fa905amendment8.htm


Return to Form 8-k



 



	 HealthEase of Florida, Inc.	 	 Medicaid HMO Non-Reform Contract
	 	AHCA CONTRACT NO. FA905	 
	 	AMENDMENT NO. 8	 
	 	 	 





 



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





 



	 	
1.

	
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 1., Covered Medicaid Services, sub-item b.(3)(c), is hereby amended to include Table 5-A, Revised Health Plan Covered Services Chart, as follows.  All references in the Contract to Table 5, Health Plan Covered Services Chart shall hereinafter also refer to Table 5-A, Revised Health Plan Covered Services Chart, as appropriate.







 


 





	
TABLE 5-A


	
Revised Health Plan Covered Services Chart

	
Non- Reform Covered

	
Reform


Covered


	
Advanced Registered Nurse Practitioner Services

	
X

	  
	
Ambulatory Surgical Center Services

	
X

	  
	
Birth Center Services

	
X

	  
	
Child Health Check-Up Services

	
X

	  
	
Chiropractic Services

	
X

	  
	
Community Behavioral Health Services

	
X

	  
	
County Health Department Services

	
X

	  
	
Dental Services*

	  	  
	
Durable Medical Equipment and Medical Supplies

	
X

	  
	
Dialysis Services

	
X

	  
	
Emergency Room Services

	
X

	  
	
Family Planning Services

	
X

	  
	
Federally Qualified Health Center Services

	
X

	  
	
Frail/Elderly Program Services*

	  	  
	
Freestanding Dialysis Centers

	
X

	  
	
Hearing Services

	
X

	  
	
Home Health Care Services

	
X

	  
	
Hospital Services – Inpatient

	
X

	  
	
Hospital Services – Outpatient

	
X

	  
	
Immunizations

	
X

	  
	
Independent Laboratory Services

	
X

	  
	
Licensed Midwife Services

	
X

	  
	
Optometric Services

	
X

	  
	
Physician Services

	
X

	  
	
Physician Assistant Services

	
X

	  
	
Podiatry Services

	
X

	  







 



 AHCA Contract No. FA905, Amendment No. 8, Page 1 of 3












  






 



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









	
TABLE 5-A

	  	  
	
Revised Health Plan Covered Services Chart

	
Non- Reform Covered

	
Reform


Covered


	
Portable X-ray Services

	
X

	  
	
Prescribed Drugs

	
X

	  
	
Prescribed Pediatric Extended Care Services

	  	  
	
Primary Care Case Management Services

	
X

	  
	    Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY)	 	
 


	
Rural Health Clinic Services

	
X

	  
	
Targeted Case Management

	
X

	  
	
Therapy Services: Occupational

	
X

	  
	
Therapy Services: Physical

	
X

	  
	
Therapy Services: Respiratory

	
X

	  
	
Therapy Services: Speech

	
X

	  
	
Transplant Services

	
X

	  
	
Transportation Services*

	  	  
	
Vision Services

	
X

	  





 


 


 



	 	
2.

	
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a., is hereby amended to include Table 6-B, Revised Expanded Services, as follows.  All references in the Contract to Table 6, Expanded Services, and Table 6-A, Revised Expanded Services shall hereinafter also refer to Table 6-B, as appropriate.







 



	
TABLE 6-B


	
Revised Expanded Services


	
Effective January 1, 2012


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







 


 



	 	
3.  

	
Effective September 1, 2011, Attachment I, Scope of  Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract.  All references in the Contract to Exhibit 2-NR-B, shall hereinafter refer to Exhibit 2- NR-C, as appropriate.







 



	 	Unless otherwise stated, this amendment is effective upon execution.





 



	 	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.



 









AHCA Contract No. FA905, Amendment No. 8, Page 2 of 3





  











  








 




	HealthEase of Florida, Inc.	 	 Medicaid HMO Non-Reform 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 eight (8) page amendment (including all attachments) to be executed by their officials thereunto duly authorized.





 



	HEALTHEASE OF FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR 	 
	 	 	HEALTH CARE ADMINISTRATION	 
	 	 	 	 
	By:	/s/Christina Cooper	 	By:	/s/ Tonya Kidd for	 
	 	 	 	 
	Name:	Christina Cooper	 	Name:	Elizabeth Dudek	 
	 	 	 	 
	Title: 	President, FL & HI Division	 	Title:	Secretary	 
	 	 	 	 
	Date:  	12/27/11	 	Date:	12/29/11	 





 


 


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


 


 



	
Specify


Type

	
Letter/


Number

	
 


Description


	 Attachment I	Exhibit 2-NR-C	
Medicaid Non-Reform HMO Capitation Rates, 


Effective September 1, 2011 (5 pages)







 


 


REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
















  AHCA Contract No. FA905, Amendment No. 8, Page 3 of 3





  











  










 






 


 



	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011





 






	
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

	
944.58

	
184.93

	
99.14

	
62.81

	
127.84

	
67.50

	
271.85

	
155.86

	
430.03

	
12,534.08

	
1,853.67

	
459.10

	
183.60

	
219.90

	
719.01

	
846.95

	
304.31

	
95.72

	
75.16


	
02

	
809.74

	
158.54

	
85.26

	
55.17

	
110.84

	
59.12

	
234.16

	
134.73

	
369.40

	
10,634.20

	
1,571.89

	
378.61

	
129.11

	
165.06

	
567.50

	
702.50

	
304.31

	
85.34

	
66.80


	
03

	
977.48

	
191.38

	
102.88

	
66.37

	
133.57

	
71.13

	
282.47

	
162.44

	
445.78

	
13,033.48

	
1,927.78

	
480.73

	
199.09

	
235.25

	
760.70

	
885.63

	
304.31

	
86.58

	
67.80


	
04

	
982.26

	
192.25

	
101.91

	
59.51

	
127.52

	
64.77

	
277.81

	
157.18

	
443.92

	
13,413.62

	
1,983.70

	
490.64

	
194.84

	
234.00

	
766.84

	
905.39

	
304.31

	
79.94

	
62.45


	
05

	
1,109.71

	
217.27

	
116.92

	
75.94

	
152.20

	
81.32

	
321.19

	
184.92

	
506.42

	
14,476.72

	
2,141.09

	
531.81

	
215.85

	
257.04

	
836.50

	
980.51

	
304.31

	
74.93

	
58.42


	
06

	
1,021.04

	
199.94

	
108.39

	
73.89

	
143.78

	
78.57

	
298.90

	
173.52

	
468.21

	
13,062.91

	
1,932.30

	
484.19

	
205.34

	
240.45

	
771.66

	
891.12

	
304.31

	
73.50

	
57.26


	
07

	
966.83

	
189.24

	
100.39

	
58.99

	
125.91

	
64.15

	
273.80

	
155.07

	
437.19

	
13,593.51

	
2,010.10

	
494.41

	
190.58

	
231.59

	
766.17

	
913.39

	
304.31

	
72.84

	
56.74


	
08

	
952.04

	
186.41

	
100.57

	
66.44

	
131.76

	
70.95

	
276.63

	
159.73

	
435.19

	
12,412.16

	
1,835.77

	
456.44

	
186.23

	
221.31

	
719.07

	
841.38

	
304.31

	
80.42

	
62.84


	
09

	
1,032.49

	
202.14

	
108.41

	
68.86

	
139.93

	
73.98

	
297.32

	
170.54

	
470.17

	
14,347.56

	
2,121.42

	
519.54

	
195.54

	
239.92

	
799.72

	
960.67

	
304.31

	
82.17

	
64.25


	
10

	
1,028.53

	
201.37

	
108.26

	
69.90

	
140.62

	
74.92

	
297.28

	
170.98

	
469.11

	
17,915.36

	
2,649.60

	
657.40

	
265.37

	
316.67

	
1,032.39

	
1,212.35

	
304.31

	
92.58

	
72.64


	
11

	
1,187.84

	
232.59

	
125.70

	
84.02

	
165.46

	
89.59

	
346.10

	
200.24

	
543.62

	
15,014.29

	
2,220.47

	
549.99

	
220.03

	
263.49

	
861.45

	
1,014.60

	
304.31

	
120.99

	
95.51


	
6B *

	
1,020.54

	
199.85

	
108.39

	
74.07

	
143.91

	
78.73

	
298.94

	
173.63

	
468.11

	
13,061.73

	
1,932.14

	
484.22

	
205.49

	
240.58

	
771.87

	
891.14

	
304.31

	
73.50

	
57.26







 


 



TABLE 2





	
General + Mental Health Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB


	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)


	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.04

	
101.42

	
73.90

	
138.20

	
77.86

	
281.21

	
165.22

	
436.32

	
12,535.85

	
1,855.44

	
479.56

	
233.51

	
260.16

	
798.67

	
877.14

	
321.65

	
105.67

	
85.11


	
02

	
809.82

	
158.62

	
86.94

	
63.35

	
118.47

	
66.75

	
241.06

	
141.63

	
374.03

	
10,636.65

	
1,574.34

	
406.90

	
198.14

	
220.74

	
677.67

	
744.25

	
321.65

	
95.29

	
76.75


	
03

	
977.58

	
191.48

	
104.95

	
76.48

	
143.01

	
80.57

	
291.00

	
170.97

	
451.51

	
13,035.03

	
1,929.33

	
498.65

	
242.81

	
270.52

	
830.48

	
912.07

	
321.65

	
96.53

	
77.75


	
04

	
982.44

	
192.43

	
105.47

	
76.86

	
143.72

	
80.97

	
292.45

	
171.82

	
453.76

	
13,415.57

	
1,985.65

	
513.21

	
249.90

	
278.41

	
854.72

	
938.69

	
321.65

	
89.89

	
72.40


	
05

	
1,109.82

	
217.38

	
119.15

	
86.82

	
162.35

	
91.47

	
330.37

	
194.10

	
512.59

	
14,478.63

	
2,143.00

	
553.88

	
269.70

	
300.48

	
922.45

	
1,013.08

	
321.65

	
84.88

	
68.37


	
06

	
1,021.10

	
200.00

	
109.62

	
79.88

	
149.37

	
84.16

	
303.96

	
178.58

	
471.61

	
13,064.26

	
1,933.65

	
499.77

	
243.36

	
271.12

	
832.34

	
914.11

	
321.65

	
83.45

	
67.21


	
07

	
967.00

	
189.41

	
103.81

	
75.65

	
141.46

	
79.70

	
287.85

	
169.12

	
446.63

	
13,595.73

	
2,012.32

	
520.10

	
253.26

	
282.15

	
866.20

	
951.30

	
321.65

	
82.79

	
66.69


	
08

	
952.12

	
186.49

	
102.22

	
74.49

	
139.28

	
78.47

	
283.42

	
166.52

	
439.76

	
12,413.76

	
1,837.37

	
474.89

	
231.24

	
257.62

	
790.90

	
868.60

	
321.65

	
90.37

	
72.79


	
09

	
1,032.61

	
202.26

	
110.86

	
80.78

	
151.06

	
85.11

	
307.38

	
180.60

	
476.93

	
14,350.11

	
2,123.97

	
548.96

	
267.31

	
297.81

	
914.26

	
1,004.08

	
321.65

	
92.12

	
74.20


	
10

	
1,028.64

	
201.48

	
110.43

	
80.47

	
150.48

	
84.78

	
306.20

	
179.90

	
475.10

	
17,917.79

	
2,652.03

	
685.44

	
333.77

	
371.85

	
1,141.56

	
1,253.72

	
321.65

	
102.53

	
82.59


	
11

	
1,187.93

	
232.68

	
127.53

	
92.93

	
173.78

	
97.91

	
353.62

	
207.76

	
548.67

	
15,016.41

	
2,222.59

	
574.45

	
279.72

	
311.64

	
956.71

	
1,050.70

	
321.65

	
130.94

	
105.46


	
6B *

	
1,020.60

	
199.91

	
109.57

	
79.84

	
149.30

	
84.12

	
303.81

	
178.50

	
471.38

	
13,063.07

	
1,933.48

	
499.73

	
243.33

	
271.10

	
832.26

	
914.03

	
321.65

	
83.45

	
67.21













  





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











  








 


 



	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011



 


 







	
 


TABLE 3

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
General + MH + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	  
	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)


	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.06

	
103.23

	
76.91

	
140.85

	
80.79

	
282.97

	
166.83

	
439.41

	
12,535.91

	
1,855.47

	
481.31

	
235.72

	
262.09

	
800.18

	
879.25

	
323.95

	
106.76

	
86.03


	
02

	
809.83

	
158.64

	
89.86

	
68.21

	
122.74

	
71.49

	
243.79

	
144.12

	
378.82

	
10,636.74

	
1,574.39

	
409.58

	
201.51

	
223.69

	
679.30

	
746.53

	
323.95

	
96.63

	
77.87


	
03

	
977.59

	
191.53

	
110.77

	
86.18

	
151.54

	
90.02

	
294.80

	
174.45

	
458.19

	
13,035.24

	
1,929.45

	
504.95

	
250.74

	
277.45

	
832.71

	
915.19

	
323.95

	
98.64

	
79.52


	
04

	
982.45

	
192.46

	
108.89

	
82.56

	
148.73

	
86.53

	
296.76

	
175.76

	
461.32

	
13,415.69

	
1,985.72

	
516.72

	
254.31

	
282.27

	
857.39

	
942.42

	
323.95

	
92.21

	
74.35


	
05

	
1,109.84

	
217.44

	
125.83

	
97.95

	
172.14

	
102.32

	
334.38

	
197.77

	
519.63

	
14,478.85

	
2,143.13

	
560.70

	
278.28

	
307.98

	
924.69

	
1,016.22

	
323.95

	
87.28

	
70.38


	
06

	
1,021.11

	
200.04

	
114.54

	
88.08

	
156.58

	
92.15

	
306.21

	
180.64

	
475.56

	
13,064.42

	
1,933.74

	
504.77

	
249.66

	
276.62

	
833.92

	
916.32

	
323.95

	
85.20

	
68.68


	
07

	
967.01

	
189.46

	
109.65

	
85.37

	
150.01

	
89.18

	
290.76

	
171.78

	
451.74

	
13,595.93

	
2,012.43

	
526.15

	
260.87

	
288.80

	
868.02

	
953.84

	
323.95

	
84.50

	
68.13


	
08

	
952.14

	
186.58

	
112.21

	
91.13

	
153.91

	
94.69

	
286.81

	
169.62

	
445.71

	
12,414.04

	
1,837.53

	
483.35

	
241.89

	
266.93

	
792.93

	
871.43

	
323.95

	
92.29

	
74.40


	
09

	
1,032.63

	
202.32

	
118.34

	
93.24

	
162.01

	
97.26

	
310.56

	
183.50

	
482.50

	
14,350.33

	
2,124.09

	
555.67

	
275.75

	
305.19

	
916.18

	
1,006.76

	
323.95

	
93.99

	
75.77


	
10

	
1,028.65

	
201.51

	
114.40

	
87.08

	
156.30

	
91.23

	
307.29

	
180.90

	
477.01

	
17,917.96

	
2,652.12

	
690.55

	
340.20

	
377.47

	
1,142.86

	
1,255.53

	
323.95

	
103.74

	
83.61


	
11

	
1,188.00

	
232.75

	
137.40

	
108.70

	
186.71

	
110.84

	
355.80

	
209.75

	
552.50

	
15,016.42

	
2,222.60

	
586.08

	
291.88

	
320.59

	
959.38

	
1,054.43

	
323.95

	
134.01

	
108.03


	
6B *

	
1,020.61

	
199.95

	
114.49

	
88.04

	
156.51

	
92.11

	
306.06

	
180.56

	
475.33

	
13,063.23

	
1,933.57

	
504.73

	
249.63

	
276.60

	
833.84

	
916.24

	
323.95

	
85.20

	
68.68







 


 


 


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

	
951.62

	
187.12

	
102.70

	
74.71

	
140.05

	
80.81

	
284.50

	
169.78

	
440.86

	
12,591.13

	
1,898.82

	
487.69

	
238.50

	
269.54

	
826.05

	
900.84

	
324.43

	
109.55

	
88.28


	
02

	
816.21

	
160.54

	
88.12

	
64.09

	
120.17

	
69.47

	
244.09

	
145.84

	
378.22

	
10,685.88

	
1,612.98

	
414.14

	
202.58

	
229.10

	
702.06

	
765.36

	
324.43

	
98.51

	
79.370


	
03

	
984.48

	
193.55

	
106.22

	
77.28

	
144.85

	
83.50

	
294.27

	
175.51

	
456.03

	
13,083.83

	
1,967.63

	
505.83

	
247.21

	
278.80

	
854.65

	
932.99

	
324.43

	
100.56

	
81.04


	
04

	
988.24

	
194.17

	
106.54

	
77.53

	
145.26

	
83.43

	
295.20

	
175.63

	
457.56

	
13,465.86

	
2,025.12

	
520.61

	
254.44

	
286.95

	
879.63

	
960.26

	
324.43

	
94.30

	
75.99


	
05

	
1,114.99

	
218.93

	
120.10

	
87.42

	
163.73

	
93.67

	
332.82

	
197.50

	
515.98

	
14,525.16

	
2,179.52

	
560.72

	
273.90

	
308.38

	
945.50

	
1,033.03

	
324.43

	
88.93

	
71.67


	
06

	
1,026.36

	
201.58

	
110.59

	
80.49

	
150.77

	
86.40

	
306.46

	
182.04

	
475.06

	
13,112.00

	
1,971.11

	
506.79

	
247.67

	
279.22

	
855.98

	
934.58

	
324.43

	
87.18

	
70.25


	
07

	
972.68

	
191.11

	
104.86

	
76.31

	
142.97

	
82.11

	
290.54

	
172.85

	
450.35

	
13,646.03

	
2,051.80

	
527.50

	
257.80

	
290.69

	
891.11

	
972.87

	
324.43

	
85.88

	
69.21


	
08

	
958.75

	
188.48

	
103.44

	
75.26

	
141.04

	
81.29

	
286.56

	
170.88

	
444.10

	
12,462.04

	
1,875.26

	
481.99

	
235.60

	
265.82

	
814.81

	
889.30

	
324.43

	
93.02

	
74.95


	
09

	
1,039.33

	
204.28

	
112.10

	
81.56

	
152.85

	
87.97

	
310.57

	
185.02

	
481.33

	
14,399.99

	
2,163.12

	
556.29

	
271.81

	
306.28

	
938.96

	
1,025.47

	
324.43

	
96.06

	
77.41


	
10

	
1,034.50

	
203.24

	
111.51

	
81.15

	
152.04

	
87.27

	
308.98

	
183.75

	
478.93

	
17,971.60

	
2,694.26

	
693.35

	
338.63

	
380.98

	
1,168.21

	
1,276.79

	
324.43

	
106.30

	
85.66


	
11

	
1,192.81

	
234.14

	
128.43

	
93.50

	
175.08

	
99.98

	
355.93

	
210.97

	
551.86

	
15,061.69

	
2,258.13

	
581.11

	
283.81

	
319.33

	
979.14

	
1,070.12

	
324.43

	
134.22

	
108.13


	
6B *

	
1,025.86

	
201.49

	
110.54

	
80.45

	
150.70

	
86.36

	
306.31

	
181.96

	
474.83

	
13,110.81

	
1,970.94

	
506.75

	
247.64

	
279.20

	
855.90

	
934.50

	
324.43

	
87.18

	
70.25













  





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











  












	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011



 






	
 


TABLE 5

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
General + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB


	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)


	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.51

	
187.01

	
100.42

	
63.62

	
129.69

	
70.45

	
275.14

	
160.42

	
434.57

	
12,589.36

	
1,897.05

	
467.23

	
188.59

	
229.28

	
746.39

	
870.65

	
307.09

	
99.60

	
78.33


	
02

	
816.13

	
160.46

	
86.44

	
55.91

	
112.54

	
61.84

	
237.19

	
138.94

	
373.59

	
10,683.43

	
1,610.53

	
385.85

	
133.55

	
173.42

	
591.89

	
723.61

	
307.09

	
88.56

	
69.42


	
03

	
984.38

	
193.45

	
104.15

	
67.17

	
135.41

	
74.06

	
285.74

	
166.98

	
450.30

	
13,082.28

	
1,966.08

	
487.91

	
203.49

	
243.53

	
784.87

	
906.55

	
307.09

	
90.61

	
71.09


	
04

	
988.06

	
193.99

	
102.98

	
60.18

	
129.06

	
67.23

	
280.56

	
160.99

	
447.72

	
13,463.91

	
2,023.17

	
498.04

	
199.38

	
242.54

	
791.75

	
926.96

	
307.09

	
84.35

	
66.04


	
05

	
1,114.88

	
218.82

	
117.87

	
76.54

	
153.58

	
83.52

	
323.64

	
188.32

	
509.81

	
14,523.25

	
2,177.61

	
538.65

	
220.05

	
264.94

	
859.55

	
1,000.46

	
307.09

	
78.98

	
61.72


	
06

	
1,026.30

	
201.52

	
109.36

	
74.50

	
145.18

	
80.81

	
301.40

	
176.98

	
471.66

	
13,110.65

	
1,969.76

	
491.21

	
209.65

	
248.55

	
795.30

	
911.59

	
307.09

	
77.23

	
60.30


	
07

	
972.51

	
190.94

	
101.44

	
59.65

	
127.42

	
66.56

	
276.49

	
158.80

	
440.91

	
13,643.81

	
2,049.58

	
501.81

	
195.12

	
240.13

	
791.08

	
934.96

	
307.09

	
75.93

	
59.26


	
08

	
958.67

	
188.40

	
101.79

	
67.21

	
133.52

	
73.77

	
279.77

	
164.09

	
439.53

	
12,460.44

	
1,873.66

	
463.54

	
190.59

	
229.51

	
742.98

	
862.08

	
307.09

	
83.07

	
65.00


	
09

	
1,039.21

	
204.16

	
109.65

	
69.64

	
141.72

	
76.84

	
300.51

	
174.96

	
474.57

	
14,397.44

	
2,160.57

	
526.87

	
200.04

	
248.39

	
824.42

	
982.06

	
307.09

	
86.11

	
67.46


	
10

	
1,034.39

	
203.13

	
109.34

	
70.58

	
142.18

	
77.41

	
300.06

	
174.83

	
472.94

	
17,969.17

	
2,691.83

	
665.31

	
270.23

	
325.80

	
1,059.04

	
1,235.42

	
307.09

	
96.35

	
75.71


	
11

	
1,192.72

	
234.05

	
126.60

	
84.59

	
166.76

	
91.66

	
348.41

	
203.45

	
546.81

	
15,059.57

	
2,256.01

	
556.65

	
224.12

	
271.18

	
883.88

	
1,034.02

	
307.09

	
124.27

	
98.18


	
6B *

	
1,025.80

	
201.43

	
109.36

	
74.68

	
145.31

	
80.97

	
301.44

	
177.09

	
471.56

	
13,109.47

	
1,969.60

	
491.24

	
209.80

	
248.68

	
795.51

	
911.61

	
307.09

	
77.23

	
60.30







 


 


 



TABLE 6





	
General + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB


	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)


	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.58

	
184.95

	
100.95

	
65.82

	
130.49

	
70.43

	
273.61

	
157.47

	
433.12

	
12,534.14

	
1,853.70

	
460.85

	
185.81

	
221.83

	
720.52

	
849.06

	
306.61

	
96.81

	
76.08


	
02

	
809.75

	
158.56

	
88.18

	
60.03

	
115.11

	
63.86

	
236.89

	
137.22

	
374.19

	
10,634.29

	
1,571.94

	
381.29

	
132.48

	
168.01

	
569.13

	
704.78

	
306.61

	
86.68

	
67.92


	
03

	
977.49

	
191.43

	
108.70

	
76.07

	
142.10

	
80.58

	
286.27

	
165.92

	
452.46

	
13,033.69

	
1,927.90

	
487.03

	
207.02

	
242.18

	
762.93

	
888.75

	
306.61

	
88.69

	
69.57


	
04

	
982.27

	
192.28

	
105.33

	
65.21

	
132.53

	
70.33

	
282.12

	
161.12

	
451.48

	
13,413.74

	
1,983.77

	
494.15

	
199.25

	
237.86

	
769.51

	
909.12

	
306.61

	
82.26

	
64.40


	
05

	
1,109.73

	
217.33

	
123.60

	
87.07

	
161.99

	
92.17

	
325.20

	
188.59

	
513.46

	
14,476.94

	
2,141.22

	
538.63

	
224.43

	
264.54

	
838.74

	
983.65

	
306.61

	
77.33

	
60.43


	
06

	
1,021.05

	
199.98

	
113.31

	
82.09

	
150.99

	
86.56

	
301.15

	
175.58

	
472.16

	
13,063.07

	
1,932.39

	
489.19

	
211.64

	
245.95

	
773.24

	
893.33

	
306.61

	
75.25

	
58.73


	
07

	
966.84

	
189.29

	
106.23

	
68.71

	
134.46

	
73.63

	
276.71

	
157.73

	
442.30

	
13,593.71

	
2,010.21

	
500.46

	
198.19

	
238.24

	
767.99

	
915.93

	
306.61

	
74.55

	
58.18


	
08

	
952.06

	
186.50

	
110.56

	
83.08

	
146.39

	
87.17

	
280.02

	
162.83

	
441.14

	
12,412.44

	
1,835.93

	
464.90

	
196.88

	
230.62

	
721.10

	
844.21

	
306.61

	
82.34

	
64.45


	
09

	
1,032.51

	
202.20

	
115.89

	
81.32

	
150.88

	
86.13

	
300.50

	
173.44

	
475.74

	
14,347.78

	
2,121.54

	
526.25

	
203.98

	
247.30

	
801.64

	
963.35

	
306.61

	
84.04

	
65.82


	
10

	
1,028.54

	
201.40

	
112.23

	
76.51

	
146.44

	
81.37

	
298.37

	
171.98

	
471.02

	
17,915.53

	
2,649.69

	
662.51

	
271.80

	
322.29

	
1,033.69

	
1,214.16

	
306.61

	
93.79

	
73.66


	
11

	
1,187.91

	
232.66

	
135.57

	
99.79

	
178.39

	
102.52

	
348.28

	
202.23

	
547.45

	
15,014.30

	
2,220.48

	
561.62

	
232.19

	
272.44

	
864.12

	
1,018.33

	
306.61

	
124.06

	
98.08


	
6B *

	
1,020.55

	
199.89

	
113.31

	
82.27

	
151.12

	
86.72

	
301.19

	
175.69

	
472.06

	
13,061.89

	
1,932.23

	
489.22

	
211.79

	
246.08

	
773.45

	
893.35

	
306.61

	
75.25

	
58.73

















  





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











  














	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011





 




	
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

	
951.51

	
187.03

	
102.23

	
66.63

	
132.34

	
73.38

	
276.90

	
162.03

	
437.66

	
12,589.42

	
1,897.08

	
468.98

	
190.80

	
231.21

	
747.90

	
872.76

	
309.39

	
100.69

	
79.25


	
02

	
816.14

	
160.48

	
89.36

	
60.77

	
116.81

	
66.58

	
239.92

	
141.43

	
378.38

	
10,683.52

	
1,610.58

	
388.53

	
136.92

	
176.37

	
593.52

	
725.89

	
309.39

	
89.90

	
70.54


	
03

	
984.39

	
193.50

	
109.97

	
76.87

	
143.94

	
83.51

	
289.54

	
170.46

	
456.98

	
13,082.49

	
1,966.20

	
494.21

	
211.42

	
250.46

	
787.10

	
909.67

	
309.39

	
92.72

	
72.86


	
04

	
988.07

	
194.02

	
106.40

	
65.88

	
134.07

	
72.79

	
284.87

	
164.93

	
455.28

	
13,464.03

	
2,023.24

	
501.55

	
203.79

	
246.40

	
794.42

	
930.69

	
309.39

	
86.67

	
67.99


	
05

	
1,114.90

	
218.88

	
124.55

	
87.67

	
163.37

	
94.37

	
327.65

	
191.99

	
516.85

	
14,523.47

	
2,177.74

	
545.47

	
228.63

	
272.44

	
861.79

	
1,003.60

	
309.39

	
81.38

	
63.73


	
06

	
1,026.31

	
201.56

	
114.28

	
82.70

	
152.39

	
88.80

	
303.65

	
179.04

	
475.61

	
13,110.81

	
1,969.85

	
496.21

	
215.95

	
254.05

	
796.88

	
913.80

	
309.39

	
78.98

	
61.77


	
07

	
972.52

	
190.99

	
107.28

	
69.37

	
135.97

	
76.04

	
279.40

	
161.46

	
446.02

	
13,644.01

	
2,049.69

	
507.86

	
202.73

	
246.78

	
792.90

	
937.50

	
309.39

	
77.64

	
60.7


	
008

	
958.69

	
188.49

	
111.78

	
83.85

	
148.15

	
89.99

	
283.16

	
167.19

	
445.48

	
12,460.72

	
1,873.82

	
472.00

	
201.24

	
238.82

	
745.01

	
864.91

	
309.39

	
84.99

	
66.61


	
09

	
1,039.23

	
204.22

	
117.13

	
82.10

	
152.67

	
88.99

	
303.69

	
177.86

	
480.14

	
14,397.66

	
2,160.69

	
533.58

	
208.48

	
255.77

	
826.34

	
984.74

	
309.39

	
87.98

	
69.03


	
10

	
1,034.40

	
203.16

	
113.31

	
77.19

	
148.00

	
83.86

	
301.15

	
175.83

	
474.85

	
17,969.34

	
2,691.92

	
670.42

	
276.66

	
331.42

	
1,060.34

	
1,237.23

	
309.39

	
97.56

	
76.73


	
11

	
1,192.79

	
234.12

	
136.47

	
100.36

	
179.69

	
104.59

	
350.59

	
205.44

	
550.64

	
15,059.58

	
2,256.02

	
568.28

	
236.28

	
280.13

	
886.55

	
1,037.75

	
309.39

	
127.34

	
100.75


	
6B *

	
1,025.81

	
201.47

	
114.28

	
82.88

	
152.52

	
88.96

	
303.69

	
179.15

	
475.51

	
13,109.63

	
1,969.69

	
496.24

	
216.10

	
254.18

	
797.09

	
913.82

	
309.39

	
78.98

	
61.77







 


 



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

	
951.62

	
187.14

	
104.51

	
77.72

	
142.70

	
83.74

	
286.26

	
171.39

	
443.95

	
12,591.19

	
1,898.85

	
489.44

	
240.71

	
271.47

	
827.56

	
902.95

	
326.73

	
110.64

	
89.20


	
02

	
816.22

	
160.56

	
91.04

	
68.95

	
124.44

	
74.21

	
246.82

	
148.33

	
383.01

	
10,685.97

	
1,613.03

	
416.82

	
205.95

	
232.05

	
703.69

	
767.64

	
326.73

	
99.85

	
80.49


	
03

	
984.49

	
193.60

	
112.04

	
86.98

	
153.38

	
92.95

	
298.07

	
178.99

	
462.71

	
13,084.04

	
1,967.75

	
512.13

	
255.14

	
285.73

	
856.88

	
936.11

	
326.73

	
102.67

	
82.81


	
04

	
988.25

	
194.20

	
109.96

	
83.23

	
150.27

	
88.99

	
299.51

	
179.57

	
465.12

	
13,465.98

	
2,025.19

	
524.12

	
258.85

	
290.81

	
882.30

	
963.99

	
326.73

	
96.62

	
77.94


	
05

	
1,115.01

	
218.99

	
126.78

	
98.55

	
173.52

	
104.52

	
336.83

	
201.17

	
523.02

	
14,525.38

	
2,179.65

	
567.54

	
282.48

	
315.88

	
947.74

	
1,036.17

	
326.73

	
91.33

	
73.68


	
06

	
1,026.37

	
201.62

	
115.51

	
88.69

	
157.98

	
94.39

	
308.71

	
184.10

	
479.01

	
13,112.16

	
1,971.20

	
511.79

	
253.97

	
284.72

	
857.56

	
936.79

	
326.73

	
88.93

	
71.72


	
07

	
972.69

	
191.16

	
110.70

	
86.03

	
151.52

	
91.59

	
293.45

	
175.51

	
455.46

	
13,646.23

	
2,051.91

	
533.55

	
265.41

	
297.34

	
892.93

	
975.41

	
326.73

	
87.59

	
70.65


	
08

	
958.77

	
188.57

	
113.43

	
91.90

	
155.67

	
97.51

	
289.95

	
173.98

	
450.05

	
12,462.32

	
1,875.42

	
490.45

	
246.25

	
275.13

	
816.84

	
892.13

	
326.73

	
94.94

	
76.56


	
09

	
1,039.35

	
204.34

	
119.58

	
94.02

	
163.80

	
100.12

	
313.75

	
187.92

	
486.90

	
14,400.21

	
2,163.24

	
563.00

	
280.25

	
313.66

	
940.88

	
1,028.15

	
326.73

	
97.93

	
78.98


	
10

	
1,034.51

	
203.27

	
115.48

	
87.76

	
157.86

	
93.72

	
310.07

	
184.75

	
480.84

	
17,971.77

	
2,694.35

	
698.46

	
345.06

	
386.60

	
1,169.51

	
1,278.60

	
326.73

	
107.51

	
86.68


	
11

	
1,192.88

	
234.21

	
138.30

	
109.27

	
188.01

	
112.91

	
358.11

	
212.96

	
555.69

	
15,061.70

	
2,258.14

	
592.74

	
295.97

	
328.28

	
981.81

	
1,073.85

	
326.73

	
137.29

	
110.70


	
6B *

	
1,025.87

	
201.53

	
115.46

	
88.65

	
157.91

	
94.35

	
308.56

	
184.02

	
478.78

	
13,110.97

	
1,971.03

	
511.75

	
253.94

	
284.70

	
857.48

	
936.71

	
326.73

	
88.93

	
71.72

















  






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










  








 



	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011



 





	
Area

	
Corresponding  Counties


	  	  
	
Area 1

	
Escambia, Okaloosa, Santa Rosa, Walton


	
Area 2

	
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla


	
Area 3

	
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union


	
Area 4

	
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia


	
Area 5

	
Pasco, Pinellas


	
Area 6

	
Hardee, Highlands, Manatee, Polk


	
Area 6B *

	
Hillsborough


	
Area 7

	
Brevard, Orange, Osceola, Seminole


	
Area 8

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


	
Area 9

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


	
Area 10

	
Broward


	
Area 11

	
Dade, Monroe











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