fa904amendment7.htm


Return to Form 8-k


 


 


  

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





 



	 AHCA CONTRACT NO. FA904
	 AMENDMENT NO. 7





 



	     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.

	
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.












 


 



	
  

	
2.

	
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 also refer to Exhibit 2-NR-C, as appropriate.







 



	
  

	
3.

	
Attachment II, Core Contract Provisions, Section XVI., Terms and Conditions, is hereby amended to include Item HH. as follows:







 



	
  

	
HH.

	 	
Scrutinized Companies Lists







 



	
  

	 	 	
The Vendor shall complete Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, attached hereto and made a part of the Contract, certifying that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to section 215.473, Florida Statutes (F.S.). Pursuant to section 287.135(5), F.S., the Vendor agrees the Agency may immediately terminate this Contract for cause if the Vendor is found to have submitted a false certification or if the Vendor is placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities  in  the  Iran  Petroleum  Energy  Sector  List  during  the  term  of  the Contract







 



	
  

	
4.

	
Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, is hereby attached and made a part of the Contract.







 




	
  

	
 

	
Unless otherwise stated, this amendment is effective upon execution by both Parties.









 



	
  

	
 

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







 







	
AHCA Contract No. FA904, Amendment No. 7, Page 1 of 2














  





  











  




	
 


 








	
 




















 



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



 





	 	
 

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







 



	 	
 

	
This amendment cannot be executed unles 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.







 









	
WELLCARE OF FLORIDA, INC., D/B/A


STAYWELL HEALTH PLAN OF FLORIDA

	
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION













	
SIGNED


BY:

	/s/ Christina Cooper	  	
SIGNED


BY:

	
/s/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)	
 








 



	
Attachment

	VI	Vendor Certification Regarding Scrutinized Companies Lists (1Page)	
 









       


REMAINDER OF PAGE INTENTIONALLY LEFT BLANK










  





  











  








 



	 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. FA904, 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

	
79.37


	
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









 


 





  





ACHAContract No. FA904, Attachment I, Exhibit 2-NR, 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. FA904, 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

	
60.70


	
08

	
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

	
76.50


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











  








 



	 ATTACHMENT VI
	 VENDOR CERTIFICATION REGARDING
	 SCRUTINIZED COMPANIES LIST





 




	 






	 	 	 	 
	Vendor Name:	 WellCare of Florida Inc.	 	 






	 







	Vendor FEIN:	 59-2583622	 	 






	 






	Vendor's Authorized Representative Name and Title:	Christina Cooper, President	 	 






	 






	Address:	 8735 Henderson Road	 






	 	 	 
	City:	Tampa	 State:	FL	 Zip:	33634	 






	 	 	 
	Telephone Number:	813-206-3213	 	 






	 	 	 
	Email Address:	chrissie.cooper@wellcare.com	 
	 	 	 
	 	 	 









 


 



	Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  Both lists are created pursuant to section 215.473, Florida Statutes.





 



	As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified above in the section entitled "Vendor Name" is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney's fees, and/or costs.





 


 



	 	 	 	 
	 	 	 	 
	Certified By:	/s/Christina Cooper	 ,	 
	 	 	 	 
	who is authorized to sign on behalf of the above referenced company.	 	 
	 	 	 	 
	Authorized Signature Print Name and Title:	Christina Cooper, President	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 





 


 


AHCA Contract No. FA904, Attachment VI, Page 1of 1