Exhibit 10.16


    
      
        

      

    

    Back
      to Form 10-Q

     

    Exhibit
      10.16

     

     

    Contract
      with Eligible Medicare Advantage Organization Pursuant to 

    Sections
      1851 through 1859 of the Social Security Act for the Operation 

     

    of
      a
      Medicare Advantage Private Fee-For-Service Plan(s)

     

    


     

    CONTRACT
      (#4577)

     

    Between

     

    Centers
      for Medicare & Medicaid Services (hereinafter referred to as
      CMS)

     

    And

    


    Home
      Owners / WellCare PFFS Insurance, Inc.

    (hereinafter
      referred to as the MA Organization)

     

    CMS
      and
      the MA Organization, an entity which has been determined to be an eligible
      Medicare Advantage Organization by the Administrator of the Centers for Medicare
      & Medicaid Services under 42 CFR 422.503, agree to the following for the
      purposes of sections 1851 through 1859 of the Social Security Act (hereinafter
      referred to as the Act):

     

    (NOTE:
      Citations indicated in brackets are placed in the text of this contract to
      note
      the regulatory authority for certain contract provisions. All references to
      Part
      422 are to 42 CFR Part 422.)

     

    

      You
        must check off AND initial each required Addendum type to reflect the coverage
        offered under the H (or R) number associated with this
        contract

       

    

    
      	
              Addendum
                Type

            	
              Initials

            
	
              ü 

            	
              Part
                D Addendum

            	
              TF   
                

            
	
              ü

            	
              Employer-Only
                MA-PD Addendum (800 Series)

            	
              TF    

            
	
              __

            	
              Employer-Only
                MA Only Addendum (800 Series)

            	
              ____

            
	
              __

            	
              Variances/Waivers
                (Provided directly to Demonstration Organizations by CMS)

            	
              ____

            


    

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

       

      Article
        I

       

      Term
        of
        Contract


       

      The
        term
        of this contract shall be from the date of signature by CMS' authorized
        representative through December 31, 2007, after which this contract may be
        renewed for successive one-year periods in accordance with 42 CFR 422.505(c).
        [422.505]

      This
        contract governs the respective rights and obligations of the parties as
        of the
        effective date set forth above, and supersedes any prior agreements between
        the
        MA Organization and CMS as of such date. MA organizations offering Part D
        benefits also must execute an Addendum to the Medicare Managed Care Contract
        Pursuant to Sections 1860D-1 through 1860D-42 of the Social Security Act
        for the
        Operation of a Voluntary Medicare Prescription Drug Plan (hereafter the "Part
        D
        Addendum"). For MA Organizations offering MA-PD plans, the Part D Addendum
        governs the rights and obligations of the parties relating to the provision
        of
        Part D benefits, in accordance with its terms, as of its effective
        date.

      


      Article
        II

      


      Private
        Fee-For-Service Plan

       

      A.
        The MA
        Organization agrees to operate one or more private fee-for-service plans
        (as
        defined in
        42 CFR
        422.4(a)(3)), as described in its final Plan Benefit Package (PBP) bid
        submission (benefit
        and price bid) proposal as approved by CMS and as attested to in the Medicare
        Advantage
        Attestation of Benefit Plan and Price, and in compliance with the requirements
        of this contract
        and applicable Federal statutes, regulations, and policies.

       

      B.
        Except
        as provided in paragraph (C) of this Article, this contract is deemed to
        incorporate any changes
        that are required by statute to be implemented during the term of the contract
        and any regulations
        or policies implementing or interpreting such statutory provisions.


       

      C.
        CMS
        will not implement, other than at the beginning of a calendar year, requirements
        under 42 CFR
        Part
        422 that impose a new significant cost or burden on MA organizations or plans,
        unless a
        different effective date is required by statute.
        [422.521]

      


      Article
        III

      


      Functions
        To Be
        Performed By Medicare Advantage Organization

       

      A.
        PROVISION OF BENEFITS

      1.
        The MA
        Organization agrees to provide enrollees in each of its MA plans the basic
        benefits as
        required under §422.101 and, to the extent applicable, supplemental benefits
        under §422.102 and as established in the MA Organization's final benefit and
        price bid proposal as approved by CMS and listed in The MA Organization
        Attestation of Benefit Plan and Price, which is attached to this contract.
        The
        MA Organization agrees to provide access to
        such
        benefits as required under
        subpart C in a manner consistent with professionally recognized standards
        of
        health care and according to the access standards stated in §422.114. The MA
        Organization agrees to

       

      2


      provide
        post-hospital extended care services, should an MA enrollee elect such coverage,
        through
        a
        skilled nursing facility according to the requirements of section 1852(1)
        of the
        Act and §422.133 . A home skilled nursing facility is a facility in which an MA
        enrollee resided at the time of admission to the hospital, a facility that
        provides services through a continuing care retirement community, or a facility
        in which the spouse of the enrollee is residing at the time of the enrollee's
        discharge from the hospital, or hospital, or wherever the enrollee resides
        immediately before admission for extended care services. [422.133;
        422.504(a)(3)]

      2.
        The MA
        Organization shall authorize benefits according to the local medical review
        policies (LMRPs) for services provided in geographic areas where the LMRPs
        represent an expansion of Medicare coverage policies as compared to national
        Medicare coverage policies.
        [422.101(b)(2)]

       

      B.
        ENROLLMENT REQUIREMENTS

      1.
        The MA
        Organization agrees to accept new enrollments, make enrollments effective,
        process voluntary disenrollments, and limit involuntary disenrollments, as
        provided in subpart B of part 422.

      2.
        The MA
        Organization shall comply with the provisions of §422.110 concerning
        prohibitions against discrimination in beneficiary enrollment. [422.504(a)(2)]

       

      C.
        BENEFICIARY PROTECTIONS

      1.
        The MA
        Organization agrees to comply with all requirements in subpart M of part
        422
        governing coverage determinations, grievances, and appeals. [422.504(a)(7)]

      2.
        The MA
        Organization agrees to comply with the confidentiality and enrollee record
        accuracy requirements in §422.118.

      3.
        Beneficiary
        Financial Protection.
        The MA
        Organization agrees to comply with the following requirements:

      (a)
        Each
        MA Organization must adopt and maintain arrangements satisfactory to CMS
        to
        protect its enrollees from incurring liability for payment of any fees that
        are
        the legal obligation of the MA Organization. To meet this requirement the
        MA
        Organization must—

      (i)
        Ensure that all contractual (including deemed contracts under §422.216) or other
        written arrangements with providers prohibit the Organization's providers
        from
        holding any beneficiary enrollee liable for payment of any fees that are
        the
        legal obligation of the MA Organization; and

      (ii)
        Indemnify the beneficiary enrollee for payment of any fees that are the legal
        obligation of the MA Organization for services furnished by providers that
        do
        not contract, or that have not otherwise entered into an agreement with the
        MA
        Organization, to provide services to the organization's beneficiary enrollees.
        This provision does not apply to providers operating under deemed contracts
        under §422.216.
        [422.504(g)(l)]

      (iii)
        Ensure that in the MA Organization's terms and conditions of payment to
        hospitals, if balance billing is imposed, the hospitals are obligated to
        provide
        notice to enrollees of their potential liability for services where balance
        billing could amount to not less than $500. This notice shall be provided
        according to the requirements of §422.216(d)(2).

      (b)
        The
        MA Organization must provide for continuation of enrollee health care
        benefits-

      (i)
        For
        all enrollees, for the duration of the contract period for which CMS payments
        have been made" and

      (ii)
        For
        enrollees who are hospitalized on the date its contract with CMS terminates,
        or,
        in the event of the MA Organization's insolvency, through the date of discharge.
        [422.504(g)(2)]

      (c)
        In
        meeting the requirements of this section (C), other than the provider contract
        requirements specified in paragraph (C)(3)(a) of this Article, the MA
        Organization may use—

      (i)
        Contractual arrangements;

      (ii)
        Insurance acceptable to CMS;

      (iii)
        Financial reserves acceptable to CMS; or

      (iv)
        Any
        other arrangement acceptable to CMS.
        [422.504(g)(3)

       

      3

       

      D.
        PROVIDER PROTECTIONS

      1.
        The MA
        Organization agrees to comply with all applicable provider requirements in
        42
        CFR Part 422 Subpart E, including provider certification requirements,
        anti-discrimination requirements, provider participation and consultation
        requirements, the prohibition on interference with provider advice, limits
        on
        provider indemnification, rules governing payments to providers, and limits
        on
        physician incentive plans.
        [422.504(a)(6)]

      2.
        Prompt
        Payment.

      (a)
        The
        MA Organization must pay 95 percent of "clean claims" within 30 days of receipt
        if they are submitted by, or on behalf of, an enrollee of a MA PFFS plan
        or are
        for claims for services that are not furnished under a written agreement
        between
        the organization and the provider.

      (i)
        The
        MA Organization must pay interest on clean claims that are not paid within
        30
        days in accordance with sections 1816(c)(2) and 1842(c)(2) of the
        Act.

      (ii)
        All
        other claims from non-contracted providers must be paid or denied within
        60
        calendar days from the date of the request. [422.520(a)]

      (b)
        Contracts, deemed contracts, or other written agreements between the MA
        Organization and its providers must contain a prompt payment provision, the
        terms of which are developed and agreed to by both the MA Organization and
        the
        relevant provider.
        [422.520(b)]

      (c)
        If
        CMS determines, after giving notice and opportunity for hearing, that the
        MA
        Organization has failed to make payments in accordance with subparagraph
        (2)(a)
        of this section, CMS may provide—

      (i)
        For
        direct payment of the sums owed to providers; and

      (ii)
        For
        appropriate reduction in the amounts that would otherwise be paid to the
        MA
        Organization, to reflect the amounts of the direct payments and the cost
        of
        making those payments.
        [422.520(c)]

       

      3.
        Payment
        Rates:

      (a)
        The
        MA Organization shall make payments to providers according to the requirements
        of §422.114.

      (b)
        CMS
        and the MA Organization shall reach agreement, on or before the effective
        date
        of this contract, on provider payment methodologies, which shall include
        provider payment proxies, also described as estimated Original Medicare payment
        amounts.

      (c)
        The
        MA Organization agrees to implement revised provider payment schedules on
        the
        same date that such changes are required of contractors administering the
        Original Medicare benefit.

       

      4

       

      



      (d)
        The
        MA Organization agrees that it shall revise its provider payment schedule
        to
        reflect the requirements of legislative or regulatory changes made during
        the
        term of this contract. Also, the MA Organization agrees that CMS may require
        the
        MA Organization to revise its provider payment schedule if CMS determines
        that
        the existing schedule does not comply with the provisions
        of§422.114(a)(2).
        [422.114]

      (e)
        The
        MA Organization agrees that it shall establish and maintain a payment appeal
        system under which MA plan providers may have their payment claims reviewed
        in
        the event that the provider believes he was paid less than he would have
        been
        paid under Original Medicare. Under such a system, if a provider reasonably
        demonstrates that they have not received proper payment, the MA Organization
        shall pay the provider the difference between what the provider had received
        and
        what he would have received under Original Medicare.

      (f)
        The
        MA Organization agrees to make its provider payment schedule available to
        the
        public in such a manner as to allow providers a reasonable opportunity to
        be
        informed about payment methodologies under the MA plan. This includes posting
        the schedule on a Web site maintained by the Organization.

      


      E.
        QUALITY REQUIREMENTS 

      The
        MA
        Organization agrees to comply with quality requirements as described in
§422.152(f).

       

      F.
        COMPLIANCE PLAN

      The
        MA
        Organization agrees to implement a compliance plan in accordance with the
        requirements
        of§422.503(b)(4)(vi). [422.503(b)(4)(vi)]

       

      G.
        COMPLIANCE DEEMED ON THE BASIS OF ACCREDITATION: CMS may deem the MA
        Organization to have met the quality improvement requirements of§1852(e) of the
        Act and §422.152, the confidentiality and accuracy ofenrollee records
        requirements of§1852(h) of the Act and §422.118, the anti-discrimination
        requirements of§1852(b) of the Act and §422.110, the access to services
        requirements of§1852(d) of the Act and §422.112, the advance directives
        requirements of§1852(i) of the Act and §422,128, the provider participation
        requirements of §1852(j) of the Act and 42 CFR Part 422, Subpart F, and the
        applicable requirements described in §423.165, if the MA Organization is fully
        accredited (and periodically reaccredited) by a private, national accreditation
        organization approved by CMS and the accreditation organization used the
        standards approved by CMS for the purposes of assessing the MA Organization's
        compliance with Medicare requirements. The provisions of §422.156 shall govern
        the MA Organization's use of deemed status to meet MA program
        requirements.

       

      H.
        PROGRAM INTEGRITY

      1.
        The MA
        Organization agrees to provide notice based on best knowledge, information,
        and
        belief to CMS of any integrity items related to payments from governmental
        entities, both federal and state, for healthcare or prescription drug services.
        These items include any investigations, legal actions or matters subject
        to
        arbitration brought involving the MA Organization (or MA Organization's firm
        if
        applicable) and its subcontractors (excluding contracted network providers),
        including any key management or executive staff, or any major shareholders
        (5%
        or more), by a government agency (state or federal) on matters relating to
        payments from governmental entities, both federal and state, for healthcare
        and/or prescription drug services. 

      


      


      5

      


      


      



      In
        providing the notice, the sponsor shall keep the government informed of when
        the
        integrity item is initiated and when it is closed. Notice should be provided
        of
        the details concerning any resolution and monetary payments as well as any
        settlement agreements or corporate integrity agreements.

       

      2.
        The MA
        Organization agrees to provide notice based on best knowledge, information,
        and
        belief to CMS in the event the; MA Organization or any of its subcontractors
        is
        criminally convicted or has a civil judgment entered against it for fraudulent
        activities or is sanctioned under any Federal program involving the provision
        of
        health care or prescription drug services.

       

      I.
        MARKETING

      1.
        The MA
        Organization may not distribute any marketing materials, as defined in 42
        CFR
        422.80(b) and in the Marketing Materials Guidelines for Medicare
        Advantage-Prescription Drug Plans and Prescription Drug Plans (Medicare
        Marketing Guidelines), unless they have been filed with and not disapproved
        by
        CMS in accordance with §422.80. The file and use process set out at
§422.80(a)(2) must be used, unless the MA organization notifies CMS that it
        will
        not use this process.

      2.
        CMS
        and the MA Organization shall agree upon language setting forth the benefits,
        exclusions and other language of the Plan. The MA Organization bears full
        responsibility for the accuracy of its marketing materials. CMS, in its sole
        discretion, may order the MA Organization to print and distribute the agreed
        upon marketing materials, in a format approved by CMS. The MA Organization
        must
        disclose the information to each enrollee electing a plan as outlined in
        42 CFR
        422. 111.

      3.
        The MA
        Organization agrees that any advertising material, including that labeled
        promotional material, marketing materials, or supplemental literature, shall
        be
        truthful and not misleading. All marketing materials must include the Contract
        number. All membership identification cards must include the Contract number
        on
        the front of the card.

      4.
        The MA
        Organization must comply with the Medicare Marketing Guidelines, as well
        as all
        applicable statutes and regulations, including and without limitation Section
        1851(h) of the Act and 42 CFR §§422.80, 422.111 and 423.50. Failure to comply
        may result in sanctions as provided in 42 CFR Part 422 Subpart 0.

      


      Article
        IV 

      


      CMS
        Payment to MA Organization

       

      A.
        The MA
        Organization agrees to develop its annual benefit and price bid proposal
        and
        submit to CMS all required information on premiums, benefits, and cost sharing,
        as required under 42 CFR Part 422 Subpart F.
        [422.504(a)(10)]

       

      B.
        Methodology.
        CMS
        agrees to pay the MA Organization under this contract in accordance with
        the
        provisions of section 1853 of the Act and 42 CFR Part 422 Subpart G.
        [422.504(a)(9)]

       

      


       

      


       

      6

       


      C.
        Attestation
        of
        payment data (Attachments A, B. and C).
        

      As
        a
        condition for receiving a monthly payment under paragraph B of this article,
        and
        42 CFR Part 422 Subpart G, the MA Organization agrees that its chief executive
        officer (CEO), or chief financial officer (CFO), or an individual delegated
        with
        the authority to sign on behalf of one of these officers, and who reports
        directly to such officer, must request payment under the contract on the
        forms
        attached as Attachment A (enrollment attestation) and Attachment B (risk
        adjustment data) hereto which attest to (based
        on best knowledge, information and belief, as of the date specified on the
        attestation form)
        the
        accuracy, completeness, and truthfulness of the data identified on these
        attachments. The Medicare Advantage Plan Attestation of Benefit Plan and
        Price
        must be signed and attached to the executed version of this
        contract.

      1.
        Attachment A requires that the CEO, or CFO, or an individual delegated with
        the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest based on best knowledge, information, and belief
        that each enrollee-for whom the MA Organization is requesting payment is
        validly
        enrolled, or was validly enrolled during the period for which payment is
        requested, in an MA plan offered by the MA Organization. The MA Organization
        shall submit completed enrollment attestation forms to CMS, or its contractor,
        on a monthly basis. (NOTE: The forms included as attachments to this contract
        are for reference only. CMS will provide instructions for the completion
        and
        submission of the forms in separate documents. MA Organizations should not
        take
        any action on the forms until appropriate CMS instructions become
        available.)

      2.
        Attachment B requires that: the CEO, or CFO, or an individual delegated with
        the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest
        to (based on best knowledge, information and belief, as of the date specified
        on
        the attestation form)
        that the
        risk adjustment data it submits to CMS under §422.310 are accurate, complete,
        and truthful. The MA Organization shall make annual attestations to this
        effect
        for risk adjustment data on Attachment B and according to a schedule to be
        published by CMS. If such risk adjustment data are generated by a related
        entity, contractor, or subcontractor of an MA Organization, such entity,
        contractor, or subcontractor must similarly attest
        to (based on best knowledge, information, and belief, as of the date specified
        on the attestation form)
        the
        accuracy, completeness, and truthfulness of the data. [422.504(1)]

      3.
        The
        Medicare Advantage Plan Attestation of Benefit Plan and Price (which is attached
        hereto) requires that the CEO, CFO, or an individual delegated with the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest (based
        on best knowledge, information and belief, as of the date specified on the
        attestation form)
        that the
        information and documentation comprising the bid submission proposal is
        accurate, complete, and truthful and fully conforms to the Bid Form and Plan
        Benefit Package requirements; and that the benefits described in the
        CMS-approved proposal bid submission agree with the benefit package the MA
        Organization will offer during the period covered by the proposal bid
        submission. This document is being sent separately to the MA Organization
        and
        must be signed and attached to the executed version of this contract, and
        is
        incorporated herein by reference. [422.502(1)]

       

       

      7

      


      


      



      Article
        V


      


      MA
        Organization Relationship with Related Entities, Contractors, and
        Subcontractors

       

      A.
        All
        references to "contracts" and "contractors" in this Article shall include
        deemed
        contracts (where applicable) and deemed contract providers (where applicable)
        as
        defined in §422.216(f).

       

      B.
        Notwithstanding any relationship(s) that the MA Organization may have with
        related entities, contractors, or subcontractors, the MA Organization maintains
        full responsibility for adhering to and otherwise fully complying with all
        terms
        and conditions of its contract with CMS.
        [422.504(i)(l)]

       

      C.
        The MA
        Organization agrees to require all related entities, contractors, or
        subcontractors to agree that—

      1.
        HHS,
        the Comptroller General, or their designees have the right to inspect, evaluate,
        and audit any pertinent contracts, books, documents, papers, and records
        of the
        related entity(s), contractors), or subcontractor(s) involving transactions
        related to this contract; and

      2.
        HHS,
        the Comptroller General, or their designees have the right to inspect, evaluate,
        and audit any pertinent information for any particular contract period for
        10
        years from the final date of the contract period or from the date of completion
        of any audit, whichever is later.
        [422.504(i)(2)]

       

      D.
        The MA
        Organization agrees that all contracts or written arrangements into which
        the MA
        Organization enters with providers, related entities, contractors, or
        subcontractors (first tier and downstream entities) shall contain the following
        elements:

      1.
        Enrollee protection provisions that provide—

      (a)
        Consistent with Article III(C), arrangements that prohibit providers from
        holding an enrollee liable for payment of any fees that are the legal obligation
        of the MA Organization; and

      (b)
        Consistent with Article III(C), provision for the continuation of
        benefits.

      2.
        Accountability provisions that indicate that—

      (a)
        The
        MA Organization oversees and is accountable to CMS for any functions or
        responsibilities that are described in these standards; and

      (b)
        The
        MA Organization may only delegate activities or functions to a provider,
        related
        entity, contractor, or subcontractor in a manner consistent with requirements
        set forth at paragraph D of this article.

      3.
        A
        provision requiring that any services or other activity performed by a related
        entity, contractor or subcontractor in accordance with a contract or written
        agreement between the related entity, contractor, or subcontractor and the
        MA
        Organization will be consistent and comply with the MA Organization's
        contractual obligations to CMS. [422.504(i)(3)]

       

      E.
        If any
        of the MA Organization's activities or responsibilities under this contract
        with
        CMS is delegated to other parties, the following requirements apply to any
        related entity, contractor, subcontractor, or provider:

       

      1.
        Written arrangements must specify delegated activities and reporting
        responsibilities.

       

       

      8

       

       

      2.
        Written arrangements must either provide for revocation of the delegation
        activities and reporting requirements or specify other remedies in instances
        where CMS or the MA Organization determine that such parties have not performed
        satisfactorily.

      3.
        Written arrangements must specify that the performance of the parties is
        monitored by the MA Organization on an ongoing basis.

      4.
        Written arrangements must specify that either—

      (a)
        The
        credentials of medical professionals affiliated with the party or parties
        will
        be either reviewed by the MA Organization; or

      (b)
        The
        provider verification process will be reviewed and approved by the MA
        Organization and the MA Organization must audit the provider verification
        process on an ongoing basis. The provider verification process will consist,
        at
        a minimum, of ensuring that providers have a state license to operate and
        be
        eligible for payment by Medicare.

      5.
        All
        contracts or written arrangements must specify that the related entity,
        contractor, or subcontractor must comply with all applicable Medicare laws,
        regulations, and CMS instructions.
        [422.504(i)(4)]

       

      F.
        If the
        MA Organization delegates selection of the providers, contractors, or
        subcontractors to another organization, the MA Organization's written
        arrangements with that organization must state that the MA Organization retains
        the right to approve, suspend, or terminate any such arrangement. [422.504(i)(5)]

      


       

      Article
        VI 

       

      Records
        Requirements

       

      A.
        MAINTENANCE OF RECORDS

      1.
        The MA
        Organization agrees to maintain for 10 years books, records, documents, and
        other

      evidence
        of accounting procedures and practices that—

      (a)
        Are
        sufficient to do the following:

      (i)
        Accommodate periodic auditing of the financial records (including data related
        to Medicare utilization, costs, and computation of the benefit and price
        bid) of
        the MA Organization.

      (ii)
        Enable CMS to inspect or otherwise evaluate the quality, appropriateness
        and
        timeliness of services performed under the contract, and the facilities of
        the
        MA Organization.

      (iii)
        Enable CMS to audit and inspect any books and records of the MA Organization
        that pertain to the ability of the organization to bear the risk of potential
        financial losses, or to services performed or determinations of amounts payable
        under the contract.

      (iv)
        Properly reflect all direct and indirect costs claimed to have been incurred
        and
        used in the preparation of the benefit and price bid proposal.

      (v)
        Establish component rates of the benefit and price bid for determining
        additional and supplementary benefits.

      (vi)
        Determine the rates utilized in setting premiums for State insurance agency
        purposes and for other government and private purchasers; and

      (b)
        Include at least records of the following:

      


       

      9

      



      (i)
        Ownership and operation of the MA Organization's financial, medical, and
        other
        record keeping systems.

      (ii)
        Financial statements for the current contract period and ten prior
        periods.

      (iii)
        Federal income tax or informational returns for the current contract period
        and
        ten prior periods.

      (iv)
        Asset acquisition, lease, sale, or other action.

      (v)
        Agreements, contracts (including, but not limited to with related or unrelated
        prescription drug benefit managers) and subcontracts.

      (vi)
        Franchise, marketing, and management agreements.

      (vii)
        Schedules of charges for the MA Organization's fee-for-service
        patients.

      (viii)
        Matters pertaining to costs of operations.

      (ix)
        Amounts of income received, by source and payment.

      (x)
        Cash
        flow statements.

      (xi)
        Any
        financial reports filed with other Federal programs or State authorities.
        [422.504(d)]
        

      2.
        Access
        to facilities and records.
        The MA
        Organization agrees to the following:

      (a)
        The
        Department of Health and Human Services (HHS), the Comptroller General, or
        their
        designee may evaluate, through inspection or other means—

      (i)
        The
        quality, appropriateness, and timeliness of services furnished to Medicare
        enrollees under the contract;

      (ii)
        The
        facilities of the MA Organization; and

      (iii)
        The
        enrollment and disenrollment records for the current contract period and
        ten
        prior periods.

      (b)
        HHS,
        the Comptroller General, or their designees may audit, evaluate, or inspect
        any
        books, contracts, medical records, documents, papers, patient care
        documentation, and other records of the MA Organization, related entity,
        contractor (including deemed contract providers as defined in §422.216(f)),
        subcontractor, or its transferee that pertain to any aspect of services
        performed, reconciliation of benefit liabilities, and determination of amounts
        payable under the contract, or as the Secretary may deem necessary to enforce
        the contract.

      (c)
        The
        MA Organization agrees to make available, for the purposes specified in section
        (A) of this article, its premises, physical facilities and equipment, records
        relating to its Medicare enrollees, and any additional relevant information
        that
        CMS may require, in a manner that meets CMS record maintenance
        requirements.

      (d)
        HHS,
        the Comptroller General, or their designee's right to inspect, evaluate,
        and
        audit extends through 10 years from the final date of the contract period
        or
        completion of audit, whichever is later unless-

      (i)
        CMS
        determines there is a special need to retain a particular record or group
        of
        records for a longer period and notifies the MA Organization at least 30
        days
        before the normal disposition date;

      (ii)
        There has been a termination, dispute, or fraud or similar fault by the MA
        Organization, in which case the retention may be extended to 10 years from
        the
        date of any resulting final resolution of the termination, dispute, or fraud
        or
        similar fault; or

      (iii)
        HHS, the Comptroller General, or their designee determines that there is
        a
        reasonable possibility of fraud, in which case they may inspect, evaluate,
        and
        audit the MA Organization at any time.
        [422.504(e)]

       

      10

       

      



      B.
        REPORTING REQUIREMENTS

      1.
        The MA
        Organization shall have an effective procedure to develop, compile, evaluate,
        and report to CMS, to its enrollees, and to the general public, at the times
        and
        in the manner that CMS requires, and while safeguarding the confidentiality
        of
        the doctor-patient relationship, statistics and other information as described
        in the remainder of this section (B).
        [422.516(a)]

       

      2.
        The MA
        Organization agrees to submit to CMS certified financial information that
        must
        include the following:

      (a)
        Such
        information as CMS may require demonstrating that the organization has a
        fiscally sound operation, including:

      (i)
        The
        cost of its operations;

      (ii)
        A
        description, submitted to CMS annually and within 120 days of the end of
        the
        fiscal year, of significant business transactions (as defined in §422.500)
        between the MA Organization and a party in interest showing that the costs
        of
        the transactions listed in paragraph (2)(a)(v) of this section do not exceed
        the
        costs that would be incurred if these transactions were with someone who
        is not
        a party in interest; or

      (iii)
        If
        they do exceed, a justification that the higher costs are consistent with
        prudent management and fiscal soundness requirements.

      (iv)
        A
        combined financial statement for the MA Organization and a party in interest
        if
        either of the following conditions is met:

      (aa)
        Thirty-five percent or more of the costs of operation of the MA Organization
        go
        to a party in interest.

      (bb)
        Thirty-five percent or more of the revenue of a party in interest is from
        the MA
        Organization.
        [422.516(b)]

      (v)Requirements
        for combined financial statements.

      (aa)
        The
        combined financial statements required by paragraph (2)(a)(iv) must display
        in
        separate columns the financial information for the MA Organization and each
        of
        the parties in interest.

      (bb)
        Inter-entity transactions must be eliminated in the consolidated
        column.

      (cc)
        The
        statements must have been examined by an independent auditor in accordance
        with
        generally accepted accounting principles and must include appropriate opinions
        and notes.

      (dd)
        Upon
        written request from the MA Organization showing good cause, CMS may waive
        the
        requirement that the organization's combined financial statement include
        the
        financial information required in paragraph (2)(a)(v) with respect to a
        particular entity.
        [422.516(c)]

      (vi)
        A
        description of any loans or other special financial arrangements the MA
        Organization makes with contractors, subcontractors, and related
        entities.

      (b)
        Such
        information as CMS may require pertaining to the disclosure of ownership
        and
        control of the MA Organization. [422.504(f)(l)(ii)]

      (c)
        Patterns of utilization of the MA Organization's services.

      3.
        The MA
        Organization agrees to participate in surveys required by CMS and to submit
        to
        CMS all information that is necessary for CMS to administer and evaluate
        the
        program and to simultaneously establish and facilitate a process for current
        and
        prospective beneficiaries to exercise choice in obtaining Medicare services.
        This information includes, but is not limited to:

      (a)
        The
        benefits covered under the MA plan;

      (b)
        The
        MA monthly basic beneficiary premium and MA monthly supplemental beneficiary
        premium, if any, for the plan.

       

      11

       

      



      (c)
        The
        service area and continuation area,' if any, of each plan and the enrollment
        capacity of each plan;

      (d)
        Plan
        performance indicators for the benefits under the plan including — (i)
        Disenrollment rates for Medicare enrollees electing to receive benefits through
        the plan
        for
        the previous 2 years;

      (ii)
        Information on Medicare enrollee satisfaction;

      (iii)
        The
        patterns of utilization of plan services;

      (iv)
        The
        availability, accessibility, and acceptability of the plan's
        services;

      (v)
        Information on health outcomes and other performance measures required by
        CMS;

      (vi)
        The
        recent record regarding compliance of the plan with requirements of this
        part,
        as determined
        by CMS; and

      (vii)
        Other information determined by CMS to be necessary to assist beneficiaries
        in
making
        an
        informed choice among MA plans and traditional Medicare;

      (e)
        Information about beneficiary appeals and their disposition;

      (f)
        Information regarding all formal actions, reviews, findings, or other similar
        actions by States, other regulatory bodies, or any other certifying or
        accrediting organization;

      (g)
        Any
        other information deemed necessary by CMS for the administration or evaluation
        of the Medicare program.
        [422.504(f)(2)]

       

      4.
        The MA
        Organization agrees to provide to its enrollees and upon request, to any
        individual eligible to elect an MA plan, all informational requirements under
        §422.64 and, upon an enrollee's, request, the financial disclosure information
        required under §422.516.
        (422.504(f)(3)]

      5.
        Reporting
        and disclosure under ERISA.

      (a)
        For
        any employees' health benefits plan that includes an MA Organization in its
        offerings, the MA Organization must furnish, upon request, the information
        the
        plan needs to fulfill its reporting and disclosure obligations (with respect
        to
        the MA Organization) under the Employee Retirement Income Security Act of
        1974
        (ERISA).

      (b)
        The
        MA Organization must furnish the information to the employer or the employer's
        designee, or to the plan administrator, as the term "administrator" is defined
        in ERISA. [422.516(d)]

      6.
        Electronic
        communication.
        The MA
        Organization must have the capacity to communicate with CMS
        electronically.
        [422.504(b)j

      7.
        Risk
        Adjustment data. The MA Organization agrees to comply with the requirements
        in
§422.310 for submitting risk adjustment data to CMS.
        [422.504(a)(8)]

       

      


      Article
        VII 

       

      Renewal
        of the MA Contract

       

      A.
        Renewal
        of contract:
        In
        accordance with §422.505, following the initial contract period, this contract
        is renewable annually only if-

       

      (1)
        The
        MA Organization has not provided CMS with a notice of intention not to renew;
        [422.506(a)]

       

      12

       

      



      (2)
        CMS
        and the MA Organization reach-agreement on the bid under 42 CFR Part 422
        Subpart
        F; and
        [422.505(d)]

      (3)
        CMS
        informs the MA Organization that it authorizes a renewal.

       

      B.
        Nonrenewal of contract

      (1)
        Nonrenewal
        by the Organization.

      (a)
        In
        accordance with §422.506, the MA Organization may elect not to renew its
        contract with CMS as of the end of the term of the contract for any reason,
        provided it meets the time frames for doing so set forth in subparagraphs
        (b)
        and (c) of this paragraph.

      (b)
        If
        the MA Organization does not intend to renew its contract, it must
        notify—

      (i)
        CMS,
        in writing, by the first Monday in June of the year in which the contract
        would
        end, pursuant to §422.506;

      (ii)
        Each
        Medicare enrollee, at least 90 days before the date on which the nonrenewal
        is
        effective. This notice must include a written description of all alternatives
        available for obtaining Medicare services within the service area including
        alternative MA plans, Medigap options, and original Medicare and prescription
        drug plans and must receive CMS approval prior to issuance.

      (iii)
        The
        general public, at least 90 days before the end of the current calendar year,
        by
        publishing a CMS-approved notice in one or more newspapers of general
        circulation in each community located in the MA Organization's service
        area.

      (c)
        CMS
        may accept a nonrenewal notice submitted after the applicable annual non-renewal
        notice deadline if —

      (i)
        The
        MA Organization notifies its Medicare enrollees and the public in accordance
        with subparagraph (l)(b)(ii) and (l)(b)(iii) of this section; and

      (ii)
        Acceptance is not inconsistent with the effective and efficient administration
        of the Medicare program.

      (d)
        If
        the MA Organization does not renew a contract under subparagraph (1), CMS
        will
        not enter into an MA contract with the Organization for 2 years from the
        date of
        contract separation unless there are special circumstances that warrant special
        consideration, as determined by CMS. [422.506(a)]

      (2)
        CMS
        decision not to renew.

      (a)
        CMS
        may elect not to authorize renewal of a contract for any of the following
        reasons:

      (i)
        The
        MA Organization's level of enrollment, growth in enrollment, or insufficient
        number of contracted providers is determined by CMS to threaten the viability
        of
        the organization under the MA program and or be an indicator of beneficiary
        dissatisfaction with the MA plan(s) offered by the organization.

      (ii)
        For
        any of the reasons listed in §422.510(a) [Article VIII, section (B)(l)(a) of
        this contract], which would also permit CMS to terminate the
        contract.

      (iii)
        The
        MA Organization has committed any of the acts in §422.752(a) that would support
        the imposition of intermediate sanctions or civil money penalties under 42
        CFR
        Part 422 Subpart 0.

      (iv)
        The
        MA Organization did not submit a benefit and price bid or the benefit and
        price
        bid was not acceptable.

       

      13

       

      



      (b)
        Notice.
        CMS
        shall provide notice of its decision whether to authorize renewal of the
        contract as follows:

      (i)
        To
        the MA Organization by May 1 of the contract year, except in the event of
        (2)(a)(iv) above, for which notice will be sent by September 1.

      (ii)
        To
        the MA Organization's Medicare enrollees by mail at least 90 days before
        the end
        of the current calendar year.

      (iii)
        To
        the general public at least 90 days before the end of the current calendar
        year,
        by publishing a notice in one or more newspapers of general circulation in
        each
        community or county located in the MA Organization's service area.

      (c)
        Notice
        of appeal rights.
        CMS
        shall give the MA Organization written notice of its right to reconsideration
        of
        the decision not to renew in accordance with §422.644. [422.506(b)]

      


       

      Article
        VIII 

       

      Modification
        or Termination of the Contract

       

      A.
        Modification or Termination of Contract by Mutual Consent

      1.
        This
        contract may be modified or terminated at any time by written mutual
        consent.

      (a)
        If
        the contract is modified by written mutual consent, the MA Organization must
        notify its Medicare enrollees of any changes that CMS determines are appropriate
        for notification within time frames specified by CMS. [422.508(a)(2)]

      (b)
        If
        the contract is terminated by written mutual consent, except as provided
        in
        section (A)(2) of this Article, the MA Organization must provide notice to
        its
        Medicare enrollees and the general public as provided in section B(2)(b)(ii)
        and
        B(2)(b)(iii) of this Article.
        [422.508(a)(l)]

      2.
        If
        this contract is terminated by written mutual consent and replaced the day
        following such termination by a new MA contract, the MA Organization is not
        required to provide the notice specified in section B of this article.
[422.508(b)]

       

      B.
        Termination of the Contract by CMS or the MA Organization 1. Termination
        by CMS.

      (a)
        CMS
        may terminate a contract for any of the following reasons:

      (i)
        The
        MA Organization has failed substantially to carry out the terms of its contract
        with CMS.

      (ii)
        The
        MA Organization is carrying out its contract with CMS in a manner that is
        inconsistent with the effective and efficient implementation of 42 CFR Part
        422.

      (iii)
        CMS
        determines that the MA Organization no longer meets the requirements of 42
        CFR
        Part 422 for being a contracting organization.

      (iv)
        There is credible evidence that the MA Organization committed or participated
        in
        false, fraudulent or abusive activities affecting the Medicare program,
        including submission of false or fraudulent data.

      (v)
        The
        MA Organization experiences financial difficulties so severe that its ability
        to
        make necessary health services available is impaired to the point of posing
        an
        imminent and serious risk to the health of its enrollees, or otherwise fails
        to
        make services available to the extent that such a risk to health
        exists.

       

      14

       

      



      (vi)
        The
        MA Organization substantially fails to comply with the requirements in 42
        CFR
        Part 422 Subpart M relating to grievances and appeals.

      (vii)
        The
        MA Organization fails to provide CMS with valid risk adjustment data as required
        under §422.310 and 423.329(b)(3).

      (viii)
        The MA Organization substantially fails to comply with the prompt payment
        requirements in §422.520.

      (ix)
        The
        MA Organization substantially fails to comply with the service access
        requirements in §422.114.

      (x)
        The
        MA Organization fails to comply with the requirements of §422.208 regarding
        physician incentive plans.

      (xi)
        The
        MA Organization substantially fails to comply with the marketing requirements
        in
§422.80.

      (b)
        Notice.
        If CMS
        decides to terminate a contract for reasons other than the grounds specified
        in
        section (B)(l)(a) above, it will give notice of the termination as
        follows:

      (i)
        CMS
        will notify the MA Organization in writing 90 days before the intended date
        of
        the termination.

      (ii)
        The
        MA Organization will notify its Medicare enrollees of the termination by
        mail at
        least 30 days before the effective date of the termination.

      (iii)
        The
        MA Organization will notify the general public of the termination at least
        30
        days before the effective date of the termination by publishing a notice
        in one
        or more newspapers of general circulation in each community or county located
        in
        the MA Organization's service area.

      (c)
        Immediate
        termination of contract by CMS.

      (i)
        For
        terminations based on violations prescribed in paragraph (B)(l)(a)(v) of
        this
        article, CMS will notify the MA Organization in writing that its contract
        has
        been terminated effective the date of the termination decision by CMS. If
        termination is effective in the middle of a month, CMS has the right to recover
        the prorated share of the capitation payments made to the MA Organization
        covering the period of the month following the contract
        termination.

      (ii)
        CMS
        will notify the MA Organization's Medicare enrollees in writing of CMS' decision
        to terminate the MA Organization's contract. This notice will occur no later
        than 30 days after CMS notifies the plan of its decision to terminate this
        contract. CMS will simultaneously inform the Medicare enrollees of alternative
        options for obtaining Medicare services, including alternative MA Organizations
        in a similar geographic area and original Medicare.

      (iii)
        CMS
        will notify the general public of the termination no later than 30 days after
        notifying the MA Organization of CMS' decision to terminate this contract.
        This
        notice will be published in one or more newspapers of general circulation
        in
        each community or county located in the MA Organization's service
        area.

      (d)
        Corrective
        action plan

      (i)
        General.
        Before
        terminating a contract for reasons other than the grounds specified in section
        (B)(l)(a)(v) of this article, CMS will provide the MA Organization with
        reasonable opportunity, not to exceed time frames specified at 42 CFR Part
        422
        Subpart N, to develop and receive CMS approval of a corrective action plan
        to
        correct the deficiencies that are the basis of the proposed
        termination.

       

      15

       

      



      (ii)
        Exception.
        If a
        contract is terminated under section (B)(l)(a)(v) of this article, the MA
        Organization will not have the opportunity to submit a corrective action
        plan.

      (e)
        Appeal
        rights.
        IfCMS
        decides to terminate this contract, it will send written notice to the MA
        Organization informing it of its termination appeal rights in accordance
        with 42
        CFR Part 422 Subpart N.
        [422.510] 2.
        Termination by the MA Organization

      (a)
        Cause
        for termination.
        The MA
        Organization may terminate this contract ifCMS fails to substantially carry
        out
        the terms of the contract.

       

      (b)
        Notice.
        The MA
        Organization must give advance notice as follows:

      (i)
        To
        CMS, at least 90 days before the intended date of termination. This notice
        must
        specify the reasons why the MA Organization is requesting contract
        termination.

      (ii)
        To
        its Medicare enrollees, at least 60 days before the termination effective
        date.
        This notice must include a written description of alternatives available
        for
        obtaining Medicare services within the service area, including alternative
        MA
        and MA-PD plans, PDP plans, Medigap options, and original Medicare and must
        receive CMS approval.

      (iii)
        To
        the general public at least 60 days before the termination effective date
        by
        publishing a CMS-approved notice in one or more newspapers of general
        circulation in each community or county located in the MA Organization's
        geographic area.

      c)
        Effective
        date of termination.
        The
        effective date of the termination will be determined by CMS and will be at
        least
        90 days after the date CMS receives the MA Organization's notice of intent
        to
        terminate.

      (d)
        CMS'
        liability.
        CMS'
        liability for payment to the MA Organization ends as of the first day of
        the
        month after the last month for which the contract is in effect, but CMS shall
        make payments for amounts owed prior to termination but not yet
        paid.

      (e)
        Effect
        of termination by the organization.
        CMS will
        not enter into an agreement with the MA Organization for a period of two
        years
        from the date the Organization has terminated this contract, unless there
        are
        circumstances that warrant special consideration, as determined by CMS.
[422.512]

      


       

      Article
        IX 

       

      Restrictions
        on Use of Data

       

      The
        MA
        Organization agrees that its use of the data it is authorized to collect
        to
        carry out the terms of this contract shall be used exclusively for the purpose
        of operating its MA private fee-for-service plan. The MA Organization may
        not
        use data collected under this contract in the operation of any other line
        of
        business offered by the MA Organization or its related entities, contractors,
        or
        subcontractors.

       

      16

       

      



      Article
        X


       

      Requirements
        of Other Laws and Regulations

       

      A.
        The MA
        Organization agrees to comply with—

      (1)
        Federal laws and regulations designed to prevent or ameliorate fraud, waste,
        and
        abuse, including, but not limited to, applicable provisions of Federal criminal
        law, the False Claims Act (31 USC 3729 et seq.), and the anti-kickback statute
        (section 1128B(b) of the Act):

      and

      (2)
        HIPAA
        administrative simplification rules at 45 CFR Parts 160, 162, and 164.
[422.504(h)]

       

      B.
        The MA
        Organization maintains ultimate responsibility for adhering to and otherwise
        fully complying with all terms and conditions of its contract with CMS,
        notwithstanding any relationship(s) that the MA organization may have with
        related entities, contractors, or subcontractors.
        [422.504(i)]

       

      C.
        In the
        event that any provision of this contract conflicts with the provisions of
        any
        statute or regulation applicable to an MA Organization, the provisions of
        the
        statute or regulation shall have full force and effect.

      


      Article
        XI Severability

       

      The
        MA
        Organization agrees that, upon CMS' request, this contract will be amended
        to
        exclude any MA plan or State-licensed entity specified by CMS, and a separate
        contract for any such excluded plan or entity will be deemed to be in place
        when
        such a request is made.
        [422.504(k)]

      


      Article
        XI

       

      Miscellaneous

       

      A.
        Definitions. Terms not otherwise defined in this contract shall have the
        meaning
        given to such terms in 42 CFR Part 422.

      B.
        Alteration to Original Contract Terms. The MA Organization agrees that it
        has
        not altered in any way the terms of this contract presented for signature
        by
        CMS. The MA Organization agrees that any alterations to the original text
        the MA
        Organization may make to this contract shall not be binding on the
        parties.

      C.
        Approval to Begin Marketing and Enrollment. The MA Organization agrees that
        it
        must complete CMS operational requirements prior to receiving CMS approval
        to
        begin Part C marketing and enrollment activities. Such activities include,
        but
        are not limited to, establishing and successfully testing connectivity with
        CMS
        systems to process enrollment applications (or contracting with an entity
        qualified to perform such functions on the MA Organization's Sponsor's behalf)
        and successfully demonstrating capability to submit accurate and timely
        price

       

      17

       

      



      comparison
        data. To establish and successfully test connectivity, the MA Organization
        must,


       1)
        establish and test physical connectivity to the CMS data center, 2) acquire
        user
        identifications and
        passwords, 3) receive, store, and maintain data necessary to perform enrollments
        and send and
        receive transactions to and from CMS, and 4) check and receive transaction
        status information.

      D.
        Incorporation of Applicable Addenda. All addenda checked off and initialed
        on
        the cover sheet
        of
        this contract by the MA Organization are hereby incorporated by
        reference.

       

      18



     

    



    In
      witness whereof, the parties hereby execute this contract. 

    FOR
      THE
      MA ORGANIZATION

     

    
      	
              Todd
                S. Farha 

              Printed
                Name

            	
              President
                and CEO

              Title

               

            
	
                
                /s/ Todd S. Farha    

              Signature

            	
              9/14/06

              Date

               

            
	
              Homeowner’s/WellCare
                PFFS Insurance, Inc.

              Organization

            	
              8735
                Henderson Rd Tampa, FL 33634

              Address

            
	 	 
	
              FOR
                THE CENTERS FOR MEDICARE & MEDICAID SERVICES

            
	
               

              /s/  
                David Lewis 

              David
                A. Lewis

              Acting
                Director

              Medicare
                Advantage Group

              Center
                for Beneficiary Choices

            	
               

              9/25/06

              Date

            


    

     

     


    19

    


    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

      ATTACHMENT
        A

       

      ATTESTATION
        OF ENROLLMENT INFORMATION RELATING TO CMS PAYMENT TO A MEDICARE ADVANTAGE
        ORGANIZATION

       

      Pursuant
        to the contract(s) between the Centers for Medicare & Medicaid Services
        (CMS) and (INSERT
        NAME OF MA ORGANIZATION),
        hereafter referred to as the MA Organization, governing the operation of
        the
        following Medicare Advantage plans (INSERT
        PLAN IDENTIFICATION NUMBERS HERE),
        the MA
        Organization hereby requests payment under the contract, and in doing so,
        makes
        the following attestation concerning CMS payments to the MA Organization.
        The MA
        Organization acknowledges that the information described below directly affects
        the calculation of CMS payments to the MA Organization and that
        misrepresentations to CMS about the accuracy of such information may result
        in
        Federal civil action and/or criminal prosecution. This attestation shall
        not be
        considered a waiver of the MA Organization's right to seek payment adjustments
        from CMS based on information or data which does not become available until
        after the date the MA Organization submits this attestation.

       

      1.
        The MA
        Organization has reported to CMS for the month of (INDICATE MONTH AND
        YEAR)
        all new
        enrollments, disenrollments, and changes in enrollees' institutional status
        with
        respect to the above-stated MA plans. Based on best knowledge, information,
        and
        belief, all information submitted to CMS in this report is accurate, complete,
        and truthful.

       

      2.
        The MA
        Organization has reviewed the CMS monthly membership report and reply listing
        for the month of (INDICATE MONTH AND YEAR) for the above-stated MA plans
        and has
        reported to CMS any discrepancies between the report and the MA Organization's
        records. For those portions of the monthly membership report and the reply
        listing to which the MA Organization raises no objection, the MA Organization,
        through the certifying CEO/CFO, will be deemed to have attested, based on
        best
        knowledge, information, and belief, as of the date indicated below, to their
        accuracy, completeness, and truthfulness.

      


      


      


      To
        be
        signed monthly by CFO

      (INDICATE
        TITLE [CEO or CFO, or person delegated to sign for either officer])

       

      (INDICATE
        MA ORGANIZATION)

       

      20

       

      


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      ATTACHMENT
        B

       

      ATTESTATION
        OF RISK ADJUSTMENT DATA INFORMATION RELATING TO CMS PAYMENT TO A MEDICARE
        ADVANTAGE ORGANIZATION

       

      Pursuant
        to the contract(s) between the Centers for Medicare & Medicaid Services
        (CMS) and (INSERT
        NAME OF MA ORGANIZATION),
        hereafter referred to as the MA Organization, governing the operation of
        the
        following Medicare Advantage plans (INSERT
        PLAN IDENTIFICATION NUMBERS HERE),
        the MA
        Organization hereby requests payment under the contract, and in doing so,
        makes
        the following attestation concerning CMS payments to the MA Organization.
        The MA
        Organization acknowledge-s that the information described below directly
        affects
        the calculation of CMS payments to the MA Organization or additional benefit
        obligations of the MA Organization and that misrepresentation to CMS about
        the
        accuracy of such information may result in Federal civil action and/or criminal
        prosecution.

       

      The
        MA
        Organization has reported to CMS for the period of (INDICATE DATES) all
        (INDICATE TYPE OF D AT'A
        -INPATIENT HOSPITAL, OUTPATIENT HOSPITAL. OR PHYSICIAN)
        risk
        adjustment data available to the MA Organization with respect to the
        above-stated MA plans. Based on best knowledge, information, and belief that,
        as
        of the date indicated below, all information submitted to CMS in this report
        is
        accurate, complete, and truthful.

      


      


      


      To
        be
        signed by CFO 

      (INDICATE
        TITLE [CEOor
        CFO,
        or person delegated to sign for either officer]) 

       

      (INDICATE
        MA ORGANIZATION)

       

      21

    

    


     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
 

    [SAMPLE
      - DO NOT USE
      - THIS DOCUMENT WILL BE
      SENT
      DIRECTLY TO THE MAO THROUGH HPMS] ATTACHMENT
      C
      -
      Medicare Advantage Plan Attestation of Benefit Plan and Price

    


    <Legal
      Entity Name>

    <Contract
      #>

    


    Date:
      <XX/XX/XXXX>

     

    I
      attest
      that the following plan numbers as established in the final Plan Benefit Package
      (PBP) will be operated by the above-stated organization and made available
      to
      eligible Medicare beneficiaries in the approved service area during program
      year
      2007.

     

    
      	
              Plan
                ID

            	
              Segment
                ID

            	
              Version

            	
              Plan
                Name

            	
              Plan
                Type

            	
              Transaction
                Type

            	
              MA
                Premium

            	
              Part
                D Premium

            	
              CMS
                Approval
                Date

            	
              Effective
                Date

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            


    

    


    


    



    
      	
              CEO

            	 	
              CFO

            	 
	 	 	 	 
	
              <Name
                of CEO>

            	
              Date

            	
              <Name
                of CEO>

            	
              Date

            
	
              <Title>

            	 	
              <Title>

            	 
	
              <Address
                1>

            	 	
              <Address
                1>

            	 
	
              <Address
                2>

            	 	
              <Address
                2>

            	 
	
              <City,
                State Zip>

            	 	
              <City,
                State Zip>

            	 
	
              <Phone
                #>

            	 	
              <Phone
                #>

            	 


    

     

    22

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    ADDENDUM
      TO MEDICARE MANAGED CARE CONTRACT PURSUANT 

    TO
      SECTIONS 1860D-1 THROUGH 1860D-42 OF THE SOCIAL SECURITY ACT


    FOR
      THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG
      PLAN

     

    The
      Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")
      and HomeOwner’s
      WellCare PFFS Ins. Inc. ,
      a
      Medicare managed care organization (hereinafter referred to as the MA-PD
      Sponsor) agree to amend the contract (INSERT
      "H.OR "R" NUMBER)
      governing the MA-PD Sponsor's operation of a Part C plan described in Section
      1851(a)(2)(A) of the Social Security Act (hereinafter referred to as "the Act")
      or a Medicare cost plan to include this addendum under which the MA-PD Sponsor
      shall operate a Voluntary Medicare Prescription Drug Plan pursuant to sections
      1860D-1 through 1860D-42 (with the exception of section 1860D-22 and 1860D-31)
      of the Act.

     

    This
      addendum is made pursuant to Subpart L of 42 CFR Part 417 (in the case of cost
      plan sponsors offering a Part D benefit) and Subpart K- of 42 CFR Part 422
      (in
      the case of an MA-PD Sponsor offering a Part C plan).

     

    NOTE:
      For
      purposes of this addendum, unless otherwise noted, reference to an "MA-PD
      Sponsor" or "MA-PD Plan" is deemed to include a cost plan sponsor or a MA
      private fee-for-service contractor offering a Part D benefit.

     

    



    Article
      I 

    Medicare
      Voluntary Prescription Drug Benefit

     

    A.
      The
      MA-PD Sponsor agrees to operate one or more Medicare Voluntary Prescription
      Drug
      Plans as described in its application and related materials, including but
      not
      limited to all the attestations contained therein and all supplemental guidance,
      for Medicare approval and in compliance with the provisions of this addendum,
      which incorporates in its entirety the Solicitation
      For Applications for New Medicare Advantage Prescription Drug Plan (MA-PD)
      Sponsors, released on January 24, 2006 [applicable
      to Medicare Part C contractors] or the Solicitation
      for Applications for New
      Cost
      Plan Sponsors, released on January 24. 2006 [applicable to Medicare cost plan
      contractors] (hereinafter collectively referred to as "the addendum"). The
      MA-PD
      Sponsor also agrees to operate in accordance witlrthe regulations at 42 CFR
      §423.1 through 42 CFR §423.910 (with the exception ofSubparts Q, R, and S),
      sections 1860D-1 through 1860D-42 (with the exception of sections 1860D-22(a)
      and 1860D-31) of the Social Security Act, and the applicable solicitation
      identified above, as well as all other applicable Federal statutes, regulations,
      and policies. This addendum is deemed to incorporate any changes that are
      required by statute to be implemented during the term of this addendum and
      any
      regulations or policies implementing or interpreting such statutory
      provisions.

     

    B.
      CMS
      agrees to perform its obligations to the MA-PD Sponsor consistent with the
      regulations at 42 CFR §423.1 through 42 CFR §423.910 (with the exception of
      Subparts Q, R, and S), sections 1860D-1 through 1860D-42 (with the exception
      of
      sections 1860D-22(a) and 1860D-31) of the Social Security Act, and the
      applicable solicitation, as well as all other applicable Federal statutes,
      regulations, and policies.

     

    C.
      CMS
      agrees that it will not implement, other than at the beginning of a calendar
      year, regulations under 42 CFR Part 423 that impose new, significant regulatory
      requirements on the MA-PD Sponsor. This provision does not apply to new
      requirements mandated by statute.

     

    D.
      This
      addendum is in no way intended to supersede or modify 42 CFR, Parts 417, 422
      or
      423. Failure to reference a regulatory requirement in this addendum does not
      affect the applicability of such requirements to the MA-PD Sponsor and
      CMS.

     

    


    Article
      II 

    Functions
      to be Performed by the MA-PD Sponsor

     

    A.
      ENROLLMENT

     

    1.
      MA-PD
      Sponsor agrees to enroll in its MA-PD plan only Part D-eligible

    beneficiaries
      as they are defined in 42 CFR §423.30(a) and who have elected to enroll in MA-PD
      Sponsor's Part C or Section 1876 benefit.

    


    2

    


     


    2.
      If the
      MA-PD Sponsor is a cost plan sponsor, the MA-PD Sponsor acknowledges that its
      Section 1876 plan enrollees are not required to elect enrollment in its Part
      D
      plan.

     

    B.
      PRESCRIPTION DRUG BENEFIT

     

    1.
      MA-PD
      Sponsor agrees to provide the required prescription drug coverage as defined
      under 42 CFR §423.100 and, to the extent applicable, supplemental benefits as
      defined in 42 CFR §423.100 and in accordance with Subpart C of 42 CFR Part 423.
      MA-PD Sponsor also agrees to provide Part D benefits as described in the MA-PD
      Sponsor's Part D bid(s) approved each year by CMS (and in the Attestation of
      Benefit Plan and Price, attached hereto).

    2.
      MA-PD
      Sponsor agrees to calculate and collect beneficiary Part D premiums in
      accordance with 42 CFR §§423.286 and 423.293.

    3.
      If the
      MA-PD Sponsors is a cost plans sponsor, it acknowledge that its Part D benefit
      is offered as an optional supplemental service in accordance with 42 CFR
§417.440(b)(2)(n).

     

    C.
      DISSEMINATION OF PLAN INFORMATION

     

    1.
      MA-PD
      Sponsor agrees to provide the information required in 42 CFR
§423.48.

     

    2.
      MA-PD
      Sponsor agrees to disclose information related to Part D benefits to
      beneficiaries in the manner and the form specified by CMS under 42 CFR §§423.128
      and 423.50 and in the "Marketing Materials Guidelines for Medicare
      Advantage-Prescription Drug Plans (MA-PDs) and Prescription Drug Plans
      (PDPs)."

     

    3.
      MA-PD
      Sponsor certifies that all materials it submits to CMS under the File and Use
      Certification authority described in the Marketing Materials Guidelines are
      accurate, truthful, not misleading, and consistent with CMS marketing
      guidelines.

     

    D.
      QUALITY ASSURANCE/UTILIZATION MANAGEMENT

     

    MA-PD
      Sponsor agrees to operate quality assurance, cost, and utilization management,
      medication therapy management programs, and support electronic prescribing
      in
      accordance with Subpart D of 42 CFR Part 423.

     

    E.
      APPEALS AND GRIEVANCES

     

    MA-PD
      Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part
      423
      governing coverage determinations, grievances and appeals, and formulary
      exceptions. MA-PD Sponsor acknowledges that these requirements are separate
      and
      distinct from the appeals and grievances requirements applicable to the MA-PD
      Sponsor through the operation of its Part C or cost plan benefits.

     

     

    3

     


    F.
      PAYMENT TO MA-PD SPONSOR

     

    1.
      MA-PD
      Sponsor and CMS agree that payment paid for Part D services under the addendum
      will be governed by the rules in Subpart G of 42 CFR Part 423.

     

    2.
      If the
      MA-PD Sponsor is participating in the Part D Reinsurance Payment

    Demonstration,
      described in 70 FR 9360 (Feb. 25, 2005), it affirms that it will not seek
      payment under the demonstration for services provided to employer group
      enrollees.

     

    G.
      BID
      SUBMISSION AND REVIEW

     

    If
      the
      MA-PD Sponsor intends to participate in the Part D program for the future year,
      MA-PD Sponsor agrees to submit a future year's Part D bid, including all
      required information on premiums, benefits, and cost-sharing, by the applicable
      due date, as provided in Subpart F of 42 CFR Part 423 so that CMS and the MA-PD
      Sponsor may conduct negotiations regarding the terms and conditions of the
      proposed bid and benefit plan renewal. MA-PD Sponsor acknowledges that failure
      to submit a timely bid under this section may affect the sponsor's ability
      to
      offer a Part C plan, pursuant to the provisions of 42 CFR
§422.4(c).

     

    H.
      COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

     

    1.
      MA-PD
      Sponsor agrees to comply with the coordination requirements with State Pharmacy
      Assistance Programs (SPAPs) and plans that provide other prescription drug
      coverage as described in Subpart J of 42 CFR Part 423.

     

    2.
      MA-PD
      Sponsor agrees to comply with Medicare Secondary Payer procedures as stated
      in
      42 CFR §423.462.

     

    I.
      SERVICE AREA AND PHARMACY ACCESS

     

    1.
      The
      MA-PD Sponsor agrees to provide Part D benefits in the service area for which
      it
      has been approved by CMS to offer Part C or cost plan benefits utilizing a
      pharmacy network and formulary approved by CMS that meet the requirements of
      42
      CFR §423.120.

     

    2.
      The
      MA-PD Sponsor agrees to ensure adequate access to Part D-covered drugs at
      out-of-network pharmacies according to 42 CFR §423.124.

     

    3.
      MA-PD
      Sponsor agrees to provide benefits by means ofpoint-of-service systems to
      adjudicate prescription drug claims in a timely and efficient manner in
      compliance with CMS standards, except when necessary to provide access in
      underserved areas, I/T/U pharmacies (as defined in 42 CFR §423.100), and
      long-term care pharmacies (as defined in 42 CFR §423.100).

     

    4

     

    4.
      MA-PD
      Sponsor agrees to contract with any pharmacy that meets the MA-PD Sponsor's
      reasonable and relevant standard terms and conditions. If MA-PD Sponsor has
      demonstrated that it historically fills 98% or more of its enrollees'
      prescriptions at pharmacies owned and operated by the MA-PD Sponsor (or presents
      compelling circumstances that prevent the sponsor from meeting the 98% standard
      or demonstrates that its Part D plan design will enable the sponsor to meet
      the
      98% standard during the contract year), this provision does not apply to MA-PD
      Sponsor's plan.

     

    5.
      The
      provisions of 42 CFR §423.120(a) concerning the TRICARE retail pharmacy access
      standard do not apply to MA-PD Sponsor if the Sponsor has demonstrated to CMS
      that it historically fills more than 50% of its enrollees' prescriptions at
      pharmacies owned and operated by the MA-PD Sponsor. MA-PD Sponsors excused
      from
      meeting the TRICARE standard are required to demonstrate retail pharmacy access
      that meets the requirements of 42 CFR §422.112 for a Part C contractor and 42
      CFR §417.416(e) for a cost plan contractor.

     

    J.
      COMPLIANCE PLAN/PROGRAM INTEGRITY

     

    MA-PD
      Sponsor agrees that it will develop and implement a compliance plan that applies
      to its Part D-related operations, consistent with 42 CFR
§423.504(b)(4)(vi).

     

    K.
      LOW-INCOME SUBSIDY

     

    MA-PD
      Sponsor agrees that it will participate in the administration of subsidies
      for
      low-income individuals according to Subpart P of 42 CFR Part 423.

     

    L.
      BENEFICIARY FINANCIAL PROTECTIONS

     

    The
      MA-PD
      Sponsor agrees to afford its enrollees protection from liability for payment
      of
      fees that are the obligation of the MA-PD Sponsor in accordance with 42 CFR
      §423.505(g).

     

    M.
      RELATIONSHIP WITH RELATED ENTITIES, CONTRACTORS, AND SUBCONTRACTORS

     

    1.
      The
      MA-PD Sponsor agrees that it maintains ultimate responsibility for adhering
      to
      and otherwise fully complying with all terms and conditions of this
      addendum.

     

    2.
      The
      MA-PD Sponsor shall ensure that any contracts or agreements with

    subcontractors
      or agents performing functions on the MA-PD Sponsor's behalf related to the
      operation of the Part D benefit are in compliance with 42 CFR
§423.505(1).

    


     

    


    5

     


    N.
      CERTIFICATION OF DATA THAT DETERMINE PAYMENT MA-PD
      Sponsor must provide certifications in accordance with 42 CFR
§423.505(k).

     

    Article
      III

    Record
      Retention and Reporting Requirements

     

    A.
      MAINTENANCE OF RECORDS

     

    MA-PD
      Sponsor agrees to maintain records and provide access in accordance with 42
      CFR
§§423.504(d) and 505(d) and (e).

     

    B.
      GENERAL REPORTING REQUIREMENTS

     

    The
      MA-PD
      Sponsor agrees to submit to information to CMS according to 42 CFR §§423.505(1),
      423.514, and the "Final Medicare Part D Reporting Requirements," a document
      issued by CMS and subject to modification each program year.

     

    C.
      CMS
      LICENSE FOR USE OF PLAN FORMULARY

     

    PDP
      Sponsor agrees to submit to CMS each plan's formulary information, including
      any
      changes to its formularies, and hereby grants to the Government[ and any person
      or entity who might receive the formulary from the Government,] a non-exclusive
      license to use all or any portion of the formulary for any purpose related
      to
      the administration of the Part D program, including without limitation publicly
      distributing, displaying, publishing or reconfiguration of the information
      in
      any medium, including www.medicare.gov, and by any electronic, print or other
      means of distribution.

     

    


    Article
      IV HIPAA Transactions/Privacy/Security

     

    A.
      MA-PD
      Sponsor agrees to comply with the confidentiality and enrollee record accuracy
      requirements specified in 42 CFR §423.136.

     

    B.
      MA-PD
      Sponsor agrees to enter into a business associate agreement with the entity
      with
      which CMS has contracted to track Medicare beneficiaries' true out-of-pocket
      costs.

    
 

     

    6

     

    


    Article
      V 

    Addendum
      Term and Renewal

     

    A.
      TERM
      OF ADDENDUM

     

    This
      addendum is effective from the date ofCMS' authorized representative's signature
      through December 31, 2007. This addendum shall be renewable for successive
      one-year periods thereafter according to 42 CFR §423.506. MA-PD Sponsor shall
      not conduct Part D-related marketing activities prior to October 1, 2006 and
      shall not process enrollment applications prior to November 15, 2006. MA-PD
      Sponsor shall begin delivering Part D benefit services on January 1,
      2007.

     

    B.
      QUALIFICATION TO RENEW ADDENDUM

     

    1.
      In
      accordance with 42 CFR §423.507, the MA-PD Sponsor will be determined qualified
      to renew this addendum annually only if—

    (a)
      CMS
      informs the MA-PD Sponsor that it is qualified to renew its addendum;
      and

    (b)
      The
      MA-PD Sponsor has not provided CMS with a notice of intention not to renew
      in
      accordance with Article VII of this addendum.

     

    2.
      Although MA-PD Sponsor may be determined qualified to renew its addendum under
      this Article, if the MA-PD Sponsor and CMS cannot reach agreement on the Part
      D
      bid under Subpart F of 42 CFR Part 423, no renewal takes place, and the failure
      to reach agreement is not subject to the appeals provisions in Subpart N of
      42
      CFR Parts 422 or 423. (Refer to Article XI for consequences of non-renewal
      on
      the Part C contract and the ability to enter into a Part C
      contract.)

    


    Article
      VI 

    Nonrenewal
      of Addendum

     

    A.
      NONRENEWAL BY
      THE
      MA-PD SPONSOR

     

    1.
      MA-PD
      Sponsor may non-renew this addendum in accordance with 42
      CFR423.507(a).

    2.
      If the
      MA-PD Sponsor non-renews this addendum under this Article, CMS cannot enter
      into
      a Part D addendum with the organization for 2 years unless there are special
      circumstances that warrant special consideration, as determined by
      CMS.

     

    B.
      NONRENEWAL BY CMS

     

    CMS
      may
      non-renew this addendum under the rules of 42 CFR 423.507(b). (Refer to Article
      X for consequences of non-renewal on the Part C contract and the ability to
      enter into a Part C contract.)

     

    


     

    7

    



    Article
      VII 

    Modification
      or Termination of Addendum by Mutual Consent

    


     

    This
      addendum may be modified or terminated at any time by written mutual consent
      in
      accordance with 42 CFR 423.508. (Refer to Article X for consequences of
      non-renewal on the Part C contract and the ability to enter into a Part C
      contract.)

     

    


    Article
      VIII 

    Termination
      of Addendum by CMS

    


     

    CMS
      may
      terminate this addendum in accordance with 42 CFR 423.509. (Refer to Article
      X
      for consequences of non-renewal on the Part C contract and the ability to enter
      into a Part C contract.)

    Article
      IX 

    Termination
      of Addendum by the MA-PD Sponsor

    


     

    A.
      The
      MA-PD Sponsor may terminate this addendum only in accordance with 42 CFR
      423.510.

     

    B.
      CMS
      will not enter into a Part D addendum with an organization that has terminated
      its addendum within the preceding 2 years unless there are circumstances that
      warrant special consideration, as determined by CMS.

     

    C.
      If the
      addendum is terminated under section A of this Article, the MA-PD Sponsor must
      ensure the timely transfer of any data or files. (Refer to Article X for
      consequences of non-renewal on the Part C contract and the ability to enter
      into
      a Part C contract.)

     

    


    Article
      X 

    Relationship
      Between Addendum and Part C Contract or 1876 Cost Contract

    


     

    A.
      MA-PD
      Sponsor acknowledges that, if it is a Medicare Part C contractor, the
      termination or nonrenewal of this addendum by either party may require CMS
      to
      terminate or non-renew the Sponsor's Part C contract in the event that such
      non-renewal or termination prevents the MA-PD Sponsor from meeting the
      requirements of 42 CFR §422.4(c), in which case the Sponsor must provide the
      notices specified in this contract, as well as the notices specified under
      Subpart K of 42 CFR Part 422. MA-PD Sponsor also acknowledges that Article
      X.B.
      of this addendum may prevent the sponsor from entering into a Part C contract
      for two years following an addendum termination or non-renewal where such
      non-renewal or termination prevents the MA-PD Sponsor from meeting the
      requirements of 42 CFR §422.4(c).

    


     

    8

     

    


     

    



    B.
      The
      termination of this addendum by either party shall not, by itself, relieve
      the
      parties from their obligations under the Part C or cost plan contracts to which
      this document is an addendum.

     

    C.
      In the
      event that the MA-PD Sponsor's Part C or cost plan contract (as applicable)
      is
      terminated or nonrenewed by either party, the provisions of this addendum shall
      also terminate. In such an event, the MA-PD Sponsor and CMS shall provide notice
      to enrollees and the public as described in this contract as well as 42 CFR
      Part
      422, Subpart K or 42 CFR Part 417, Subpart K, as applicable.

     

    


    Article
      XI 

    Intermediate
      Sanctions

     

    The
      MA-PD
      Sponsor shall be subject to sanctions and civil monetary penalties, consistent
      with Subpart 0 of 42 CFR Part 423.

     

    


    Article
      XII 

    Severability

     

    Severability
      of the addendum shall be in accordance with 42 CFR §423.504(e).

     

    Article
      XIII 

    Miscellaneous

     

    A.
      DEFINITIONS: Terms not otherwise defined in this addendum shall have the meaning
      given such terms at 42 CFR Part 423 or, as applicable, 42 CFR Part 422 or Part
      417.

     

    B.
      ALTERATION TO ORIGINAL ADDENDUM TERMS: The MA-PD Sponsor

    agrees
      that it has not altered in any way the terms of the MA-PD addendum presented
      for
      signature by CMS. MA-PD Sponsor agrees that any alterations to the original
      text
      the MA-PD Sponsor may make to this addendum shall not be binding on the
      parties.

     

    C.
      ADDITIONAL CONTRACT TERMS: The MA-PD Sponsor agree to include in this addendum
      other terms and conditions in accordance with 42 CFR §423.505(j).

     

    D.
      CMS
      APPROVAL TO BEGIN MARKETING AND ENROLLMENT ACTIVITIES:

    The
      MA-PD
      Sponsor agrees that it must complete CMS operational requirements related to
      its
      Part D benefit prior to receiving CMS approval to begin MA-PD plan marketing
      activities relating to its Part D benefit. Such activities include, but are
      not
      limited to, establishing and successfully testing connectivity with CMS systems
      to process enrollment applications (or contracting with an entity qualified
      to
      perform

     

    


    


    9

    


     


    such
      functions on MA-PD Sponsor's behalf) and successfully demonstrating the
      capability to submit accurate and timely price comparison data. To establish
      and
      successfully test connectivity, the PDP Sponsor must, 1) establish and test
      physical connectivity to the CMS data center, 2) acquire user identifications
      and passwords, 3) receive, store, and maintain data necessary to perform
      enrollments and send and receive transactions to and from CMS, and 4) check
      and
      receive transaction status information.

     

    10

     

     

    


    


    MA-PD
      PART D CONTRACT ADDENDUM

     

    In
      witness whereof, the parties hereby execute this Addendum.

     

    FOR
      THE
      MA ORGANIZATION

    


    


    
      	
              Todd
                Farha

            	 	
              President
                and CEO

            
	
              Printed
                Name

               

            	 	
              Title

            
	
                 
                /s/ Todd Farha       

            	 	
              9-14-06

            
	
              Signature

               

            	 	
              Date

            
	
              Home
                Owners /WellCare PFFS Insurance,  Inc.

            	 	
              8735
                Henderson Road-Ren 2 Tampa FL 33634

            
	
              Organization

            	 	
              Address

            
	 	 	 
	 FOR THE CENTERS
              FOR MEDICARE & MEDICAID SERVICES	 	 
	 	 	 
	   /s/  
              Brenda Tranchida        
              Brenda
                J. Tranchida

              Deputy
                Director

              Employer
                Policy & Operations Group

              Center
                for Beneficiary Choices

            	 	 


    

    


     

    Page 1
      of  1

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    



    PART
      C/D BENEFIT PLAN(S) DESCRIPTION

    TO
      BE ATTACHED TO MA CONTRACT

     

    SECTION
      1876/PART D OPTIONAL SUPPLEMENTAL BENEFIT PLAN DESCRIPTION TO BE ATTACHED TO
      SECTION 1876 CONTRACT

    


     

    


    


    11

     

    



    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    EMPLOYER/UNION-ONLY
      GROUP ADDENDUM TO CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1851
      THROUGH 1859 AND

    1860D-1
      THROUGH 1860D-42 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A MEDICARE
      ADVANTAGE PRESCRIPTION DRUG PLAN

     

    The
      Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")
      and HomeOwner’s/WellCare
      PFFS Ins. Inc. a
      Medicare Advantage Organization (hereinafter referred to as the "MA
      Organization") agree to amend the contract H4577
      (INSERT
      "H" OR "R" NUMBER)
      governing the MA Organization's operation of a Medicare Advantage plan described
      in section 1851(a)(2)(A) or section 1851(a)(2)(C) of the Social Security Act
      (hereinafter referred to as "the Act"), including all attachments, addenda,
      and
      amendments thereto, to include the provisions contained in this Addendum
      (collectively hereinafter referred to as the "contract"), under which the MA
      Organization shall offer Employer/Union-Only Group MA-PD Plans (hereinafter
      referred to as "employer/union-only group MA-PDs") in accordance with the
      waivers granted by CMS under section 1857(i) of the Act. The terms of this
      Addendum shall only apply to MA-PD plans offered exclusively to
      employers/unions.

     

    This
      Addendum is made pursuant to Subparts K of 42 CFR Parts 422 and
      423.

     

    Page
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      10

     

    



    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    ARTICLE
      I

    EMPLOYER/UNION-ONLY
      GROUP MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS

     

    A.
      MA
      Organization agrees to operate one or more employer/union-only group MA-PDs
      in
      accordance with the terms of the Medicare Advantage contract, this Addendum,
      which incorporates in its entirety: either the 2006 Solicitation For
      Applications From Prescription Drug Plans released on January 21, 2005 (as
      revised on March 9, 2005) or the 2007 Solicitation For Applications For New
      Medicare Advantage Prescription Drug (MA-PD) Sponsors released on January 27,
      2006 (as revised on February 2, 2006), as modified by the 2007 Application
      For
      Medicare Advantage Organizations To Offer New Employer/Union-Only Group Waiver
      Plans (EGWPs) (released on January 27, 2006) (except for requirements contained
      therein that are expressly waived or modified by this Addendum), all provisions
      of Federal statutes, regulations, and policies applicable to MA Organizations
      and MA plans (except to the extent any such provisions are expressly waived
      or
      modified by this Addendum); and any employer/union-only group waiver guidance.
      MA Organization also agrees to operate one or more employer/union-only group
      MA-PDs in accordance with the regulations at 42 CFR Parts 422 and 423 (with
      the
      exception of Subparts Q, R, and S), sections 1851 through 1859 and 1860D-1
      through 1860D-42 of the Act (with the exception of 1860D-22(a) and 1860D-31),
      and the applicable solicitations/applications, as well as all other applicable
      Federal statutes, regulations, and policies, including any employer/union-only
      group waiver guidance.

     

    B.
      This
      Addendum is deemed to incorporate any changes that are required by statute
      to be
      implemented during the term of the contract, and any regulations and policies
      implementing or interpreting such statutory provisions.

     

    C.
      In the
      event of any conflict between the employer/union-only group waiver guidance
      issued prior to the execution of the contract and this Addendum, the provisions
      of this Addendum shall control. In the event of any conflict between the
      employer/union-only group waiver guidance issued after the execution of the
      contract and this Addendum, the provisions of the employer/union-only group
      guidance shall control.

     

    D.
      This
      Addendum is in no way intended to supersede or modify 42 CFR Parts 422 and
      423
      or sections 1851 through 1859 and 1860D-1 through D-42 of the Act, except as
      specifically provided in applicable employer/union-only group waiver guidance
      and/or in this Addendum. Failure to reference a statutory or regulatory
      requirement in this Addendum does not affect the applicability of such
      requirement to the MA Organization and CMS.

     

    E.
      The
      provisions of this Addendum apply to all employer/union-only group MA-PDs
      offered by MA Organization under this contract number. In the event of any
      conflict between the provisions of this Addendum and any other provision of
      the
      contract, the terms of this Addendum shall control.

     

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    MA-PD
      EMPLOYERAJNION-ONLY GROUP CONTRACT ADDENDUM

     

    ARTICLE
      II

    FUNCTIONS
      TO BE PERFORMED BY THE MEDICARE ADVANTAGE ORGANIZATION

     

    A.
      PROVISION OF MA BENEFITS

     

    1.
      MA
      Organization agrees to provide enrollees in each of its employer/union-only
      group MA-PDs the basic benefits (hereinafter referred to as "basic benefits")
      as
      required under 42 CFR §422.101 and, to the extent applicable, supplemental
      benefits under 42 CFR §422.102 and as established in the MA Organization's final
      benefit and price bid proposal as approved by CMS.

     

    2.
      The
      requirements in section 1852 of the Act and 42 CFR §422.100(c)(l) pertaining to
      the offering of benefits covered under Medicare Part A and in section 1851
      of
      the Act and 42 CFR §422.50(a)(l) pertaining to who may enroll in an MA-PD are
      waived for employer/union-only group MA-PD enrollees who are not entitled to
      Medicare Part A.

     

    3.
      For
      employer/union-only group MA-PDs offering non-calendar year coverage, MA
      Organization may determine basic and supplemental benefits (including
      deductibles, out-of-pocket limits, etc.) on a non-calendar year basis subject
      to
      the following requirements:

     

    (a)
      Applications, bids, and other submissions to CMS must be submitted on a calendar
      year basis; and

     

    (b)
      CMS
      payments will be determined on a calendar year basis.

     

    4.
      For
      employer/union-only group MA-PDs that have a monthly beneficiary rebate
      described in 42 CFR §422.266:

     

    (a)
      MA
      Organization may vary the form of rebate for a particular plan benefit package
      so that the total monthly rebate amount may be credited differently for each
      employer/union group to whom MA Organization offers the plan benefit package,
      with the exception of a rebate credited toward the reduction of the Part B
      premium as stated in II.A.4(b); and

     

    (b)
      MA
      Organization must:

     

    (i)
      ensure Part B premium reductions are the same for all enrollees in a plan
      benefit package;

     

    (ii)
      ensure that the total monthly rebate amount per enrollee is uniform across
      all
      employer/union groups within the plan benefit package;

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    (iii)
      ensure that all rebates are accounted for and used only for the purposes
      provided in the Act; and

     

    (iv)
      retain documentation that supports the use of all of the rebates on a detailed
      basis for each employer/union group within the plan benefit package and must
      provide access to this documentation in accordance with the requirements of
      42
      CFR §422.501.

     

    B.
      PROVISION OF PRESCRIPTION DRUG BENEFITS

     

    1.
      (a)
      Except as provided in II.B. 1 (b), MA Organization agrees to provide basic
      prescription drug coverage, as defined under 42 CFR §423.100, under any
      employer/union-only group MA-PD, in accordance with Subpart C of 42 CFR Part
      423. MA Organization also agrees to provide Part D benefits under any
      employer/union-only group MA-PD as described in MA Organization's bid approved
      each year by CMS.

     

    (b)
      CMS
      agrees that MA Organization will not be subject to the actuarial equivalence
      requirement set forth in 42 CFR §423.104(e)(5) with respect to any
      employer/union-only group MA-PD and may provide less than the defined standard
      coverage between the deductible and initial coverage limit. MA Organization
      agrees that its basic prescription drug coverage under any employer/union-only
      group MA-PD will satisfy all of the other actuarial equivalence standards set
      forth in 42 CFR §423.104, including but not limited to the requirement set forth
      in 42 CFR §423.104(e)(3) that the plan has a total or gross value that is at
      least equal to the total or gross value of defined standard
      coverage.

     

    (c)
      CMS
      agrees that nothing in this Addendum prevents MA Organization from offering
      benefits in addition to basic prescription drug coverage to employers/unions.
      Such additional benefits offered pursuant to private agreements between MA
      Organization and employers/unions will be considered non-Medicare Part D
      benefits. MA Organization agrees that such additional benefits may not reduce
      the value of basic prescription drug coverage (e.g., additional benefits cannot
      impose a cap that would preclude enrollees from realizing the full value of
      such
      basic prescription drug coverage).

     

    (d)
      MA
      Organization agrees that enrollees of employer/union-only group MA-PDs shall
      not
      be charged more than the sum of his or her monthly beneficiary premium
      attributable to basic prescription drug coverage and 100% of the monthly
      beneficiary premium attributable to his or her supplemental prescription drug
      coverage (if any). MA Organization must pass through the direct subsidy payments
      received from CMS to reduce the amount that the beneficiary pays.

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    (e)
      MA
      Organization agrees that any additional non-Medicare Part D benefits offered
      to
      an employer/union will always pay primary to the subsidies provided by CMS
      to
      low-income individuals under Subpart P of 42 CFR Part 423 (the "Low-Income
      Subsidy").

     

    2.
      MA
      Organization agrees enrollees of employer/union-only group MA-PDs will not
      be
      permitted to make payment of premiums under 42 CFR §423.293(a) through
      withholding from the enrollee's Social Security, Railroad Retirement Board,
      or
      Office of Personnel Management benefit payment.

     

    3.
      MA
      Organization agrees it shall obtain written agreements from each

    employer/union
      that provide that the employer/union may determine how much of an enrollee's
      Part D monthly beneficiary premium it will subsidize, subject to the
      restrictions set forth in II.B.3(a) through (e). MA Organization agrees to
      retain these written agreements with employers/unions and provide access to
      these written agreements to CMS in accordance with 42
      CFR§§423.504(d)
      and 423.505(d)and(e).

     

    (a)
      The
      employer/union can subsidize different amounts for different classes of
      enrollees in the employer/union-only group MA-PD provided such classes are
      reasonable and based on objective business criteria, such as years of service,
      date of retirement, business location, job category, and nature of compensation
      (e.g., salaried v. hourly). Different classes cannot be based on eligibility
      for
      the Low Income Subsidy.

     

    (b)
      The
      employer/union cannot vary the premium subsidy for individuals within a given
      class of enrollees.

     

    (c)
      The
      employer/union cannot charge an enrollee for prescription drug coverage provided
      under the plan more than the sum of his or her monthly beneficiary premium
      attributable to basic prescription drug coverage and 100% of the monthly
      beneficiary premium attributable to his or her supplemental prescription drug
      coverage (if any). The employer/union must pass through direct subsidy payments
      received from CMS to reduce the amount that the beneficiary pays.

     

    (d)
      For
      all enrollees eligible for the Low Income Subsidy, the low income premium
      subsidy amount will first be used to reduce the portion of the monthly
      beneficiary premium attributable to basic prescription drug coverage paid by
      the
      enrollee, with any remaining portion of the premium subsidy amount then applied
      toward the portion of the monthly beneficiary premium attributable to basic
      prescription drug coverage paid by the employer/union.

     

    (e)
      If
      the low income premium subsidy amount for which an enrollee is eligible is
      less
      than the portion of the monthly beneficiary premium paid by the enrollee, then
      the employer/union should communicate to the enrollee the financial consequences
      for the beneficiary
      of
      enrolling in the employer/union-only group

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    MA-PD
      as
      compared to enrolling in another Part D plan with a monthly beneficiary premium
      equal to or below the low income premium subsidy amount.

     

    4.
      For
      non-calendar year employer/union-only group MA-PDs, MA Organization may
      determine benefits (including deductibles, out-of-pocket limits, etc.) on a
      non-calendar year basis subject to the following requirements:

     

    (a)
      Applications, formularies, bids and other submissions to CMS must be submitted
      on a calendar year basis;

     

    (b)
      The
      employer/union-only group MA-PD must be actuarially equivalent to defined
      standard coverage for the portion of its plan year that falls in a given
      calendar year. An employer/union-only group MA-PD will meet this standard if
      it
      is actuarially equivalent for the calendar year in which the plan year starts
      and no design change is made for the remainder of the plan year. In no event
      can
      MA Organization increase during the plan year the annual out-of-pocket
      threshold;

     

    (c)
      After
      an enrollee's incurred costs exceed the annual out-of-pocket threshold, the
      employer/union-only group MA-PD must provide coverage that is at least
      actuarially equivalent to that provided under standard prescription drug
      coverage;

    eligibility
      for such coverage can be determined on a plan year basis.

     

    C.
      ENROLLMENT REQUIREMENTS

     

    1.
      MA
      Organization agrees to restrict enrollment in an employer/union-only group
      MA-PD
      to those individuals eligible for the employer's/union's employment-based group
      coverage.

     

    2.
      MA
      Organization will not be subject to the requirement to offer the

    employer/union-only
      group MA-PD to all Medicare eligible beneficiaries residing in its service
      area
      as set forth in 42 CFR §422.50.

     

    3.
      If an
      employer/union elects to enroll individuals eligible for its employer/union-only
      group MA-PD through a group enrollment process, MA Organization will not be
      subject to the individual enrollment requirements set forth in 42 CFR §422.60
      and §423.32(b). MA Organization agrees that all individuals eligible for its
      employer/union-only group MA-PD will be advised that the employer/union
      contracting with MA Organization to offer an employer/union-only group MA-PD
      (hereinafter referred to as "employer/union") intends to enroll them into the
      plan through a group enrollment process unless the individual affirmatively
      opts
      out of such enrollment. MA Organization agrees that all such individuals will
      be
      provided this information at least 30 days prior to the effective date of the
      individual's enrollment in the employer/union-only group MA-PD. MA Organization
      agrees the information must include a summary of benefits offered under the
      employer/union-only group MA-PD, an explanation of how to get more information
      on such plan, and an explanation of how to contact Medicare for

     

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      6 of
      10

     

    



    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    information
      on other MA-PD plans that' might be available to the individual. In addition,
      MA
      Organization agrees that all information necessary to effectuate enrollment
      must
      be submitted electronically to CMS, consistent with CMS
      instructions.

     

    D.
      BENEFICIARY PROTECTIONS

     

    1.
      Except
      as provided in II.D.2., CMS agrees that, with respect to any

    employer/union-only
      group MA-PDs, MA Organization will not be subject to the information
      requirements set forth in 42 CFR §423.48 and the prior review and approval of
      marketing materials and election forms requirements set forth in 42 CFR §422.80
      and §423.50. MA Organization will be subject to all other disclosure and
      dissemination requirements contained in 42 CFR §422.111, §423.128 and in CMS
      guidance, including those requirements contained in the "Medicare Marketing
      Materials Guidelines for Medicare Advantage Plans (MAs), Medicare Advantage
      Prescription Drug Plans (MA-PDs), Prescription Drug Plans (PDPs) and 1876 Cost
      Plans."

     

    2.
      CMS
      agrees that the disclosure and dissemination requirements set forth in 42 CFR
      §422.111 and §423.128 will not apply with respect to any employer/union-only
      group MA-PD when the employer/union is subject to alternative disclosure
      requirements (e.g., the Employee Retirement Income Security Act of 1974
      ("ERISA")) and fully complies with such alternative requirements. MA
      Organization agrees to comply with the requirements for this waiver contained
      in
      employer/union-only group waiver guidance, including those requirements
      contained in Chapter 13 of the "Medicare Marketing Guidelines for Medicare
      Advantage Plans (MAs), Medicare Advantage Prescription Drug Plans (MA-PDs),
      Prescription Drug Plans (PDPs) and 1876 Cost Plans."

     

    E.
      SERVICE AREA, FORMULARIES AND PHARMACY ACCESS

     

    1.
      CMS
      agrees that employer/union-only group Local MA-PDs that provide coverage to
      individuals in any part of a State can offer coverage to retirees eligible
      for
      the employer/union-only group MA-PD throughout that State. CMS also agrees
      that
      employer/union-only group Regional MA-PDs that provide coverage to individuals
      in any part of a Region can offer coverage to retirees eligible for the
      employer/union-only group MA-PD throughout that Region.

     

    2.
      CMS
      agrees that non-network Private Fee-for-Service employer/union-only group MA-PDs
      may extend coverage beyond their designated service areas to all enrollees
      of a
      particular employer/union-only group plan, regardless of where they reside
      in
      the nation, when the most substantial portion of the employer's employees (or
      in
      the case of a union, the union's participants) reside in the service area where
      the MA Organization, either itself or through subcontractors or other partners,
      is a provider of non-group MA-PD coverage. The MA Organization agrees to conduct
      an actual review of where the substantial portion of the

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    employer's/union's
      employees/participants resideand
      to
      maintain adequate supporting documentation of such review (including the date
      of
      such review, by whom the review was conducted, and any other relevant
      documentation to substantiate the review), and to permit CMS to audit and review
      such documentation. Such expanded service areas must have convenient Part D
      pharmacy access sufficient to meet the needs of enrollees wherever they
      reside.

     

    3.
      MA
      Organization agrees to utilize, as the formulary for any employer/union-only
      group MA-PD, a base formulary that has received approval from CMS, in accordance
      with CMS formulary guidance, for use in a non-group MA-PD offered by MA
      Organization. Except as set forth in 42 CFR §423.120(b) and sub-regulatory
      guidance, MA Organization may not modify the approved base formulary used for
      any employer/union-only group MA-PD by removing drugs, adding additional
      utilization management restrictions, or increasing the cost-sharing status
      of a
      drug from the base formulary. Enhancements that are permitted to the base
      formulary include adding additional drugs, removing utilization management
      restrictions, and improving the cost-sharing status of drugs.

     

    4.
      For
      any employer/union-only group MA-PD, MA Organization agrees to provide Part
      D
      benefits in the plan's service area utilizing a pharmacy network and formulary
      that meets the requirements of 42 CFR §423.120, with the following exception:
      CMS agrees that the retail pharmacy access requirements set forth in 42 CFR
      §423.120(a)(l) ("Tricare" standards) will not apply when the employer/union-only
      group MA-PD's pharmacy network is sufficient to meet the needs of its enrollees
      throughout the employer/union-only group MA-PD's service area, as determined
      by
      CMS. CMS may periodically review the adequacy of the employer/union-only group
      MA-PD's pharmacy network and require the employer/union-only group MA-PD to
      expand access if CMS determines that such expansion is necessary in order to
      ensure that the employer/union-only group MA-PD's network is sufficient to
      meet
      the needs of its enrollees.

     

    F.
      PAYMENT TO MA ORGANIZATION

     

    Except
      as
      provided in II.F.I through 4, payment under this Addendum will be governed
      by
      the rules of Subparts G and J of 42 CFR Part 423.

     

    1.
      MA
      Organization acknowledges that the risk sharing, plan entry and retention bonus
      provisions of section 1858 of the Act and 42 CFR §422.458 shall not apply to any
      employer/union-only group Regional MA-PDs.

     

    2.
      MA
      Organization acknowledges that the risk-sharing payment adjustment described
      in
      42 CFR §423.336 is not applicable for any employer/union-only group MA-PD
      enrollee.

     

    3.
      MA
      Organization will receive a monthly direct subsidy under 42 CFR Subpart
      G

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    for
      each
      employer/union-only group MA-PD enrollee equal to the amount of the national
      average monthly bid amount (not its approved standardized bid), adjusted for
      health status (as determined under 42 CFR §423.329(b)(l)) and reduced by the
      base beneficiary premium for the employer/union-only group MA-PD, as adjusted
      under 42 CFR §423.286(d)(3), if applicable. The further adjustments to the base
      beneficiary premium contained in 42 CFR §423.286(d)(l) and (2) will not
      apply.

     

    4.
      MA
      Organization will not receive monthly reinsurance payment amounts in the manner
      set forth in 42 CFR §423.329(c)(2)(i) for any employer/union-only group MA-PD
      enrollee, but instead will receive the full reinsurance payment following the
      end of year reconciliation as described in 42 CFR
§423.329(c)(2)(ii).

     

    5.
      For
      non-calendar year plans:

     

    (a)
      CMS
      payments will be determined on a calendar year basis;

     

    (b)
      Low
      income subsidy payments and reconciliations will be determined based on the
      calendar year for which the payments are made; and

     

    (c)
      MA
      Organization acknowledges that it will not receive reinsurance payments under
      42
      CFR §423.329(c).

     

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    In
      witness whereof, the parties hereby execute this Addendum.

     

    FOR
      THE
      MA ORGANIZATION

     

    


    
      	
              Todd
                Farha

            	 	
              President
                and CEO

            
	
              Printed
                Name

               

            	 	
              Title

            
	
              /s/
                Todd Farha         
                

            	 	
              9-14-06

            
	
              Signature

               

            	 	
              Date

            
	
              Home
                Owners/WellCare PFFS Ins. Inc

            	 	
              8735
                Henderson Road-Ren 2 Tampa FL 33634

            
	
              Organization

            	 	
              Address

            
	 	 	 
	
               FOR THE CENTERS FOR MEDICARE & MEDICAID
                SERVICES

               

              
                 
                  /s/  Brenda
                  Tranchida                 
                    

                Brenda
                  J. Tranchida

                Deputy
                  Director

                Employer
                  Policy & Operations Group

                Center
                  for Beneficiary Choices

              

            	 	
               

              9/28/06

              
                Date

              

            


    

     

     

     

    
 

    
    

    Page
      10
      of 10

     

    


    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    


    Medicare
      Advantage Attestation of Benefit Plan and Price 

    HOME
      OWNERS/WELLCARE PFFS INSURANCE INC. 

    H4577
      

    Date:
      09/12/2006 

     

    
      	
              I
                attest that the following plan numbers as established in the final
                Plan
                Benefit Package (PBP) will be operated by the above-stated organization
                and made available to eligible beneficiaries in the approved service
                area
                during program year 2007. I further attest that the organization
                will
                comply with all applicable program guidance that CMS has issued to
                date
                and will issue during the remainder of 2006 and 2007 pursuant to
                Medicare
                program authorizing statutes and regulations, including but not limited
                to, the 2007 Call Letters, the 2007 Solicitations for New Contract
                Applicants, and
                the CMS memoranda issued through the Health Plan Management System
                (HPMS).

               

            
	
              Plan
                ID

            	
              Segment
                ID

            	
              Version

            	
              Plan
                Name

            	
              Plan
                Type

            	
              Transaction
                Type

            	
              MA
                Premium

            	
              Part
                D Premium

            	
              CMS
                Approval Date

            	
              Effective
                Date

            
	
              001

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              002

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              003

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              004

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              005

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              91.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              006

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              121.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              007

            	
              0

            	
              5

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              126.50

            	
              14.40

            	
              9/12/2006

            	
              01/01/2007

            
	
              008

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              129.70

            	
              31.30

            	
              9/12/2006

            	
              01/01/2007

            
	
              009

            	
              0

            	
              4

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              137.90

            	
              43.10

            	
              9/12/2006

            	
              01/01/2007

            
	
              010

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              160.90

            	
              50.10

            	
              9/12/2006

            	
              01/01/2007

            
	
              011

            	
              0

            	
              3

            	
              Freedom

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              012

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              013

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              39.10

            	
              1.90

            	
              9/12/2006

            	
              01/01/2007

            
	
              014

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              42.80

            	
              38.20

            	
              9/12/2006

            	
              01/01/2007

            
	
              015

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              60.30

            	
              48.70

            	
              9/12/2006

            	
              01/01/2007

            
	
              801

            	
              0

            	
              5

            	
              Employer
                Plan 3

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              28.50

            	
              9/12/2006

            	
              01/01/2007

            
	
              802

            	
              0

            	
              5

            	
              Employer
                Plan 4

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              28.50

            	
              9/12/2006

            	
              01/01/2007

            


    

     

    Page 1
      of 3 - HOME OWNERS/WELLCARE PFFS INSURANCE INC. - H4577 -
      09/12/2006

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    


    *
      For all
      800-series Plan IDs, plans have the flexibility to vary the premium amounts
      that
      they charge. Therefore, the amount listed in the "MA Premium" and "Part D
      Premium" columns may not coincide with the amount actually charged. For CY2007,
      the direct subsidy payment will be based on the national average monthly bid
      amount rather than on the bid submitted by the plan. Also, the base beneficiary
      premium will be used rather than the plan's premium as derived from their
      standardized bid in determining the low-income premium subsidy.

    


    


    
      	
              /s/
                Todd Farha         
                

            	 	
              9-14-06

            
	
              CEO:

            	 	
              Date:

            
	
              Todd
                Farha

            	 	 
	
              CEO/President

            	 	 
	
              8735
                Henderson Rd Ren 2

            	 	 
	 	 	 
	
              Tampa,
                FL 33634

            	 	 
	
              813-290-6200

            	 	 
	 	 	 
	
              CFO:

            	 	 
	
              Paul
                Behrens

            	 	
              Date:

            
	
              CFO

            	 	 
	
              8735
                Henderson Rd Ren 2

            	 	 
	 	 	 
	 	 	 
	
              Tampa,
                FL 33634

            	 	 
	
              813-290-6200

            	 	 


    

     

    Page
      3 of
      3 - HOME OWNERS/WELLCARE PFFS INSURANCE INC. - H4577 - 09/12/2006