Agency;

                


        

      

      
         

        
          	
                  (2)  

                	
                  Telephone
      contact at the number obtained from Agency enrollment reports, the local
      telephone directory, directory assistance, city directory, or other
      directory; and

                


        

      

      
         

        
          	
                  (3)  

                	
                  Routine
      checks (at least once a month for the first three (3) months of
      enrollment) on services or claims authorized or denied by the Health Plan
      to determine if the enrollee has received services, and to locate updated
      address and telephone number
information.

                


        

      

      
         

        
          	
                  10.

                	
                  Attachment
      II, Core Contract Provisions, Section IV, Enrollee Services, Community
      Outreach and Marketing,
      Item A., Enrollee Services, sub-item 7.d. is hereby amended to include the
      following:

                


        

         

      

      
        If the
Health Plan uses the Medicaid fee-for-service pharmacy network as its pharmacy
network, the provider directory shall include a statement to this
effect.

      

      
         

        
          	
                  11.

                	
                  Attachment
      II, Core Contract Provisions, Section IV, Enrollee Services, Community
      Outreach and Marketing,
      Item A., Enrollee Services, sub-item 15., Enhanced Services is hereby
      deleted in its entirety and replaced
      as follows:

                


        

         

        AHCA
Contract No. FA905, Amendment No. 2, Page 3 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

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

      

      
         

        
          	
                  12.

                	
                  Attachment
      II, Core Contract Provisions, Section V, Covered Services, Item F., Moral
      or Religious Objections,
      sub-item 1. is hereby amended to now read as
    follows:

                


        

         

      

      
        
          	
                   
      

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

                


        

      

      
         

        
          	
                  13.

                	
                  Attachment
      II, Core Contract Provisions, Section V, Covered Services, Item H.,
      Coverage Provisions, sub-item
      1., Requirements, the first sentence is hereby amended to now read as
      follows:

                


        

         

        
        

      

      
        The
Health Plan shall provide the services listed in Section V in accordance with
the provisions herein, and in accordance with the Florida Medicaid Coverage and
Limitations Handbooks and the Florida Medicaid State Plan unless, for Reform
HMOs, a customized benefit package is certified in the benefit grid in
Attachment I.

      

      
         

        
          	
                  14.

                	
                  Attachment
      II, Core Contract Provisions, Section V, Covered Services, Item H.,
      Coverage Provisions, is hereby
      amended to include sub-item 10.a.(11) as
      follows:

                


        

         

      

      
        
          	
                          (11)

                	
                  The
      Health Plan shall report quarterly to BMHC, within thirty (30) calendar
      days after the end of the quarter being reported, the Health Plan's
      complete listing of all Medicaid enrollees discharged from inpatient
      hospitalization, using the format provided in the Health Plan Report Guide
      referenced in Attachment II, Section XII, Reporting
      Requirements.

                


        

      

      
         

        
          	
                  15.

                	
                  Attachment
      II, Core Contract Provisions, Section V, Covered Services, Item H.,
      Coverage Provisions, sub-item
      14.e. is hereby amended to now read as
  follows:

                


        

         

      

      
        
          	
                        
       e.

                	
                  Submit
      an attestation with accompanying documentation annually, by October 1 of
      each Contract year, to BMHC that the Health Plan has advised its providers
      to enroll in the VFC program. The Agency may waive this requirement in
      writing if the Health Plan provides documentation to BMHC that the Health
      Plan is enrolled in the VFC
program;

                


        

      

      
         

        
          	
                  16.

                	
                  Attachment
      II, Core Contract Provisions, Section V, Covered Services, Item H.,
      Coverage Provisions, is hereby
      amended to include sub-item 16.k. as
  follows:

                


        

         

      

      
        
          	
                         
      k.

                	
                  Capitated
      Health Plans covering Reform populations shall submit a complete pharmacy
      drug list to the Agency's Reform choice counseling vendor annually by
      December 1, using the format provided in the Health Plan Report Guide
      referenced in Attachment II, Section XII, Reporting
      Requirements.

                


        

      

      
         

        
          	
                  17.

                	
                  Attachment
      II, Core Contract Provisions, Section VII, Provider Network, Item C,
      Network Changes, sub-item
      6. is hereby amended to now read as
  follows:

                


        

         

      

      
        
          	
                         
      6.

                	
                  The
      Health Plan shall notify BMHC of any new network providers by the
      fifteenth (15th)
      of the month following
      execution of the provider agreement and terminated providers by the
      fifteenth (15th)
      of the month
      following the report month using the format provided in the Health Plan
      Report Guide referenced in Attachment II, Section XII,
      Reporting Requirements.

                


        

         

      

      
        
          	
                  18.  

                	
                  Attachment
      II, Core Contract Provisions, Section VII, Provider Network, Item E.,
      Provider Termination, sub-item 3., the second sentence is hereby deleted
      in its entirety.

                


        

      

      
         

        
          	
                  19.  

                	
                  Attachment
      II,  Core Contract Provisions, Section  IX, Grievance
      System, Item  E.,  Resolution and Notification,
      sub-item 7.c. is hereby amended to now read as
  follows:

                


        

      

      
         

        AHCA
Contract No. FA905, Amendment No. 2, Page 4 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

      
        
          	
                         
      c.

                	
                  The
      right to appeal an adverse decision on an appeal to the Subscriber
      Assistance Program (SAP) for HMOs or the Beneficiary Assistance Program
      (BAP) for PSNs, including how to initiate such a review and the
      following:

                


        

      

      
         

        
        

         

        
          	 	    
      (1)	Before
      filing with the SAP or BAP, the enrollee must complete the Health Plan's
      appeal process;
	 	 	 
	 	   
       (2)	
                  The
      enrollee must submit the appeal to the SAP or BAP within one (1) year
      after receipt of the final decision letter from the Health
      Plan;

                
	 	 	 
	 	     (3)	
                  Neither
      the SAP nor the BAP will consider an appeal that has already been to a
      Medicaid Fair Hearing;

                
	 	  	 
	 	    
       (4)	The address and
      toll-free telephone numbers of the
SAP/BAP:


        

         

        
          
            	 	 Agency
      for Health Care Administration 

                    
                       Subscriber
      Assistance Program / Beneficiary Assistance Program

                      
                        
                           Building
      1, MS #26

                        

                        
                           2727
      Mahan Drive 

                        

                        
                           Tallahassee,
      Florida 32308

                        

                        
                           (850)
      921-5458

                           (888)
      419-3456
(toll-free)

                        

                      

                    

                  


          

           

        

      

      
        
          	
                  20.

                	
                  Attachment
      II, Core Contract Provisions, Section XI, Information Management and
      Systems, Item D., Systems
      Availability, Performance and Problem Management Requirements, sub-item
      8.a. is hereby amended
      to include the
following:

                


        

         

      

      
        If the
approved plan is unchanged from the previous year, the Health Plan shall submit
a certification to BMHC that the prior year's plan is still in place annually by
April 30th of
each Contract year. Changes in the plan are due to BMHC within ten (10) business
days after the change.

      

      
         

        
          	
                  21.

                	
                  Attachment
      II, Core Contract Provisions, Section XII, Reporting Requirements, Item
      A., Health Plan Reporting
      Requirements, Table 1, Summary of Reporting Requirements, is hereby
      deleted in its entirety and
      replaced with the following Table 1-A, Revised Summary of Reporting
      Requirements. All references in the
      Contract to Table 1 shall hereinafter refer to Table
      1-A.

                


        

         

      

      
        TABLE
1-A


      

      
         

        REVISED
SUMMARY OF REPORTING REQUIREMENTS

      

       

      
        	
                
                  Contract

                  Section

                

              	
                
                  Report
      

                  Name

                

              	
                
                  Plan
      

                  Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      II

                  and
      Exhibit 2

                

              	
                
                  Benefit
      Maximum Report

                

              	
                
                  Ref
      HMO;

                  
                    Ref
      FFS PSN;

                    
                      Ref
      Cap PSN;

                      
                        CCC

                      

                    

                  

                

              	
                
                  Monthly, fifteen (15)
      calendar 

                  days
      after
      the end of the
      

                  reporting
      month in which
      

                  claims reach $450,000 in
      

                  enrollee
      costs

                

              	
                
                  HSD
      

                    Contract

                    
                      Manager

                      
                        
                          once

                          $450,000
      is 

                          reached,
      and to   

                          BMHC
      that initial 

                          month
      and  

                          monthly
      thereafter

                           through 
      

                          end
      of state fiscal
  year

                        

                      

                    

                  

                

              


      

      
        


        AHCA
Contract No. FA905, Amendment No. 2, Page 5 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

                                                                                                                        

          

        

      

      
        	
                
                  Contract
      

                  Section

                

              	
                
                  Report
      Name

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      III 

                  and
      Exhibit 3

                

              	
                
                  Newborn
      Enrollment  

                  Report

                

              	
                
                  NR
      FFS PSN;  

                  Ref
      FFS PSN;  

                  CCC

                

              	
                
                  Weekly, on

                  Wednesday

                

              	
                
                  Medicaid
      Area Office

                

              
	
                
                  Section
      III 

                  and
      Exhibit 3

                

              	
                
                  Involuntary
      

                  Disenrollment
      Report

                

              	
                
                  Ref
      HMO; Ref  

                  FFS
      PSN; Ref  

                  Cap
      PSN; 

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Monthly, first Thursday
      of month

                

              	
                
                  Choice

                  Counseling

                  Vendor

                

              
	
                
                  Section
      IV

                

              	
                
                  Medicaid

                

                
                  Redetermination
      Notice   

                  Summary
      Report

                

              	
                
                  All
      Plans that 

                  participate
      per 

                  Attachment
      I

                

              	
                
                  Quarterly, forty-five
      (45) calendar days  

                  after
      end of reporting quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV

                

              	
                
                  Community
      Outreach   

                  Health
      Fairs/Public 

                  Events
      Notification

                

              	
                
                  All
      Plans

                

              	
                
                  Monthly, no later than
      20th
      calendar day of

                  month
      before event month;

                  amendments
      two (2) weeks before event

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV

                

              	
                
                  Community
      Outreach   

                  Representative
      Report

                

              	
                
                  All
      Plans

                

              	
                
                  Two (2)
      weeks before activity

                

                
                   

                  Quarterly, forty-five
      (45) calendar days   

                  after
      end of reporting quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV and 

                  Exhibit
      4

                

              	
                
                  Enhanced
      Benefits Report

                

              	
                
                  Ref
      HMO; Ref  

                  FFS
      PSN; Ref 

                  Cap
      PSN; 

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Monthly, ten (10)
      calendar days after end 

                  of
      reporting month

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V, 

                  Exhibit
      5

                

              	
                
                  Customized
      Benefit   

                  Notifications
      Report

                

              	
                
                  Ref
      HMO; Ref  

                  Cap
      PSN

                

              	
                
                  Monthly, fifteen (15)
      calendar days after 

                  end
      of reporting month

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V

                

              	
                
                  CHCUP
      (CMS-416) & FL 

                  60%
      Screening (Child  

                  Health
      Check Up report)

                

              	
                
                  All
      Plans

                

              	
                
                  Annually,

                  unaudited
      by

                  January
      15th
      for

                  prior
      federal fiscal

                  year;

                  Annually,
      audited

                  report
      by October

                  1st

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 6 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          
                                                                                                                 

      

      
        	
                
                  Contract
      Section

                

              	
                
                  Report
      Name

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      V

                

              	
                
                  Inpatient
      Discharge 

                  Report

                

              	
                
                  NR
      Ref HMO;               
      

                  NR
      Cap PSN; 

                  Ref
      HMO; 

                  Ref
      Cap
      PSN; 

                  HIV/AIDS

                

              	
                
                  Quarterly, thirty (30)
      calendar days after end
      of reporting quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V

                

              	
                
                  Hernandez
      Settlement   

                  Ombudsman
      Log

                

              	
                
                  NR
      HMO; 

                  NR
      FFS
      PSN*; 

                  NR
      Cap
      PSN; 

                  Ref
      HMO;
      

                  Ref
      FFS PSN*;
      

                  Ref
      Cap PSN;
      

                  CCC*;
      

                  HIV/AIDS

                   
      

                  *
      If the FFS   

                  Health
      Plan 

                  has
      authorization
      

                  requirements
      

                  for
      prescribed 

                  drug
      services

                

              	
                
                  Quarterly, fifteen (15)
      calendar days after end
      of reporting quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V

                

              	
                
                  Hernandez
      Settlement 

                  Agreement
      Survey

                

              	
                
                  NR
      HMO; 

                  NR
      FFS
      PSN*; 

                  NR
      Cap
      PSN; 

                  Ref
      HMO;
      

                  Ref
      FFS PSN*;
      

                  Ref
      Cap PSN;
      

                  CCC*;
      

                  HIV/AIDS

                

                
                   
      

                  *
      If the FFS 

                  Health
      Plan 

                  has
      authorization
      

                  requirements
      

                  for
      prescribed 

                  drug
      services

                

              	
                
                  Annually,
on

                  August
      1st

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V

                

              	
                
                  Quarterly
      Pharmacy (RX 

                  Quarterly)
      Encounter Data 

                  Submissions

                

              	
                
                  NR
      HMO; 

                  NR
      Cap
      PSN; 

                  Ref
      HMO;
      

                  Ref
      Cap PSN;
      

                  HIV/AIDS

                

              	
                
                  Quarterly,
      thirty

                

                
                  (30)
      calendar days after end of reporting quarter

                

              	
                
                  MEDS
      Team

                

              
	
                
                  Section
      V and

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health -

                  Pharmacy
      Encounter 

                  Data Report

                

              	
                
                  NR
      HMO; 

                  Ref
      HMO;
      

                  Ref
      Cap PSN;
      

                  HIV/AIDS

                

              	
                
                  Quarterly, forty-five
      (45) calendar days after
      end of reporting quarter

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 7 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
         

        
          
            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

                                                                                                                                          

      

      
        	
                
                  Contract

                  
                    Section

                  

                

              	
                
                  Report
      Name

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      V

                

              	
                
                  Pharmacy
      Navigator 

                  Report

                

              	
                
                  Ref
      HMO; 

                  Ref
      Cap PSN; 

                  HIV/AIDS

                

              	
                
                  Annually, by
      

                  December
      1st

                

              	
                
                  Choice
      

                  Counseling
      

                  Vendor

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health Annual 80/20 Expenditure Report

                

              	
                
                  NR
      HMO

                

              	
                
                  Annually, by
      

                  April
      1st

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VI, 

                  Exhibit 6

                

              	
                
                  Behavioral
      Health Critical Incident Report - Individual

                

              	
                
                  NR
      HMO; 

                  Ref-HMO; 

                  Ref. FFS PSN; 

                  Ref Cap. PSN;
      

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Immediately,
      no later than
      twenty-four (24) hours 

                    after
      occurrence or 

                    knowledge
      of incident

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health Critical Incident Report - Summary

                

              	
                
                  NR
      HMO; 

                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap PSN; 

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Monthly, by the 15th

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health - Required
      Staff/Providers  Report

                

              	
                
                  NR
      HMO; 

                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap PSN;
      

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Quarterly, forty-five
      (45) calendar days after end of 

                    reporting quarter
      for Health Plans operating
      less than one (1) year;

                     

                    Annually, by
      August
      15th,
      for all other Health
      Plans

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health - FARS/CFARS

                

              	
                
                  NR
      HMO 

                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap PSN; 

                  CCC; 
      

                  HIV/AIDS

                

              	
                
                  Semi-Annually,
      August 15th
      and February 15th

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health - Enrollee Satisfaction Survey Summary

                

              	
                
                  NR
      HMO; 

                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap   

                  PSN;
      

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Annually
      by March 1st

                

              	
                
                  BMHC 
      behavioral

                  health
      analyst

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health -Stakeholders' Satisfaction Survey - Summary

                

              	
                
                  NR
      HMO;
      

                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap PSN; 

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Annually, by March
      1st

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 8 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

                                                                                                                          

      

      
        	
                
                  Contract

                  
                    Section

                  

                

              	
                
                  Report
      Name

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      VI, 

                  Exhibit
      6

                

              	
                
                  Behavioral
      Health - Encounter Data Report

                

              	
                
                  NR
      HMO; 

                  Ref
      HMO; 

                  Ref
      Cap PSN; 

                  HIV/AIDS

                

              	
                
                  Quarterly, forty-five
      (45) calendar days 

                    after
      end of reporting 

                    quarter

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VII

                

              	
                
                  Provider
      Network File

                

              	
                
                  All
      Plans

                

              	
                
                  Monthly, first Thursday
      of 

                  month
      (optional weekly

                

                
                  submissions
      each 

                  Thursday
      for remainder of 

                  month)

                

              	
                
                  AHCA
      Choice 

                  Counseling
      

                  Vendor
      for 

                  Reform;

                

                
                   
      

                  For
      non-Reform, to 

                  Medicaid
      fiscal 

                  agent
      and BMHC

                

              
	
                
                  Section
      VII

                

              	
                
                  Provider
      Termination and New 

                  Provider
      Notification Report

                

              	
                
                  All
      Plans

                

              	
                
                  Summary
      of new and  

                  terminated
      providers due 

                  monthly, by the
      fifteenth 

                  (15th)
      calendar day of the 

                  month
      following the 

                  reportinq
      month

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VII

                

              	
                
                  PCP
      Wait Times Report

                

              	
                
                  All
      Plans

                

              	
                
                  Annually,
by

                  February
      1st

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VIII

                

              	
                
                  Cultural
      Competency Plan (and Annual Evaluation)

                

              	
                
                  All
      Plans

                

              	
                
                  Annually,
      October 1st

                

              	
                
                  BMHC

                

              
	
                
                  Section 
      VIII and Exhibit 5

                

              	
                
                  Performance
      Measures

                

              	
                
                  All
      Plans

                

              	
                
                  Annually, on July 1st

                

              	
                
                  BMQM

                

              
	
                
                  Section
      IX

                

              	
                
                  Complaints,
      Grievance, and Appeals 

                  Report

                

              	
                
                  All
      Plans

                

              	
                
                  Quarterly, fifteen (15)
      

                  calendar
      days after end of 

                  quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      X

                

              	
                
                  MPI
      - Quarterly Fraud & Abuse 

                  Activity
      Report

                

              	
                
                  All
      Plans

                

              	
                
                  Quarterly, fifteen
      (15)   

                  calendar
      days after the end 

                  of
      reporting quarter

                

              	
                
                  MPI

                

              
	
                
                  Section
      X

                

              	
                
                  MPI
      - Suspected/ Confirmed Fraud & 

                  Abuse
      Reporting

                

              	
                
                  All
      Plans

                

              	
                
                  Within fifteen
      (15)  

                  calendar
      days of detection

                

              	
                
                  MPI

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 9 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

                                                                                                                                           

      

      
        	
                
                  Contract
      Section

                

              	
                
                  Report
      Name

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      X

                

              	
                
                  Claims
      Aging Report & Supplemental 

                  Filing
      Report

                

              	
                
                  All
      Plans

                

              	
                
                  Quarterly, forty-five
      (45) 

                  calendar
      days after end of 

                  reporting
      quarter;

                

                
                   

                  Capitated
      Plans,

                  optional

                

                
                  supplemental
      filing - one-

                  hundred
      and five (105) 

                  calendar
      days after end of 

                  reporting
      quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XIII,   

                  Exhibit
      13

                

              	
                
                  Medicaid
      Reform Supplemental 

                  HIV/AIDS
      Report

                

              	
                
                  Ref
      HMO; 

                  Ref
      FFS PSN; 

                  Ref
      Cap PSN; 

                  CCC;
      

                  HIV/AIDS

                

              	
                
                  Monthly,
      by

                

                
                  second
      Thursday of month

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XIII, 

                  Exhibit
      13

                

              	
                
                  Catastrophic
      Component Threshold 

                  Report

                

              	
                
                  Ref
      HMO; 

                  Ref
      FFS PSN;  

                  Ref
      Cap PSN; 

                  CCC
      per Attachment
      I

                

              	
                
                  Monthly, fifteen (15)
      

                  calendar
      days after end of 

                  reporting
      month

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XV, 

                  Exhibit
      15

                

              	
                
                  Insolvency
      Protection Multiple 

                  Signatures
      Agreement Form

                

              	
                
                  NR
      HMO; 

                  NR
      Cap PSN; 

                  Ref
      HMO; 

                  Ref
      Cap PSN; 

                  HIV/AIDS

                

              	
                
                  Annually,
by

                  April
      1st;

                   

                

                
                  Thirty
      (30) calendar days

                

                
                  after
      any change

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XV

                

              	
                
                  Audited
      Annual and Unaudited 

                  Quarterly
      Financial Reports

                

              	
                
                  All
      Plans except CCC

                

              	
                
                  Audited -Annually by April
      

                  1st
      for calendar year;

                   

                

                
                  Unaudited - Quarterly, 

                  forty-five
      (45) calendar 

                  days
      after end of reporting 

                  quarter

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, 0. 

                  and
      Section XVI, 

                   
      W.

                

              	
                
                  Minority
      Participation Report

                

              	
                
                  All
      Plans

                

              	
                
                  Monthly, fifteen
      (15)

                  calendar
      days after month 

                  being
      reported

                

              	
                
                  BMHC
      and HSD

                

              


      

      
         

        NR
HMO = Non-Reform health maintenance organization, includes Health Plans
covering

        Frail/Elderly
Program services as specified in Attachment I

        Ref
HMO = Reform health maintenance organization

        Ref
Cap PSN = Reform capitated provider service network

        Ref
FFS PSN = Reform Fee-for-Service Provider Service Network

      

      
        NR
Cap PSN = Non-Reform Capitated Provider Service Network

      

      
        NR
FFS PSN = Non-Reform Fee-for-Service Provider Service Network

      

      
        CCC
= Specialty plan for children with chronic conditions

      

      
        HIV/AIDS
= Specialty plan for recipients living with HIV/AIDS

      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 10 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

      
        
          	
                  22. 
      

                	
                  Attachment
      II, Core Contract Provisions, Section XII, Reporting Requirements, Item
      A., Health Plan Reporting Requirements, Table 2, Summary of Submission
      Requirements, is hereby deleted in its entirety and replaced with the
      following Table 2-A, Revised Summary of Submission Requirements. All
      references in the Contract to Table 2 shall hereinafter refer to Table
      2-A.

                


        

      

      
        


        TABLE
2-A

      

      
         

        REVISED
SUMMARY OF SUBMISSION REQUIREMENTS

      

      
         

        2.  Other
Health Plan submissions (not in Table 1-A) required by the Agency are as
follows:

      

       

      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Attachment
      I, Section B., Item 3.a.

                

              	
                
                  Increase
      in enrollment levels

                

              	
                
                  Capitated
      Health Plans; 

                  FFS
      PSNs; 

                  CCC

                

              	
                
                  Before
      increases occur

                

              	
                
                  BMHC
      and HSD

                

              
	
                
                  Attachment
      I, Section D., Item 3.b.

                

              	
                
                  Changes
      to optional or expanded services

                

              	
                
                  FFS
      PSNs; 

                  CCC

                

              	
                
                  Annually,
      by June

                  15th

                

              	
                
                  HSD

                

              
	
                
                  Attachment
      I, Section D., Item 3.c.

                

              	
                
                  Changes
      to optional or expanded services

                

              	
                
                  Capitated
      Health Plans

                

              	
                
                  Annually,
      by June

                  15th

                

              	
                
                  HSD

                

              
	
                
                  Subsequent
      references are to Attachment II and its Exhibits

                

              
	
                
                  Section
      II, 

                  Item
      D.4.

                

              	
                
                  Policies,
      procedures, model
      provider agreements
      &

                  amendments,
      subcontracts,

                  All
      materials related to

                  Contract
      for distribution
      to

                  enrollees,
      providers, public

                

              	
                
                  All

                

              	
                
                  Before
      beginning use; whenever changes occur

                

              	
                
                  BMHC

                

              
	
                
                  Section
      II, 

                  Item
      D.4.a.

                

              	
                
                  Written
      materials

                

              	
                
                  All

                

              	
                
                  Forty-five
      (45) calendar days before effective date

                

              	
                
                  BMHC

                

              
	
                
                  Section
      II, 

                  Item
      D.4.b

                

              	
                
                  Written
      notice of change to enrollees

                

              	
                
                  All

                

              	
                
                  Thirty
      (30) calendar days before effective date

                

              	
                
                  Enrollees
      affected by change

                

              
	
                
                  Section
      II, Item D.6.

                

              	
                
                  Enrollee
      materials, PDL, provider & enrollee handbooks

                

              	
                
                  All

                

              	
                
                  Available
      on Health Plan's web site without log-in

                

              	
                
                  Plan
      web site

                

              
	
                
                  Section
      III,

                  Item

                  B.3.c.(l)

                

              	
                
                  Enrollee
      pregnancy

                

              	
                
                  All

                

              	
                
                  Upon
      confirmation

                

              	
                
                  DCF
      & MPI

                

              
	
                
                  Section
      III,

                  Item

                  B.3.c.(3)

                

              	
                
                  Unborn
      activation notice

                

              	
                
                  All

                

              	
                
                  Presentation
      for delivery

                

              	
                
                  DCF
      & MPI

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 11 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
        	
                
                  Contract

                  Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      III, 

                    Item
      B.3.d.

                  

                

              	
                
                  Birth
      information if no unborn
      activation

                

              	
                
                  All

                

              	
                
                  Upon
      delivery

                

              	
                
                  DCF

                

              
	
                
                  Section
      III, 

                    Item
      C.4.b.

                  

                

              	
                
                  Involuntary
      disenrollment
      request

                

              	
                
                  All

                

              	
                
                  Forty-five
      (45) calendar
      days before effective date

                

              	
                
                  BMHC

                

              
	
                
                  Section
      III, 

                    Item
      C.4.e.

                  

                

              	
                
                  Notice
      that Health Plan
      is requesting disenrollment in next Contract month

                

              	
                
                  All

                

              	
                
                  Before
      effective date

                

              	
                
                  Enrollee
      affected

                

              
	
                
                  Section
      IV, 

                    Item
      A.l.e.

                  

                

              	
                
                  Notice
      of reinstatement
      of enrollee

                

              	
                
                  All

                

              	
                
                  By
      1st
      calendar day 

                    of
      month after learning of reinstatement or within five (5) calendar days
      from receipt of enrollment file, whichever is
      later

                  

                

              	
                
                  Person
      being 

                    reinstated

                  

                

              
	
                
                  Section
      IV, 

                    Item
      A.2.a. 

                      and
      Item A. 

                        6.a.(17);
      

                          Section
      VIII, 

                            Item
      A.4.

                          

                        

                      

                    

                  

                

              	
                
                  How
      to get Health 

                    Plan
      information in 

                      alternative
      formats

                    

                  

                

              	
                
                  All

                

              	
                
                  Include
      in cultural 

                    competency
      plan and
      enrollee 

                      
                        handbook,
      and upon
      request

                      

                    

                  

                

              	
                
                  Enrollees
      & 

                    potential
      enrollees

                  

                

              
	
                
                  Section
      IV, 

                    Item
      A.2.c.

                  

                

              	
                
                  Right
      to get 

                    information
      about Health Plan

                  

                

              	
                
                  All

                

              	
                
                  Annually

                

              	
                
                  Enrollees

                

              
	
                
                  Section
      IV, 

                    Item
      A.7.c.

                  

                

              	
                
                  Provider
      directory 

                    online
      file

                  

                

              	
                
                  All

                

              	
                
                  Update
      monthly & 

                    submit
      attestation

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      A.9.a.

                  

                

              	
                
                  Enrollee
      assessments 

                

              	
                
                  All

                

              	
                
                  Within
      thirty (30) 

                    days
      of enrollment notify about pregnancy screening

                  

                

              	
                
                  Enrollees
      

                     

                  

                

              
	
                
                  Section
      IV, 

                    Item
      A.9.c.

                  

                

              	
                
                  
                    
                      Enrollees
      more than 2 

                        months
      behind in periodicity screening

                      

                    

                  

                

              	
                
                  All

                

              	
                
                  Contact
      twice, if 

                    needed

                  

                

              	
                
                  Enrollees
      who 

                    meet
      criteria

                  

                

              
	
                
                  Section
      IV, 

                    Item
      A.ll.f.

                  

                

              	
                
                  Toll-free
      help line 

                    performance
      standards

                  

                

              	
                
                  All

                

              	
                
                  Get
      approval 

                    before
      beginning operation

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      A.12. 

                      and
      Item 

                        A.,6.a.(17);
      

                        Section
      VIII, 

                        
                          Item
      A.4.

                        

                      

                    

                  

                

              	
                
                  How
      to access 

                    translation
      services

                  

                

              	
                
                  All

                

              	
                
                  Include
      in cultural 

                    competence
      plan 

                      and
      enrollee 

                        handbook

                      

                    

                  

                

              	
                
                  Enrollees

                

              
	
                
                  Section
      IV, 

                    Item
      A.14.a.

                  

                

              	
                
                  Incentive
      program

                

              	
                
                  All

                

              	
                
                  Get
      approval 

                    before
      offering

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      A.14.g.

                  

                

              	
                
                  Pre-natal
      care 

                    programs

                  

                

              	
                
                  All

                

              	
                
                  Before
      

                    implementation

                  

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 12 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      IV, 

                    Item
      A.17.c.

                  

                

              	
                
                  Notice
      of change in 

                    
                      participation
      in

                      redetermination

                      notices

                    

                  

                

              	
                
                  All

                

              	
                
                  If
      change in 

                    participation,
      annually, by June 1st

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV,

                    Item
      

                      A.17.c.(1)

                    

                  

                

              	
                
                  Redetermination
      

                    policies
      & procedures

                  

                

              	
                
                  All

                

              	
                
                  When
      Health Plan 

                    agrees
      to 

                      participate

                    

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      

                      A.17.c.(l)(a)

                    

                  

                

              	
                
                  Notice
      in writing to 

                    discontinue
      Medicaid 

                      redetermination
      date data use

                    

                  

                

              	
                
                  All

                

              	
                
                  Thirty
      (30) 

                    calendar
      days

                      before
      stopping

                    

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      B.3.c.

                  

                

              	
                
                  Member
      services 

                    phone
      script responding to community outreach calls and outreach
      materials

                  

                

              	
                
                  All

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      B.4.c.

                  

                

              	
                
                  In
      case of force

                    majeure,
      notice of participation in health fair or other public
      event

                  

                

              	
                
                  All

                

              	
                
                  By
      day of event

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IV, 

                    Item
      B.6.f.

                  

                

              	
                
                  Report
      of staff or 

                    community
      outreach rep. violations

                  

                

              	
                
                  All

                

              	
                
                  Within
      fifteen (15) 

                    calendar
      days of knowledge

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V, 

                    Item
      C.l.

                  

                

              	
                
                  Written
      details of 

                    expanded
      services

                  

                

              	
                
                  All

                

              	
                
                  Before
      

                    implementation

                  

                

              	
                
                  HSD

                

              
	
                
                  Section
      V, 

                    Item
      F.

                  

                

              	
                
                  Decision
      to not offer a 

                    
                      service
      on

                      moral/religious

                      grounds

                    

                  

                

              	
                
                  All

                

              	
                
                  One-hundred
      and 

                    
                      twenty
      (120) calendar days before implementation

                       

                      Thirty
      (30) calendar days before implementation

                    

                  

                

              	
                
                  BMHC

                   

                   

                  Enrollees

                

              
	
                
                  Section
      V, 

                    Item
      

                      H.10.b.2.

                    

                  

                

              	
                
                  UNOS
      form & 

                    disenrollment
      request 

                      for
      specified transplants

                    

                  

                

              	
                
                  All

                

              	
                
                  When
      enrollee 

                    listed

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V, 

                    Item
      H.14.e.

                  

                

              	
                
                  Attestation
      that the 

                    Health
      Plan has advised providers to enroll in VFC program 

                       

                    

                  

                

              	
                
                  All

                

              	
                
                  Annually,
      by 

                    October
      1st

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      V, 

                    Item
      

                      H.16.a.(4)

                    

                  

                

              	
                
                  PDL
      update

                

              	
                
                  All

                

              	
                
                  Annually,
      by 

                    October
      1st.

                     

                    
                      Thirty
      (30) calendar days written notice of
    change.

                    

                  

                

              	
                
                  BMHC
      and Bureau 

                    of
      Medicaid 

                      Pharmacy
      Services

                    

                  

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 13 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
           

          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
 

      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      VII, 

                    Item
      A.2.

                  

                

              	
                
                  Capacity
      to provide 

                    covered
      services

                  

                

              	
                
                  All

                

              	
                
                  Before
      taking 

                    enrollment

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VII, 

                    Item
      C.l.

                  

                

              	
                
                  Request
      for initial or 

                    expansion
      review

                  

                

              	
                
                  All

                

              	
                
                  When
      requesting 

                    initial
      enrollment or expansion into a county.

                  

                

              	
                
                  BMHC
      and HSD

                

              
	
                
                  Section
      VII, 

                    Item
      C.2.

                  

                

              	
                
                  Compliance
      with 

                    access
      requirements following significant changes in service area or new
      populations

                  

                

              	
                
                  All

                

              	
                
                  Before
      expansion

                

              	
                
                  BMHC
      and HSD

                

              
	
                
                  Section
      VII, 

                    Item
      C.3.

                  

                

              	
                
                  Significant
      network 

                    changes

                  

                

              	
                
                  All

                

              	
                
                  Within
      seven (7) 

                    business
      days

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VII, 

                    Item
      C.5.

                  

                

              	
                
                  When
      PCP leaves 

                    network

                  

                

              	
                
                  All

                

              	
                
                  Within
      fifteen (15) 

                    
                      calendar
      days of knowledge.

                      A
      copy of the enrollee notice for terminated providers is due no more than fifteen (15) calendar days after
      receipt of the PCP termination
      notice.

                    

                  

                

              	
                
                  BMHC
      & affected 

                    enrollees

                  

                

              
	
                
                  Section
      VII, 

                    Item
      D.2.jj.

                  

                

              	
                
                  Waiver
      of provider 

                    agreement
      indemnifying clause

                  

                

              	
                
                  All

                

              	
                
                  Approval
      before 

                    use

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VII, 

                    Item
      E.3.

                  

                

              	
                
                  Notice
      of terminated 

                    
                      providers
      due to

                      imminent

                      danger/impairment

                    

                  

                

              	
                
                  All

                

              	
                
                  Immediate

                

              	
                
                  BMHC
      and Provider

                

              
	
                
                  Section
      VII, 

                    Item
      E.4.

                  

                

              	
                
                  Termination
      or 

                    suspension
      of

                    
                      providers;
      for "for 

                        cause"
      terminations, 

                          include
      reasons for 

                            termination

                          

                        

                      

                    

                  

                

              	
                
                  All

                

              	
                
                  Sixty
      (60) calendar 

                    days
      before 

                      termination
      

                        effective
      date

                      

                    

                  

                

              	
                
                  BMHC,
      affected 

                    enrollees,
      & 

                      provider

                    

                  

                

              
	
                
                  Section
      VIII, 

                    Item
      A.l.b.

                  

                

              	
                
                  Written
      Quality 

                    Improvement
      Plan

                  

                

              	
                
                  All

                

              	
                
                  Within
      thirty (30) 

                    calendar
      days of initial Contract execution; Thereafter, Annually by April 1st

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      A.3.a.(6)

                    

                  

                

              	
                
                  Measurement
      periods 

                    and
      methodologies

                  

                

              	
                
                  All

                

              	
                
                  Any
      new PIPs 

                    before
      initiation

                  

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 14 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
        	
                
                  Contract

                  Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      A.3.a.(7)

                    

                  

                

              	
                
                  Proposal
      for each

                    planned
      PIP

                  

                

              	
                
                  All

                

              	
                
                  Ninety
      (90)

                    calendar
      days after 

                      Contract
      execution; Thereafter, Annually by June 1st

                    

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      A.3.c.(l)

                    

                  

                

              	
                
                  Performance
      measure 

                    data
      and auditor 

                      certification

                    

                  

                

              	
                
                  All

                

              	
                
                  Annually
      by July 1st

                

              	
                
                  BMQM

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      A.3.c.(4)

                    

                  

                

              	
                
                  Performance
      measure 

                    action
      plan

                  

                

              	
                
                  All

                

              	
                
                  Within
      thirty (30) 

                    calendar
      days of 

                      
                        determination
      of

                        unacceptable

                        performance

                      

                    

                  

                

              	
                
                  BMQM

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      A.3.e.(7)

                    

                  

                

              	
                
                  Written
      strategies for 

                    medical
      record review

                  

                

              	
                
                  All

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VIII, 

                    Item
      

                      B.l.a.(4)(a)

                    

                  

                

              	
                
                  Service
      authorization 

                    protocols
      & any 

                      changes

                    

                  

                

              	
                
                  All

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              
	
                
                  Section
      VIII, 

                    Item
      B.4.

                  

                

              	
                
                  Changes
      to UM 

                    component

                  

                

              	
                
                  All

                

              	
                
                  Thirty
      (30) 

                    calendar
      days before 

                    effective
      date

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      IX, 

                    Item
      A.8.

                  

                

              	
                
                  Complaint
      log

                

              	
                
                  All

                

              	
                
                  Upon
      request

                

              	
                
                  BMHC

                

              
	
                
                  Section
      X, 

                    Item
      B.2.

                  

                

              	
                
                  Changes
      in staffing

                

              	
                
                  All

                

              	
                
                  Five
      (5) business 

                    days
      of any change

                  

                

              	
                
                  BMHC
      & HSD

                

              
	
                
                  Section
      X, 

                    Item
      B.2.b.

                  

                

              	
                
                  Full-Time
      

                    Administrator

                  

                

              	
                
                  All

                

              	
                
                  Before
      designating 

                    duties
      of any other position

                  

                

              	
                
                  BMHC

                

              
	
                
                  Section
      X, 

                    Item
      D. 3. a.

                  

                

              	
                
                  Reform
      and non- 

                    Reform
      historical encounter data for all typical and atypical
      services

                  

                

              	
                
                  All

                

              	
                
                  According
      to 

                    Agency-approved
      schedules and no later than 10/31/09

                  

                

              	
                
                  MEDS
      team & 

                    Fiscal
      Agent

                  

                

              
	
                
                  Section
      X, 

                    Item
      D.3.b.

                  

                

              	
                
                  Encounter
      data for all 

                    typical
      and atypical 

                      services

                    

                  

                

              	
                
                  All

                

              	
                
                  Within
      sixty (60) 

                    calendar
      days 

                      following
      end of month in which Health Plan paid claims for services, and as
      specified in MEDS Companion Guide

                    

                  

                

              	
                
                  MEDS
      Team & 

                    Agency
      Fiscal 

                      Agent

                    

                  

                

              
	
                
                  Section
      X, 

                    Item
      E.4.

                  

                

              	
                
                  Fraud
      & abuse 

                    compliance
      plan & policies & procedures

                  

                

              	
                
                  All

                

              	
                
                  Before
      

                    implementation

                  

                

              	
                
                  MPI

                

              
	
                
                  Section
      XI, 

                    Item
      D.4.a.

                  

                

              	
                
                  Any
      problem that 

                    threatens
      system performance

                  

                

              	
                
                  All

                

              	
                
                  Within
      one (1) 

                    hour

                  

                

              	
                
                  Applicable
      Agency 

                    staff

                  

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 15 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          
                                                                                                                               

      

      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      XI, Item D.8.a.

                

              	
                
                  Business
      Continuity-Disaster Recovery Plan

                

              	
                
                  All

                

              	
                
                  Before
      beginning operation and certification if plan is unchanged by April 30
      annually thereafter;

                

                
                   

                  Changes
      within ten (10) business days of change

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XI, Item E.l.

                

              	
                
                  System
      changes

                

              	
                
                  All

                

              	
                
                  Ninety
      (90) calendar days before change

                

              	
                
                  HSD

                

              
	
                
                  Section
      XIV, Item A.l.(a.)

                

              	
                
                  Corrective
      action plan

                

              	
                
                  All

                

              	
                
                  Within
      ten (10) business days of notice of violation or non-compliance with
      Contract

                

              	
                
                  Agency
      Bureau sending violation notice

                

              
	
                
                  Section
      XIV, Item A.l.(b)

                

              	
                
                  Performance
      measure action plan

                

              	
                
                  All

                

              	
                
                  Within
      thirty (30) calendar days of notice of failure to meet a performance
      standard

                

              	
                
                  Agency
      Bureau sending violation notice

                

              
	
                
                  Section
      XV, Item C.

                

              	
                
                  Proof
      of working capital

                

              	
                
                  All

                

              	
                
                  Before
      enrollment

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XV, Item G.2.

                

              	
                
                  Physician
      incentive plan

                

              	
                
                  All

                

              	
                
                  Written
      description before use

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XV, Item H.

                

              	
                
                  Third
      party coverage identified

                

              	
                
                  All

                

              	
                
                  As
      soon as known

                

              	
                
                  Medicaid
      Third Party Liability Vendor

                

              
	
                
                  Section
      XV, Item I.

                

              	
                
                  Proof
      of fidelity bond coverage

                

              	
                
                  All

                

              	
                
                  Within
      sixty (60) calendar days of Contract execution & before delivering
      health care

                

              	
                
                  HSD
      Contract manager

                

              
	
                
                  Section
      XVI, Item C.l.

                

              	
                
                  Request
      for Assignment or Transfer of Contract in approved
      merger/acquisition

                

              	
                
                  All

                

              	
                
                  Ninety
      (90) days before effective date

                

              	
                
                  HSD

                

              
	
                
                  Section
      XVI, Item M.

                

              	
                
                  Use
      of "Medicaid" or "AHCA"

                

              	
                
                  All

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, Item O.

                

              	
                
                  All
      subcontracts for Agency approval

                

              	
                
                  All

                

              	
                
                  Before
      effective date

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, Item O.l.f.

                

              	
                
                  Subcontract
      monitoring schedule

                

              	
                
                  All

                

              	
                
                  Annually,
      by December 1

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, Item V.l.

                

              	
                
                  Ownership
      & management disclosure forms

                

              	
                
                  All

                

              	
                
                  With
      initial application; and then annually by 

                  September
      1

                

              	
                
                  HSD
      - for initial application; BMHC & HSD for
  annual

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 16 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
           

          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        



      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Section
      XVI, Item V.I.

                

              	
                
                  Changes
      in ownership & control

                

              	
                
                  All

                

              	
                
                  Within
      five (5) calendar days of knowledge & sixty (60) days before effective
      date

                

              	
                
                  BMHC
      & HSD

                

              
	
                
                  Section
      XVI, Item V.4.

                

              	
                
                  Fingerprints
      for principals

                

              	
                
                  All

                

              	
                
                  Before
      Contract execution; Thereafter, annually by September
    1

                

              	
                
                  HSD

                

              
	
                
                  Section
      XVI, Item V.4.c.

                

              	
                
                  Fingerprints
      of newly hired principals

                

              	
                
                  All

                

              	
                
                  Within
      thirty (30) calendar days of hire date

                

              	
                
                  HSD

                

              
	
                
                  Section
      XVI, Item V.5.

                

              	
                
                  Information
      about offenses listed in 435.03

                

              	
                
                  All

                

              	
                
                  Within
      five (5) business days of knowledge

                

              	
                
                  HSD

                

              
	
                
                  Section
      XVI, Item V.6.

                

              	
                
                  Corrective
      action plan related to principals committing offenses under
      435.03

                

              	
                
                  All

                

              	
                
                  As
      prescribed by the Agency

                

              	
                
                  HSD

                

              
	
                
                  Section
      XVI, Item Y.

                

              	
                
                  General
      insurance policy declaration pages

                

              	
                
                  All

                

              	
                
                  Annually
      upon renewal

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, Item Z.

                

              	
                
                  Workers'
      compensation insurance declaration page

                

              	
                
                  All

                

              	
                
                  Annually
      upon renewal

                

              	
                
                  BMHC

                

              
	
                
                  Section
      XVI, Item BB.

                

              	
                
                  Emergency
      Management Plan

                

              	
                
                  All

                

              	
                
                  Before
      beginning operation and by May 31 annually
thereafter

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      2, Section II, Item D.4.c.

                

              	
                
                  Policies
      & procedures for screening for clinical eligibility & any changes
      to them

                

              	
                
                  CCC

                

              	
                
                  Before
      implementation

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      3, Section III, Item C.5.

                

              	
                
                  Disenrollment
      notice

                

              	
                
                  CCC

                

              	
                
                  Get
      template approved before use

                

                
                   

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

                

              	
                
                  BMHC
      

                   

                  Enrollee

                

              
	
                
                  Exhibit
      5, Section V, Item A.6.

                

              	
                
                  Letters
      about exhaustion of benefits under customized benefit
      package

                

              	
                
                  Reform
      

                  capitated
      Health Plans

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 17 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
           

          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
 

      
        	
                
                  |      Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency                  Submit
      To

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.g.

                

              	
                
                  Transportation
      subcontract

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Before
      execution

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.h.

                

              	
                
                  Transportation
      policies & procedures

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Before
      use

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.i.

                

              	
                
                  Transportation
      adverse incidents

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Within
      two (2) business days of the occurrence

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.i

                

              	
                
                  Transportation
      suspected fraud

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Immediately
      upon identification

                

              	
                
                  MPI

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.p.

                

              	
                
                  Performance
      measures

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Annually
      report by July l

                

              	
                
                  BMQM

                

              
	
                
                  Exhibit
      5, Section V, Item H.20.q. &r.

                

              	
                
                  Attestation
      that Health Plan complies with transportation policies & procedures
      & drivers pass background checks & meet
      qualifications

                

              	
                
                  NR
      HMO offering transportation; Reform Health Plans

                

              	
                
                  Annually
      by January 1

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6, Item A.3.

                

              	
                
                  Review
      & approval of behavioral health services staff & subcontractors
      for licensure compliance

                

              	
                
                  Reform
      Health Plans & NR HMOs

                

              	
                
                  Before
      providing services

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6, Item B.9.

                

              	
                
                  Model
      agreement with community mental health centers

                

              	
                
                  Reform
      Health Plans & NR HMOs

                

              	
                
                  Before
      agreement is executed

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6, Item C.3.e.

                

              	
                
                  Denied
      appeals from providers for emergency services claims

                

              	
                
                  Plans
      covering

                  behavioral

                  health

                

              	
                
                  Within
      ten (10) calendar days after Health Plan's final
    denial

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6,

                  Item

                  C.5.a.(3)

                

              	
                
                  Medical
      necessity criteria for community mental health
    services

                

              	
                
                  Plans
      covering

                  behavioral

                  health

                

              	
                
                  Before
      use and before changes implemented

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6, Item L.2.

                

              	
                
                  MBHO
      staff psychiatrist and model contracts for each specialty
      type

                

              	
                
                  Plans
      covering

                  behavioral

                  health

                

              	
                
                  Before
      execution

                

              	
                
                  BMHC

                

              


      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 18 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
           

          
            	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


          

           

        

      

      
 

      
        	
                
                  Contract
      Section

                

              	
                
                  Submission

                

              	
                
                  Plan
      Type

                

              	
                
                  Frequency

                

              	
                
                  Submit
      To

                

              
	
                
                  Exhibit
      6, Item M.

                

              	
                
                  Optional
      services

                

              	
                
                  Plans
      covering

                  behavioral

                  health

                

              	
                
                  Before
      offering

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      6, Item R.3.a.

                

              	
                
                  Schedule
      for administrative and program monitoring and clinical record
      review

                

              	
                
                  Plans
      covering

                  behavioral

                  health

                

              	
                
                  Annually
      by July 1

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      8, Section VIII, Item B. 5.

                

              	
                
                  Substitute
      disease

                  management

                  initiatives

                

              	
                
                  CCC

                

              	
                
                  Within
      sixty (60) calendar days of Contract execution

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      8, Section VIII, Item A.3.f.

                

              	
                
                  Provider
      satisfaction survey

                

              	
                
                  All
      Reform Health Plans

                

              	
                
                  By
      end of 8th
      month of Contract

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      8, Section VIII, Item B.5.b.

                

              	
                
                  Policies
      and procedures and program descriptions for each disease management
      program

                

              	
                
                  All
      Reform Health Plans

                

              	
                
                  Annually,
      by April

                  1

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      8, Section VIII, Item B. 1. e. (5)

                

              	
                
                  Caseload
      maximums for case managers

                

              	
                
                  HIV/AIDS
      specialty plan

                

              	
                
                  Before
      providing services

                

              	
                
                  BMHC

                

              
	
                
                  Exhibit
      10, Section X, Item C. 5. a.

                

              	
                
                  Discrepancies
      in ERV

                

              	
                
                  FFS
      Health

                  Plans;

                  CCC

                

              	
                
                  Within
      ten (10) business days of discovery

                

              	
                
                  HSD
      analyst

                

              
	
                
                  Exhibit
      15, Section XV, Item A. 1. a.

                

              	
                
                  Plan
      for transition from FFS to prepaid capitated plan

                

              	
                
                  FFS
      PSNs; CCC

                

              	
                
                  Last
      calendar day of 24th
      month of Health Plan's initial Reform operation

                

              	
                
                  HSD

                

              
	
                
                  Exhibit
      15, Section XV, Item A. 1. b.

                

              	
                
                  Conversion
      application to capitated Health Plan

                

              	
                
                  FFS
      PSNs; CCC

                

              	
                
                  By
      August 1 of 4th
      year of Reform operation

                

              	
                
                  HSD

                

              
	
                
                  Exhibit
      15, Section XV, Item I.

                

              	
                
                  Proof
      of coverage for any non-government subcontractor

                

              	
                
                  CCC

                

              	
                
                  Within
      sixty (60) calendar days of execution and before delivery of
      care

                

              	
                
                  BMHC

                

              


      

      
        


         

        NR
HMO = Non-Reform health maintenance organization, includes Health Plans
covering

      

      
        Frail/Elderly
Program services as specified in Attachment I

      

      
        Ref
HMO = Reform health maintenance organization

      

      
        Ref
Cap PSN = Reform capitated provider service network

        Ref
FFS PSN = Reform Fee-for-Service Provider Service Network

        NR
Cap PSN = Non-Reform Capitated Provider Service Network

        NR
FFS PSN = Non-Reform Fee-for-Service Provider Service Network

      

      
        CCC
= Specialty plan for children with chronic conditions

      

      
        HIV/AIDS
= Specialty plan for recipients living with HIV/AIDS

      

      
         

        
          	
                  23.

                	
                  Attachment
      II, Core Contract Provisions, Section XIV, Sanctions, Item F., Notice of
      Sanction, sub-item 4. is hereby amended to now read as
      follows:

                


        

      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 19 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
         

        
          	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


        

         

      

      
        
          	
                    
      4. 

                	
                  For
      FFS PSNs and the Specialty Plan for Children with Chronic Conditions, the
      Agency reserves the right to withhold all or a portion of the Health
      Plan's monthly administrative allocation for any amount owed pursuant to
      this section.

                


        

      

      
         

        
          	
                  24.

                	
                  Attachment
      II, Core Contract Provisions, Section XVI, Terms and Conditions, Item C,
      Assignment, sub-item
      1., the second sentence is hereby amended to now read as
      follows:

                


        

         

        
        

      

      
         The
entity requesting the assignment or transfer shall notify HSD of the request
ninety (90) calendar days before the anticipated effective
date.

      

      
         

        
          	
                  25.

                	
                  Attachment
      II, Core Contract Provisions, Section XVI, Terms and Conditions, Item O.,
      Subcontracts, sub-item
      1.e., the third sentence is hereby amended to now read as
      follows:

                


        

         

      

      
        The
Health Plan shall provide a monthly Minority Participation Report (see
Attachment II, Section XII, Reporting Requirements, Table 1), to BMHC and the
HSD designated minority participation report contact, summarizing the business
it does with minority subcontractors or vendors.

      

      
         

        
          	
                  26.

                	
                  Attachment
      II, Core Contract Provisions, Section XVI, Terms and Conditions, Item V.,
      Ownership and Management
      Disclosure, sub-item 4.c. is hereby amended to now read as
      follows:

                


        

         

      

      
        
          	
                    
      c.

                	
                  The
      Health Plan shall submit to the Agency Contract Manager complete sets of
      fingerprints of newly hired principals (officers, directors, agents, and
      managing employees) within thirty (30) calendar days of the hire
      date.

                


        

      

      
         

        
          	
                  27.

                	
                  Attachment
      II, Core Contract Provisions, Section XVI, Terms and Conditions, Item BB.,
      Emergency Management
      Plan, the first sentence is hereby amended to now read as
      follows:

                


        

         

      

      
        Before
beginning operations and annually by May 31 of each Contract year, the Health
Plan shall submit to BMHC for approval an emergency management plan specifying
what actions the Health Plan shall conduct to ensure the ongoing provision of
health services in a disaster or man-made emergency including, but not limited
to, localized acts of nature, accidents, and technological and/or attack-related
emergencies.


      

      
         

        
          	
                  28.

                	
                  Attachment
      II, Core Contract Provisions, Exhibit 5, Covered Services, Item 3,
      Non-Reform HMOs covering transportation
      as an optional service and Reform Health Plans, Section V, Covered
      Services, Item H., Coverage
      Provisions, sub-item 20.i. is hereby amended to now read as
      follows:

                


        

         

      

      
        
          	
                   
      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.)

                


        

      

      
         

        
          	
                  29.

                	
                  Attachment
      II, Core Contract Provisions, Exhibit 5, Covered Services, Item 6,
      Non-Reform HMOs covering transportation
      as an optional service and Reform Health Plans, Section V, Covered
      Services, Item H., Coverage
      Provisions, sub-item 20.p. is hereby amended to now read as
      follows:

                


        

         

      

      
        
          	
                     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.c. and
      Attachment II, Section XII, Reporting Requirements, and the Health Plan
      Report Guide.

                


        

      

      
         

        
          	
                  30.

                	
                  Attachment
      II, Core Contract Provisions, Exhibit 6, HMOs & Reform Health Plans,
      Behavioral Health Care, Item
      1., Reform Health Plans and Non-Reform HMOs, sub-item K.4. is hereby
      amended to now read as follows:

                


        

         

      

      
        AHCA
Contract No. FA905, Amendment No. 2, Page 20 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

      
        
          
             

            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

      
               
4.      The Health Plan shall submit the
FARS/CFARS reports to BMHC semi-annually August 15th and
February
15th, as
required in Attachment II, Section XII, Reporting

                        
Requirements, and the Health Plan Report Guide.

      

      
         

        
          	
                  31.

                	
                  Attachment
      II, Core Contract Provisions, Exhibit 6, HMOs and Reform Health Plans,
      Behavioral Health Care, Item
      1., Reform Health Plans and Non-Reform HMOs, sub-item S., Behavioral
      Health Reporting Requirements
      is hereby amended to now read as
  follows:

                


        

         

               
S.     Behavioral Health Reporting
Requirements

      

      
         

        Additional
behavioral health reporting requirements are listed below. Behavioral health
reporting requirements are also listed in Attachment II, Section XII, Reporting
Requirements, and must be submitted as required in Attachment II, Section XII,
Reporting Requirements, and the Health Plan Report Guide.

      

      
         

        
          	
                  1.  

                	
                  Behavioral
      Health Critical Incident Report - Individual - The Health Plan shall
      report the following events immediately, no later than twenty-four (24)
      hours after occurrence or knowledge of incident, to the BMHC behavioral
      health analyst and in accordance with Attachment II, Section XII,
      Reporting Requirements, and the Health Plan Report
  Guide.

                


        

      

      
        


         

        
          	
                  2.  

                	
                  Behavioral
      Health Critical Incident Report - Summary - The Health Plan shall submit
      to BMHC a summary of the previous calendar month's incidents regarding
      behavioral health critical incidents, involving Health Plan enrollees, by
      the 15th
      calendar day of every month, in accordance with Attachment II, Section
      XII, Reporting Requirements, and the Health Plan Report
    Guide.

                


        

      

      
        


         

        
          	
                  3.  

                	
                  Behavioral
      Health Encounter Data Report - The Health Plan shall submit to BMHC,
      quarterly within forty-five (45) calendar days of the end of the quarter
      being reported, an electronic representation of the Health Plan's complete
      listing of behavioral health services provided during the report period
      and in accordance with Attachment II, Section XII, Reporting Requirements,
      and the Health Plan Report
Guide.

                


        

      

      
        


         

        
          	
                  4.  

                	
                  Behavioral
      Health Pharmacy Encounter Data Report - The Health Plan shall submit to
      BMHC quarterly, within forty-five (45) calendar days after the end of the
      quarter being reported, an accurate electronic representation of the
      Health Plan's complete listing of behavioral health prescription services
      administered during the quarter being reported and in accordance with
      Attachment II, Section XII, Reporting Requirements, and the Health Plan
      Report Guide.

                


        

      

      
        


         

        
          	
                  5.  

                	
                  Behavioral
      Health Required Staff/Providers Report - The Health Plan shall submit to
      BMHC the Behavioral Health Required Staff/Providers Report annually, by
      August 15. For Health Plans operating less than one (1) year, the Health
      Plan shall submit this report to BMHC quarterly, forty-five (45) days
      after the end of the quarter being reported. Submissions shall be
      submitted in accordance with Attachment II, Section XII, Reporting
      Requirements, and the Health Plan Report
Guide.

                


        

      

      
         

        
          	
                  32.

                	
                  Attachment
      II, Core Contract Provisions, Exhibit 10, Administration and Management,
      Item 1., All Capitated Health
      Plans, Section X, Administration and Management, Item C, Claims Payment,
      is hereby amended to include
      sub-item 7. as
follows:

                


        

         

      

      
        
          	
                     
      7.

                	
                  The
      Health Plan shall reimburse providers for Medicare deductibles and
      co-insurance payments for Medicare dually eligible members according to
      the lesser of the following:

                


        

      

      
         

         a.  The
rate negotiated with the provider; or

         

         b.  The
reimbursement amount as stipulated in s. 409.908 F.S.

      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 21 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      

       

      
        
          
            
              	HealthEase of Florida,
      Inc.	Medicaid HMO Non-Reform
      Contract
	 	 


            

             

          

        

      

      
         Unless
otherwise stated, this Amendment is effective upon execution by both parties or
January 1, 2010, (whichever is later).


      

      
         

         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 part of the
Contract.

      

      
         

         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 twenty-seven (27) page Amendment (including all
attachments) to be executed by their officials thereunto duly
authorized.

      

      
         

        
        

         

        
          	
                  HEALTHEASE OF FLORIDA,
      INC.    

                   

                	 	
                   

                    STATE OF FLORIDA, AGENCY
      FOR

                    HEALTH CARE
      ADMINISTRATION

                


           

          
            	
                     

                    SIGNED

                    BY:

                  	
                     

                     

                    /s/
      Thomas L. Tran

                  	 	  

                    SIGNED

                    BY:  

                  	
                     

                     

                    [Illegible] for

                  	 
	 	 	 	 	 	 
	NAME:	Thomas
Tran	 	NAME:	Thomas W.
      Arnold	 
	 	 	 	 	 	 
	TITLE:	Chief
      Financial Officer	 	TITLE:	Secretary	 
	 	 	 	 	 	 
	DATE:	January 13,
      2010	 	DATE:	1-14-10	 


          

        

         

                                                                        

      

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

      

      
        
        

         

        
          	
                   Specify 

                  Type    

                	 	
                   Letter/

                  Number

                	 	 Description	 
	Attachment
      I    	 	Exhibit
    2-NR-A	 	
                  Medicaid
      Non-Reform HMO Capitation Rates, Effective 

                  
                    November
      1, 2009 - August 31, 2012 (5 Pages)

                  

                	 


        

                                                                            

      

      
                                                              

      

      
        REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK

      

      
        


         

        AHCA
Contract No. FA905, Amendment No. 2, Page 22 of 22

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        ATTACHMENT
I 

        EXHIBIT
2-NR-A

      

      
        MEDICAID
NON-REFORM HMO CAPITATION RATES 

        By
Area , Age and Eligibility Category

      

      
        Effective
November 1, 2009 - August 31, 2012

      

      
        
          AGE
(65+)



        
           


        

        TABLE
1

      

      
        	
                
                  General
      Rates

                

              	 
      	 
      	 
      	
                
                  TANF

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-N

                

              	 
      	 
      	
                
                  SSI-B

                

              	
                
                  SSI-AB

                

              
	
                
                  Area

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	
                
                  AGE
      (6-13)

                

              	
                
                  AGE
      (14-20)

                

              	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      (55+)

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	 AGE
      (6-13)	 AGE
      (14-20)	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      (55+)

                

              	 
      	
                 AGE  (65-) 

              	
                
                  
                    AGE
      (65+)

                  

                

              
	 
      	 
      	 
      	 
      	 
      	
                
                  Female

                

              	
                
                  Male

                

              	
                
                  Female

                

              	
                
                  Male

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                
                  01

                

              	
                
                  1,130.45

                

              	
                
                  171.80

                

              	
                
                  102.22

                

              	
                
                  61.92

                

              	
                
                  136.81

                

              	
                
                  72.25

                

              	
                
                  266.35

                

              	
                
                  158.36

                

              	
                
                  341.82

                

              	
                
                  12,166.98

                

              	
                
                  1,661.31

                

              	
                
                  450.32

                

              	
                
                  195.11

                

              	
                
                  211.04

                

              	
                
                  684.60

                

              	
                
                  713.62

                

              	
                
                  345.23

                

              	
                
                  81.01

                

              	
                
                  75.25

                

              
	
                
                  02

                

              	
                
                  1,130.45

                

              	
                
                  171.80

                

              	
                
                  102.22

                

              	
                
                  61.92

                

              	
                
                  136.81

                

              	
                
                  72.25

                

              	
                
                  266.35

                

              	
                
                  158.36

                

              	
                
                  341.82

                

              	
                
                  12,166.98

                

              	
                
                  1,661.31

                

              	
                
                  450.32

                

              	
                
                  195.11

                

              	
                
                  211.04

                

              	
                
                  684.60

                

              	
                
                  713.62

                

              	
                
                  345.23

                

              	
                
                  81.01

                

              	
                
                  75.25

                

              
	
                
                  03

                

              	
                
                  1,204.98

                

              	
                
                  184.85

                

              	
                
                  110.04

                

              	
                
                  67.83

                

              	
                
                  147.39

                

              	
                
                  78.95

                

              	
                
                  288.08

                

              	
                
                  172.19

                

              	
                
                  374.81

                

              	
                
                  12,984.80

                

              	
                
                  1,788.35

                

              	
                
                  485.21

                

              	
                
                  215.10

                

              	
                
                  232.17

                

              	
                
                  751.31

                

              	
                
                  786.48

                

              	
                
                  219.92

                

              	
                
                  78.09

                

              	
                
                  72.84

                

              
	
                
                  04

                

              	
                
                  1,050.61

                

              	
                
                  162.46

                

              	
                
                  96.93

                

              	
                
                  60.59

                

              	
                
                  129.54

                

              	
                
                  70.25

                

              	
                
                  254.54

                

              	
                
                  152.86

                

              	
                
                  335.21

                

              	
                
                  12,420.29

                

              	
                
                  1,720.68

                

              	
                
                  467.26

                

              	
                
                  210.34

                

              	
                
                  226.43

                

              	
                
                  732.37

                

              	
                
                  768.88

                

              	
                
                  158.79

                

              	
                
                  76.07

                

              	
                
                  71.40

                

              
	
                
                  05

                

              	
                
                  1,184.66

                

              	
                
                  182.33

                

              	
                
                  108.66

                

              	
                
                  67.27

                

              	
                
                  145.40

                

              	
                
                  78.31

                

              	
                
                  284.72

                

              	
                
                  170.59

                

              	
                
                  372.41

                

              	
                
                  14,030.18

                

              	
                
                  1,934.34

                

              	
                
                  524.96

                

              	
                
                  233.58

                

              	
                
                  251.40

                

              	
                
                  814.40

                

              	
                
                  853.04

                

              	
                
                  257.97

                

              	
                
                  63.54

                

              	
                
                  59.91

                

              
	
                
                  06

                

              	
                
                  1,065.08

                

              	
                
                  165.73

                

              	
                
                  99.12

                

              	
                
                  62.65

                

              	
                
                  132.43

                

              	
                
                  72.63

                

              	
                
                  260.83

                

              	
                
                  157.38

                

              	
                
                  347.13

                

              	
                
                  12,740.87

                

              	
                
                  1,765.91

                

              	
                
                  479.44

                

              	
                
                  216.29

                

              	
                
                  232.64

                

              	
                
                  751.93

                

              	
                
                  789.61

                

              	
                
                  332.29

                

              	
                
                  65.62

                

              	
                
                  61.55

                

              
	
                
                  07

                

              	
                
                  1,094.60

                

              	
                
                  170.03

                

              	
                
                  101.66

                

              	
                
                  64.09

                

              	
                
                  135.85

                

              	
                
                  74.27

                

              	
                
                  267.33

                

              	
                
                  161.18

                

              	
                
                  354.76

                

              	
                
                  13,685.78

                

              	
                
                  1,905.44

                

              	
                
                  518.10

                

              	
                
                  236.50

                

              	
                
                  253.97

                

              	
                
                  819.80

                

              	
                
                  862.97

                

              	
                
                  278.88

                

              	
                
                  68.32

                

              	
                
                  64.02

                

              
	
                
                  08

                

              	
                
                  1,037.09

                

              	
                
                  161.01

                

              	
                
                  96.20

                

              	
                
                  60.62

                

              	
                
                  128.67

                

              	
                
                  70.25

                

              	
                
                  253.12

                

              	
                
                  152.46

                

              	
                
                  335.67

                

              	
                
                  12,799.17

                

              	
                
                  1,774.58

                

              	
                
                  482.11

                

              	
                
                  218.12

                

              	
                
                  234.44

                

              	
                
                  756.47

                

              	
                
                  794.55

                

              	
                
                  315.60

                

              	
                
                  66.83

                

              	
                
                  62.63

                

              
	
                
                  09

                

              	
                
                  1,052.10

                

              	
                
                  161.97

                

              	
                
                  96.51

                

              	
                
                  59.97

                

              	
                
                  129.16

                

              	
                
                  69.61

                

              	
                
                  253.28

                

              	
                
                  151.74

                

              	
                
                  331.35

                

              	
                
                  12,607.35

                

              	
                
                  1,749.19

                

              	
                
                  475.00

                

              	
                
                  215.23

                

              	
                
                  231.33

                

              	
                
                  746.37

                

              	
                
                  783.86

                

              	
                
                  278.68

                

              	
                
                  73.65

                

              	
                
                  68.75

                

              
	
                
                  10

                

              	
                
                  1,097.08

                

              	
                
                  171.38

                

              	
                
                  102.63

                

              	
                
                  65.26

                

              	
                
                  137.12

                

              	
                
                  75.61

                

              	
                
                  270.62

                

              	
                
                  163.74

                

              	
                
                  362.13

                

              	
                
                  16,173.96

                

              	
                
                  2,267.27

                

              	
                
                  616.85

                

              	
                
                  286.58

                

              	
                
                  306.25

                

              	
                
                  989.86

                

              	
                
                  1,043.17

                

              	
                
                  351.29

                

              	
                
                  80.41

                

              	
                
                  75.32

                

              
	
                
                  11

                

              	
                
                  1,387.45

                

              	
                
                  213.12

                

              	
                
                  126.92

                

              	
                
                  78.43

                

              	
                
                  169.76

                

              	
                
                  91.10

                

              	
                
                  332.48

                

              	
                
                  199.01

                

              	
                
                  433.39

                

              	
                
                  16,510.81

                

              	
                
                  2,276.81

                

              	
                
                  618.22

                

              	
                
                  275.31

                

              	
                
                  296.69

                

              	
                
                  960.17

                

              	
                
                  1,005.22

                

              	
                
                  380.51

                

              	
                
                  117.49

                

              	
                
                  109.41

                

              
	
                
                  6B*

                

              	
                
                  1,064.96

                

              	
                
                  165.71

                

              	
                
                  99.11

                

              	
                
                  62.64

                

              	
                
                  132.41

                

              	
                
                  72.62

                

              	
                
                  260.80

                

              	
                
                  157.36

                

              	
                
                  347.08

                

              	
                
                  12,740.29

                

              	
                
                  1,765.81

                

              	
                
                  479.42

                

              	
                
                  216.27

                

              	
                
                  232.63

                

              	
                
                  751.89

                

              	
                
                  789.57

                

              	
                
                  332.29

                

              	
                
                  65.62

                

              	
                
                  61.55

                

              


      

      
        
            

            


        

        TABLE
2

      

      
        	
                
                  General
      + Mental Health Rates:

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	
                
                  TANF

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-N

                

              	 
      	 
      	
                
                  SSI-B

                

              	
                
                  SSkAB

                

              
	
                
                  Area

                

              	 BTHMO+2MO	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	
                
                  AGE
      (6-13)

                

              	
                
                  AGE
      (14-20)

                

              	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      (55+)

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	 AGE
      (6-13) 	 AGE
      (14-20) 	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      (55+)

                

              	 
      	AGE
      (65-)  	
                AGE
    (65+)

              
	 
      	 
      	 
      	 
      	 
      	
                
                  Female

                

              	
                
                  Male

                

              	
                
                  Female

                

              	
                
                  Male

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                
                  01

                

              	
                
                  1,130.48

                

              	
                
                  171.83

                

              	
                
                  104.08

                

              	
                
                  74.27

                

              	
                
                  148.20

                

              	
                
                  83.64

                

              	
                
                  270.41

                

              	
                
                  162.42

                

              	
                
                  345.39

                

              	
                
                  12,167.05

                

              	
                
                  1,661.38

                

              	
                
                  458.53

                

              	
                
                  246.95

                

              	
                
                  257.82

                

              	
                
                  765.70

                

              	
                
                  745.22

                

              	
                
                  353.34

                

              	
                
                  93.55

                

              	
                
                  87.79

                

              
	
                
                  02

                

              	
                
                  1,130.47

                

              	
                
                  171.82

                

              	
                
                  103.70

                

              	
                
                  73.65

                

              	
                
                  148.12

                

              	
                
                  83.56

                

              	
                
                  271.15

                

              	
                
                  163.16

                

              	
                
                  346.04

                

              	
                
                  12,167.09

                

              	
                
                  1,661.42

                

              	
                
                  462.52

                

              	
                
                  271.63

                

              	
                
                  281.47

                

              	
                
                  815.81

                

              	
                
                  764.75

                

              	
                
                  353.34

                

              	
                
                  93.55

                

              	
                
                  87.79

                

              
	
                
                  03

                

              	
                
                  1,205.00

                

              	
                
                  184.87

                

              	
                
                  111.59

                

              	
                
                  80.12

                

              	
                
                  159.24

                

              	
                
                  90.80

                

              	
                
                  293.11

                

              	
                
                  177.22

                

              	
                
                  379.23

                

              	
                
                  12,984.86

                

              	
                
                  1,788.41

                

              	
                
                  491.82

                

              	
                
                  256.56

                

              	
                
                  270.33

                

              	
                
                  822.40

                

              	
                
                  814.18

                

              	
                
                  228.03

                

              	
                
                  90.63

                

              	
                
                  85.38

                

              
	
                
                  04

                

              	
                
                  1,050.63

                

              	
                
                  162.48

                

              	
                
                  98.39

                

              	
                
                  72.22

                

              	
                
                  140.75

                

              	
                
                  81.46

                

              	
                
                  259.29

                

              	
                
                  157.61

                

              	
                
                  339.39

                

              	
                
                  12,420.35

                

              	
                
                  1,720.74

                

              	
                
                  474.10

                

              	
                
                  253.25

                

              	
                
                  265.92

                

              	
                
                  805.95

                

              	
                
                  797.55

                

              	
                
                  166.90

                

              	
                
                  88.61

                

              	
                
                  83.94

                

              
	
                
                  05

                

              	
                
                  1,184.68

                

              	
                
                  182.35

                

              	
                
                  110.60

                

              	
                
                  82.70

                

              	
                
                  160.27

                

              	
                
                  93.18

                

              	
                
                  291.03

                

              	
                
                  176.90

                

              	
                
                  377.96

                

              	
                
                  14,030.25

                

              	
                
                  1,934.41

                

              	
                
                  532.58

                

              	
                
                  281.37

                

              	
                
                  295.39

                

              	
                
                  896.35

                

              	
                
                  884.97

                

              	
                
                  266.08

                

              	
                
                  76.08

                

              	
                
                  72.45

                

              
	
                
                  06

                

              	
                
                  1,065.10

                

              	
                
                  165.75

                

              	
                
                  100.09

                

              	
                
                  69.11

                

              	
                
                  138.39

                

              	
                
                  78.59

                

              	
                
                  262.96

                

              	
                
                  159.51

                

              	
                
                  349.00

                

              	
                
                  12,740.90

                

              	
                
                  1,765.94

                

              	
                
                  483.54

                

              	
                
                  242.20

                

              	
                
                  256.02

                

              	
                
                  792.46

                

              	
                
                  805.41

                

              	
                
                  340.40

                

              	
                
                  78.16

                

              	
                
                  74.09

                

              
	
                
                  07

                

              	
                
                  1,094.63

                

              	
                
                  170.06

                

              	
                
                  104.05

                

              	
                
                  83.04

                

              	
                
                  154.12

                

              	
                
                  92.54

                

              	
                
                  275.08

                

              	
                
                  168.93

                

              	
                
                  361.57

                

              	
                
                  13,685.85

                

              	
                
                  1,905.51

                

              	
                
                  525.43

                

              	
                
                  282.49

                

              	
                
                  296.30

                

              	
                
                  898.66

                

              	
                
                  893.70

                

              	
                
                  286.99

                

              	
                
                  80.86

                

              	
                
                  76.56

                

              
	
                
                  08

                

              	
                
                  1,037.10

                

              	
                
                  161.02

                

              	
                
                  97.18

                

              	
                
                  66.36

                

              	
                
                  136.14

                

              	
                
                  77.72

                

              	
                
                  256.29

                

              	
                
                  155.63

                

              	
                
                  338.45

                

              	
                
                  12,799.21

                

              	
                
                  1,774.62

                

              	
                
                  486.19

                

              	
                
                  243.72

                

              	
                
                  258.00

                

              	
                
                  800.37

                

              	
                
                  811.65

                

              	
                
                  323.71

                

              	
                
                  79.37

                

              	
                
                  75.17

                

              
	
                
                  09

                

              	
                
                  1,052.12

                

              	
                
                  161.99

                

              	
                
                  98.40

                

              	
                
                  74.97

                

              	
                
                  143.62

                

              	
                
                  84.07

                

              	
                
                  259.41

                

              	
                
                  157.87

                

              	
                
                  336.74

                

              	
                
                  12,607.42

                

              	
                
                  1,749.26

                

              	
                
                  482.36

                

              	
                
                  261.41

                

              	
                
                  273.83

                

              	
                
                  825.55

                

              	
                
                  814.71

                

              	
                
                  286.79

                

              	
                
                  86.19

                

              	
                
                  81.29

                

              
	
                
                  10

                

              	
                
                  1,097.10

                

              	
                
                  171.40

                

              	
                
                  104.57

                

              	
                
                  80.68

                

              	
                
                  151.99

                

              	
                
                  90.48

                

              	
                
                  276.93

                

              	
                
                  170.05

                

              	
                
                  367.67

                

              	
                
                  16,174.08

                

              	
                
                  2,267.39

                

              	
                
                  629.65

                

              	
                
                  366.88

                

              	
                
                  380.16

                

              	
                
                  1,127.55

                

              	
                
                  1,096.82

                

              	
                
                  359.40

                

              	
                
                  92.95

                

              	
                
                  87.86

                

              
	
                
                  11

                

              	
                
                  1,387.47

                

              	
                
                  213.14

                

              	
                
                  128.49

                

              	
                
                  90.88

                

              	
                
                  181.77

                

              	
                
                  103.11

                

              	
                
                  337.57

                

              	
                
                  204.10

                

              	
                
                  437.87

                

              	
                
                  16,510.92

                

              	
                
                  2,276.92

                

              	
                
                  630.84

                

              	
                
                  354.52

                

              	
                
                  369.60

                

              	
                
                  1,096.00

                

              	
                
                  1,058.15

                

              	
                
                  388.62

                

              	
                
                  130.03

                

              	
                
                  121.95

                

              
	
                
                  6B*

                

              	
                
                  1,064.97

                

              	
                
                  165.72

                

              	
                
                  99.83

                

              	
                
                  66.35

                

              	
                
                  137.92

                

              	
                
                  78.13

                

              	
                
                  263.14

                

              	
                
                  159.70

                

              	
                
                  349.13

                

              	
                
                  12,740.32

                

              	
                
                  1,765.84

                

              	
                
                  483.29

                

              	
                
                  240.54

                

              	
                
                  254.97

                

              	
                
                  793.50

                

              	
                
                  805.79

                

              	
                
                  340.40

                

              	
                
                  78.16

                

              	
                
                  74.09

                

              


      

      
        


         

        AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 1 of
5

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        ATTACHMENT
I 

        EXHIBIT
2-NR-A

      

      
        MEDICAID NON-REFORM HMO CAPITATION
RATES 

        By Area , Age and Eligibility
Category

      

      
        Effective
November 1, 2009 -August 31, 2012

      

      
        
          
             


               


            

          

        

        TABLE
3

      

      
        	
                
                  General
      

                

              	
                
                   +
      MH + Dental Rates:

                   

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-N

                

              	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-B

                

              	
                
                  SSI-AB

                

              	 
      
	 	                 
      TANF	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                
                  Area

                

              	 BTHMO+2MO	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	 AGE
      (6-13)	
                
                  AGE
      (14-20)

                

              	
                
                               
      AGE (21-54)

                

              	 
      	
                
                  AGE
      (55+)

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE
      (1-5)

                

              	 AGE
      (6-13)	 AGE
      (14-20)	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      (55+)

                

              	 
      	
                
                  AGE
      

                  (65-)

                

              	
                
                  AGE
      (65+)

                

              
	 
      	 
      	 
      	 
      	 
      	
                
                  Female

                

              	
                
                  Male

                

              	
                
                  Female

                

              	
                
                  Male

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                
                  01

                

              	
                
                  1,130.49

                

              	
                
                  171.84

                

              	
                
                  105.46

                

              	
                
                  76.79

                

              	
                
                  150.71

                

              	
                
                  85.83

                

              	
                
                  271.81

                

              	
                
                  163.93

                

              	
                
                  348.70

                

              	
                
                  12,167.05

                

              	
                
                  1,661.38

                

              	
                
                  459.71

                

              	
                
                  248.69

                

              	
                
                  259.34

                

              	
                
                  767.10

                

              	
                
                  747.24

                

              	
                
                  353.34

                

              	
                
                  94.73

                

              	
                
                  88.76

                

              
	
                
                  02

                

              	
                
                  1,130.48

                

              	
                
                  171.83

                

              	
                
                  105.08

                

              	
                
                  76.17

                

              	
                
                  150.63

                

              	
                
                  85.75

                

              	
                
                  272.55

                

              	
                
                  164.67

                

              	
                
                  349.35

                

              	
                
                  12,167.09

                

              	
                
                  1,661.42

                

              	
                
                  463.70

                

              	
                
                  273.37

                

              	
                
                  282.99

                

              	
                
                  817.21

                

              	
                
                  766.77

                

              	
                
                  353.34

                

              	
                
                  94.73

                

              	
                
                  88.76

                

              
	
                
                  03

                

              	
                
                  1,205.01

                

              	
                
                  184.89

                

              	
                
                  114.60

                

              	
                
                  85.61

                

              	
                
                  164.70

                

              	
                
                  95.58

                

              	
                
                  295.67

                

              	
                
                  179.97

                

              	
                
                  385.26

                

              	
                
                  12,984.86

                

              	
                
                  1,788.42

                

              	
                
                  494.65

                

              	
                
                  260.76

                

              	
                
                  273.98

                

              	
                
                  824.81

                

              	
                
                  817.66

                

              	
                
                  229.28

                

              	
                
                  92.63

                

              	
                
                  87.02

                

              
	
                
                  04

                

              	
                
                  1,050.64

                

              	
                
                  162.49

                

              	
                
                  100.16

                

              	
                
                  75.45

                

              	
                
                  143.97

                

              	
                
                  84.27

                

              	
                
                  261.36

                

              	
                
                  159.84

                

              	
                
                  344.27

                

              	
                
                  12,420.35

                

              	
                
                  1,720.74

                

              	
                
                  475.76

                

              	
                
                  255.71

                

              	
                
                  268.06

                

              	
                
                  808.10

                

              	
                
                  800.67

                

              	
                
                  168.79

                

              	
                
                  90.28

                

              	
                
                  85.30

                

              
	
                
                  05

                

              	
                
                  1,184.69

                

              	
                
                  182.37

                

              	
                
                  114.20

                

              	
                
                  89.29

                

              	
                
                  166.83

                

              	
                
                  98.92

                

              	
                
                  294.84

                

              	
                
                  181.00

                

              	
                
                  386.95

                

              	
                
                  14,030.26

                

              	
                
                  1,934.42

                

              	
                
                  536.45

                

              	
                
                  287.10

                

              	
                
                  300.37

                

              	
                
                  899.47

                

              	
                
                  889.49

                

              	
                
                  266.16

                

              	
                
                  79.19

                

              	
                
                  75.00

                

              
	
                
                  06

                

              	
                
                  1,065.11

                

              	
                
                  165.77

                

              	
                
                  102.78

                

              	
                
                  74.04

                

              	
                
                  143.29

                

              	
                
                  82.87

                

              	
                
                  265.06

                

              	
                
                  161.76

                

              	
                
                  353.94

                

              	
                
                  12,740.90

                

              	
                
                  1,765.95

                

              	
                
                  486.45

                

              	
                
                  246.51

                

              	
                
                  259.76

                

              	
                
                  795.04

                

              	
                
                  809.15

                

              	
                
                  343.25

                

              	
                
                  80.33

                

              	
                
                  75.87

                

              
	
                
                  07

                

              	
                
                  1,094.64

                

              	
                
                  170.08

                

              	
                
                  106.68

                

              	
                
                  87.86

                

              	
                
                  158.91

                

              	
                
                  96.73

                

              	
                
                  276.71

                

              	
                
                  170.68

                

              	
                
                  365.40

                

              	
                
                  13,685.85

                

              	
                
                  1,905.52

                

              	
                
                  528.40

                

              	
                
                  286.88

                

              	
                
                  300.12

                

              	
                
                  900.23

                

              	
                
                  895.97

                

              	
                
                  287.74

                

              	
                
                  82.30

                

              	
                
                  77.75

                

              
	
                
                  08

                

              	
                
                  1,037.12

                

              	
                
                  161.05

                

              	
                
                  101.81

                

              	
                
                  76.83

                

              	
                
                  144.58

                

              	
                
                  85.09

                

              	
                
                  258.91

                

              	
                
                  158.45

                

              	
                
                  344.63

                

              	
                
                  12,799.22

                

              	
                
                  1,774.63

                

              	
                
                  489.94

                

              	
                
                  249.27

                

              	
                
                  262.83

                

              	
                
                  802.91

                

              	
                
                  815.32

                

              	
                
                  326.18

                

              	
                
                  81.28

                

              	
                
                  76.74

                

              
	
                
                  09

                

              	
                
                  1,052.13

                

              	
                
                  162.01

                

              	
                
                  101.61

                

              	
                
                  80.84

                

              	
                
                  149.46

                

              	
                
                  89.17

                

              	
                
                  260.82

                

              	
                
                  159.38

                

              	
                
                  340.05

                

              	
                
                  12,607.42

                

              	
                
                  1,749.27

                

              	
                
                  485.15

                

              	
                
                  265.54

                

              	
                
                  277.43

                

              	
                
                  827.10

                

              	
                
                  816.96

                

              	
                
                  292.18

                

              	
                
                  87.67

                

              	
                
                  82.50

                

              
	
                
                  10

                

              	
                
                  1,097.11

                

              	
                
                  171.41

                

              	
                
                  106.64

                

              	
                
                  84.47

                

              	
                
                  155.76

                

              	
                
                  93.78

                

              	
                
                  277.61

                

              	
                
                  170.79

                

              	
                
                  369.29

                

              	
                
                  16,174.08

                

              	
                
                  2,267.40

                

              	
                
                  631.84

                

              	
                
                  370.13

                

              	
                
                  382.99

                

              	
                
                  1,128.63

                

              	
                
                  1,098.38

                

              	
                
                  359.53

                

              	
                
                  94.31

                

              	
                
                  88.97

                

              
	
                
                  11

                

              	
                
                  1,387.53

                

              	
                
                  213.20

                

              	
                
                  134.76

                

              	
                
                  98.83

                

              	
                
                  189.24

                

              	
                
                  110.58

                

              	
                
                  338.63

                

              	
                
                  205.24

                

              	
                
                  440.36

                

              	
                
                  16,511.00

                

              	
                
                  2,277.00

                

              	
                
                  637.97

                

              	
                
                  361.66

                

              	
                
                  375.08

                

              	
                
                  1,097.92

                

              	
                
                  1,060.93

                

              	
                
                  391.98

                

              	
                
                  132.45

                

              	
                
                  123.94

                

              
	
                
                  6B*

                

              	
                
                  1,064.98

                

              	
                
                  165.74

                

              	
                
                  102.52

                

              	
                
                  73.28

                

              	
                
                  142.82

                

              	
                
                  82.41

                

              	
                
                  263.14

                

              	
                
                  159.70

                

              	
                
                  349.13

                

              	
                
                  12,740.32

                

              	
                
                  1,765.85

                

              	
                
                  486.20

                

              	
                
                  244.85

                

              	
                
                  258.71

                

              	
                
                  793.50

                

              	
                
                  805.79

                

              	
                
                  343.25

                

              	
                
                  80.33

                

              	
                
                  75.87

                

              


      

      
        
               

        

        
           

        

        TABLE
4

      

      
        	
                
                  General
      

                

              	
                
                  + MH
      + Transportation Rates:

                   

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	
                
                  TANF

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-N

                

              	 
      	 
      	 
      	
                
                  SSI-B

                

              	
                
                  SSI-AB

                

              
	
                
                  Area

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE

                   (1-5)

                

              	
                
                  AGE
      

                  (6-13)

                

              	
                
                  AGE
      (14-20)

                

              	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      

                  (55+)

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE
      

                  (1-5)

                

              	
                 AGE
      

                (6-13)

              	
                 AGE

                 (14-20)
      

              	
                
                  AGE
      

                  (21-54)

                

              	
                
                  AGE

                   (55+)

                

              	 
      	
                 AGE
      

                (65-)

              	
                
                  AGE
      (65+)

                

              
	 
      	 
      	 
      	 
      	 
      	
                
                  Female

                

              	
                
                  Male

                

              	
                
                  Female

                

              	
                
                  Male

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                
                  01

                

              	
                
                  1,135.62

                

              	
                
                  173.12

                

              	
                
                  104.94

                

              	
                
                  74.77

                

              	
                
                  150.36

                

              	
                
                  85.08

                

              	
                
                  273.90

                

              	
                
                  165.08

                

              	
                
                  349.30

                

              	
                
                  12,218.57

                

              	
                
                  1,694.83

                

              	
                
                  463.16

                

              	
                
                  249.41

                

              	
                
                  263.76

                

              	
                
                  785.58

                

              	
                
                  762.27

                

              	
                
                  361.36

                

              	
                
                  106.87

                

              	
                
                  97.94

                

              
	
                
                  02

                

              	
                
                  1,135.61

                

              	
                
                  173.11

                

              	
                
                  104.56

                

              	
                
                  74.15

                

              	
                
                  150.28

                

              	
                
                  85.00

                

              	
                
                  274.64

                

              	
                
                  165.82

                

              	
                
                  349.95

                

              	
                
                  12,218.61

                

              	
                
                  1,694.87

                

              	
                
                  467.15

                

              	
                
                  274.09

                

              	
                
                  287.41

                

              	
                
                  835.69

                

              	
                
                  781.80

                

              	
                
                  361.36

                

              	
                
                  106.87

                

              	
                
                  97.94

                

              
	
                
                  03

                

              	
                
                  1,211.17

                

              	
                
                  186.41

                

              	
                
                  112.62

                

              	
                
                  80.72

                

              	
                
                  161.83

                

              	
                
                  92.53

                

              	
                
                  297.30

                

              	
                
                  180.41

                

              	
                
                  383.92

                

              	
                
                  13,050.22

                

              	
                
                  1,830.85

                

              	
                
                  497.71

                

              	
                
                  259.69

                

              	
                
                  277.85

                

              	
                
                  847.61

                

              	
                
                  835.81

                

              	
                
                  236.53

                

              	
                
                  109.68

                

              	
                
                  99.91

                

              
	
                
                  04

                

              	
                
                  1,054.64

                

              	
                
                  163.49

                

              	
                
                  99.06

                

              	
                
                  72.61

                

              	
                
                  142.43

                

              	
                
                  82.58

                

              	
                
                  262.02

                

              	
                
                  159.69

                

              	
                
                  342.45

                

              	
                
                  12,468.39

                

              	
                
                  1,751.95

                

              	
                
                  478.42

                

              	
                
                  255.56

                

              	
                
                  271.46

                

              	
                
                  824.49

                

              	
                
                  813.45

                

              	
                
                  173.13

                

              	
                
                  103.96

                

              	
                
                  95.64

                

              
	
                
                  05

                

              	
                
                  1,188.16

                

              	
                
                  183.22

                

              	
                
                  111.18

                

              	
                
                  83.04

                

              	
                
                  161.73

                

              	
                
                  94.16

                

              	
                
                  293.39

                

              	
                
                  178.70

                

              	
                
                  380.61

                

              	
                
                  14,071.98

                

              	
                
                  1,961.51

                

              	
                
                  536.34

                

              	
                
                  283.37

                

              	
                
                  300.20

                

              	
                
                  912.45

                

              	
                
                  898.78

                

              	
                
                  272.12

                

              	
                
                  89.99

                

              	
                
                  83.06

                

              
	
                
                  06

                

              	
                
                  1,068.60

                

              	
                
                  166.62

                

              	
                
                  100.67

                

              	
                
                  69.45

                

              	
                
                  139.86

                

              	
                
                  79.57

                

              	
                
                  265.34

                

              	
                
                  161.32

                

              	
                
                  351.66

                

              	
                
                  12,781.60

                

              	
                
                  1,792.38

                

              	
                
                  487.20

                

              	
                
                  244.15

                

              	
                
                  260.70

                

              	
                
                  808.15

                

              	
                
                  818.87

                

              	
                
                  346.35

                

              	
                
                  89.27

                

              	
                
                  82.57

                

              
	
                
                  07

                

              	
                
                  1,098.45

                

              	
                
                  171.02

                

              	
                
                  104.69

                

              	
                
                  83.42

                

              	
                
                  155.72

                

              	
                
                  93.60

                

              	
                
                  277.67

                

              	
                
                  170.90

                

              	
                
                  364.47

                

              	
                
                  13,731.89

                

              	
                
                  1,935.41

                

              	
                
                  529.58

                

              	
                
                  284.70

                

              	
                
                  301.60

                

              	
                
                  916.43

                

              	
                
                  908.94

                

              	
                
                  293.06

                

              	
                
                  92.62

                

              	
                
                  85.52

                

              
	
                
                  08

                

              	
                
                  1,042.08

                

              	
                
                  162.27

                

              	
                
                  98.01

                

              	
                
                  68.84

                

              	
                
                  138.22

                

              	
                
                  79.11

                

              	
                
                  259.67

                

              	
                
                  158.21

                

              	
                
                  342.24

                

              	
                
                  12,849.85

                

              	
                
                  1,807.50

                

              	
                
                  490.75

                

              	
                
                  246.15

                

              	
                
                  263.83

                

              	
                
                  819.90

                

              	
                
                  828.40

                

              	
                
                  329.66

                

              	
                
                  93.23

                

              	
                
                  85.73

                

              
	
                
                  09

                

              	
                
                  1,057.08

                

              	
                
                  163.23

                

              	
                
                  99.23

                

              	
                
                  75.46

                

              	
                
                  145.70

                

              	
                
                  85.46

                

              	
                
                  262.78

                

              	
                
                  160.44

                

              	
                
                  340.51

                

              	
                
                  12,659.96

                

              	
                
                  1,783.38

                

              	
                
                  487.10

                

              	
                
                  263.94

                

              	
                
                  279.88

                

              	
                
                  845.83

                

              	
                
                  832.09

                

              	
                
                  292.82

                

              	
                
                  101.59

                

              	
                
                  93.03

                

              
	
                
                  10

                

              	
                
                  1,099.02

                

              	
                
                  171.88

                

              	
                
                  104.89

                

              	
                
                  80.87

                

              	
                
                  152.79

                

              	
                
                  91.02

                

              	
                
                  278.23

                

              	
                
                  171.04

                

              	
                
                  369.13

                

              	
                
                  16,191.10

                

              	
                
                  2,278.44

                

              	
                
                  631.18

                

              	
                
                  367.69

                

              	
                
                  382.12

                

              	
                
                  1,134.12

                

              	
                
                  1,102.45

                

              	
                
                  361.29

                

              	
                
                  98.42

                

              	
                
                  92.03

                

              
	
                
                  11

                

              	
                
                  1,390.39

                

              	
                
                  213.87

                

              	
                
                  128.97

                

              	
                
                  91.16

                

              	
                
                  183.00

                

              	
                
                  103.93

                

              	
                
                  339.56

                

              	
                
                  205.61

                

              	
                
                  440.10

                

              	
                
                  16,547.82

                

              	
                
                  2,300.88

                

              	
                
                  634.16

                

              	
                
                  356.30

                

              	
                
                  373.85

                

              	
                
                  1,110.23

                

              	
                
                  1,070.36

                

              	
                
                  394.15

                

              	
                
                  141.29

                

              	
                
                  130.53

                

              
	
                
                  6B*

                

              	
                
                  1,068.47

                

              	
                
                  166.59

                

              	
                
                  100.41

                

              	
                
                  68.69

                

              	
                
                  139.39

                

              	
                
                  79.11

                

              	
                
                  265.52

                

              	
                
                  161.51

                

              	
                
                  351.79

                

              	
                
                  12,781.02

                

              	
                
                  1,792.28

                

              	
                
                  486.95

                

              	
                
                  242.49

                

              	
                
                  259.65

                

              	
                
                  809.19

                

              	
                
                  819.25

                

              	
                
                  346.35

                

              	
                
                  89.27

                

              	
                
                  82.57

                

              


      

      
        


         

        AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 2 of
5

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        ATTACHMENT
I 

        EXHIBIT
2-NR-A 

        MEDICAID NON-REFORM HMO CAPITATION
RATES

      

      
        By Area , Age and Eligibility Category


        Effective
November 1, 2009 -August 31, 2012


      

      
        
           


                 TABLE
5

          

        

      

      
        	
                
                  General
      

                

              	
                
                   +
      Transportation Rates:

                   

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	
                
                  TANF

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	
                
                  SSI-N

                

              	 
      	 
      	 
      	 
      	 
      	
                
                  5SI-B

                

              	
                
                  S5I-AB

                

              
	
                
                  Area

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE

                   (1-5)

                

              	
                
                  AGE

                   (6-13)

                

              	
                
                  AGE
      (14-20)

                

              	
                
                  AGE
      (21-54)

                

              	
                
                  AGE
      

                  (55+)

                

              	
                
                  BTHMO+2MO

                

              	
                
                  3MO-11MO

                

              	
                
                  AGE

                   (1-5)

                

              	
                AGE

                 (6-13)

              	
                 AGE

                 (14-20)
      

              	
                AGE

                 (21-54)

              	
                
                  AGE
      (55+)

                

              	 
      	
                 AGE
      

                (65-)

              	
                
                  AGE
      (65+)

                

              
	 
      	 
      	 
      	 
      	 
      	
                
                  Female

                

              	
                
                  Male

                

              	
                
                  Female

                

              	
                
                  Male

                

              	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	
                
                  01

                

              	
                
                  1,135.59

                

              	
                
                  173.09

                

              	
                
                  103.08

                

              	
                
                  62.42

                

              	
                
                  138.97

                

              	
                
                  73.69

                

              	
                
                  269.84

                

              	
                
                  161.02

                

              	
                
                  345.73

                

              	
                
                  12,218.50

                

              	
                
                  1,694.76

                

              	
                
                  454.95

                

              	
                
                  197.57

                

              	
                
                  216.98

                

              	
                
                  704.48

                

              	
                
                  730.67

                

              	
                
                  353.25

                

              	
                
                  94.33

                

              	
                
                  85.40

                

              
	
                
                  02

                

              	
                
                  1,135.59

                

              	
                
                  173.09

                

              	
                
                  103.08

                

              	
                
                  62.42

                

              	
                
                  138.97

                

              	
                
                  73.69

                

              	
                
                  269.84

                

              	
                
                  161.02

                

              	
                
                  345.73

                

              	
                
                  12,218.50

                

              	
                
                  1,694.76

                

              	
                
                  454.95

                

              	
                
                  197.57

                

              	
                
                  216.98

                

              	
                
                  704.48

                

              	
                
                  730.67

                

              	
                
                  353.25

                

              	
                
                  94.33

                

              	
                
                  85.40

                

              
	
                
                  03

                

              	
                
                  1,211.15

                

              	
                
                  186.39

                

              	
                
                  111.07

                

              	
                
                  68.43

                

              	
                
                  149.98

                

              	
                
                  80.68

                

              	
                
                  292.27

                

              	
                
                  175.38

                

              	
                
                  379.50

                

              	
                
                  13,050.16

                

              	
                
                  1,830.79

                

              	
                
                  491.10

                

              	
                
                  218.23

                

              	
                
                  239.69

                

              	
                
                  776.52

                

              	
                
                  808.11

                

              	
                
                  228.42

                

              	
                
                  97.14

                

              	
                
                  87.37

                

              
	
                
                  04

                

              	
                
                  1,054.62

                

              	
                
                  163.47

                

              	
                
                  97.60

                

              	
                
                  60.98

                

              	
                
                  131.22

                

              	
                
                  71.37

                

              	
                
                  257.27

                

              	
                
                  154.94

                

              	
                
                  338.27

                

              	
                
                  12,468.33

                

              	
                
                  1,751.89

                

              	
                
                  471.58

                

              	
                
                  212.65

                

              	
                
                  231.97

                

              	
                
                  750.91

                

              	
                
                  784.78

                

              	
                
                  165.02

                

              	
                
                  91.42

                

              	
                
                  83.10

                

              
	
                
                  05

                

              	
                
                  1,188.14

                

              	
                
                  183.20

                

              	
                
                  109.24

                

              	
                
                  67.61

                

              	
                
                  146.86

                

              	
                
                  79.29

                

              	
                
                  287.08

                

              	
                
                  172.39

                

              	
                
                  375.06

                

              	
                
                  14,071.91

                

              	
                
                  1,961.44

                

              	
                
                  528.72

                

              	
                
                  235.58

                

              	
                
                  256.21

                

              	
                
                  830.50

                

              	
                
                  866.85

                

              	
                
                  264.01

                

              	
                
                  77.45

                

              	
                
                  70.52

                

              
	
                
                  06

                

              	
                
                  1,068.58

                

              	
                
                  166.60

                

              	
                
                  99.70

                

              	
                
                  62.99

                

              	
                
                  133.90

                

              	
                
                  73.61

                

              	
                
                  263.21

                

              	
                
                  159.19

                

              	
                
                  349.79

                

              	
                
                  12,781.57

                

              	
                
                  1,792.35

                

              	
                
                  483.10

                

              	
                
                  218.24

                

              	
                
                  237.32

                

              	
                
                  767.62

                

              	
                
                  803.07

                

              	
                
                  338.24

                

              	
                
                  76.73

                

              	
                
                  70.03

                

              
	
                
                  07

                

              	
                
                  1,098.42

                

              	
                
                  170.99

                

              	
                
                  102.30

                

              	
                
                  64.47

                

              	
                
                  137.45

                

              	
                
                  75.33

                

              	
                
                  269.92

                

              	
                
                  163.15

                

              	
                
                  357.66

                

              	
                
                  13,731.82

                

              	
                
                  1,935.34

                

              	
                
                  522.25

                

              	
                
                  238.71

                

              	
                
                  259.27

                

              	
                
                  837.57

                

              	
                
                  878.21

                

              	
                
                  284.95

                

              	
                
                  80.08

                

              	
                
                  72.98

                

              
	
                
                  06

                

              	
                
                  1,042.07

                

              	
                
                  162.26

                

              	
                
                  97.03

                

              	
                
                  61.10

                

              	
                
                  130.75

                

              	
                
                  71.64

                

              	
                
                  256.50

                

              	
                
                  155.04

                

              	
                
                  339.46

                

              	
                
                  12,849.81

                

              	
                
                  1,807.46

                

              	
                
                  486.67

                

              	
                
                  220.55

                

              	
                
                  240.27

                

              	
                
                  776.00

                

              	
                
                  811.30

                

              	
                
                  321.55

                

              	
                
                  80.69

                

              	
                
                  73.19

                

              
	
                
                  09

                

              	
                
                  1,057.06

                

              	
                
                  163.21

                

              	
                
                  97.34

                

              	
                
                  60.46

                

              	
                
                  131.24

                

              	
                
                  71.00

                

              	
                
                  256.65

                

              	
                
                  154.31

                

              	
                
                  335.12

                

              	
                
                  12,659.89

                

              	
                
                  1,783.31

                

              	
                
                  479.74

                

              	
                
                  217.76

                

              	
                
                  237.38

                

              	
                
                  766.65

                

              	
                
                  801.24

                

              	
                
                  284.71

                

              	
                
                  89.05

                

              	
                
                  80.49

                

              
	
                
                  10

                

              	
                
                  1,099.00

                

              	
                
                  171.86

                

              	
                
                  102.95

                

              	
                
                  65.45

                

              	
                
                  137.92

                

              	
                
                  76.15

                

              	
                
                  271.92

                

              	
                
                  164.73

                

              	
                
                  363.59

                

              	
                
                  16,190.98

                

              	
                
                  2,278.32

                

              	
                
                  618.38

                

              	
                
                  287.39

                

              	
                
                  308.21

                

              	
                
                  996.43

                

              	
                
                  1,048.80

                

              	
                
                  353.18

                

              	
                
                  85.88

                

              	
                
                  79.49

                

              
	
                
                  11

                

              	
                
                  1,390.37

                

              	
                
                  213.85

                

              	
                
                  127.40

                

              	
                
                  78.71

                

              	
                
                  170.99

                

              	
                
                  91.92

                

              	
                
                  334.47

                

              	
                
                  200.52

                

              	
                
                  435.62

                

              	
                
                  16,547.71

                

              	
                
                  2,300.77

                

              	
                
                  621.54

                

              	
                
                  277.09

                

              	
                
                  300.94

                

              	
                
                  974.40

                

              	
                
                  1,017.43

                

              	
                
                  386.04

                

              	
                
                  128.75

                

              	
                
                  117.99

                

              
	
                
                  6B*

                

              	
                
                  1,068.46

                

              	
                
                  166.58

                

              	
                
                  99.69

                

              	
                
                  62.98

                

              	
                
                  133.88

                

              	
                
                  73.60

                

              	
                
                  263.18

                

              	
                
                  159.17

                

              	
                
                  349.74

                

              	
                
                  12,780.99

                

              	
                
                  1,792.25

                

              	
                
                  483.08

                

              	
                
                  218.22

                

              	
                
                  237.31

                

              	
                
                  767.58

                

              	
                
                  803.03

                

              	
                
                  338.24

                

              	
                
                  76.73

                

              	
                
                  70.03

                

              


      

      
         

         

      

      
        
          TABLE
6

        

      

      
        	General
      	 + Dental Rates: 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	
                TANF

              	 	 	 	 	 	 	 	 	 	
                SSI-N

              	 	 	 	 	 	
                5SI-B

              	
                S5I-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+)
 
	
                
                  01

                

              	
                
                  1,130.46

                

              	
                
                  171.81

                

              	
                
                  103.60

                

              	
                
                  64.44

                

              	
                
                  139.32

                

              	
                
                  74.44

                

              	
                
                  267.75

                

              	
                
                      159.87

                

              	
                
                  345.13

                

              	
                
                  12,166.98

                

              	
                
                  1,661.31

                

              	
                
                  451.50

                

              	
                
                  196.85

                

              	
                
                  212.56

                

              	
                
                  686.00

                

              	
                
                  715.64

                

              	
                
                  345.23

                

              	
                
                  82.19

                

              	
                
                  76.22

                

              
	
                
                  02

                

              	
                
                  1,130.46

                

              	
                
                  171.81

                

              	
                
                  103.60

                

              	
                
                  64.44

                

              	
                
                  139.32

                

              	
                
                  74.44

                

              	
                
                  267.75

                

              	
                
                  159.87

                

              	
                
                  345.13

                

              	
                
                  12,166.98

                

              	
                
                  1,661.31

                

              	
                
                  451.50

                

              	
                
                  196.85

                

              	
                
                  212.56

                

              	
                
                  686.00

                

              	
                
                  715.64

                

              	
                
                  345.23

                

              	
                
                  82.19

                

              	
                
                  76.22

                

              
	
                
                  03

                

              	
                
                  1,204.99

                

              	
                
                  184.87

                

              	
                
                  113.05

                

              	
                
                  73.32

                

              	
                
                  152.85

                

              	
                
                  83.73

                

              	
                
                  290.64

                

              	
                
                  174.94

                

              	
                
                  380.84

                

              	
                
                  12,984.80

                

              	
                
                  1,788.36

                

              	
                
                  488.04

                

              	
                
                  219.30

                

              	
                
                  235.82

                

              	
                
                  753.72

                

              	
                
                  789.96

                

              	
                
                  221.17

                

              	
                
                  80.09

                

              	
                
                  74.48

                

              
	
                
                  04

                

              	
                
                  1,050.62

                

              	
                
                  162.47

                

              	
                
                  98.70

                

              	
                
                  63.82

                

              	
                
                  132.76

                

              	
                
                  73.06

                

              	
                
                  256.61

                

              	
                
                  155.09

                

              	
                
                  340.09

                

              	
                
                  12,420.29

                

              	
                
                  1,720.68

                

              	
                
                  468.92

                

              	
                
                  212.80

                

              	
                
                  228.57

                

              	
                
                  734.52

                

              	
                
                  772.00

                

              	
                
                  160.68

                

              	
                
                  77.74

                

              	
                
                  72.76

                

              
	
                
                  05

                

              	
                
                  1,184.67

                

              	
                
                  182.35

                

              	
                
                  112.26

                

              	
                
                  73.86

                

              	
                
                  151.96

                

              	
                
                  84.05

                

              	
                
                  288.53

                

              	
                
                  174.69

                

              	
                
                  381.40

                

              	
                
                  14,030.19

                

              	
                
                  1,934.35

                

              	
                
                  528.83

                

              	
                
                  239.31

                

              	
                
                  256.38

                

              	
                
                  817.52

                

              	
                
                  857.56

                

              	
                
                  258.05

                

              	
                
                  66.65

                

              	
                
                  62.46

                

              
	
                
                  06

                

              	
                
                  1,065.09

                

              	
                
                  165.75

                

              	
                
                  101.81

                

              	
                
                  67.58

                

              	
                
                  137.33

                

              	
                
                  76.91

                

              	
                
                  262.93

                

              	
                
                  159.63

                

              	
                
                  352.07

                

              	
                
                  12,740.87

                

              	
                
                  1,765.92

                

              	
                
                  482.35

                

              	
                
                  220.60

                

              	
                
                  236.38

                

              	
                
                  754.51

                

              	
                
                  793.35

                

              	
                
                  335.14

                

              	
                
                  67.79

                

              	
                
                  63.33

                

              
	
                
                  07

                

              	
                
                  1,094.61

                

              	
                
                  170.05

                

              	
                
                  104.29

                

              	
                
                  68.91

                

              	
                
                  140.64

                

              	
                
                  78.46

                

              	
                
                  268.96

                

              	
                
                  162.93

                

              	
                
                  358.59

                

              	
                
                  13,685.78

                

              	
                
                  1,905.45

                

              	
                
                  521.07

                

              	
                
                  240.89

                

              	
                
                  257.79

                

              	
                
                  821.37

                

              	
                
                  865.24

                

              	
                
                  279.63

                

              	
                
                  69.76

                

              	
                
                  65.21

                

              
	
                
                  08

                

              	
                
                  1,037.11

                

              	
                
                  161.04

                

              	
                
                  100.83

                

              	
                
                  69.09

                

              	
                
                  137.11

                

              	
                
                  77.62

                

              	
                
                  255.74

                

              	
                
                  155.28

                

              	
                
                  341.85

                

              	
                
                  12,799.18

                

              	
                
                  1,774.59

                

              	
                
                  485.86

                

              	
                
                  223.67

                

              	
                
                  239.27

                

              	
                
                  759.01

                

              	
                
                  798.22

                

              	
                
                  318.07

                

              	
                
                  68.74

                

              	
                
                  64.20

                

              
	
                
                  09

                

              	
                
                  1,052.11

                

              	
                
                  161.99

                

              	
                
                  99.72

                

              	
                
                  65.84

                

              	
                
                  135.00

                

              	
                
                  74.71

                

              	
                
                  254.69

                

              	
                
                  153.25

                

              	
                
                  334.66

                

              	
                
                  12,607.35

                

              	
                
                  1,749.20

                

              	
                
                  477.79

                

              	
                
                  219.36

                

              	
                
                  234.93

                

              	
                
                  747.92

                

              	
                
                  786.11

                

              	
                
                  284.07

                

              	
                
                  75.13

                

              	
                
                  69.96

                

              
	
                
                  10

                

              	
                
                  1,097.09

                

              	
                
                  171.39

                

              	
                
                  104.70

                

              	
                
                  69.05

                

              	
                
                  140.89

                

              	
                
                  78.91

                

              	
                
                  271.30

                

              	
                
                  164.48

                

              	
                
                  363.75

                

              	
                
                  16,173.96

                

              	
                
                  2,267.28

                

              	
                
                  619.04

                

              	
                
                  289.83

                

              	
                
                  309.08

                

              	
                
                  990.94

                

              	
                
                  1,044.73

                

              	
                
                  351.42

                

              	
                
                  81.77

                

              	
                
                  76.43

                

              
	
                
                  11

                

              	
                
                  1,387.51

                

              	
                
                  213.18

                

              	
                
                  133.19

                

              	
                
                  86.38

                

              	
                
                  177.23

                

              	
                
                  98.57

                

              	
                
                  333.54

                

              	
                
                  200.15

                

              	
                
                  435.86

                

              	
                
                  16,510.89

                

              	
                
                  2,276.89

                

              	
                
                  625.35

                

              	
                
                  282.45

                

              	
                
                  302.17

                

              	
                
                  962.09

                

              	
                
                  1,008.00

                

              	
                
                  383.87

                

              	
                
                  119.91

                

              	
                
                  111.40

                

              
	
                
                  6B*

                

              	
                
                  1,064.97

                

              	
                
                  165.73

                

              	
                
                  101.80

                

              	
                
                  67.57

                

              	
                
                  137.31

                

              	
                
                  76.90

                

              	
                
                  260.80

                

              	
                
                  157.36

                

              	
                
                  347.08

                

              	
                
                  12,740.29

                

              	
                
                  1,765.82

                

              	
                
                  482.33

                

              	
                
                  220.58

                

              	
                
                  236.37

                

              	
                
                  751.89

                

              	
                
                  789.57

                

              	
                
                  335.14

                

              	
                
                  67.79

                

              	
                
                  63.33

                

              


      

      
        


         

        AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 3 of
5

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        ATTACHMENT
I 

        EXHIBIT 2-NR-A 

        MEDICAID NON-REFORM
HMO CAPITATION RATES

      

      
        By Area , Age and
Eligibility Category 

        Effective
November 1, 2009 -August 31, 2012


      

      
        
           


        

        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

                

              	
                
                  1,135.60

                

              	
                
                  173.10

                

              	
                
                  104.46

                

              	
                
                  64.94

                

              	
                
                  141.48

                

              	
                
                  75.88

                

              	
                
                  271.24

                

              	
                
                  162.53

                

              	
                
                  349.04

                

              	
                
                  12,218.50

                

              	
                
                  1,694.76

                

              	
                
                  456.13

                

              	
                
                  199.31

                

              	
                
                  218.50

                

              	
                
                  705.68

                

              	
                
                  732.69

                

              	
                
                  353.25

                

              	
                
                  95.51

                

              	
                
                  86.37

                

              
	
                
                  02

                

              	
                
                  1,135.60

                

              	
                
                  173.10

                

              	
                
                  104.46

                

              	
                
                  64.94

                

              	
                
                  141.48

                

              	
                
                  75.88

                

              	
                
                  271.24

                

              	
                
                  162.53

                

              	
                
                  349.04

                

              	
                
                  12,218.50

                

              	
                
                  1,694.76

                

              	
                
                  456.13

                

              	
                
                  199.31

                

              	
                
                  218.50

                

              	
                
                  705.88

                

              	
                
                  732.69

                

              	
                
                  353.25

                

              	
                
                  95.51

                

              	
                
                  86.37

                

              
	
                
                  03

                

              	
                
                  1,211.16

                

              	
                
                  186.41

                

              	
                
                  114.06

                

              	
                
                  73.92

                

              	
                
                  155.44

                

              	
                
                  85.46

                

              	
                
                  294.83

                

              	
                
                  178.13

                

              	
                
                  385.53

                

              	
                
                  13,050.16

                

              	
                
                  1,830.60

                

              	
                
                  493.93

                

              	
                
                  222.43

                

              	
                
                  243.34

                

              	
                
                  778.93

                

              	
                
                  811.59

                

              	
                
                  229.67

                

              	
                
                  99.14

                

              	
                
                  89.01

                

              
	
                
                  04

                

              	
                
                  1,054.63

                

              	
                
                  163.48

                

              	
                
                  99.37

                

              	
                
                  64.21

                

              	
                
                  134.44

                

              	
                
                  74.18

                

              	
                
                  259.34

                

              	
                
                  157.17

                

              	
                
                  343.15

                

              	
                
                  12,468.33

                

              	
                
                  1,751.89

                

              	
                
                  473.24

                

              	
                
                  215.11

                

              	
                
                  234.11

                

              	
                
                  753.06

                

              	
                
                  787.90

                

              	
                
                  166.91

                

              	
                
                  93.09

                

              	
                
                  84.46

                

              
	
                
                  05

                

              	
                
                  1,186.15

                

              	
                
                  183.22

                

              	
                
                  112.84

                

              	
                
                  74.20

                

              	
                
                  153.42

                

              	
                
                  85.03

                

              	
                
                  290.89

                

              	
                
                  176.49

                

              	
                
                  384.05

                

              	
                
                  14,071.92

                

              	
                
                  1,961.45

                

              	
                
                  532.59

                

              	
                
                  241.31

                

              	
                
                  261.19

                

              	
                
                  833.62

                

              	
                
                  871.37

                

              	
                
                  264.09

                

              	
                
                  80.56

                

              	
                
                  73.07

                

              
	
                
                  06

                

              	
                
                  1,068.59

                

              	
                
                  166.62

                

              	
                
                  102.39

                

              	
                
                  67.92

                

              	
                
                  138.80

                

              	
                
                  77.89

                

              	
                
                  265.31

                

              	
                
                  161.44

                

              	
                
                  354.73

                

              	
                
                  12,781.57

                

              	
                
                  1,792.36

                

              	
                
                  486.01

                

              	
                
                  222.55

                

              	
                
                  241.06

                

              	
                
                  770.20

                

              	
                
                  806.81

                

              	
                
                  341.09

                

              	
                
                  78.90

                

              	
                
                  71.81

                

              
	
                
                  07

                

              	
                
                  1,098.43

                

              	
                
                  171.01

                

              	
                
                  104.93

                

              	
                
                  69.29

                

              	
                
                  142.24

                

              	
                
                  79.52

                

              	
                
                  271.55

                

              	
                
                  164.90

                

              	
                
                  361.49

                

              	
                
                  13,731.82

                

              	
                
                  1,935.35

                

              	
                
                  525.22

                

              	
                
                  243.10

                

              	
                
                  263.09

                

              	
                
                  839.14

                

              	
                
                  880.46

                

              	
                
                  285.70

                

              	
                
                  81.52

                

              	
                
                  74.17

                

              
	
                
                  08

                

              	
                
                  1,042.09

                

              	
                
                  162.29

                

              	
                
                  101.66

                

              	
                
                  69.57

                

              	
                
                  139.19

                

              	
                
                  79.01

                

              	
                
                  259.12

                

              	
                
                  157.86

                

              	
                
                  345.64

                

              	
                
                  12,849.82

                

              	
                
                  1,807.47

                

              	
                
                  490.42

                

              	
                
                  226.10

                

              	
                
                  245.10

                

              	
                
                  778.54

                

              	
                
                  814.97

                

              	
                
                  324.02

                

              	
                
                  82.60

                

              	
                
                  74.76

                

              
	
                
                  09

                

              	
                
                  1,057.07

                

              	
                
                  163.23

                

              	
                
                  100.55

                

              	
                
                  66.33

                

              	
                
                  137.08

                

              	
                
                  76.10

                

              	
                
                  258.06

                

              	
                
                  155.82

                

              	
                
                  338.43

                

              	
                
                  12,659.89

                

              	
                
                  1,783.32

                

              	
                
                  482.53

                

              	
                
                  221.89

                

              	
                
                  240.98

                

              	
                
                  768.20

                

              	
                
                  803.49

                

              	
                
                  290.10

                

              	
                
                  90.53

                

              	
                
                  81.70

                

              
	
                
                  10

                

              	
                
                  1,099.01

                

              	
                
                  171.87

                

              	
                
                  105.02

                

              	
                
                  69.24

                

              	
                
                  141.69

                

              	
                
                  79.45

                

              	
                
                  272.60

                

              	
                
                  165.47

                

              	
                
                  365.21

                

              	
                
                  16,190.98

                

              	
                
                  2,278.33

                

              	
                
                  620.57

                

              	
                
                  290.64

                

              	
                
                  311.04

                

              	
                
                  997.51

                

              	
                
                  1,050.36

                

              	
                
                  353.31

                

              	
                
                  87.24

                

              	
                
                  80.60

                

              
	
                
                  11

                

              	
                
                  1,390.43

                

              	
                
                  213.91

                

              	
                
                  133.67

                

              	
                
                  86.66

                

              	
                
                  178.46

                

              	
                
                  99.39

                

              	
                
                  335.53

                

              	
                
                  201.66

                

              	
                
                  438.11

                

              	
                
                  16,547.79

                

              	
                
                  2,300.85

                

              	
                
                  628.67

                

              	
                
                  284.23

                

              	
                
                  306.42

                

              	
                
                  976.32

                

              	
                
                  1,020.21

                

              	
                
                  389.40

                

              	
                
                  131.17

                

              	
                
                  119.98

                

              
	
                
                  6B*

                

              	
                
                  1,068.47

                

              	
                
                  166.60

                

              	
                
                  102.38

                

              	
                
                  67.91

                

              	
                
                  138.78

                

              	
                
                  77.88

                

              	
                
                  263.18

                

              	
                
                  159.17

                

              	
                
                  349.74

                

              	
                
                  12,780.99

                

              	
                
                  1,792.26

                

              	
                
                  485.99

                

              	
                
                  222.53

                

              	
                
                  241.05

                

              	
                
                  767.55

                

              	
                
                  803.03

                

              	
                
                  341.09

                

              	
                
                  78.90

                

              	
                
                  71.81

                

              


      

      
        
           

           

        

          

        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

                

              	
                
                  1,135.63

                

              	
                
                  173.13

                

              	
                
                  106.32

                

              	
                
                  77.29

                

              	
                
                  152.87

                

              	
                
                  87.27

                

              	
                
                  275.30

                

              	
                
                  166.59

                

              	
                
                  352.61

                

              	
                
                  12,218.57

                

              	
                
                  1,694.83

                

              	
                
                  464.34

                

              	
                
                  251.15

                

              	
                
                  265.28

                

              	
                
                  786.98

                

              	
                
                  764.29

                

              	
                
                  361.36

                

              	
                
                  108.05

                

              	
                
                  98.91

                

              
	
                
                  02

                

              	
                
                  1,135.62

                

              	
                
                  173.12

                

              	
                
                  105.94

                

              	
                
                  76.67

                

              	
                
                  152.79

                

              	
                
                  87.19

                

              	
                
                  276.04

                

              	
                
                  167.33

                

              	
                
                  353.26

                

              	
                
                  12,218.61

                

              	
                
                  1,694.87

                

              	
                
                  468.33

                

              	
                
                  275.83

                

              	
                
                  288.93

                

              	
                
                  837.09

                

              	
                
                  783.82

                

              	
                
                  361.36

                

              	
                
                  108.05

                

              	
                
                  98.91

                

              
	
                
                  03

                

              	
                
                  1,211.18

                

              	
                
                  186.43

                

              	
                
                  115.63

                

              	
                
                  86.21

                

              	
                
                  167.29

                

              	
                
                  97.31

                

              	
                
                  299.86

                

              	
                
                  183.16

                

              	
                
                  389.95

                

              	
                
                  13,050.22

                

              	
                
                  1,830.86

                

              	
                
                  500.54

                

              	
                
                  263.89

                

              	
                
                  281.50

                

              	
                
                  850.02

                

              	
                
                  839.29

                

              	
                
                  237.78

                

              	
                
                  111.68

                

              	
                
                  101.55

                

              
	
                
                  04

                

              	
                
                  1,054.65

                

              	
                
                  163.50

                

              	
                
                  100.83

                

              	
                
                  75.84

                

              	
                
                  145.65

                

              	
                
                  85.39

                

              	
                
                  264.09

                

              	
                
                  161.92

                

              	
                
                  347.33

                

              	
                
                  12,468.39

                

              	
                
                  1,751.95

                

              	
                
                  480.08

                

              	
                
                  258.02

                

              	
                
                  273.60

                

              	
                
                  826.64

                

              	
                
                  816.57

                

              	
                
                  175.02

                

              	
                
                  105.63

                

              	
                
                  97.00

                

              
	
                
                  05

                

              	
                
                  1,188.17

                

              	
                
                  183.24

                

              	
                
                  114.78

                

              	
                
                  89.63

                

              	
                
                  168.29

                

              	
                
                  99.90

                

              	
                
                  297.20

                

              	
                
                  182.80

                

              	
                
                  389.60

                

              	
                
                  14,071.99

                

              	
                
                  1,961.52

                

              	
                
                  540.21

                

              	
                
                  289.10

                

              	
                
                  305.18

                

              	
                
                  915.57

                

              	
                
                  903.30

                

              	
                
                  272.20

                

              	
                
                  93.10

                

              	
                
                  85.61

                

              
	
                
                  06

                

              	
                
                  1,068.61

                

              	
                
                  166.64

                

              	
                
                  103.36

                

              	
                
                  74.38

                

              	
                
                  144.76

                

              	
                
                  83.85

                

              	
                
                  267.44

                

              	
                
                  163.57

                

              	
                
                  356.60

                

              	
                
                  12,781.60

                

              	
                
                  1,792.39

                

              	
                
                  490.11

                

              	
                
                  248.46

                

              	
                
                  264.44

                

              	
                
                  810.73

                

              	
                
                  822.61

                

              	
                
                  349.20

                

              	
                
                  91.44

                

              	
                
                  84.35

                

              
	
                
                  07

                

              	
                
                  1,098.46

                

              	
                
                  171.04

                

              	
                
                  107.32

                

              	
                
                  88.24

                

              	
                
                  160.51

                

              	
                
                  97.79

                

              	
                
                  279.30

                

              	
                
                  172.65

                

              	
                
                  368.30

                

              	
                
                  13,731.89

                

              	
                
                  1,935.42

                

              	
                
                  532.55

                

              	
                
                  289.09

                

              	
                
                  305.42

                

              	
                
                  918.00

                

              	
                
                  911.21

                

              	
                
                  293.81

                

              	
                
                  94.06

                

              	
                
                  86.71

                

              
	
                
                  08

                

              	
                
                  1,042.10

                

              	
                
                  162.30

                

              	
                
                  102.64

                

              	
                
                  77.31

                

              	
                
                  146.66

                

              	
                
                  86.48

                

              	
                
                  262.29

                

              	
                
                  161.03

                

              	
                
                  348.42

                

              	
                
                  12,849.86

                

              	
                
                  1,807.51

                

              	
                
                  494.50

                

              	
                
                  251.70

                

              	
                
                  268.66

                

              	
                
                  822.44

                

              	
                
                  832.07

                

              	
                
                  332.13

                

              	
                
                  95.14

                

              	
                
                  87.30

                

              
	
                
                  09

                

              	
                
                  1,057.09

                

              	
                
                  163.25

                

              	
                
                  102.44

                

              	
                
                  81.33

                

              	
                
                  151.54

                

              	
                
                  90.56

                

              	
                
                  264.19

                

              	
                
                  161.95

                

              	
                
                  343.82

                

              	
                
                  12,659.96

                

              	
                
                  1,783.39

                

              	
                
                  489.89

                

              	
                
                  268.07

                

              	
                
                  283.48

                

              	
                
                  847.38

                

              	
                
                  834.34

                

              	
                
                  298.21

                

              	
                
                  103.07

                

              	
                
                  94.24

                

              
	
                
                  10

                

              	
                
                  1,099.03

                

              	
                
                  171.89

                

              	
                
                  106.96

                

              	
                
                  84.66

                

              	
                
                  156.56

                

              	
                
                  94.32

                

              	
                
                  278.91

                

              	
                
                  171.78

                

              	
                
                  370.75

                

              	
                
                  16,191.10

                

              	
                
                  2,278.45

                

              	
                
                  633.37

                

              	
                
                  370.94

                

              	
                
                  384.95

                

              	
                
                  1,135.20

                

              	
                
                  1,104.01

                

              	
                
                  361.42

                

              	
                
                  99.78

                

              	
                
                  93.14

                

              
	
                
                  11

                

              	
                
                  1,390.45

                

              	
                
                  213.93

                

              	
                
                  135.24

                

              	
                
                  99.11

                

              	
                
                  190.47

                

              	
                
                  111.40

                

              	
                
                  340.62

                

              	
                
                  206.75

                

              	
                
                  442.59

                

              	
                
                  16,547.90

                

              	
                
                  2,300.96

                

              	
                
                  641.29

                

              	
                
                  363.44

                

              	
                
                  379.33

                

              	
                
                  1,112.15

                

              	
                
                  1,073.14

                

              	
                
                  397.51

                

              	
                
                  143.71

                

              	
                
                  132.52

                

              
	
                
                  6B*

                

              	
                
                  1,068.48

                

              	
                
                  166.61

                

              	
                
                  103.10

                

              	
                
                  73.62

                

              	
                
                  144.29

                

              	
                
                  83.39

                

              	
                
                  265.52

                

              	
                
                  161.51

                

              	
                
                  351.79

                

              	
                
                  12,781.02

                

              	
                
                  1,792.29

                

              	
                
                  489.86

                

              	
                
                  246.80

                

              	
                
                  263.39

                

              	
                
                  809.19

                

              	
                
                  819.25

                

              	
                
                  349.20

                

              	
                
                  91.44

                

              	
                
                  84.35

                

              


      

      
        


         

        AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 4 of
5

      


      
        
           


        

        
           


          
            

          

        

        
           


        

      


      
        ATTACHMENT
I 

        EXHIBIT 2-NR-A 

        MEDICAID NON-REFORM
HMO CAPITATION RATES

      

      
        By Area, Age and
Eligibility Category 

        Effective
November 1, 2009 -August 31, 2012

      

      
        


         

        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
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

      

      
        


         

        AHCA
Contract No. FA905, Attachment I, Exhibit 2-NR-A, Page 5 of
5