fa904ahcacontractamend2.htm


    
      
        Back to Form 10-K

         

        Exhibit
10.57.2

         

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


        

         

      

    

    
      AHCA
CONTRACT NO. FA904 

      AMENDMENT
NO. 2

    

    
       

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

    

    
       

      
        	
                1.

              	
                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. FA904, Amendment No. 2, Page 1 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

        

      

    

    
      
        
                                                                                                                                       

        

      

    

    
      	
               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. FA904, Amendment No. 2, Page 2 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        

      

    

    
      
        	
                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. FA904, Amendment No. 2, Page 3 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        

      

    

    
      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. FA904, Amendment No. 2, Page 4 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        

      

    

    
      
        	
                       
      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. FA904, Amendment No. 2, Page 5 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

                                                                                                                      

        

      

    

    
      	
              
                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. FA904, Amendment No. 2, Page 6 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        
                                                                                                                 

    

    
      	
              
                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. FA904, Amendment No. 2, Page 7 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
       

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


          

           

        

      

                                                                                                                                        

    

    
      	
              
                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. FA904, Amendment No. 2, Page 8 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        

      

                                                                                                                        

    

    
      	
              
                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. FA904, Amendment No. 2, Page 9 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      
        
           

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


          

           

        

      

                                                                                                                                         

    

    
      	
              
                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. FA904, Amendment No. 2, Page 10 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      
        
           

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


          

           

        

      

    

    
      
        	
                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. FA904, Amendment No. 2, Page 11 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

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


        

         

      

    

    
      	
              
                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. FA904, Amendment No. 2, Page 12 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

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


        

         

      

    

    
      	
              
                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. FA904, Amendment No. 2, Page 13 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
         

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


        

         

      

    

    
 

    
      	
              
                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. FA904, Amendment No. 2, Page 14 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

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


        

         

      

    

    
      	
              
                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. FA904, Amendment No. 2, Page 15 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      
        
           

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


          

           

        
                                                                                                                               

    

    
      	
              
                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. FA904, Amendment No. 2, Page 16 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
         

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


        

         

      



    
      	
              
                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. FA904, Amendment No. 2, Page 17 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
         

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


        

         

      

    

    
 

    
      	
              
                |      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. FA904, Amendment No. 2, Page 18 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
         

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


        

         

      

    

    
 

    
      	
              
                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. FA904, Amendment No. 2, Page 19 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
       

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


      

       

    

    
      
        	
                  
      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.c., 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. FA904, Amendment No. 2, Page 20 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      
        
           

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


          

           

        

      

    

    
             
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. FA904, Amendment No. 2, Page 21 of 22

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

     

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


          

           

        

      

    

    
       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.

    

    
       

      
      

       

      
        	
                WELLCARE OF FLORIDA,
      INC.    

                D/B/A STAYWELL HEALTH PLAN
      OF

                FLORIDA

              	 	
                 

                  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 Executive
      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. FA904, 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

    

    
       

      
         


      

      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

              

            	
              
                462.11

              

            	
              
                218.12

              

            	
              
                234.44

              

            	
              
                756.47

              

            	
              
                794.55

              

            	
              
                315.60

              

            	
              
                66.83

              

            	
              
                62.63

              

            
	
              
                09

              

            	
              
                1,052.10

              

            	
              
                161.97

              

            	
              
                96.51

              

            	
              
                59.97

              

            	
              
                129.16

              

            	
              
                69.61

              

            	
              
                253.28

              

            	
              
                151.74

              

            	
              
                331.35

              

            	
              
                12,607.35

              

            	
              
                1,749.19

              

            	
              
                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

              

            	
              
                7B.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

              

            	
              
                68.36

              

            	
              
                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

              

            	
              
                68.35

              

            	
              
                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. FA904, 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

              

            
	
              
                0S

              

            	
              
                1,037.12

              

            	
              
                161.05

              

            	
              
                101.81

              

            	
              
                76.83

              

            	
              
                144.58

              

            	
              
                85.09

              

            	
              
                258.91

              

            	
              
                15B.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

              

            	
              
                1,867.53

              

            	
              
                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. FA904, 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

              

            
	
              
                08

              

            	
              
                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. FA904, 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

              

            	
              
                705.88

              

            	
              
                732.69

              

            	
              
                353.25

              

            	
              
                95.51

              

            	
              
                86.37

              

            
	
              
                02

              

            	
              
                1,135.60

              

            	
              
                173.10

              

            	
              
                104.46

              

            	
              
                64.94

              

            	
              
                141.48

              

            	
              
                75.88

              

            	
              
                271.24

              

            	
              
                162.53

              

            	
              
                349.04

              

            	
              
                12,218.50

              

            	
              
                1,694.76

              

            	
              
                456.13

              

            	
              
                199.31

              

            	
              
                218.50

              

            	
              
                705.88

              

            	
              
                732.69

              

            	
              
                353.25

              

            	
              
                95.51

              

            	
              
                86.37

              

            
	
              
                03

              

            	
              
                1,211.16

              

            	
              
                186.41

              

            	
              
                114.08

              

            	
              
                73.92

              

            	
              
                155.44

              

            	
              
                85.46

              

            	
              
                294.83

              

            	
              
                178.13

              

            	
              
                385.53

              

            	
              
                13,050.16

              

            	
              
                1,830.80

              

            	
              
                493.93

              

            	
              
                222.43

              

            	
              
                243.34

              

            	
              
                778.93

              

            	
              
                811.59

              

            	
              
                229.67

              

            	
              
                99.14

              

            	
              
                89.01

              

            
	
              
                04

              

            	
              
                1,054.63

              

            	
              
                163.48

              

            	
              
                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

              

            	
              
                1,188.15

              

            	
              
                183.22

              

            	
              
                112.84

              

            	
              
                74.20

              

            	
              
                153.42

              

            	
              
                85.03

              

            	
              
                290.89

              

            	
              
                176.49

              

            	
              
                384.05

              

            	
              
                14,071.92

              

            	
              
                1,961.45

              

            	
              
                532.59

              

            	
              
                241.31

              

            	
              
                261.19

              

            	
              
                833.62

              

            	
              
                871.37

              

            	
              
                264.09

              

            	
              
                80.56

              

            	
              
                73.07

              

            
	
              
                06

              

            	
              
                1,068.59

              

            	
              
                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

              

            	
              
                880.48

              

            	
              
                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

              

            	
              
                767.58

              

            	
              
                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. FA904, 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. FA904, Attachment I, Exhibit 2-NR-A, Page 5 of
5