EX-10.3







AMERIGROUP FLORIDA, INC. Medicaid HMO Contract



AHCA CONTRACT NO. FA523

AMENDMENT NO.9




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:




Section III, Item C.1. of the Standard Contract is hereby amended as follows:




The Agency’s Contract Manager’s name, address and telephone number for this Contract
is as follows:




G. Douglas Harper


Agency for Health Care Administration


Building #3, Mail
Stop #50 2727 Mahan
Drive


Tallahassee, Florida
32308 Telephone -
(850) 488-9287
Facsimile — (850)
410-1676




	 	2.	 	Attachment I, Section 90.0, Payment and Authorized
Enrollment Levels, is hereby deleted in its entirety and replaced with
the following:	 






90.0 PAYMENT AND AUTHORIZED ENROLLMENT LEVELS




	 	a.	 	The Agency assigns the Plan an authorized
maximum enrollment level for each operational county, and the
Agency shall pay the Plan capitation payments for each Agency
operational area, in accordance with the following table. The
Agency shall pay the Plan capitation payments based on the
Agency operational area (or rate zone) age group, and gender,
in accordance with Table 2. Where the Plan has implemented
behavioral health care, the Agency shall pay the Plan in
accordance with Table 3.	 






	 	b.	 	The authorized maximum enrollment level is
in effective as of July I, 2005, or upon Contract execution,
whichever is later. The Agency must approve in writing any
increase in the Plan’s maximum enrollment level for each
operational county. Such approval shall not be unreasonably
withheld, and shall be based on the Plan’s satisfactory
performance of terms of the Contract and approval of the
Plan’s administrative and service resources, as specified in
this Contract, in support of each enrollment level.	 






	 	c.	 	The Agency has developed estimated rates,
for examination and evaluation by its actuary, Milliman and
Co., to be paid to the Plan for services provided in Fiscal
Year 2005 — 2006. These estimated rates represent the Agency’s
best efforts to develop accurate rates. They are included as
Attachment Viii; entitled “ESTIMATED 2005 — 2006 HMO RATES;
NOT FOR USE UNLESS APPROVED BY CMS.” The Agency may use, or
may amend and use, these estimated rates only after
certification by its actuary and approval by the Centers for
Medicare and Medicaid Services, and by notice in a Contract
amendment to the Plan. Inclusion of these estimated rates is
not intended to convey or imply any rights, duties or
obligations of either party, nor is it intended to restrict,
restrain or control the rights of either party that may have
existed independently of this section of the Contract. By
signature of this document, the parties explicitly agree that
this section shall not independently convey any inherent
rights, responsibilities or obligations of either party,
relative to these rates, and shall not itself be the basis for
any cause of administrative, legal or equitable action brought
by either party.	 






AHCA Contract No. FA523, Amendment No. 9, Page 1 of 4




AHCA Form 2100-0002 (Rev. NOV03)



1





AMERIGROUP FLORIDA, INC. Medicaid HMO Contract




	 	d.	 	In the event the rates certified by the
actuary and approved by CMS are different from the Agency’s
estimated rates, the Contractor agrees to accept a
reconciliation performed by the Agency to bring payments to
the Contractor in line with the approved rates.	 






	 	e.	 	Upon receipt of CMS approval of 2005 -
2006 capitation rates, the Agency shall amend this Contract to
reflect accepted capitation rates effective July 1, 2005.	 






f. Table l provides the Plan’s Contract enrollment levels.




	 	g.	 	Table 2 provides capitation rates for all Agency
areas, except for areas where behavioral health care has been
implemented.	 






	 	h.	 	Table 3 provides capitation rates for
Agency areas where behavioral health care has been
implemented, including community mental health and mental
health targeted case management.	 






Table 1




Enrollment Levels




County




Maximum Enrollment Level




BREVARD




8,000




BROWARID




14,000




DADE




25,000




HILLSBOROUGH




40,000




LEE




18,000




MANATEE




3,500




ORANGE




30,000




OSCEOLA




8,500




PALM BEACH




12,000




PASCO




15,000




PINELLAS




25,000




POLK




30,000




SARASOTA




8,000




SEMINOLE




8,000




Amendment No. 9, Page 2 of 4



AHCA Form 2100-0002 (Rev. NOV03)



2





AMERIGROUP FLORIDA, INC. Medicaid HMO Contract




Table 2.



Area wide Age-banded Capitation
Rates for all agency areas of
the state other than Area 6 and
Area I.



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 05
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	344.75	 	 	 	77.20	 	 	 	47.92	 	 	 	53.39	 	 	 	110.51	 	 	 	134.26	 	 	 	206.44	 	 	 	287.43	 	 	 	287.43	 
	SSI/No Medicare
	 	 	3312.84	 	 	 	399.97	 	 	 	207.73	 	 	 	217.58	 	 	 	217.58	 	 	 	622.27	 	 	 	622.27	 	 	 	600.49	 	 	 	600.49	 
	SSI/Part B
	 	 	262.11	 	 	 	262.1I	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 
	SSI/Part A & B
	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	240.03	 
	Area 07
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	336.57	 	 	 	75.50	 	 	 	47.25	 	 	 	52.60	 	 	 	108.28	 	 	 	132.13	 	 	 	202.76	 	 	 	283.08	 	 	 	283.08	 
	SSI/No Medicare
	 	 	3320.10	 	 	 	402.55	 	 	 	211.07	 	 	 	220.72	 	 	 	220.72	 	 	 	631.77	 	 	 	631.77	 	 	 	609.58	 	 	 	609.58	 
	SSI/Part B
	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 
	5SI/Part A & B
	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	25I.20	 	 	 	25I.20	 	 	 	217.86	 
	Area 08
	 	<1 year	 	 	1-5	 	 	 	6-I3	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	2I-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	295.59	 	 	 	66.21	 	 	 	41.16	 	 	 	45.89	 	 	 	94.88	 	 	 	115.33	 	 	 	177.31	 	 	 	247.08	 	 	 	247.08	 
	SSI/No Medicare
	 	 	3101.85	 	 	 	374.62	 	 	 	194.07	 	 	 	203.31	 	 	 	203.31	 	 	 	582.39	 	 	 	582.39	 	 	 	561.96	 	 	 	561.96	 
	SSI/Part B
	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 
	SSI/Part A & B
	 	 	253.8I	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	219.39	 
	Area 09
	 	<I year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	315.38	 	 	 	70.51	 	 	 	43.83	 	 	 	48.82	 	 	 	10I.05	 	 	 	122.63	 	 	 	I88.58	 	 	 	262.53	 	 	 	262.53	 
	SSI/No Medicare
	 	 	3369.20	 	 	 	408.36	 	 	 	212.88	 	 	 	222.97	 	 	 	222.97	 	 	 	638.43	 	 	 	638.43	 	 	 	615.96	 	 	 	6I5.96	 
	SSI/Part B
	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 
	SSI/Part A & B
	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	244.68	 
	Area 10
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	I4-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	327.60	 	 	 	73.59	 	 	 	46.05	 	 	 	51.31	 	 	 	105.60	 	 	 	128.95	 	 	 	197.71	 	 	 	276.31	 	 	 	276.31	 
	SSI/No Medicare
	 	 	4270.73	 	 	 	518.41	 	 	 	272.09	 	 	 	283.90	 	 	 	283.90	 	 	 	812.87	 	 	 	812.87	 	 	 	784.90	 	 	 	784.90	 
	SSI/Part B
	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.3I	 
	SSI/Part A & B
	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.I8	 	 	 	307.18	 	 	 	266.50	 
	Area 11
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	I4-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/S0BRA
	 	 	408.42	 	 	 	91.09	 	 	 	56.29	 	 	 	62.75	 	 	 	130.48	 	 	 	157.53	 	 	 	243.00	 	 	 	337.44	 	 	 	337.44	 
	SSI/No Medicare
	 	 	4662.01	 	 	 	564.13	 	 	 	294.32	 	 	 	307.60	 	 	 	307.60	 	 	 	880.79	 	 	 	880.79	 	 	 	849.95	 	 	 	849.95	 
	SSI/Part B
	 	 	441.72	 	 	 	441.72	 	 	 	44I.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 
	SSI/Part A & B
	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	303.69	 
	Table 3.
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 






Area 6 or Area 1 Age-banded Capitation
Rates, Including Community Mental Health
and Mental Health Targeted Case
Management.



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 06
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	329.30	 	 	 	75.87	 	 	 	61.50	 	 	 	67.73	 	 	 	122.33	 	 	 	133.79	 	 	 	202.90	 	 	 	279.50	 	 	 	279.50	 
	SSI/No Medicare
	 	 	3062.53	 	 	 	377.38	 	 	 	271.33	 	 	 	247.10	 	 	 	247.10	 	 	 	657.23	 	 	 	657.23	 	 	 	596.37	 	 	 	596.37	 
	SSI/Part B
	 	 	238.I6	 	 	 	238.18	 	 	 	238.18	 	 	 	238.18	 	 	 	238.18	 	 	 	238.18	 	 	 	238.I8	 	 	 	238.18	 	 	 	238.18	 
	SSI/Part A & B
	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	255.15	 	 	 	222.29	 






For Plans participating in the frail/elderly program, the
community rate shall be paid for all members in each eligibility
category except for those SSI members determined by the
Comprehensive Assessment and Review for Long Term Care (CARES)
Unit to be at risk of nursing home institutionalization.
Evidence of such assessments shall be provided to the Agency by
the Plan prior to authorization by the Agency of payment of the
institutional rates. Payment of institutional rates for any
eligible enrollee shall continue only so long as the enrollee
meets the level of care requirements for institutionalization,
otherwise, the community capitation rate applies.




	 	j.	 	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 $680,379,083.00 as expressed in this
Contract.	 






AHCA Contract No. FA523, Amendment No. 9, Page 3 of 4




AHCA Form 2100-0002 (Rev. NOV03)



3





AMERIGROUP FLORIDA, INC. Medicaid HMO Contract




	 	3.	 	This amendment shall begin on July 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 6 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



NAME: Don Gilmore NAME: Alan Levine



	 	 	 	 	 
	S.CONTTITLE: .. CEO

	 	

	 	

	
 
	 	 
	 	

	DATE:

	 	 	 	/s/ 7/05/05
	
 
	 	 	 	 
	 
	 	 	 	 
	TITLE:

	 	Secretary
	 	

	
 
	 	 
	 	







DATE:


S.CONTList of attachments included as part of this Amendment:



	 	 	 	 	 
	Specify Type

	 	Number ..
	 	Description
	 

	 	 
	 	 
	 
	 	 	 	 
	Attachment

	 	VIII
	 	ESTIMATED 2005 — 2006 HMO

RATES; NOT FOR USE UNLESS

APPROVED BY CMS (2 Pages)







	 	 	 	REMAINDER OF PAGE INTENTIONALLY LEFT BLANK AHCA Contract No. FA523, Amendment





No. 9, Page 4 of 4




AHCA Form 2100-0002 (Rev. NOV03)



4




ATTACHMENT VIII




ESTIMATED 2005 — 2006 HMO RATES;




NOT FOR USE UNLESS APPROVED BY CMS




	 	 	 
	AMERIGROUP FLORIDA

July 1, 2005 through December 31, 2005

	 	Medicaid HMO Contract

contract Number : FA523







Table 3


Area-Wide Age-Banded Capitation Rates for all Agency Areas of the
State in Which Behavioral Health has been Implemented Area 05
General Rates plus Mental Health Plan — 015005304(PASCO)
015005305(PINELLAS)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	   BTHMO+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	9I9.98	 	 	 	183.43	 	 	 	91.15	 	 	 	64.87	 	 	 	13I.62	 	 	 	69.93	 	 	 	245.33	 	 	 	159.49	 	 	 	331.03	 	 	 	331.03	 
	SSI/No Medicare
	 	 	9248.02	 	 	 	1615.41	 	 	 	420.86	 	 	 	252.27	 	 	 	258.55	 	 	 	258.55	 	 	 	.735.80	 	 	 	735.80	 	 	 	681.19	 	 	 	681.I9	 
	SSI/Part B
	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 	 	 	332.63	 
	SSI/Part A & B
	 	 	321.24	 	 	 	321.24	 	 	 	321.24	 	 	 	32I.24	 	 	 	321.24	 	 	 	321.24	 	 	 	321.24	 	 	 	321.24	 	 	 	321.24	 	 	 	227.10	 







Area 06 General Rates plus Mental Health Plan — 0I5005300(HILLSBOROUGH) 015005307(POLK)
015005318(MANATEE)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	   BTHM0+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	839.91	 	 	 	168.14	 	 	 	84.80	 	 	 	67.94	 	 	 	131.59	 	 	 	75.16	 	 	 	230.12	 	 	 	151.25	 	 	 	309.66	 	 	 	309.66	 
	SSI/No Medicare
	 	 	8536.50	 	 	 	1494.29	 	 	 	393.28	 	 	 	262.75	 	 	 	284.04	 	 	 	284.04	 	 	 	746.59	 	 	 	746.59	 	 	 	653.76	 	 	 	653.76	 
	SSI/Part B
	 	 	319.38	 	 	 	3I9.3B	 	 	 	319.38	 	 	 	319.38	 	 	 	319.38	 	 	 	319.38	 	 	 	319.38	 	 	 	3I9.38	 	 	 	3I9.38	 	 	 	319.38	 
	SSI/Part A & B
	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	288.23	 	 	 	202.46	 







Area 07 General Rates plus Mental Health Plan — 015005308(ORANGE) 0150053I3(SEMINOLE)
015005314(OSCEOLA) 015005336(BREVARD)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHM0+2MO	 	3M0-11MO	 	1-5	 	6-13	 	14-20(F)	 	14-20(M)	 	2I-54(F)	 	21-54(M)	 	55-64	 	65+
	TANF/FC/SOBRA	 	894.05	 	178.57	 	89.54	 	68.64	 	132.32	 	72.39	 	240.41	 	156.74	 	324.62	 	324.62
	SSI/No Medicare	 	8976.52	 	1573.98	 	414.04	 	264.97	 	264.82	 	264.82	 	733.66	 	733.66	 	674.72	 	674.72
	SSI/Part B	 	312.78	 	312.78	 	312.78	 	312.78	 	312.78	 	312.78	 	312.78	 	312.78	 	3I2.78	 	3I2.78
	SSI/Part A & B
	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	296.22	 	 	 	210.25	 







Area 08 General Rates plus Mental Health Plan — 0I5005302(LEE) 015005306(SARASOTA)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHM0+2M0	 	3M0-11M0	 	1-5	 	6-13	 	14-20(F)	 	14-20(M)	 	2I-54(F)	 	21-54(M)	 	55-64	 	65+
	TANF/FC/SOBRA	 	785.53	 	156.86	 	78.13	 	56.61	 	113.39	 	60.74	 	210.44.	 	I36.92	 	284.23	 	284.23
	SSI/No Medicare	 	8247.94	 	1440.21	 	376.25	 	229.28	 	234.06	 	234.06	 	659.32	 	659.32	 	608.59	 	608.59
	SSI/Part 8	 	313.20	 	313.20	 	313.20	 	313.20'	 	313.20	 	313.20	 	313.20	 	313.20	 	313.20	 	313.20
	SSI/Part A & B
	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	297.40	 	 	 	210.20	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 09 General Rates plus Mental Health Plan - 015005310(PALM BEACH)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	   BTHM0+2MO

	 	3M0-11MO	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	850.66	 	 	 	169.57	 	 	 	84.45	 	 	 	61.30	 	 	 	122.72	 	 	 	65.7I	 	 	 	227.14	 	 	 	147,75	 	 	 	306.35	 	 	 	306.35	 
	SSI/No Medicare
	 	 	9123.68	 	 	 	1599.07	 	 	 	417.49	 	 	 	252.14	 	 	 	258.39	 	 	 	258.39	 	 	 	734.15	 	 	 	734.15	 	 	 	680.34	 	 	 	680.34	 
	SSI/Part B
	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 	 	 	292.37	 
	SSI/Part A 6 B
	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	328.87	 	 	 	233.20	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 10 General Rates plus Mental Health Plan - 015005311(BROWARD)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	BTHM0+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	854.19	 	 	 	I70.88	 	 	 	86.07	 	 	 	67.92	 	 	 	128.34	 	 	 	71.08	 	 	 	231.04	 	 	 	150.99	 	 	 	312.37	 	 	 	3I2.37	 
	SSI/No Medicare
	 	 	11134.68	 	 	 	1955.19	 	 	 	510.16	 	 	 	308.62	 	 	 	316.57	 	 	 	316.57	 	 	 	900.47	 	 	 	900.47	 	 	 	834.79	 	 	 	834.79	 
	SSI/Part B
	 	 	319.50	 	 	 	319.50	 	 	 	319.50	 	 	 	319.50	 	 	 	319.50	 	 	 	3I9.50	 	 	 	319.50	 	 	 	319.50	 	 	 	319.50	 	 	 	319.50	 
	SSI/Part A & B
	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	346.90	 	 	 	244.42	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 11 General Rates plus Mental Health Plan - 015005312(DADE)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHMO+2MO	 	3M0-11MO	 	I-5	 	6-13	 	14-20(F)	 	I4-20(M)	 	21-54(F)	 	21-54(M)	 	55-64	 	65+
	TANF/FC/SOBRA	 	1110.68	 	220.95	 	I10.34	 	8I.84	 	161.42	 	87.06	 	295.39	 	192.02	 	397.48	 	397.48
	SSI/No Medicare	 	12135.44	 	2122.05	 	554.29	 	334.42	 	342.80	 	342.80	 	971.48	 	971.48	 	898.72	 	898.72
	SSI/Part B
	 	 	457.65	 	 	 	457.65	 	 	 	457.65	 	 	 	457.65	 	 	 	457.65	 	 	 	457,65	 	 	 	457.65	 	 	 	457.65	 	 	 	457.65	 	 	 	457.65	 
	SSI/Part A & B
	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	426.65	 	 	 	300.08	 







AHCA Contract No. FA523, Attachment VIII, Page 1 of 2




AHCA Form 2100-0039 (APR04)



	 	 	 	 	 	 	 
	AMERIGROUP FLORIDA

January 1, 2006 through June

	 	Medicai

30,2006
	 	d 7840 Contract

contract Number
	 	

FA523







Table 3.


Area-Wide Age-Banded Capitation Rates for all Agency Areas of the
State in Which Behavioral Health has been Implemented Area 05
General Rates plus Mental Health Plan — 015005304(PASCO)
015005305(PINELLAS)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHM0+2M0	 	3M0-11MO	 	1-5	 	6-13	 	14-20(F)	 	14-20(M)	 	21-54(F)	 	21-54(M)	 	55-64	 	65+
	TANF/FC/S0BRA	 	919.98	 	183.43	 	91.15	 	64.87	 	131.62	 	69.93	 	245.33	 	159.49	 	331.03	 	331.03
	SSI/No Medicare	 	9248.02	 	1615.41	 	420.86	 	252.27	 	258.55	 	258.55	 	735.80	 	735.80	 	68I.19	 	681.19
	SSI/Part B	 	2I4.59	 	214.59	 	214.59	 	2I4.59	 	214.59	 	214.59	 	214.59	 	214.59	 	214.59	 	214.59
	SSI/Part A & B
	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	83.91	 	 	 	74.53	 







Area 06 General Rates plus Mental Health Plan — 015005300(HILLSBOROUGH) 015005307(P0LK)
015005318(MANATEE)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	   BTHM0+2M0

	 	3MO-11MO	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	839.91	 	 	 	168.14	 	 	 	84.80	 	 	 	67.94	 	 	 	131.59	 	 	 	75.16	 	 	 	230.12	 	 	 	151.25	 	 	 	309.66	 	 	 	309.66	 
	SSI/No Medicare
	 	 	8536.50	 	 	 	1494.29.	 	 	 	393.28	 	 	 	262.75	 	 	 	284.04	 	 	 	284.04	 	 	 	746.59	 	 	 	746.59	 	 	 	653.76	 	 	 	653.76	 
	SSI/Part B
	 	 	201.26	 	 	 	20I.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 	 	 	201.26	 
	SSI/Part A 6 B
	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	73.23	 	 	 	64.45	 







Area 07 General Rates plus Mental Health Plan — 015005308(0RANGE) 01SO05313(SEMINOLE)
015005314(OSCEOLA) 015005336(BREVARD)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHM0+2M0	 	3M0-11MO	 	1-5	 	6-13	 	I4-20(F)	 	I4-20(M)	 	21-54(F)	 	21-54(M)	 	55-64	 	65+
	TANF/FC/SOBRA	 	894.05	 	178.57	 	89.54	 	68.64	 	132.32	 	72.39	 	240.41	 	156.74	 	324.62	 	324.62
	SSI/No Medicare	 	8976.52	 	1573.98	 	414.04	 	264.97	 	264.82	 	264.82	 	733.66	 	733.66	 	674.72	 	674.72
	SSI/Part B	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20	 	203.20
	SSI/Part A 6 B
	 	 	84.13	 	 	 	84.13	 	 	 	84.13	 	 	 	84.13	 	 	 	84.I3	 	 	 	84.I3	 	 	 	84.13	 	 	 	84.13	 	 	 	84.13	 	 	 	74.97	 







Area 08 General Rates plus Mental] Health Plan — 015005302(LEE) 015005306(SARAS0TA)



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	BTHM0+2M0	 	3M0-11M0	 	1-5	 	6-13	 	14-20(F)	 	14-20(M)	 	21-54(F)	 	21-54((4)	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	785.53	 	 	 	156.86	 	 	 	78.13	 	 	 	56.61	 	 	 	113.39	 	 	 	60.74	 	 	 	210.44	 	 	 	136.92	 	 	 	284.23	 	 	 	284.23	 
	SSI/No Medicare
	 	 	8247.94	 	 	 	1440.21	 	 	 	376.25	 	 	 	229.28	 	 	 	234.06	 	 	 	234.06	 	 	 	659.32	 	 	 	659.32	 	 	 	608.59	 	 	 	608.59	 
	SSI/Part B
	 	 	191.91	 	 	 	191.91	 	 	 	191.91	 	 	 	191.9I	 	 	 	191.91	 	 	 	191.91	 	 	 	191.91	 	 	 	191.91	 	 	 	191.91	 	 	 	191.9I	 
	SSI/Part A 6 B
	 	 	77.95	 	 	 	77.95	 	 	 	77,95	 	 	 	77.95	 	 	 	77,95	 	 	 	77.95	 	 	 	77.95	 	 	 	77.95	 	 	 	77.95	 	 	 	69.I3	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 09 General Rates plus Mental Health Plan - 0I5005310(PALM BEACH)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	BTHM0+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	850.66	 	 	 	169.57	 	 	 	84.45	 	 	 	61.30	 	 	 	122.72	 	 	 	65.71	 	 	 	227.14	 	 	 	147.75	 	 	 	306.35	 	 	 	306.35	 
	SSI/No Medicare
	 	 	9123.68	 	 	 	1599.07	 	 	 	417.49	 	 	 	252.14	 	 	 	258.39	 	 	 	258.39	 	 	 	734.15	 	 	 	734.15	 	 	 	680.34	 	 	 	680.34	 
	SSI/Part B
	 	 	183.12	 	 	 	183.12	 	 	 	183.12	 	 	 	183.12	 	 	 	I83.12	 	 	 	183.12	 	 	 	183.12	 	 	 	183.12	 	 	 	183.12	 	 	 	183.12	 
	SSI/Part A & B
	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	87.73	 	 	 	78.10	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 10 General Rates plus Mental Health Plan - 015005311(BROWARD)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	BTHM0+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	854.19	 	 	 	170.88	 	 	 	86.07	 	 	 	67.92	 	 	 	128.34	 	 	 	71.08	 	 	 	231.04	 	 	 	150.99	 	 	 	312.37	 	 	 	312.37	 
	SSI/No Medicare
	 	 	11134.68	 	 	 	1955.I9	 	 	 	510.16	 	 	 	308.82	 	 	 	316.57	 	 	 	316.57	 	 	 	900.47	 	 	 	900.47	 	 	 	834.79	 	 	 	834.79	 
	SSI/Part B
	 	 	209.21	 	 	 	209.21	 	 	 	209.21	 	 	 	209.21	 	 	 	209.21	 	 	 	209.21	 	 	 	209.2I	 	 	 	209.21	 	 	 	209.21	 	 	 	209.2I	 
	SSI/Part A & B
	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	87.86	 	 	 	77.46	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 11 General Rates plus Mental Health Plan - 015005312(DADE)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	   BTHM0+2M0
	 	 	3M0-11M0	 	 	 	1-5	 	 	 	6-13	 	 	 	14-20	(F)	 	 	14-20	(M)	 	 	21-54	(F)	 	 	21-54	(M)	 	 	55-64	 	 	 	65+	 
	TANF/FC/S0BRA
	 	 	1110.68	 	 	 	220.95	 	 	 	110.34	 	 	 	81.84	 	 	 	161.42	 	 	 	87.06	 	 	 	295.39	 	 	 	192.02	 	 	 	397.48	 	 	 	397.48	 
	SSI/No Medicare
	 	 	12I35.44	 	 	 	2122.05	 	 	 	554.29	 	 	 	334.42	 	 	 	342.80	 	 	 	342.80	 	 	 	971.48	 	 	 	971.48	 	 	 	898.72	 	 	 	898.72	 
	SSI/Part B
	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 	 	 	276.22	 
	SSI/Part A & B
	 	 	118.35	 	 	 	118.35	 	 	 	118.35	 	 	 	118.35	 	 	 	118.35	 	 	 	118.35	 	 	 	I18.35	 	 	 	118.35	 	 	 	118.35	 	 	 	104.11	 







AHCA Contract No. FA523, Attachment VIII, Page 2 of 2




AHCA Form 2100-0039 (APR04)




5