ahcaamend11far001.htm


    Back to Form 10-Q

    Exhibit 10.19

     

    
      	 HealthEase of Florida,
      Inc. 	 	
               Medicaid Reform HMO
      Contract

            


    

     

     

    AHCA
CONTRACT NO. FAR001

    AMENDMENT
NO. 11

    


    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," is hereby amended as
follows:

    


    1.        
    Attachment II, Table of Contents, is hereby amended as
follows:

    


    
      	
               
      

            	
              --

            	
              Section
      IV Enrollee Services and Marketing is hereby amended to now
      read:

            


    

    


    Section
IV Enrollee Services, Community Outreach and Marketing

    


    
      	
               
      

            	
              --

            	
              Section
      IV, Item B. is hereby amended to now
read:

            


    

    


    
      	
               
      

            	
              B.

            	
              Community
      Outreach and Marketing

            


    

    


    
      	
              2.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section I, Item A.,
      Definitions, is hereby amended as
follows:

            


    

    


    
      	
               
      

            	
              --

            	
              The
      definition of Community Outreach Representative is hereby included as
      follows:

            


    

    


    Community
Outreach Representative – A person who provides Community Outreach,
including health information,  information that promotes healthy
lifestyles, information that provides guidance about social assistance programs,
and information that provides culturally and linguistically appropriate health
or nutritional education.  Such representatives must be appropriately
trained, certified and/or licensed, including but not limited to, social
workers, nutritionists, physical therapists and other health care
professionals.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Community Outreach is hereby included as
      follows:

            


    

    


    Community
Outreach – The provision of health or nutritional information, or
information for the benefit and education of, or assistance to, a community in
regard to health-related matters or public awareness that promotes healthy
lifestyles.  Community Outreach also includes the provision of
information about health care services, preventive techniques and other health
care projects and the provision of information related to health, welfare, and
social services or social assistance programs offered by the State of Florida or
local communities.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Community Outreach Materials is hereby included as
      follows:

            


    

    


    Community
Outreach Materials – Materials regarding health or nutritional
information, or information for the benefit and education of, or assistance to,
a community in regard to health-related matters or public awareness that
promotes healthy lifestyles; such materials are specifically meant for the
community at-large and may also include information about health care services,
preventive techniques and other health care projects and the provision of
information related to health, welfare, and social services or social assistance
programs offered by the State of Florida or local
communities.  Community Outreach Materials are limited to brochures,
fact sheets, posters, and ad copy for radio, television, print or the
Internet.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Market Area is hereby amended to read as
      follows:

            


    

    


    Market
Area – The
geographic area in which the Health Plan is authorized to conduct Community
Outreach.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Marketing Representative is hereby deleted in its
      entirety.

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 1 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

                      --     The
definition of Pre-Enrollment is hereby amended to read as
follows:

    

    


    Pre-Enrollment
– The provision of Marketing materials to a Medicaid Recipient.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Pre-Enrollment Application is hereby deleted in its
      entirety.

            


    

    


    
      	
               
      

            	
              --

            	
              The
      definition of Public Event is hereby amended to read as
      follows:

            


    

    


    Public
Event – An event that is organized or sponsored by an organization, for
the benefit and education of, or assistance to, a community in regard to
health-related matters or public awareness.

    


    
      	
               
      

            	
              --

            	
              The
      definition of Remediation is hereby included as
  follows:

            


    

    


    Remediation
- Remediation of encounter claims; where remediation is “the act or process of
correcting a fault or deficiency.”

    


    
      	
               
      

            	
              --

            	
              The
      definition of Request for Benefit Information (RBI)is hereby deleted in
      its entirety.

            


    

    


    
      	
              3.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section I, Item B.,
      Acronyms, is hereby amended as
follows:

            


    

    


    
      	
               
      

            	
              --

            	
              The
      acronym ACCESS is hereby included as
follows:

            


    

    


    ACCESS – Automated Community
Connection to Economic Self-Sufficiency:  The Department of Children
and Families’ (DCF’s) public assistance service delivery system.

    


    
      	
               
      

            	
              --

            	
              The
      acronym SNIP is hereby included as
follows:

            


    

    


    SNIP – Strategic National
Implementation Process

    


    
      	
               
      

            	
              --

            	
              The
      acronym WEDI is hereby included as
follows:

            


    

    


    WEDI – Workgroup for
Electronic Data Interchange

    


    
      	
              4.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section III, Eligibility
      and Enrollment, Item C., Disenrollment, sub-item 2.a.(4), is hereby
      amended as follows:

            


    

    


    
      	
               
      

            	
              (4)

            	
              A
      substantiated Marketing or Community Outreach violation has
      occurred.

            


    

    


    
      	
              5.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section IV, Enrollee
      Services and Marketing, is hereby retitled “Enrollee Services, Community
      Outreach and Marketing.”

            


    

    


    
      	
              6.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section IV, Enrollee
      Services, Community Outreach and Marketing, Item A., Enrollee Services,
      sub-item 11.d.(3), the first sentence is hereby amended to read as
      follows:

            


    

    


    The
Health Plan may not include the redetermination date information in any file
viewable by customer service or Community Outreach staff.

    


    
      	
              7.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section IV, Item B.,
      Marketing, is hereby deleted in its entirety and replaced as
      follows:

            


    

    


    
      	
               
      

            	
              B.

            	
              Community
      Outreach and Marketing

            


    

    


    
      	
               
      

            	
              1.

            	
              General
      Provisions

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 2 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
               
      

            	
              a.

            	
              The
      Health Plan’s Community Outreach Representative(s) may provide Community
      Outreach at Health Fairs/Public events as noticed by the Health Plan to
      the Agency in accordance with sub-item 4. of this Section.  The
      main purpose of a Health Fair/Public Event shall be to provide Community
      Outreach and shall not be for the purpose of Medicaid Health Plan
      Marketing.

            


    

    


    
      	
               
      

            	
              b.

            	
              For
      each new Contract Period, the Health Plan shall submit to the Agency
      Bureau of Managed Health Care for written approval, all Community Outreach
      material no later than sixty (60) Calendar Days prior to Contract renewal,
      and for any changes in the Community Outreach material, no later than
      thirty (30) Calendar Days prior to implementation.  All
      materials developed shall be governed by the requirements set forth in
      this Section.

            


    

    


    
      	
               
      

            	
              c.

            	
              To
      announce participation at a specific event (Health Fair/Public Event), the
      Health Plan shall submit a notice to the Agency in accordance with
      sub-item B.3., Permitted
Activities.

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Health Plan shall be responsible for developing and implementing a written
      plan designed to control the actions of its Community Outreach
      Representatives.

            


    

    


    
      	
               
      

            	
              e.

            	
              All
      of the Community Outreach policies set forth in this Contract apply to
      staff, Subcontractors, Health Plan volunteers and all persons acting for
      or on behalf of the Health Plan.

            


    

    


    
      	
               
      

            	
              f.

            	
              The
      Health Plan is vicariously liable for any Outreach and Marketing
      violations of its employees, agents or Subcontractors.  Any
      violations of this section shall subject the health plan to administrative
      action by the Agency as determined by the Agency.  The health
      plan may dispute any such administrative action pursuant to Section XVI,
      Item I., Disputes.

            


    

    


    
      	
               
      

            	
              g.

            	
              Nothing
      in this Section shall preclude a Health Plan from otherwise donating to or
      sponsoring an event with a community organization where time, money or
      expertise is provided for the benefit of the community.  At such
      events no Community Outreach materials or Marketing materials may be
      distributed by the Health Plan, but the Health Plan may engage in
      brand-awareness activities, including the display of Health Plan or
      Product logos.  Inquiries at such events from prospective
      enrollees must be referred to the Health Plan’s member services section
      and the Agency’s Choice Counselor/Enrollment
  Broker.

            


    

    


    
      	
               
      

            	
              2.

            	
              Prohibited
      Activities

            


    

    


    The
Health Plan is prohibited from engaging in the following non-exclusive list of
activities:

    


    
      	
               
      

            	
              a.

            	
              Marketing
      for Enrollment to any potential members or conducting any Pre-Enrollment
      activities not expressly allowed under this
  Contract.

            


    

    


    
      	
               
      

            	
              b.

            	
              Any
      of the prohibited practices or activities listed in Section 409.912,
      F.S.

            


    

    


    
      	
               
      

            	
              c.

            	
              Engaging
      in activities for the purpose of recruitment or
  Enrollment.

            


    

    


    
      	
               
      

            	
              d.

            	
              In
      accordance with sections 409.912 and 409.91211, F.S., practices that are
      discriminatory, including, but not limited to, attempts to discourage
      Enrollment or reenrollment on the basis of actual or perceived health
      status.

            


    

    


    
      	
               
      

            	
              e.

            	
              Direct
      or indirect Cold Call Marketing or other solicitation of Medicaid
      Recipients, either by door-to-door, telephone or other means, in
      accordance with section 4707 of the Balanced Budget Act of 1997, and
      section 409.912, F.S.

               

            


    

     

    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 3 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

      
        
          	
                   
      

                	
                  f.

                	
                  In
      accordance with section 409.912, F.S., activities that could mislead or
      confuse Medicaid Recipients, or misrepresent the Health Plan, its
      Community Outreach Representatives, or the
      Agency.  No fraudulent, misleading, or misrepresentative
      information shall be used in Community Outreach, including information
      regarding other governmental programs.  Statements that could
      mislead or confuse include, but are not limited to, any assertion,
      statement or claim (whether written or oral) that:

                   

                


        

      

    

    
      	
               
      

            	
              (1)

            	
              The
      Medicaid Recipient must enroll in the Health Plan in order to obtain
      Medicaid, or in order to avoid losing Medicaid
  benefits;

            


    

    


    
      	
               
      

            	
              (2)

            	
              The
      Health Plan is endorsed by any federal, State or county government, the
      Agency, or CMS, or any other organization which has not certified its
      endorsement in writing to the Health
Plan;

            


    

    


    
      	
               
      

            	
              (3)

            	
              Community
      Outreach Representatives are employees or representatives of the federal,
      State or county government, or of anyone other than the Health Plan or the
      organization by whom they are
reimbursed;

            


    

    


    
      	
               
      

            	
              (4)

            	
              The
      State or county recommends that a Medicaid Recipient enroll with the
      Health Plan; and/or

            


    

    


    
      	
               
      

            	
              (5)

            	
              A
      Medicaid Recipient will lose benefits under the Medicaid program, or any
      other health or welfare benefits to which the Recipient is legally
      entitled, if the Recipient does not enroll with the Health
      Plan.

            


    

    


    
      	
               
      

            	
              g.

            	
              Granting
      or offering of any monetary or other valuable consideration for
      Enrollment.

            


    

    


    
      	
               
      

            	
              h.

            	
              Offers
      of insurance, such as but not limited to, accidental death, dismemberment,
      disability or life insurance.

            


    

    


    
      	
               
      

            	
              i.

            	
              Enlisting
      the assistance of any employee, officer, elected official or agent of the
      State in recruitment of Medicaid Recipients except as authorized in
      writing by the Agency.

            


    

    


    
      	
               
      

            	
              j.

            	
              Offers
      of material or financial gain to any persons soliciting, referring or
      otherwise facilitating Medicaid Recipient Enrollment.  The
      Health Plan shall ensure that no plan staff market the Health Plan to
      Medicaid Recipients at any location including State offices or DCF ACCESS
      centers.

            


    

    


    
      	
               
      

            	
              k.

            	
              Giving
      away promotional items in excess of $5.00 retail value.  Items
      to be given away shall bear the Health Plan's name and shall only be given
      away at Health Fairs/Public Events.  In addition, such
      promotional items must be offered to the general public and shall not be
      limited to Medicaid Recipients.

            


    

    


    
      	
               
      

            	
              l.

            	
              Providing
      any gift, commission, or any form of compensation to the Choice
      Counselor/Enrollment Broker, including the Choice Counselor/Enrollment
      Broker's full-time, part-time or temporary employees and
      Subcontractors.

            


    

    


    
      	
               
      

            	
              m.

            	
              Provide
      information, prior to the Enrollment, about the incentives that shall be
      offered to the Enrollee as described in Section VIII.B.7., Incentive
      Programs.  The Health Plan may inform Enrollees on or after
      their Enrollment effective date about the specific incentives or programs
      available.

            


    

    


    
      	
               
      

            	
              n.

            	
              Discussing,
      explaining or speaking to a potential member about
      Health-Plan-benefit-specific information other than to refer all Health
      Plan inquiries to the Member Services section of the Health Plan or the
      Agency’s Choice Counselor/Enrollment
Broker.

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 4 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
               
      

            	
              o.

            	
              Distributing
      any Community Outreach Materials without prior written notice to the
      Agency except as otherwise allowed under Permitted Activities and Provider
      Compliance subsections.

            


    

    


    
      	
               
      

            	
              p.

            	
              Distributing
      any Marketing materials.

            


    

    


    
      	
               
      

            	
              q.

            	
              Subcontract
      with any brokerage firm or independent agent as defined in Chapters 624 –
      651, F.S., for purposes of Marketing or Community
  Outreach.

            


    

    


    
      	
               
      

            	
              r.

            	
              Pay
      commission compensation to Community Outreach Representatives for new
      Enrollees.  The payment of a bonus to a Community Outreach
      Representative shall not be considered a commission if such bonus is not
      related to enrollment or membership
growth.

            


    

    


    
      	
               
      

            	
              s.

            	
              All
      activities included in Section 641.3903,
F.S.

            


    

    


    
      	
               
      

            	
              3.

            	
              Permitted
      Activities

            


    

    


    The
Health Plan may engage in the following activities upon prior written notice to
the Agency Bureau of Managed Health Care:

    


    
      	
               
      

            	
              a.

            	
              The
      Health Plan may attend Health Fairs/Public Events upon request by the
      sponsor and after written notification to the Agency as described in
      sub-item 4.

            


    

    


    
      	
               
      

            	
              b.

            	
              The
      Health Plan may leave Community Outreach materials at Health Fairs/Public
      Events at which the Health Plan
participates.

            


    

    


    
      	
               
      

            	
              c.

            	
              The
      Health Plan may provide Agency-approved Community Outreach
      Materials.  Such materials may include Medicaid enrollment and
      eligibility information and information related to other health care
      projects and social services provided by the State of Florida or local
      communities.  The Health Plan staff, including Community
      Outreach Representatives, must refer all Health Plan inquiries to the
      member services section of the Health Plan and the Agency’s Choice
      Counselor/Enrollment Broker.  The Agency must approve the script
      used by the Health Plan’s member services section before
      usage.

            


    

    


    
      	
               
      

            	
              d.

            	
              Health
      Plans may distribute Community Outreach Materials to community
      agencies.

            


    

    


    
      	
               
      

            	
              4.

            	
              Community Outreach Notification
      Process

            


    

    


    
      	
               
      

            	
              a.

            	
              The
      Health Plan shall submit in writing to the Agency Bureau of Managed Health
      Care, a notice of its intent to attend and provide Community Outreach
      Materials at Health Fairs/Public Events at least two (2) weeks prior to
      the event (see 4.b. and c. below for further notice
      information).  Such submission shall include the items listed
      below:

            


    

    


    
      	
               
      

            	
              (1)

            	
              The
      following Health Fair/Public Event disclosure information and other
      information as may be required by the
Agency:

            


    

    


    
      	
               
      

            	
              (a)

            	
              The
      announcement of the event that will be given out to the
      public;

            


    

    
      	
               
      

            	
              (b)

            	
              The
      date, time and location of the
event;

            


    

    
      	
               
      

            	
              (c)

            	
              The
      name and type of organization sponsoring the
  event;

            


    

    
      	
               
      

            	
              (d)

            	
              The
      event contact person and contact
information;

            


    

    
      	
               
      

            	
              (e)

            	
              The
      Health Plan contact person and contact information;
  and

            


    

    
      	
               
      

            	
              (f)

            	
              Names
      of participating Community Outreach Representative(s), their contact
      information and services they will provide at the
  event.

            


    

    



    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 5 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
               
      

            	
              (2)

            	
              In
      addition to the disclosure information listed in (1) above, if the Health
      Plan is the primary organizer of the Health Fair, the Health Plan shall
      submit complete disclosure of information from each organization
      participating in a Health Fair prior to the event.  Such
      information shall include the name of the organization, contact person
      information, and confirmation of
participation.

            


    

    


    
      	
               
      

            	
              (3)

            	
              In
      addition to the disclosure information listed in (1) above, if the Health
      Plan has been invited by a community organization to be a sponsor or
      attendee of an event, the Health Plan shall provide to the Agency Bureau
      of Managed Health Care a copy of the letter of invitation from the Health
      Fair/Public Event sponsor(s) to the Health Plan requesting sponsorship of,
      or attendance at, the event.

            


    

    


    
      	
               
      

            	
              b.

            	
              The
      Health Plan shall submit notice to the Agency of Health Fairs/Public
      Events no later than ten (10) Business Days after the Health Plan’s
      receipt of the invitation to attend or, if the Health Plan is the primary
      organizer of the Health Fair, no later than ten (10) days after a decision
      has been made to organize the
event.

            


    

    


    
      	
               
      

            	
              c.

            	
              Notwithstanding
      the other notice requirements in this subsection, the two week and the
      10-day advance notice requirements are waived in cases of force majeure
      provided the Health Plan notices the Bureau of Managed Health Care by the
      time of the event.  Force majeure events includes destruction
      due to hurricanes, fires, war, riots, and other similar
      acts.  When providing the Agency with notice of attendance at
      such events, the Health Plan shall include a description of the force
      majeure event requiring waiver of
notice.

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Agency will establish a statewide log to track the Community Outreach
      notifications received and may monitor such
  events.

            


    

    


    
      	
               
      

            	
              5.

            	
              Provider
      Compliance

            


    

    


    The
Health Plan shall ensure, through provider education and outreach, that its
health care Providers are aware and comply with the following
requirements:

    


    
      	
               
      

            	
              a.

            	
              Health
      care Providers may display Health-Plan-specific materials in their own
      offices.

            


    

    


    
      	
               
      

            	
              b.

            	
              Health
      Care Providers cannot orally or in writing compare Benefits or provider
      networks among Health Plans, other than to confirm Health Plan network
      participation.

            


    

    


    
      	
               
      

            	
              c.

            	
              Health
      care Providers may announce a new affiliation with a Health Plan or give a
      list of Health Plans with which they contract to their
      patients.

            


    

    


    
      	
               
      

            	
              d.

            	
              Health
      care Providers may co-sponsor events, such as Health Fairs, and advertise
      with the Health Plan in indirect ways; such as television, radio, posters,
      fliers, and print advertisement.

            


    

    


    
      	
               
      

            	
              e.

            	
              Health
      care Providers shall not furnish lists of their Medicaid Recipients to
      Health Plans with which they contract, or any other entity, nor can
      Providers furnish other Health Plans' membership lists to any Health Plan,
      nor can Providers assist with Health Plan
  Enrollment.

            


    

    


    
      	
               
      

            	
              f.

            	
              For
      the Health Plan, health care Providers may distribute information about
      non-Health-Plan-specific health care services and the provision of health,
      welfare and social services provided by the State of Florida or local
      communities as long as any inquiries from prospective enrollees are
      referred to the member services section of the health plan or the Agency’s
      Choice Counselor/Enrollment Broker.

            


    

    



    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 6 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

    
       

      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
               
      

            	
              6.

            	
              Community
      Outreach Representatives

            


    

    


    
      	
               
      

            	
              a.

            	
              The
      Health Plan shall report to the Agency Bureau of Managed Health Care any
      Health Plan staff or Community Outreach Representative who violates any
      requirements of this Contract, within fifteen (15) Calendar Days of
      knowledge of such violation.

               

            


    

    
      	
               
      

            	
              b.

            	
              While
      attending Health Fairs/Public Events, Community Outreach Representatives
      shall wear picture identification that identifies the Health Plan
      represented.

            


    

    


    
      	
               
      

            	
              c.

            	
              If
      asked, the Community Outreach Representative shall inform the Medicaid
      Recipient that the Representative is not an employee of the State and is
      not a Choice Counseling Specialist, but is a Representative of the Health
      Plan.

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Health Plan shall instruct and provide initial and periodic training to
      its Community Outreach Representatives regarding the Community Outreach
      and Marketing provisions of this
Contract.

            


    

    


    
      	
               
      

            	
              e.

            	
              The
      Health Plan shall implement procedures for background and reference checks
      for use in its Community Outreach Representative hiring
      practices.

            


    

    


    
      	
               
      

            	
              f.

            	
              The
      Health Plan shall register each Community Outreach Representative with the
      Agency’s Bureau of Managed Health Care in accordance with Section XII of
      this Contract.

            


    

    


    
      	
              8.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section X, Administration
      and Management, Item B., Staffing, sub-item 1.g., is hereby deleted in its
      entirety and replaced as follows:

            


    

    


    
      	
               
      

            	
              g.

            	
              Community Outreach
      Oversight Coordinator:  If the Health Plan engages in
      Community Outreach, the Health Plan shall have a designated person,
      qualified by training and experience, to assure the Health Plan adheres to
      the community outreach and marketing requirements of this
      Contract.

            


    

    


    
      	
              9.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section X, Administration
      and Management, Item C., Provider Contract Requirements, sub-item 2.s., is
      hereby deleted in its entirety and replaced as
  follows:

            


    

    


    
      	
               
      

            	
              s.

            	
              Require
      that any Community Outreach Materials related to this Contract that are
      distributed by the Provider be submitted to the Agency for written
      approval before use;

            


    

    


    
      	
              10.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section X, Administration
      and Management, Item E., Provider Services, sub-item 5.d., is hereby
      deleted in its entirety and replaced as
follows:

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Health Plan’s call center systems shall have the capability to track call
      management metrics identified in Section IV, Community Outreach and
      Marketing, Item A., Enrollee Services, sub-item 7., Toll-free Help
      Line.

            


    

    


    
      	
              11.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section X, Administration
      and Management, Item H., Encounter Data, is hereby deleted in its entirety
      and replaced as follows:

            


    

    


    
      	
               
      

            	
              H.

            	
              Encounter
      Data

            


    

    


    
      	
               
      

            	
              1.

            	
              The
      Health Plan shall submit Encounter Data that meets established Agency data
      quality standards as defined herein.  These standards are
      defined by the Agency to ensure receipt of complete and accurate data for
      program administration and will be closely monitored and
      enforced.  The Agency will revise and amend these standards with
      ninety (90) Calendar Days advance notice to the Health Plan to ensure
      continuous quality improvement.  The Health Plan shall make
      changes or corrections to any systems, processes or data transmission
      formats as needed
      to comply with Agency data quality standards as originally defined or
      subsequently amended.

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 7 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
               
      

            	
              2.

            	
              The
      Encounter Data submission standards required to support encounter
      reporting and submission are defined by the Agency in the Medicaid
      Encounter Data System (MEDS) Companion Guide and this
      Section.  In addition, the Agency will post encounter reporting
      requirements on its MEDS website for the Health Plans to follow: http://ahca.myflorida.com/Medicaid/meds/.

            


    

    


    
      	
               
      

            	
              3.

            	
              The
      Health Plan shall adhere to the following requirements for the Encounter
      Data submission process:

            


    

    


    
      	
               
      

            	
              a.

            	
              The
      Agency shall notify the Health Plan, in writing, of the start date for
      resuming the submission of encounters through the current Fiscal
      Agent.

            


    

    


    
      	
               
      

            	
              b.

            	
              Once
      the Health Plan is notified by the Agency of the date for recommencing
      encounter submissions (submission start date), the Health Plan shall
      submit its schedule for transmitting Encounter Data for all typical and
      atypical services collected for historical claims beginning January 1,
      2007, and up to the submission start
date.

            


    

    


    
      	
               
      

            	
              (1)

            	
              The
      Health Plan shall submit this schedule for approval to the Agency’s
      Medicaid Encounter Data System team (at medsteam@ahca.myflorida.com)
      within ten (10) Business days after the date of the Agency’s notice to
      begin submitting encounters.

            


    

    


    
      	
               
      

            	
              (2)

            	
              At
      a minimum, such submission schedule must include that historical encounter
      transmissions will begin no later than sixty (60) Calendar Days after the
      submission start date.

            


    

    


    
      	
               
      

            	
              c.

            	
              In
      accordance with the submission schedule approved by the Agency, the Health
      Plan shall submit the historical encounters for all typical and atypical
      services with Health Plan paid dates of January 1, 2007, up to the
      submission start date.

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Health Plan shall submit encounters for all typical and atypical services
      with Health Plan paid dates on or after the submission start date on an
      ongoing basis within sixty (60) Calendar Days following the end of the
      month in which the Health Plan paid the claims for
    services.

            


    

    


    
      	
               
      

            	
              e.

            	
              For
      all encounters submitted after the recommencing of encounter submissions
      (submission start date), including historical and ongoing claims, if the
      Agency or its Fiscal Agent notifies the Health Plan of encounters failing
      X12 Electronic Data Interface (EDI) compliance edits or FMMIS threshold
      and repairable compliance edits, the Health Plan shall Remediate all such
      encounters within sixty (60) Calendar Days after such
    notice.

            


    

    


    
      	
               
      

            	
              f.

            	
              There
      will be no requirement to submit encounters for Health Plan paid dates
      prior to January 1, 2007.

            


    

    


    
      	
               
      

            	
              4.

            	
              The
      Health Plan shall have a comprehensive automated and integrated Encounter
      Data system that is capable of meeting the requirements
      below.  The Health Plan shall comply as
  follows:

            


    

    


    
      	
               
      

            	
              a.

            	
              All
      Health Plan encounters shall be submitted to the Agency in the standard
      HIPAA transaction formats, namely the ANSI X12N 837 Transaction formats (P
      - Professional, I - Institutional, and D – Dental), and, for Pharmacy
      services, in the National Council for Prescription Drug Programs (NCPDP)
      format.  Health Plan paid amounts must be provided for
      non-capitated network
providers.

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 8 of 11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

      
        


        
          	
                   
      

                	
                  b.

                	
                  The
      Health Plan shall collect and submit to the Agency’s Fiscal Agent,
      Enrollee service level Encounter Data for all Covered
      Services.  Health Plans will be held responsible for errors or
      noncompliance resulting from their own actions or the actions of an agent
      authorized to act on their behalf.

                


        

         

      

    

    
      	
               
      

            	
              c.

            	
              The
      Health Plan shall convert all information that enters their claims systems
      via hard copy paper claims or other proprietary formats to Encounter Data
      to be submitted in the appropriate HIPAA compliant
  formats.

            


    

    


    
      	
               
      

            	
              d.

            	
              The
      Health Plan shall provide complete and accurate encounters to the
      Agency.  Health Plans will implement review procedures to
      validate Encounter Data submitted by
providers.

            


    

    


    
      	
               
      

            	
              (1)

            	
              Complete:  A
      Health Plan submitting encounters that represent at least 95% of the
      Covered Services provided by the Health Plan’s Providers and
      non-participating providers.  It is expected that the Health
      Plan will strive to make every effort to achieve a 100% complete
      submission rate.

            


    

    


    
      	
               
      

            	
              (2)

            	
              Accurate:  95%
      of the records in a Health Plan’s encounter batch submission pass X12 EDI
      compliance edits and the FMMIS threshold and repairable compliance
      edits.  The X12 EDI compliance edits are established through
      SNIP levels 1 through 4.  FMMIS threshold and repairable edits
      that report exceptions are defined in the MEDS Companion
      Guide.

            


    

    


    
      	
               
      

            	
              e.

            	
              The
      Health Plan shall designate sufficient IT and staffing resources to
      perform these encounter functions as determined by generally accepted best
      industry practices.

            


    

    


    
      	
               
      

            	
              f.

            	
              The
      Health Plan shall retain submitted historical Encounter Data for a period
      not less than five years as specified in I.D., Retention of Records, in
      the Agency’s Standard Contract.

            


    

    


    
      	
               
      

            	
              5.

            	
              Where
      a Health Plan has entered into capitation reimbursement arrangements with
      Providers, the Health Plan must comply with sub-item 4. of this
      Section.  The Health Plan shall require timely submissions from
      its Providers as a condition of the capitation
  payment.

            


    

    


    
      	
               
      

            	
              6.

            	
              The
      Health Plan shall participate in Agency sponsored workgroups directed at
      continuous improvements in Encounter Data quality and
      operations.

            


    

    


    
      	
               
      

            	
              7.

            	
              If
      the Agency determines that the Health Plan’s MEDS performance is not
      acceptable, the Agency shall require the Health Plan to submit a
      corrective action plan (CAP).  If the Health Plan fails to
      provide a CAP or to implement an approved CAP within the time specified by
      the Agency, the Agency shall sanction the Health Plan in accordance with
      the provisions of Section XIV, Sanctions, and may immediately terminate
      all Enrollment activities and Mandatory Assignments.  When
      considering whether to impose a Sanction, the Agency will take into
      account the Health Plan’s cumulative performance on all MEDS activities,
      including progress made toward completeness and accuracy of Encounter Data
      as defined in sub-item H.4.d. of this
Section.

            


    

    


    
      	
               
      

            	
              8.

            	
              The
      Encounter Data submission time frames specified in this Section do not
      affect time frames specified in Section XII for either pharmacy data
      encounter reporting for risk adjustment or behavioral health encounter
      (including pharmacy) reporting.

            


    

    


    
      	
              12.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section XII, Reporting
      Requirements, Item A., Health Plan Reporting Requirements, sub-item 7.,
      Digit 1 Report Identifiers table, is hereby deleted in its entirety and
      replaced as follows:

            


    


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 9 of
11 

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    
      	
              Digit
      1 Report Identifiers

            
	
               
      R

            	
               
      Community Outreach Representative

            
	
               
      I

            	
               
      Information Systems Availability

            
	
               
      G

            	
               
      Grievance System Reporting

            
	
               
      H

            	
               
      Inpatient Discharge Reporting

            
	
               
      F

            	
               
      Financial Reporting

            
	
               
      M

            	
               
      Minority Reporting

            
	
               
      C

            	
               
      Claims Inventory

            
	
               
      T

            	
               
      Transportation

            
	
               
      S

            	
               
      Critical Incident Summary

            
	
               
      E

            	
               
      Behavioral Health Encounter Data

            
	
               
      B

            	
               
      Behavioral Health Pharmacy Encounter Data

            
	
               
      P

            	
               
      Behavioral Health Required Staff/Providers

            
	
               
      O

            	
               
      FARS/CFARS

            


    

    


    
      	
              13.

            	
              Attachment
      II, Medicaid Reform Health Plan Model Contract, Section XII, Reporting
      Requirements, Table 1, Summary of Reporting Requirements, “Marketing
      Representative Report” is hereby retitled “Community Outreach
      Representative Report.”

            


    

    


    
      	
              14.

            	
              Attachment
      II, Medicaid Reform  Health Plan Model Contract, Section XII,
      Reporting Requirements, Item E., Marketing Representative Report, is
      hereby deleted in its entirety and replaced as
  follows:

            


    

    


    
      	
               
      

            	
              E.

            	
              Community Outreach
      Representative Report

            


    

    


    
      	
               
      

            	
              1.

            	
              The
      Health Plan shall register each Community Outreach Representative with the
      Agency as specified below.  The registration file must be
      submitted to the Agency at the following e-mail address prior to any
      initial Community Outreach
      activity:  MMCDATA@ahca.myflorida.com.  The
      Agency-supplied template must be used – Community Outreach Representative
      Registration Template.xls.  This template is provided at
      http://www.ahca.myflorida.com/mchq/managed_health_care/mhmo/med_prov.shtml.

            


    

    


    
      	
               
      

            	
              2.

            	
              Changes
      to the Community Outreach Representative’s initial registration must be
      submitted to the Agency immediately upon occurrence at e-mail
      address:  MMCDATA@ahca.myflorida.com.  The
      Agency-supplied template must be used.  The Health Plan shall
      not change or alter the template. This template contains the following
      required data elements:

            


    

    


    
      	
              15.

            	
              Attachment
      II, Medicaid Reform  Health Plan Model Contract, Section XVI,
      Terms and Conditions, Item Q., Termination Procedures, sub-item 2.c., is
      hereby deleted in its entirety and replaced as
  follows:

            


    

    


    
      	
               
      

            	
              c.

            	
              Terminate
      all Community Outreach activities and subcontracts relating to Community
      Outreach.

            


    

    


    This Amendment shall have an effective
date of March 1, 2009, or the date on which both parties execute the Amendment,
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 part of the
Contract.

     

    This Amendment cannot be executed unless all previous Amendments
to this Contract have been fully executed.


    
      
        
          AHCA
Contract No. FAR001, Amendment No. 11, Page 10 of
11

        

         


      

      
         


        
          

        

      

      
         


      

    

     

    
      
        	 HealthEase of Florida,
      Inc. 	 	
                 Medicaid Reform HMO
      Contract

              


      

       

    

    IN
WITNESS WHEREOF, the parties hereto have caused this eleven (11) 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

            


    

    


    
      	
              SIGNED

              BY:

            	
               
      

              /s/ Heath Schiesser

            	 
      	
              SIGNED

              BY:

            	
               
      

              /s/ Holly Benson

            
	
               

              NAME:

            	
               

              Heath
      Schiesser

            	 
      	
               

              NAME:

            	
               

              Holly
      Benson

            
	
               

              TITLE:

            	
               

              President
      & CEO

            	 
      	
               

              TITLE:

            	
               

              Secretary

            
	
               

              DATE:

            	
               
      

              24 March 2009

            	 
      	
               

              DATE:

            	
               
      

              3/26/09

            


    

    


    


    REMAINDER
OF PAGE INTENTIONALLY LEFT BLANK

     

    
      AHCA
Contract No. FAR001, Amendment No. 11, Page 11 of
11