EX-10.25.4






AHCA CONTRACT NO. FA523




AMENDMENT NO. 5




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



1. Standard Contract, Section II.A, Contract Amount, the first sentence is hereby amended to now
read:




To pay for contracted services according to the conditions of Attachment I in an amount not to
exceed $666,784,520.00 (an increase of $3,426,823.00), subject to the availability of funds.




	 	2.	 	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 2 is hereby
amended to now read as follows:





Table 2.


Area wide Age-banded Capitation Rates for All Agency Areas of the State other than Areas 5, 6, and
7.



Area 08 General Rates Plan — 015005302(LEE) 015005306(SARASOTA)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male
	 	21-54Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	296.66	 	 	 	66.37	 	 	 	41.76	 	 	 	46.19	 	 	 	95.19	 	 	 	117.62	 	 	 	179.02	 	 	 	250.96	 	 	 	250.96	 
	SSI/No Medicare
	 	 	3079.30	 	 	 	371.80	 	 	 	192.49	 	 	 	201.68	 	 	 	201.68	 	 	 	577.71	 	 	 	577.71	 	 	 	557.45	 	 	 	557.45	 
	SSI/Part B
	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 
	SSI/Part A & B
	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	199.47	 







Area 09 General Rates Plan — 015005310(PALM BEACH)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male
	 	21-54Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	316.78	 	 	 	70.74	 	 	 	44.52	 	 	 	49.17	 	 	 	101.48	 	 	 	125.24	 	 	 	190.60	 	 	 	266.97	 	 	 	266.97	 
	SSI/No Medicare
	 	 	3344.05	 	 	 	405.22	 	 	 	211.12	 	 	 	221.15	 	 	 	221.15	 	 	 	633.22	 	 	 	633.22	 	 	 	610.93	 	 	 	610.93	 
	SSI/Part B
	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 
	SSI/Part A & B
	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	224.19	 







Area 10 General Rates Plan — 015005311(BROWARD)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male
	 	21-54Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	328.74	 	 	 	73.77	 	 	 	46.68	 	 	 	51.61	 	 	 	105.94	 	 	 	131.31	 	 	 	199.49	 	 	 	280.33	 	 	 	280.33	 
	SSI/No Medicare
	 	 	4151.82	 	 	 	503.54	 	 	 	263.75	 	 	 	275.32	 	 	 	275.32	 	 	 	788.23	 	 	 	788.23	 	 	 	761.08	 	 	 	761.08	 
	SSI/Part B
	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 
	SSI/Part A & B
	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	245.95	 







Area 11 General Rates Plan — 015005312(DADE)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male
	 	21-54Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	409.16	 	 	 	91.08	 	 	 	56.97	 	 	 	62.97	 	 	 	130.55	 	 	 	160.40	 	 	 	244.76	 	 	 	341.98	 	 	 	341.98	 
	SSI/No Medicare
	 	 	4551.55	 	 	 	550.33	 	 	 	286.57	 	 	 	299.62	 	 	 	299.62	 	 	 	857.90	 	 	 	857.90	 	 	 	827.83	 	 	 	827.83	 
	SSI/Part B
	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 
	SSI/Part A & B
	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	292.00	 








	 	3.	 	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 3 is hereby
amended to now read as follows:





Table 3 Area



Age-banded Capitation Rates, Including Community Mental Health and Mental Health Targeted Case
Management



Table 3.


Areas 5, 6, and 7 Age-banded Capitation Rates, Including Community Mental Health and Mental Health
Targeted Case Management



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 05 General Rates plus Mental Health

	 	Plan -	 	015005304(PASCO) 015005305(PINELLAS)
	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	345.77	 	 	 	79.28	 	 	 	51.94	 	 	 	57.32	 	 	 	114.37	 	 	 	139.01	 	 	 	210.44	 	 	 	291.84	 	 	 	291.84	 
	SSI/No Medicare
	 	 	3265.63	 	 	 	429.24	 	 	 	240.86	 	 	 	235.59	 	 	 	235.59	 	 	 	628.37	 	 	 	628.37	 	 	 	594.95	 	 	 	594.95	 
	SSI/Part B
	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 
	SSI/Part A & B
	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	225.77	 







AHCA Contract No. FA523, Amendment No. 5, Page 1 of 2




AHCA Form 2100-0002 (Rev. NOV03)





1





Area 06 General Rates plus Mental Health Plan — 015005300(HILLSBOROUGH) 015005307(POLK)
015005318(MANATEE)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	1-5	 	6-13	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male	 	21-54Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	330.07	 	 	 	75.91	 	 	 	61.92	 	 	 	67.67	 	 	 	122.23	 	 	 	135.83	 	 	 	204.29	 	 	 	282.98	 	 	 	282.98	 
	SSI/No Medicare
	 	 	3017.05	 	 	 	371.69	 	 	 	265.72	 	 	 	243.82	 	 	 	243.82	 	 	 	647.81	 	 	 	647.81	 	 	 	587.26	 	 	 	587.26	 
	SSI/Part B
	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 
	SSI/Part A & B
	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	202.64	 







Area 07 General Rates plus Mental Health Plan — 015005308(ORANGE) 015005313(SEMINOLE)
015005314(OSCEOLA)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	 	 	 	 	14-20 Male 14-20 Female 21-54 Male
	 	21-54Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	337.20	 	 	 	76.92	 	 	 	58.07	 	 	 	59.10	 	 	 	114.69	 	 	 	136.45	 	 	 	206.32	 	 	 	287.87	 	 	 	287.87	 
	SSI/No Medicare
	 	 	3237.90	 	 	 	406.84	 	 	 	260.45	 	 	 	239.73	 	 	 	239.73	 	 	 	628.24	 	 	 	628.24	 	 	 	594.96	 	 	 	594.96	 
	SSI/Part B
	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 
	SSI/Part A & B
	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	208.25	 








	 	4.	 	Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table 3, the second
paragraph is hereby amended to now read:






Notwithstanding the payment amounts which may be computed with the above rate table, the sum of
total capitation payments under this contract shall not exceed the total contract amount of
$666,784,520.00 (an increase of $3,426,823.00), expressed on page seven of this contract.




	 	5.	 	This amendment shall begin on April 1, 2005, or the date on which the amendment has been
signed by both parties, whichever is later.





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



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




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



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



IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.



	 	 	 
	AMERIGROUP FLORIDA, INC. STATE OF FLORIDA, AGENCY FOR
	 	 	HEALTH CARE ADMINISTRATION
	SIGNED

BY: /s/ Don Gilmore

	 	SIGNED

BY:
	 

	 	

	 
	 	 
	NAME: Don Gilmore

TITLE: CEO

	 	NAME: Alan Levine

TITLE: Secretary
	 

	 	 
	DATE: 3/31/05

	 	DATE:
	 

	 	 







THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY




AHCA Contract No. FA523, Amendment No. 5, Page 2 of 2




AHCA Fenn 2100-0002 (Rev. NOV03)




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