Document:

Exhibit 10.32

 

Dated:  August 30, 2006

NEITHER THIS DEBENTURE NOR THE SECURITIES INTO WHICH THIS DEBENTURE IS CONVERTIBLE HAVE BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION OR THE SECURITIES COMMISSION OF ANY STATE IN RELIANCE UPON AN EXEMPTION FROM REGISTRATION UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “SECURITIES ACT”), AND, ACCORDINGLY, MAY NOT BE OFFERED OR SOLD EXCEPT PURSUANT TO AN EFFECTIVE REGISTRATION STATEMENT UNDER THE SECURITIES ACT OR PURSUANT TO AN AVAILABLE EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT AND IN ACCORDANCE WITH APPLICABLE STATE SECURITIES LAWS.

	
            No. MEP-4
 	
            $300,000
 

CONNECTED MEDIA TECHNOLOGIES, INC.

Secured Convertible Debenture

 

Due November 30, 2007

This Secured Convertible Debenture (the “Debenture”) is issued by CONNECTED MEDIA TECHNOLOGIES, INC., a Delaware corporation (the “Obligor”), to MONTGOMERY EQUITY PARTNERS, LTD. (the “Holder”), pursuant to that certain Securities Purchase Agreement (the “Securities Purchase Agreement”) dated January 31, 2006. 

FOR VALUE RECEIVED, the Obligor hereby promises to pay
to the Holder or its successors and assigns the principal sum of Three Hundred
Thousand Dollars ($300,000) together with accrued but unpaid interest on or
before November 30, 2007 (the “Maturity
Date”) in accordance with the following
terms:

Interest. Interest shall accrue on the outstanding principal balance hereof at an annual rate equal to fourteen percent (14%). Interest shall be calculated on the basis of a 365-day year and the actual number of days elapsed, to the extent permitted by applicable law. Interest hereunder will be paid to the Holder or its assignee  (as defined in Section 5) in whose name this Debenture is registered on the records of the Obligor regarding registration and transfers of Debentures (the “Debenture Register”).

Right of Redemption. The Obligor at its option shall have the right, with thirty (30) business days advance written notice (the “Redemption Notice”), to redeem a portion or all amounts outstanding under this Debenture prior to the Maturity Date. The Obligor shall pay an amount equal to the principal amount being redeemed plus a redemption premium (“Redemption Premium”) equal to twenty five percent (25%) of the principal amount being redeemed, and accrued interest, (collectively referred to as the “Redemption Amount”). The Obligor shall deliver to the Holder the Redemption Amount on the thirtieth (30th) business day after the
Holder’s receipt of the Redemption Notice. 

 

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Exhibit 10.32

 

 

Notwithstanding the foregoing in the event that the Obligor has elected to redeem a portion of the outstanding principal amount and accrued interest under this Debenture the Holder shall be permitted to convert all or any portion of this Debenture following receipt of the Redemption Notice. 

Security Agreements. This Debenture is secured by an Amended and Restated Pledge and Escrow Agreement (the “Pledge Agreement”) dated January 31, 2006 among the Obligor, the Holder, the Escrow Agent, and an Amended and Restated Security Agreement (the “Security Agreement”) dated January 31, 2006 between the Obligor and the Holder.

Consent  of Holder to Sell Capital Stock or Grant Security Interests. So long as any of the principal amount or interest on this Debenture remains unpaid and unconverted, the Obligor shall not, without the prior consent of the Holder, (i) issue or sell any shares of Common Stock or preferred stock without consideration or for consideration per share less than the Closing Bid Price of the Common Stock determined immediately prior to its issuance, (ii) issue or sell any preferred stock, warrant, option, right, contract, call, or other security or instrument granting the holder thereof the right to acquire Common Stock without consideration or for consideration per share less than the Closing Bid Price of the Common Stock determined immediately prior to its issuance, (iii) enter into any security instrument granting the
holder a security interest in any of the assets of the Obligor, or (iv) file any registration statements on Form S-8.

Rights of First Refusal. So long as any portion of this Debenture is outstanding (including principal or accrued interest), if the Obligor intends to raise additional capital by the issuance or sale of capital stock of the Obligor, including without limitation shares of any class of Common Stock, any class of preferred stock, options, warrants or any other securities convertible or exercisable into shares of Common Stock (whether the offering is conducted by the Obligor, underwriter, placement agent or any third party) the Obligor shall be obligated to offer to the Holder such issuance or sale of capital stock, by providing in writing the principal amount of capital it intends to raise and outline of the material terms of such capital raise, prior to the offering such issuance or sale of capital stock  to any third parties including, but not limited
to, current or former officers or directors, current or former shareholders and/or investors of the obligor, underwriters, brokers, agents or other third parties. The Holder shall have ten (10) business days from receipt of such notice of the sale or issuance of capital stock to accept or reject all or a portion of such capital raising offer.

This Debenture is subject to the following additional provisions:

Section 1.         This Debenture is exchangeable for an equal aggregate principal amount of Debentures of different authorized denominations, as requested by the Holder surrendering the same. No service charge will be made for such registration of transfer or exchange.

	
            Section 2.
 	
            Events of Default.
 

(a)        An “Event of Default”, wherever used herein, means any one of the following events (whatever the reason and whether it shall be voluntary or involuntary or effected by operation of law or pursuant to any judgment, decree or order of any court, or any order, rule or regulation of any administrative or governmental body):

 

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Exhibit 10.32

 

 

(i)         Any default in the payment of the principal of, interest on or other charges in respect of this Debenture, or any other Debenture issued on the date hereof, free of any claim of subordination, as and when the same shall become due and payable (whether on a due date, a Conversion Date or the Maturity Date or by acceleration or otherwise);

(ii)        The Obligor shall fail to observe or perform any other covenant, agreement or warranty contained in, or otherwise commit any breach or default of any provision of this Debenture (except as may be covered by Section 2(a)(i) hereof) or any Transaction Document (as defined in Section 5) which is not cured with in the time prescribed;

(iii)       The Obligor or any subsidiary of the Obligor shall commence, or there shall be commenced against the Obligor or any subsidiary of the Obligor under any applicable bankruptcy or insolvency laws as now or hereafter in effect or any successor thereto, or the Obligor or any subsidiary of the Obligor commences any other proceeding under any reorganization, arrangement, adjustment of debt, relief of debtors, dissolution, insolvency or liquidation or similar law of any jurisdiction whether now or hereafter in effect relating to the Obligor or any subsidiary of the Obligor or there is commenced against the Obligor or any subsidiary of the Obligor any such bankruptcy, insolvency or other proceeding which remains undismissed for a period of 61 days; or the Obligor or any subsidiary of the Obligor is adjudicated insolvent or bankrupt; or any order of
relief or other order approving any such case or proceeding is entered; or the Obligor or any subsidiary of the Obligor suffers any appointment of any custodian, private or court appointed receiver or the like for it or any substantial part of its property which continues undischarged or unstayed for a period of sixty one (61) days; or the Obligor or any subsidiary of the Obligor makes a general assignment for the benefit of creditors; or the Obligor or any subsidiary of the Obligor shall fail to pay, or shall state that it is unable to pay, or shall be unable to pay, its debts generally as they become due; or the Obligor or any subsidiary of the Obligor shall call a meeting of its creditors with a view to arranging a composition, adjustment or restructuring of its debts; or the Obligor or any subsidiary of the Obligor shall by any act or failure to act expressly indicate its consent to, approval of or acquiescence in any of the foregoing; or any corporate or other action is taken by
the Obligor or any subsidiary of the Obligor for the purpose of effecting any of the foregoing;

(iv)       The Obligor or any subsidiary of the Obligor shall default in any of its obligations under any other debenture or any mortgage, credit agreement or other facility, indenture agreement, factoring agreement or other instrument under which there may be issued, or by which there may be secured or evidenced any indebtedness for borrowed money or money due under any long term leasing or factoring arrangement of the Obligor or any subsidiary of the Obligor in an amount exceeding $100,000, whether such indebtedness now exists or shall hereafter be created and such default shall result in such indebtedness becoming or being declared due and payable prior to the date on which it would otherwise become due and payable;

(v)        The Common Stock shall cease to be quoted for trading or listed for trading on either the Nasdaq OTC Bulletin Board (“OTC”), Nasdaq Capital Market, New York Stock Exchange, American Stock Exchange or the Nasdaq National Market (each, a “Subsequent Market”) and shall not again be quoted or listed for trading thereon within five (5) Trading Days of such delisting;

 

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Exhibit 10.32

 

 

(vi)       The Obligor or any subsidiary of the Obligor shall be a party to any Change of Control Transaction other than as contemplated in the Stock Purchase Agreement between the Company and Natcom Marketing International, Inc. (as defined in Section 5); 

(vii)      The Obligor shall fail to file the Underlying Shares Registration Statement (as defined in Section 5) with the Commission (as defined in Section 5), or the Underlying Shares Registration Statement shall not have been declared effective by the Commission, in each case within the time periods set forth in the Investor Registration Rights Agreement (“Registration Rights Agreement”) dated January 31, 2006 and as amended on the date hereof between the Obligor and the Holder;

(viii)     If the effectiveness of the Underlying Shares Registration Statement lapses for any reason or the Holder shall not be permitted to resell the shares of Common Stock underlying this Debenture under the Underlying Shares Registration Statement, in either case, for more than five (5) consecutive Trading Days or an aggregate of eight Trading Days (which need not be consecutive Trading Days);

(ix)       The Obligor shall fail for any reason to deliver Common Stock certificates to a Holder prior to the fifth (5th) Trading Day after a Conversion Date or the Obligor shall provide notice to the Holder, including by way of public announcement, at any time, of its intention not to comply with requests for conversions of this Debenture in accordance with the terms hereof; 

(x)        The Obligor shall fail for any reason to deliver the payment in cash pursuant to a Buy-In (as defined herein) within three (3) days after notice is claimed delivered hereunder; 

 (b)       During the time that any portion of this Debenture is outstanding, if any Event of Default has occurred, the full principal amount of this Debenture, together with interest and other amounts owing in respect thereof, to the date of acceleration shall become at the Holder’s election, immediately due and payable in cash, provided however, the Holder may request (but shall have no obligation to request) payment of such amounts in Common Stock of the Obligor. If an uncured Event of Default shall occur the Conversion Price shall be permanently reduced to $0.0001 (the “Default Conversion Price”). Notwithstanding the foregoing, the Default Conversion Price shall not be applicable to Section 2(a) (viii) relating to the effectiveness of the Underlying Shares Registration Statement provided that the Obligor (i) files the Underlying Shares Registration Statement within the time period set forth in the Registration Rights Agreement (and as amended on the date hereof) and (ii) the Obligor files timely responses to SEC comments, which shall be no later than ten (10) business days from receipt of each comment letter from the SEC. In addition to any other remedies, the Holder shall have the right (but not the obligation) to convert this Debenture at any time after (x) an Event of Default or (y) the Maturity Date at the Conversion Price then in-effect. The Holder need not provide and the Obligor hereby waives any presentment, demand, protest or other notice of any kind, and the Holder may immediately and without expiration of any grace period enforce any and all of its rights and remedies hereunder and all other remedies available to it under applicable law. Such declaration may be
rescinded and annulled by Holder at any time prior to payment hereunder. No such rescission or annulment shall affect any subsequent Event of Default or impair any right 

 

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Exhibit 10.32

 

consequent thereon. Upon an Event of Default, notwithstanding any other provision of this Debenture or any Transaction Document, the Holder shall have no obligation to comply with or adhere to any limitations, if any, on the conversion of this Debenture or the sale of the Underlying Shares. 

	
            Section 3.
 	
            Conversion.
 	
             

	
            (a)
 	
            Conversion at Option of Holder.
 
				

(i)         This Debenture shall be convertible into shares of Common Stock at the option of the Holder, in whole or in part at any time and from time to time, after the Original Issue Date (as defined in Section 5) (subject to the limitations on conversion set forth in Section 3(b) hereof). The number of shares of Common Stock issuable upon a conversion hereunder equals the quotient obtained by dividing (x) the outstanding amount of this Debenture to be converted by (y) the Conversion Price (as defined in Section 3(c)(i)). The Obligor shall deliver Common Stock certificates to the Holder prior to the Fifth (5th) Trading Day after a Conversion Date.

(ii)        Notwithstanding anything to the contrary contained herein, if on any Conversion Date:  (1) the number of shares of Common Stock at the time authorized, unissued and unreserved for all purposes, or held as treasury stock, is insufficient to pay principal and interest hereunder in shares of Common Stock; (2) the Common Stock is not listed or quoted for trading on the OTC or on a Subsequent Market; (3) the Obligor has failed to timely satisfy its conversion; or (4) the issuance of such shares of Common Stock would result in a violation of Section 3(b), then, at the option of the Holder, the Obligor, in lieu of delivering shares of Common Stock pursuant to Section 3(a)(i), shall deliver, within three (3) Trading Days of each applicable Conversion
Date, an amount in cash equal to the product of the outstanding principal amount to be converted plus any interest due therein divided by the Conversion Price, chosen by the Holder, and multiplied by the highest closing price of the stock from date of the conversion notice till the date that such cash payment is made.

Further, if the Obligor shall not have delivered any cash due in respect of conversion of this Debenture or as payment of interest thereon by the fifth (5th) Trading Day after the Conversion Date, the Holder may, by notice to the Obligor, require the Obligor to issue shares of Common Stock pursuant to Section 3(c), except that for such purpose the Conversion Price applicable thereto shall be the lesser of the Conversion Price on the Conversion Date and the Conversion Price on the date of such Holder demand. Any such shares will be subject to the provisions of this Section.

(iii)       The Holder shall effect conversions by delivering to the Obligor a completed notice in the form attached hereto as Exhibit A (a “Conversion Notice”). The date on which a Conversion Notice is delivered is the “Conversion Date.” Unless the Holder is converting the entire principal amount outstanding under this Debenture, the Holder is not required to physically surrender this Debenture to the Obligor in order to effect conversions. Conversions hereunder shall have the effect of lowering the outstanding principal amount of this Debenture plus all accrued and unpaid interest thereon in an amount equal to the applicable conversion. The Holder and the Obligor shall maintain records showing the principal amount 

 

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Exhibit 10.32

 

converted and the date of such conversions. In the event of any dispute or discrepancy, the records of the Holder shall be controlling and determinative in the absence of manifest error.

	
            (b)
 	
            Certain Conversion Restrictions.
 

(i)         A Holder may not convert this Debenture or receive shares of Common Stock as payment of interest hereunder to the extent such conversion or receipt of such interest payment would result in the Holder, together with any affiliate thereof, beneficially owning (as determined in accordance with Section 13(d) of the Exchange Act and the rules promulgated thereunder) in excess of 4.9% of the then issued and outstanding shares of Common Stock, including shares issuable upon conversion of, and payment of interest on, this Debenture held by such Holder after application of this Section. Since the Holder will not be obligated to report to the Obligor the number of shares of Common Stock it may hold at the time of a conversion hereunder, unless the conversion at issue would result in the issuance of shares of Common Stock in excess of 4.9% of
the then outstanding shares of Common Stock without regard to any other shares which may be beneficially owned by the Holder or an affiliate thereof, the Holder shall have the authority and obligation to determine whether the restriction contained in this Section will limit any particular conversion hereunder and to the extent that the Holder determines that the limitation contained in this Section applies, the determination of which portion of the principal amount of this Debenture is convertible shall be the responsibility and obligation of the Holder. If the Holder has delivered a Conversion Notice for a principal amount of this Debenture that, without regard to any other shares that the Holder or its affiliates may beneficially own, would result in the issuance in excess of the permitted amount hereunder, the Obligor shall notify the Holder of this fact and shall honor the conversion for the maximum principal amount permitted to be converted on such Conversion Date in accordance
with the periods described in Section 3(a)(i) and, at the option of the Holder, either retain any principal amount tendered for conversion in excess of the permitted amount hereunder for future conversions or return such excess principal amount to the Holder. The provisions of this Section may be waived by a Holder (but only as to itself and not to any other Holder) upon not less than 65 days prior notice to the Obligor. Other Holders shall be unaffected by any such waiver.    

	
            (c)
 	
            Conversion Price and Adjustments to Conversion Price.
 

(i)        The conversion price in effect on any Conversion Date shall be equal to the lesser of (a) $0.016 (the “Fixed Conversion Price”) or (b) seventy five percent (75%) of the Closing Bid Price of the Common Stock during the ten (10) trading days immediately preceding the Conversion Date as quoted by Bloomberg, LP (the “Market Conversion Price”). The Fixed Conversion Price and the Market Conversion Price are collectively referred to as the “Conversion Price.”  The Conversion Price may be adjusted pursuant to the other terms of this Debenture.

 (ii)       If the Obligor, at any time while this Debenture is outstanding, shall (a) pay a stock dividend or otherwise make a distribution or distributions on shares of its Common Stock or any other equity or equity equivalent securities payable in shares of Common Stock, (b) subdivide outstanding shares of Common Stock into a larger number of shares, (c) combine (including by way of reverse stock split) outstanding shares of Common Stock into a smaller number of shares, or (d) issue by reclassification of shares of the Common Stock any 

 

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Exhibit 10.32

 

shares of capital stock of the Obligor, then the Fixed Conversion Price shall be multiplied by a fraction of which the numerator shall be the number of shares of Common Stock (excluding treasury shares, if any) outstanding before such event and of which the denominator shall be the number of shares of Common Stock outstanding after such event. Any adjustment made pursuant to this Section shall become effective immediately after the record date for the determination of stockholders entitled to receive such dividend or distribution and shall become effective immediately after the effective date in the case of a subdivision, combination or re-classification.

(iii)       If the Obligor, at any time while this Debenture is outstanding, shall issue rights, options or warrants to all holders of Common Stock (and not to the Holder) entitling them to subscribe for or purchase shares of Common Stock at a price per share less than the Fixed Conversion Price, then the Fixed Conversion Price shall be multiplied by a fraction, of which the denominator shall be the number of shares of the Common Stock (excluding treasury shares, if any) outstanding on the date of issuance of such rights or warrants (plus the number of additional shares of Common Stock offered for subscription or purchase), and of which the numerator shall be the number of shares of the Common Stock (excluding treasury shares, if any) outstanding on the date of issuance of such rights or warrants, plus the number of shares which the aggregate offering
price of the total number of shares so offered would purchase at the Fixed Conversion Price. Such adjustment shall be made whenever such rights or warrants are issued, and shall become effective immediately after the record date for the determination of stockholders entitled to receive such rights, options or warrants. However, upon the expiration of any such right, option or warrant to purchase shares of the Common Stock the issuance of which resulted in an adjustment in the Fixed Conversion Price pursuant to this Section, if any such right, option or warrant shall expire and shall not have been exercised, the Fixed Conversion Price shall immediately upon such expiration be recomputed and effective immediately upon such expiration be increased to the price which it would have been (but reflecting any other adjustments in the Fixed Conversion Price made pursuant to the provisions of this Section after the issuance of such rights or warrants) had the adjustment of the Fixed Conversion
Price made upon the issuance of such rights, options or warrants been made on the basis of offering for subscription or purchase only that number of shares of the Common Stock actually purchased upon the exercise of such rights, options or warrants actually exercised.

(iv)       If the Obligor or any subsidiary thereof, as applicable, at any time while this Debenture is outstanding, shall issue shares of Common Stock or rights, warrants, options or other securities or debt that are convertible into or exchangeable for shares of Common Stock (“Common Stock Equivalents”) entitling any Person to acquire shares of Common Stock, at a price per share less than the Fixed Conversion Price (if the holder of the Common Stock or Common Stock Equivalent so issued shall at any time, whether by operation of purchase price adjustments, reset provisions, floating conversion, exercise or exchange prices or otherwise, or due to warrants, options or rights per share which is issued in connection with such issuance, be entitled to receive shares of Common Stock at a price per share
which is less than the Fixed Conversion Price, such issuance shall be deemed to have occurred for less than the Fixed Conversion Price), then, at the sole option of the Holder, the Fixed Conversion Price shall be adjusted to mirror the conversion, exchange or purchase price for such Common Stock or Common Stock Equivalents (including any reset provisions thereof) at issue. Such adjustment shall be made whenever such Common Stock or Common Stock Equivalents are issued. The Obligor shall notify the Holder in writing, no later than one (1) business day following the 

 

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Exhibit 10.32

 

issuance of any Common Stock or Common Stock Equivalent subject to this Section, indicating therein the applicable issuance price, or of applicable reset price, exchange price, conversion price and other pricing terms. No adjustment under this Section shall be made as a result of issuances and exercises of options to purchase shares of Common Stock issued for compensatory purposes pursuant to any of the Obligor’s stock option or stock purchase plans.

(v)        If the Obligor, at any time while this Debenture is outstanding, shall distribute to all holders of Common Stock (and not to the Holder) evidences of its indebtedness or assets or rights or warrants to subscribe for or purchase any security, then in each such case the Fixed Conversion Price at which this Debenture shall thereafter be convertible shall be determined by multiplying the Fixed Conversion Price in effect immediately prior to the record date fixed for determination of stockholders entitled to receive such distribution by a fraction of which the denominator shall be the Closing Bid Price determined as of the record date mentioned above, and of which the numerator shall be such Closing Bid Price on such record date less the then fair market value at such record date of the portion of such assets or evidence of indebtedness so
distributed applicable to one outstanding share of the Common Stock as determined by the Board of Directors in good faith. In either case the adjustments shall be described in a statement provided to the Holder of the portion of assets or evidences of indebtedness so distributed or such subscription rights applicable to one share of Common Stock. Such adjustment shall be made whenever any such distribution is made and shall become effective immediately after the record date mentioned above.

(vi)       In case of any reclassification of the Common Stock or any compulsory share exchange pursuant to which the Common Stock is converted into other securities, cash or property, the Holder shall have the right thereafter to, at its option,  (A) convert the then outstanding principal amount, together with all accrued but unpaid interest and any other amounts then owing hereunder in respect of this Debenture into the shares of stock and other securities, cash and property receivable upon or deemed to be held by holders of the Common Stock following such reclassification or share exchange, and the Holder of this Debenture shall be entitled upon such event to receive such amount of securities, cash or property as the shares of the Common Stock of the Obligor into which the then outstanding principal amount, together with all accrued but unpaid interest
and any other amounts then owing hereunder in respect of this Debenture could have been converted immediately prior to such reclassification or share exchange would have been entitled, or (B) require the Obligor to prepay the outstanding principal amount of this Debenture, plus all interest and other amounts due and payable thereon. The entire prepayment price shall be paid in cash. This provision shall similarly apply to successive reclassifications or share exchanges.

(vii)      The Obligor shall at all times reserve and keep available out of its authorized Common Stock the full number of shares of Common Stock issuable upon conversion of all outstanding amounts under this Debenture; and within three (3) Business Days following the receipt by the Obligor of a Holder’s notice that such minimum number of Underlying Shares is not so reserved, the Obligor shall promptly reserve a sufficient number of shares of Common Stock to comply with such requirement.

(viii)     All calculations under this Section 3 shall be rounded up to the nearest $0.001 or whole share.

 

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Exhibit 10.32

 

 

(ix)       Whenever the Conversion Price is adjusted pursuant to Section 3 hereof, the Obligor shall promptly mail to the Holder a notice setting forth the Conversion Price after such adjustment and setting forth a brief statement of the facts requiring such adjustment.

(x)        If (A) the Obligor shall declare a dividend (or any other distribution) on the Common Stock; (B) the Obligor shall declare a special nonrecurring cash dividend on or a redemption of the Common Stock; (C) the Obligor shall authorize the granting to all holders of the Common Stock rights or warrants to subscribe for or purchase any shares of capital stock of any class or of any rights; (D) the approval of any stockholders of the Obligor shall be required in connection with any reclassification of the Common Stock, any consolidation or merger to which the Obligor is a party, any sale or transfer of all or substantially all of the assets of the Obligor, of any compulsory share exchange whereby the Common Stock is converted into other securities, cash or property; or (E) the Obligor shall authorize the voluntary or involuntary dissolution,
liquidation or winding up of the affairs of the Obligor; then, in each case, the Obligor shall cause to be filed at each office or agency maintained for the purpose of conversion of this Debenture, and shall cause to be mailed to the Holder at its last address as it shall appear upon the stock books of the Obligor, at least twenty (20) calendar days prior to the applicable record or effective date hereinafter specified, a notice stating (x) the date on which a record is to be taken for the purpose of such dividend, distribution, redemption, rights or warrants, or if a record is not to be taken, the date as of which the holders of the Common Stock of record to be entitled to such dividend, distributions, redemption, rights or warrants are to be determined or (y) the date on which such reclassification, consolidation, merger, sale, transfer or share exchange is expected to become effective or close, and the date as of which it is expected that holders of the Common Stock of record shall
be entitled to exchange their shares of the Common Stock for securities, cash or other property deliverable upon such reclassification, consolidation, merger, sale, transfer or share exchange, provided, that the failure to mail such notice or any defect therein or in the mailing thereof shall not affect the validity of the corporate action required to be specified in such notice. The Holder is entitled to convert this Debenture during the 20-day calendar period commencing the date of such notice to the effective date of the event triggering such notice.

(xi)       In case of any (1) merger or consolidation of the Obligor or any subsidiary of the Obligor with or into another Person, or (2) sale by the Obligor or any subsidiary of the Obligor of more than one-half of the assets of the Obligor in one or a series of related transactions, a Holder shall have the right to (A) exercise any rights under Section 2(b), (B) convert the aggregate amount of this Debenture then outstanding into the shares of stock and other securities, cash and property receivable upon or deemed to be held by holders of Common Stock following such merger, consolidation or sale, and such Holder shall be entitled upon such event or series of related events to receive such amount of securities, cash and property as the shares of Common Stock into which such aggregate principal amount of this
Debenture could have been converted immediately prior to such merger, consolidation or sales would have been entitled, or (C) in the case of a merger or consolidation, require the surviving entity to issue to the Holder a convertible Debenture with a principal amount equal to the aggregate principal amount of this Debenture then held by such Holder, plus all accrued and unpaid interest and other amounts owing thereon, which such newly issued convertible Debenture shall have terms identical (including with respect to conversion) to the terms of this Debenture, and shall be entitled to all of the rights and privileges of the Holder of this Debenture set forth herein and the 

 

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Exhibit 10.32

 

agreements pursuant to which this Debentures were issued. In the case of clause (C), the conversion price applicable for the newly issued shares of convertible preferred stock or convertible Debentures shall be based upon the amount of securities, cash and property that each share of Common Stock would receive in such transaction and the Conversion Price in effect immediately prior to the effectiveness or closing date for such transaction. The terms of any such merger, sale or consolidation shall include such terms so as to continue to give the Holder the right to receive the securities, cash and property set forth in this Section upon any conversion or redemption following such event. This provision shall similarly apply to successive such events.

	
            (d)
 	
            Other Provisions.
 

(i)         The Obligor covenants that it will at all times reserve and keep available out of its authorized and unissued shares of Common Stock solely for the purpose of issuance upon conversion of this Debenture and payment of interest on this Debenture, each as herein provided, free from preemptive rights or any other actual contingent purchase rights of persons other than the Holder, not less than such number of shares of the Common Stock as shall (subject to any additional requirements of the Obligor as to reservation of such shares set forth in this Debenture) be issuable (taking into account the adjustments and restrictions of Sections 2(b) and 3(c)) upon the conversion of the outstanding principal amount of this Debenture and payment of interest hereunder. The Obligor covenants that all
shares of Common Stock that shall be so issuable shall, upon issue, be duly and validly authorized, issued and fully paid, nonassessable and, if the Underlying Shares Registration Statement has been declared effective under the Securities Act, registered for public sale in accordance with such Underlying Shares Registration Statement.

(ii)        Upon a conversion hereunder the Obligor shall not be required to issue stock certificates representing fractions of shares of the Common Stock, but may if otherwise permitted, make a cash payment in respect of any final fraction of a share based on the Closing Bid Price at such time. If the Obligor elects not, or is unable, to make such a cash payment, the Holder shall be entitled to receive, in lieu of the final fraction of a share, one whole share of Common Stock.

(iii)       The issuance of certificates for shares of the Common Stock on conversion of this Debenture shall be made without charge to the Holder thereof for any documentary stamp or similar taxes that may be payable in respect of the issue or delivery of such certificate, provided that the Obligor shall not be required to pay any tax that may be payable in respect of any transfer involved in the issuance and delivery of any such certificate upon conversion in a name other than that of the Holder of such Debenture so converted and the Obligor shall not be required to issue or deliver such certificates unless or until the person or persons requesting the issuance thereof shall have paid to the Obligor the amount of such tax or shall have established to the satisfaction of the Obligor that such tax has been paid.

(iv)       Nothing herein shall limit a Holder’s right to pursue actual damages or declare an Event of Default pursuant to Section 2 herein for the Obligor ‘s failure to deliver certificates representing shares of Common Stock upon conversion within the period specified herein and such Holder shall have the right to pursue all remedies available to it at law or in equity including, without limitation, a decree of specific performance and/or injunctive relief, in 

 

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Exhibit 10.32

 

each case without the need to post a bond or provide other security. The exercise of any such rights shall not prohibit the Holder from seeking to enforce damages pursuant to any other Section hereof or under applicable law. 

(v)        In addition to any other rights available to the Holder, if the Obligor fails to deliver to the Holder such certificate or certificates pursuant to Section 3(a)(i) by the fifth (5th) Trading Day after the Conversion Date, and if after such fifth (5th) Trading Day the Holder purchases (in an open market transaction or otherwise) Common Stock to deliver in satisfaction of a sale by such Holder of the Underlying Shares which the Holder anticipated receiving upon such conversion (a “Buy-In”), then the Obligor shall (A) pay in cash to the Holder (in addition to any remedies available to or elected by the Holder) the amount by which (x) the
Holder’s total purchase price (including brokerage commissions, if any) for the Common Stock so purchased exceeds (y) the product of (1) the aggregate number of shares of Common Stock that such Holder anticipated receiving from the conversion at issue multiplied by (2) the market price of the Common Stock at the time of the sale giving rise to such purchase obligation and (B) at the option of the Holder, either reissue a Debenture in the principal amount equal to the principal amount of the attempted conversion or deliver to the Holder the number of shares of Common Stock that would have been issued had the Obligor timely complied with its delivery requirements under Section 3(a)(i). For example, if the Holder purchases Common Stock having a total purchase price of $11,000 to cover a Buy-In with respect to an attempted conversion of Debentures with respect to which the market price of the Underlying Shares on the date of conversion
was a total of $10,000 under clause (A) of the immediately preceding sentence, the Obligor shall be required to pay the Holder $1,000. The Holder shall provide the Obligor written notice indicating the amounts payable to the Holder in respect of the Buy-In.

Section 4.         Notices.          Any notices, consents, waivers or other communications required or permitted to be given under the terms hereof must be in writing and will be deemed to have been delivered:  (i) upon receipt, when delivered personally; (ii) upon receipt, when sent by facsimile (provided confirmation of transmission is mechanically or electronically generated and kept on file by the sending party); or (iii) one (1) trading day after deposit with a nationally recognized overnight delivery service, in each case properly addressed to the party to receive the same. The addresses and facsimile numbers for such communications shall be:

 

 

	
            If to the Company, to:
 	
            Connected Media Technologies, Inc.
 
	
             
 	
            950 South Pine Island Road, Suite A150-1094
 
	
             
 	
            Plantation, Florida 33324
 
	
             
 	
            Attention:   Jeffrey Sass
 
	
             
 	
            Telephone:        (954) 727-8438
 
	
             
 	
            Facsimile:         (954) 727-8219
 
	
             
 	
             
 
	
            With a copy to: 
 	
            Anslow & Jaclin, LLP 
 
	
             
 	
            195 Route 9 South, Suite 204
 
	
             
 	
            Manalapan, NJ 07726
 
	
             
 	
            Attention:          Gregg E. Jaclin, Esq.
 
	
             
 	
            Telephone:        (732) 409-1212
 
	
             
 	
            Facsimile:         (732) 577-1188
 

 

 

11

 

Exhibit 10.32

 

 

 

	
             
 	
             
 
	
            If to the Holder:
 	
            Montgomery Equity Partners, Ltd.
 
	
             
 	
            101 Hudson Street, Suite 3700
 
	
             
 	
            Jersey City, NJ  07303
 
	
             
 	
            Attention:          Mark Angelo
 
	
             
 	
            Telephone:        (201) 985-8300
 
	
             
 	
             
 
	
            With a copy to:
 	
            David Gonzalez, Esq. 
 
	
             
 	
            101 Hudson Street – Suite 3700
 
	
             
 	
            Jersey City, NJ 07302
 
	
             
 	
            Telephone:        (201) 985-8300
 
	
             
 	
            Facsimile:         (201) 985-8266
 
	
             
 	
             
 

 

or at such other address and/or facsimile number and/or to the attention of such other person as the recipient party has specified by written notice given to each other party three (3) business days prior to the effectiveness of such change. Written confirmation of receipt (i) given by the recipient of such notice, consent, waiver or other communication, (ii) mechanically or electronically generated by the sender’s facsimile machine containing the time, date, recipient facsimile number and an image of the first page of such transmission or (iii) provided by a nationally recognized overnight delivery service, shall be rebuttable evidence of personal service, receipt by facsimile or receipt from a nationally recognized overnight delivery service in accordance with clause (i), (ii) or (iii) above, respectively.

Section 5.         Definitions. For the purposes hereof, the following terms shall have the following meanings:

“Business Day” means any day except Saturday, Sunday and any day which shall be a federal legal holiday in the United States or a day on which banking institutions are authorized or required by law or other government action to close.

“Change of Control Transaction” means the occurrence of (a) an acquisition after the date hereof by an individual or legal entity or “group” (as described in Rule 13d-5(b)(1) promulgated under the Exchange Act) of effective control (whether through legal or beneficial ownership of capital stock of the Obligor, by contract or otherwise) of in excess of fifty percent (50%) of the voting securities of the Obligor (except that the acquisition of voting securities by the Holder shall not constitute a Change of Control Transaction for purposes hereof), (b) a replacement at one time or over time of more than one-half of the members of the board of directors of the Obligor which is not approved by a majority of those individuals who are members of the board of directors on the date hereof (or by those individuals who are serving
as members of the board of directors on any date whose nomination to the board of directors was approved by a majority of the members of the board of directors who are members on the date hereof), (c) the merger, consolidation or sale of fifty percent (50%) or more of the assets of the Obligor or any subsidiary of the Obligor in one or a series of related transactions with or into another entity, or (d) the execution by the Obligor of an agreement to which the Obligor is a party or by which it is bound, providing for any of the events set forth above in (a), (b) or (c).

 

12

 

Exhibit 10.32

 

 

“Commission” means the Securities and Exchange Commission.

“Common Stock” means the common stock, par value $0.0001, of the Obligor and stock of any other class into which such shares may hereafter be changed or reclassified.

“Conversion Date” shall mean the date upon which the Holder gives the Obligor notice of their intention to effectuate a conversion of this Debenture into shares of the Company’s Common Stock as outlined herein.

“Closing Bid Price” means the price per share in the last reported trade of the Common Stock on the OTC or on the exchange  which the Common Stock is then listed as quoted by Bloomberg, LP.

“Exchange Act” means the Securities Exchange Act of 1934, as amended.

“Original Issue Date” shall mean the date of the first issuance of this Debenture regardless of the number of transfers and regardless of the number of instruments, which may be issued to evidence such Debenture.

“Person” means a corporation, an association, a partnership, organization, a business, an individual, a government or political subdivision thereof or a governmental agency.

 “Securities Act” means the Securities Act of 1933, as amended, and the rules and regulations promulgated thereunder.

“Trading Day” means a day on which the shares of Common Stock are quoted on the OTC or quoted or traded on such Subsequent Market on which the shares of Common Stock are then quoted or listed; provided, that in the event that the shares of Common Stock are not listed or quoted, then Trading Day shall mean a Business Day.

“Transaction Documents” means the Securities Purchase Agreement or any other agreement delivered in connection with the Securities Purchase Agreement, including, without limitation, Amended and Restated Security Agreement, the Pledge Agreement, the Irrevocable Transfer Agent Instructions, and the Registration Rights Agreement.

“Underlying Shares” means the shares of Common Stock issuable upon conversion of this Debenture or as payment of interest in accordance with the terms hereof.

“Underlying Shares Registration Statement” means a registration statement meeting the requirements set forth in the Registration Rights Agreement, covering among other things the resale of the Underlying Shares and naming the Holder as a “selling stockholder” thereunder.

Section 6.         Except as expressly provided herein, no provision of this Debenture shall alter or impair the obligations of the Obligor, which are absolute and unconditional, to pay the principal of, interest and other charges (if any) on, this Debenture at the time, place, and rate, and in the coin or currency, herein prescribed. This Debenture is a direct obligation of the Obligor. This Debenture ranks pari passu with all other Debentures now or hereafter issued under the terms set forth herein. As long as this Debenture is outstanding, the Obligor shall not and shall 

 

13

 

Exhibit 10.32

 

cause their subsidiaries not to, without the consent of the Holder, (i) amend its certificate of incorporation, bylaws or other charter documents so as to adversely affect any rights of the Holder; (ii) repay, repurchase or offer to repay, repurchase or otherwise acquire shares of its Common Stock or other equity securities other than as to the Underlying Shares to the extent permitted or required under the Transaction Documents; or (iii) enter into any agreement with respect to any of the foregoing. 

Section 7.         This Debenture shall not entitle the Holder to any of the rights of a stockholder of the Obligor, including without limitation, the right to vote, to receive dividends and other distributions, or to receive any notice of, or to attend, meetings of stockholders or any other proceedings of the Obligor, unless and to the extent converted into shares of Common Stock in accordance with the terms hereof.

Section 8.         If this Debenture is mutilated, lost, stolen or destroyed, the Obligor shall execute and deliver, in exchange and substitution for and upon cancellation of the mutilated Debenture, or in lieu of or in substitution for a lost, stolen or destroyed Debenture, a new Debenture for the principal amount of this Debenture so mutilated, lost, stolen or destroyed but only upon receipt of evidence of such loss, theft or destruction of such Debenture, and of the ownership hereof, and indemnity, if requested, all reasonably satisfactory to the Obligor.

Section 9.         No indebtedness of the Obligor is senior to this Debenture in right of payment, whether with respect to interest, damages or upon liquidation or dissolution or otherwise. Without the Holder’s consent, the Obligor will not and will not permit any of their subsidiaries to, directly or indirectly, enter into, create, incur, assume or suffer to exist any indebtedness of any kind, on or with respect to any of its property or assets now owned or hereafter acquired or any interest therein or any income or profits there from that is senior in any respect to the obligations of the Obligor under this Debenture.

Section 10.       This Debenture shall be governed by and construed in accordance with the laws of the State of New Jersey, without giving effect to conflicts of laws thereof. Each of the parties consents to the jurisdiction of the Superior Courts of the State of New Jersey sitting in Hudson County, New Jersey and the U.S. District Court for the District of New Jersey  sitting in Newark, New Jersey in connection with any dispute arising under this Debenture and hereby waives, to the maximum extent permitted by law, any objection, including any objection based on forum non conveniens to the bringing of any such proceeding in such jurisdictions. 

Section 11.       If the Obligor fails to strictly comply with the terms of this Debenture, then the Obligor shall reimburse the Holder promptly for all fees, costs and expenses, including, without limitation, attorneys’ fees and expenses incurred by the Holder in any action in connection with this Debenture, including, without limitation, those incurred: (i) during any workout, attempted workout, and/or in connection with the rendering of legal advice as to the Holder’s rights, remedies and obligations, (ii) collecting any sums which become due to the Holder, (iii) defending or prosecuting any proceeding or any counterclaim to any proceeding or appeal; or (iv) the protection, preservation or enforcement of any rights or remedies of the Holder.

 

14

 

Exhibit 10.32

 

 

Section 12.       Any waiver by the Holder of a breach of any provision of this Debenture shall not operate as or be construed to be a waiver of any other breach of such provision or of any breach of any other provision of this Debenture. The failure of the Holder to insist upon strict adherence to any term of this Debenture on one or more occasions shall not be considered a waiver or deprive that party of the right thereafter to insist upon strict adherence to that term or any other term of this Debenture. Any waiver must be in writing.

Section 13.       If any provision of this Debenture is invalid, illegal or unenforceable, the balance of this Debenture shall remain in effect, and if any provision is inapplicable to any person or circumstance, it shall nevertheless remain applicable to all other persons and circumstances. If it shall be found that any interest or other amount deemed interest due hereunder shall violate applicable laws governing usury, the applicable rate of interest due hereunder shall automatically be lowered to equal the maximum permitted rate of interest. The Obligor covenants (to the extent that it may lawfully do so) that it shall not at any time insist upon, plead, or in any manner whatsoever claim or take the benefit or advantage of, any stay, extension or usury law or other law which would prohibit or forgive the Obligor from
paying all or any portion of the principal of or interest on this Debenture as contemplated herein, wherever enacted, now or at any time hereafter in force, or which may affect the covenants or the performance of this indenture, and the Obligor (to the extent it may lawfully do so) hereby expressly waives all benefits or advantage of any such law, and covenants that it will not, by resort to any such law, hinder, delay or impeded the execution of any power herein granted to the Holder, but will suffer and permit the execution of every such as though no such law has been enacted.

Section 14.       Whenever any payment or other obligation hereunder shall be due on a day other than a Business Day, such payment shall be made on the next succeeding Business Day.

Section 15.       THE PARTIES HEREBY KNOWINGLY, VOLUNTARILY AND INTENTIONALLY WAIVE THE RIGHT ANY OF THEM MAY HAVE TO A TRIAL BY JURY IN RESPECT OF ANY LITIGATION BASED HEREON OR ARISING OUT OF, UNDER OR IN CONNECTION WITH THIS AGREEMENT OR ANY TRANSACTION DOCUMENT OR ANY COURSE OF CONDUCT, COURSE OF DEALING, STATEMENTS (WHETHER VERBAL OR WRITTEN) OR ACTIONS OF ANY PARTY. THIS PROVISION IS A MATERIAL INDUCEMENT FOR THE PARTIES’ ACCEPTANCE OF THIS AGREEMENT.

[REMAINDER OF PAGE INTENTIONLLY LEFT BLANK]

 

15

 

Exhibit 10.32

 

 

IN WITNESS WHEREOF, the Obligor has caused this Secured Convertible Debenture to be duly executed by a duly authorized officer as of the date set forth above.

	
             
 	
            CONNECTED MEDIA TECHNOLOGIES, INC. 
 
	
             
 	
             
 
	
             
 	
            By: /s/ Jeffrey W. Sass                                                                                                       
 
	
             
 	
            Name:  Jeffrey W. Sass
 
	
             
 	
            Title:    CEO
 

 

 

16

 

Exhibit 10.32

 

 

EXHIBIT “A”

NOTICE OF CONVERSION

(To be executed by the Holder in order to convert the Debenture)

 

	
            TO:
 	
             
 

 

The undersigned hereby irrevocably elects to convert $                                          
              of the principal amount of the above Debenture into Shares of Common Stock of Connected Media Technologies, Inc., according to the conditions stated therein, as of the Conversion Date written below.

	
            Conversion Date:
 	
             
 
	
            Applicable Conversion Price:
 	
             
 
	
            Signature:
 	
             
 
	
            Name:
 	
             
 
	
            Address:
 	
             
 
	
            Amount to be converted:
 	
            $ 
 
	
            Amount of Debenture unconverted:
 	
            $  
 
	
            Conversion Price per share: 
 	
            $  
 
	
            Number of shares of Common Stock to be issued:
 	
             
 
	
            Please issue the shares of Common Stock in the following name and to the following address:
 	
             
 
	
            Issue to:
 	
             
 
	
            Authorized Signature:
 	
             
 
	
            Name:
 	
             
 
	
            Title:
 	
             
 
	
            Phone Number:
 	
             
 
	
            Broker DTC Participant Code:
 	
             
 
	
            Account Number:Exhibit
      10.1

     

    

    Contract
      No. FAR001

    

    STATE
      OF FLORIDA

    AGENCY
      FOR HEALTH CARE ADMINISTRATION

    STANDARD
      CONTRACT

    

    THIS
      CONTRACT is
      entered into between the State of Florida,
      AGENCY FOR HEALTH CARE ADMINISTRATION,
      hereinafter referred to as the "Agency",
      whose
      address is 2727 Mahan Drive, Tallahassee, Florida 32308, and HEALTHEASE
      HEALTH PLAN OF FLORIDA, INC.
      hereinafter referred to as the "Vendor",
      whose
      address is Post
      Office Box 26011, Tampa, Florida 33623-6011,
      a
Florida
      for profit corporation, to
      deliver
      health care services at the component level and to the TANF and SSI
      populations.

    

    
      	I.  	
              THE
                VENDOR HEREBY AGREES:

            

    

    

    A. General
      Provisions

    

    
      	 	 	
              1.

            	
              To
                provide services according to the terms and conditions set forth
                in this
                Contract, Attachment
                I,
                Scope of Services, and all other attachments named herein which are
                attached hereto and incorporated by
                reference.

            

    

    

    
      	2.  	
              To
                perform as an independent vendor and not as an agent, representative,
                or
                employee of the Agency.

            

    

    

    
      	3.  	
              To
                recognize that the State of Florida, by virtue of its sovereignty,
                is not
                required to pay any taxes on the services or goods purchased under
                the
                terms of this Contract.

            

    

    

    
      	B.  	
              Federal
                Laws and Regulations

            

    

    

    
      	1.  	
              The
                Vendor shall comply with the provisions of 45 CFR, Part 74, and/or
                45 CFR,
                Part 92, and other applicable regulations as specified in Attachments
                I and II.

            

    

    

    
      	2.  	
              This
                Contract contains federal funding in excess of $25,000. Pursuant
                to 45
                CFR, Part 76, if this Contract contains federal funding in excess
                of
                $25,000, the Vendor must, upon Contract execution, complete the
                Certification Regarding Debarment, Suspension, Ineligibility, and
                Voluntary Exclusion Contracts/Subcontracts, Attachment
                IV.

            

    

    

    
      	3.  	
              This
                Contract contains federal funding in excess of $100,000. The Vendor
                must,
                upon Contract execution, complete the Certification Regarding Lobbying
                form, Attachment
                V.
                If a Disclosure of Lobbying Activities form, Standard Form LLL, is
                required, it may be obtained from the Agency’s Contract Manager. All
                disclosure forms as required by the Certification Regarding Lobbying
                form
                must be completed and returned to the Agency’s Contract
                Manager.

            

    

    

    
      	C.  	
              Audits
                and Records

            

    

    

    
      	 	
              1.

            	
              To
                maintain books, records, and documents (including electronic storage
                media) pertinent to performance under this Contract in accordance
                with
                generally accepted accounting procedures and practices which sufficiently
                and properly reflect all revenues and expenditures of funds provided
                by
                the Agency under this Contract.

            

    

    

    

    
      	 	
              2.

            	
              To
                assure that these records shall be subject at all reasonable times
                to
                inspection, review, or audit by state personnel and other personnel
                duly
                authorized by the Agency, as well as by federal
                personnel.

            

    

    

    
      	 	
              3.

            	
              To
                maintain and file with the Agency such progress, fiscal and inventory
                reports as specified in Attachment
                II,
                and other reports as the Agency may require within the period of
                this
                Contract. In addition, access to relevant computer data and applications
                which generated such reports should be made available upon
                request.

            

    

    

    
      	 	
              4.

            	
              To
                ensure that all related party transactions are disclosed to the Agency
                Contract Manager. 

            

    

    

    
      	 	 	
              5.

            	
              To
                include these aforementioned audit and record keeping requirements
                in all
                approved subcontracts and
                assignments.

            

    

    

    
      	D.  	
              Retention
                of Records

            

    

    

    
      	 	 	
              1.

            	
              To
                retain all financial records, supporting documents, statistical records,
                and any other documents (including electronic storage media) pertinent
                to
                performance under this Contract for a period of five (5) years after
                termination of this Contract, or if an audit has been initiated and
                audit
                findings have not been resolved at the end of five (5) years, the
                records
                shall be retained until resolution of the audit
                findings.

            

    

    

    2.Persons
      duly authorized by the Agency and federal auditors, pursuant to 45 CFR, Part
      74
      and/or 45 CFR, Part 92, shall have full access to and the right to examine
      any
      of said records and documents.

    

    3.The
      rights of access in this section must not be limited to the required retention
      period but shall last as long as the records are retained.

    

    
      	E.  	
              Monitoring

            

    

    

    
      	 	 	
              1.

            	
              To
                provide reports as specified in Attachment
                II.
                These reports will be used for monitoring progress or performance
                of the
                contractual services as specified in Attachment
                II.

            

    

    

    
      	 	 	
              2.

            	
              To
                permit persons duly authorized by the Agency to inspect any records,
                papers, documents, facilities, goods and services of the Vendor which
                are
                relevant to this Contract.

            

    

    

    
      	F.  	
              Indemnification

            

    

    

    The
      Vendor shall save and hold harmless and indemnify the State of Florida and
      the
      Agency against any and all liability, claims, suits, judgments, damages or
      costs
      of whatsoever kind and nature resulting from the use, service, operation or
      performance of work under the terms of this Contract, resulting from any act,
      or
      failure to act, by the Vendor, his subcontractor, or any of the employees,
      agents or representatives of the Vendor or subcontractor.

    

    G. Insurance

    

    
      	 	 	
              1.

            	
              To
                the extent required by law, the Vendor will be self-insured against,
                or
                will secure and maintain during the life of the Contract, Worker’s
                Compensation Insurance for all his employees connected with the work
                of
                this project and, in case any work is subcontracted, the Vendor shall
                require the subcontractor similarly to provide Worker’s Compensation
                Insurance for all of the latter’s employees unless such employees engaged
                in work under this Contract are covered by the Vendor’s self insurance
                program. Such self insurance or insurance coverage shall comply with
                the
                Florida Worker’s Compensation law. In the event hazardous work is being
                performed by the Vendor under this Contract and any class of employees
                performing the hazardous work is not protected under Worker’s Compensation
                statutes, the Vendor shall provide, and cause each subcontractor
                to
                provide, adequate insurance satisfactory to the Agency, for the protection
                of his employees not otherwise
                protected.

            

    

    

    
      	 	
              2.

            	
              The
                Vendor shall secure and maintain Commercial General Liability insurance
                including bodily injury, property damage, personal & advertising
                injury and products and completed operations. This insurance will
                provide
                coverage for all claims that may arise from the services and/or operations
                completed under this Contract, whether such services and/or operations
                are
                by the Vendor or anyone directly, or indirectly employed by him.
                Such
                insurance shall include a Hold Harmless Agreement in favor of the
                State of
                Florida and also include the State of Florida as an Additional Named
                Insured for the entire length of the Contract. The Vendor is responsible
                for determining the minimum limits of liability necessary to provide
                reasonable financial protections to the Vendor and the State of Florida
                under this Contract.

            

    

    

    
      	 	
              3.

            	
              All
                insurance policies shall be with insurers licensed or eligible to
                transact
                business in the State of Florida. The Vendor’s current certificate of
                insurance shall contain a provision that the insurance will not be
                canceled for any reason except after thirty (30) days written notice
                to
                the Agency’s Contract Manager.

            

    

    

    H. Assignments
      and Subcontracts

    

    
      	
            	 	
              Toneither
                assign the responsibility of this Contract to another party nor
                subcontract for any of the work contemplated under this Contract
                without
                prior written approval of the Agency.
                No such approval by the Agency of any assignment or subcontract shall
                be
                deemed in any event or in any manner to provide for the incurrence
                of any
                obligation of the Agency in addition to the total dollar amount agreed
                upon in this Contract. All such assignments or subcontracts shall
                be
                subject to the conditions of this Contract and to any conditions
                of
                approval that the Agency shall deem
                necessary.

            

    

    

    I. Financial
      Reports

     

    
      	
            	 	
               
                To provide financial reports to the Agency as specified in Attachment
                II.

            

    

    

    J. Return
      of Funds

    

    
      	
            	 	
              To
                return to the Agency any overpayments due to unearned funds or funds
                disallowed pursuant to the terms of this Contract that were disbursed
                to
                the Vendor by the Agency. The Vendor shall return any overpayment
                to the
                Agency within forty (40) calendar days after either discovery by
                the
                Vendor, its independent auditor, or notification by the Agency, of
                the
                overpayment.

            

    

    

    K. Purchasing

    

    1. P.R.I.D.E.

    

    It
      is
      expressly understood and agreed that any articles which are the subject of,
      or
      required to carry out this Contract shall be purchased from the corporation
      identified under Chapter 946, Florida Statutes, if available, in the same manner
      and under the same procedures set forth in Section 946.515(2), (4), Florida
      Statutes; and for purposes of this Contract the person, firm or other business
      entity carrying out the provisions of this Contract shall be deemed to be
      substituted for this agency insofar as dealings with such corporation are
      concerned.

    

    The
      “Corporation identified” is PRISON REHABILITATIVE INDUSTRIES AND DIVERSIFIED
      ENTERPRISES, INC. (P.R.I.D.E.) which may be contacted at:

    

    P.R.I.D.E.

    2720-G
      Blair Stone Road

    Tallahassee,
      Florida 32301

    (850)
      487-3774

    Toll
      Free: 1-800-643-8459

    Website:
      www.pridefl.com

    

    
      	 	 	
              2.

            	
              RESPECT
                of Florida

            

    

    

    
      	
            	 	
              It
                is expressly understood and agreed that any articles that are the
                subject
                of, or required to carry out, this Contract shall be purchased from
                a
                nonprofit agency for the blind or for the severely handicapped that
                is
                qualified pursuant to Chapter 413, Florida Statutes, in the same
                manner
                and under the same procedures set forth in Section 413.036(1) and
                (2),
                Florida Statutes; and for purposes of this Contract the person, firm,
                or
                other business entity carrying out the provisions of this Contract
                shall
                be deemed to be substituted for the state agency insofar as dealings
                with
                such qualified nonprofit agency are
                concerned.

            

    

    

    The
      "nonprofit agency” identified is RESPECT of Florida which may be contacted
      at:

    

    
      	
              RESPECT
                of Florida.

              2475
                Apalachee Parkway, Suite 205

              Tallahassee,
                Florida 32301-4946

              (850)
                487-1471

              Website:
                www.respectofflorida.org

            

    

    

    
      	 	
              3.

            	
              Procurement
                of Products or Materials with Recycled
                Content

            

    

    

    It
      is
      expressly understood and agreed that any products which are required to carry
      out this Contract shall be procured in accordance with the provisions of Section
      403.7065, Florida Statutes.

    

    L. Civil
      Rights Requirements/Vendor Assurance

    

    The
      Vendor assures that it will comply with:

    

    
      	 	 	
              1.

            	
              Title
                VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et
                seq., which prohibits discrimination on the basis of race, color,
                or
                national origin.

            

    

    
      	 	 	
              2.

            	
              Section
                504 of the Rehabilitation Act of 1973, as amended,
                29 U.S.C. 794, which prohibits discrimination on the basis of
                handicap.

            

    

    
      	 	 	
              3.

            	
              Title
                IX of the Education Amendments of 1972, as amended,
                20 U.S.C. 1681 et seq., which prohibits discrimination on the
                basis of sex.

            

    

    
      	 	 	
              4.

            	
              The
                Age Discrimination Act of 1975, as amended, 42 U.S.C. 6101 et seq.,
                which
                prohibits discrimination on the basis of
                age.

            

    

    
      	 	 	
              5.

            	
              Section
                654 of the Omnibus Budget Reconciliation Act of 1981, as amended,
                42 U.S.C. 9849, which prohibits discrimination on the basis of
                race, creed, color, national origin, sex, handicap, political affiliation
                or beliefs.

            

    

    
      	 	 	
              6.

            	
              The
                Americans with Disabilities Act of 1990, P.L. 101-336, which prohibits
                discrimination on the basis of disability and requires reasonable
                accommodation for persons with
                disabilities.

            

    

    
      	 	 	
              7.

            	
              All
                regulations, guidelines, and standards as are now or may be lawfully
                adopted under the above statutes.

            

    

    

    The
      Vendor agrees that compliance with this assurance constitutes a condition of
      continued receipt of or benefit from funds provided through this Contract,
      and
      that it is binding upon the Vendor, its successors, transferees, and assignees
      for the period during which services are provided. The Vendor further assures
      that all contractors, subcontractors, subgrantees, or others with whom it
      arranges to provide services or benefits to participants or employees in
      connection with any of its programs and activities are not discriminating
      against those participants or employees in violation of the above statutes,
      regulations, guidelines, and standards.

    

    M. Discrimination

    

    
      	
            	 	
              Anentity
                or affiliate who has been placed on the discriminatory vendor list
                may not
                submit a bid, proposal, or reply on a contract to provide any goods
                or
                services to a public entity; may not submit a bid, proposal, or reply
                on a
                contract with a public entity for the construction or repair of a
                public
                building or public work; may not submit bids, proposals, or replies
                on
                leases of real property to a public entity; may not be awarded or
                perform
                work as a contractor, supplier, subcontractor, or consultant under
                a
                contract with any public entity; and may not transact business with
                any
                public entity. The Florida Department of Management Services is
                responsible for maintaining the discriminatory vendor list and intends
                to
                post the list on its website. Questions regarding the discriminatory
                vendor list may be directed to the Florida Department of Management
                Services, Office of Supplier Diversity at (850)
                487-0915.

            

    

    

    N. Requirements
      of Section 287.058, Florida Statutes

    

    
      	 	
              1.

            	
              To
                submit bills for fees or other compensation for services or expenses
                in
                sufficient detail for a proper pre-audit and post-audit
                thereof.

            

    

    

    
      	 	 	
              2.

            	
              Where
                applicable, to submit bills for any travel expenses in accordance
                with
                Section 112.061, Florida Statutes.

            

    

    

    
      	 	
              3.

            	
              To
                provide units of deliverables, including reports, findings, and drafts,
                in
                writing and/or in an electronic format agreeable to both parties,
                as
                specified in Attachment
                II, to
                be received and accepted by the Contract Manager prior to
                payment.

            

    

    

    
      	 	
              4.

            	
              To
                comply with the criteria and final date by which such criteria must
                be met
                for completion of this Contract as specified in Section III, Paragraph
                A.
                of this Contract.

            

    

    

    
      	 	
              5.

            	
              To
                allow public access to all documents, papers, letters, or other material
                made or received by the Vendor in conjunction with this Contract,
                unless
                the records are exempt from Section 24(a) of Article I of the State
                Constitution and Section 119.07(1), Florida Statutes. It is expressly
                understood that substantial evidence of the Vendor's refusal to comply
                with this provision shall constitute a breach of
                Contract.

            

    

    

    O. Sponsorship

    

    As
      required by Section 286.25, Florida Statutes, if the Vendor is a
      nongovernmental organization which sponsors a program financed wholly or in
      part
      by state funds, including any funds obtained through this Contract, it shall,
      in
      publicizing, advertising or describing the sponsorship of the program,
      state:

    

    "Sponsored
      by HEALTHEASE
      HEALTH PLAN OF FLORIDA, INC.
      and
      the
      State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION".

    

    If
      the
      sponsorship reference is in written material, the words "State of Florida,
      AGENCY FOR HEALTH CARE ADMINISTRATION" shall appear in the same size letters
      or
      type as the name of the organization.

     

    P. Final
      Invoice

    

    
      	
            	 	
              TheVendor
                must submit the final invoice for payment to the Agency no more than
                365
                days after the Contract ends or is terminated. If the Vendor fails
                to do
                so, all right to payment is forfeited and the Agency will not honor
                any
                requests submitted after the aforesaid time period. Any payment due
                under
                the terms of this Contract may be withheld until all reports due
                from the
                Vendor and necessary adjustments thereto have been approved by the
                Agency.

            

    

    

    
      	 	
              Q.

            	
              Use
                Of Funds For Lobbying
                Prohibited

            

    

    

    To
      comply
      with the provisions of Section 216.347, Florida Statutes, which prohibits the
      expenditure of Contract funds for the purpose of lobbying the Legislature,
      the
      judicial branch or a state agency. 

    

    R. Public
      Entity Crime

    

    
      	
            	 	
              A
                person or affiliate who has been placed on the convicted vendor list
                following a conviction for a public entity crime may not be awarded
                or
                perform work as a contractor, supplier, subcontractor, or consultant
                under
                a contract with any public entity, and may not transact business
                with any
                public entity in excess of the threshold amount provided in Section
                287.017, Florida Statutes, for category two, for a period of 36 months
                from the date of being placed on the convicted vendor
                list.

            

    

    

    S. Health
      Insurance Portability and Accountability Act

     

    
      	
            	 	
              To
                comply with the Department of Health and Human Services Privacy
                Regulations in the Code of Federal Regulations, Title 45, Sections
                160 and
                164, regarding disclosure of protected health information as specified
                in
                Attachment
                III.

            

    

    

    T. Confidentiality
      of Information

    

    
      	
            	 	
               Not to
                use or disclose any confidential information, including social security
                numbers that may be supplied under this Contract pursuant to law,
                and also
                including the identity or identifying information concerning a Medicaid
                recipient or services under this Contract for any purpose not in
                conformity with state and federal laws, except upon written consent
                of the
                recipient, or his/her guardian.

            

    

    

    U. Employment

    

    
      	
            	 	
              To
                comply with Section 274A (e) of the Immigration and Nationality Act.
                The
                Agency shall consider the employment by any contractor of unauthorized
                aliens a violation of this Act. If the Vendor knowingly employs
                unauthorized aliens, such violation shall be cause for unilateral
                cancellation of this Contract. The Vendor shall be responsible for
                including this provision in all subcontracts with private organizations
                issued as a result of this
                Contract.

            

    

    

    V. Vendor
      Performance

    

    Penalties
      or sanctions for unsatisfactory performance under this Contract are specified
      in
Attachment
      II,
      if
      applicable.

    

    II. THE
      AGENCY HEREBY AGREES:

    

    A. Contract
      Amount

    

    
      	
            	 	
              To
                pay for contracted services according to the conditions of Attachment
                I
                in
                an amount not to exceed $380,666,421.00
                subject to the availability of funds. The State of Florida's performance
                and obligation to pay under this Contract is contingent upon an annual
                appropriation by the Legislature.

            

    

    

    B. Contract
      Payment

    

    
      	
            	 	
              Section
                215.422, Florida Statutes, provides that agencies have 5 working
                days to
                inspect and approve goods and services, unless bid specifications,
                Contract or purchase order specifies otherwise. With the exception
                of
                payments to health care providers for hospital, medical, or other
                health
                care services, if payment is not available within forty (40) days,
                measured from the latter of the date the invoice is received or the
                goods
                or services are received, inspected and approved, a separate interest
                penalty set by the Comptroller pursuant to Section 55.03, F. S.,
                will be
                due and payable in addition to the invoice amount. To obtain the
                applicable interest rate, please contact the Agency’s Fiscal Section at
                (850) 488-5869, or utilize the Department of Financial Services website
                at
                www.dfs.state.fl.us/interest.html.
                Payments to health care providers for hospitals, medical or other
                health
                care services, shall be made not more than 35 days from the date
                of
                eligibility for payment is determined, and the daily interest rate
                is
                .0003333%. Invoices returned to a vendor due to preparation errors
                will
                result in a payment delay. Invoice payment requirements do not start
                until
                a properly completed invoice is provided to the Agency. A Vendor
                Ombudsman, whose duties include acting as an advocate for vendors
                who may
                be experiencing problems in obtaining timely payment(s) from a State
                agency, may be contacted at (850) 410-9724 or by calling the State
                Comptroller’s Hotline,
                1-800-848-3792.

            

    

    

    III. THE
      VENDOR AND AGENCY HEREBY MUTUALLY AGREE:

    

    A. Effective/End
      Date

    

    This
      Contract shall begin upon execution by both parties or on July
      1, 2006, (whichever
      is later) and end August
      31, 2009,
      inclusive.

    

    B. Termination

    

    1. Termination
      at Will

    

    This
      Contract may be terminated by either party upon no less than thirty (30)
      calendar days written notice, without cause, unless a lesser time is mutually
      agreed upon by both parties. Said notice shall be delivered by certified mail,
      return receipt requested, or in person with proof of delivery.

     

    2. Termination
      Due To Lack of Funds

    

    In
      the
      event funds to finance this Contract become unavailable, the Agency may
      terminate the Contract upon no less than twenty-four (24) hours written notice
      to the Vendor. Said notice shall be delivered by certified mail, return receipt
      requested, or in person with proof of delivery. The Agency shall be the final
      authority as to the availability of funds.

    

    3. Termination
      for Breach

    

    Unless
      the Vendor's breach is waived by the Agency in writing, the Agency may, by
      written notice to the Vendor, terminate this Contract upon no less than
      twenty-four (24) hours written notice. Said notice shall be delivered by
      certified mail, return receipt requested, or in person with proof of delivery.
      If applicable, the Agency may employ the default provisions in
      Chapter 60A-1.006(4), Florida Administrative Code.

    

    Waiver
      of
      breach of any provisions of this Contract shall not be deemed to be a waiver
      of
      any other breach and shall not be construed to be a modification of the terms
      of
      this Contract. The provisions herein do not limit the Agency's right to remedies
      at law or to damages.

    

    C. Contract
      Managers

    

    
      	 	 	
              1.

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

            

    

    

    G.
      Douglas Harper

    Agency
      for Health Care Administration

    2727
      Mahan Drive, MS #50 

    Tallahassee,
      FL 32308

    (850)
      487-2355

    

    
      	2.  	
              The
                Vendor’s Contract Manager’s name, address and telephone number for this
                Contract is as follows:

            

    

    

    Imtiaz
      ("MT") Sattaur

    HealthEase
      Health Plan of Florida, Inc.

    P.O.
      Box 26011

    Tampa,
      FL 33623-6011

    (813)
      290-6316

    

    
      	 	 	
              3.

            	
              All
                matters shall be directed to the Contract Managers for appropriate
                action
                or disposition. A change in Contract Manager by either party shall
                be
                reduced to writing through an amendment to this Contract by the
                Agency.

            

    

     

    D. Renegotiation
      or Modification

    

    
      	 	 	
              1.

            	
              Modifications
                of provisions of this Contract shall only be valid when they have
                been
                reduced to writing and duly signed during the term of the Contract.
                The
                parties agree to renegotiate this Contract if federal and/or state
                revisions of any applicable laws, or regulations make changes in
                this
                Contract necessary.

            

    

    

    
      	 	 	 	
              2.

            	
              The
                rate of payment and the total dollar amount may be adjusted retroactively
                to reflect price level increases and changes in the rate of payment
                when
                these have been established through the appropriations process and
                subsequently identified in the Agency's operating
                budget.

            

    

     

    E. Name,
      Mailing and Street Address of Payee

    

    
      	 	 	
              1.

            	
              The
                name (Vendor name as shown on Page 1 of this Contract) and mailing
                address
                of the official payee to whom the payment shall be
                made:

            

    

    

    HealthEase
      Health Plan of Florida, Inc.

    P.O.
      Box 26011

    Tampa,
      FL 33623-6011

    

    
      	 	
              2.

            	
              The
                name of the contact person and street address where financial and
                administrative records are
                maintained:

            

    

    

    Paul
      L. Behrens

    Renaissance
      One

    8735
      Henderson Road

    Tampa,
      FL 33634

    

    F. All
      Terms and Conditions

    

    
      	 	 	 	
              This
                Contract and its attachments as referenced herein contain all the
                terms
                and conditions agreed upon by the
                parties.

            

    

    

    IN
      WITNESS THEREOF,
      the
      parties hereto have caused this two-hundred and ninety-six (296) page Contract,
      which includes any referenced attachments, to be executed by their undersigned
      officials as duly authorized. This Contract is not valid until signed
and
      dated by
      both parties.

    

    
      	
              HEALTHEASE
                HEALTH PLAN OF FLORIDA, INC.

            	
              STATE
                OF FLORIDA, AGENCY FOR

              HEALTH
                CARE ADMINISTRATION

            
	 	 	 	 	 
	
              SIGNED
                BY:

            	   
              /s/ Todd S.
              Farha              
              	
              SIGNED
                BY:

            	  /s/ 
              Thomas Arnold        
              	 
	 	 	 	 	 
	
              NAME:

            	
                
Todd
                S. Farha 

            	
              NAME:

            	
               
                Thomas W. Arnold

            	 
	 	 	 	 	 
	
              TITLE:

            	
                
                President and CEO 

            	
              TITLE:

            	
               
                Deputy Secretary, Medicaid

            	 
	 	 	 	 	 
	
              DATE:

            	 6/26/06	
              DATE:

            	 6/26/06	 
	 	 	 	 	 

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    FEDERAL
      ID NUMBER: 59-3646690

    

    VENDOR
      FISCAL YEAR ENDING DATE: December
      31st 

    

    List
      of
      attachments included as part of this Contract:

    

    Attachment I Scope
      of
      Services (16
      Pages)

    Attachment II Medicaid
      Reform Health Plan Model Contract (265 Pages)

    Attachment III Business
      Associate Agreement (3 Pages)

    Attachment IV Debarment
      Certification (1 Page)

    Attachment V Lobbying
      Certification (1 Page)

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    

    
ATTACHMENT
      I

    SCOPE
      OF SERVICES

    

    

    A. Service
      (s) to be Provided:

    

    The
      Vendor (Health Plan) shall deliver health care services at the component level
      and to the specific population(s) approved below:

    

    (___)
      PSN
      - Prepaid - Comprehensive Component

    (___)
      PSN
      - Prepaid - Comprehensive and Catastrophic Components

    (___)
      HMO
      - Prepaid - Comprehensive Component

    (_X_)
      HMO -
      Prepaid - Comprehensive and Catastrophic Components

    (___)
      Other Authorized Health Plan - Prepaid - Comprehensive Component

    (___)
      Other Authorized Health Plan - Prepaid - Comprehensive and
      Catastrophic Components

    
 

    (_X_)
      Temporary Assistance for Needy Families (TANF)

    (_X_)
      Supplemental Security Income (SSI)

    (___)
      Children with Chronic Conditions (CCC)

    (___)
      HIV/AIDS

    

    

    B. Manner
      of Service (s) Provision:

    

    
      	1.  	
              Policies
                and Procedures

            

    

    

    The
      Health Plan shall comply with all provisions of this Contract and any subsequent
      amendments, and shall act in good faith in the performance of the Contract's
      provisions. The Health Plan shall develop, maintain and implement written
      policies and procedures covering all provisions of this Contract. All policies
      and procedures shall be prior-approved by the Agency in writing. The Health
      Plan
      agrees that failure to comply with all provisions of this Contract shall result
      in the assessment of penalties and/or termination of this Contract, in whole
      or
      in part, as set forth in this Contract.

    

    
      	2.  	
              Benefit
                Grid/Customized Benefit Package

            

    

    

    Exhibit
      1, Benefit Grid (Grid), attached hereto, describes the Health Plan’s Customized
      Benefit Package (CBP). The CBP includes all Covered Services, Qualified Benefits
      and Expanded Services as specified in Attachment II, Section V, Covered
      Services, and VI, Behavioral Health Care. The CBP has been determined to meet
      actuarial equivalency and sufficiency standards for the population or
      populations covered by the CBP. The Health Plan is required to provide these
      services to all Enrollees in accordance with Contract provisions.

    

    The
      Health Plan shall submit its CBP for recertification of actuarial equivalency
      and sufficiency standards for the upcoming year no later than June 30 of each
      year. CBPs may be changed on a Contract-Year basis and only if approved by
      the
      Agency in writing.

    

    C. Method
      of Payment:

    

    1. General

    

    Notwithstanding
      the payment amounts which may be computed with the rate tables specified in
      Tables 2-6, the sum of total capitation payments under this Contract shall
      not
      exceed the total Contract amount of $380,666.421.00.
      

    

    
      	 	
              a.

            	
              The
                Health Plan shall be paid capitation payments for each Agency Service
                Area, based upon Exhibits 3 through 7, Tables 2 through 6, attached
                hereto, depending on whether the Health Plan contracts for both the
                Comprehensive Component and the Catastrophic Component, or Comprehensive
                Component only, and whether the Health Plan is a Specialty Plan.
                Kick
                Payments shall be paid based upon the amounts specified in Exhibit
                8,
                Table 7, attached hereto, for covered transplant services and Exhibit
                9,
                Table 8, attached hereto, for covered obstetrical delivery
                services.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plans overall payment will be dependent upon the actual Plan
                Factor
                and the percentage adjustment deducted for the Enhanced Benefits
                Accounts.
                Each month the Agency will provide, in writing, the Health Plan with
                its
                Plan Factor. 

            

    

    

    
      	 	
              c.

            	
              All
                payments made to the Health Plan shall be in accordance with this
                section
                (Section C, Method of Payment) and Attachment II, Section XIII, Payment
                Methodology.

            

    

    

    2. Enrollment
      Levels

    

    The
      Agency assigns the Health Plan an authorized maximum Enrollment level for each
      operational county. The authorized maximum Enrollment level is in effect on
      September 1, 2006, or upon Contract execution, whichever is later. 

    

    
      	a.  	
              The
                Agency must approve, in writing, any increase in the Health Plan’s maximum
                Enrollment level for each operational county and subpopulation to
                be
                served, as applicable. Such approval shall not be unreasonably withheld,
                and shall be based upon the Health Plan’s satisfactory performance of
                terms of the Contract and upon the Agency’s approval of the Health Plan’s
                administrative and service resources, as specified in this Contract,
                in
                support of each Enrollment level. 

            

    

    

    
      	b.  	
              Exhibit
                2, Table 1, attached hereto, indicates the Health Plan’s maximum
                authorized Enrollment levels for each Medicaid Reform county and
                each
                applicable authorized eligibility category.

            

    

    

    3. Capitation
      Rate Tables

    

    Tables
      2
      through 6 provide the capitation rates respective to the authorized areas of
      operation, as identified in subsection C, Method of Payment, Item 2, above,
      and
      for the specific populations identified in subsection A., Service(s) To Be
      Provided, above. The Capitation Rate payment shall be in accordance with
      Attachment II, Section XIII, Payment Methodology.

    

    
      	a.  	
              Table
                2 - Capitation Rates for Comprehensive Component and Catastrophic
                Component Health Plans for each Medicaid Reform county for Children
                and
                Families and the Aged and Disabled without Medicare eligibility
                categories. .

            

    

    

    
      	b.  	
              Table
                3 - Capitation Rates for Comprehensive Component Only Health Plans
                for
                each Medicaid Reform county for Children and Families and the Aged
                and
                Disabled without Medicare eligibility categories.
                

            

    

    

    
      	c.  	
              Table
                4 - Capitation Rate Table for SSI Medicare Part B Only and SSI Medicare.
                Parts A and B Enrollees for all Medicaid Reform Counties.
                

            

    

    

    
      	d.  	
              Table
                5 - Capitation Rates for HIV/AIDS Populations for each Medicaid Reform
                county. 

            

    

    

    
      	e.  	
              Table
                6 - Capitation Rates for Medicaid Reform counties for All Medicaid
                Reform
                counties. 

            

    

    

    4. Kick
      Payment Tables

    

    Beginning
      September 1, 2006, the Health Plan shall be paid Kick Payments for each Kick
      Payment service provided in accordance with the following tables:

    

    
      	a.  	
              Table
                7 - Covered Transplant Services. 

            

    

    

    
      	b.  	
              Table
                8 - Obstetrical Delivery Services, regardless of whether or not the
                Health
                Plan is at risk for the Comprehensive Component only, or is at risk
                for
                both the Comprehensive Component and the Catastrophic Component.
                

            

    

    

    The
      Kick
      Payments shall be in accordance with Attachment II, Section XIII, Payment
      Methodology.

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    
       

      
        
          
            
              
                 

              

              
              

            

            
              
              

              
                

              

            

            
              
              

              
                HEALTHEASE
                  OF FLORIDA

                EXHIBIT
                  1

                BENEFIT
                  GRID

              

            

          

        

         

        
          	(i)  	
                  Broward
                    - Children and Families

                

        

        

        
          	
                  Covered
                    Service Category

                	
                   

                	
                  Visit/Script
                    Limit

                	
                  Limit
                    Period

                	
                  Dollar
                    Limit

                	
                  Limit
                    Period (Annual)

                	
                  Copay
                    Amount

                	
                  Copay
                    Application

                
	
                  (Annual/
                    Monthly)

                
	
                  Hospital
                    Inpatient

                
	
                  Behavioral
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                  Physical
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                   

                
	
                  Transplant
                    Services

                
	
                  Transplant
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient-services

                
	
                  Emergency
                    Room

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Medical/Drug
                    Therapies (Chemo, Dialysis)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Ambulatory
                    Surgery - ASC

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Hospital
                    Outpatient Surgery

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Lab/X-ray

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  day

                
	
                  Hospital
                    Outpatient Services NOS

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Outpatient
                    Therapy (PT/RT)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                  Outpatient
                    Therapy (OT/ST)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Maternity
                    and Family Planning Services

                
	
                  Inpatient
                    Hospital

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Birthing
                    Centers

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Physician
                    Care

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Family
                    Planning

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Pharmacy

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Physician
                    and Phys Extender Services (non maternity)

                
	
                  EPSDT

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Primary
                    Care Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Specialty
                    Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  ARNP/Physician
                    Assistant

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (FQHC, RHC)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (CHD)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Other

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Outpatient Professional Services

                
	
                  Home
                    Health Services

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Chiropractor

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Podiatrist

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Dental
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  coinsurance

                
	
                  Vision
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Hearing
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient
                    Mental Health

                
	
                  Outpatient
                    Mental Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                   

                
	
                  Outpatient
                    Pharmacy

                
	
                  Outpatient
                    Pharmacy

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Services

                
	
                  Ambulance

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Non-emergent
                    Transporation

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  trip

                
	
                  Durable
                    Medical Equipment

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                  Expanded
                    Benefit 

                
	
                  Adult
                    Dental

                	
                  Adult
                    dental expanded to include unlimited fillings, periodontic deep
                    cleanings,
                    annual exam, two cleanings per year, and x-rays.

                
	
                  Circumcision

                	
                  Routine
                    newborn circumcision up to one year of age.

                
	
                  Over
                    the Counter Benefit

                	
                  Agency
                    approved over-the-counter drug benefit, not to exceed $25 per
                    household,
                    per month. Limited to non-prescription drugs containing a National
                    Drug
                    Code number, first aid and birth control supplies. Benefit must
                    be offered
                    through a plan’s pharmacy or plan’s
                    subcontractor.

                

        

        

        

        
          
            
              

              
              

            

            
              
              

              
                

              

            

            
              
              

              HEALTHEASE
                OF FLORIDA

              EXHIBIT
                1

              BENEFIT
                GRID

            

          

        

         

        
          	(ii)  	
                  Broward
                    - Elderly and Disabled

                

        

         

        
          
            
              	
                      Covered
                        Service Category

                    	
                       

                    	
                      Visit/Script
                        Limit

                    	
                      Limit
                        Period

                    	
                      Dollar
                        Limit

                    	
                      Limit
                        Period (Annual)

                    	
                      Copay
                        Amount

                    	
                      Copay
                        Application

                    
	
                      (Annual/
                        Monthly)

                    
	
                      Hospital
                        Inpatient

                    
	
                      Behavioral
                        Health

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      admit

                    
	
                      Physical
                        Health

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      admit

                    
	
                       

                    
	
                      Transplant
                        Services

                    
	
                      Transplant
                        Services

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Outpatient-services

                    
	
                      Emergency
                        Room

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Medical/Drug
                        Therapies (Chemo, Dialysis)

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Ambulatory
                        Surgery - ASC

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Hospital
                        Outpatient Surgery

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                      Lab/X-ray

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      day

                    
	
                      Hospital
                        Outpatient Services NOS

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      visit

                    
	
                      Outpatient
                        Therapy (PT/RT)

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                       

                    	
                       

                    
	
                      Outpatient
                        Therapy (OT/ST)

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Maternity
                        and Family Planning Services

                    
	
                      Inpatient
                        Hospital

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Birthing
                        Centers

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Physician
                        Care

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Family
                        Planning

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Pharmacy

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Physician
                        and Phys Extender Services (non maternity)

                    
	
                      EPSDT

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Primary
                        Care Physician

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                      Specialty
                        Physician

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                      ARNP/Physician
                        Assistant

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                      Clinic
                        (FQHC, RHC)

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                      Clinic
                        (CHD)

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Other

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Other
                        Outpatient Professional Services

                    
	
                      Home
                        Health Services

                    	
                       

                    	
                      120

                    	
                      Annual

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      visit

                    
	
                      Chiropractor

                    	
                       

                    	
                      24

                    	
                      Annual

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      visit

                    
	
                      Podiatrist

                    	
                       

                    	
                      24

                    	
                      Annual

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      visit

                    
	
                      Dental
                        Services

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      coinsurance

                    
	
                      Vision
                        Services

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                      0

                    	
                      visit

                    
	
                      Hearing
                        Services

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Outpatient
                        Mental Health

                    
	
                      Outpatient
                        Mental Health

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      visit

                    
	
                       

                    
	
                      Outpatient
                        Pharmacy

                    
	
                      Outpatient
                        Pharmacy

                    	
                       

                    	
                      16

                    	
                      Monthly

                    	
                       

                    	
                      Annual

                    	
                       

                    	
                       

                    
	
                       

                    
	
                      Other
                        Services

                    
	
                      Ambulance

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    
	
                      Non-emergent
                        Transporation

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      0

                    	
                      trip

                    
	
                      Durable
                        Medical Equipment

                    	
                       

                    	
                       

                    	
                       

                    	
                       

                    	
                      Annual

                    	
                       

                    	
                       

                    

            

          

        

         

        Expanded
          Benefit

        
          	
                  Adult
                    Dental

                	
                  Adult
                    dental expanded to include unlimited fillings, periodontic deep
                    cleanings,
                    crowns, clear fillings, restorations, annual exam, two cleanings
                    per year,
                    and x-rays.

                
	
                  Circumcision

                	
                  Routine
                    newborn circumcision up to one year of age. 

                
	
                  Over
                    the Counter Benefit

                	
                  Agency
                    approved over-the-counter drug benefit, not to exceed $25 per
                    household,
                    per month. Limited to non-prescription drugs containing a National
                    Drug
                    Code number, first aid and birth control supplies. Benefit must
                    be offered
                    through a plan’s pharmacy or plan’s subcontractor.

                
	
                  Meals
                    on Wheels

                	
                  10
                    meals within 15 days of post discharge (medically
                    necessary)

                

        

        

        

        
          
            
               

              
              

            

            
              
              

              
                

              

            

            
              
              

              HEALTHEASE
                OF FLORIDA

              EXHIBIT
                1

              BENEFIT
                GRID

            

          

        

         

        
          	(iii)  	
                  Duval
                    - Children and Families

                

        

        

        
          	
                  Covered
                    Service Category

                	
                   

                	
                  Visit/Script
                    Limit

                	
                  Limit
                    Period

                	
                  Dollar
                    Limit

                	
                  Limit
                    Period (Annual)

                	
                  Copay
                    Amount

                	
                  Copay
                    Application

                
	
                  (Annual/
                    Monthly)

                
	
                  Hospital
                    Inpatient

                
	
                  Behavioral
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                  Physical
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                   

                
	
                  Transplant
                    Services

                
	
                  Transplant
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient-services

                
	
                  Emergency
                    Room

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Medical/Drug
                    Therapies (Chemo, Dialysis)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Ambulatory
                    Surgery - ASC

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Hospital
                    Outpatient Surgery

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Lab/X-ray

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  day

                
	
                  Hospital
                    Outpatient Services NOS

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Outpatient
                    Therapy (PT/RT)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                  Outpatient
                    Therapy (OT/ST)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Maternity
                    and Family Planning Services

                
	
                  Inpatient
                    Hospital

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Birthing
                    Centers

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Physician
                    Care

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Family
                    Planning

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Pharmacy

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Physician
                    and Phys Extender Services (non maternity)

                
	
                  EPSDT

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Primary
                    Care Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Specialty
                    Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  ARNP/Physician
                    Assistant

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (FQHC, RHC)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (CHD)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Other

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Outpatient Professional Services

                
	
                  Home
                    Health Services

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Chiropractor

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Podiatrist

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Dental
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  coinsurance

                
	
                  Vision
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Hearing
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient
                    Mental Health

                
	
                  Outpatient
                    Mental Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                   

                
	
                  Outpatient
                    Pharmacy

                
	
                  Outpatient
                    Pharmacy

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Services

                
	
                  Ambulance

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Non-emergent
                    Transporation

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  trip

                
	
                  Durable
                    Medical Equipment

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                

        

        Expanded
          Benefit

        
          	
                  Adult
                    Dental

                	
                  Adult
                    dental expanded to include unlimited fillings, periodontic deep
                    cleanings,
                    annual exam, two cleanings per year and x-rays.

                
	
                  Circumcision

                	
                  Routine
                    newborn circumcision up to one year of age. 

                
	
                  Over
                    the Counter Benefit

                	
                  Agency
                    approved over-the -counter drug benefit, not to exceed $25 per
                    household,
                    per month. Limited to non-prescription drugs containing a National
                    Drug
                    Code number, first aid and birth control supplies. Benefit must
                    be offered
                    through a plan’s pharmacy or plan’s
                    subcontractor.

                

        

        

        

        
          
            
               

              
              

            

            
              
              

              
                

              

            

            
              
              

              HEALTHEASE
                OF FLORIDA

              EXHIBIT
                1

              BENEFIT
                GRID

            

          

        

         

        
          	(iv)  	
                  Duval
                    - Elderly and Disabled

                

        

        

        
          	
                  Covered
                    Service Category

                	
                   

                	
                  Visit/Script
                    Limit

                	
                  Limit
                    Period

                	
                  Dollar
                    Limit

                	
                  Limit
                    Period (Annual)

                	
                  Copay
                    Amount

                	
                  Copay
                    Application

                
	
                  (Annual/
                    Monthly)

                
	
                  Hospital
                    Inpatient

                
	
                  Behavioral
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                  Physical
                    Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  admit

                
	
                   

                
	
                  Transplant
                    Services

                
	
                  Transplant
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient-services

                
	
                  Emergency
                    Room

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Medical/Drug
                    Therapies (Chemo, Dialysis)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Ambulatory
                    Surgery - ASC

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Hospital
                    Outpatient Surgery

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Lab/X-ray

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  day

                
	
                  Hospital
                    Outpatient Services NOS

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Outpatient
                    Therapy (PT/RT)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                  Outpatient
                    Therapy (OT/ST)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Maternity
                    and Family Planning Services

                
	
                  Inpatient
                    Hospital

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Birthing
                    Centers

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Physician
                    Care

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Family
                    Planning

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Pharmacy

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Physician
                    and Phys Extender Services (non maternity)

                
	
                  EPSDT

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Primary
                    Care Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Specialty
                    Physician

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  ARNP/Physician
                    Assistant

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (FQHC, RHC)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                  Clinic
                    (CHD)

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Other

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Outpatient Professional Services

                
	
                  Home
                    Health Services

                	
                   

                	
                  120

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Chiropractor

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Podiatrist

                	
                   

                	
                  24

                	
                  Annual

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Dental
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  coinsurance

                
	
                  Vision
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                  0

                	
                  visit

                
	
                  Hearing
                    Services

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Outpatient
                    Mental Health

                
	
                  Outpatient
                    Mental Health

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  visit

                
	
                   

                
	
                  Outpatient
                    Pharmacy

                
	
                  Outpatient
                    Pharmacy

                	
                   

                	
                  16

                	
                  Monthly

                	
                   

                	
                  Annual

                	
                   

                	
                   

                
	
                   

                
	
                  Other
                    Services

                
	
                  Ambulance

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                
	
                  Non-emergent
                    Transporation

                	
                   

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  0

                	
                  trip

                
	
                  Durable
                    Medical Equipment

                	
                   

                	
                   

                	
                   

                	
                   

                	
                  Annual

                	
                   

                	
                   

                

        

        Expanded
          Benefit

        
          	
                  Adult
                    Dental

                	
                  Adult
                    dental expanded to include unlimited fillings, periodontic deep
                    cleanings,
                    crowns, clear fillings, restorations, annual exam, two cleanings
                    per year
                    and x-rays.

                
	
                  Circumcision

                	
                  Routine
                    newborn circumcision up to one year of age.. 

                
	
                  Over
                    the Counter Benefit

                	
                  Agency
                    approved over-the -counter drug benefit, not to exceed $25 per
                    household,
                    per month. Limited to non-prescription drugs containing a National
                    Drug
                    Code number, first aid and birth control supplies. Benefit must
                    be offered
                    through a plan’s pharmacy or plan’s subcontractor.

                
	
                  Meals
                    on Wheels

                	
                  10
                    meals within 15 days of post discharge (medically
                    necessary)

                

        

        
 

        
          
            
              
                
                  

                

                
                

              

              
                
                

                
                  

                

              

              
                
                

                
                  HEALTHEASE
                    OF FLORIDA

                  EXHIBIT
                    2

                  ENROLLMENT
                    LEVELS

                

              

            

          

          

          

            TABLE
              1 (Duval - Area 4, Broward - Area 10)

            

            Agency
              Area
              04

            

            
              	
                       

                      Eligibility
                        Category/ Population

                    	
                       

                      County

                    	
                       

                      Health
                        Plan Provider Number

                    	
                       

                      Plan
                        Type

                       

                      (Comp
                        or Comp & Catastrophic)

                    	
                       

                      Maximum
                        Enrollment Level

                    
	
                       

                      TANF

                    	
                       

                      Duval

                    	 	
                       

                      Comprehensive
                        & Catastrophic

                       

                    	
                       

                       

                       

                       

                      55,000

                       

                    
	
                       

                      SSI

                    	
                       

                      Duval

                       

                    	 	
                       

                      Comprehensive
                        & Catastrophic

                       

                    
	
                       

                      HIV/AIDS

                       

                    	 	 	 	 
	
                       

                      Children
                        with Chronic Conditions

                       

                    	 	 	 	 

            

            

            Agency
              Area 10

            

            
              	
                       

                      Eligibility
                        Category/ Population

                    	
                       

                      County

                    	
                       

                      Health
                        Plan Provider Number

                    	
                       

                      Plan
                        Type

                       

                      (Comp
                        or Comp & Catastrophic)

                       

                    	
                       

                      Maximum
                        Enrollment Level

                    
	
                       

                      TANF

                       

                    	
                       

                      Broward
                        

                       

                    	 	
                       

                      Comprehensive
                        & Catastrophic

                       

                    	
                       

                       

                       

                       

                      13,500

                       

                    
	
                       

                      SSI

                       

                    	
                       

                      Broward

                       

                    	 	
                       

                      Comprehensive
                        & Catastrophic

                       

                    
	
                       

                      HIV/AIDS

                       

                    	 	 	 	 
	
                       

                      Children
                        with Chronic Conditions

                       

                    	 	 	 	 

            

            

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                      HEALTHEASE
                        OF FLORIDA

                      EXHIBIT
                        3

                      COMPREHENSIVE
                        COMPONENT AND CATASTROPHIC

                      COMPONENT
                        CAPITATION
                        RATES

                    

                  

                

              

              
Table
                2

              

              Area:
                10   Area:
                10                 
County:
                Broward                 
September
                1, 2006

               

              

              ESTIMATED
                HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

              

              
                	
                        Age
                          Range

                      	
                        FY0607
                          Discounted Reform rates Under Current Methodology

                      	
                        Percentage
                          of Current Methodology

                      	
                        75%
                          of Current Methodology

                      	
                        Preliminary
                          FY0607 Base rates for Risk Adjusted Methodology

                      	
                        Budget
                          Neutrality Factor 

                      	
                        FY0607
                          Base rates for Risk Adjusted Methodology after Budget
                          Neutrality

                      	
                        Percentage
                          of Risk Adjusted Methodology

                      	
                        25%
                          of Risk Adjusted Methodology

                      	
                        Final
                          Rate (with Enhanced Benefit Adjustment)

                      
	
                        a
                          

                      	
                        b

                      	
                        c

                      	
                        d

                      	
                        e

                      	
                        f

                      	
                        g

                      	
                        h
                          

                      	
                        i

                      	
                        j

                      
	
                        Eligibility
                          Category:

                      	
                        Children
                          and Family

                      	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                        Month
                          0-2 All

                      	
                        $688.92
                          

                      	
                        75%

                      	
                        $516.69

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $551.66

                      
	
                        Month
                          3-11 All

                      	
                        $180.09
                          

                      	
                        75%

                      	
                        $135.07

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $170.04

                      
	
                        1-5
                          All

                      	
                        $94.03
                          

                      	
                        75%

                      	
                        $70.52

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $105.49

                      
	
                        6-13
                          All

                      	
                        $77.55
                          

                      	
                        75%

                      	
                        $58.16

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $93.13

                      
	
                        14-20
                          Female

                      	
                        $107.54
                          

                      	
                        75%

                      	
                        $80.65

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $115.62

                      
	
                        14-20
                          Male

                      	
                        $74.59
                          

                      	
                        75%

                      	
                        $55.94

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $90.91

                      
	
                        21-54
                          Female

                      	
                        $181.88
                          

                      	
                        75%

                      	
                        $136.41

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $171.37

                      
	
                        21-54
                          Male

                      	
                        $131.39
                          

                      	
                        75%

                      	
                        $98.54

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $133.51

                      
	
                        55+
                          All

                      	
                        $288.52
                          

                      	
                        75%

                      	
                        $216.39

                      	
                        $117.60

                      	
                        1.18930

                      	
                        $139.86

                      	
                        25%

                      	
                        $34.97

                      	
                        $251.36

                      
	 	 	 	 	 	 	 	 	 	 
	
                        Composite
                          Based on Total Casemonths

                      	
                        $110.18

                      	 	 	 	 	
                        $139.86

                      	 	 	
                        $117.60

                      
	 	 	 	 	 	 	 	 	 	 
	
                        Eligibility
                          Category:

                      	
                        Aged
                          and Disabled

                      	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                        Month
                          0-2 All

                      	
                        $15,308.07
                          

                      	
                        75%

                      	
                        $11,481.05

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $11,715.71

                      
	
                        Month
                          3-11 All

                      	
                        $3,277.86
                          

                      	
                        75%

                      	
                        $2,458.40

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $2,693.06

                      
	
                        1-5
                          All

                      	
                        $550.34
                          

                      	
                        75%

                      	
                        $412.75

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $647.42

                      
	
                        6-13
                          All

                      	
                        $317.37
                          

                      	
                        75%

                      	
                        $238.03

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $472.69

                      
	
                        14-20
                          All

                      	
                        $319.91
                          

                      	
                        75%

                      	
                        $239.93

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $474.59

                      
	
                        21-54
                          All

                      	
                        $825.64
                          

                      	
                        75%

                      	
                        $619.23

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $853.89

                      
	
                        55+
                          All

                      	
                        $833.65
                          

                      	
                        75%

                      	
                        $625.24

                      	
                        $777.12

                      	
                        1.20785

                      	
                        $938.64

                      	
                        25%

                      	
                        $234.66

                      	
                        $859.90

                      
	 	 	 	 	 	 	 	 	 	 
	
                        Composite
                          Based on Total Casemonths

                      	
                        $723.28
                          

                      	 	 	 	 	
                        $938.64

                      	 	 	
                        $777.12

                      

              

              

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                HEALTHEASE
                  OF FLORIDA

                EXHIBIT
                  3

                COMPREHENSIVE
                  COMPONENT AND
                  CATASTROPHIC

                COMPONENT
                  CAPITATION RATES

              

            

          

           

          Table
            2

           

          Area:
            04    County: Duval      September
            1, 2006

          Area:
            04  

          ESTIMATED
            HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

          

          
            	
                    Age
                      Range

                  	
                    FY0607
                      Discounted Reform rates Under Current Methodology

                  	
                    Percentage
                      of Current Methodology

                  	
                    75%
                      of Current Methodology

                  	
                    Preliminary
                      FY0607 Base rates for Risk Adjusted Methodology

                  	
                    Budget
                      Neutrality Factor 

                  	
                    FY0607
                      Base rates for Risk Adjusted Methodology after Budget
                      Neutrality

                  	
                    Percentage
                      of Risk Adjusted Methodology

                  	
                    25%
                      of Risk Adjusted Methodology

                  	
                    Final
                      Rate (with Enhanced Benefit Adjustment)

                  
	
                    a
                      

                  	
                    b

                  	
                    c

                  	
                    d

                  	
                    e

                  	
                    f

                  	
                    g

                  	
                    h
                      

                  	
                    i

                  	
                    j

                  
	
                    Eligibility
                      Category:
                      Children and Family

                  	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                    Month
                      0-2 All

                  	
                    $738.35
                      

                  	
                    75%

                  	
                    $553.76

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $589.19

                  
	
                    Month
                      3-11 All

                  	
                    $192.52
                      

                  	
                    75%

                  	
                    $144.39

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $179.81

                  
	
                    1-5
                      All

                  	
                    $98.55
                      

                  	
                    75%

                  	
                    $73.91

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $109.33

                  
	
                    6-13
                      All

                  	
                    $74.83
                      

                  	
                    75%

                  	
                    $56.12

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $91.55

                  
	
                    14-20
                      Female

                  	
                    $109.44
                      

                  	
                    75%

                  	
                    $82.08

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $117.50

                  
	
                    14-20
                      Male

                  	
                    $73.83
                      

                  	
                    75%

                  	
                    $55.37

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $90.80

                  
	
                    21-54
                      Female

                  	
                    $192.76
                      

                  	
                    75%

                  	
                    $144.57

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $179.99

                  
	
                    21-54
                      Male

                  	
                    $139.38
                      

                  	
                    75%

                  	
                    $104.53

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $139.95

                  
	
                    55+
                      All

                  	
                    $305.74
                      

                  	
                    75%

                  	
                    $229.31

                  	
                    $125.17

                  	
                    1.13200

                  	
                    $141.69

                  	
                    25%

                  	
                    $35.42

                  	
                    $264.73

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Composite
                      Based on Total Casemonths

                  	
                    $119.67

                  	 	 	 	 	
                    $141.69

                  	 	 	
                    $125.17

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Eligibility
                      Category:
                      Aged and Disabled

                  	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                    Month
                      0-2 All

                  	
                    $13,652.29
                      

                  	
                    75%

                  	
                    $10,239.22

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $10,420.52

                  
	
                    Month
                      3-11 All

                  	
                    $2,911.78
                      

                  	
                    75%

                  	
                    $2,183.83

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $2,365.13

                  
	
                    1-5
                      All

                  	
                    $493.16
                      

                  	
                    75%

                  	
                    $369.87

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $551.16

                  
	
                    6-13
                      All

                  	
                    $300.32
                      

                  	
                    75%

                  	
                    $225.24

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $406.54

                  
	
                    14-20
                      All

                  	
                    $294.02
                      

                  	
                    75%

                  	
                    $220.51

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $401.81

                  
	
                    21-54
                      All

                  	
                    $741.27
                      

                  	
                    75%

                  	
                    $555.95

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $737.25

                  
	
                    55+
                      All

                  	
                    $736.02
                      

                  	
                    75%

                  	
                    $552.01

                  	
                    $635.88

                  	
                    1.14045

                  	
                    $725.19

                  	
                    25%

                  	
                    $181.30

                  	
                    $733.31

                  
	 	 	 	 	 	 	 	 	 	 
	
                    Composite
                      Based on Total Casemonths

                  	
                    $606.11
                      

                  	 	 	 	 	
                    $725.19

                  	 	 	
                    $635.88

                  

          

          

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                    HEALTHEASE
                      OF FLORIDA

                    EXHIBIT
                      4

                    COMPREHENSIVE
                      COMPONENT ONLY

                  

                

              

            

            
Table
              3

             

            Area:______________        County:
              __________________                                                 September
              1,
              2006

            

             

            ESTIMATED
              HEALTH PLAN RATES (NOT FOR USE UNELSS APPROVED BY CMS)

            
              	
                      Area
                        ________

                    	 	 	 	 	 	 	 	 	 	 	 
	
                      Age
                        Range

                    	
                       

                    	
                      FY0607
                        Discounted Reform rates Under Current Methodology

                    	
                      Percentage
                        of Current Methodology

                    	
                      75%
                        of Current Methodology

                    	
                      FY0607
                        Base Rates for Risk-Adjusted Methodology

                    	
                      Percentage
                        of Risk-Adjusted Methodology

                    	
                      25%
                        of Risk-Adjusted Methodology

                    	
                      Budget
                        Neutrality Factor 

                    	
                      Budget
                        Adjusted of 25% of Risk Adjusted Method-ology 

                    	
                      Blended
                        Rate (Risk = 1.00)

                    	
                      Final
                        Rate (with Enhanced Benefit Adjustment)

                    
	
                      (a)

                    	
                       

                    	
                      (b)

                    	
                      (c)

                    	
                      (d)

                    	
                      (e)

                    	
                      (f)

                    	
                      (g)

                    	
                      (h)

                    	
                      (i)

                    	
                      (j)

                    	
                      (k)

                    
	
                      Eligibility
                        Category:

                    	
                      Children
                        and Family

                    	 	 	 	 	 	 	 	 	 
	
                      Month
                        0-2 All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      Month
                        3-11 All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      1-5
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      6-13
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      14-20
                        Female

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      14-20
                        Male

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      21-54
                        Female

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      21-54
                        Male

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      55+
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      Composite

                    	
                       

                    	 	 	 	 	 	 	
                      $

                    	 	
                      $

                    	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                      Eligibility
                        Category:

                    	 	
                      Aged
                        and Disabled

                    	 	 	 	 	 	 	 	 	 
	
                      Month
                        0-2 All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      Month
                        3-11 All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      1-5
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      6-13
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      14-20
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      21-54
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      55+
                        All

                    	 	
                      $

                    	
                      75%

                    	
                      $

                    	
                      $

                    	
                      25%

                    	
                      $

                    	
                      $

                    	 	
                      $

                    	 
	
                      Composite

                    	 	 	 	 	 	 	 	
                      $

                    	 	
                      $

                    	 
	 	 	 	 	 	 	 	 	 	 	 	 

            

            

            

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                        HEALTHEASE
                          OF FLORIDA

                        EXHIBIT
                          5

                        CAPITATION
                          RATES

                        SSI
                          MEDICARE PART B ONLY

                        AND

                        SSI
                          MEDICARE PARTS A AND B ENROLLEES

                        FOR
                          ALL MEDICAID REFORM COUNTIES

                      

                    

                  

                

              

              
 

              TABLE
                4 

              

              

              Area:
                4
                 County:
                Duval
                

              

              

              ESTIMATED
                HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

               

              
                	 	
                        Under
                          Age 65

                      	
                        Age
                          65 & Over

                      
	
                         

                        SSI/Parts
                          A & B 

                      	
                         

                        $146.72

                      	
                         

                        $98.34

                      
	
                         

                        SSI/Part
                          B Only

                      	
                         

                        $300.24

                      	
                         

                        $300.24

                      

              

               

              Area:
                10
                 County:
                Broward
                

              

              

              ESTIMATED
                HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

               

              
                	 	
                        Under
                          Age 65

                      	
                        Age
                          65 & Over

                      
	
                         

                        SSI/Parts
                          A & B 

                      	
                         

                        $136.17

                      	
                         

                        $91.25

                      
	
                         

                        SSI/Part
                          B Only

                      	
                         

                        $210.84

                      	
                         

                        $210.84

                      

              

              

               

              

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                  HEALTHEASE
                    OF FLORIDA

                  EXHIBIT
                    6

                  CAPITATION
                    RATES FOR HIV/AIDS POPULATIONS FOR EACH 

                  MEDICAID
                    REFORM COUNTY

                

              

               

              

              TABLE
                5

               

              Area:
                4
                 County:
                Duval 

              

              ESTIMATED
                HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

               

              
                	 	
                        Capitation
                          Rate

                      
	 	 
	
                        HIV
                          (No Medicare)

                      	
                        $950.48

                      
	
                        AIDS
                          (No Medicare)

                      	
                        $2133.29

                      
	
                        HIV-SSI/Parts
                          A & B, SSI Part B Only

                      	
                        $177.88

                      
	
                        AIDS-SSI/Parts
                          A & B, SSI Part B Only 

                      	
                        $249.55

                      

              

               

              Area:
                10
                 County:
                Broward 

              

              ESTIMATED
                HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

               

              
                	 	
                        Capitation
                          Rate

                      
	 	 
	
                        HIV
                          (No Medicare)

                      	
                        $1484.87

                      
	
                        AIDS
                          (No Medicare)

                      	
                        $3155.16

                      
	
                        HIV-SSI/Parts
                          A & B, SSI Part B Only

                      	
                        $213.18

                      
	
                        AIDS-SSI/Parts
                          A & B, SSI Part B Only 

                      	
                        $299.07

                      

              

              

              

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                    HEALTHEASE
                      OF FLORIDA

                    EXHIBIT
                      7

                    CAPITATION
                      RATES FOR MEDICAID REFORM COUNTIES FOR ALL MEDICAID REFORM
                      COUNTIES

                  

                

                
TABLE
                  6

                

                Area:
                  __________________  County:
                  ____________________

                

                

                ESTIMATED
                  HEALTH PLAN RATES (NOT FOR USE UNLESS APPROVED BY CMS)

                 

                
                  	 	
                          Age
                            

                          <
                            1 Yr

                        	
                          Age
                            1 Yr

                        	
                          Age
                            2 - 20 Yrs

                        
	 	 	 	 
	
                          Children
                            with Chronic Conditions

                        	
                          $

                        	
                          $

                        	
                          $

                        

                

                 

                

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                    HEALTHEASE
                      OF FLORIDA

                    EXHIBIT
                      8

                    KICK
                      PAYMENT AMOUNTS FOR COVERED TRANSPLANT SERVICES

                  

                

                 

                TABLE
                  7

                

                Area:
                  __10_______
                   County:
                  ____Broward_______

                

                Area:
                  ___04______
                   County:
                  _____Duval________

                

                

                
                  	
                          CPT
                            Code

                        	
                          Transplant
                            CPT Code Description

                        	
                          Children/Adolescents
                            or Adult

                        	
                          Payment
                            Amount

                        
	
                          32851

                           

                        	
                          lung
                            single, without bypass

                           

                        	
                          Children/Adolescents

                           

                        	
                          $320,800.00

                           

                        
	
                          32851

                           

                        	
                          lung
                            single, without bypass

                           

                        	
                          Adult

                           

                        	
                          $238,000.00

                        
	
                          32852

                           

                        	
                          lung
                            single, with bypass

                           

                        	
                          Children/Adolescents

                           

                        	
                          $320,800.00

                           

                        
	
                          32852

                           

                        	
                          lung
                            single, with bypass

                           

                        	
                          Adult

                           

                        	
                          $238,000.00

                        
	
                          32853

                           

                        	
                          lung
                            double, without bypass

                           

                        	
                          Children/Adolescents

                           

                        	
                          $320,800.00

                           

                        
	
                          32853

                           

                        	
                          lung
                            double, without bypass

                           

                        	
                          Adult

                           

                        	
                          $238,000.00

                        
	
                          32854

                           

                        	
                          lung
                            double, with bypass

                           

                        	
                          Children/Adolescents

                           

                        	
                          $320,800.00

                           

                        
	
                          32854

                           

                        	
                          lung
                            double, with bypass

                           

                        	
                          Adult

                           

                        	
                          $238,000.00

                        
	
                          33945

                           

                        	
                          heart
                            transplant with or without recipient cardiectomy

                           

                        	
                          Children/Adolescents

                           

                        	
                          $162,000.00

                           

                        
	
                          33945

                           

                        	
                          heart
                            transplant with or without recipient cardiectomy

                           

                        	
                          Adult

                           

                        	
                          $162,000.00

                           

                        
	
                          47135

                           

                        	
                          liver,
                            allotransplation, orthotopic, partial or whole from cadaver
                            or living
                            donor

                           

                        	
                          Children/Adolescents

                           

                        	
                          $122,600.00

                        
	
                           

                          47135

                           

                        	
                           

                          liver,
                            allotransplation, orthotopic, partial or whole from cadaver
                            or living
                            donor

                           

                        	
                           

                          Adult

                           

                        	
                           

                          $122,600.00

                           

                        
	
                           

                          47136

                           

                        	
                           

                          liver,
                            heterotopic, partial or whole from cadaver or living
                            donor any
                            age

                           

                        	
                           

                          Children/Adolescents

                           

                        	
                           

                          $122,600.00

                           

                        
	
                           

                          47136

                           

                        	
                           

                          liver,
                            heterotopic, partial or whole from cadaver or living
                            donor any
                            age

                           

                        	
                           

                          Adult

                           

                        	
                           

                          $122,600.00

                           

                        

                

                

                

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      HEALTHEASE
        OF FLORIDA

      EXHIBIT
        9

      KICK
        PAYMENT AMOUNTS FOR COVERED

      OBSTETRICAL
        DELIVERY SERVICES

       

      TABLE
        8

      

      Area:
        ____10_______
         County:
        _____Broward_______

      

      
        	
                CPT
                  Code

              	
                Obstetrical
                  Delivery CPT Code Description

              	
                Payment
                  Amount

              
	
                59409

              	
                Vaginal
                  delivery only

              	
                 

                $4,143.00

              
	
                59410

              	
                Vaginal
                  delivery including postpartum care

              
	
                59515

              	
                Cesarean
                  delivery including postpartum care

              
	
                59612

              	
                Vaginal
                  delivery only, after previous cesarean delivery

              
	
                59614

              	
                Vaginal
                  delivery only, after previous cesarean delivery including postpartum
                  care

              
	
                59622

              	
                Cesarean
                  delivery only, following attempted vaginal delivery after previous
                  cesarean delivery including postpartum
                  care

              

      

      

      Area:
        ______04_________
         County:
        _____Duval________

      

      
        	
                CPT
                  Code

              	
                Obstetrical
                  Delivery CPT Code Description

              	
                Payment
                  Amount

              
	
                59409

              	
                Vaginal
                  delivery only

              	
                 

                $4,097.62

              
	
                59410

              	
                Vaginal
                  delivery including postpartum care

              
	
                59515

              	
                Cesarean
                  delivery including postpartum care

              
	
                59612

              	
                Vaginal
                  delivery only, after previous cesarean delivery

              
	
                59614

              	
                Vaginal
                  delivery only, after previous cesarean delivery including postpartum
                  care

              
	
                59622

              	
                Cesarean
                  delivery only, following attempted vaginal delivery after previous
                  cesarean delivery including postpartum
                  care

              

      

      

      

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    ATTACHMENT
      II

    

    

    

    

    

    Medicaid
      Reform 

    Health
      Plan Model Contract

    

    July
      2006

    

    

    

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

    

    

    Table
      of Contents

    
 

    Section
      I Definitions and Acronyms

    A. Definitions 

    B. Acronyms 

    
 

    Section
      II General Overview

    A. Background 

    B. Purpose 

    C. Responsibilities
      of the State of Florida (the
      State) and the Agency for Health Care Administration (the
      Agency) 

    D. General
      Responsibilities of the Health
      Plan 

    
 

     Section
      III Eligibility and Enrollment

    A. Eligibility 

    B. Enrollment 

    C. Disenrollment 

    
 

    Section
      IV Enrollee Services and Marketing

    A. Enrollee
      Services 

    B. Marketing 

    
 

    Section
      V Covered Services

    A. Covered
      Services 

    B. Expanded
      Services 

    C. Excluded
      Services 

    D. Moral
      or Religious
      Objections 

    E. Customized
      Benefit Package

    F. Coverage
      Provisions

    
 

    Section
      VI Behavioral Health Care

    A. General
      Provisions 

    B. Service
      Requirements 

    
 

    Section
      VII Provider Network

    A. General
      Provisions 

    B. Primary
      Care Providers 

    C. Minimum
      Standards 

    D. Appointment
      Waiting Times and Geographic Access
      Standards 

    E. Behavioral
      Health Services

    F. Specialists
      and Other Providers

    H. Continuity
      of Care 

    I. Network
      Changes

    
 

    Section
      VIII Quality Management

    A. Quality
      Improvement 

    B. Utilization
      Management (UM) 

    
 

    Section
      IX Grievance System

    A. General
      Requirements 

    B. Grievance
      Process 

    C. Appeal
      Process 

    D. Medicaid
      Fair Hearing
      System 

    
 

    Section
      X Administration and Management

    A. General
      Provisions 

    B. Staffing 

    C. Provider
      Contracts
      Requirements 

    D. Provider
      Termination 

    E. Provider
      Services

    F. Medical
      Records Requirements

    G. Claims
      Payment 

    H. Encounter
      Data 

    I. Fraud
      Prevention

    
 

    Section
      XI Information Management and Systems

    A. General
      Provisions 

    B. Data
      and Document Management
      Requirements 

    C. System
      and Data Integration
      Requirements 

    D. Systems
      Availability, Performance and Problem
      Management Requirements 

    E. System
      Testing and Change Management
      Requirements

    F. Information
      Systems Documentation
      Requirements

    G. Reporting
      Requirements - Specific to Information
      Management and Systems Functions and Capabilities - and Technological
      Capabilities 

    H. Other
      Requirements 

    I. Compliance
      with Standard Coding
      Schemes

    J. Data
      Exchange and Formats and Methods Applicable
      to Health Plans

    
 

     Section
      XII Reporting Requirements

    A. Health
      Plan Reporting Requirements 

    B. Enrollment/Disenrollment
      Reports: 

    C. Grievance
      System 

    D. Provider
      Reporting 

    E. Marketing
      Representative Report

    F. Enhanced
      Benefits Report

    G. Catastrophic
      Component Threshold and Benefit
      Maximum Report 

    H. Critical
      Incidents 

    I. Hernandez
      Settlement Agreement (HAS)
      Report

    J. Performance
      Measure Report

    K. Financial
      Reporting 

    L. Suspected
      Fraud Reporting

    M.Denials
      of Authorization Reporting
      Requirements 

    N.
      Systems Availability and Performance
      Report 

    O. Claims
      Inventory Summary
      Report 

    P.
      Child Health Check-Up Reports 

    Q. Pharmacy
      Encounter Data 

    R. Health
      Plan Benefit Package 

    S. Transportation
      Services

    T. Enrollee
      Satisfaction Survey
      Summary

    U. Stakeholders’
Satisfaction
      Survey
      Summary 

    V. Behavioral
      Health Services Grievance and Appeals
      Reporting Requirements

    W. Critical
      Incident Reporting 

    X. Required
      Staff/Providers

    Y. FARS/CFARS

    Z. Behavioral
      Health Encounter
      Report

    AA. Minority
      Participation
      Report 

    
 

    Section
      XIII Method of Payment

    
 

    Section
      XIV Sanctions

    A. General
      Provisions 

    B. Specific
      Sanctions 

    
 

    Section
      XV Financial Requirements

    A. Insolvency
      Protection 

    B. Insolvency
      Protection for a Capitated Provider
      Service Network (PSN) 

    C. Surplus
      Start Up Account 

    D. Surplus
      Requirement 

    E. Interest

    F. Inspection
      and Audit of Financial
      Records

    G. Physician
      Incentive Plans 

    H. Third
      Party Resources 

    I. Fidelity
      Bonds

    
 

    Section
      XVI Terms and Conditions

    A. Agency
      Contract Management 

    B. Applicable
      Laws and
      Regulations 

    C. Assignment 

    D. Attorney's
      Fees 

    E. Conflict
      of Interest

    F. Contract
      Variation

    G. Court
      of Jurisdiction or
      Venue 

    H. Damages
      for Failure to Meet Contract
      Requirements 

    I. Disputes

    J. Force
      Majeure

    K. Legal
      Action Notification 

    L. Licensing

    M. Misuse
      of Symbols, Emblems, or Names in Reference
      to Medicaid 

    N. Offer
      of Gratuities 

    O. Subcontracts 

    P. Hospital
      Subcontracts

    Q. Termination
      Procedures 

    R. Waiver 

    S. Withdrawing
      Services from a
      County

    T. MyFloridaMarketPlace
      Vendor
      Registration

    U. MyFloridaMarketplace
      Vendor Registration and
      Transaction Fee Exemption 

    V. Ownership
      and Management
      Disclosure

    W. Minority
      Recruitment and Retention
      Plan 

    X. Independent
      Provider

    Y. General
      Insurance Requirements

    Z. Worker's
      Compensation Insurance

    AA. State
      Ownership 

    BB. Disaster
      Plan 

    

    

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    Section
      I

    Definitions
      and Acronyms

    

    
      	A.  	
              Definitions

            

    

     

    

    The
      following terms as used in this Contract shall be construed and/or interpreted
      as follows, unless the Contract otherwise expressly requires a different
      construction and/or interpretation. 

    

    Abandoned
      Call—
A
      call
      in which the caller elects an option and is either not permitted access to
      that
      option or disconnects from the system.

    

    Abuse — Provider
      practices that are inconsistent with generally accepted business or medical
      practices and that result in an unnecessary cost to the Medicaid program or
      in
      reimbursement for goods or services that are not medically necessary or that
      fail to meet professionally recognized standards for health care; or recipient
      practices that result in unnecessary cost to the Medicaid program.

    

    Action—
The
      denial or limited authorization of a requested service, including the type
      or
      level of service, pursuant to 42 CFR 438.400(b). The reduction, suspension
      or
      termination of a previously authorized service. The denial, in whole or in
      part,
      of payment for a service. The failure to provide services in a timely manner,
      as
      defined by the State. The failure of the Health Plan to act within ninety (90)
      days from the date the Health Plan receives a Grievance, or 45 days from the
      date the Health Plan receives an Appeal. For a resident of a rural area with
      only one (1) managed care entity, the denial of an Enrollee's request to
      exercise his or her right to obtain services outside the network.

    

    Advance
      Directive—
A
      written instruction, such as a living will or durable power of attorney for
      health care, recognized under State law (whether statutory or as recognized
      by
      the courts of the State), relating to the provision of health care when the
      individual is incapacitated.

    

    Advanced
      Registered Nurse Practitioner (ARNP) — A
      licensed advanced registered nurse practitioner who works in collaboration
      with
      a physician according to protocol, to provide diagnostic and clinical
      interventions. An ARNP must be authorized to provide these services by Chapter
      464, F.S., and protocols filed with the Board of Medicine. 

    

    Agency—
State
      of Florida, Agency for Health Care Administration.

    

    Agent—
      When
      spelled with a capital "A" herein, is a term that refers to certain independent
      contractors with the state that perform administrative functions, including
      but
      not limited to: Fiscal Agent activities; outreach, eligibility and Enrollment
      activities; Systems and Technical Support. The term as used herein does not
      create a principal-agent relationship.

    

    Ancillary
      Provider—
A
      Provider of ancillary medical services who has contracted with a Health Plan
      to
      provide ancillary medical services to the Health Plan's Enrollees.

    

    Authoritative
      Host—
A
      system that contains the master or “authoritative” data for a particular data
      type, e.g. Enrollee, Provider, Health Plan, etc. The Authoritative Host may
      feed
      data from its master data files to other systems in real time or in batch mode.
      Data in an Authoritative Host is expected to be up-to-date and
      reliable.

    

    Automatic
      Assignment (or Auto-Assign)—
The
      Enrollment of an eligible Medicaid Recipient, for whom Enrollment is mandatory,
      in a Health Plan chosen by AHCA or its Agent, and/or the assignment of a new
      Enrollee to a PCP chosen by the Health Plan. 

    

    Appeal—
A
      request for review of an Action, pursuant to 42 CFR 438.400(b).

    

    Baker
      Act—
The
      Florida Mental Health Act, pursuant to Sections 394.479 through 394.484, Florida
      Statutes. 

    

    Behavioral
      Health Services—
      Services listed in the Community Mental Health Services Coverage &
Limitations Handbook and the Targeted Case Management Coverage & Limitations
      Handbook as specified in this Contract in Section VI.A Behavioral Health Care,
      General Provisions.

    

    Behavioral
      Health Care Case Manager—
An
      individual who provides mental health care Case Management services directly
      to
      or on behalf of an Enrollee on an individual basis in accordance with 65E-15,
      F.A.C., and the Medicaid Targeted Case Management Handbook.

    

    Behavioral
      Health Care Provider—
A
      licensed mental health professional, such as a "Clinical Psychologist," or
      registered nurse qualified due to training or competency in mental health care,
      who is responsible for the provision of mental health care to patients, or
      a
      physician licensed under Chapters 458 or 459, F.S., who is under contract to
      provide Behavioral Health Services to Enrollees.

    

    Beneficiary
      Assistance Program
      - An
      external grievance program, similar to the Subscriber Assistance Program,
      available to Medicaid Reform recipients that will allow an additional avenue
      to
      resolve a grievance.

    

    Benefit
      Maximum
      - The
      point when the cost of Covered Services received by a non-pregnant Enrollee,
      ages 21 and older reaches $550,000 in a state fiscal year, based on Medicaid
      Fee-for-Service payment levels. Care coordination services must continue to
      be
      offered by the Health Plan but the cost of additional services will not be
      covered by the Medicaid program for the remainder of the Contract Year in which
      the Benefit Maximum is met. 

    

    Benefits—
A
      schedule of health care services to be delivered to Enrollees covered by the
      Health Plan as set forth in Section V and Section VI of this Contract.

    

    Blocked
      Call—
A
      call
      that cannot be connected immediately because no circuit is available at the
      time
      the call arrives or the telephone system is programmed to block calls from
      entering the queue when the queue backs up behind a defined
      threshold.

    

    Business
      Days—
      Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday, and
      Friday. State holidays are excluded. 

    

    Calendar
      Days—
All
      seven (7) days of the week. 

    

    Capitation
      Rate—
The
      per
      member per month amount, including any adjustments, that is paid by the Agency
      to a capitated Health Plan for each Medicaid Recipient enrolled under a contract
      for the provision of Medicaid services during the payment period.

    

    Care
      Coordination/Case Management—
A
      process which assesses, plans, implements, coordinates, monitors and evaluates
      the options and services required to meet an Enrollee's health needs using
      communication and all available resources to promote quality cost-effective
      outcomes. Proper Case Management occurs across a continuum of care, addressing
      the ongoing individual needs of an Enrollee rather than being restricted to
      a
      single practice setting. For purposes of this contract Care Coordination and
      Case Management are the same.

    

    Catastrophic
      Component --
      The
      amount of financial risk assumed by a Health Plan or the Agency to provide
      Covered Services above $50,000 per Enrollee, based on Medicaid Fee-for-Service
      payment levels, and up to the overall annual Benefit Maximum.

    

    Catastrophic
      Component Threshold
      - The
      point when the cost of Covered Services, based on Medicaid Fee-for-Service
      payment levels, reaches $50,000 for an Enrollee in a state fiscal year. For
      a
      Health Plan that accepts the Comprehensive Capitation Rate only, the Agency
      begins reimbursing the Health Plan for the cost of Covered Services received
      by
      the Enrollee for the remainder of the Contract Year. This reimbursement is
      based
      on a percentage of Medicaid Fee-for-Service payment levels,. 

    

    Cause—
Special
      reasons that allow Mandatory Enrollees to change their Health Plan option
      outside their Open Enrollment period. May also be referred to as “Good
      Cause.”

    

    Centers
      for Medicare & Medicaid Services (CMS) —
The
      agency within the United States Department of Health & Human Services that
      provides administration and funding for Medicare under Title XVIII, Medicaid
      under Title XIX, and the State Children’s Health Insurance Program under Title
      XXI of the Social Security Act.

    

    Certification—
The
      process of determining that a facility, equipment or an individual meets the
      requirements of federal or State law, or whether Medicaid payments are
      appropriate or shall be made in certain situations.

    

    Child
      Health Check-Up Program (CHCUP) —
A
      comprehensive and preventative health examinations provided on a periodic basis
      that are aimed at identifying and correcting medical conditions in
      Children/Adolescents. Policies and procedures are described in the Child Health
      Check-Up Services Coverage and Limitations Handbook.

    

    Children/Adolescents—
      Enrollees under the age of 21.

    

    Children
      & Families Services Program Office—
Also
      referred to as the Children & Families Safety & Preservation Program
      Office, located in the DCF; the State agency responsible for overseeing programs
      that identify and protect abused and neglected Children and attempt to prevent
      domestic violence.

    

    Choice
      Counselor/Enrollment Broker—
The
      State’s contracted or designated entity that performs functions related to
      outreach, education, counseling, Enrollment, and Disenrollment of Potential
      Enrollees into a Health Plan. 

    

    Choice
      Counseling Specialists—
      Certified individuals authorized by an Agency-approved process who provide
      one-on-one information to Medicaid Recipients, to assist the Medicaid Recipients
      in choosing the Health Plan that best meets their health care needs and those
      of
      their family. 

    

    Cold
      Call Marketing—
Any
      unsolicited personal contact with a Medicaid Recipient by the Health Plan,
      its
      staff, its volunteers or its vendors with the purpose of influencing the
      Medicaid Recipient to enroll in the Health Plan or either to not enroll in,
      or
      disenroll from, another Health Plan.

     

    Community
      Living Support Plan -
      A
      written document prepared by a mental health resident of an assisted living
      facility with a limited mental health license and the resident's mental health
      case manager in consultation with the administrator or the administrator's
      designee of the assisted living facility with a limited mental health license.
      A
      copy must be provided to the administrator. The plan must include information
      about the supports, services, and special needs of the resident which enable
      the
      resident to live in the assisted living facility and a method by which facility
      staff can recognize and respond to the signs and symptoms particular to that
      resident which indicate the need for professional services.

    

    Comprehensive
      Component --
      The
      amount of financial risk assumed by a Health Plan to provide covered service
      up
      to 50,000 dollars per Enrollee based on Medicaid Fee-for-Service payment
      levels.

    

    Continuous
      Quality Improvement—
A
      management philosophy that mandates continually pursuing efforts to improve
      the
      quality of products and services produced by an organization.

    

    Contract—
The
      agreement between the Health Plan and the Agency to provide Medicaid services
      to
      Enrollees, comprised of the Contract, any addenda, appendices, attachments,
      or
      amendments thereto.

    

    Contract
      Period
      - The
      term of the contract from July 1, 2006 through August 31, 2009. 

    

    Contract
      Year -
      The
      period of time from September 1 through August 31 of each calendar
      year.

    

    Contracting
      Officer—
      The
      Secretary of the Agency or his/her delegate.

    

    County
      Health Department (CHD)—
CHDs
      are organizations administered by the Department of Health for the purpose
      of
      providing health services as defined in Chapter 154, F.S., which include the
      promotion of the public's health, the control and eradication of preventable
      diseases, and the provision of primary health care for special
      populations.

    

    Coverage
      & Limitations Handbook (Handbook)—
A
      document that provides information to a Medicaid Provider regarding Enrollee
      eligibility, claims submission and processing, Provider participation, covered
      care, goods and services, limitations, procedure codes and fees, and other
      matters related to participation in the Medicaid program.

    

    Covered
      Services—
Those
      services provided by the Health Plan in accordance with this Contract, as
      outlined in Section V, Covered Services, and Section VI, Behavioral Health
      Care,
      in this Contract.

    

    Crisis
      Support—
      Services for persons initially perceived to need emergency mental health
      services, but upon assessment, do not meet the criteria for such emergency
      care.
      These are acute care services that are available twenty-four (24) hours a day,
      seven (7) days a week, for intervention. Examples include: mobile crisis,
      crisis/emergency screening, crisis hot-line and emergency walk-in.

    

    Customized
      Benefit Package (CBP)
      -
      Covered Services, which may vary in amount, scope and/or duration from those
      listed in Section V, Covered Services and Section VI, Behavioral Health
      Services. The CBP must meet State standards for actuarial equivalency and
      sufficiency.

    

    Direct
      Ownership Interest —
      The
      ownership of stock, equity in capital or any interest in the profits of the
      disclosing entity. A disclosing entity is defined as a Medicaid provider or
      supplier, or other entity that furnishes services or arranges for furnishing
      services under Medicaid, or health related services under the social services
      program.

    

    Direct
      Service Behavioral Health Care Provider—
An
      individual qualified by training or experience to provide direct behavioral
      health services under the supervision of the Health Plan’s medical
      director.

    

    Disease
      Management
      - A
      system
      of coordinated health care intervention and communication for populations with
      conditions in which patient self-care efforts are significant. Disease
      Management supports the physician or practitioner/patient relationship and
      plan
      of care; emphasized prevention of exacerbations and complications utilizing
      evidence-based practice guidelines and patient empowerment strategies, and
      evaluates clinical, humanistic and economic outcomes on an ongoing basis with
      the goal of improving overall health.

    

    Disenrollment—
The
      Agency-approved discontinuance of an Enrollee's Enrollment in a Health
      Plan.

    

    Disclosing
      Entities—
A
      Medicaid provider, other than an individual practitioner or group of
      practitioners, or a fiscal agent that furnishes services or arranges for
      furnishing services under Medicaid, or health related services under the social
      services program.

    

    Downward
      Substitution of Care—
The
      use
      of less restrictive, lower cost services than otherwise might have been
      provided, that are considered clinically acceptable and necessary to meet
      specified objectives outlined in an Enrollee's plan of treatment, provided
      as an
      alternative to higher cost services. For services related to mental health,
      Downward Substitution of Care may include care provided by private practice
      psychologists and social workers, psycho-social rehabilitation, Medicaid
      community mental health services or Medicaid mental health targeted Case
      Management, and other services considered clinically appropriate, more
      cost-effective and less restrictive. 

    

    Durable
      Medical Equipment (DME)—
Medical
      equipment that can withstand repeated use, is customarily used to serve a
      medical purpose, is generally not useful in the absence of illness or injury
      and
      is appropriate for use in the Enrollee's home.

    

    Early
      and Periodic Screening, Diagnosis and Treatment Program
      (EPSDT)—
See
      Child Health Check-Up Program.

    

    Emergency
      Behavioral Health Services—
Those
      services required to meet the needs of an individual who is experiencing an
      acute crisis, resulting from a mental illness, which is a level of severity
      that
      would meet the requirements for an involuntary examination as specified in
      Section 394.463, Florida Statutes, and in the absence of a suitable alternative
      or psychiatric medication, would require hospitalization.

    

    Emergency
      Medical Condition—
(a)
      A
      medical condition manifesting itself by acute symptoms of sufficient severity,
      which may include severe pain or other acute symptoms, such that a prudent
      layperson who possesses an average knowledge of health and medicine, could
      reasonably expect that the absence of immediate medical attention could
      reasonably be expected to result in any of the following: (1) Serious jeopardy
      to the health of a patient, including a pregnant woman or fetus; (2) Serious
      impairment to bodily functions; (3) Serious dysfunction of any bodily organ
      or
      part. (b) With respect to a pregnant woman: (1) That there is inadequate time
      to
      effect safe transfer to another Hospital prior to delivery; (2) That a transfer
      may pose a threat to the health and safety of the patient or fetus; (3) That
      there is evidence of the onset and persistence of uterine contractions or
      rupture of the membranes, in accordance with Section 395.002, F.S.

    

    Emergency
      Services and Care—
Medical
      screening, examination and evaluation by a physician or, to the extent permitted
      by applicable laws, by other appropriate personnel under the supervision of
      a
      physician, to determine whether an Emergency Medical Condition exists. If an
      Emergency Medical Condition exists, Emergency Services and Care includes the
      care or treatment that is necessary to relieve or eliminate the Emergency
      Medical Condition within the service capability of the facility.

    

    Encounter
      Data
      - A
      record of covered services provided to Enrollees of a Health Plan. An Encounter
      is an interaction between a patient and provider (health plan, rendering
      physician, pharmacy, lab, etc.) who delivers services or is professionally
      responsible for services delivered to a patient.

    

    Enhanced
      Benefit —
An
      activity or behavior identified by the State as beneficial to the health of
      an
      individual and designated to earn a credit in the Enhanced Benefit
      Program.

    

    Enhanced
      Benefit Account—
The
      individual account resulting from an Enrollee earning rewards for healthy
      behaviors under the Enhanced Benefit Program.

    

    Enhanced
      Benefit Program—
A
      program offered through Medicaid Reform whereby Enrollees are rewarded, through
      individual Enhanced Benefit Accounts, for healthy behaviors.

    

    Enrollee—
A
      Medicaid Recipient currently enrolled in the Health Plan.

    

    Enrollment—
The
      process by which an eligible Medicaid Recipient becomes an Enrollee in a Health
      Plan.

    

    Enrollee
      Suicide Attempt—
An
      act
      which clearly reflects an attempt by an Enrollee to cause his or her own death,
      which results in bodily injury requiring medical treatment by a licensed health
      care professional.

    

    Expanded
      Services—
A
      Health Plan Covered Service for which the Health Plan receives no direct payment
      from the Agency.

    

    Expedited
      Appeal Process—
The
      process by which the Appeal of an Action is accelerated because the standard
      time-frame for resolution of the Appeal could seriously jeopardize the
      Enrollee's life, health or ability to obtain, maintain or regain maximum
      function.

    

    External
      Quality Review (EQR) —
The
      analysis and evaluation by an EQRO
      of
      aggregated information on quality, timeliness, and access to the health care
      services that are furnished to Medicaid recipients by a Health
      Plan.

    

    External
      Quality Review Organization (EQRO)—
An
      organization that meets the competence and independence requirements set forth
      in federal regulations 42 CFR 438.354, and performs EQR, other related
      activities as set forth in federal regulations or both.

    

    Federal
      Fiscal Year
      - The
      United States government’s fiscal year starts October 1 and ends on September
      30.

    

    Federally
      Qualified Health Center (FQHC)—
An
      entity that is receiving a grant under section 330 of the Public Health Service
      Act, as amended, and Section 1905(1)(2)(B) of the Social Security
      Act.
      FQHCs
      provide primary health care and related diagnostic services and may provide
      dental, optometric, podiatry, chiropractic and mental health
      services.

    

    Fee-for-Service
      (FFS)—
A
      method of making payment by which the Agency sets prices for defined medical
      or
      allied care, goods or services.

    

    Fiscal
      Agent—
Any
      corporation or other legal entity that enters into a contract with the Agency
      to
      receive, process and adjudicate claims under the Medicaid program. 

    

    Fiscal
      Year — The
      State
      of Florida’s Fiscal Year starts July 1 and ends on June 30.

    

    Florida
      Medicaid Management Information System (FMMIS)—
      The
      information system used to process Florida Medicaid claims and payments to
      Health Plans, and to produce management information and reports relating to
      the
      Florida Medicaid program. This system is used to maintain Medicaid eligibility
      data and provider enrollment data.

    

    Florida
      Mental Health Act —
      Includes
      the Baker Act that covers admissions for persons who are considered to have
      an
      emergency mental health condition (a threat to themselves or others), as
      specified in Sections 394.479 through 394.484, Florida Statutes.

    

    Fraud —
An
      intentional deception or misrepresentation made by a person with the knowledge
      that the deception results in unauthorized benefit to herself or himself or
      another person. The term includes any act that constitutes fraud under
      applicable federal or state law.

    

    Full-Time
      Equivalent Position (FTE)—
The
      equivalent of one (1) full-time employee who works 40 hours per week.

    

    Good
      Cause—
See
      Cause.

    

    Grievance—
An
      expression of dissatisfaction about any matter other than an Action. Possible
      subjects for grievances include, but are not limited to, the quality of care,
      the quality of services provided and aspects of interpersonal relationships
      such
      as rudeness of a Provider or employee or failure to respect the Enrollee's
      rights.

    

    Grievance
      Procedure—
The
      procedure for addressing Enrollees' grievances.

    

    Grievance
      System—
The
      system for reviewing and resolving Enrollee Grievances and Appeals. Components
      must include a Grievance process, an Appeal process and access to the Medicaid
      Fair Hearing system.

    

    Health
      Assessment—
A
      complete health evaluation combining health history, physical assessment and
      the
      monitoring of physical and psychological growth and development.

    

    Health
      Care Professional—
A
      physician or any of the following: podiatrist, optometrist, chiropractor,
      psychologist, dentist, Physician Assistant, physical or occupational therapist,
      therapist assistant, speech-language pathologist, audiologist, Registered or
      practical Nurse (including nurse practitioner, clinical nurse specialist,
      certified Registered Nurse anesthetist and certified nurse midwife), a licensed
      certified social worker, registered respiratory therapist and certified
      respiratory therapy technician.

    

    Health
      Fair—
An
      event conducted in a setting that is open to the public or segment of the public
      (such as the "elderly" or "school children") during which information about
      health-care services, facilities, research, preventative techniques or other
      health-care subjects is disseminated. At least two (2) health-related
      organizations that are not affiliated under common ownership must actively
      participate in the Health Fair.

    

    Health
      Maintenance Organization (HMO)—
An
      organization or entity licensed in accordance with Section 641 of the Florida
      Statutes or in accordance with the Florida Medicaid State plan definition of
      an
      HMO. 

    

    Health
      Plan—
An
      entity that integrates financing and management with the delivery of health
      care
      services to an enrolled population. It employs or contracts with an organized
      system of Providers, which deliver services and frequently shares financial
      risk. For the purposes of this Contract, a Health Plan has also contracted
      with
      the Agency to provide Medicaid services under the Florida Medicaid Reform
      program, and includes health maintenance organizations authorized under chapter
      641 of the Florida Statutes, exclusive provider organizations as defined in
      Chapter 627 of the Florida Statutes, health insurers authorized under chapter
      624 of the Florida Statutes, and Provider Service Networks as defined in Section
      409.912, Florida Statutes. 

    

    Hospital—
A
      facility licensed in accordance with the provisions of Chapter 395, Florida
      Statutes, or the applicable laws of the state in which the service is
      furnished.

    

    Hospital
      Services Agreement—
The
      agreement between the Health Plan and a Hospital to provide medical services
      to
      the Health Plan's Enrollees.

    

    Indirect
      Ownership Interest — Ownership
      interest in an entity that has direct or indirect ownership interest in the
      disclosing entity. The amount of indirect ownership in the disclosing entity
      that is held by any other entity is determined by multiplying the percentage
      of
      ownership interest at each level. An indirect ownership interest must be
      reported if it equates to an ownership interest of five percent (5%) or more
      in
      the disclosing entity. Example: If “A” owns ten percent (10%) of the stock in a
      corporation that owns eighty percent (80) of the stock of the disclosing entity,
      “A’s” interest equates to an eight percent (8%) indirect ownership and must be
      reported.

    

    Individuals
      with Special Health Care Needs —
Adults
      and Children/Adolescents, who face physical, mental or environmental challenges
      daily that place at risk their health and ability to fully function in society.
      Factors include individuals with mental retardation or related conditions;
      individuals with serious chronic illnesses, such as human immunodeficiency
      virus
      (HIV), schizophrenia or degenerative neurological disorders; individuals with
      disabilities resulting from many years of chronic illness such as arthritis,
      emphysema or diabetes; and Children/Adolescents and adults with certain
      environmental risk factors such as homelessness or family problems that lead
      to
      the need for placement in foster care.

    

    Information—
(a)
      Structured Data: Data that adhere to specific properties and Validation criteria
      that are stored as fields in database records. Structured queries can be created
      and run against structured data, where specific data can be used as criteria
      for
      querying a larger data set; (b) Document: Information that does not meet the
      definition of structured data includes text, files, spreadsheets, electronic
      messages and images of forms and pictures.

    

    Information
      System(s)—
A
      combination of computing hardware and software that is used in: (a) the capture,
      storage, manipulation, movement, control, display, interchange and/or
      transmission of information, i.e. structured data (which may include digitized
      audio and video) and documents; and/or (b) the processing of such information
      for the purposes of enabling and/or facilitating a business process or related
      transaction.

    

    Insolvency—
A
      financial condition that exists when an entity is unable to pay its debts as
      they become due in the usual course of business, or when the liabilities of
      the
      entity exceeds its assets.

    

    Licensed — A
      facility, equipment, or an individual that has formally met state, county,
      and
      local requirements, and has been granted a license by a local, state or federal
      government entity. 

    

    Kick
      Payment -
      The
      method of reimbursing managed care organizations in the form of a separate
      one-time fixed payment for specific services.

    

    Licensed
      Practitioner of the Healing Arts — A
      psychiatric nurse, Registered Nurse, advanced registered nurse practitioner,
      Physician Assistant, clinical social worker, mental health counselor, marriage
      and family therapist, or psychologist. 

    

    List
      of Excluded Individuals and Entities (LEIE)—
A
      database maintained by the Department of Health & Human Services, Office of
      the Inspector General. The LEIE provides information to the public, health
      care
      providers, patients and others relating to parties excluded from participation
      in Medicare, Medicaid and all other federal health care programs.

    

    Managed
      Behavioral Health Organization (MBHO)—
A
      behavioral health-care delivery system managing quality, utilization and cost
      of
      services. Additionally, an MBHO measures performance in the area of mental
      disorders.

    

    Mandatory
      Assignment—
The
      process the Agency uses to assign Potential Enrollees to a Health Plan. The
      Agency automatically assigns those Mandatory Potential Enrollees who did not
      voluntarily choose a Health Plan.

    

    Mandatory
      Enrollee—
The
      categories of eligible beneficiaries who must be enrolled in a Health
      Plan.

    

    Mandatory
      Potential Enrollee—
A
      Medicaid Recipient who is required to enroll in a Health Plan, but has not
      yet
      chosen a Health Plan in which to enroll.

    

    Market
      Area—
The
      geographic area in which the Health Plan is authorized to market and/or conduct
      pre-enrollment activities.

    

    Marketing—
Any
      activity or communication conducted by or on behalf of any Health Plan to a
      Medicaid Recipient who is not Enrolled with the Health Plan, that can reasonably
      be interpreted as intended to influence the Medicaid Recipient to enroll in
      the
      particular Health Plan.

    

    Marketing
      Representative — A
      person
      who provides information, pre-enrollment assistance, or otherwise promotes
      a
      Health Plan. Marketing Representatives shall be limited to licensed insurance
      agents. 

    

    Medicaid
      Area — The
      specific counties designated by the Agency.

    

    Medicaid—
The
      medical assistance program authorized by Title XIX of the Social Security Act,
      42 U.S.C. §1396 et seq., and regulations there under, as administered in the
      State of Florida by the Agency under 409.901 et seq., F.S.

    Medicaid
      Recipient—
Any
      individual whom DCF, or the Social Security Administration on behalf of the
      DCF,
      determines is eligible, pursuant to federal and State law, to receive medical
      or
      allied care, goods or services for which the Agency may make payments under
      the
      Medicaid program, and who is enrolled in the Medicaid program.

    

    Medicaid
      Reform—
The
      program resulting from Chapter 409.91211, F.S.

    

    Medical
      Record—
      Documents corresponding to medical or allied care, goods or services furnished
      in any place of business. The records may be on paper, magnetic material, film
      or other media. In order to qualify as a basis for reimbursement, the records
      must be dated, legible and signed or otherwise attested to, as appropriate
      to
      the media.

    

    Medically
      Necessary or Medical Necessity—
      Services that include medical or allied care, goods or services furnished or
      ordered to:

    

    1. Meet
      the
      following conditions:

    

    a. Be
      necessary to protect life, to prevent significant illness or significant
      disability or to alleviate severe pain;

    

    b. Be
      individualized, specific and consistent with symptoms or confirm diagnosis
      of
      the illness or injury under treatment and not in excess of the patient's
      needs;

    

    c. Be
      consistent with the generally accepted professional medical standards as
      determined by the Medicaid program, and not be experimental or
      investigational;

    

    d. Be
      reflective of the level of service that can be furnished safely and for which
      no
      equally effective and more conservative or less costly treatment is available
      statewide; and

    

    e. Be
      furnished in a manner not primarily intended for the convenience of the
      Enrollee, the Enrollee's caretaker or the provider.

    

    
      	 	
              2.

            	
              Medically
                Necessary or Medical Necessity for those services furnished in a
                Hospital
                on an inpatient basis cannot, consistent with the provisions of
                appropriate medical care, be effectively furnished more economically
                on an
                outpatient basis or in an inpatient facility of a different
                type.

            

    

    

    
      	 	
              3.

            	
              The
                fact that a provider has prescribed, recommended or approved medical
                or
                allied goods or services does not, in itself, make such care, goods
                or
                services Medically Necessary, a Medical Necessity or a Covered
                Service/Benefit.

            

    

    

    Medicare —
      The
      medical assistance program authorized by Title XVIII of the Social Security
      Act.

    

    Meds
      AD—
Those
      recipients up to 88% of FPL with assets up to $5,000 for an individual and
      $6,000 for a couple without Medicare and those with Medicare that are not
      receiving institutional care, hospice care, or home and community based
      services.

    

    Neglect —
A
      failure or omission to provide care, supervision, and services necessary to
      maintain enrollee’s physical and mental health, including but not limited to,
      food, nutrition, supervision and medical services that are essential for the
      well-being of the enrollee. Neglect might be a single incident or repeated
      conduct that results in, or could reasonably expected to result in, serious
      physical or psychological injury, or a substantial risk of death.

    Newborn—
A
      live
      child born to an Enrollee, who is a member of the Health Plan.

    

    Non-Covered
      Service—
A
      service that is not a Covered Service/Benefit of the Medicaid State Plan or
      of
      the Health Plan.

    

    Nursing
      Facility—
An
      institutional care facility that furnishes medical or allied inpatient care
      and
      services to individuals needing such services. See Chapters 395 and 400,
      F.S.

    

    Open
      Enrollment—
The
      sixty (60) day period before the end of an Enrollee's Enrollment year, during
      which an Enrollee may choose to change Health Plans for the following Enrollment
      year. 

    

    Outpatient—
A
      patient of an organized medical facility, or distinct part of that facility,
      who
      is expected by the facility to receive, and who does receive, professional
      services for less than a twenty-four (24) hour period, regardless of the hours
      of admission, whether or not a bed is used and/or whether or not the patient
      remains in the facility past midnight.

    

    Overpayment —
      Includes any amount that is not authorized to be paid by the Medicaid program
      whether paid as a result of inaccurate or improper cost reporting, improper
      claiming, unacceptable practices, fraud, abuse, or mistake. 

    

    Participating
      Specialist—
A
      physician, licensed to practice medicine in the State of Florida, who contracts
      with the Health Plan to provide specialized medical services to the Health
      Plan's Enrollees.

    

    Peer
      Review—
An
      evaluation of the professional practices of a provider by the provider's peers
      in order to assess the necessity, appropriateness and quality of care furnished
      as such care is compared to that customarily furnished by the provider's peers
      and to recognized health care standards.

    

    Penultimate
      Saturday—
The
      Saturday preceeding the last Saturday of the month.

    

    Penultimate
      Sunday —
      The
      Sunday preceeding the last Sunday of the month.

    

    Pharmacy
      Benefits Administrator—
An
      entity contracted to or included in a health plan accepting pharmacy
      prescription claims for enrollees in the plan, assuring these claims conform
      to
      coverage policy and determining the allowed payment.

    

    Physician’s
      Assistant — A
      person
      who is a graduate of an approved program or its equivalent or meets standards
      approved by the Board of Medicine and is certified to perform medical services
      delegated by the supervising physician in accordance with Chapter 458, F.S.
      

    

    Physicians'
      Current Procedural Terminology (CPT)—A
      systematic listing and coding of procedures and services published annually
      by
      the American Medical Association.

    

    Plan
      Factor
      - A
      budget-neutral adjustment using a Health Plan's available historical Enrollee
      diagnosis data grouped by a health-based risk assessment model.  A Health
      Plan's Plan Factor is developed from the aggregated individual risk scores
      of
      the Health Plan's prior Enrollment.  The Plan Factor modifies a Health
      Plan's monthly capitation payment to reflect the health status of its
      Enrollees.

    

    Portable
      X-Ray Equipment—
X-ray
      equipment transported to a setting other than a hospital, Clinic or office
      of a
      physician or other Licensed Practitioner of the Healing Arts.

    

    Post-Stabilization
      Care Services—
Covered
      Services related to an Emergency Medical Condition that are provided after
      an
      Enrollee is stabilized in order to maintain the condition, or to improve or
      resolve the Enrollee's condition pursuant to 42 CFR 422.113.

    

    Potential
      Enrollee — Pursuant
      to 42 CFR 438.10(a), an eligible Medicaid Recipient who is subject to Mandatory
      Assignment or may voluntarily elect to enroll in a given Health Plan, but is
      not
      yet an Enrollee of a specific Health Plan. 

    

    Pre-Enrollment —
The
      provision of Marketing and educational materials to a Medicaid Recipient and
      assistance in completing the Request for Benefit Information (RBI).

    

    Pre-Enrollment
      Application—
See
      Request for Benefit Information.

    

    Prepaid
      Health Plan—
A
      Health Plan reimbursed on a prepaid basis. (see Health Plan)

    

    Primary
      Care—
      Comprehensive, coordinated and readily-accessible medical care including: health
      promotion and maintenance; treatment of illness and injury; early detection
      of
      disease; and referral to specialists when appropriate. 

    

    Primary
      Care Case Management—
The
      provision or arrangement of Enrollees’ primary care and the referral of
      Enrollees for other necessary medical services on a 24-hour basis. 

    

    Primary
      Care Provider
      (PCP)—
A
      Health Plan staff or contracted physician practicing as a general or family
      practitioner, internist, pediatrician, obstetrician, gynecologist, advanced
      registered nurse practitioners, physician assistants or other specialty approved
      by the Agency, who furnishes Primary Care and patient management services to
      an
      Enrollee. See sections 641.19, 641.31 and 641.51, Florida Statutes.

    

    Prior
      Authorization—
The
      act
      of authorizing specific services before they are rendered. 

    

    Protocols—
Written
      guidelines or documentation outlining steps to be followed for handling a
      particular situation, resolving a problem or implementing a plan of medical,
      nursing, psychosocial, developmental and educational services.

    

    Provider — A
      person
      or entity that is eligible to provide Medicaid services and has a contractual
      agreement with the Health Plan to provide Medicaid services. 

    

    Provider
      Contract — An
      agreement between the Health Plan and a health care Provider as described above.
      

    

    Provider
      Service Network — A
      network
      established or organized and operated by a health care provider, or group of
      affiliated health care providers, including minority physician networks and
      emergency room diversion programs that meet the requirements of s.
      409.91211, which
      provides a substantial proportion of the health care items and services under
      a
      contract directly through the provider or affiliated group of providers and
      may
      make arrangements with physicians or other health care professionals, health
      care institutions, or any combination of such individuals or institutions to
      assume all or part of the financial risk on a prospective basis for the
      provision of basic health services by the physicians, by other health
      professionals, or through the institutions. The health care providers must
      have
      a controlling interest in the governing body of the provider service
      network organization.
      For
      purposes of this Contract, the PSN shall operate in accordance with section
      409.91211(3)(e), F.S., and is exempt from licensure under Chapter 641, F.S.
      The
      PSN shall be responsible for meeting certain standards in Chapter 641, F.S.
      as
      required in this Contract.

    

    Public
      Event—
An
      event sponsored for the public or segment of the public by two (2) or more
      actively participating organizations, one (1) of which may be a health
      organization.

    

    Quality—
      The
      degree to which a Health Plan increases the likelihood of desired health
      outcomes of its Enrollees through its structural and operational characteristics
      and through the provision of health services that are consistent with current
      professional knowledge. 

    

    Quality
      Enhancements
      - Certain
      health-related, community-based services that the Health Plan must offer and
      coordinate access to for its Enrollees, such as children’s programs, domestic
      violence classes, pregnancy prevention, smoking cessation, or substance abuse
      programs. Health Plans are not reimbursed by the Agency for these types of
      services. 

    

    Quality
      Improvement (QI) —
      The
      process of monitoring and assuring that the delivery of health care services
      are
      available, accessible, timely, Medically Necessary, and provided in sufficient
      quantity, of acceptable Quality, within established standards of excellence,
      and
      appropriate for meeting the needs of the Enrollees. 

     

    Quality
      Improvement Program (QIP) —
      The
      process of assuring the delivery of health care is appropriate, timely,
      accessible, available and Medically Necessary.

    

    Registered
      Nurse (RN) —
      An
      individual who is licensed to practice professional nursing in accordance with
      Chapter 464, F.S.

     

    Request
      for Benefit Information (RBI)—
The
      form completed by a Potential Enrollee with the assistance of a Health Plan
      representative and submitted by the Health Plan to the Choice
      Counselor/Enrollment Broker to initiate the receipt of information for the
      Enrollment process. Also known as Pre-Enrollment Application.

    

    Residential
      Services —
      As
      applied to DJJ, refers to the out-of-home placement for use in a level 4, 6,
      8
      or 10 facility as a result of a delinquency disposition order. Also referred
      to
      as a Residential Commitment Program.

    

    Risk
      Adjustment (also Risk-Adjusted)
      - A
      process to adjust Capitation Rates to reflect the health conditions relative
      to
      the health status of the enrolled population. This process includes but is
      not
      limited to, risk assessment models, demographics, or population grouping.

    

    Risk
      Assessment —
      The
      process of collecting information from a person about hereditary, lifestyle
      and
      environmental factors to determine specific diseases or conditions for which
      the
      person is at risk.

    

    Rural—
      An
      area
      with a population density of less than 100 individuals per square mile, or
      an
      area defined by the most recent United State Census as rural, i.e.
      lacking a metropolitan statistical area (MSA). 

    

    Rural
      Health Clinic (RHC)—
A
      clinic that is located in an area that has a health-care provider shortage.
      An
      RHC provides primary health care and related diagnostic services and may provide
      optometric, podiatry, chiropractic and mental health services. An RHC employs,
      contracts or obtains volunteer services from licensed health care practitioners
      to provide services.

    

    Sales
      Activities —
      Actions
      performed by an agent of any Health Plan, including the acceptance of
      Pre-Enrollment Application Requests for Benefit Information, for the purpose
      of
      Enrollment of Potential Enrollees.

    

    Screen
      or Screening—
      Assessment of an Enrollee's physical or mental condition to determine evidence
      or indications of problems and need for further evaluation or
      services.

    

    Service
      Area—
The
      designated geographical area within which the Health Plan is authorized by
      the
      Contract to furnish Covered Services to Enrollees.

    

    Service
      Authorization—
      The
      Health Plan’s approval for services to be rendered. The process of authorization
      must at least include a Health Plan Enrollee’s or a Provider’s request for the
      provision of a service. 

    

    Service
      Location —
      Any
      location at which an Enrollee obtains any health care service provided by the
      Health Plan under the terms of the Contract.

    

    Sick
      Care —
      Non-urgent problems that do not substantially restrict normal activity, but
      could develop complications if left untreated (e.g., chronic
      disease).

    

    Span
      of Control —
      Information systems and telecommunications capabilities that the Health Plan
      itself operates or for which it is otherwise legally responsible according
      to
      the terms and Conditions of this Contract. The Health Plan span of control
      also
      includes Systems and telecommunications capabilities outsourced by the Health
      Plan.

    

    Special
      Supplemental Nutrition Program for Women, Infants & Children
      (WIC)—
Program
      administered by the Department of Health that provides nutritional counseling;
      nutritional education; breast-feeding promotion and nutritious foods to
      pregnant, postpartum and breast-feeding women, infants and children up to the
      age of five (5) who are determined to be at nutritional risk and who have a
      low
      to moderate income. An individual who is eligible for Medicaid is automatically
      income eligible for WIC benefits. Additionally, WIC income eligibility is
      automatically provided to an Enrollee's family that includes a pregnant woman
      or
      infant certified eligible to receive Medicaid.

    

    Specialty
      Plan
      - A
      Health Plan designed for a specific population and whose Enrollees are primarily
      composed of Medicaid Recipients, Children with Chronic Conditions or for
      Medicaid Recipients who have been diagnosed with the human immunodeficiency
      virus or acquired immunodeficiency syndrome (HIV/AIDS). A Health Plan must
      be
      licensed under Chapter 641, Florida Statutes, in order to offer a Specialty
      Plan
      for the population with HIV/AIDS.

    

    State —
      State of
      Florida.

    

    Subcontract —
      An
      agreement entered into by the Health Plan for provision of administrative
      services on its behalf. 

    

    Subcontractor —
      Any
      person or entity with which the Health Plan has contracted or delegated some
      of
      its functions, services or responsibilities for providing services under this
      Contract.

    

    Surface
      Mail —
      Mail
      delivery via land, sea, or air, rather than via electronic transmission.

     

    Surplus —
      Net
      worth, i.e., total assets minus total liabilities.

    

    System
      Unavailability —
      As
      measured within the Health Plan’s information systems Span of Control, when a
      system user does not get the complete, correct full-screen response to an input
      command within three (3) minutes after depressing the “Enter” or other function
      key.

    

    Systems —
      See
      Information Systems.

    

    Temporary
      Assistance to Needy Families (TANF)—
Public
      financial assistance provided to low-income families.

    

    Transportation—
An
      appropriate means of conveyance furnished to an Enrollee to obtain Medicaid
      authorized/covered services.

    

    Unborn
      Activation—
The
      process by which an unborn child, who has been assigned a Medicaid ID number
      is
      made Medicaid eligible upon birth.

    

    Urban — An
      area
      with a population density of greater than 100 individuals per square mile or
      an
      area defined by the most recent United State Census as urban, i.e. as
      having
      a metropolitan statistical area (MSA). 

    

    Urgent
      Behavioral Health Care—
Those
      situations that require immediate attention and assessment within twenty-three
      (23) hours even though the Enrollee is not in immediate danger to
      himself/herself or others and is able to cooperate in treatment.

    

    Urgent
      Care—
      Services for conditions, which, though not life-threatening, could result in
      serious injury or disability unless medical attention is received (e.g., high
      fever, animal bites, fractures, severe pain, etc.) or do substantially restrict
      an Enrollee's activity (e.g., infectious illnesses, flu, respiratory ailments,
      etc.).

    

    Validation — The
      review of information, data, and procedures to determine the extent to which
      they are accurate, reliable, free from bias and in accord with standards for
      data collection and analysis.

    

    Vendor — An
      entity
      submitting a proposal to become a Health Plan contractor. 

    

    Violation—
A
      determination by the Agency that a Health Plan failed to act as specified in
      this Contract or applicable statutes, rules or regulations governing Medicaid
      Health Plans. Each day that an ongoing violation continues shall be considered,
      for the purposes of this Contract, to be a separate Violation. In addition,
      each
      instance of failing to furnish necessary and/or required medical services or
      items to Enrollees shall be considered, for purposes of this Contract, to be
      a
      separate Violation. As well, each day that a Health Plan fails to furnish
      necessary and/or required medical services or items to Enrollees shall be
      considered, for purposes of this Contract, to be a separate
      Violation.

    

    Voluntary
      Enrollee—
An
      Enrollee that is not mandated to enroll in a Health Plan, but chooses to enroll
      in a Health Plan.

    

    Voluntary
      Potential Enrollee—
A
      Potential Enrollee that is not mandated to enroll in a Health Plan, and is
      not
      yet Enrolled in a Health Plan. 

     

    Well
      Care Visit—
A
      routine medical visit for one (1) of the following: CHCUP visit, family
      planning, routine follow-up to a previously treated condition or illness, adult
      physicals or any other routine visit for other than the treatment of an
      illness.

    

    

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              B.  

            	
               

              Acronyms

            

    

     

    

    ADL
      — Activities
      of Daily Living

     

    ADM—
      Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
      Children & Families (aka SAMH — listed below)

     

    ALF—
      Assisted Living Facility

     

    APD—
Agency
      for People with Disabilities

     

    BBA
      —
      Balanced Budget Act of 1997

     

    CAP
      — Corrective
      Action Plan

     

    CARES
      — Comprehensive
      Assessment & Review for Long-Term Care Services

     

    CDC
      — Centers
      for Disease Control

     

    CHD
      — County
      Health Department

     

    CMS
      — Centers
      for Medicare & Medicaid Services

     

    CFR
      — Code
      of
      Federal Regulations

     

    CHCUP
      — Child
      Health Check-Up Program

     

    CPT—
      Physicians’ Current Procedural Terminology

     

    DCF—
      Department of Children & Families

     

    DFS
      -
      Department of Financial Services

     

    DHHS—
United
      States Department of Health & Human Services

     

    DOH—
      Department of Health

     

    DJJ—
      Department of Juvenile Justice

     

    DEA—
Drug
      Enforcement Administration

     

    DME—
Durable
      Medical Equipment

     

    EDI
      —
      Electronic Data Interchange 

     

    EDT
      -
      Eastern Daylight Time

     

    EPSDT—
Early
      and Periodic Screening, Diagnosis & Treatment Program

     

    EQR
      —
      External Quality Review

     

    EQRO—
      External Quality Review Organization

     

    EST—
Eastern
      Standard Time

     

    FAC—
Florida
      Administrative Code

     

    FFS—
      Fee-for-Service

     

    FQHC—
      Federally Qualified Health Center

     

    FTE—
Full
      Time Equivalent Position

     

    HIPAA—
Health
      Insurance Portability & Accountability Act

     

    HMO—
Health
      Maintenance Organization

     

    IBNR
      -
      Incurred but not reported

     

    LEIE—
List
      of
      Excluded Individuals & Entities

     

    MBHO—
Managed
      Behavioral Health Organization

     

    ODBC
      —
Open
      Database Connectivity

     

    PCCB
      - Per
      capita capitation benchmark

     

    PCP—
Primary
      Care Physician

     

    QI
      -
      Quality
      Improvement

     

    QIP—
Quality
      Improvement Program

     

    RBI
      -
      Request for Benefit Information

     

    RFP—
Request
      for Proposal

     

    RHC—
Rural
      Health Clinic

     

    SAMH—
      Alcohol, Drug Abuse & Mental Health Office of the Florida Department of
      Children & Families (aka ADM — listed above)

     

    SFTP—
Secure
      File Transfer Protocol

     

    SOBRA—
Sixth
      Omnibus Budget Reconciliation Act

     

    SQL
      —
      Structured Query Language

     

    SSI
      —
      Supplemental Security Income 

     

    UM
      —
      Utilization Management

     

    WIC—
Special
      Supplemental Nutrition Program for Women, Infants & Children

     

    

    
      
        
           

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    Section
      II

    General
      Overview 

    

    
      	A.  	
              Background

            

    

     

    

    
      	 	
              1.

            	
              Effective
                July 1, 2006, the Agency for Health Care Administration will begin
                implementing Medicaid Reform in the counties of Broward and Duval.
                At the
                end of the first year of implementation, Medicaid Reform will be
                extended
                to Nassau, Clay and Baker counties. Medicaid Reform will transform
                the
                Medicaid program by empowering Medicaid Recipients to take control
                of
                their health care, providing more choices for Recipients, and enhancing
                their health status through increased health literacy and incentives
                to
                engage in healthy behaviors. 

            

    

    

    
      	 	
              2.

            	
              The
                principles governing Medicaid Reform
                are:

            

    

    

    
      	a.  	
              Patient
                Responsibility and Empowerment;

            

    

    

    
      	b.  	
              Marketplace
                Decisions;

            

    

    

    
      	c.  	
              Bridging
                Public and Private Coverage; and

            

    

    

    
      	d.  	
              Sustainable
                Growth Rate.

            

    

    

    
      	 	
              3.

            	
              These
                principles will empower Medicaid Recipients, provide flexibility
                to
                Providers, and facilitate program management for government.
                

            

    

    

    
      	B.  	
              Purpose

            

    

     

    

    One
      of
      the key goals of Medicaid Reform is the expansion of health care choices for
      Medicaid Recipients and enhanced access to services. To achieve this goal the
      Agency proceeded with an open application process to obtain the services of
      Health Plans. This Contract is the agreement between the Agency and entities
      operating under Medicaid Reform as a Health Plan.

    

    
      	C.  	
              Responsibilities
                of the State of Florida (the State) and the Agency for Health Care
                Administration (the Agency)

            

    

     

    

    
      	1.  	
              The
                Agency will be responsible for administering the Medicaid program,
                including all aspects of Medicaid Reform. The Agency will administer
                contracts, monitor Health Plan performance, and provide oversight
                in all
                aspects of the Health Plan’s
                operations.

            

    

    

    
      	2.  	
              The
                State of Florida has sole authority for determining eligibility for
                Medicaid and whether Medicaid Recipients are mandated to enroll in,
                may
                enroll in, or may not enroll in Medicaid
                Reform.

            

    

    

    
      	3.  	
              The
                Agency or its Agent will review the Florida Medicaid Management
                Information System (FMMIS) file daily and will send written notification
                and information to all Potential Enrollees. A Potential Enrollee
                will have
                thirty (30) Calendar Days to select a Health Plan.
                

            

    

    

    
      	4.  	
              The
                Agency or its Agent will Auto-Assign Mandatory Potential Enrollees
                who do
                not select a Health Plan during their choice period to a Health Plan
                using
                a pre-established algorithm.

            

    

    

    
      	5.  	
              Enrollment
                in a Health Plan, whether chosen or Auto-Assigned, will be effective
                at
                12:01 a.m. on the first (1st) Calendar Day of the month following
                Potential Enrollee selection or Auto-Assignment, for those Potential
                Enrollees who choose or are Auto- Assigned to a Health Plan on or
                between
                the first (1st) Calendar Day of the month and the Penultimate Saturday
                of
                the month. For those Enrollees who choose or are Auto-Assigned a
                Health
                Plan between the Sunday after the Penultimate Saturday and before
                the last
                Calendar Day of the month, Enrollment in a Health Plan will be effective
                on the first (1st) Calendar Day of the second (2nd) month after choice
                or
                Auto-assignment.

            

    

    

    
      	6.  	
              The
                Agency or its Agent will notify the Health Plan of an Enrollee’s selection
                or assignment to a Health Plan. 

            

    

    

    
      	7.  	
              The
                Agency or it Agent will send a written confirmation notice to Enrollees
                identifying the chosen or Auto-Assigned Health Plan. If the Enrollee
                has
                not chosen a PCP, the confirmation notice will advise the Enrollee
                that a
                PCP will be chosen for him/her. Notice to the Enrollee will be made
                in
                writing and sent via Surface Mail. Notice to the Health Plan will
                be made
                via file transfer. 

            

    

    

    
      	8.  	
              Conditioned
                on continued eligibility, Mandatory Enrollees will have a Lock-In
                period
                of twelve (12) consecutive months. After an initial ninety (90) day
                change
                period, Mandatory Enrollees will only be able to disenroll from their
                Health Plan for Cause. The Agency or its Agent will notify Enrollees
                at
                least once every twelve (12) months, and at least sixty (60) Calendar
                Days
                prior to the date the Lock-In period ends (the Open Enrollment period),
                that they have the opportunity to change Health Plans. Enrollees
                who do
                not make a choice will be deemed to have chosen to remain with their
                current Health Plan, unless the current Health Plan no longer participates
                in Medicaid Reform. In this case, the Enrollee will be Auto-Assigned
                to a
                new Health Plan.

            

    

    

    
      	9.  	
              The
                Agency or its Agent will automatically re-enroll an Enrollee into
                the
                Health Plan in which he or she was most recently enrolled if the
                Enrollee
                has a temporary loss of eligibility, defined for purposes of this
                Contract
                as less than 180 Calendar Days. In this instance, for Mandatory Potential
                Enrollee, the Lock-In period will continue as though there had been
                no
                break in eligibility, keeping the original twelve (12) month period.
                

            

    

    

    
      	10.  	
              If
                a temporary loss of eligibility has caused the Enrollee to miss the
                Open
                Enrollment period, the Agency or its Agent will enroll the Enrollee
                in the
                Health Plan in which he or she was enrolled prior to the loss of
                eligibility. The Enrollee will have ninety (90) Calendar Days to
                disenroll
                without Cause.

            

    

    

    
      	11.  	
              The
                State will issue a Medicaid identification (ID) number to a newborn
                upon
                notification from the Health Plan, the hospital, or other authorized
                Medicaid provider, consistent with the unborn activation process.
                

            

    

    

    
      	12.  	
              The
                Agency or its Agent will notify Enrollees of their right to request
                Disenrollment as follows:

            

    

    

    a. For
      Cause
      at any time, or

    

    b. Without
      Cause, at the following times:

    

    
      	 	
              (1)

            	
              During
                the ninety (90) days following the Enrollee's initial Enrollment,
                or the
                date the Agency or its Agent sends the Enrollee notice of the enrollment,
                whichever is later;

            

    

    

    
      	 	
              (2)

            	
              At
                least every twelve (12) months;

            

    

    

    
      	 	
              (3)

            	
              If
                the temporary loss of Medicaid eligibility has caused the Enrollee
                to miss
                the Open Enrollment period; or

            

    

    

    
      	(4)  	
              When
                the Agency or its Agent grants the Enrollee the right to terminate
                Enrollment without Cause. The Agency or its Agent determines the
                Enrollee's right to terminate Enrollment on a case-by-case basis.
                

            

    

    

    
      	(5)  	
              If
                the individual chooses to opt out and enroll in their employer-sponsored
                health insurance plan.

            

    

    

    
      	13.  	
              The
                Agency or its Agent will process all Disenrollments from the Health
                Plan.
                The Agency or its Agent will make final determinations about granting
                Disenrollment requests and will notify the Health Plan via file transfer
                and the Enrollee via Surface Mail of any Disenrollment decision.
                Enrollees
                dissatisfied with an Agency determination may have access to the
                Medicaid
                Fair Hearing process.

            

    

    

    
      	14.  	
              When
                Disenrollment is necessary because an Enrollee loses Medicaid eligibility,
                Disenrollment shall be immediate. 

            

    

    

    
      	15.  	
              The
                Agency and/or its Agent shall determine the activities and behaviors
                that
                qualify for contributions to the individual’s Enhanced Benefit Account.
                

            

    

    

    
      	16.  	
              The
                Agency will conduct periodic monitoring of the Health Plan’s operations
                for compliance with the provisions of the Contract and applicable
                federal
                and State laws and regulations.

            

    

    

    
      	D.  	
              General
                Responsibilities of the Health Plan 

            

    

     

    

    
      	1.  	
              The
                Health Plan shall comply with all provisions of this Contract and
                its
                amendments, if any, and shall act in good faith in the performance
                of the
                Contract's provisions. The Health Plan shall develop and maintain
                written
                policies and procedures to implement all provisions of this Contract.
                The
                Health Plan agrees that failure to comply with all provisions of
                this
                Contract shall result in the assessment of penalties and/or termination
                of
                the Contract, in whole or in part, as set forth in this
                Contract.

            

    

    

    
      	2.  	
              The
                Health Plan shall comply with all pertinent Agency rules in effect
                throughout the duration of the
                Contract.

            

    

    

    
      	3.  	
              The
                Health Plan shall comply with all current Florida Medicaid Handbooks
                ("Handbooks") as noticed in the Florida Administrative Weekly ("FAW"),
                or
                incorporated by reference in rules relating to the provision of services
                set forth in Section V Covered Services, and Section VI, Behavioral
                Health
                Care, except where the provisions of the Contract alter the requirements
                set forth in the Handbooks promulgated in the Florida Administrative
                Code
                (FAC) unless a customized benefit package has been certified by the
                Agency. In addition, the Health Plan shall comply with the limitations
                and
                exclusions in the Handbooks, unless otherwise specified by this Contract.
                In no instance may the limitations or exclusions imposed by the Health
                Plan be more stringent than those specified in the Handbooks, unless
                authorized in the Customized Benefit Package by the Agency. The Health
                Plan may not arbitrarily deny or reduce the amount, duration or scope
                of a
                required service solely because of the diagnosis, type of illness,
                or
                condition. The Health Plan may exceed Handbook limits by offering
                Expanded
                Services, as described in Section V, Covered Services or through
                its
                approved Customized Benefit package.

            

    

    

    
      	4.  	
              The
                Capitated PSN may only choose to offer a Specialty Plan for Medicaid
                Recipients in:

            

    

    

    
      	 	
              a.

            	
              Temporary
                Assistance to Needy Families (TANF) eligibility
                category;

            

    

    

    
      	 	
              b.

            	
              Supplemental
                Security Income (SSI) eligibility category;
                or

            

    

    

    
      	 	
              c.

            	
              Children
                with Chronic Conditions.

            

    

    

    
      	5.  	
              The
                Health Plan may offer Expanded Services, as described in Section
                V,
                Covered Services to Enrollees, in addition to the required services
                and
                Quality Enhancements. The Health Plan shall define with specificity
                its
                Expanded Services in regards to amount, duration and scope, and obtain
                approval, in writing, by the Agency prior to
                implementation.

            

    

    

    
      	6.  	
              This
                Contract including all attachments and exhibits, represents the entire
                agreement between the Health Plan and the Agency and supersedes all
                other
                contracts between the parties when it is executed by duly authorized
                signatures of the Health Plan and the Agency. Correspondence and
                memoranda
                of understanding do not constitute part of this Contract. In the
                event of
                a conflict of language between the Contract and the attachments,
                the
                provisions of the Contract shall govern. The Agency reserves the
                right to
                clarify any contractual relationship in writing and such clarification
                shall govern. Pending final determination of any dispute over any
                Agency
                decision, the Health Plan shall proceed diligently with the performance
                of
                its duties as specified under the Contract and in accordance with
                the
                direction of the Agency's Division of
                Medicaid.

            

    

    

    
      	7.  	
              The
                Health Plan shall have a Quality Improvement program that ensures
                enhancement of quality of care and emphasizes improving the quality
                of
                patient outcomes. The Agency may restrict the Health Plan’s Enrollment
                activities if the Health Plan does not meet acceptable Quality Improvement
                and performance indicators, based on HEDIS reports and other outcome
                measures to be determined by the Agency. Such restrictions may include,
                but shall not be limited to, the termination of mandatory
                assignments.

            

    

    

    
      	8.  	
              The
                Health Plan must demonstrate that it has adequate knowledge of Medicaid
                programs, provision of health care services, disease management
                initiatives, medical claims data, and the capability to design and
                implement cost savings methodologies. The Health Plan must demonstrate
                the
                capacity for financial analyses, as necessary to fulfill the requirements
                of this Contract. Additionally, the Health Plan must meet all requirements
                for doing business in the State of Florida.

            

    

    

    
      	9.  	
              The
                Health Plan may be required to provide to the Agency or its Agent
                information or data that is not specified under this Contract. In
                such
                instances, and at the direction of the Agency, the Health Plan shall
                fully
                cooperate with such requests and furnish all information in a timely
                manner, in the format in which it is requested. The Health Plan shall
                have
                at least thirty (30) Calendar Days to fulfill such ad hoc
                requests.

            

    

    

    
      	10.  	
              The
                Health Plan shall fully cooperate with, and provide necessary data
                to, the
                Agency and its Agent for the design, management, operations and monitoring
                of the Enhanced Benefits Program.

            

    

    

    
      	11.  	
              A
                Health Plan, who accepts the Comprehensive Component of the Capitation
                Rate only, shall continue to provide all Covered Services to each
                Enrollee, who reaches the Catastrophic Component Threshold. The Health
                Plan shall continue to apply its QM and UM program components, as
                well as
                other administrative policies and protocols to the delivery of care
                and
                services to the Enrollees who meet the threshold. The Health Plan
                may
                submit documentation for reimbursement for Covered Services costs as
                outlined in Section XIII., Method of Payment, subsection D. Claims
                Payment
                for Health Plans Providing the Comprehensive Component Only.
                

            

    

    

    
      	12.  	
              When
                the cost of an Enrollee’s Covered Services reaches the Benefit Maximum of
                $550,000 in a Contract Year, the Health Plan shall assist the Enrollee
                in
                obtaining necessary health care services in the community. The Health
                Plan
                shall continue to coordinate the care received by the Enrollee in
                the
                community. The Health Plan shall resume all responsibilities for
                the
                provision of Covered Services at the beginning of the Contract Year
                (September 1) following the year in which the Maximum Benefit was
                reached
                by the Enrollee.

            

    

    

    
      	13.  	
              Health
                Maintenance Organizations and other licensed managed care organizations
                shall enroll all network providers with the Agency’s Fiscal Agent, no
                later than November 30, 2006, using the Agency’s streamlined Provider
                Enrollment process. All Capitated PSNs shall use the streamlined
                Provider
                Enrollment process to enroll network providers prior to contract
                execution.

            

    

    

    
      	14.  	
              The
                Health Plans shall collect and submit Encounter Data for each Contract
                Year in the format required by the Agency and within the time frames
                specified by the Agency. An encounter guide along with technical
                assistance will be forthcoming. At a minimum the Health Plans shall
                be
                responsible for the following:

            

    

    

    
      	a.  	
              Health
                Plans shall collect and submit to the Agency or its designee, enrollee
                service level encounter data for all covered
                services.

            

    

    
      	b.  	
              Encounter
                data shall be submitted following HIPAA standards, namely the ANSI
                X12N
                837 Transaction formats (P - Professional, I - Institutional, and
                D -
                Dental), and the National Council for Prescription Drug Programs
                NCPDP
                format (for Pharmacy services).

            

    

    
      	c.  	
              All
                covered services rendered to health plan enrollees shall result in
                the
                creation of an encounter record.

            

    

    

    

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    Section
      III

    Eligibility
      and Enrollment

    

    
      	A.  	
              Eligibility

            

    

     

    The
      following Populations represent broad categories that contain multiple
      eligibility groups. Certain exceptions may apply within the broad categories
      and
      will be determined by the Agency.

    

    
      	1.  	
              Mandatory
                Populations 

            

    

    

    The
      categories of eligible recipients authorized to be enrolled in the Health Plan
      are: Low Income Families and Children; Sixth Omnibus Budget Reconciliation
      Act
      (SOBRA) Children; Supplemental Security Income (SSI) Medicaid Only, Refugees,
      and the Meds AD population. 

    

    Title
      XXI
      MediKids are eligible for enrollment in the plan in accordance with section
      409.8132, F.S. Except as otherwise specified in this contract, Title XXI
      MediKids eligible participants are entitled to the same conditions and services
      as currently eligible Title XIX Medicaid beneficiaries. 

    

    Women
      enrolled in the plan who change eligibility categories to the SOBRA eligibility
      category due to the pregnancy will remain eligible for enrollment in the
      plan.

    

    
      	2.  	
              Voluntary
                Populations 

            

    

    

    The
      following categories describe beneficiaries who may enroll in a health plan
      but
      are not required to do so:

    

    a. Foster
      care Children/Adolescents;

    

    b. Individuals
      diagnosed with developmental disabilities, as defined by the
      Agency;

    

    c. Children
      with chronic conditions who are eligible to participate in the Children’s
      Medical Services Program or a Specialty Plan for children with chronic
      conditions but not enrolled in the program; 

    

    d.
       Individuals
      with Medicare coverage (e.g. dual eligible individuals); and

    

    e. Children
      and adolescents who have an open case for services in the Department of Children
      and Families’ HomeSafenet database system.

    

    
      	3.  	
              Excluded
                Populations

            

    

    

    The
      following categories describe Medicaid Recipients who are not eligible to enroll
      in a Health Plan: 

    

    a. Pregnant
      women who have not enrolled in Medicaid Reform prior to the effective date
      of
      their SOBRA eligibility;

    

    b. Medicaid
      Recipients who, at the time of application for Enrollment and/or at the time
      of
      Enrollment, are domiciled or residing in an institution, including nursing
      facilities (and have been CARES assessed), sub-acute inpatient psychiatric
      facility for individuals under the age of 21, or an Intermediate Care
      Facility/Developmentally Disabled (ICF-DD);

    

    c. Medicaid
      Recipients whose Medicaid eligibility was determined through the medically
      needy
      program.

    

    d. Qualified
      Medicare Beneficiaries ("QMBs"), Special Low Income Medicare Beneficiaries
      (SLMBs), or Qualified Individuals at Level 1 (QI-1s).

    

    e. Medicaid
      Recipients who have other creditable health-care coverage, such as TriCare
      or a
      private health maintenance organization (HMO).

    

    f. Medicaid
      Recipients who reside in the following:

    

    (1) Residential
      commitment programs/facilities operated through the Department of Juvenile
      Justice (DJJ);

    

    (2) Residential
      group care operated by the Family Safety & Preservation Program of the
      DCF;

    

    (3) Children's
      residential treatment facilities purchased through the Substance Abuse &
Mental Health District ("SAMH") Offices of the DCF (also referred to as
      Purchased Residential Treatment Services - "PRTS");

    

    (4) SAMH
      residential treatment facilities licensed as Level I and Level II facilities;
      and

    

    (5) Residential
      Level I and Level II substance abuse treatment programs, as described in
Sections
      65D-30.007(2)(a) and (b), F.A.C.

    

    g. Medicaid
      Recipients participating in the Family Planning waiver.

    

    h. Participants
      in the Sub-acute Inpatient Psychiatric Program ("SIPP").

    

    i. Title
      XXI-funded children with chronic conditions who are enrolled in Children’s
      Medical Services Network.

    

    j. Women
      eligible for Medicaid due to breast and/or cervical cancer.

    

    k. Individuals
      eligible under a hospice-related eligibility group.

    

    
      	B.  	
              Enrollment

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    a. Only
      Medicaid Recipients who are included in the mandatory or voluntary group and
      living in counties with authorized Health Plans are eligible to enroll and
      receive services from the Health Plan.

    

    b. The
      Agency or its Agent shall be responsible for Enrollment, including Enrollment
      into a Health Plan, Disenrollment, and outreach and education activities. The
      Health Plan shall coordinate with the Agency and its Agent as necessary for
      all
      Enrollment and Disenrollment functions.

    

    c.
       The
      Health Plan shall accept Medicaid Recipients without restriction and in the
      order in which they enroll. The Health Plan shall not discriminate against
      Medicaid Recipients on the basis of religion, gender, race, color, age, or
      national origin, and shall not use any policy or practice that has the effect
      of
      discriminating on the basis of religion, gender, race, color, or national
      origin, or on the basis of health, health status, pre-existing condition, or
      need for health care services.

    

    d. The
      Health Plan shall accept new Enrollees through-out the Contract period up to
      the
      authorized maximum enrollment levels approved in Attachment I. 

    

    
      	2.  	
              Enrollment
                in a Specialty Plan

            

    

    

    Enrollment
      in a plan authorized to serve individuals diagnosed with HIV/AIDS or Children
      with Chronic Conditions will be limited to individuals in a mandatory or
      voluntary population who are diagnosed with such a condition and their family
      members. For a specialty plan for children with chronic conditions, only sibling
      family members under the age of 18 years of age may enroll when an eligible
      sibling is enrolled.

    

    
      	3.  	
              Enrollment
                with a Primary Care Provider
                (PCP)

            

    

    

    a. The
      Health Plan shall offer each Enrollee a choice of PCPs. After making a choice,
      each Enrollee shall have a single PCP.

    

    b. The
      Health Plan shall assign a PCP to those Enrollees who did not choose a PCP
      at
      the time of Health Plan selection. The Health Plan shall take into consideration
      the Enrollee's last PCP (if the PCP is known and available in the Health Plan's
      network), closest PCP to the Enrollee's home address, ZIP code location, keeping
      Children/Adolescents within the same family together, age (adults versus
      Children/Adolescents) and gender (OB/GYN).

    

    c. The
      Health Plan shall provide written notice via Surface Mail to the Enrollees,
      by
      the first day of the Enrollee's enrollment, of the following:

    

    (1) The
      Enrollee's PCP assignment;

    

    (2) The
      Enrollee's ability to choose a different PCP;

    

    (3) A
      list of
      Participating Providers from which to make a choice; and

     

    (4) The
      procedures for changing PCPs.

    

    d. The
      Health Plan shall permit Enrollees to change PCPs at any time. 

    

    e. The
      Health Plan shall assign all Enrollees that are reinstated after a temporary
      loss of eligibility to the PCP who was treating them prior to loss of
      eligibility, unless the Enrollee specifically requests another PCP, the PCP
      no
      longer participates in the Health Plan or is at capacity, or the Enrollee has
      changed geographic areas.

    

    
      	4.  	
              Newborn
                Enrollment

            

    

    

    a. The
      Health Plan shall utilize the unborn activation process to facilitate enrollment
      and shall be responsible for newborns from the date they are enrolled in the
      Health Plan. 

    

    b. Upon
      unborn activation, the newborn shall be enrolled in the Health Plan in which
      his/her mother was enrolled during the next enrollment cycle. 

    

    c. Newborn
      Enrollment shall occur through the following procedures:

    

    (1) Upon
      identification of an Enrollee's pregnancy, the Health Plan shall immediately
      notify DCF of the pregnancy and any relevant information known (i.e., due date
      and gender). The Health Plan must provide this notification by completing the
      DCF-ES 2039 Form and submitting the completed form to DCF. The Health Plan
      shall
      indicate its name and number as the entity initiating the referral. The DCF-ES
      2039 form is located on the Medicaid web site: http://www.fdhc.state.fl.us/Medicaid/Newborn.
      

    

    (2) DCF
      will
      generate a Medicaid ID number and the unborn child will be added to the Medicaid
      file. This information will be transmitted to the Medicaid Fiscal Agent. The
      Medicaid ID number will remain inactive until after the child is
      born.

    

    (3) The
      Health Plan shall comply with all requirements set forth by the Agency or its
      Agent related to Unborn Activation (see Policy Transmittal 06-02, Unborn
      Activation Process). To ensure the prompt Enrollment of newborns, the Health
      Plan shall ensure that the form DCF-ES 2039 is completed and submitted, via
      electronic submission, to the local DCF Economic Self-Sufficiency Services
      Office immediately upon the birth of the child. If the hospital is not a
      Participating Hospital, the Plan must submit Form 2039 to DCF. With regard
      to
      Participating Hospitals, the Plan must include, as part of its Participating
      Hospital Agreement, a clause that states whether the Plan or the Participating
      Hospital will complete the Form 2039 for all who lack an unborn
      record.

    

    (4) Upon
      notification that a pregnant Enrollee has presented to the Hospital for
      delivery, the Health Plan shall inform the Hospital, the pregnant Enrollee’s
      attending physician and the newborn’s attending and consulting physicians that
      the newborn is an Enrollee only if the Health Plan has verified that the newborn
      has an unborn record on the system that is awaiting activation. At this time
      the
      Health Plan shall initiate the Unborn Activation process.

    

    (5) Upon
      activation, the newborn shall be enrolled in the Health Plan in which his/her
      mother was enrolled during the month of birth.  

    

    
      	5.  	
              Enrollment
                Cessation

            

    

    

    The
      Health Plan may request that the Agency halt or reduce Enrollment temporarily
      if
      continued full Enrollment would exceed its capacity to provide required services
      under the Contract. The Agency may also limit Health Plan Enrollments when
      such
      action is considered to be in the Agency's best interest. 

    

    
      	6.  	
              Enrollment
                Notice

            

    

    

    a. Prior
      to
      or upon Enrollment, the Health Plan shall provide the following information
      to
      all new Enrollees:

    

    (1) A
      written
      notice providing the actual date of Enrollment, and the name, telephone number
      and address of the Enrollee’s PCP assignment.

    

    (2) Notification
      that Enrollees can change their Health Plan selection, subject to Medicaid
      limitations.

    

    (3) Enrollment
      materials regarding PCP choice as described in Section III, B.

    

    (4) New
      Enrollee Materials as described in Section IV.

     

    

    
      	C.  	
              Disenrollment

            

    

     

    
      	1.  	
              General
                Provisions

            

    

    

    a. If
      the
      Contract is renewed, the Enrollment status of all Enrollees shall continue
      uninterrupted.

    

    b. The
      Health Plan shall ensure that it does not restrict the Enrollee's right to
      disenroll voluntarily in any way. 

    

    c. The
      Health Plan or its agents shall not provide or assist in the completion of
      a
      Disenrollment request or assist the Agency’s Choice Counselor/Enrollment Broker
      in the Disesnrollment process.

    

    d. The
      Health Plan shall ensure that Enrollees that are disenrolled and wish to file
      an
      appeal have the opportunity to do so. All Enrollees shall be afforded the right
      to file an appeal except for the following reasons for Disenrollment:

    

    (1) Moving
      out of the Service Area; 

    (2) Loss
      of
      Medicaid eligibility; and 

    (3) Enrollee
      death.

    

    e. An
      Enrollee may submit to the Agency or its Agent a request to disenroll from
      the
      Health Plan without Cause during the ninety (90) Calendar Day change period
      following the date of the Enrollee's initial Enrollment with the Health Plan,
      or
      the date the Agency or its Agent sends the Enrollee notice of the Enrollment,
      whichever is later. An Enrollee may request Disenrollment without Cause every
      twelve (12) months thereafter.

    

    f. The
      effective date of an approved Disenrollment shall be the last Calendar Day
      of
      the month in which Disenrollment was made effective by the Agency or its Agent,
      but in no case shall Disenrollment be later than the first (1st) Calendar Day
      of
      the second (2nd) month following the month in which the Enrollee or the Health
      Plan files the Disenrollment request. If the Agency or its Agent fails to make
      a
      Disenrollment determination within this timeframe, the Disenrollment is
      considered approved. 

    

    g. The
      Health Plan shall keep a daily written log or electronic documentation of all
      oral and written Enrollee Disenrollment requests and the disposition of such
      requests. The log shall include the following: 

    

    (1) The
      date
      the request was received by the Health Plan;

    

    (2) The
      date
      the Enrollee was referred to the Agency's Choice Counselor/Enrollment Broker
      or
      the date of the letter advising the Enrollee of the Disenrollment procedure,
      as
      appropriate; and

    

    (3) The
      reason that the Enrollee is requesting Disenrollment.

    

    h. The
      Health Plan shall send to the Agency or its Agent a monthly summary report
      of
      all submitted Disenrollment requests. This report must specify the reason for
      such Disenrollment requests. It shall be reconciled to the Health Plan
      Enrollment Report processed by the Agency or its Agent for the applicable month
      and shall be reviewed by the Agency or its Agent for compliance with acceptable
      reasons for Disenrollment. The Agency may reinstate Enrollment for any Enrollee
      whose reason for Disenrollment is not consistent with established
      guidelines.

    

    
      	2.  	
              Cause
                for Disenrollment 

            

    

    

    a. A
      Mandatory Enrollee may request Disenrollment from the Health Plan for Cause
      at
      any time. Such request shall be submitted to the Agency or its Agent. The
      following reasons constitute Cause for Disenrollment from the Health
      Plan:

    

    
      	 	
              (1)

            	
              The
                Enrollee moves out of the Service Area or his/her address is
                incorrect.

            

    

    

    
      	 	
              (2)

            	
              The
                Provider is no longer with the Health
                Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                Enrollee is excluded from
                enrollment.

            

    

    

    
      	 	
              (4)

            	
              A
                substantiated marketing violation
                occurred.

            

    

    

    
      	 	
              (5)

            	
              The
                Enrollee is prevented from participating in the development of his/her
                treatment plan.

            

    

    

    
      	 	
              (6)

            	
              The
                Enrollee has an active relationship with a provider who is not on
                the
                Health Plan's panel, but is on the panel of another Health
                Plan.

            

    

    

    
      	 	
              (7)

            	
              The
                Enrollee is in the wrong Health Plan due to an
                error.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan no longer participates in the
                county.

            

    

    

    
      	 	
              (9)

            	
              The
                State has imposed intermediate sanctions upon the Health Plan, as
                specified in 42 CFR 438.702(a)(3).

            

    

    

    
      	 	
              (10)

            	
              The
                Enrollee needs related services to be performed concurrently, but
                not all
                related services are available within the Health Plan network; or,
                the
                Enrollee's PCP has determined that receiving the services separately
                would
                subject the Enrollee to unnecessary
                risk.

            

    

    

    
      	 	
              (11)

            	
              The
                Health Plan does not, because of moral or religious objections, cover
                the
                service the Enrollee seeks.

            

    

    

    
      	 	
              (12)

            	
              The
                Enrollee missed his/her Open Enrollment due to a temporary loss of
                eligibility, defined as 180 days or
                less.

            

    

    

    
      	 	
              (13)

            	
              Other
                reasons per 42 CFR 438.56(d)(2), including, but not limited to, poor
                quality of care; lack of access to services covered under the Contract;
                inordinate or inappropriate changes of PCPs; service access impairments
                due to significant changes in the geographic location of services;
                lack of
                access to Providers experienced in dealing with the Enrollee’s health care
                needs; or fraudulent Enrollment. 

            

    

    

    b. Voluntary
      Enrollees may disenroll from the Health Plan at any time. 

    

    
      	3.  	
              Involuntary
                Disenrollment

            

    

    

    a. With
      proper written documentation, the following are acceptable reasons for which
      the
      Health Plan shall submit involuntary Disenrollment requests to the
      Agency:

    

    (1) Enrollee
      has moved out of the Service Area;

    

    (2) Enrollee
      death;

    

    (3) Determination
      that the Enrollee is ineligible for Enrollment based on the criteria specified
      in this Contract in Section III.A.3, Excluded Populations, and

    

    (4) Fraudulent
      use of the Enrollee ID card. 

    

    b. The
      Health Plan shall promptly submit such Disenrollment requests to the Agency.
      In
      no event shall the Health Plan submit the Disenrollment request at such a date
      as would cause the Disenrollment to be effective later than forty-five (45)
      Calendar Days after the Health Plan’s receipt of the reason for involuntary
      Disenrollment. The Health Plan shall ensure that involuntary Disenrollment
      documents are maintained in an identifiable Enrollee record.

    

    c. If
      the
      Health Plan submitted the Disenrollment request for one of the above reasons,
      the Health Plan shall verify that the information is accurate.

    

    d. If
      the
      Health Plan discovers that an ineligible Enrollee has been enrolled, then it
      shall request Disenrollment of the Enrollee and shall notify the Enrollee in
      writing that the Health Plan is requesting Disenrollment and the Enrollee will
      be disenrolled in the next Contract month, or earlier if necessary. Until the
      Enrollee is Disenrolled, the Health Plan shall be responsible for the provision
      of services to that Enrollee.

    

    e. On
      a
      monthly basis, the Health Plan shall review its ongoing Enrollment report (FLMR
      8200-R0004) to ensure that all Enrollees are residing in the Health Plan’s
      authorized Service Area. For Enrollees with out-of-Service Area addresses on
      the
      Enrollment report, the Health Plan shall notify the Enrollee in writing that
      the
      Enrollee should contact the Choice Counselor/Enrollment Broker to choose another
      Health Plan, or other managed care option available in the Enrollee’s new
      Service Area, and that the Enrollee will be Disenrolled.

    f. The
      Health Plan may submit involuntary Disenrollment requests to the Agency or
      its
      Agent for assigned Enrollees that meet both of the following
      requirements:

    

    (1) The
      Health Plan was unable to contact the Enrollee by mail, phone, or personal
      visit
      within the first three (3) months of Enrollment; and

    

    (2) The
      Enrollee did not use Health Plan services within the first three (3) months
      of
      Enrollment. Such Disenrollments shall be submitted in accordance with Section
      XII, Reporting Requirements, of this Contract. The Health Plan shall maintain
      documentation of its inability to contact the Enrollee and that it has no record
      of providing services to the Enrollee, or to another family unit member, in
      the
      Enrollee's file.

    

    g. The
      Health Plan may submit an involuntary Disenrollment request to the Agency or
      its
      Agent after providing to the Enrollee at least one (1)verbal warning and at
      least one (1) written warning of the full implications of his/her failure of
      actions:

    

    
      	 	
              (1)

            	
              For
                an Enrollee who continues not to comply with a recommended plan of
                health
                care or misses three (3) consecutive appointments within a continuous
                six
                (6) month period. Such requests must be submitted at least sixty
                (60)
                Calendar Days prior to the requested effective
                date.

            

    

    

    
      	 	
              (2)

            	
              For
                an Enrollee whose behavior is disruptive, unruly, abusive or uncooperative
                to the extent that his or her Enrollment in the Health Plan seriously
                impairs the organization's ability to furnish services to either
                the
                Enrollee or other Enrollees. This Section does not apply to Enrollees
                with
                mental health diagnoses if the Enrollee’s behavior is attributable to the
                mental illness.

            

    

    

    h. The
      Agency may approve such requests provided that the Health Plan documents that
      attempts were made to educate the Enrollee regarding his/her rights and
      responsibilities, assistance which would enable the Enrollee to comply was
      offered through case management, and it has been determined that the Enrollee’s
      behavior is not related to the Enrollee’s medical or behavioral condition. All
      requests will be reviewed on a case-by-case basis and subject to the sole
      discretion of the Agency. Any request not approved is final and not subject
      to
      dispute or appeal.

    

    i. The
      Health Plan shall not request Disenrollment of an Enrollee due to:

    

    
      	(1)  	
              Health
                diagnosis;

            

    

    

    
      	(2)  	
              Adverse
                changes in an Enrollee’s health
                status;

            

    

    

    
      	(3)  	
              Utilization
                of medical services;

            

    

    

    
      	(4)  	
              Diminished
                mental capacity;

            

    

    

    
      	(5)  	
              Pre-existing
                medical condition;

            

    

    

    
      	(6)  	
              Uncooperative
                or disruptive behavior resulting from the Enrollee’s special needs (with
                the exception of C.3.g.2 above);

            

    

    

    
      	(7)  	
              Attempt
                to exercise rights under the Health Plan's Grievance System;
                or

            

    

    

    
      	(8)  	
              Request
                of one (1) PCP to have an Enrollee assigned to a different Provider
                out of
                the Health Plan.

            

    

    

    

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    Section
      IV

    Enrollee
      Services and Marketing

    

    
      	A.	
              Enrollee
                Services

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    a. The
      Health Plan shall have written policies and procedures for the provision of
      Enrollee Services, as specified in this Contract. Such policies and procedures
      shall be submitted to the Agency for approval.

    

    b. The
      Health Plan shall ensure that Enrollees are aware of their rights and
      responsibilities, the role of PCPs, how to obtain care, what to do in an
      emergency or urgent medical situation, how to request a Grievance, Appeal or
      Medicaid Fair Hearing, how to report suspected Fraud and Abuse, procedures
      for
      obtaining required Behavioral Health Services, including any additional Health
      Plan phone numbers to be used for obtaining services, and all other requirements
      and Benefits of the Health Plan. 

    

    c. The
      Health Plan shall have the capability to answer Enrollee inquiries via written
      materials, telephone, electronic transmission, and face-to-face
      communication.

    

    d. Mailing
      envelopes for Enrollee materials shall contain a request for address correction.
      For Enrollees whose Enrollee Materials are returned to the Health Plan as
      undeliverable, the Health Plan shall use and maintain in a file a record of
      all
      of the following methods to contact the Enrollee: 

    

    
      	 	
              (1)

            	
              Telephone
                contact at the telephone number obtained from the local telephone
                directory, directory assistance, city directory, or other
                directory.

            

    

    

    
      	 	
              (2)

            	
              Telephone
                contact with DCF and Families Economic Self-Sufficiency Services
                Office
                staff to determine if they have updated address information and telephone
                number.

            

    

    

    
      	 	
              (3)

            	
              Routine
                checks (at least once a month for the first three (3) months of
                Enrollment) on services or claims authorized or denied by the Health
                Plan
                to determine if the Enrollee has received services, and to locate
                updated
                address and telephone number
                information.

            

    

    

    e. New
      Enrollee materials are not required for a former Enrollee who was disenrolled
      because of the loss of Medicaid eligibility and who regains his/her eligibility
      within 180 days and is automatically reinstated as a Health Plan Enrollee.
      In
      addition, unless requested by the Enrollee, new Enrollee materials are not
      required for a former Enrollee subject to Open Enrollment who was disenrolled
      because of the loss of Medicaid eligibility, who regains his/her eligibility
      within 6 months of his/her managed care enrollment, and is reinstated as a
      Health Plan Enrollee. A notation of the effective date of the reinstatement
      is
      to be made on the most recent application or conspicuously identified in the
      Enrollee's administrative file. Enrollees, who were previously enrolled in
      a
      Health Plan, lose and regain eligibility after 180 days, will be treated as
      new
      Enrollees.

    

    f. The
      Health Plan shall notify, in writing, each person who is to be reinstated,
      of
      the effective date of the reinstatement and the assigned primary care physician.
      The notifications shall distinguish between Enrollees subject to Open Enrollment
      and Enrollees not subject to Open Enrollment and shall include information
      regarding change procedures for cause, or general Health Plan change procedures
      through the Agency’s toll-free Choice Counselor/Enrollment Broker telephone
      number as appropriate. The notification shall also instruct the Enrollee to
      contact the Health Plan if a new Enrollee card and/or a new Enrollee handbook
      are needed. The Health Plan shall provide such notice to each affected Enrollee
      by the first (1st) Calendar Day of the month following the Health Plan’s receipt
      of the notice of reinstatement.

    

    
      	2.  	
              Requirements
                for Written Materials

            

    

    

    a. The
      Health Plan shall make all written materials available in alternative formats
      and in a manner that takes into consideration the Enrollee's special needs,
      including those who are visually impaired or have limited reading proficiency.
      The Health Plan shall notify all Enrollees and Potential Enrollees that
      information is available in alternative formats and how to access those
      formats.

    

    b. The
      Health Plan shall make all written material available in English, Spanish,
      and
      all other appropriate foreign languages. The appropriate foreign languages
      comprise all languages in the Health Plan Service Area spoken by approximately
      five percent (5%) or more of the total population. The Health Plan shall
      provide, free of charge, interpreters for Potential Enrollees or Enrollees
      whose
      primary language is a foreign language.

    

    c. The
      Health Plan shall provide Enrollee information in accordance with 42 CFR 438.10,
      which
      addresses information requirements related to written and oral information
      provided to Enrollees, including: languages; format; Health Plan features,
      such
      as benefits, cost sharing, service area, Provider network, and physician
      incentive plans; Enrollment and Disenrollment rights and responsibilities;
      Grievance Systems; and Advance Directives.
      The
      Health Plan shall notify Enrollees on at least an annual basis of their right
      to
      request and obtain information in accordance with the above
      regulations.

    

    d. All
      written materials shall be at or near the fourth (4th) grade comprehension
      level. Suggested reference materials to determine whether the Health Plan’s
      written materials meet this requirement are:

    

    
      	 	
              (1)

            	
              Fry
                Readability Index;

            

    

    

    
      	 	
              (2)

            	
              PROSE
                The Readability Analyst (software developed by Education Activities,
                Inc.);

            

    

    

    
      	 	
              (3)

            	
              Gunning
                FOG Index;

            

    

    

    
      	 	
              (4)

            	
              McLaughlin
                SMOG Index;

            

    

    

    
      	 	
              (5)

            	
              The
                Flesch-Kincaid Index; or

            

    

    

    
      	 	
              (6)

            	
              Other
                software approved by the Agency.

            

    

    

    e. The
      Health Plan shall provide written notice to the Agency of any changes to any
      written materials provided to Enrollees. Written materials shall be provided
      to
      the Agency at least forty-five (45) Calendar Days prior to the effective date
      of
      the change. Written notice of such changes shall be provided to Enrollees at
      least thirty (30) days prior to the effective date of the change.

    

    f. All
      written materials, including any materials for the Health Plan Web site, shall
      be submitted to the Agency for approval prior to being distributed.

    

    
      	3.  	
              New
                Enrollee Materials 

            

    

    

    Immediately
      upon the assigned Enrollees Enrollment, the Health Plan shall mail to the new
      Enrollee: the Enrollee Handbook; the Provider Directory; the Enrollee
      Identification; and the following additional materials:

    

    a. A
      request
      for the following information to be updated: Enrollee’s name, address (home and
      mailing), county of residence, and telephone number; 

    

    b. A
      completed, signed and dated release form authorizing the Health Plan to release
      medical information to the federal and State governments or their duly appointed
      agents; and, current behavioral health care provider information;

    

    c. A
      notice
      that Enrollees who lose eligibility and are disenrolled shall be automatically
      re-Enrolled in the Health Plan if eligibility is regained within 180
      days;

    

    d. Each
      mailing shall include a postage paid, pre-addressed return envelope; and

    

    e. The
      initial mailing may be combined with the PCP assignment notification. Each
      mailing shall be documented in the Health Plan’s records.

    

    
      	4.  	
              Enrollee
                Handbook Requirements 

            

    

    

    a. The
      Enrollee services handbook shall include the following information:

    

    
      	 	
              (1)

            	
              Table
                of Contents;

            

    

    

    
      	 	
              (2)

            	
              Terms
                and conditions of Enrollment including the reinstatement process;
                

            

    

    

    
      	 	
              (3)

            	
              Description
                of the Open Enrollment process;

            

    

    

    
      	 	
              (4)

            	
              Description
                of services provided, including limitations and general restrictions
                on
                Provider access, exclusions and out-of-network use;
                

            

    

    

    
      	 	
              (5)

            	
              Procedures
                for obtaining required services, including second opinions, and
                authorization requirements, including those services available without
                Prior Authorization; 

            

    

    

    
      	 	
              (6)

            	
              Toll-free
                telephone number of the appropriate Area Medicaid Office;
                

            

    

    

    
      	 	
              (7)

            	
              Emergency
                Services and procedures for obtaining services both in and out of
                the
                Health Plan’s Service Area, including explanation that Prior Authorization
                is not required for Emergency Services, the locations of any emergency
                settings and other locations at which Providers and Hospitals furnish
                Emergency Services and Post-Stabilization Care Services, and use
                of the
                911-telephone system or its
                equivalent;

            

    

    

    
      	 	
              (8)

            	
              The
                extent to which, and how, after-hours and emergency coverage is provided,
                and that the Enrollee has a right to use any Hospital or other setting
                for
                Emergency Care;

            

    

    

    
      	 	
              (9)

            	
              Procedures
                for Enrollment, including Enrollee rights and protections;
                

            

    

    

    (10) A
      notice
      advising Enrollees how to change PCPs; 

    

    (11) Grievance
      System components and procedures; 

    

    (12) Enrollee
      rights and procedures for Disenrollment, including the toll-free telephone
      number for the Agency’s contracted Choice Counselor/Enrollment Broker;

    

    (13) Procedures
      for filing a request for Disenrollment for Cause; 

    

    (14) Information
      regarding newborn enrollment, including the mother’s responsibility to notify
      the Health Plan and the mother’s DCF case worker of the newborn’s birth and
      selection of a PCP; 

    

    (15) Enrollee
      rights and responsibilities, including the extent to which, and how, Enrollees
      may obtain services from out-of-network providers and the right to obtain family
      planning services from any participating Medicaid provider without Prior
      Authorization for such services, and other provisions in accordance with 42
      CFR
      438.100; 

    

    (16) Information
      on emergency transportation and non-emergency transportation, counseling and
      referral services available under the Health Plan; and how to access these
      services; 

    

    (17) Information
      that interpretation services and alternative communication systems are
      available, free of charge, for all foreign languages, and how to access these
      services; 

    

    (18) Information
      that Post-Stabilization Services are provided without Prior Authorization and
      other Post-Stabilization Care Services rules set forth in 42 CFR 422.113(c);
      

    

    (19) Information
      that services will continue upon appeal of a suspended authorization and that
      the Enrollee may have to pay in case of an adverse ruling; 

    

    (20) Information
      regarding health care Advance Directives pursuant to Chapter 765, F.S., and
      42
      CFR 422.128; 

    

    (21) Cost
      sharing for the Enrollee, if any; 

    

    (22) Instructions
      explaining how Enrollees may obtain information from the Health Plan regarding
      quality performance indicators, including beneficiary information; 

    

    (23) How
      and
      where to access any benefits that are available under the Medicaid State Plan
      but are not covered under the Contract, including any cost sharing;

    

    (24) Any
      restrictions on the Enrollee's freedom of choice among network Providers;

    

    (25) A
      release
      document for each Enrollee authorizing the Health Plan to release medical
      information to the federal and State governments or their duly appointed
      Agents.

    

    (26) A
      notice
      that clearly states that the Enrollee may select an alternative behavioral
      health case manager or direct service provider within the Health Plan, if one
      is
      available;

    

    (27) A
      description of Behavioral Health Services provided, including limitations,
      exclusions and out-of-network use;

    

    (28) An
      explanation that Enrollees may choose to have all family members served by
      the
      same PCP or they may choose different PCPs based on each Enrollee’s
      needs

    

    (29) A
      description of Emergency Behavioral Health Services procedures both in and
      out
      of the Health Plan's Service Area; 

    

    (30) Information
      to assist the Enrollee in assessing a potential behavioral health
      problem;

    

    (31)
      Procedures for reporting fraud, abuse and overpayment; and

    

    (32) Information
      regarding HIPAA relative to the Enrollee’s personal health information (PHI).

    

    b. For
      a
      counseling or referral service that the Health Plan does not cover because
      of
      moral or religious objections, the Health Plan need not furnish information
      on
      how and where to obtain the service. 

    

    c. Written
      information regarding Advance Directives provided by the Health Plan must
      reflect changes in State law as soon as possible, but no later than ninety
      (90)
      days after the effective date of the change.

    

    d. The
      Health Plan, in its Enrollee handbook and provider manual, shall clearly specify
      required procedural steps in the Grievance process, including the address,
      telephone number and office hours of the Grievance staff. The Health Plan shall
      specify phone numbers for a grievant to call to present a Grievance or to
      contact the Grievance staff. Each phone number shall be toll-free within the
      grievant’s geographic area and provide reasonable access to the Health Plan
      without undue delays. The Grievance System must provide an adequate number
      of
      phone lines to handle incoming Grievances and Appeals.

    

    e. The
      Health Plan shall make information available upon request regarding the
      structure and operation of the health plan and any physician incentive plans,
      as
      set forth in 42 CFR 438.10(g)(3).

    

    
      	5.  	
              Provider
                Directory

            

    

    

    a. The
      Health Plan shall mail a Provider Directory to all new Enrollees, including
      Enrollees re-Enrolled after an Open Enrollment period. This Provider Directory
      shall be the most current printed Directory with an addendum providing the
      most
      up to date Provider information. The Health Plan shall update and re-print
      the
      Provider Directory at least annually. The Provider Directory shall include
      names, locations, office hours, telephone numbers of, and non-English languages
      spoken by, current Health Plan Providers. This includes at a minimum,
      information on PCPs, specialists, pharmacies, hospitals, certified nurse
      midwives and licenses midwives, and Ancillary Providers. The Provider Directory
      shall also identify Providers that are not accepting new patients.

    

    b. The
      Health Plan shall maintain an on-line Provider Directory. Such on-line Provider
      Directory shall be updated at least monthly. The Health Plan shall file an
      attestation to this effect with the Bureau of Managed Health Care and the Bureau
      of Health Systems Development.

    

    c. If
      the
      Health Plan elects to use a more restrictive pharmacy network than the network
      available to Medicaid Recipients enrolled in the non-Medicaid Reform FFS
      program, then the directory shall include the names of the pharmacies. If all
      pharmacies that are part of a chain and are within the Health Plan's Service
      Area are under contract with the Health Plan, the Provider Directory need only
      list the chain name.

    

    d. In
      accordance with section 1932(b)(3) of the Social Security Act, the Provider
      Directory shall include an advisement that some Providers may not perform
      certain services based on religious or moral beliefs.

    

    e. Lists
      of
      Providers shall be arranged alphabetically, showing the Provider's name and
      specialty, and separately, by specialty, in alphabetical order.

    

    f. List
      of
      the Health Plan's behavioral health service centers, including city and
      county.

    

    
      	6.  	
              Enrollee
                ID Card

            

    

    

    a. Immediately
      upon the Enrollee’s enrollment with the Health Plan, the Health Plan shall mail,
      via Surface Mail, an Enrollee Identification (ID) Card. The Enrollee ID Card
      shall include, at a minimum:

    

    
      	 	
              (1)

            	
              The
                Enrollee's name and Medicaid ID
                number;

            

    

    

    (2) The
      Health Plan's name, address and Enrollee services number;  and

    

    
      	 	
              (3)

            	
              A
                telephone number that a non-contracted provider may call for billing
                information.

            

    

    

    
      	7.  	
              Toll-free
                Help Line

            

    

    

    a. The
      Health Plan shall operate a toll-free telephone help line. Such help line shall
      respond to all areas of Enrollee inquiry.

    

    b. If
      the
      Health Plan has authorization requirements for prescribed drug services and
      is
      subject to the Hernandez Settlement Agreement (HSA), the Health Plan may allow
      the telephone help line staff to act as Hernandez Ombudsman, pursuant to the
      terms of the HSA, so long as the Health Plan maintains a Hernandez Ombudsman
      Log. The Health Plan may maintain the Hernandez Ombudsman Log as part of the
      Health Plan’s telephone help line log, so long as the Health Plan can access the
      Hernandez Ombudsman Log information separately for reporting purposes. The
      log
      shall contain information as described in Section V.D.14, Prescribed Drug
      Services, of this Contract.

    

    b. The
      Health Plan shall have telephone call policies and procedures that shall include
      requirements for staffing, personnel, hours of operation, call response times,
      maximum hold times, and maximum abandonment rates, monitoring of calls via
      recording or other means, and compliance with standards. 

    

    c. The
      telephone helpline shall handle calls from non-English speaking Enrollees,
      as
      well as calls from Enrollees who are hearing impaired.

    

    d. The
      telephone help line shall be fully staffed between the hours of 8:00 a.m. and
      7:00 p.m., EDT or EST, as appropriate, Monday through Friday, excluding State
      holidays. The telephone help line staff shall be trained to respond to Enrollee
      questions in all areas, including but not limited to, Covered Services, the
      Provider network, and non-emergency transportation. 

    

    e. The
      Health Plan shall develop performance standards and monitor telephone help
      line
      performance by recording calls and employing other monitoring activities. Such
      standards shall be submitted and approved by the Agency. At a minimum, the
      standards shall require that, measured on a monthly basis: 

    

    
      	 	
              (1)

            	
              One
                hundred percent (100%) of all calls are answered within four (4)
                rings
                (these calls may be placed in a
                queue);

            

    

    

    
      	 	
              (2)

            	
              The
                wait time in the queue shall not exceed three (3)
                minutes;

            

    

    

    
      	 	
              (3)

            	
              The
                Blocked Call rate does not exceed one percent (1%); and
                

            

    

    

    
      	 	
              (4)

            	
              The
                rate of Abandoned Calls does not exceed five percent (5%).
                

            

    

    

    f. The
      Health Plan shall have an automated system available between the hours of 7:00
      p.m. and 8:00 a.m., EDT or EST, as appropriate, Monday through Friday and at
      all
      hours on weekend and holidays. This automated system must provide callers with
      operating instructions on what to do in case of an emergency and shall include,
      at a minimum, a voice mailbox for callers to leave messages. The Health Plan
      shall ensure that the voice mailbox has adequate capacity to receive all
      messages. A Health Plan Representative shall return messages on the next
      Business Day.

    

    
      	8.  	
              Cultural
                Competency

            

    

    

    a. In
      accordance with 42 CFR 438.206, the Health Plan shall have a comprehensive
      written Cultural Competency Plan describing how the Health Plan will ensure
      that
      services are provided in a culturally competent manner to all Enrollees,
      including those with limited English proficiency. The Cultural Competency Plan
      must describe how the Providers, Health Plan employees, and systems will
      effectively provide services to people of all cultures, races, ethnic
      backgrounds, and religions in a manner that recognizes values, affirms, and
      respects the worth of the individual Enrollees and protects and preserves the
      dignity of each.

    

    b. The
      Health Plan may distribute a summary of the Cultural Competency Plan to network
      Providers if the summary includes information on how the Provider may access
      the
      full Cultural Competency Plan on the Web site. This summary shall also detail
      how the Provider can request a hard-copy from the Health Plan at no charge
      to
      the Provider.

    

    
      	9.  	
              Translation
                Services

            

    

    

    The
      Health Plan is required to provide oral translation services of information
      to
      any Enrollee who speaks any non-English language regardless of whether an
      Enrollee speaks a language that meets the threshold of a prevalent non-English
      language. The Health Plan is required to notify its Enrollees of the
      availability of oral interpretation services and to inform them of how to access
      oral interpretation services. Oral interpretation services are required for
      all
      Health Plan information provided to Enrollees and includes notices of Action.
      There shall be no charge to the Enrollee for translation services.

    

    
      	B.	
              Marketing

            

    

    

    
      	1.  	
              General
                Provisions

            

    

    

    a. For
      each
      new Contract period, the Health Plan shall submit to the Agency for written
      approval, pursuant to section 409.912, F.S., its Marketing plan and all
      Marketing and pre-Enrollment materials no later than sixty (60) Calendar Days
      prior to Contract renewal, and for any changes in Marketing and pre-Enrollment
      materials during the re-contracting and renewal period, no later than sixty
      (60)
      Calendar Days prior to implementation. The Marketing materials shall be
      distributed in the Health Plan’s entire Service Area in accordance with 42 CFR
      438.104.

    

    b. Marketing
      materials include, but are not limited to, all solicitation materials, forms,
      brochures, fact sheets, posters, lectures, ad copy for radio or television,
      Medicaid recruitment materials and presentations, Request for Benefit
      Information forms (previously known as pre-enrollment applications),
      etc.

    

    c. To
      announce a specific event, the Health Plan shall submit a request to market
      pursuant to Section IV.B.4, Approval Process, of this Contract, and shall
      include the announcement of the event that will be given out to the
      public.

    

    d. The
      Health Plan shall be responsible for developing and implementing a written
      plan
      designed to solicit Enrollment from Potential Enrollees and to control the
      actions of its Marketing staff. All of the Marketing policies set forth in
      this
      Contract apply to staff, Subcontractors, Health Plan volunteers and all persons
      acting for or on behalf of the Health Plan. All materials developed shall be
      governed by the requirements set forth in this Section. Additionally, the Health
      Plan is vicariously liable for any Marketing violations of its employees, agents
      or Subcontractors.

    

    e. The
      Health Plan shall limit its Market Area to residents of the Service Area and
      shall not market to residents of a Service Area not approved by the
      Agency.

    

    
      	2.  	
              Prohibited
                Activities

            

    

    

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

    

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

    

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

    

    c. Overly
      aggressive solicitation, such as repeated telephoning, continued recruitment
      after an offer for Enrollment is declined by a Medicaid Recipient, or similar
      techniques. Health Plan representatives shall not directly solicit Potential
      Enrollees for the purpose of enrolling in the Health Plan except as provided
      in
      Section IV.B.3., Permitted Activities. 

    

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

    

    
      	 	
              (1)

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

            

    

    

    
      	 	
              (2)

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

            

    

    

    
      	 	
              (3)

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

            

    

    

    
      	 	
              (4)

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

            

    

    

    
      	 	
              (5)

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

            

    

    

    e. In
      accordance with section 409.912, F.S., granting or offering of any monetary
      or
      other valuable consideration for Enrollment, except as authorized by section
      409.912, F.S.

    

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

    

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

    

    h. Offers
      of
      material or financial gain to any persons soliciting, referring or otherwise
      facilitating Medicaid Recipient Enrollment, except for authorized licensed
      Marketing Representatives. The Health Plan shall ensure that only licensed
      Marketing Representatives market the Health Plan to Medicaid
      Recipients.

    

    i. Giving
      away promotional items in excess of $1.00 retail value to attract attention.
      Items to be given away shall bear the Health Plan's name and shall only be
      given
      away at Health Fairs or other general Public Events. In addition, such
      promotional items must be offered to the general public and shall not be limited
      to Medicaid Recipients who indicate they will enroll in the Health
      Plan.

    

    j. In
      accordance with section 409.912, F.S., Marketing to Medicaid Recipients in
      State
      offices unless approved in writing and approved by the affected State Agency
      when solicitation occurs in the office of another State Agency. The Agency
      shall
      ensure that Marketing Representatives stationed in State offices market to
      Medicaid Recipients only in designated areas and in such a way as to not
      interfere with the Medicaid Recipients' activities in the State office. The
      Health Plan shall not use any other State facility, program, or procedure in
      the
      recruitment of Medicaid Recipients except as authorized in writing by the
      Agency. Request for approval of activities at State offices must be submitted
      to
      the Agency at least thirty (30) Calendar Days prior to the
      activity.

    

    k. Marketing
      face-to-face to assigned Enrollees or Medicaid Recipients unless the Enrollee
      or
      Recipient contacts the Health Plan and requests information. Upon such request
      the Health Plan shall notify the Choice Counselor/Enrollment Broker of such
      request, and the Health Plan shall keep documentation of such contacts and
      visits in the Enrollee’s file. 

    

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

    

    m. The
      Health Plan shall not market, prior to the Enrollment, the incentives that
      shall
      be offered to the Enrollee as described in Section VIII.B.7., Incentive
      Programs. Marketing may describe the programs (not the incentives) that shall
      be
      offered (e.g., prenatal classes). The Health Plan may inform Enrollees once
      they
      are actually enrolled in the Health Plan about the specific incentives
      available.

    

    n. All
      activities included in section 641.3903, F.S. 

    

    
      	3.  	
              Permitted
                Activities

            

    

    

    The
      Health Plan may engage in the following activities under the supervision and
      with the written approval of the Agency: 

    

    a. The
      Health Plan upon written approval of the Agency, may have a marketer in Provider
      offices as long as the Provider approves and the marketer provides information
      to the Potential Enrollee only upon request. In addition, the Health Plan and
      the Provider shall not require the Potential Enrollee to visit the marketer,
      nor
      shall the marketer approach the Potential Enrollee. No Sales Activities shall
      be
      allowed in Provider offices. 

    

    b. The
      Health Plan may leave Request for Benefit Information (RBI) cards (as described
      in Section V, B.7) in Provider offices, at Public Events and Health Fairs.
      These
      cards may be completed by Potential Enrollees and delivered to the Health Plan
      or turned in at the Provider office. Information on the card is limited to
      name,
      address and telephone number of the Potential Enrollee and space for signature.
      A space to note a contact time may be provided. A follow up visit to the
      Potential Enrollee’s home may not occur prior to the referral being logged by
      the Health Plan’s regional or headquarters Enrollee services office. Twenty-four
      (24) hours or the next Business Day shall elapse after the request is logged
      before the home visit may occur.

    

    c. The
      Health Plan may market at State offices, Health Fairs and Public Events and
      contact thereafter, in person, Potential Enrollees who request further
      information about the Health Plan, in accordance with section 4707 of the BBA.
      The Health Plan shall submit, for review and approval by the Agency, its intent
      to market at Health Fairs and Public Events at least two (2) weeks prior to
      the
      event. The Health Plan shall obtain complete disclosure of information, in
      a
      format to be approved by the Agency, from each organization participating in
      a
      Health Fair or Public Event prior to the event. The information disclosure
      is
      only required when the Health Plan is the primary organizer of the Health Fair
      or Public Event. If the Health Plan has been invited by a community organization
      to be a sponsor of an event, the Health Plan shall provide the Agency with
      a
      copy of the invitation in lieu of the information disclosure. All disclosure
      information shall be sent to the Agency with the Health Plan’s request for
      approval of the event.

    

    d. The
      main
      purpose of a Health Fair or a Public Event shall not be Medicaid Health Plan
      marketing, but Medicaid Health Plan marketing may be provided at these events,
      subject to Agency rules and oversight.

    

    e. Upon
      the
      effective date of Enrollment, Health Plan marketing staff or other Health Plan
      staff may visit Enrollees in order to obtain completed new Enrollee materials.
      All such visits must be documented in the Enrollee's file.

    

    f. The
      Health Plan may leave Agency approved written materials (brochures or posters,
      etc) in Provider Offices, at Public Events, and at Health Fairs.

    

    g. Marketing
      face-to-face to Potential Enrollees may be allowed if the Potential Enrollee
      contacts the Health Plan’s headquarters or regional Enrollee services office
      directly to request a home visit. The Health Plan shall not allow the visit
      to
      the Potential Enrollee’s home to occur before the next Business Day or
      twenty-four (24) hours have elapsed since the request for the visit. The Health
      Plan must be able to provide evidence to the Agency that the twenty-four (24)
      hour or next Business Day requirement has been met. The Health Plan will be
      required, upon request by the Agency, to provide a log that shows how initial
      contact with the Potential Enrollee was made. Only Agency registered Marketing
      Representatives shall be allowed to make home visits. Each Health Plan shall
      make available to the Agency, as requested, a report of the number of home
      visits made by each Agency registered Marketing Representative to Potential
      Enrollee’s homes.

    

    
      	4.  	
              Approval
                Process

            

    

    

    a. The
      Health Plan shall submit a detailed description of its Marketing plan and copies
      of all Marketing materials, the Health Plan or its Subcontractors plan to
      distribute, to the Agency for prior approval. This requirement includes, but
      is
      not limited to: posters, brochures, Web sites, and any materials that contain
      statements regarding the Benefit package and Provider network-related materials.
      Neither the Health Plan nor its Subcontractors shall distribute any Marketing
      materials without prior approval from the Agency.

    

    b. Health
      Fairs and Public Events shall be approved or denied by the Agency using the
      following process:

    

    
      	 	
              (1)

            	
              A
                Health Plan shall submit its bi-monthly Marketing schedule to the
                Agency,
                two (2) weeks in advance of each month. The Marketing Schedule may
                be
                revised if a Health Plan provides notice to the Agency one (1) week
                prior
                to the Public Event or the Health Fair. The Agency may expedite this
                process as needed.

            

    

    

    
      	 	
              (2)

            	
              The
                Agency will approve or deny the Health Plan's bi-monthly Marketing
                schedule and revision request no later than five (5) Business Days
                from
                receipt of the schedule and/or revision request.
                

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall use the standard Agency format. Such format will
                include
                minimum requirements for necessary information. The Agency will explain
                in
                writing what is sufficient information for each
                requirement.

            

    

    

    
      	 	
              (4)

            	
              The
                Agency will establish a statewide log to track the approval and
                disapproval of Health Fairs and Public
                Events.

            

    

    

    
      	 	
              (5)

            	
              The
                Agency may provide verbal approvals or disapprovals to meet the five
                (5)
                Business Day requirement, but the Agency will follow up in writing
                with
                specific reasons for disapprovals within five (5) Business Days of
                verbal
                disapprovals.

            

    

    

    

    

    
      	5.  	
              Provider
                Compliance

            

    

    

    The
      Health Plan shall ensure its health care Providers comply with the following
      Marketing requirements:

    

    a. Health
      care Providers may give out Health Plan brochures at Health Fairs or in their
      own offices comparing the Benefits of different Health Plans with which they
      contract. However, they cannot orally compare Benefits among Health Plans,
      unless Marketing Representatives from each Health Plan are present.

    

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

    

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

    

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

    

    
      	6.  	
              Marketing
                Representatives

            

    

    

    a. The
      Health Plan shall not Subcontract with any brokerage firm or independent agent
      for purposes of Marketing.

    

    b. The
      Health Plan shall be required to register each Marketing Representative with
      the
      Agency. The registration shall consist of providing the Agency with the
      representative's name; address; telephone number; cellular telephone number;
      DFS
      license number; the names of all Medicaid Health Plans with which the Marketing
      Representative was previously employed; and the name of the Medicaid Health
      Plan
      with which the Marketing Representative is presently employed. 

    

    c. The
      Health Plan shall provide the Agency, on a monthly basis, information on
      terminations of all Marketing Representatives. The Health Plan shall maintain
      and make available to the Agency upon request evidence of current licensure
      and
      contractual agreements with all Marketing Representatives used by the Health
      Plan to recruit Medicaid Recipients. 

    

    d. The
      Health Plan shall report to DFS and the Agency any Marketing Representative
      who
      violates any requirements of this Contract, within fifteen (15) Calendar Days
      of
      knowledge of such violation.

    

    e. While
      Marketing, Marketing Representatives shall wear picture identification that
      includes their DFS license number and identifies the Health Plan
      represented.

    

    f. The
      Marketing Representative shall inform the Medicaid Recipient that the
      Representative is not an employee of the State and is not a Choice Counseling
      Specialist, but is a Representative of the Health Plan.

    

    g. The
      Health Plan shall not pay commission compensation, or shall recoup commissions
      paid, to Marketing Representatives for new Enrollees whose voluntary
      Disenrollment is effective within the first (1st) three (3) months of their
      initial Enrollment, unless the Disenrollment is due to the Enrollee moving
      out
      of the county in which the Health Plan has been authorized to operate. In
      addition, the Health Plan shall not pay commission compensation, or shall recoup
      commission paid, to Marketing Representatives for excluded Medicaid Recipients,
      per Section III.A.3, Excluded Populations, who were enrolled in error. A
      Marketing Representative's total monthly commission cannot exceed forty percent
      (40%) of the Marketing Representative's total monthly compensation, excluding
      benefits.

    

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

    

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

    

    
      	7.  	
              Request
                for Benefit Information (RBI)
                Activities

            

    

    

    a. The
      Health Plan shall refer Potential Enrollees interested in enrolling in the
      Health Plan to the Choice Counselor/Enrollment Broker.

    

    b. In
      accordance with section 409.912, F.S., and Agency guidelines, and upon approval
      of the Agency, the Health Plan may assist Potential Enrollees in obtaining
      information through the completion of a RBI, previously known as a
      pre-Enrollment application for information.

    

    c. RBIs
      may
      be for an individual or for a family. No health status information may be asked
      on the RBI. Each RBI shall include an option for the Potential Enrollee to
      request information about all Health Plan choices and shall include the name
      of
      the Choice Counselor/Enrollment Broker Help Line. All RBIs shall contain at
      least the following information for each Potential Enrollee

    

    
      	 	
              (1)

            	
              Name;

            

    

    
      	 	
              (2)

            	
              Address
                (home and mailing);

            

    

    
      	 	
              (3)

            	
              County
                of residence; 

            

    

    
      	 	
              (4)

            	
              Telephone
                number;

            

    

    
      	 	
              (5)

            	
              Date
                of Application;

            

    

    
      	 	
              (6)

            	
              Applicant’s
                signature or signature of parent or guardian;
                and,

            

    

    
      	 	
              (7)

            	
              Marketing
                Representative’s signature and DFS license
                number.

            

    

    

    d. At
      the
      time of completion of the RBI, the Health Plan shall furnish the Potential
      Enrollee with a copy of the completed RBI.

    

    e. The
      Health Plan shall accept RBIs only from Potential Enrollees who reside within
      the authorized Service Area. In addition, the Health Plan shall use the Provider
      number associated with the county in which the Potential Enrollee
      resides.

    

    f. If
      the
      Voluntary Potential Enrollee is recognized to be in foster care by the Health
      Plan, and is dependent, prior to Enrollment, the Health Plan must receive
      written authorization from (1) a parent, (2) a legal guardian, or (3) DCF or
      DCF’s delegate. If a parent is unavailable, the Health Plan shall obtain
      authorization from DCF. The RBI shall include information that the Potential
      Enrollee is in foster care.

    

    g. The
      Health Plan shall provide a reasonable written explanation of the Health Plan
      Benefits to the Potential Enrollee prior to accepting the RBI. The Health Plan
      shall explain to all Potential Enrollees that the family may choose to have
      all
      members served by the same PCP or they may choose different PCPs based on each
      Enrollee’s needs. The information must comply with 42 CFR 438.10.

    

    h. Upon
      completion of the RBI and all pre-Enrollment Marketing to Potential Enrollees,
      the Health Plan shall submit the RBI to the Choice Counselor/Enrollment Broker
      for further education and counseling and verification that the Potential
      Enrollee made an informed, voluntary choice, free from duress. 

    

    

    

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    Section
      V

    Covered
      Services 

    

    
      	A.	
              Covered
                Services

            

    

    1. The
      Health Plan shall ensure the provision of services in sufficient amount,
      duration and scope to be reasonably expected to achieve the purpose for which
      the services are furnished and shall ensure the provision of the following
      covered services as defined and specified in this Contract. The Health Plan
      may
      implement appropriate utilization management techniques and procedures, as
      established in this Contract and the Health Plans approved policies and
      procedures manuals.

    

    2. The
      Health Plan’s policies and procedures manuals shall be prior approved by the
      Agency and shall incorporate provider, service and product standards specified
      in the Agency’s Medicaid Services Coverage and Limitations Handbooks, as
      appropriate, and this Contract.

    

    3. The
      Health Plan must require out-of-network providers to coordinate with respect
      to
      payment and must ensure that cost to the beneficiary is no greater than it
      would
      be if the covered services were furnished within the network. 

    

    4. The
      Health Plan may submit a Customized Benefit Package (CBP), which may vary the
      co-pays or the amount, duration and scope of the following services for
      non-pregnant adults: hospital outpatient not otherwise specified (NOS), home
      health, dental, pharmacy, chiropractic, podiatry, vision, durable medical
      equipment and physical therapy services as specified below. 

    

    
      	 	
              a.

            	
              Amount,
                duration and scope may vary for durable medical supplies (DME) with
                the
                exception of any prosthetic/orthotic supply priced over $3,000 on
                the
                Medicaid fee schedule and except for motorized wheelchairs, which
                must be
                covered up to the State Plan limit.

            

    

    

    
      	 	
              b.

            	
              Dialysis
                services, contraceptives, and chemotherapy-related medical and
                pharmaceutical services must be covered up to the State Plan limit.
                

            

    

    

    
      	 	
              c.

            	
              Hearing
                services for non-pregnant adults may vary amount, duration and scope
                except for hearing aid services, which must be covered up to the
                State
                Plan limit. 

            

    

    

    
      	 	
              d.

            	
              The
                CBP must meet the Agency’s actuarial equivalency and sufficiency standards
                for the population or populations which will be covered by the CBP.
                

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall submit its CBP to the Agency for recertification
                of
                actuarial equivalency and sufficiency standards on an annual basis.
                

            

    

    

    5. The
      Health Plan shall provide all medically necessary services in accordance with
      Medicaid Handbook requirements for pregnant women, Children/Adolescents, and
      Enrollees with a HIV/AIDS diagnoses as identified by the Agency.

    

    

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    6. The
      Health Plan shall ensure the provision of the services listed below.

    

    
      	
              Health
                Plan Covered Service Chart

            
	
              Advanced
                Registered Nurse Practitioner Services

            
	
              Ambulatory
                Surgical Centers

            
	
              Birth
                Center Services

            
	
              Child
                Health Check-Up Services

            
	
              Chiropractic
                Services

            
	
              Community
                Mental Health Services

            
	
              County
                Health Department Services

            
	
              Dental
                Services 

            
	
              Durable
                Medical Equipment and Medical Supplies

            
	
              Dialysis
                Services

            
	
              Emergency
                Room Services

            
	
              Family
                Planning Services 

            
	
              Federally
                Qualified Health Center Services 

            
	
              Freestanding
                Dialysis Centers

            
	
              Hearing
                Services 

            
	
              Home
                Health Care Services

            
	
              Hospital
                Services - Inpatient

            
	
              Hospital
                Services - Outpatient 

            
	
              Immunizations

            
	
              Independent
                Laboratory Services 

            
	
              Licensed
                Midwife Services

            
	
              Optometric
                Services 

            
	
              Physician
                Services 

            
	
              Physician
                Assistant Services

            
	
              Podiatry
                Services

            
	
              Portable
                X-ray Services

            
	
              Prescribed
                Drugs

            
	
              Primary
                Care Case Management Services

            
	
              Rural
                Health Clinic Services

            
	
              Targeted
                Case Management

            
	
              Therapy
                Services: Occupational 

            
	
              Therapy
                Services: Physical 

            
	
              Therapy
                Services: Respiratory 

            
	
              Therapy
                Services: Speech 

            
	
              Transplant
                Services 

            
	
              Transportation
                Services

            
	
              Vision
                Services

            

    

     

     

    
      	B.	
              Expanded
                Services

            

    

    

    Expanded
      services are those services offered by the Health Plan as specified in
      Attachment I of this contract and approved in writing by the Agency. These
      services are in excess of the amount, duration and scope of those services
      listed in Section V. Covered Services and Section VI. Behavioral Health Care.
      Such services may include, but are not limited to:

    

    
      	 	
              1.

            	
              Expanded
                Behavioral Health Services - respite care services, prevention services
                in
                the community, parental education programs, community-based therapeutic
                services for adults, and any other new and innovative interventions
                or
                services designed to improve the mental well-being of
                Enrollees.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan may offer an Agency-approved over-the-counter expanded
                drug
                benefit, not to exceed twenty-five dollars ($25.00) per household,
                per
                month. Such benefits shall be limited to nonprescription drugs containing
                a National Drug Code ("NDC") number, first aid supplies and birth
                control
                supplies. Such benefits must be offered through the Health Plan's
                pharmacy
                or the Health Plan's agreement with a pharmacy. The Health Plan shall
                make
                payments for the over-the-counter drug benefit directly to the
                pharmacy.

            

    

    

    
      	 	
              3.

            	
              Adult
                Dental Services - routine preventive services, diagnostic and restorative
                services, radiology services and discounts on dental
                services.

            

    

    

    
      	 	
              4.

            	
              Adult
                Vision Services - eye exams, eye glasses and contact
                lens.

            

    

    

    
      	 	
              5.

            	
              Adult
                Hearing Services - hearing evaluations, hearing aid devices and hearing
                aid repairs.

            

    

    

    
      	C.	
              Excluded
                Services 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan is not obligated to provide for any services not specified
                in
                this Contract. Enrollees who require services available through Medicaid
                but not specified by this Contract shall receive the services through
                the
                Medicaid Fee-for-Service reimbursement system unless those services
                have
                been limited by the Health Plan’s Agency-approved CBP. In such cases, the
                Health Plan's responsibility is limited to case management and referral.
                Therefore, the Health Plan shall determine the need for the services
                and
                refer the Enrollee to the appropriate service provider. The Health
                Plan
                may request assistance from the local Medicaid Field Office for referral
                to the appropriate service setting.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall consult the DCF office to identify appropriate
                methods
                of assessment and referral for those Enrollees requiring long-term
                care
                institutional services, institutional services for persons with
                developmental disabilities or state hospital services. The Health
                Plan is
                responsible for transition and referral of these Enrollees to appropriate
                service providers, including helping the Enrollees to obtain an attending
                physician. The Plan shall disenroll all Enrollees requiring these
                services
                in accordance with Section III.C.3.a.(3) of this
                Contract.

            

    

    

    
      	D.	
              Moral
                or Religious Objections

            

    

    

    The
      Health Plan is required to provide or arrange for all Covered Services. If,
      during the course of the Contract period, pursuant to 42 CFR 438.102, the Health
      Plan elects not to provide, reimburse for, or provide coverage of a counseling
      or referral service because of an objection on moral or religious grounds,
      the
      Health Plan shall notify:

    

    
      	 	
              1.

            	
              The
                Agency within one hundred and twenty (120) Calendar Days prior to
                adopting
                the policy with respect to any
                service.

            

    

    

    
      	 	
              2.

            	
              Enrollees
                thirty (30) Calendar Days prior to adopting the policy with respect
                to any
                service.

            

    

    

    

    
      	E.	
              Customized
                Benefit Package

            

    

    

    
      	 	
              1.

            	
              The
                Health Plans may choose to have a benefit package for non-pregnant
                adults,
                which includes all of the Covered Services described above in this
                section
                and those in Section VI, Behavioral Health Care, or may choose to
                offer a
                Customized Benefit Package (CBP).

            

    

    

    
      	 	
              2.

            	
              Should
                a Health Plan choose to offer a CBP, the Health Plan shall provide
                all of
                the Covered Services described above in this section and those in
                Section
                VI, Behavioral Health Care, to pregnant women, Children/Adolescents,
                and
                Enrollees with a HIV/AIDS diagnoses as identified by the
                Agency.

            

    

    

    
      	 	
              3.

            	
              Approved
                CBPs must comport with the Benefit Grid and the attached instructions
                found in Attachment I that have been tested for actuarial equivalency
                and
                sufficiency of benefits, before being approved by the
                Agency.

            

    

    

    
      	 	
              a.

            	
              Actuarial
                equivalency is tested by using a Benefit Plan Evaluation Model
                that:

            

    

    

    
      	 	
              (1)

            	
              Compares
                the value of the level of benefits in the proposed package to the
                value of
                the current Medicaid State Plan package for the average member of
                the
                covered population; and

            

    

    

    
      	 	
              (2)

            	
              Ensures
                that the overall level of benefits is
                appropriate.

            

    

    

    
      	 	
              b.

            	
              Sufficiency
                is tested by comparing the proposed CBP to State established standards.
                The standards are based on the covered population’s historical use of
                Medicaid State Plan services. These standards are used to ensure
                that the
                proposed CBP is adequate to cover the needs of the vast majority
                of the
                Enrollees. 

            

    

    

    
      	 	
              c.

            	
              If,
                in its CBP, the Health Plan limits a service to a maximum annual
                dollar
                value, the Health Plan must calculate the dollar value of the service
                using the Medicaid fee schedule. If the Health Plan limits pharmacy
                services to a maximum annual dollar value, pharmacy dollar values
                are
                evaluated at a pre-rebate level.

            

    

    

    
      	F.	
              Coverage
                Provisions 

            

    

    

    The
      Health Plan shall provide the following services in accordance with the
      provisions herein, and in accordance with the Florida Medicaid Coverage and
      Limitations Handbooks and the Florida Medicaid State Plan unless certified
      in a
      Customized Benefit Package in the Benefit Grid. The Health Plan shall comply
      with all State and federal laws pertaining to the provision of such
      services.

    

    
      	 	
              1.

            	
              Advance
                Directives

            

    

    

    a. In
      compliance with 42 CFR 438.6(i)(1)-(2) and 42 CFR 422.128, the Health Plan
      shall
      maintain written policies and procedures for Advance Directives, including
      mental health Advance Directives. Such Advance Directives shall be included
      in
      each Enrollee's medical record. The Health Plan shall provide these policies
      to
      all Enrollee's eighteen (18) years of age and older and shall advise Enrollees
      of:

    

    
      	 	
              (1)

            	
              Their
                rights under the law of the State of Florida, including the right
                to
                accept or refuse medical, surgical, or behavioral health treatment
                and the
                right to formulate Advance Directives;
                and

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's written policies respecting the implementation of those
                rights, including a statement of any limitation regarding the
                implementation of Advance Directives as a matter of
                conscience.

            

    

    

    b. The
      information must include a description of State law and must reflect changes
      in
      State law as soon as possible, but no later than ninety (90) Calendar Days
      after
      the effective change.

    

    c. The
      Health Plan's information must inform Enrollees that complaints may be filed
      with the State's complaint hotline.

    

    d. The
      Health Plan shall educate its staff about its policies and procedures on Advance
      Directives, situations in which Advance Directives may be of benefit to
      Enrollees, and their responsibility to educate Enrollees about this tool and
      assist them to make use of it.

    

    e. The
      Health Plan shall educate Enrollees about their ability to direct their care
      using this mechanism and shall specifically designate which staff and/or network
      Providers are responsible for providing this education.

    

    
      	 	
              2.

            	
              Child
                Health Check-Up Program (CHCUP)

            

    

    

    a. The
      Health Plan shall provide a health screening evaluation that shall consist
      of:
      comprehensive health and developmental history, including assessment of past
      medical history, developmental history and behavioral health status;
      comprehensive unclothed physical examination; developmental assessment;
      nutritional assessment; appropriate immunizations according to the appropriate
      Recommended Childhood Immunization Schedule for the United States; laboratory
      testing (including blood lead testing); health education (including anticipatory
      guidance); dental screening (including a direct referral to a dentist for
      Enrollees beginning at three (3) years of age or earlier as indicated); vision
      screening, including objective testing as required; hearing screening, including
      objective testing as required; diagnosis and treatment; and referral and
      follow-up as appropriate.

    

    b. For
      Children/Adolescents who the Health Plan identifies through blood lead
      screenings as having abnormal levels of lead, the Health Plan shall provide
      Case
      Management follow-up services as required in Chapter Two (2) of the Child Health
      Check-Up Services Coverage and Limitations Handbook. Screening for lead
      poisoning is a required component of this Contract. The Health Plan shall
      require all Providers to screen all Enrolled Children for lead poisoning at
      twelve (12) and twenty-four (24) months of age. In addition,
      Children/Adolescents between the ages of twenty-four (24) months and seventy-two
      (72) months of age must receive a screening blood lead test if there is no
      record of a previous test. The Health Plan shall provide additional diagnostic
      and treatment services determined to be Medically Necessary to a
      Child/Adolescent diagnosed with an elevated blood lead level. The Health Plan
      shall recommend, but shall not require, the use of paper filter tests as part
      of
      the lead screening requirement.

    

    c. The
      Health Plan shall inform Enrollees of all testing/screenings due in accordance
      with the periodicity schedule specified in the Medicaid Child Health Check-Up
      Services Coverage and Limitations Handbook. The Health Plan shall contact
      Enrollees to encourage them to obtain health assessment and preventative
      care.

    

    d.
       The
      Health Plan shall refer Enrollees to appropriate service Providers within six
      (6) months of the examination for further assessment and treatment of conditions
      found during the examination.

    

    e. The
      Health Plan shall offer scheduling assistance and Transportation to Enrollees
      in
      order to assist them to keep, and travel to, medical appointments.

    

    f. The
      CHCUP
      program includes the maintenance of a coordinated system to follow the Enrollee
      through the entire range of screening and treatment, as well as supplying CHCUP
      training to medical care Providers.

    

    g. The
      Health Plan shall achieve a CHCUP screening rate of at least sixty percent
      (60%)
      for those Enrollees who are continuously enrolled for at least eight (8) months
      during the Federal Fiscal Year (October 1 - September 30) in accordance with
      section 409.912, F.S. This screening compliance rate shall be based on the
      CHCUP
      screening data reported by the Health Plan and due to the Agency by January
      15
      following the end of each Federal Fiscal Year as specified in Section XII,
      Reporting, of this Contract. The data shall be monitored by the Agency for
      accuracy and, if the Health Plan does not achieve the 60 percent (60%) screening
      rate for the Federal Fiscal Year reported, the Health Plan shall file a
      corrective action plan (CAP) with the Agency no later than February 15,
      following the fiscal year reported. Any data reported by the Health Plan that
      is
      found to be inaccurate shall be disallowed by the Agency and the Agency shall
      consider such findings as being in violation of the Contract and may sanction
      the Health Plan accordingly.

    

    h. The
      Health Plan shall adopt annual screening and participation goals to achieve
      at
      least an eighty percent (80%) CHCUP screening and participation rate. For each
      Federal Fiscal Year that the Health Plan does not meet the eighty percent (80%)
      screening and participation rate, it must file a CAP with the Agency no later
      than February 15 following the Federal Fiscal Year being reported.

    

    
      	 	
              3.

            	
              Cost
                Sharing

            

    

    

    Cost-sharing
      amounts shall be delineated in the Florida State Medicaid Plan, and the Florida
      Coverage and Limitations Handbooks, as promulgated in Florida Administrative
      Code. The Health Plan may choose to eliminate cost sharing requirements as
      approved by the Agency. Attachment I outlines the approved cost sharing
      limits.

    

    

    

    
      	 	
              4.

            	
              Dental

            

    

    

    The
      Health Plan shall cover diagnostic services, preventive treatment, CHCUP dental
      screening (including a direct referral to a dentist for Enrollees beginning
      at
      three (3) years of age or earlier as indicated); restorative treatment,
      endodontic treatment, periodontal treatment, restorative treatment, surgical
      procedures and/or extractions, orthodontic treatment, complete and partial
      dentures, complete and partial denture relines and repairs, and adjunctive
      and
      emergency services for Enrollees under the age of twenty-one (21). Adult
      services include medically necessary emergency dental procedures to alleviate
      pain or infection. Emergency dental care shall be limited to emergency oral
      examinations, necessary radiographs, extractions, and incisions and drainage
      of
      abscesses. Adult dental services shall also include dentures. 

    

    
      	 	
              5.

            	
              Emergency
                Services 

            

    

    

    a. The
      Health Plan shall advise all Enrollees of the provisions governing Emergency
      Services and Care. The Health Plan shall not deny claims for Emergency Services
      and Care received at a Hospital due to lack of parental consent. In addition,
      the Health Plan shall not deny payment for treatment obtained when a
      representative of the Health Plan instructs the Enrollee to seek Emergency
      Services and Care.

    

    

    b. The
      Health Plan shall not:

    

    
      	 	
              (1)

            	
              Require
                Prior Authorization for an Enrollee to receive pre-Hospital transport
                or
                treatment or for Emergency Services and
                Care;

            

    

    

    
      	 	
              (2)

            	
              Specify
                or imply that Emergency Services and Care are covered by the Health
                Plan
                only if secured within a certain period of
                time;

            

    

    

    
      	 	
              (3)

            	
              Use
                terms such as "life threatening" or "bona fide" to qualify the kind
                of
                emergency that is covered; or

            

    

    

    
      	 	
              (4)

            	
              Deny
                payment based on a failure by the Enrollee or the Hospital to notify
                the
                Health Plan before, or within a certain period of time after, Emergency
                Services and Care were given.

            

    

    

    c. The
      Health Plan shall provide pre-Hospital and Hospital-based trauma services and
      Emergency Services and Care to Enrollees. See
      sections 395.1041, 395.4045 and 401.45, F.S.

    

    d. When
      an
      Enrollee presents himself/herself at a Hospital seeking Emergency Services
      and
      Care, the determination that an Emergency Medical Condition exists shall be
      made, for the purposes of treatment, by a physician of the Hospital or, to
      the
      extent permitted by applicable law, by other appropriate personnel under the
      supervision of a Hospital physician. See
      sections 409.9128 and 409.901, F.S 

    

    
      	 	
              (1)

            	
              The
                physician, or the appropriate personnel, shall indicate on
                the Enrollee's chart the results of all screenings, examinations
                and
                evaluations.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall compensate the provider for all screenings, evaluations
                and examinations that are reasonably calculated to assist the provider
                in
                arriving at the determination as to whether the Enrollee's condition
                is an
                Emergency Medical Condition.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall for all Emergency Services and
                Care.

            

    

    

    
      	 	
              (4)

            	
              If
                the provider determines that an Emergency Medical Condition does
                not
                exist, the Health Plan is not required to pay for services rendered
                subsequent to the provider's
                determination.

            

    

    

    e. If
      the
      provider determines that an Emergency Medical Condition exists, and the Enrollee
      notifies the Hospital or the Hospital emergency personnel otherwise have
      knowledge that the patient is an Enrollee of the Health Plan, the Hospital
      must
      make a reasonable attempt to notify the Enrollee's PCP, if known, or the Health
      Plan, if the Health Plan has previously requested in writing that said
      notification be made directly to the Health Plan, of the existence of the
      Emergency Medical Condition.

    

    f. If
      the
      Hospital, or any of its affiliated providers, do not know the Enrollee's PCP,
      or
      have been unable to contact the PCP, the Hospital must:

    

    
      	 	
              (1)

            	
              Notify
                the Health Plan as soon as possible before discharging the Enrollee
                from
                the emergency care area; or

            

    

    

    
      	 	
              (2)

            	
              Notify
                the Health Plan within twenty-four (24) hours or on the next Business
                Day
                after admission of the Enrollee as an inpatient to the
                Hospital.

            

    

    

    g. If
      the
      Hospital is unable to notify the Health Plan, the Hospital must document
      its attempts to notify the Health Plan, or the circumstances that precluded
      the
      Hospital's attempts to notify the Health Plan. The Health Plan shall not deny
      payment for Emergency Services and Care based on a Hospital's failure to comply
      with the notification requirements of this Section.

    

    h. If
      the
      Enrollee's PCP responds to the Hospital's notification, and the Hospital
      physician and the PCP discuss the appropriate care and treatment of the
      Enrollee, the Health Plan may have a member of the Hospital staff with whom
      it
      has a Participating Provider contract participate in the treatment of the
      Enrollee within the scope of the physician's Hospital staff
      privileges.

    

    i. The
      Health Plan may transfer the Enrollee, in accordance with State and federal
      law,
      to a Participating Hospital that has the service capability to treat the
      Enrollee's Emergency Medical Condition. The attending emergency physician,
      or
      the provider actually treating the Enrollee, is responsible for determining
      when
      the Enrollee is sufficiently stabilized for transfer discharge, and that
      determination is binding on the entities identified in 42 CFR 438.114(b) as
      responsible for coverage and payment.

    

    j. Notwithstanding
      any other State law, a Hospital may request and collect any insurance or
      financial information necessary to determine if the patient is an Enrollee
      of
      the Health Plan, in accordance with federal law, from an Enrollee, so long
      as
      Emergency Services and Care are not delayed in the process.

    

    k. In
      accordance with 42 CFR 438.411 and 42 CFR 422.113(c), the Health Plan shall
      cover Post Stabilization Care Services without authorization, regardless of
      whether the Enrollee obtains a service within or outside the Health Plan's
      network for the following situations:

    

    
      	 	
              (1)

            	
              Post-Stabilization
                Care Services that were pre-approved by the Health
                Plan;

            

    

    

    
      	 	
              (2)

            	
              Post-Stabilization
                Care Services that were not pre-approved by the Health Plan because
                the
                Health Plan did not respond to the treating provider's request for
                pre-approval within one (1) hour after the treating provider sent
                the
                request; 

            

    

    

    
      	 	
              (3)

            	
              The
                treating Provider could not contact the Health Plan for pre-approval;
                and

            

    

    

    
      	 	
              (4)

            	
              Those
                Post-Stabilization Care Services that a treating physician viewed
                as
                Medically Necessary after stabilizing an Emergency Medical Condition.
                These are non-emergency services; the Health Plan can choose not
                to cover
                if provided by a nonparticipating provider, except in those circumstances
                detailed in k. (1), (2), and (3) above.

            

    

    

    l. The
      Health Plan shall not deny claims for the provision of Emergency Services and
      Care submitted by a nonparticipating provider solely based on the period between
      the date of service and the date of clean claim submission, unless that period
      exceeds 365 days.

    

    m. Reimbursement
      for services provided to an Enrollee under this Section by a nonparticipating
      provider shall be the lesser of:

    

    
      	 	
              (1)

            	
              The
                nonparticipating provider's
                charges;

            

    

    

    
      	 	
              (2)

            	
              The
                usual and customary provider charges for similar services in the
                community
                where the services were provided;

            

    

    

    
      	 	
              (3)

            	
              The
                amount mutually agreed to by the Health Plan and the nonparticipating
                provider within sixty (60) Calendar Days after the nonparticipating
                provider submits a claim; or

            

    

    

    
      	 	
              (4)

            	
              The
                Medicaid rate.

            

    

    

    n. Notwithstanding
      the requirements set forth in this Section, the Health Plan shall make payment
      on all claims for Emergency Services and Care by nonparticipating providers
      pursuant to the requirements set forth in section 641.3155, F.S.

    

    
      	 	
              6.

            	
              Emergency
                Services - Behavioral Health
                Services

            

    

    

    a. An
      out-of-area, non-participating provider shall notify the Health Plan within
      twenty-four (24) hours of the Enrollee presenting for Emergency Behavioral
      Health Services. In cases in which the Enrollee has no identification, or is
      unable to verbally identify himself/herself when presenting for Behavioral
      Health Services, the out of area, non-participating provider shall notify the
      Health Plan within twenty-four (24) hours of learning the Enrollee's identity.
      The out of area, non-participating provider shall deliver to the Health Plan
      the
      Medical Records that document that the identity of the Enrollee could not be
      ascertained at the time the Enrollee presented for Emergency Behavioral Health
      Services due to the Enrollee's condition.

    

    b. If
      the
      out-of-area, non-participating provider fails to provide the Health Plan with
      an
      accounting of the Enrollee's presence and status within twenty-four (24) hours
      after the Enrollee presents for treatment and provides identification, the
      Health Plan shall only approve claims for the time period required for treatment
      of the Enrollee's Emergency Behavioral Health Services, as documented by the
      Enrollee's Medical Record.

    

    c. The
      Health Plan shall review and approve or disapprove all out-of-plan Emergency
      Behavioral Health Service claims within the time frames specified for emergency
      claims payment in Section V.D.3., Emergency Care Requirements.

    

    d. The
      Health Plan shall submit to the Agency for review and final determination all
      denied Appeals from behavioral health care providers and out-of-plan,
      non-participating Behavioral Health Care Providers for denied Emergency
      Behavioral Health Service claims. The provider, whether a participating provider
      or not, must submit the denied Appeal to the Agency within ten (10) days after
      receiving notice of the Health Plan's final Appeal determination. 

    

    e. The
      Health Plan must evaluate and authorize or deny services for Enrollees
      presenting at non-participating receiving facilities (that are not Crisis
      Stabilization Units), within the Health Plan's service area, for involuntary
      examination within three (3) hours of being notified by phone by the receiving
      facility.

    

    f. The
      receiving facility must notify the Health Plan within four (4) hours of the
      Enrollee presenting. If the Receiving Facility fails to notify the Health Plan
      of the Enrollee's presence and status within four (4) hours, the Health Plan
      shall pay only for the first four (4) hours of the Enrollee's treatment, subject
      to Medical Necessity.

    

    g. If
      the
      receiving facility is a non-participating receiving facility and documents
      in
      the Medical Record that it is unable, after a good faith effort, to identify
      the
      Enrollee and, therefore, fails to notify the Health Plan of the Enrollee's
      presence, the Health Plan shall pay for medical stabilization lasting no more
      than three (3) days from the date the Enrollee presented at the receiving
      facility, as documented by the Enrollee's Medical Record and subject to Medical
      Necessity, unless there is irrefutable evidence in the Medical Record that
      a
      longer period was required to treat the Enrollee.

    

    
      	 	
              7.

            	
              Family
                Planning Services

            

    

    

    The
      Health Plan shall provide family planning services for the purpose of enabling
      Enrollees to make comprehensive and informed decisions about family size and/or
      spacing of births. The Health Plan shall provide the following services:
      planning and referral, education and counseling, initial examination, diagnostic
      procedures and routine laboratory studies, contraceptive drugs and supplies,
      and
      follow-up care in accordance with the Medicaid Physicians Services Coverage
      and
      Limitations Handbook. Policy requirements include: 

    

    a. The
      Health Plan shall furnish services on a voluntary and confidential
      basis. 

    

    b. The
      Health Plan shall allow Enrollees freedom of choice of family planning methods
      covered under the Medicaid program, including Medicaid covered implants, where
      there are no medical contra-indications.

    

    c. The
      Health Plan shall render the services to Enrollees under the age of eighteen
      (18) provided the Enrollee is married, a parent, pregnant, has written consent
      by a parent or legal guardian, or in the opinion of a physician, the Enrollee
      may suffer health hazards if the services are not provided. See
      section 31.0051, F.S.

    

    d. The
      Health Plan shall allow each Enrollee to obtain family planning services from
      any Medicaid Provider and require no prior authorization for such services.
      If
      the Enrollee receives services from a non-network Medicaid provider, then the
      Health Plan must reimburse at the Medicaid reimbursement rate, unless another
      payment rate is negotiated.

    

    e. The
      Health Plan shall make available and encourage all pregnant women and mothers
      with infants to receive postpartum visits for the purpose of voluntary family
      planning, including discussion of all appropriate methods of contraception,
      counseling and services for family planning to all women and their partners.
      The
      Health Plan shall direct Providers to maintain documentation in the Enrollee's
      Medical Records to reflect this provision. See
      section 409.912, F.S.

    

    f. The
      provisions of this subsection shall not be interpreted so as to prevent a health
      care provider or other person from refusing to furnish any contraceptive or
      family planning service, supplies or information for medical or religious
      reasons. A health care provider or other person shall not be held liable for
      such refusal.

    

    
      	 	
              8.

            	
              Hospital
                Services — Inpatient

            

    

    

    Inpatient
      Services - Medically Necessary services ordinarily furnished by a State licensed
      acute care Hospital for the medical care and treatment of inpatients provided
      under the direction of a physician or dentist in a Hospital maintained primarily
      for the care and treatment of patients with disorders other than mental
      diseases. Inpatient psychiatric Hospital services are Medically Necessary
      Behavioral Health Care Services and may be provided in a general Hospital
      psychiatric unit or in a specialty Hospital.

    

    a. Inpatient
      services include, but are not limited to, rehabilitation Hospital care (which
      are counted as inpatient Hospital days), medical supplies, diagnostic and
      therapeutic services, use of facilities, drugs and biologicals, room and board,
      nursing care and all supplies and equipment necessary to provide adequate care.
      See
      the
      Medicaid Hospital Services Coverage & Limitations Handbook. 

    

    b. Inpatient
      services also include inpatient care for any diagnosis including psychiatric
      and
      mental health (Baker Act and non-Baker Act), tuberculosis and renal failure
      when
      provided by general acute care Hospitals in both emergent and non-emergent
      conditions. 

    

    c. The
      Health Plan may provide services in a nursing home as downward substitution
      for
      Inpatient Services. Such services shall not be counted as inpatient hospital
      days.

    

    d. The
      Health Plan shall provide Medically Necessary transplants covered in the
      Handbook, including pre-transplant care and post-transplant care. For other
      transplants not covered by Medicaid, the Health Plan shall cover pre-transplant
      care and post-transplant follow-up.

     

    e. The
      Health Plan shall cover physical therapy services when Medically Necessary
      and
      when provided during an Enrollee's inpatient stay.

    

    f. The
      Health Plan shall provide up to twenty-eight (28) inpatient hospital days in
      an
      inpatient Hospital substance abuse treatment program for pregnant substance
      abusers who meet ISD Criteria with Florida Medicaid modifications, as specified
      in InterQual Level of Care 2003-Acute Criteria-Pediatric and/or InterQual Level
      of Care 2003-Acute Criteria-Adult (McKesson Health Solutions, LLC, “McKesson”),
      2003 Edition or the most current edition, for use in screening cases admitted
      to
      rehabilitative Hospitals and CON approved rehabilitative units in acute care
      Hospitals with admission dates of January 1, 2003 and after. In addition, the
      Health Plan shall provide inpatient Hospital treatment for severe withdrawal
      cases exhibiting medical complications which meet the severity of illness
      criteria under the alcohol/substance abuse system-specific set which generally
      requires treatment on a medical unit where complex medical equipment is
      available. Withdrawal cases (not meeting the severity of illness criteria under
      the alcohol/substance abuse criteria) and substance abuse rehabilitation (other
      than for pregnant women), including court ordered services, are not covered
      in
      the inpatient Hospital setting.

    

    g. The
      Health Plan shall adhere to the provisions of the Newborns and Mothers Health
      Protection Act (NMHPA) of 1996 regarding postpartum coverage for mothers and
      their newborns. Therefore, the Health Plan shall provide for no less than a
      forty-eight (48) hour Hospital length of stay following a normal vaginal
      delivery, and at least a ninety-six (96) hour Hospital length of stay following
      a Cesarean section. In connection with coverage for maternity care, the Hospital
      length of stay is required to be decided by the attending physician in
      consultation with the mother.

    

    h. The
      Health Plan shall prohibit the following practices:

    

    
      	 	
              (1)

            	
              Denying
                the mother or newborn child eligibility, or continued eligibility,
                to
                enroll or renew coverage under the terms of the Health Plan, solely
                for
                the purpose of avoiding the NMHPA
                requirements;

            

    

    

    
      	 	
              (2)

            	
              Providing
                monetary payments or rebates to mothers to encourage them to accept
                less
                than the minimum protections available under
                NMHPA;

            

    

    

    
      	 	
              (3)

            	
              Penalizing
                or otherwise reducing or limiting the reimbursement of an attending
                physician because the physician provided care in a manner consistent
                with
                NMHPA;

            

    

    

    
      	 	
              (4)

            	
              Providing
                incentives (monetary or otherwise) to an attending physician to induce
                the
                physician to provide care in a manner inconsistent with NMHPA;
                and

            

    

    

    
      	 	
              (5)

            	
              Restricting
                for any portion of the forty-eight (48) hour, or ninety-six (96)
                hour,
                period prescribed by NMHPA in a manner that is less favorable than
                the
                Benefits provided for any preceding portion of the Hospital
                stay.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan shall pay for any Medically Necessary duration of stay
                in a
                noncontracted facility which results from a medical emergency until
                such
                time as the Plan can safely transport the Enrollee to a Plan participating
                facility.

            

    

    

    

    
      	 	
              9.

            	
              Hospital
                Services — Outpatient

            

    

    

    Outpatient
      hospital services consist of preventive, diagnostic, therapeutic or palliative
      care under the direction of a physician or dentist at a licensed acute care
      Hospital. Outpatient hospital services include Medically Necessary emergency
      room services, dressings, splints, oxygen and physician ordered services and
      supplies for the clinical treatment of a specific diagnosis or
      treatment.

    

    a. The
      Health Plan shall provide Emergency Services and Care as Medically Necessary.
      

    

    b. The
      Health Plan shall have a procedure for the authorization of dental care and
      associated ancillary medical services provided in an outpatient hospital setting
      if that care meets the following requirements:

    

    
      	 	
              (1)

            	
              Is
                provided under the direction of a dentist at a licensed Hospital;
                and

            

    

    

    
      	 	
              (2)

            	
              Is
                Medically Necessary; or

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall pay for any Medically Necessary duration of stay
                in a
                noncontracted facility which results from a medical emergency until
                such
                time as the Plan can safely transport the Enrollee to a Plan participating
                facility.

            

    

    

    
      	 	
              10.

            	
              Hospital
                Services — Ancillary
                Services

            

    

    

    a. The
      Health Plan shall provide Medically Necessary ancillary medical services at
      the
      Hospital without limitation. Ancillary Hospital services include, but are not
      limited to, radiology, pathology, neurology, neonatology, and anesthesiology.
      When the Health Plan or the Health Plan's authorized physician authorizes these
      services (either inpatient or outpatient), the Health Plan must reimburse the
      provider of the service at the Medicaid line item rate, unless the Health Plan
      and the Hospital have negotiated another reimbursement rate. Also, the Health
      Plan must reimburse non-network physicians for emergency ancillary services
      provided in a hospital setting.

    

    b. The
      Health Plan shall have a procedure for the authorization of Medically Necessary
      dental care and associated ancillary services provided in licensed ambulatory
      surgical center settings if that care is provided under the direction of a
      dentist as described in state plan.

    

    
      	 	
              11.

            	
              Hysterectomies,
                Sterilizations and Abortions

            

    

    

    The
      Health Plan shall maintain a log of all hysterectomy, sterilization and abortion
      procedures performed for its Enrollees. The log must include, at a minimum,
      the
      Enrollee’s name and identifying information, date of procedure, and type of
      procedure. The Health Plan shall provide abortions only in the following
      situations:

    

    a. If
      the
      pregnancy is a result of an act of rape or incest; or

    

    b. The
      physician certifies that the woman is in danger of death unless an abortion
      is
      performed.

    

    
      	 	
              12.

            	
              Immunizations

            

    

    

    The
      Health Plan shall: 

    

    a. Provide
      immunizations in accordance with the Recommended Childhood Immunization Schedule
      for the United States, or when Medically Necessary for the Enrollee's
      health;

    

    b. Provide
      for the simultaneous administration of all vaccines for which an Enrollee up
      to
      the age of 20 is eligible at the time of each visit; and

    

    c. Follow
      only true contraindications established by the Advisory Committee on
      Immunization Practices ("ACIP"), unless:

    

    
      	 	
              (1)

            	
              In
                making a medical judgment in accordance with accepted medical practices,
                such compliance is deemed medically inappropriate;
                or

            

    

    

    
      	 	
              (2)

            	
              The
                particular requirement is not in compliance with Florida law, including
                Florida law relating to religious or other
                exemptions.

            

    

    

    d. Participate,
      or direct its Providers to participate, in the Vaccines For Children Program
      ("VFC"). See
      Section 1905(r)(1) of the Social Security Act. The VFC is administered by the
      Department of Health, Bureau of Immunizations, and provides vaccines at no
      charge to physicians and eliminates the need to refer children to CHDs for
      immunizations.

    

    e. The
      Health Plan shall provide coverage and reimbursement to the Participating
      Provider for immunizations covered by Medicaid, but not provided through
      VFC;

    

    f.
       Ensure
      that Providers have a sufficient supply of vaccines if the Health Plan is the
      VFC enrollee. The Health Plan shall direct those Providers that are directly
      enrolled in the VFC program to maintain adequate vaccine supplies;

    

    g. Pay
      no
      more than the Medicaid program vaccine administration fee of $10.00 per
      administration, unless another rate is negotiated with the Participating
      Provider.

    

    h. Pay
      the
      immunization administration fee at no less than the Medicaid rate when an
      Enrollee receives immunizations from a nonparticipating provider, so long
      as:...

    

    (i) The
      nonparticipating provider contacts the Health Plan at the time of service
      delivery;

    

    (ii) The
      Health Plan is unable to document to the nonparticipating provider that the
      Enrollee has already received the immunization; and

    

    (iii) The
      nonparticipating provider submits a claim for the administration of immunization
      services and provides medical records documenting the immunization to the Health
      Plan. 

     

     

    
      	 	
              13.

            	
              Pregnancy
                Related Requirements

            

    

    

    The
      Health Plan must provide the most appropriate and highest level of Quality
      care
      for pregnant Enrollees. Required care includes the following: 

    

    a. Florida's
      Healthy Start Prenatal Risk Screening - The Health Plan shall ensure that the
      Provider offers Florida's Healthy Start prenatal risk screening to each pregnant
      Enrollee as part of her first prenatal visit. As
      required by section 383.14, F.S., 2004 and 64C-7.009, F.A.C. 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure that the Provider uses the DOH prenatal
                risk form
                (DH Form 3134), which can be obtained from the local CHD.
                

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall ensure that the Provider retains a copy of the
                completed
                screening instrument in the Enrollee's Medical Record and provides
                a copy
                to the Enrollee.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall ensure that the Provider submits the completed
                DH Form
                3134 to the CHD in the county in which the prenatal screen was completed
                within ten (10) Business Days of
                completion.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan shall collaborate with the Healthy Start care coordinator
                within the Enrollee's county of residence to assure risk appropriate
                care
                is delivered.

            

    

    

    b. Florida's
      Healthy Start Infant (Postnatal) Risk Screening Instrument - The Health Plan
      shall ensure that the Provider completes the Florida Healthy Start Infant
      (Postnatal) Risk Screening Instrument (DH Form 3135) with the Certificate of
      Live Birth and transmits the documents to the CHD in the county in which the
      infant was born within ten (10) Business Days of completion. The Health Plan
      shall ensure that the Participating Provider retains a copy of the completed
      DH
      Form 3135 in the Enrollee's Medical Record and provides a copy to the
      Enrollee.

    

    c. Pregnant
      Enrollees or infants who do not score high enough to be eligible for Healthy
      Start care coordination may be referred for services, regardless of their score
      on the Healthy Start risk screen, in the following ways: 

    

    
      	 	
              (1)

            	
              If
                the referral is to be made at the same time the Healthy Start risk
                screen
                is administered, the Provider may indicate on the risk screening
                form that
                the Enrollee or infant is invited to participate based on factors
                other
                than score; or 

            

    

     

    
      	 	
              (2)

            	
              If
                the determination is made subsequent to risk screening, the Participating
                Provider may refer the Enrollee or infant directly to the Healthy
                Start
                care coordinator based on assessment of actual or potential factors
                associated with high risk, such as HIV, hepatitis B, substance abuse
                or
                domestic violence.

            

    

    

    d. The
      Health Plan shall refer all pregnant women, breast-feeding and postpartum women,
      infants and Children up to age five (5) to the local WIC office. 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide:

            

    

    

    i. A
      completed Florida WIC program Medical Referral Form with the current height
      or
      length and weight (taken within 60 Calendar Days of the WIC
      appointment);

    

    ii. Hemoglobin
      or hematocrit; and

    

    iii. Any
      identified medical/nutritional problems.

    

    
      	 	
              (2)

            	
              For
                subsequent WIC certifications, the Health Plan shall ensure that
                Providers
                coordinate with the local WIC office to provide the above referral
                data
                from the most recent CHCUP.

            

    

    

    
      	 	
              (3)

            	
              Each
                time the Health Plan completes a WIC Referral Form, the Health Plan
                shall
                ensure that the Provider gives a copy of the WIC Referral Form to
                the
                Enrollee and retains a copy in the Enrollee's Medical
                Record.

            

    

    

    e. The
      Health Plan shall ensure that the Providers provide all women of childbearing
      age HIV counseling and offer them HIV testing. See Chapter
      381, F.S.

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure that its Providers, in accordance with Florida
                law, offer all pregnant women counseling an HIV testing at the initial
                prenatal care visit and again at twenty-eight (28) to thirty-two
                (32)
                weeks.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall ensure that its Providers attempt to obtain a signed
                objection if a pregnant woman declines an HIV test. See Section 384.31,
                F.S., 2004 and 64D-3.019, F.A.C.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall ensure that all pregnant women who are infected
                with HIV
                are counseled about and offered the latest antiretroviral regimen
                recommended by the U.S. Department of Health & Human Services. (U.S.
                Department of Health & Human Services, Public Health Service Task
                Force Report entitled Recommendations for the Use of Antiretroviral
                Drugs
                in Pregnant HIV-1 Infected Women for Maternal Health and Interventions
                to
                Reduce Perinatal HIV-1 Transmission in the United States. To receive
                a
                copy of the guidelines, contact the DOH, Bureau of HIV/AIDS at (850)
                245-4334, or go to http://aidsinfo.nih.gov/guidelines/.)

            

    

    

    f. The
      Health Plan shall ensure that its Providers screen all pregnant Enrollees
      receiving prenatal care for the Hepatitis B surface antigen (HBsAg) during
      the
      first prenatal visit.

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure that the Providers perform a second HBsAg
                test
                between twenty-eight (28) and thirty-two (32) weeks of pregnancy
                for all
                pregnant Enrollees who tested negative at the first (1st) prenatal
                visit
                and are considered high-risk for Hepatitis B infection. This test
                shall be
                performed at the same time that other routine prenatal screening
                is
                ordered.

            

    

    

    
      	 	
              (2)

            	
              All
                HBsAg-positive women shall be reported to the local CHD and to Healthy
                Start, regardless of their Healthy Start screening
                score.

            

    

    

    g. The
      Health Plan shall ensure that infants born to HBsAg-positive Enrollees shall
      receive Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine once
      they
      are physiologically stable, preferably within twelve (12) hours of birth and
      shall complete the Hepatitis B Maxine series according to the recommended
      vaccine schedule established by the Recommended Childhood Immunization Schedule
      for the United States.

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure that its Providers test infants born to
                HBsAg-positive Enrollees for HBsAg and Hepatitis B surface antibodies
                (anti-HBs) six (6) months after the completion of the vaccine series
                to
                monitor the success or failure of the
                therapy.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall ensure that Providers report to the local CHD a
                positive
                HBsAg result in any child aged twenty-four (24) months or less within
                twenty-four (24) hours of receipt of the positive test
                results.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall ensure that infants born to Enrollees who are
                HBsAg-positive are referred to Healthy Start regardless of their
                Healthy
                Start screening score.

            

    

    

    h. The
      Health Plan shall report to the Perinatal Hepatitis B Prevention Coordinator
      at
      the local CHD all prenatal or postpartum Enrollees who test HBsAg-positive.
      The
      Health Plan also shall report said Enrollees’ infants and contacts to the
      Perinatal Hepatitis B Prevention Coordinator at the local CHD.

    

    
      	 	
              (1)

            	
              The
                Health Plan shall report the following information - name, date of
                birth,
                race, ethnicity, address, infants, contacts, laboratory test performed,
                date the sample was collected, the due date or EDC, whether or not
                the
                Enrollee received prenatal care, and immunization dates for infants
                and
                contacts.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall use the Perinatal Hepatitis B Case and Contact
                Report (DH Form 1876) for reporting purposes.

            

    

    

    i. The
      Health Plan shall ensure that the PCP maintains all documentation of Healthy
      Start screenings, assessments, findings and referrals in the Enrollees’ Medical
      Records. The Health Plan shall ensure quick access to Enrollees’ Medical Records
      in the Provider contract.

    

    j. The
      Health Plan shall provide the most appropriate and highest level of Quality
      care
      for pregnant Enrollees, including, but not limited to, the
      following:

    

    
      	 	
              (1)

            	
              Prenatal
                Care - The Health Plan shall:

            

    

    

    i. Require
      a
      pregnancy test and a nursing assessment with referrals to a physician, PA or
      ARNP for comprehensive evaluation;

    

    ii. Require
      Case Management through the gestational period according to the needs of the
      Enrollee; 

    

    iii. Require
      any necessary referrals and follow-up;

    

    iv. Schedule
      return prenatal visits at least every four (4) weeks until the thirty-second
      (32nd) week, every two (2) weeks until the thirty-sixth (36th) week, and every
      week thereafter until delivery, unless the Enrollee’s condition requires more
      frequent visits; 

    

    v. Contact
      those Enrollees who fail to keep their prenatal appointments as soon as
      possible, and arrange for their continued prenatal care;

    

    vi. Assist
      Enrollees in making delivery arrangements, if necessary; and

    

    vii. Ensure
      that all Providers screen all pregnant Enrollees for tobacco use and make
      certain that the Providers make available to the pregnant Enrollees smoking
      cessation counseling and appropriate treatment as needed.

    

    
      	 	
              (2)

            	
              Nutritional
                Assessment/Counseling - The Health Plan shall ensure that its Providers
                supply nutritional assessment and counseling to all pregnant Enrollees.
                The Health Plan shall:

            

    

    

    i. Ensure
      the provision of safe and adequate nutrition for infants by promoting
      breast-feeding and the use of breast milk substitutes;

    

    ii. Offer
      a
      mid-level nutrition assessment;

    

    iii. Provide
      individualized diet counseling and a nutrition care plan by a public health
      nutritionist, a nurse or physician following the nutrition assessment;
      and

    

    iv. Documentation
      of the nutrition care plan in the Medical Record by the person providing
      counseling.

    

    
      	 	
              (3)

            	
              Obstetrical
                Delivery - The Health Plan shall develop and use generally accepted
                and
                approved protocols for both low risk and high risk deliveries which
                reflect the highest standards of the medical profession, including
                Healthy
                Start and prenatal screening, and ensure that all Providers use these
                protocols.

            

    

    

    i. The
      Health Plan shall ensure that all Providers document preterm delivery risk
      assessments in the Enrollee’s Medical Record by the twenty-eighth (28th)
      week.

    

    ii. If
      the
      Provider determines that the Enrollee’s pregnancy is high risk, the Health Plan
      shall ensure that the Provider’s obstetrical care during labor and delivery
      includes preparation by all attendants for symptomatic evaluation and that
      the
      Enrollee progresses through the final stages of labor and immediate postpartum
      care.

    

    
      	 	
              (4)

            	
              Newborn
                Care - The Health Plan shall make certain that its Providers supply
                the
                highest level of care for the Newborn beginning immediately after
                birth.
                Such level of care shall include, but not be limited to, the
                following:

            

    

    

    i. Instilling
      of prophylactic eye medications into each eye of the Newborn;

    

    ii. When
      the
      mother is Rh negative, the securing of a cord blood sample for type Rh
      determination and direct Coombs test;

    

    iii. Weighing
      and measuring of the Newborn;

    

    iv. Inspecting
      the Newborn for abnormalities and/or complications;

    

    v. Administering
      of one half milligram of vitamin K;

    

    vi. APGAR
      scoring;

    

    vii. Any
      other
      necessary and immediate need for referral in consultation from a specialty
      physician, such as the Healthy Start (postnatal) infant screen; and

    

    viii. Any
      necessary Newborn and infant hearing screenings. (To
      be
      conducted by a licensed audiologist pursuant to Chapter 468, F.S., 2004, a
      physician licensed under Chapters 458 or 459, F.S., 2004, or an individual
      who
      has completed documented training specifically for newborn hearing screenings
      and who is directly or indirectly supervised by a licensed physician or a
      licensed audiologist.)

    

    
      	 	
              (5)

            	
              Postpartum
                Care - The Health Plan shall:

            

    

    

    i. Provide
      a
      postpartum examination for the Enrollee within six (6) weeks after
      delivery;

    

    ii. Ensure
      that its Providers supply voluntary family planning, including a discussion
      of
      all methods of contraception, as appropriate;

    

    iii. Ensure
      that eligible Newborns are enrolled with the Health Plan and that continuing
      care of the Newborn be provided through the CHCUP program
      component.

    

    
      	 	
              14.

            	
              Prescribed
                Drug Services

            

    

    

    a. The
      Health Plan shall provide those products and services associated with the
      dispensing of medicinal drugs pursuant to a valid prescription, as
      defined in Chapter 465, F.S.
      Prescribed Drug Services generally include all prescription drugs listed in
      the
      Agency’s Prescribed Drug List (“PDL,” See
      section 409.91195, F.S.),
      except for specific hemophilia-related drugs identified by the Agency to be
      reimbursed as Fee-for-Service beginning September 1, 2006. The PDL shall include
      at least two (2) products, when available, in each therapeutic class.
      Antiretroviral agents are not subject to the PDL Policy requirements, pursuant
      to
      section
      409.912(39), F.S.,
      include,
      but are not limited to, the following:

    

    
      	 	
              (1)

            	
              The
                Health Plan shall make available those drugs and dosage forms listed
                in
                the PDL.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall not arbitrarily deny or reduce the amount, duration
                or
                scope of prescriptions solely based on the Enrollee’s diagnosis, type of
                illness or condition. The Health Plan may place appropriate limits
                on
                prescriptions based on criteria such as Medical Necessity, or for
                the
                purpose of utilization control, provided the Health Plan reasonably
                expects said limits to achieve the purpose of the Prescribed Drug
                Services
                set forth in the Medicaid State Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall make available those drugs not on the PDL, when
                requested and approve, if the drugs on the PDL have been used in
                a step
                therapy sequence or when other documentation is provided.
                

            

    

    

    b. The
      Health Plan shall provide to Enrollees, who desire to quit smoking, one (1)
      course of nicotine replacement therapy, of twelve (12) weeks duration, or the
      manufacturer’s recommended duration, per year. The Health Plan may use either
      nicotine transdermal patches or nicotine gum.

    

    c. If
      the
      Health Plan has authorization requirements for prescribed drug services, the
      Health Plan shall comply with all aspects of the Settlement Agreement to
      Hernandez, et. al. v. Medows (case number 02-20964 Civ-Gold/Simonton) (HSA).
      An
      HSA situation arises when an Enrollee attempts to fill a prescription at a
      participating pharmacy location and is unable to receive his/her prescription
      as
      a result of:

    

    
      	 	
              (1)

            	
              An
                unreasonable delay in filling the
                prescription;

            

    

    

    
      	 	
              (2)

            	
              A
                denial of the prescription;

            

    

    

    
      	 	
              (3)

            	
              The
                reduction of a prescribed good or service;
                and/or

            

    

    

    
      	 	
              (4)

            	
              The
                termination of a prescription.

            

    

    

    d. The
      Health Plan shall ensure that its Enrollees are receiving the functional
      equivalent of those goods and services received by non-Medicaid Reform
      Fee-for-Service Medicaid Recipients in accordance with the HSA. 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall maintain a log of all correspondences and communications
                from Enrollees relating to the HSA Ombudsman process. The “Ombudsman Log”
                shall contain, at a minimum, the Enrollee’s name, address and telephone
                number and any other contact information, the reason for the participating
                pharmacy location’s denial (and unreasonable delay in filling a
                prescription, a denial of a prescription and/or the termination of
                a
                prescription), the pharmacy’s name (and store number, if applicable), the
                date of the call, a detailed explanation of the final resolution,
                and the
                name of prescribed good or service.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan’s Enrollees are third party beneficiaries for this Section of
                the Contract.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall conduct HSA surveys on an annual basis, of no less
                than
                five percent (5%) of all participating pharmacy locations to ensure
                compliance with the HSA.

            

    

    

    
      	(a)  	
              The
                Health Plan may survey less than five percent (5%), with written
                approval
                from the Agency, if the Health Plan can show that the number of
                participating pharmacies it surveys is a statistically significant
                sample
                that adequately represents the pharmacies that have contracted with
                the
                Health Plan to provide pharmacy
                services.

            

    

    

    
      	(b)  	
              The
                Health Plan shall not include in the HSA Survey any participating
                pharmacy
                location that the Health Plan found to be in complete compliance
                with the
                HSA requirements within the last twelve
                months.

            

    

    

    
      	(c)  	
              The
                Health Plan shall require all participating pharmacy locations that
                fail
                any aspect of the HSA survey to undergo mandatory training within
                six (6)
                months and then be re-evaluated within one (1) month of the Health
                Plan’s
                HSA training to ensure that the participating pharmacy location is
                in
                compliance with the HSA.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan shall offer to train all new and existing participating
                pharmacy locations regarding the HSA
                requirements.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan may delegate any or all functions to one (1) or more
                Pharmacy
                Benefits Administrators (PBA), so long as none of the PBAs are owned,
                operated, related to, or subsidiaries of, any pharmacy. Before entering
                into a Subcontract, the Health Plan
                shall:

            

    

    

    
      	(a)  	
              Provide
                a copy of the model Subcontract between the Health Plan and the PBA
                to the
                Bureau of Managed Health Care; 

            

    

    

    
      	(b)  	
              Receive
                written approval from the Bureau of Managed Health Care for the use
                of
                said model Subcontract; and 

            

    

    

    
      	(c)  	
              Work
                with the Fiscal Agent to integrate the
                systems.

            

    

    

    e. The
      Health Plan shall provide name brand drugs in compliance with State law. The
      Health Plan shall authorize claims from a pharmacy for the cost of a
      multi-source brand drug if the prescriber: 

    

    
      	 	
              (1)

            	
              Writes
                in his or her own handwriting on the valid prescription that the
                drug is
                Medically Necessary; as determined by
                section 465.025, F.S
                and 

            

    

    

    
      	 	
              (2)

            	
              The
                prescriber submits the functionally equivalent of the FDA MedWatch
                form to
                the Health Plan, in his or her own handwriting, that an Enrollee
                has had
                an adverse reaction to a generic drug or has had, in his or her medical
                opinion, better results when taking the brand-name
                drug.

            

    

    

    f. Effective
      September 1, 2006, hemophilia-related drugs identified by the Agency for
      distribution through the Hemophilia Disease Management Pilot Program will be
      reimbursed on a Fee-for-Service basis. Upon implementation of the Hemophilia
      Disease Management Pilot Program, the Health Plan shall coordinate the care
      of
      its’ enrollees with Agency-approved organizations and shall not be responsible
      for the distribution of Hemophilia-related drugs.

    

    g. Health
      Plans shall submit pharmacy encounter data in a format supplied by the Agency
      on
      an ongoing quarterly payment schedule, as specified in Section XII of this
      Contract. For example, data for all claims paid during 04/01/06 and 06/30/06
      is
      due to the Agency by 07/31/06.

    

    
      	 	
              15.

            	
              Quality
                Enhancements 

            

    

    

    In
      addition to the covered services specified in this Section, the Health Plan
      shall offer Quality Enhancements ("QEs") to Enrollees as specified
      below.

    

    a. The
      Health Plan shall offer QEs in community settings that are accessible to
      Enrollees.

    

    b. The
      Health Plan shall inform Enrollees and Providers of the QEs, and how to access
      services related to QEs, through the Enrollee and Provider
      Handbooks.

    

    c. The
      Health Plan shall develop and maintain written policies and procedures to
      implement QEs.

    

    d. The
      Health Plan may cosponsor the annual training of Providers, provided that the
      training meets the Provider training requirements for the programs listed below.
      The Plan is encouraged to actively collaborate with community agencies and
      organizations, including CHD's, local Early Intervention Programs, Healthy
      Start
      Coalitions and local school districts in offering these services. 

    

    e. If
      the
      Health Plan involves the Enrollee in an existing community program for purposes
      of meeting the QE requirement, the Health Plan shall document referrals to
      the
      community program, shall follow-up on the Enrollee's receipt of services from
      the community program and record the Enrollee's involvement in the Enrollee’s
      Medical Record.

    

    f. QE
      programs shall include, but not be limited to, the following:

    

    
      	 	
              (1)

            	
              Children's
                Programs - The Health Plan shall provide regular general wellness
                programs
                targeted specifically toward Enrollees from birth to the age of five
                (5),
                or the Health Plan shall make a good faith effort to involve Enrollees
                in
                existing community Children's
                Programs.

            

    

    

    i. Children's
      Programs shall promote increased utilization of prevention and early
      intervention services for at risk Enrollees with Children/Adolescents in the
      target population. The Health Plan shall approve claims for services recommended
      by the Early Intervention Program when they are Covered Services and Medically
      Necessary.

    

    ii. The
      Health Plan shall offer annual training to Providers that promote proper
      nutrition, breast-feeding, immunizations, CHCUP, wellness, prevention and early
      intervention services.

    

    
      	 	
              (2)

            	
              Domestic
                Violence - The Health Plan shall ensure that PCPs screen Enrollees
                for
                signs of domestic violence and shall offer referral services to applicable
                domestic violence prevention community agencies.
                

            

    

    

    
      	 	
              (3)

            	
              Pregnancy
                Prevention - The Health Plan shall conduct regularly scheduled Pregnancy
                Prevention programs, or shall make a good faith effort to involve
                Enrollees in existing community Pregnancy Prevention programs, such
                a the
                Abstinence Education Program. The programs shall be targeted towards
                teen
                Enrollees, but shall be open to all Enrollees, regardless of age,
                gender,
                pregnancy status or parental consent.

            

    

    

    
      	 	
              (4)

            	
              Prenatal/Postpartum
                Pregnancy Programs - The Health Plan shall provide regular home visits,
                conducted by a home health nurse or aide, and counseling and educational
                materials to pregnant and postpartum Enrollees who are not in compliance
                with the Health Plan's prenatal and postpartum programs. The Health
                Plan
                shall coordinate its efforts with the local Healthy Start Care Coordinator
                to prevent duplication of services.

            

    

    

    
      	 	
              (5)

            	
              Smoking
                Cessation - The Health Plan shall conduct regularly scheduled Smoking
                Cessation programs as an option for all Enrollees, or the Health
                Plan
                shall make a good faith effort to involve Enrollees in existing community
                or Smoking Cessation programs. The Health Plan shall provide Smoking
                Cessation counseling to Enrollees. The Health Plan shall provide
                Participating PCPs with the Quick Reference Guide to assist in identifying
                tobacco users and supporting and delivering effective Smoking Cessation
                interventions. (The Quick Reference Guide is a distilled version
                of the
                Public Health Service sponsored Clinical Practice Guideline, Treating
                Tobacco Use & Dependence. The Plan can obtain copies of the Quick
                Reference guide by contacting the DHHS, Agency for Health Care Research
                & Quality (AHR) Publications Clearinghouse at (800) 358-9295 or P.O.
                Box 8547, Silver Spring, MD 20907.)

            

    

    

    
      	 	
              (6)

            	
              Substance
                Abuse - The Health Plan shall offer Substance Abuse screening training
                to
                its Providers on an annual basis. 

            

    

    

    i. The
      Health Plan shall have all PCPs screen Enrollees for signs of Substance Abuse
      as
      part of prevention evaluation at the following times:

    

    
      	 	
              (a)

            	
              Initial
                contact with a new Enrollee;

            

    

    

    
      	 	
              (b)

            	
              Routine
                physical examinations;

            

    

    

    
      	 	
              (c)

            	
              Initial
                prenatal contact;

            

    

    

    
      	 	
              (d)

            	
              When
                the Enrollee evidences serious over-utilization of medical, surgical,
                trauma or emergency services; and

            

    

    

    
      	 	
              (e)

            	
              When
                documentation of emergency room visits suggests the
                need.

            

    

    

    ii. The
      Health Plan shall offer targeted Enrollees either community or Health Plan
      sponsored Substance Abuse programs.

    

    
      	 	
              16.

            	
              Protective
                Custody 

            

    

    

    The
      Health Plan shall provide a physical screening within seventy-two (72) hours,
      or
      immediately, if required, for all enrolled Children/Adolescsents taken into
      protective custody, emergency shelter or the foster care program by DCF,
See
      Rule
      65C-12.002, F.A.C.

    

    a. The
      Health Plan shall provide these required examinations, or, if unable to do
      so
      within the required time frames, must approve the out of network claim and
      forward it to the Agency and/or its Agent. 

    

    b. For
      all
      CHCUP screenings for Children/Adolescents whose Enrollment and Medicaid
      eligibility are undetermined at the time of entry into the care and custody
      of
      DCF, and who are later determined to be Enrollees at the time the examinations
      took place, the Health Plan shall approve the claims and forward them to the
      Agency and/or the Fiscal Agent. 

    

    
      	 	
              17.

            	
              Therapy
                Services 

            

    

    

    Medicaid
      Therapy Services are physical, speech-language (including augmentative and
      alternative communication systems), occupational and respiratory therapies.
      The
      Health Plan shall cover therapy services consistent with handbook requirements.
      Adults are covered for physical and respiratory therapy services under the
      Outpatient Hospital Services program. The Agency shall reimburse schools
      participating in the certified school match program for school-based Therapy
      Services rendered to Enrollees. The provision of school-based Therapy Services
      to an Enrollee does not replace, substitute or fulfill a service prescription
      or
      doctors' orders for Therapy Services external to the Health Plan. The Health
      Plan shall:

     

    
      	 	
              a.

            	
              Refer
                Enrollees to appropriate Participating Providers for further assessment
                and treatment of conditions;

            

    

    

    
      	 	
              b.

            	
              Offer
                Enrollees scheduling assistance in making treatment appointments
                and
                obtaining transportation; and

            

    

    

    
      	 	
              c.

            	
              Provide
                for care management in order to follow the Enrollee’s progress from
                screening through his/her course of
                treatment.

            

    

    

    
      	 	
              18.

            	
              Transportation

            

    

    

    a. Transportation
      services are the arrangement and provision of an appropriate mode of
      Transportation for Enrollees to receive medical care services. The Health Plan
      shall comply with the limitations and exclusions in the Medicaid Transportation
      Coverage, Limitations & Reimbursement Handbook (the “Transportation
      Handbook”) except where compliance conflicts with the terms of this Contract,
      the Contract terms shall take precedence. In no instance may the limitations
      or
      exclusions imposed by the Health Plan be more stringent than those specified
      in
      the Transportation Handbook. 

    

    b. The
      Health Plan shall have the option to provide
      Transportation services directly through the Health Plan’s network of
      Transportation Providers, or through a Provider contract relationship, which
      may
      include the Commission for the Transportation Disadvantaged (CTD).

    

    c. Regardless
      of whether the Health Plan chooses to coordinate with a Transportation Provider
      or provide Transportation services directly, the Health Plan shall be
      responsible for monitoring the provision of services. The Health
      Plan:

    

    
      	 	
              (1)

            	
              Shall
                assure that Transportation providers are appropriately licensed and
                insured in accordance with the provisions of the Transportation
                Handbook;

            

    

    

    
      	 	
              (2)

            	
              Must
                provide Transportation Services for all Enrollees seeking necessary
                Medicaid services;

            

    

    

    
      	 	
              (3)

            	
              Is
                not obligated to follow the requirements of the Commission for the
                Transportation Disadvantaged or the Transportation Coordinating Boards
                as
                set forth in Chapter 427, F.S., 2004; unless the Health Plan has
                chosen to
                coordinate services with the CTD;

            

    

    

    
      	 	
              (4)

            	
              Shall
                be responsible for the cost of transporting an Enrollee from a
                nonparticipating facility or Hospital to a participating facility
                or
                Hospital if the reason for transport is solely for the Health Plan's
                convenience; and

            

    

    

    
      	 	
              (5)

            	
              Shall
                approve claims for Transportation Services providers in accordance
                with
                the requirements set forth in this
                Contract.

            

    

    

    d. The
      Health Plan may delegate the provision of Transportation Services to a third
      party.

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide a copy of the model Participating Transportation
                Subcontract to the Bureau of Managed Health
                Care.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan may subcontract with more than one Transportation services
                Provider.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan shall maintain oversight of any third party providing
                services
                on the Health Plan's behalf.

            

    

    

    e. The
      Health Plan shall provide the following non-emergency Transportation, at a
      minimum, as part of its line of Transportation Services:

    

    (1) Ambulatory
      Transportation;

    

    (2) Long
      haul
      ambulatory Transportation;

    

    (3) Wheelchair
      Transportation;

    

    (4) Stretcher
      Transportation;

    

    (5) Multiload
      Transportation;

    

    (6) Mass
      transit Transportation;

    

    (7) Over-the-road
      bus;

    

    (8) Over-the-road
      train;

    

    (9) Private
      volunteer Transportation; 

    

    (10) Escort
      services (including medical escort); and

    

    (11) Commercial
      air carrier Transportation.

    

    f. Before
      providing Transportation Services, the Health Plan shall provide to the Bureau
      of Managed Health Care a copy of its policies and procedures relating to the
      following:

    

    
      	 	
              (1)

            	
              How
                the Health Plan will determine eligibility for each
                Enrollee;

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's course of action as to how it will determine what type
                of
                Transportation to provide to a particular
                Enrollee;

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan's procedure for providing Prior Authorization to Enrollees
                requesting Transportation Services;

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan's comprehensive employee training program to investigate
                potential fraud;

            

    

    

    
      	 	
              (5)

            	
              How
                the Health Plan will review Transportation Providers who demonstrate
                a
                pattern or practice of:

            

    

    

    (a) Falsified
      encounter or service reports; 

    

    (b) Overstated
      reports or up-coded levels of service; and/or

    

    (c) Fraud
      or
      abuse, as defined in section 409.913, F.S.

    

    
      	 	
              (6)

            	
              How
                the Health Plan will review Transportation Providers
                that:

            

    

    

    (a) Alter,
      falsify or destroy records prior to the end of the five (5) year records
      retention requirement;

    

    (b) Make
      false statements about credentials;

    

    (c) Misrepresent
      medical information to justify referrals;

    

    (d) Failed
      to
      provide scheduled Transportation for Enrollees; 

    

    (e) Charge
      Enrollees for covered services; and/or

    

    (f) Have,
      or
      been suspected of committing, fraud or abuse, as defined in section 409.913,
      F.S.

    

    
      	 	
              (7)

            	
              How
                the Health Plan will provide Transportation Services outside of the
                Health
                Plan's service area. The Health Plan shall state clearly the guidelines
                it
                will use in order to control costs when providing Transportation
                Services
                outside of the Health Plan's service
                area.

            

    

    

    g. The
      Health Plan shall report immediately, in writing to the Agency Contract Manager,
      the Bureau of Medicaid Program Integrity (MPI), and Medicaid Fraud Control
      Unit
      (MFCU), any aspect of Transportation Service delivery, by any Transportation
      services provider, any adverse or untoward incident. (See
      section 641.55, F.S.)
      The
      Health Plan shall also report, immediately upon identification, in writing
      to
      the Agency Contract Manager, the MPI and the MFCU, all instances of suspected
      Enrollee or Transportation Services Provider fraud or abuse.( As
      defined in section 409.913, F.S.)

    

    The
      Health Plan shall file a written report with the MPI, the MFCU, and the Agency
      Contract Manager immediately upon the detection of a potentially or suspected
      fraudulent or abusive action by a Transportation services provider. At a
      minimum, the report must contain the name, tax identification number and
      contract information of the Transportation services provider and a description
      of the suspected fraudulent or abusive act. The report shall be in the form
      of a
      narrative.

    

    h. Insurance,
      Safety Requirements and Standards (Including,
      but not limited to, 41-2, F.A.C.)

    

    
      	 	
              (1)

            	
              The
                Health Plan shall ensure compliance with the minimum liability insurance
                requirement of $100,000 per person and $200,000 per incident for
                all
                Transportation services purchased or provided for the Transportation
                disadvantaged through the Health Plan. See
                section 768.28(5), F.S.
                The Health Plan shall indemnify and hold harmless the local, State,
                and
                federal governments and their entities and the Agency from any liabilities
                arising out of or due to an accident or negligence on the part of
                the
                Health Plan and/or all Transportation Providers under contract to
                the
                Health Plan. The Health Plan may act as a Transportation Provider,
                in
                which case it must follow all requirements set forth below for
                Transportation Providers.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan, and all Transportation Providers, shall ensure that
                all
                operations and services are in compliance with all federal and State
                safety requirements, including, but not limited to, section 341.061(2)(a),
                Florida Statutes, and Chapter 14-90,
                F.A.C.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan, and all Transportation Providers, shall ensure continuing
                compliance with all applicable State or federal laws relating to
                drug
                testing, including, but not limited to, to section 112.0455, Florida
                Statutes, 2004, Rule 14-17.012, Chapters 59A-24 and 60L-19, F.A.C.,
                41
                U.S.C. 701, 49 C.F.R., Parts 29 and 382, and 46 C.F.R., Parts 4,
                5, 14,
                and 16.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan and all Transportation Providers shall adhere to the
                following
                standards, including, but not limited to, the
                following:

            

    

    

    (a) Drug
      and
      alcohol testing for safety sensitive job positions relating to the provision
      of
      Transportation Services regarding pre-employment, randomization, post-accident,
      and reasonable suspicion as required by the Federal Highway Administration
      and
      the Federal Transit Administration;

    

    (b) Use
      of
      child safety restraint devices, where the use of such devices would not
      interfere with the safety of a child (for example, a child in a
      wheelchair);

    

    (c)
       Enrollee
      property that can be carried by the passenger and/or driver, and can be stowed
      safely on the vehicle, shall be transported with the passenger at no additional
      charge. The driver shall provide Transportation of the following items, as
      applicable, within the capabilities of the vehicle: 

    

    
      	 	
              i.

            	
              Wheelchairs;

            

    

    

    
      	 	
              ii.

            	
              Child
                seats;

            

    

    

    
      	 	
              iii.

            	
              Stretchers;

            

    

    

    
      	 	
              iv.

            	
              Secured
                oxygen;

            

    

    

    
      	 	
              v.

            	
              Personal
                assistive devices; and/or

            

    

    

    
      	 	
              vi.

            	
              Intravenous
                devices.

            

    

    

    (d) Vehicle
      transfer points shall provide shelter, security, and safety of
      Enrollees;

    

    (e) Maintain
      inside all vehicles copies of the Health Plan’s toll-free phone number for
      Enrollee complaints;

    

    (f) The
      interior of all vehicles shall be free from dirt, grime, oil, trash, torn
      upholstery, damaged or broken seats, protruding metal or other objects or
      materials which could soil items placed in the vehicle or provide discomfort
      for
      Enrollees;

    

    (g) Maintain
      a passenger/trip database for each Enrollee transported by the Health
      Plan/Transportation Provider;

    

    (h) Ensure
      adequate seating for paratransit services for each Enrollee and escort, child,
      or personal care attendant, and shall ensure that the vehicle does not transport
      more passengers than the registered passenger seating capacity in a vehicle
      at
      any time; 

    

    (i) Ensure
      adequate seating space for transit services for each Enrollee and escort, child,
      or personal care attendant, and shall ensure that transit vehicles provide
      adequate seating or standing space to each rider, and shall ensure that the
      vehicle does not transport more passengers than the registered passenger seating
      or standing capacity in a vehicle at any time;

    

    (j) Drivers
      for paratransit services shall identify themselves by name and company in a
      manner that is conducive to communications with the specific passenger, upon
      pickup of each Enrollee, group of Enrollees, or representative, guardian, or
      associate of the Enrollee, except in situations where the driver regularly
      transports the Enrollee on a recurring basis;

    

    (k)
       Each
      driver must have photo identification that is viewable by the passenger. Name
      patches, inscriptions or badges that affix to driver clothing are acceptable.
      For transit services, the driver photo identification shall be in a conspicuous
      location in the vehicle;

    

    (l) The
      paratransit driver shall provide the Enrollee with boarding assistance, if
      necessary or requested, to the seating portion of the vehicle. The boarding
      assistance shall include, but not be limited to, opening the vehicle door,
      fastening the seat belt or utilization of wheel chair securement devices,
      storage of mobility assistive devices and closing the vehicle door. In the
      door-through-door paratransit service category, the driver shall open and close
      doors to buildings, except in situations in which assistance in opening and/or
      closing building doors would not be safe for passengers remaining in the
      vehicle. The driver shall provide assisted access in a dignified manner. Drivers
      may not assist wheelchair passengers up or down more than one (1) step, unless
      it can be performed safely as determined by the Enrollee, guardian, and
      driver;

    

    (m) Smoking,
      eating and drinking are prohibited in any vehicle, except in cases in which,
      as
      a Medical Necessity, the Enrollee requires fluids or sustenance during
      transport;

    

    (n) 
      Ensure
      that all vehicles are equipped with two-way communications, in good working
      order and audible to the driver at all times, by which to communicate with
      the
      Transportation Services hub or base of operations;

    

    (o) Ensure
      that all vehicles have working air conditioners and heaters. The Health Plan
      shall ensure that all vehicles that do not have a working air conditioner or
      heater are removed from the vehicle pool and scheduled for repair or
      replacement;

    

    (p) Develop
      and implement a first aid policy and cardiopulmonary resuscitation
      policy;

    

    (q) Ensure
      that all drivers providing Transportation Services undergo a background
      screening;

    

    (r) Establish
      Enrollee pick-up windows and communicate these windows to Transportation
      Providers and Enrollees;

    

    (s)
       Establish
      a minimum 24-hour advance notification policy to obtain Transportation Services.
      The Health Plan shall communicate said policy to Transportation Providers and
      Enrollees;

    

    (t) Establish
      a performance measure to evaluate the safety of the Transportation Services
      provided by Transportation Providers;

    

    (u) Establish
      a performance measure to evaluate the reliability of the vehicles utilized
      by
      Transportation Providers;

    

    (v) Establish
      a performance measure to evaluate the quality of service provided by a
      Transportation Provider;

    

    (w) The
      Health Plan shall submit these performance measures to the Agency for written
      approval by the end of the first month of this contract term;

    

    (x) The
      Health Plan shall report the results of these evaluation to the Agency as
      described in Section XI; and

    

    (y) Ensure
      that all drivers speak English.

    

    i. Operational
      Standards - Each Health Plan shall implement, or ensure that each Transportation
      Provider has implemented, policies and procedures that, at a minimum, comply
      with the following (For
      reference, see 14-90, F.A.C.):
      

    

    
      	 	
              (1)

            	
              Address
                the following safety elements and
                requirements:

            

    

    

    (a) Safety
      policies and responsibilities;

    

    (b) Vehicle
      and equipment standards and procurement criteria;

    

    (c) Operational
      standards and procedures;

    

    (d) Vehicle
      driver and employee selection;

    

    (e) Driving
      requirements;

    

    (f) Vehicle
      driver and employee training;

    

    (g) Vehicle
      maintenance;

    

    (h) Investigations
      of events described below;

    

    (i) Hazard
      identification and resolution;

    

    (j) Equipment
      for transporting wheelchairs;

    

    (k) Safety
      data acquisition and analysis;

    

    (l) Safety
      standards for private contract vehicle transit system(s) that provide(s)
      Transportation services for compensation as a result of a contractual agreement
      with the vehicle transit system.

    

    
      	 	
              (2)

            	
              Shall
                submit an annual safety certification to the Agency verifying the
                following:

            

    

    

    (a) Adoption
      of policies and procedures that, at a minimum, establish standard set forth
      in
      this Section; and

    

    (b) The
      Health Plan/Transportation Provider is in full compliance with the policies
      and
      procedures relating to Transportation Services, and that it has performed annual
      safety inspections on all vehicles operated by the Health Plan/Transportation
      Provider, by persons meeting the requirements set forth below.

    

    
      	 	
              (3)

            	
              The
                Health Plan shall suspend immediately a Transportation Provider if,
                in the
                sole discretion of the Health Plan, and at any time, continued use
                of that
                Transportation Provider, is unsafe for passenger service or poses
                a
                potential danger to public safety.

            

    

    

    
      	 	
              (4)

            	
              Address
                the following security
                requirements:

            

    

    

    (a) Security
      policies, goals, and objectives;

    

    (b) Organization,
      roles, and responsibilities;

    

    (c) Emergency
      management processes and procedures for mitigation, preparedness, response,
      and
      recovery;

    

    (d) Procedures
      for investigation of any event involving a vehicle, or taking place on vehicle
      transit system controlled property, resulting in a fatality, injury, or property
      damage as discussed below;

    

    (e) Procedures
      for the establishment of interfaces with emergency response
      organizations;

    

    (f) Employee
      security and threat awareness training programs;

    

    (g) Conduct
      and participate in emergency preparedness drills and exercises; and

    

    (h) Security
      requirements for Transportation Providers that provide Transportation Services
      for compensation as a result of a contractual agreement with the Health
      Plan/Transportation Provider.

    

    
      	 	
              (5)

            	
              Shall
                establish criteria and procedures for selection, qualification, and
                training of all drivers. The criteria shall include, at a minimum,
                the
                following:

            

    

    

    (a) Driver
      qualifications and background checks with minimum hiring standards;

    

    (b) Driving
      and criminal background checks for all new drivers;

    

    (c) Verification
      and documentation of valid driver licenses for all employees who drive
      vehicles;

    

    (d) Training
      and testing to demonstrate and ensure adequate skills and capabilities to safely
      operate each type of vehicle or vehicle combination before driving
      unsupervised;

    

    (e) At
      a
      minimum, drivers shall be given explicit instructional and procedural training
      and testing in the following areas:

    

    
      	 	
              i.

            	
              The
                Health Plan’s/Transportation Provider’s safety and operational policies
                and procedures;

            

    

    

    
      	 	
              ii.

            	
              Operational
                vehicle and equipment inspections;

            

    

    

    
      	 	
              iii.

            	
              Vehicle
                equipment familiarization;

            

    

    

    
      	 	
              iv.

            	
              Basic
                operations and maneuvering;

            

    

    

    
      	 	
              v.

            	
              Boarding
                and alighting passengers;

            

    

    

    
      	 	
              vi.

            	
              Operation
                of wheelchair lift and other special equipment and driving
                conditions;

            

    

    

    
      	 	
              vii.

            	
              Defensive
                driving;

            

    

    

    
      	 	
              viii.

            	
              Passenger
                assistance and securement;

            

    

    

    
      	 	
              ix.

            	
              Handling
                of emergencies and security threats;
                and

            

    

    

    
      	 	
              x.

            	
              Security
                and threat awareness.

            

    

    

    (f) Shall
      provide written operational and safety procedures to all vehicle drivers before
      the drivers are allowed to drive unsupervised. These procedures and instructions
      shall address, at a minimum, the following:

    

    
      	 	
              i.

            	
              Communication
                and handling of unsafe conditions, security threats, and
                emergencies;

            

    

    

    
      	 	
              ii.

            	
              Familiarization
                and operation of safety and emergency equipment, wheelchair lift
                equipment, and restraining devices;
                and

            

    

    

    
      	 	
              iii.

            	
              Application
                and compliance with applicable federal and State rules and regulations.
                The provisions in Sections 10.8.14.h.5(e) and (f), above, shall not
                apply
                to personnel licensed and authorized by the Plan/Transportation Provider
                to drive, move, or road test a vehicle in order to perform repairs
                or
                maintenance services where it has been determined that such temporary
                operation does not create an unsafe operating condition or create
                a hazard
                to public safety.

            

    

    

    (g) Shall
      maintain the following records for at least five (5) years:

    

    
      	 	
              i.

            	
              Records
                of vehicle driver background checks and
                qualifications;

            

    

    

    
      	 	
              ii.

            	
              Detailed
                descriptions of training administered and completed by each vehicle
                driver; 

            

    

    

    
      	 	
              iii.

            	
              A
                record of each vehicle driver’s duty status, which shall include total
                days worked, on-duty hours, driving hours and time of reporting on-
                and
                off-duty each day; and

            

    

    

    
      	 	
              iv.

            	
              Any
                documents required to be prepared by this
                Contract.

            

    

    

    (h) Shall
      establish a drug-free workplace policy statement, in accordance with 49 C.F.R.
      Part 29, and a substance abuse management and testing program; in accordance
      with 49 C.F.R. Parts 40 and 655, and
      

    

    (i) Shall
      require that drivers write and submit a daily vehicle inspection report,
      pursuant to Rule 14-90.006, F.A.C. 

    

    
      	 	
              (6)

            	
              Shall
                establish a maintenance policy and procedures for preventative and
                routine
                maintenance for all vehicles. The maintenance policy and procedures
                shall
                ensure, at a minimum, that:

            

    

    

    (a) All
      vehicles, all parts and accessories on such vehicles, and any additional parts
      and accessories which may affect the safety of vehicle operation, including
      frame and frame assemblies, suspension systems, axles and attaching parts,
      wheels and rims, and steering systems, are regularly and systematically
      inspected, maintained and lubricated in accordance with the standards developed
      and established according to the vehicle manufacturer’s recommendations and
      requirements;

    

    (b) That
      a
      recording and tracking system is established for the types of inspections,
      maintenance, and lubrication intervals, including the date or mileage when
      these
      services are due. Required maintenance inspections shall be more comprehensive
      than daily inspections performed by the driver;

    

    (c) That
      proper preventive maintenance is performed when on all vehicles;
      and

    

    (d) That
      the
      Health Plan/Transportation Provider maintains and provides written documentation
      of preventive maintenance, regular maintenance, inspections, lubrication, and
      repairs performed for each vehicle under their control. Such records shall
      be
      maintained by the Health Plan/Transportation Provider for at least five (5)
      years and include, at a minimum, the following information:

    

    
      	 	
              i.

            	
              Identification
                of the vehicle, including make, model, and license number or other
                means
                of positive identification and
                ownership;

            

    

    

    
      	 	
              ii.

            	
              Date,
                mileage, and type of inspection, maintenance, lubrication, or repair
                performed;

            

    

    

    
      	 	
              iii.

            	
              Date,
                mileage, and description of each inspection, maintenance, and lubrication
                intervals performed;

            

    

    

    
      	 	
              iv.

            	
              If
                not owned by the Health Plan/Transportation Provider, the name of
                any
                person or lessor furnishing any vehicle;
                and

            

    

    

    
      	 	
              v.

            	
              The
                name and address of any entity or contractor performing an inspection,
                maintenance, lubrication, or
                repair.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan/Transportation Provider shall investigate, or cause to
                be
                investigated, any event involving a vehicle or taking place on Health
                Plan/Transportation Provider controlled property resulting in a fatality,
                injury, or property damage as
                follows:

            

    

    

    (a) 
      A
      fatality, where an individual is confirmed dead, within three (3) days of a
      Transportation Services related event, excluding suicides and deaths from
      illnesses. The Health Plan must file detailed report of the incident with the
      Agency within ten (10) days of the event (See section 641.55(6),
      F.S.);

    

    (b) Injuries
      requiring immediate medical attention away from the scene for two (2) or more
      individuals;

    

    (c) Property
      damage to Health Plan/Transportation Provider vehicles, other Health
      Plan/Transportation Provider property or facilities, or any other property,
      except the Health Plan/Transportation Provider shall have the discretion to
      investigate events resulting in property damage totaling less than $1,000;
      

    

    (d) Evacuation
      of a vehicle due where there is imminent danger to passengers on the vehicle,
      excluding evacuations due to vehicle operation issues;

    

    (e) Each
      investigation shall be documented in a final report that includes a description
      of investigation activities, identified causal factors and a corrective action
      plan;

    

    
      	 	
              i.

            	
              Each
                corrective action plan shall identify the action to be taken by the
                Health
                Plan/Transportation Provider and the schedule for its implementation;
                and

            

    

    

    
      	 	
              ii.

            	
              The
                Health Plan/Transportation Provider must monitor and track the
                implementation of each corrective action
                plan.

            

    

    

    (f) The
      Health Plan/Transportation Provider shall maintain all investigation reports,
      corrective action plans, and related supporting documentation for a minimum
      of
      five (5) years from the date of completion of the investigation.

    

    j. Medical
      Examinations for Drivers - The Health Plan/Transportation Provider shall
      establish medical examination requirements for all applicants for driver
      positions and for existing drivers. The medical examination requirements shall
      include a pre-employment examination for applicants, an examination at least
      once every two (2) years for existing drivers, and a return to duty examination
      for any driver prior to returning to duty after having been off duty for thirty
      (30) or more days due to an illness, medical condition, or injury.

    

    
      	 	
              (1)

            	
              Medical
                examinations may be performed and recorded according to qualification
                standards adopted by the Health Plan/Transportation Provider, provided
                the
                medical examination qualification standards adopted by the Health
                Plan/Transportation Provider meet or exceed those provided in Department
                Form Number 725-030-11, Medical Examination Report for Bus Transit
                System
                Driver, Rev. 07/05, hereby incorporated by reference. Copies of Form
                Number 725-030-11 are available from the Florida Department of
                Transportation, Public Transit Office, 605 Suwannee Street, Mail
                Station
                26, Tallahassee, Florida 32399-0450 or on-line at
                www.dot.state.fl.us/transit.

            

    

    

    
      	 	
              (2)

            	
              Medical
                examinations shall be performed by a Doctor of Medicine or Osteopathy,
                a
                Physician Assistant (PA) or ARNP licensed or certified by the State
                of
                Florida. The examination shall be conducted in person, and not via
                the
                Internet. If medical examinations are performed by a PA or ARNP,
                they must
                be performed under the supervision or review of a Doctor of Medicine
                or
                Osteopathy.

            

    

    

    (a) An
      ophthalmologist or optometrist licensed by the State of Florida may perform
      as
      much of the examination as pertains to visual acuity, field of vision and color
      recognition.

    

    (b) Upon
      completion of the examination, the examining medical professional shall
      complete, sign, and date the medical examination report.

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall have on file proof of medical
                examination, i.e., a completed and signed medical examination report
                for
                each driver, dated within the past 24 months. Medical examination
                reports
                of employee drivers shall be maintained by the Health Plan/Transportation
                Provider for a minimum of five (5) years from the date of the
                examination.

            

    

    

    k. Operational
      and Driving Requirements

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall not permit a driver to
                drive a
                vehicle when such driver’s license has been suspended, canceled or
                revoked. The Health Plan/Transportation Provider shall require a
                driver
                who receives a notice that his or her license to operate a motor
                vehicle
                has been suspended, canceled, or revoked notify his or her employer
                of the
                contents of the notice immediately, and no later than the end of
                the
                business day following the day he or she received the
                notice.

            

    

    

    
      	 	
              (2)

            	
              At
                all times, the Health Plan/Transportation Provider shall operate
                vehicles
                in compliance with applicable traffic regulations, ordinances and
                laws of
                the jurisdiction in which they are being
                operated.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall not permit or require a
                driver
                to drive more than twelve (12) hours in any one 24-hour period, or
                drive
                after having been on duty for sixteen (16) hours in any one twenty-four
                (24) hour period. The Health Plan/Transportation Provider shall not
                permit
                a driver to drive until the driver fulfills the requirement of a
                minimum
                eight (8) consecutive hours off-duty. A driver’s work period shall begin
                from the time he or she first reports for duty to his or her employer.
                A
                driver is permitted to exceed his or her regulated hours in order
                to reach
                a regularly established relief or dispatch point, provided the additional
                driving time does not exceed one (1)
                hour.

            

    

    

    
      	 	
              (4)

            	
              The
                Health Plan/Transportation Provider shall not permit or require a
                driver
                to be on duty more than seventy-two (72) hours in any period of seven
                (7)
                consecutive days; however, twenty-four (24) consecutive hours off-duty
                shall constitute the end of any such period of seven (7) consecutive
                days.
                The Health Plan/Transportation Provider shall ensure that a driver
                who has
                reached the maximum 72 hours of on-duty time during the seven (7)
                consecutive days has a minimum of twenty-four (24) consecutive hours
                off-duty before returning to on-duty
                status.

            

    

    

    
      	 	
              (5)

            	
              A
                driver is permitted to drive for more than the regulated hours for
                safety
                and protection of the public due to conditions such as adverse weather,
                disaster, security threat, a road or traffic condition, medical emergency
                or an accident.

            

    

    

    
      	 	
              (6)

            	
              The
                Health Plan/Transportation Provider shall not permit or require any
                driver
                to drive when his or her ability is impaired, or likely to be impaired,
                by
                fatigue, illness, or other causes, as to make it unsafe for the driver
                to
                begin or continue driving.

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan/Transportation Provider shall require pre-operational
                or daily
                inspection of all vehicles and reporting of all defects and deficiencies
                likely to affect safe operation or cause mechanical
                malfunctions.

            

    

    

    (a) The
      Health Plan/Transportation Provider shall maintain a log detailing a daily
      inspection or test of the following parts and devices to ascertain that they
      are
      in safe condition and in good working order:

    

    
      	 	
              i.

            	
              Service
                brakes;

            

    

    

    
      	 	
              ii.

            	
              Parking
                brakes;

            

    

    

    
      	 	
              iii.

            	
              Tires
                and wheels;

            

    

    

    
      	 	
              iv.

            	
              Steering;

            

    

    

    
      	 	
              v.

            	
              Horn;

            

    

    

    
      	 	
              vi.

            	
              Lighting
                devices;

            

    

    

    
      	 	
              vii.

            	
              Windshield
                wipers;

            

    

    

    
      	 	
              viii.

            	
              Rear
                vision mirrors;

            

    

    

    
      	 	
              ix.

            	
              Passenger
                doors and seats;

            

    

    

    
      	 	
              x.

            	
              Exhaust
                system;

            

    

    

    
      	 	
              xi.

            	
              Equipment
                for transporting wheelchairs; and

            

    

    

    
      	 	
              xii.

            	
              Safety,
                security, and emergency equipment.

            

    

    

    (b) The
      Health Plan/Transportation Provider shall review daily inspection reports and
      document corrective actions taken as a result of any deficiencies identified
      by
      any inspections.

    

    (c) The
      Health Plan/Transportation Provider shall retain records of all inspections
      and
      any corrective action documentation for five (5) years.

    

    (8) The
      driver shall not operate a vehicle with passenger doors in the open position
      when passengers are aboard. The driver shall not open the vehicle’s doors until
      the vehicle comes to a complete stop. The Health Plan/Transportation Provider
      shall not operate a vehicle with inoperable passenger doors with passengers
      aboard, except to move the vehicle to a safe location.

    

    (9) During
      darkness, interior lighting and lighting in stepwells on vehicles shall be
      sufficient for passengers to enter and exit safely.

    

    (10) Passenger(s)
      shall not be permitted in the stepwell(s) of any vehicle while the vehicle
      is in
      motion, or to occupy an area forward of the standee line.

    

    (11) Passenger(s)
      shall not be permitted to stand on or in vehicles not designed and constructed
      for that purpose.

    

    (12) The
      Health Plan/Transportation Provider shall not refuel vehicles in a closed
      building. The Health Plan/Transportation Provider shall minimize the number
      of
      times a vehicle shall refuel when passengers are onboard.

    

    (13) The
      Health Plan/Transportation Provider shall require the driver to be properly
      secured to the driver’s seat with a restraining belt at all times while the
      vehicle is in motion.

    

    (14) The
      driver shall not leave vehicles unattended with passenger(s) aboard for longer
      than five (5) minutes. The Health Plan/Transportation Provider shall ensure
      that
      the driver sets the parking or holding brake any time the vehicle is left
      unattended.

    

    (15) The
      Health Plan/Transportation Provider shall not leave vehicles unattended in
      an
      unsafe condition with passenger(s) aboard at any time.

    

    l. Vehicle
      Equipment Standards and Procurement Criteria

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall ensure that vehicles procured
                and operated meet the following requirements, at a
                minimum:

            

    

    

    (a) The
      capability and strength to carry the maximum allowed load and not exceed the
      manufacturer’s gross vehicle weight rating (GVWR), gross axle weighting, or tire
      rating;

    

    (b) Structural
      integrity that mitigates or minimizes the adverse effects of collisions;
      and

    

    (c) Federal
      Motor Vehicle Safety Standards (FMVSS), 49 C.F.R. Part 571, Sections 102, 103,
      104, 105, 108, 207, 209, 210, 217, 220, 221, 225, 302, 403, and 404, October
      1,
      2004, are hereby incorporated by reference. 

    

    
      	 	
              (2)

            	
              Proof
                of strength and structural integrity tests on new vehicles procured
                shall
                be submitted by manufacturers or the Health Plan/Transportation Providers
                to the Department of Transportation. (See 14-90,
                F.A.C.)

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall ensure that every vehicle
                operated in the State in connection with this Contract shall be equipped
                as follows:

            

    

    

    (a) Mirrors
      -
      There must be at least two (2) exterior rear vision mirrors, one (1) at each
      side. The mirrors shall be firmly attached to the outside of the vehicle and
      so
      located as to reflect to the driver a view to the rear along both sides of
      the
      vehicle. 

    

    
      	 	
              i.

            	
              Each
                exterior rear vision mirror, on Type I buses shall have a minimum
                reflective surface of fifty (50) square inches and the right (curbside)
                mirror shall be located on the bus so that the lowest part of the
                mirror
                and its mounting is a minimum eighty (80) inches above the ground.
                All
                Type I buses shall be equipped with an inside rear vision mirror
                capable
                of giving the driver a clear view of seated or standing passengers.
                Buses
                having a passenger exit door that is located inconveniently for the
                driver’s visual control shall be equipped with additional interior
                mirror(s), enabling the driver to view the passenger exit door. The
                exterior right (curbside) rear vision mirror and its mounting on
                Type I
                buses may be located lower than 80 inches from the ground, provided
                such
                buses are used exclusively for paratransit services.  See
                section 341.031, F.S. 

            

    

    

    
      	 	
              ii.

            	
              In
                lieu of interior mirrors, trailer buses and articulated buses may
                be
                equipped with closed circuit video systems or adult monitors in voice
                control with the driver.

            

    

    

    (b) Wiring
      and Battery - Electrical wiring shall be maintained so as not to come in contact
      with moving parts, or heated surfaces, or be subject to chafing or abrasion
      which may cause insulation to become worn. 

    

    
      	 	
              i.

            	
              Every
                Type I bus manufactured on or after February 7, 1988, shall be equipped
                with a storage battery(ies) electrical power main disconnect switch.
                The
                disconnect switch shall be practicably located in an accessible location
                adjacent to or near to the battery(ies) and be legibly and permanently
                marked for identification. 

            

    

    

    
      	 	
              ii.

            	
              Every
                storage battery on each public-sector bus shall be mounted with proper
                retainment devices in a compartment which provides adequate ventilation
                and drainage.

            

    

    

    (c) Brake
      Interlock Systems - All Type I buses having a rear exit door shall be equipped
      with a rear exit door/brake interlock that automatically applies the brake(s)
      upon driver activation of the rear exit door to the open position. Interlock
      brake application shall remain activated until deactivation by the driver and
      the rear exit door returns to the closed position. The rear exit door interlock
      on such buses shall be equipped with an identified override switch enabling
      emergency release of the interlock function, which shall not be located within
      reach of the seated driver. Air pressure application to the brake(s) during
      interlock operation, on buses equipped with rear exit door/brake interlock,
      shall be regulated at the original equipment manufacturer’s
      specifications.

    

    
      	 	
              (4)

            	
              Standee
                Line and Warning - Every vehicle designed and constructed to allow
                standees shall be plainly marked with a line of contrasting color
                at least
                two (2) inches wide or be equipped with some other means to indicate
                that
                any passenger is prohibited from occupying a space forward of a
                perpendicular plane drawn through the rear of the driver’s seat and
                perpendicular to the longitudinal axis of the vehicle. A sign shall
                be
                posted at or near the front of the vehicle stating that it is a violation
                for a vehicle to be operated with passengers occupying an area forward
                of
                the line.

            

    

    

    
      	 	
              (5)

            	
              Handrails
                and Stanchions - Every vehicle designed and constructed to allow
                standees
                shall be equipped with overhead grab rails for standee passengers.
                Overhead grab rails shall be continuous, except for a gap at the
                rear exit
                door, and terminate into vertical stanchions or turn up into a ceiling
                fastener. 

            

    

    

    Every
      Type I and Type II bus designed for carrying more than sixteen (16) passengers
      shall be equipped with grab handles, stanchions, or bars at least ten (10)
      inches long and installed to permit safe on-board circulation, seating and
      standing assistance, and boarding and unloading by elderly and handicapped
      persons. Type I buses shall be equipped with a safety bar and panel directly
      behind each entry and exit stepwell.

    

    
      	 	
              (6)

            	
              Flooring,
                Steps, and Thresholds - Flooring, steps, and thresholds on all vehicles
                shall have slip resistant surfaces without protruding or sharp edges,
                lips, or overhangs, to prevent tripping hazards. All step edges and
                thresholds shall have a band of color(s) running the full width of
                the
                step or edge which contrasts with the step tread and riser, either
                light-on-dark or dark-on-light.

            

    

    

    
      	 	
              (7)

            	
              Doors
                - Power activated doors on all vehicles shall be equipped with a
                manual
                device designed to release door closing
                pressure.

            

    

    

    
      	 	
              (8)

            	
              Emergency
                Exits - All vehicles shall have an emergency exit door, or in lieu
                thereof, shall be provided with emergency escape push-out windows.
                Each
                emergency escape window shall be in a form of a parallelogram with
                dimensions of not less than 18" by 24", and each shall contain an
                area of
                not less than 432 square inches. There shall be a sufficient number
                of
                such push-out or kick-out windows in each vehicle to provide a total
                escape area equivalent to 67 square inches per seat, including the
                driver’s seat.

            

    

    

    (a) No
      less
      than forty percent (40%) of the total escape area shall be on one (1) side
      of
      the vehicle. Emergency escape kick-out or push-out windows and emergency exit
      doors shall be conspicuously marked by a sign or light and shall always be
      kept
      in good working order so that they may be readily opened in an emergency.

    

    (b) All
      such
      windows and doors shall not be obstructed by bars or other such means located
      either inside or outside so as to hinder escape. Vehicles equipped with an
      auxiliary door for emergency exit shall be equipped with an audible alarm and
      light indicating to the driver when a door is ajar or opened while the engine
      is
      running. 

    

    (c) Supplemental
      security locks operable by a key are prohibited on emergency exit doors unless
      these security locks are equipped and connected with an ignition interlock
      system or an audio visual alarm located in the driver’s compartment. Any
      supplemental security lock system used on emergency exits shall be kept unlocked
      whenever a vehicle is in operation.

    

    
      	 	
              (9)

            	
              Tires
                and Wheels - Tires shall be properly inflated in accordance with
                manufacturer’s recommendations.

            

    

    

    (a) No
      vehicle shall be operated with a tread groove pattern depth:

    

    
      	 	
              i.

            	
              Less
                than 4/32 (1/8) of an inch, measured at any point on a major tread
                groove
                for tires on the steering axle of all vehicles. The measurements
                shall not
                be made where tie bars, humps, or fillets are
                located.

            

    

    

    
      	 	
              ii.

            	
              Less
                than 2/32 (1/16) of an inch, measured at any point on a major tread
                groove
                for all other tires of all vehicles. The measurements shall not be
                made
                where tie bars, humps, or fillets are
                located.

            

    

    

    (b) The
      Health Plan/Transportation Provider shall not operate any vehicle with recapped,
      regrooved, or retreaded tires on the steering axle.

    

    (c) The
      Health Plan/Transportation Provider shall ensure that all wheels are visibly
      free from cracks and distortion and shall not have missing, cracked, or broken
      mounting lugs.

    

    (10) Suspension
      - The suspension system of all vehicles, including springs, air bags, and all
      other suspension parts as applicable, shall be free from cracks, leaks, or
      any
      other defect which would or may cause its impairment or failure to function
      properly.

    

    (11) Steering
      and Front Axle - The steering system of all vehicles shall have no indication
      of
      leaks which would or may cause its impairment to function properly, and shall
      be
      free from cracks and excessive wear of components that would or may cause
      excessive free play or loose motion in the steering system or above normal
      effort in steering control.

    

    (12) Seat
      Belts - Every vehicle shall be equipped with an adjustable driver’s restraining
      belt in compliance with the requirements of FMVSS 209, “Seat Belt Assemblies”
(See 49 C.F.R. 571.209) and FMVSS 210, “Seat Belt Assembly Anchorages.” (See 49
      C.F.R. 571.210) 

    

    (13) Safety
      Equipment - Every vehicle shall be equipped with one (1) fully charged dry
      chemical or carbon dioxide fire extinguisher, having at least a 1A:BC rating
      and
      bearing the label of Underwriter’s Laboratory, Inc.

    

    (a) Each
      fire
      extinguisher shall be securely mounted on the vehicle in a conspicuous place
      or
      a clearly marked compartment and be readily accessible.

    

    (b) Each
      fire
      extinguisher shall be maintained in efficient operating condition and equipped
      with some means of determining if it is fully charged.

    

    (c) Every
      Type I bus shall be equipped with portable red reflector warning devices (See
      section 316.300, F.S.).

    

    (14) Vehicles
      used for the purpose of transporting individuals with disabilities shall meet
      the requirements set forth in 49 C.F.R. Part 38, hereby incorporated by
      reference, and the following:

    

    (a) Installation
      of a wheelchair lift or ramp shall not cause the manufacturer’s GVWR, gross axle
      weight rating, or tire rating to be exceeded.

    

    (b) Except
      in
      locations within 3 1/2 inches of the vehicle floor, all readily accessible
      exposed edges or other hazardous protrusions of parts of wheelchair lift
      assemblies or ramps that are located in the passenger compartment shall be
      padded with energy absorbing material to mitigate injury in normal use and
      in
      case of a collision. This requirement shall also apply to parts of the vehicle
      associated with the operation of the lift or ramp.

    

    (c) The
      controls for operating the lift shall be at a location where the driver or
      lift
      attendant has a full view, unobstructed by passengers, of the lift platform,
      its
      entrance and exit, and the wheelchair passenger, either directly or with partial
      assistance of mirrors. Lifts located entirely to the rear of the driver’s seat
      shall not be operable from the driver’s seat, but shall have an override control
      at the driver’s position that can be activated to prevent the lift from being
      operated by the other controls (except for emergency manual operation upon
      power
      failure).

    

    (d) The
      installation of the wheelchair lift or ramp and its controls and the method
      of
      attachment in the vehicle body or chassis shall not diminish the structural
      integrity of the vehicle nor cause a hazardous imbalance of the vehicle. No
      part
      of the assembly, when installed and stowed, shall extend laterally beyond the
      normal side contour of the vehicle or vertically beyond the lowest part of
      the
      rim of the wheel closest to the lift.

    

    (e) Each
      wheelchair lift or ramp assembly shall be legibly and permanently marked by
      the
      manufacturer or installer with the following minimum information:

    

    i. The
      manufacturer’s name and address;

    

    ii. The
      month
      and year of manufacture; and

    

    iii. A
      certificate that the wheelchair lift or ramp securement devices, and their
      installation, conform to State of Florida requirements applicable to accessible
      vehicles.

    

    (15) Wheelchair
      lifts, ramps, securement devices, and restraints shall be inspected and
      maintained as specified above. Instructions for normal and emergency operation
      of the lift or ramp shall be carried or displayed in every vehicle.

    

    m. Vehicle
      Safety Inspections

    

    
      	 	
              (1)

            	
              The
                Health Plan/Transportation Provider shall require that all vehicles
                be
                inspected in accordance with the vehicle inspection procedures set
                forth
                above.

            

    

    

    
      	 	
              (2)

            	
              It
                is the Health Plan’s/Transportation Provider’s responsibility to ensure
                that each individual performing a vehicle safety inspection is qualified
                as follows:

            

    

    

    (a) Understands
      the requirements set forth in 14-90, F.A.C., 2004 and can identify defective
      components;

    

    (b) Is
      knowledgeable of, and has mastered the methods, procedures, tools, and equipment
      used when performing an inspection; and

    

    (c) Has
      at
      least one (1) year of training and/or experience as a mechanic or inspector
      in a
      vehicle maintenance program and has sufficient general knowledge of vehicles
      owned and operated by the Health Plan/Transportation Provider to recognize
      deficiencies or mechanical defects.

    

    
      	 	
              (3)

            	
              The
                Health Plan/Transportation Provider shall ensure that each vehicle
                receiving a safety inspection is checked for compliance with the
                safety
                devices and equipment requirements as referenced or specified above.
                Specific operable equipment and devices include the
                following:

            

    

    

    (a) Horn;

    

    (b) Windshield
      wipers;

    

    (c) Mirrors;

    

    (d) Wiring
      and battery(ies);

    

    (e) Service
      and parking brakes;

    

    (f) Warning
      devices;

    

    (g) Directional
      signals;

    

    (h) Hazard
      warning signals;

    

    (i) Lighting
      systems and signaling devices;

    

    (j) Handrails
      and stanchions;

    

    (k) Standee
      line and warning;

    

    (l) Doors
      and
      interlock devices;

    

    (m) Stepwells
      and flooring;

    

    (n) Emergency
      exits;

    

    (o) Tires
      and
      wheels;

    

    (p) Suspension
      system;

    

    (q) Steering
      system;

    

    (r) Exhaust
      system;

    

    (s) Seat
      belts; 

    

    (t) Safety
      equipment; and

    

    (u) Equipment
      for transporting wheelchairs.

    

    
      	 	
              (4)

            	
              A
                safety inspection report shall be prepared by the individual(s) performing
                the inspection and shall include the
                following:

            

    

    

    (a) Identification
      of the individual(s) performing the inspection;

    

    (b) Identification
      of the Health Plan/Transportation Provider operating the vehicle;

    

    (c) The
      date
      of the inspection;

    

    (d) Identification
      of the vehicle inspected;

    

    (e) Identification
      of the equipment and devices inspected including the identification of equipment
      and devices found deficient or defective; and

    

    (f) Identification
      of corrective action(s) for deficient or defective items and date(s) of
      completion of corrective action(s).

    

    
      	 	
              (5)

            	
              Records
                of annual safety inspections and documentation of any required corrective
                actions shall be retained, for compliance review, a minimum of five
                (5)
                years by the Health Plan/Transportation
                Provider.

            

    

    

    n. Certification
      - Each Health Plan/Transportation Provider shall submit an annual safety and
      security certification in accordance with 14-90.10, F.A.C., 2004 and shall
      submit to any and all safety and security inspections and reviews in accordance
      with 14-90.12, F.A.C., 2004.

    

    o. The
      Health Plan shall report the following by August 15th of each year:

    

    
      	 	
              (1)

            	
              The
                estimated number of one-way passenger trips to be provided in the
                following categories, as defined in the Transportation
                Handbook:

            

    

    

    (a) Ambulatory
      Transportation;

    

    (b) Long
      haul
      ambulatory Transportation;

    

    (c) Wheelchair
      Transportation;

    

    (d) Stretcher
      Transportation;

    

    (e) Ambulatory
      multiload Transportation;

    

    (f) Wheelchair
      multiload Transportation;

    

    (g) Mass
      transit pending Transportation;

    

    (h) Mass
      transit Transportation;

    

    (i) Mass
      transit Transportation (Enrollee has pass); and

    

    (j) Mass
      transit Transportation (sent pass to Enrollee).

    

    
      	 	
              (2)

            	
              The
                actual amount of funds expended and the total number of trips provided
                during the previous fiscal year;
                and

            

    

    

    
      	 	
              (3)

            	
              The
                operating financial statistics for the previous fiscal
                year.

            

    

    

    p. The
      Health Plan shall provide the total number of vehicles in each category, other
      than public Transportation, that will serve each county as well as a provider
      directory for all Transportation Services.

    

    

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    Section
      VI

    Behavioral
      Health Care

    

    
      	A.	
               General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall provide Medically Necessary Behavioral Health Services
                for all Enrollees pursuant to this Contract. The Health Plan shall
                provide
                a full range of Behavioral Health Services authorized under the State
                Plan
                and specified by this Contract. 

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall provide the following services as described in
                the
                Hospital Inpatient Handbook, Mental Health Targeted Case Management
                Coverage & Limitations Handbook, and the Community Behavioral Health
                Services Coverage & Limitations Handbook (the Handbooks). The Health
                Plan shall not alter the amount, duration and scope of such services
                from
                that specified in the Handbooks. The Health Plan shall not establish
                service limitations that are lower than, or inconsistent with the
                Handbooks. 

            

    

    

    
      	 	
              a.

            	
              Inpatient
                hospital care for psychiatric conditions (ICD-9-CM codes 290 through
                290.43, 293.0 through 298.9, 300 through 301.9, 302.7, 306.51 through
                312.4 and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                315.9);

            

    

    

    
      	 	
              b.

            	
              Outpatient
                hospital care for psychiatric conditions (ICD-9-CM codes 290 through
                290.43, 293 through 298.9, 300 through 301.9, 302.7, 306.51 through
                312.4
                and 312.81 through 314.9, 315.3, 315.31, 315.5, 315.8, and
                315.9);

            

    

    

    
      	 	
              c.

            	
              Psychiatric
                physician services (for psychiatric specialty codes 42, 43, 44 and
                ICD-9-CM codes 290 through 290.43, 293.0 through 298.9, 300 through
                301.9,
                302.7, 306.51 through 312.4 and 312.81 through 314.9, 315.3, 315.31,
                315.5, 315.8, and 315.9);

            

    

    

    
      	 	
              d.

            	
              Community
                mental health services (ICD-9-CM codes 290 through 290.43, 293.0
                through
                298.9, 300 through 301.9, 302.7, 306.51 through 312.4 and 312.81
                through
                314.9, 315.3, 315.31, 315.5, 315.8, and 315.9); and for these procedure
                codes H0001, H0001HN; H0001H0, H0001TS; H0031; H0031 HO; H0031HN;
                H0031TS;
                H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP; H2010HO; H2010HE;
                H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
                H2019HO;
                H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
                T1023HE;
                or T1023HF.

            

    

    

    
      	 	
              e.

            	
              Mental
                Health Targeted Case Management (Children: T1017HA; Adults: T1017);
                and

            

    

    

    
      	 	
              f.

            	
              Mental
                Health Intensive Targeted Case Management (Adults:
                T1017HK).

            

    

    

    3. Non
      Covered Services

    

    The
      following services are not covered by the Health Plan. Should the Health Plan
      determine the need for, or be advised of the need for, these or other services
      not customarily covered by the Health Plan, the Health Plan shall refer the
      Enrollee to the appropriate provider:

    

    
      	 	
              a.

            	
              Specialized
                Therapeutic Foster Care;

            

    

    

    
      	 	
              b.

            	
              Therapeutic
                Group Care Services;

            

    

    

    
      	 	
              c.

            	
              Behavioral
                Health Overlay Services; 

            

    

    

    
      	 	
              d.

            	
              Community
                Substance Abuse Services, except as required by this Contract;
                

            

    

    

    
      	 	
              e.

            	
              Residential
                Care;

            

    

    

    
      	 	
              f.

            	
              Sub-acute
                Inpatient Psychiatric Program (SIPP) Services;

            

    

    

    
      	 	
              g.

            	
              Clubhouse
                Services.

            

    

    

    
      	 	
              h.

            	
              Comprehensive
                Behavioral Assessment, and 

            

    

    

    
      	 	
              i.

            	
              Florida
                Assertive Community Treatment Services (FACT)

            

    

    
      	 	 	 

    

    
      	 	 	
              The
                PSN shall NOT be responsible for the provision of mental health services
                to enrollees assigned to a FACT team by the DCF Substance Abuse and
                Mental
                Health Program (SAMH) Office. These individuals will be disenrolled
                from
                the plan and receive all mental health services through the funding
                mechanism developed by DCF/SAMH and AHCA and re-enrolled in the plan
                upon
                discharge from the FACT Team Services. The FACT Team providers are
                responsible for notifying Medicaid of admissions and
                discharges

            

    

    

    4. The
      Health Plan shall provide Outpatient Medical Services in accordance with Section
      V, Covered Services, of this Contract. 

    

    5. If
      an
      Enrollee makes a request for services to the Health Plan, the Health Plan shall
      provide the Enrollee with the name (or names) of qualified Behavioral Health
      Care Providers, and if requested, assist the Enrollee with making an appointment
      with the Provider that is within the required access times indicated in Section
      VII.D., Appointment Waiting Times and Geographic Access Standards, and Section
      VII.E., Behavioral Health Services.

    

    6. Services
      available under the Health Plan shall represent a comprehensive range of
      appropriate services for both Children/Adolescents and adults who experience
      impairments ranging from mild to severe and persistent. This Section outlines
      the Agency’s expectations and requirements related to each of the categories of
      service. 

     

    Optional
      services may be provided and are defined as additional services that will
      enhance the services mandated in the contract. A list of possible optional
      services is included in the Additional Service Requirements section as an
      example of services that may be beneficial for plan enrollees. Optional services
      may be provided under the Contract as a downward substitution of care. When
      a
      service is intended to be provided as a downward substitution, the provider
      must
      use clinical rationale for determining the benefit of the service for the
      enrollee.

    

    

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      	B.
               	 Expanded
              Services

    

    
      	 	
              1.

            	
              Inpatient
                Hospital Services

            

    

    

    Inpatient
      Hospital services are medically necessary mental health care services provided
      in a hospital setting (see Section V.B.8, Covered Services, Hospital Services
      -
      Inpatient, in this Contract). Services may be provided in a general Hospital
      psychiatric unit or in a specialty Hospital. The inpatient care and treatment
      services that an Enrollee receives must be under the direction of a licensed
      physician with the appropriate Medicaid specialty requirements.

    

    a. A
      hospital’s per diem (daily rate) for inpatient mental health hospital care and
      treatment covers all services and items furnished during a 24-hour period.
      The
      facilities, supplies, appliances, and equipment furnished by the hospital during
      the inpatient stay are included in the per diem as well as the related nursing,
      social, and other services furnished by the hospital during the inpatient
      stay.

    

    b.
       For
      all
      Child/Adolescent Enrollees, the Health Plan shall be responsible for the
      provision of up to 365 days of mental health-related Hospital inpatient care
      for
      each year.

    

    c.
       For
      all
      Enrollees, the Health Plan shall pay for inpatient mental health-related
      Hospital days determined Medically Necessary by the Health Plan’s medical
      director or designee, up to the maximum number of days required under the
      Contract. 

    

    d. If
      an
      Enrollee is admitted to a Hospital for a non-psychiatric diagnosis and during
      the same hospitalization transfers to a psychiatric unit or the treatment of
      a
      psychiatric diagnosis, the Health Plan is at risk for the Medically Necessary
      mental health treatment inpatient days up to the maximum number of days required
      under the Contract.

    

    e. The
      Health Plan shall be responsible to cover the cost of all Enrollees’ Medically
      Necessary stays resulting from a mental health emergency, until such time as
      Enrollees can be safely transported to a designated facility.

    

    f. Crisis
      Stabilization Units may be used as a downward substitution for inpatient
      psychiatric hospital care when determined medically appropriate. These bed
      days
      are included toward the 45-day coverage count discussed above in A.1. They
      are
      calculated on a two for one basis. Two CSU days count toward one inpatient
      day.
      Beds funded by the Department of Children and Families, Substance Abuse and
      Mental Health (SAMH) cannot be used for Enrollees if there are non-funded
      clients in need of the beds. If CSU beds are at capacity, and some of the beds
      are occupied by Enrollees, and a non-funded client presents in need of services,
      the Enrollees must be transferred to an appropriate facility to allow the
      admission of the non-funded client. Therefore, the Health Plan must demonstrate
      adequate capacity for inpatient hospital care in anticipation of such
      transfers.

    

    
      	 	
              2.

            	
              Outpatient
                Hospital Services

            

    

    

    Outpatient
      Hospital services are Medically Necessary mental health care services provided
      in a hospital setting. The outpatient care and treatment services that an
      Enrollee receives must be under the direction of a licensed physician with
      the
      appropriate specialty.. 

     

    
      	 	
              3.

            	
              Physician
                Services

            

    

    

    a. Physician
      services are those services rendered by a licensed physician who possesses
      the
      appropriate Medicaid specialty requirements when applicable. A psychiatrist
      must
      be certified as a psychiatrist by the American Board of Psychiatry and Neurology
      or the American Osteopathic Board of Neurology and Psychiatry, or have completed
      a psychiatry residency accredited by the Accreditation Council for Graduate
      Medical Education (ACGME) or the Royal College of Physicians and Surgeons of
      Canada.

    

    b. Physician
      services include specialty consultations for evaluations. A physician
      consultation shall include an examination and evaluation of the Enrollee with
      information from family member(s) or significant others as appropriate. The
      consultation shall include written documentation on an exchange of information
      with the attending Provider. The components of the evaluation and management
      procedure code and diagnosis code must be documented in the Enrollee's medical
      record. A Hospital visit to an Enrollee in an acute care Hospital for a mental
      health diagnosis must be documented with a mental health procedure code and
      mental health diagnosis code. All procedures with a minimum time requirement
      shall be documented in the medical record to show the time spent providing
      the
      service to the Enrollee. The Health Plan must be responsive to requests for
      consultations made by the PCP.

    

    c. Physicians
      are required to coordinate Medically Necessary mental health care with the
      PCP
      and other Providers involved with the care of the Enrollee. The Health Plan
      shall have a set of protocols that indicate when such coordination will be
      required.

    

    
      	 	
              4.

            	
              Community
                Mental Health Services - Covered
                Services

            

    

    

    a. General
      Provisions

     

    Community
      mental health services include mental health services that are provided for
      the
      maximum reduction of the Enrollee’s mental health disability and restoration to
      the best possible functional level. Community mental health services can
      reasonably be expected to improve the Enrollee’s condition or prevent further
      regression so that the services will no longer be needed. The health plan must
      provide services that are medically necessary and are rendered or recommended
      by
      a physician, psychiatrist, or licensed mental health professional and included
      in an individualized treatment plan. Medically Necessary community mental health
      services must be provided to Enrollees of all ages from very young children
      through the geriatric population. Provision of services very early may reduce
      the provision of expensive services later, and the health plan is encouraged
      to
      use creativity, flexibility, and outreach to provide mental health services
      to
      its enrollees. Services should be age appropriate and sensitive to the
      developmental level of the enrollee.

    

    The
      services provided must meet the intent of the services covered in the Florida
      Medicaid Community Mental Health Services Coverage and Limitations Handbook.
      Although the Health Plan can provide flexible services, the service limits
      and
      medical necessity criteria cannot be more restrictive than those in Medicaid
      policy as stated in Medicaid handbooks and this Contract. Additionally, the
      Health Plan may have available additional services, but must have the core
      services available as outlined and discussed below.

    

    The
      health plan shall establish “Medical Necessity” criteria, including admission
      criteria, continuing stay criteria, and discharge criteria for all mandatory
      and
      optional services. Criteria must be specific to enrollee ages and diagnoses
      and
      must account for orders for involuntary outpatient placement pursuant to
      394.4655, F.S. These criteria must be submitted for review by the Agency and
      approval.

    

    The
      following describes basic categories of mental health care services considered
      core services. The frequency, duration, and content of the services should
      be
      consistent with the age, developmental level and level of functioning of the
      enrollee. The health plan shall develop clinical care criteria appropriate
      for
      each service to be provided. The health plan shall consult the most recent
      the
      Community Behavioral Health Services Coverage and Limitations Handbook published
      by the Agency.

    

    b. Treatment
      Plan Development and Modification

    

    Treatment
      planning includes working with the Enrollee, their natural support system,
      and
      all involved treating Providers to develop an individualized plan for addressing
      identified clinical needs. A Behavioral Health Care Provider must complete
      a
      face-to-face interview with the Enrollee during the development of the plan.
      

    

    The
      Individualized Treatment Plan shall:

    

    •
be
      recovery-oriented and promote resiliency;

    •
be
      enrollee-directed;

    •
      accurately reflect the presenting problems of the enrollee;

    •
be
      based on the strengths of the enrollee, family, and other natural support
systems;

    •
provide
      outcome-oriented objectives for the enrollee;

    •
include
      an outcome-oriented schedule of services that will be provided to meet
the
      enrollee’s needs;

    •
include
      the coordination of services not covered by the plan such as school- based
      services, vocational rehabilitation, housing supports, Medicaid fee-for service
      substance abuse treatment, and physical health care.

    

      Individualized
      Treatment Plan reviews shall be conducted at six-month intervals to assure
      that
      the services being provided are effective and remain appropriate for addressing
      individual needs. Additionally, a review is expected whenever clinically
      significant events occur. The provider is expected to use the Individualized
      Treatment Plan review process in the utilization management of medically
      necessary services. For further guidance see the most recent Community
      Behavioral Health Services and Coverage Handbook.

    

    c. 
      Assessment Services 

    

    
      	 	
              (1)
                

            	
              These
                services include psychological testing (standardized tests) and
                evaluations that assess the enrollee’s functioning in all areas. All
                evaluations must be appropriate to the age, developmental level and
                functioning of the enrollee. All evaluations must include a clinical
                summary that integrates all the information gathered and identifies
                enrollee’s needs. The evaluation should prioritize the clinical needs,
                evaluate the effectiveness of any prior treatment, and include
                recommendations for interventions and services to be
                provided.

            

    

    

    (2)
      Evaluation or assessment services, when determined medically necessary, must
      include assessment of mental status, functional capacity, strengths, and service
      needs by trained mental health staff. Also included in this category is the
      administration of the functional assessments that are required by the Agency,
      DCF, the EQRO, or academic research center.

    

    (3)
      Prior
      to receiving any community mental health services, children ages 0-5 must have
      a
      current assessment (within one year) of presenting symptoms and behaviors;
      developmental and medical history; family psychosocial and medical history;
      assessment of family functioning; a clinical interview with the primary
      caretaker and an observation of the child’s interaction with the caretaker; and
      an observation of the child’s language, cognitive, sensory, motor, self-care,
      and social functioning.

    

    
      	 	
              d.

            	
              Medical
                and Psychiatric Services

            

    

    

    (1) These
      services include Medically Necessary interventions that require the skills
      and
      expertise of a psychiatrist, psychiatric ARNP, or physician.

    

    (2) Medical
      psychiatric interventions include the prescribing and management of medications,
      monitoring of side effects associated with prescribed medications, individual
      or
      group medical psychotherapy, psychiatric evaluation, psychiatric review of
      treatment records for diagnostic purposes, and psychiatric consultation with
      an
      enrollee’s family or significant others, primary care providers, and other
      treatment providers.

    

    (3)
      Interventions related to specimen collections, taking vital signs and
      administering injections are also a covered service. 

    

    (4)
      These
      services are distinguished from the physician services outlined in Section
      C in
      that they are provided through a community mental health center. Psychiatric
      or
      physician services must be available at sites where substantial amounts of
      community mental health services are provided.

    

    
      	 	
              e.

            	
              Behavioral
                Health Therapy Services:

            

    

    

    (1) These
      services include individual and family therapy, group therapy, and behavioral
      health day services. These services include psychotherapy or supportive
      counseling focused on assisting enrollees with the problems or symptoms
      identified in an assessment. The focus should be on identifying and utilizing
      the strengths of the enrollee, family, and other natural support systems.
      Therapy services should be geared to the individual needs of the enrollee and
      should be sensitive to the age, developmental level, and functional level of
      the
      enrollee.

    

    (2)
      Family or marital therapy is also included in this category. Examples of
      interventions include those that focus on resolution of a life crisis or an
      adjustment reaction to an external stressor or developmental
      challenge.

    

    (3)
      Behavioral Day Services are designed to enable individuals to function
      successfully in the community in the least restrictive environment and to
      restore or enhance ability for social and prevocational life management
      services. The primary functions of behavioral health day services are
      stabilization of the symptoms related to a behavioral health disorder to reduce
      or eliminate the need for more intensive levels of care, to provide transitional
      treatment after an acute episode, or to provide a level of therapeutic intensity
      not possible in a traditional outpatient setting.

    

    

    
      	 	
              f.

            	
              Community
                Support and Rehabilitative
                Services

            

    

    

    (1) These
      services include: Psychosocial Rehabilitation Services and Clubhouse services.
      Clubhouse services are excluded from the health plan’s covered services.
      Psychosocial rehabilitation services may be provided in a facility, home, or
      community setting. These services assist enrollees in functioning within the
      limits of a disability or disabilities resulting from a mental illness. Services
      focus on restoration of a previous level of functioning or improving the level
      of functioning. Services must be individualized and directly related to goals
      for improving functioning within a major life domain.

    

    (2)
      The
      coverage must include a range of social, educational, vocational, behavioral,
      and cognitive interventions to improve enrollees’ potential for social
      relationships, occupational/educational achievement and living skills
      development. Skills training development is also included in this category
      and
      includes activities aimed toward restoration of enrollees’ skills/abilities that
      are essential for managing their illness, actively participating in treatment,
      and conducting the requirements of daily independent living. Providers must
      offer the services in a setting best suited for desired outcomes, i.e., home
      or
      community-based settings.

    

    (3)
      Psychosocial Rehabilitative Services may also be provided to assist individuals
      in finding or maintaining appropriate housing arrangements or to maintain
      employment. Interventions should focus on the restoration of skills/abilities
      that are adversely affected by the mental health illness and supports required
      to manage the individual’s housing or employment needs. The provider must be
      knowledgeable about the local TANF initiative and is responsible for medically
      necessary mental health services that will assist the individual in finding
      and
      maintaining employment.

    

    

    
      	 	
              g.
                

            	
              Therapeutic
                Behavioral On-Site Services for Children and Adolescents
                (TBOS):

            

    

    

    
      	 	 	
              Therapeutic
                Behavioral On-Site Services are community services and natural supports
                for children with serious emotional disturbances. Clinical services
                include the provision of a professional level therapeutic service
                that may
                include the teaching of problem solving skills, behavioral strategies,
                normalization activities and other treatment modalities that are
                determined to be medically necessary. These services should be designed
                to
                maximize strengths and reduce behavior problems or functional deficits
                stemming from the existence of a mental health disorder. Social services
                include interventions designed for the restoration, modification,
                and
                maintenance of social, personal adjustment and basic living
                skills.

            

    

    

    
      	 	
               

            	
              These
                services are intended to maintain the child in the home and to prevent
                reliance upon a more intensive, restrictive, and costly mental health
                placement. They are also focused on helping the child possess the
                physical, emotional, and intellectual skills to live, learn and work
                in
                their own communities. Coverage must include the provision of these
                services outside of the traditional office setting. The services
                must be
                provided where they are needed, in the home, school, childcare centers
                or
                other community sites.

            

    

    

    h. 
      Services for Children Ages 0 through 5-Years 

     

    Services
      to these children include behavioral health day services and Therapeutic
      Behavioral On-Site Services for Children Ages 0 through 5 years.

    

    Prior
      to
      receiving these services, the children in this age group must meet the criteria
      as stated in the Medicaid Community Behavioral Health Service Coverage and
      Limitations Handbook.

    

    i. Crisis
      Intervention Mental Health Services and Post-Stabilization Care Services

    

      Crisis
      intervention services include intervention activities of less than 24-hour
      duration (within a 24-hour period) designed to stabilize an individual in a
      Psychiatric emergency.

    

    Post-stabilization
      care services include any of the mandatory services that a treating physician
      views as medically necessary, that are provided after an enrollee is stabilized
      from an emergency mental health condition in order to maintain the stabilized
      condition, or under the circumstances described in 42 CFR 438.114(e) to improve
      or resolve the enrollee’s condition.

    

    j. Substance
      Abuse Services 

    

    Health
      plan Enrollees will receive Medicaid funded substance abuse services through
      the
      fee-for- service system. The health plan shall develop methods of coordinating
      and integrating mental health and substance abuse services for plan enrollees.
      The plan shall be required to use the Florida Supplement to the American Society
      of Addictions Medicine Patient Placement Criteria for the coordination of mental
      health treatment with substance abuse providers as part of the integration
      effort (Second Edition ASAM PPC-2, July 1998.) the coordination shall be
      reflected in their individualized Treatment Plan for enrollees with co-occurring
      disorder. The protocol for integrating mental health services with substance
      abuse services shall be monitored through the Quality of Care monitoring
      activities completed by the Agency’s EQRO contractor and the Quality Improvement
      requirements in Section D.34

    

    

    
      	 	
              5.

            	
              Mental
                Health Targeted Case
                Management

            

    

    

    a. The
      Health Plan must provide targeted Case Management services to
      Children/Adolescents with serious emotional disturbances and adults with a
      severe mental illness as defined below. The Health Plan shall meet the intent
      of
      the services as outlined below and in the Medicaid Mental Health Targeted Case
      Management Coverage and Limitations Handbook. The Health Plan shall set criteria
      and clinical guidelines for Case Management services. Service limits and
      criteria developed cannot be more restrictive than those in Medicaid policy
      and
      as stated below.

    

    At
      a
      minimum, case management services are to incorporate the principles of a
      strengths-based approach. Strengths-based case management services are an
      alternative service modality for working with individuals and families. This
      method stresses building on the strengths of individuals that can be used to
      resolve current problems and issues, countering more traditional approaches
      that
      focus almost exclusively on individuals’ deficits or needs.

    

    b. Target
      Populations: 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have Case Management services available to
                Children/Adolescents who have a serious emotional disturbance as
                defined
                as: a Child/Adolescent with a defined mental disorder; a level of
                functioning which requires two or more coordinated mental health
                services
                to be able to live in the community; and be at imminent risk of out
                of
                home mental health treatment
                placement.

            

    

    

    
      	 	
              (2)

            	
              The
                health plan must have case management services available for adults
                who:

            

    

    

    •
       Have
      been
      denied admission to a long-term mental health institution or residential
      treatment facility; or

    •
       Have
      been
      discharged from a long-term mental health institution or residential treatment
      facility.

    •
       Require
      numerous services from different providers and also require advocacy and
      coordination to implement or access services;

    •
       Would
      be
      unable to access or maintain consistent care within the service delivery system
      without case management services;

    •
       Do
      not
      possess the strengths, skills, or support system to allow them to access or
      coordinate services; The health plan will not be required to seek approval
      from
      the Department of Children and Families, District Substance Abuse and Mental
      Health (SAMH) Office for individual eligibility or mental health targeted case
      management agency or individual provider certification. The staffing
      requirements for case management services are listed below. Refer to section
      d.
      Additional Requirement For Case Management.

    

    
      	 	
              (3)

            	
              Mental
                health targeted Case Management services shall be available to all
                Enrollees within the principles and guidelines described as
                follows:

            

    

    

    (a) Enrollees,
      who require numerous services from different providers and also require advocacy
      and coordination to implement or access services are appropriate for Case
      Management services;

    

    (b) Enrollees
      who would be unable to access or maintain consistent care within the service
      delivery system without Case Management services are appropriate for the
      service;

    

    (c) Enrollees
      who do not possess the strengths, skills, or support system to allow them to
      access or coordinate services are appropriate for Case Management
      services;

    

    (d) Enrollees
      without the skills or knowledge necessary to access services may benefit from
      Case Management. Case Management provides support in gaining skills and
      knowledge needed to access services and enhances the Enrollee’s level of
      independence.

    

    
      	 	
              (4)

            	
              The
                Health Plan will not be required to seek approval from the DCF, District
                Substance Abuse and Mental Health Program Office for client eligibility
                or
                mental health targeted Case Management agency or individual provider
                certification. The staffing requirements for Case Management services
                are
                found in Section VII.E..7, Provider Network, Behavioral Health Services,
                in this Contract. 

            

    

     

    c. Required
      Mental Health Targeted Case Management Services 

    

    
      	 	
              (1)

            	
              Mental
                Health Targeted Case Management services include working with the
                Enrollee
                and the Enrollee’s natural support system to develop and promote a needs
                assessment-based service plan. The service plan reflects the services
                or
                supports needed to meet the needs identified in an individualized
                assessment of the following areas: education or employment, physical
                health, mental health, substance abuse, social skills, independent
                living
                skills, and support system status. The approach used should identify
                and
                utilize the strengths, abilities, cultural characteristics, and informal
                supports of the enrollee, family, and other natural support systems.
                Targeted case managers focus on overcoming barriers by collaborating
                and
                coordinating with Providers and the Enrollee to assist in the attainment
                of service plan goals. The targeted case manager takes the lead in
                both
                coordinating services/treatment and assessing the effectiveness of
                the
                services provided. A strengths-based approach to providing services
                is
                consistent with the values of individuality and uniqueness and promotes
                participant self-direction and choice. The planning process is vital
                to
                achieving desired outcomes for the individual. The person must have
                a
                sense of ownership about his/her goals, and the goals must have true
                meaning and vitality for him/her. 

            

    

    

    
      	 	
              (2)

            	
              When
                targeted case management recipients enrolled in the health plan are
                hospitalized in an acute care setting or held in a county jail or
                juvenile
                detention facility, the health plan shall maintain contact with the
                individual and shall participate actively in the discharge planning
                processes.

            

    

    

    
      	 	
              (3)

            	
              Case
                managers are also responsible for coordination and collaboration
                with the
                parents or guardians of Children/Adolescents who receive mental health
                targeted Case Management services. The Health Plan shall make reasonable
                efforts to assure that case managers include the parents or guardians
                of
                Enrollees in the process of providing targeted Case Management services.
                Integration of the parent’s input and involvement with the case manager
                and other Providers shall be reflected in Medical Record documentation
                and
                monitored through the Health Plan’s quality of care monitoring activities.
                Involvement with the child’s school and/or childcare center must also be a
                component of case management with
                children

            

    

    

    d. Additional
      Requirements for Targeted Case Management

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have a Case Management program, including clinical
                guidelines and protocol that addresses the issues
                below:

            

    

    

    (a) Caseloads
      must be set to achieve the desired results. Size limitations must clearly state
      the ratio of enrollees to each individual case manager. The limits shall be
      specified for children and adults, with a description of the clinical rationale
      for determining each limitation. If the health plan permits “mixed” caseloads,
      i.e., children and adults, a separate limitation is expected along with the
      rationale for the determination. Ratios must be no greater than the requirements
      set forth in the Medicaid Mental Health Targeted Case Management Coverage and
      Limitations Handbook.

    

    (b) A
      system
      shall be in place to manage caseloads when positions become vacant.

    

    (c) The
      modality of service provision, and the location that services will be provided,
      shall be described.

    

    (d) Case
      Management protocol and clinical practice guidelines, which outline the expected
      frequency, duration and intensity of the service, shall be
      available.

    

    (e) Clinical
      guidelines shall address issues related to recovery and self-care, including
      services that will assist Enrollees in gaining independence from the mental
      health and Case Management system.

    

    
      	 	
              (2)

            	
              The
                Case Management program shall have services available based on the
                individual needs of the Enrollees receiving the service. The service
                should reflect a flexible system that allows movement within a continuum
                of care that addresses the changing needs and abilities of
                Enrollees.

            

    

    

    (a) Case
      management staff must have expertise and training necessary to competently
      and
      promptly assist enrollees in working with Social Security Administration or
      Disability Determination in maintaining benefits from SSI and SSDI. For clients
      who wish to work, case management staff must have the expertise and training
      necessary to assist enrollees to access Social Security Work Incentives
      including development of Plans for Achieving Self-Support (PASS).

    

    (b) At
      a
      minimum, case management services are to incorporate the principles of a
      strengths-based approach. Strengths-based case management services are a
      preferred service modality for work with individuals and families. This method
      stresses building on the strengths of individuals and families that can be
      used
      to resolve current problems and issues. This approach counters more traditional
      approaches that focus almost exclusively on individuals’ deficits or needs.
      Service limits and criteria developed cannot be more restrictive than those
      in
      Medicaid policy.

    

    
      	 	
              6.

            	
              Intensive
                Case Management

            

    

    

    a. Intensive
      Case Management is intended to provide intensive team Case Management to highly
      recidivistic adults who have a severe and persistent mental illness. The service
      is intended to help Enrollees remain in the community and avoid institutional
      care. Clinical care criteria for this level of Case Management shall address
      the
      same elements required above, as well as expanded elements related to access
      and
      twenty-four (24) hour coverage as described below. Additionally, the intensive
      Case Management team composition shall be expanded to include members of the
      team selected specifically to assist with the special needs of this population.
      The Health Plan shall include the team composition and how it will assist with
      special needs in the description of how this service will be
      provided.

    

    b. The
      Health Plan shall provide this service for all Enrollees for whom the service
      is
      determined to be Medically Necessary, to include enrollees who meet the
      following criteria:

    

    
      	·  	
              Has
                resided in a state mental health treatment facility for at least
                6 months
                in the past 36 months;

            

    

    
      	·  	
              Resides
                in the community and has had two or more admissions to a state mental
                health treatment facility in the past 36
                months;

            

    

    
      	·  	
              Resides
                in the community and has had three or more admissions to a crisis
                stabilization unit, short-term residential facility, inpatient psychiatric
                unit, or any combination of these facilities within the past 12 months;
                or

            

    

    
      	·  	
              Resides
                in the community and, due to a mental illness, exhibits behavior
                or
                symptoms that could result in long-term hospitalization if frequent
                interventions for an extended period of time were not
                provided.

            

    

    

    c. Intensive
      Case Management provides services through the use of a team of case managers.
      The team can be expanded to include other specialists that are qualified to
      address identified needs of the Enrollees receiving intensive Case Management.
      This level of care for Case Management is the most intensive and serves
      Enrollees with the most severe and disabling mental conditions. Services are
      frequent and intense with a focus on assisting the Enrollee with attaining
      the
      skills and supports needed to gain independent living skills. Intensive Case
      Management services are provided primarily in the Enrollee’s residence and
      include community-based interventions.

    

    d. The
      Health Plan shall provide this service in the least restrictive setting with
      the
      goal of improving the Enrollee’s level of functioning, and providing ample
      opportunities for rehabilitation, recovery, and self-sufficiency. Intensive
      Case
      Management services shall be accessible twenty-four (24) hours per day, seven
      (7) days per week. The Health Plan shall demonstrate adequate capacity to
      provide this service for the targeted population within the guidelines
      outlined.

    

    e. Intensive
      Case Management teams shall provide the same coordination and Case Management
      services for Enrollees admitted to inpatient facilities, State mental Hospitals,
      and forensic or corrections facilities as those listed above for mental health
      targeted case management services.

    

    7. Community
      Treatment of Patients Discharged from State Mental Health Hospitals

    

    a.  The
      health plan shall provide Medically Necessary Behavioral Health Services to
      Enrollees who have been discharged from any State mental Hospital, including,
      but not limited to, follow-up services and care. All Enrollees who have
      previously received services at the State mental Hospital must receive follow
      up
      and care.

    

    The
      plan
      of care shall be aimed at encouraging Enrollees to achieve a high quality of
      life while living in the community in the least restrictive environment that
      is
      medically appropriate and reducing the likelihood that the Enrollees will be
      readmitted to a State mental Hospital.

    

    b.
       The
      health plan shall follow the progress of all Enrollees who were enrolled in
      the
      health plan to admission to a State mental Hospital until the one
      hundred-eightieth (180th) day after Disenrollment from the health plan shall
      use
      behavioral health targeted case managers to follow the progress of Enrollees.
      The behavioral health targeted case manager must attend and participate in
      the
      discharge planning activities at the facility. Targeted case managers are
      responsible for working with the former Enrollee before discharge from the
      State
      facility to assure that Benefits are reinstated as soon as possible, and that
      the Enrollee receives community Behavioral Health Services within twenty-four
      (24) hours of his/her discharge from the State facility.

    

    c.
       
      If the
      Enrollee remains in the State facility more than one hundred eighty (180) days
      after Disenrollment, the health plan shall cooperate with DCF and the Enrollee
      to ensure that the Enrollee is assigned a DCF funded Case Management provider
      who will bear the responsibility of ongoing monthly follow-up care and discharge
      planning until such time that the Enrollee is again eligible for and enrolled
      in
      a Health plan.

    

    d. The
      health plan shall develop a cooperative agreement with the behavioral health
      care facility to enable the health plan to anticipate those Medicaid Recipients
      who were Enrollees of the health plan prior to admission to the Facility, and
      will be soon discharged from the Facility. The cooperative agreement must
      address arrangements for Medicaid Recipients, whom the Facility is discharging,
      but who are not eligible for immediate re-enrollment.

    

    
      	 	
              8.

            	
              Community
                Services for Enrollees Involved with the Criminal Justice
                System

            

    

    

    The
      Health Plan shall provide medically necessary community-based services for
      plan
      enrollees who have criminal justice system involvement as follows:

    

    a. Establish
      a linkage to pre-booking sites for assessment, screening or diversion related
      to
      mental health services;

    

    b. Provide
      immediate access (within 24 hours of release) for psychiatric services upon
      release from a jail or a juvenile
      detention facility to assure that prescribed medications are available for
      all
      health plan enrollees; and

    

    c. Establish
      a linkage to post-booking sites for discharge planning and assuring that prior
      health plan Enrollees receive necessary services upon release from the facility.
      Health plan Enrollees must be linked to services and receive routine care within
      seven (7) days from the date they are released.

    

    

    d. Provide
      outreach to homeless and other populations of plan enrollees at risk of criminal
      justice system involvement, as well as those plan enrollees currently involved
      in this system, to assure that services are accessible and provided when
      necessary. This activity should be oriented toward preventative measures to
      assess mental health needs and provide services that can potentially prevent
      the
      need for future inpatient services or possible deeper involvement in the
      criminal justice system.

    

    e. The
      health plan shall develop a cooperative agreement with corrections facilities
      to
      enable the health plan to anticipate Enrollees who were health plan Enrollees
      prior to incarceration who will be released from these institutions. The
      cooperative agreement must address arrangement for persons who are to be
      released, but for whom re-Enrollment may not take effect immediately. All
      Enrollees who were health plan Enrollees prior to incarceration and Medicaid
      Recipients who are likely to enroll in the health plan upon return to the
      community must receive a community mental health service within twenty-four
      (24)
      hours of discharge from the corrections facility

    

    

    
      	 	
              9.

            	
              Treatment
                and Coordination of Care for Enrollees with Medically Complex
                Conditions

            

    

    

    a. The
      Health Plan shall ensure that there are appropriate treatment resources
      available to address the treatment of complex conditions that reflect both
      mental health and physical health involvement. The following conditions must
      be
      addressed:

    

    
      	(1)  	
              Mental
                health disorders due to or involving a general medical condition,
                specifically -9-CM Diagnoses 293.0 through 294.1, 294.9, 307.89,
                and
                310.1; and

            

    

    

    
      	
            	 (2)	
              Eating
                disorders - ICD-9-CM Diagnoses 307.1, 307.50, 307.51, and
                307.52

            

    

    

    b. The
      Health Plan shall provide medically necessary community mental health services
      to enrollees who exhibit the above diagnoses and shall develop a plan of care
      that includes all appropriate collateral providers necessary to address the
      complex medical issues involved. Clinical care criteria shall address modalities
      of treatment that are effective for each diagnosis. The Health Plan’s provider
      network must include appropriate treatment resources necessary for effective
      treatment of each diagnosis within the required access time
      periods.

    

    
      	 	
              10.

            	
              Monitoring
                of Enrollees Admitted to Children’s Residential Treatment (Levels I - IV)
                Programs 

            

    

    

    a. The
      Health Plan shall maintain contact with children who are disenrolled from the
      plan due to placement in a residential treatment facility (Statewide Inpatient
      Psychiatric Program (SIPP), Therapeutic Group Care Services (TGCS), or
      Behavioral Health Overlay Services (BHOS)). The health plan shall participate
      in
      discharge planning, assist the enrollee and their caregiver to locate
      community-based services, and notify Medicaid when the enrollee is discharged
      from the facility. The Health Plan’s contract manager or designee shall
      re-enroll the enrollee in the plan upon notification of discharge into the
      community.

    

    b. Children
      placed in SIPP, TGCS, or BHOS facilities will be disenrolled from the Health
      Plan and then covered under Medicaid Fee-for-Service for mental health services.
      The Medicaid contract manager or designee will be responsible for the
      disenrollment process. The Department of Juvenile Justice, residential
      providers, and/or the assigned Mental Health Targeted Case Management providers
      will be responsible for notifying Medicaid of all admissions and discharges.
      A
      specific agreement regarding the disenrollment and re-enrollment process will
      be
      developed between the Agency, residential providers, and the
      departments.

    

    c.
      Upon
      notification of the Enrollee's discharge from the facility the health plan
      shall
      notify the Choice Counselor/Enrollment Broker for re-Enrollment into the health
      plan , if it is within 6 months (180 days) from the
      disenrollment.

    

    
      	 	
              11.

            	
              Coordination
                of Children’s Services

            

    

    

    a.
      The
      delivery and coordination of children’s mental health services shall be provided
      for all children who exhibit the symptoms and behaviors of an emotional
      disturbance. The delivery of services must address the needs of any child served
      in an SED or EH school program. Developmentally appropriate early childhood
      mental health services must be available to children age birth to 5 years old
      and their families.

    

    b.
      Services
      for all children shall be delivered within a strengths-based, culturally
      competent service design. The service design shall recognize and ensure that
      services are family-driven and include the participation of family, significant
      others, informal support systems, school personnel, and any state entities
      or
      other service providers involved in the child’s life.

    

    c.
      For
      all
      children receiving services under the plan, the vendor shall work with the
      parents, guardians, or other responsible parties to monitor the results of
      services and determine whether progress is occurring. Active monitoring of
      the
      child’s status shall occur to detect potential risk situations and emerging
      needs or problems. Services shall be conducted in a manner that maximizes the
      participation of all involved parties, such as providing services at alternative
      sites or times.

    

    d.
      When
      the
      court mandates a parental mental health assessment, and the parent is a plan
      enrollee, the vendor must complete an assessment of the parent’s mental health
      status and the effects on the child. Time frames for completion of this service
      shall be determined by the mandates issued by the courts.

    

    12.  Evaluation
      and Treatment Services for Enrolled Children/Adolescents 

    

    a. The
      health plan shall provide all Medically Necessary evaluation and treatment
      services for Children/Adolescents referred to the health plan by DCF, DJJ and
      by
      schools (elementary, middle, and secondary schools).

    

    b. The
      health plan shall provide Medically Necessary Children/Adolescent mental health
      services in such a way as to minimize disruption of services available to
      high-risk populations served by DCF. The health plan shall promptly evaluate,
      provide psychological testing, and deliver mental health services to
      Children/Adolescents (including delinquent and dependent Children/Adolescent)
      referred by DCF in accordance with Medical Necessity. As well, the health plan
      shall adhere to the minimum staffing, availability and access standards
      described in this Contract.

    

    c.
      The
      health plan shall provide court ordered evaluation and treatment required for
      Children/Adolescents who are Enrollees.55

    

    d.
      The
      health plan must participate in all DCF or school staffings that may result
      in
      the provision of mental health services to an enrolled
      Child/Adolescent.

    

    e.
      The
      plan shall refer Children/Adolescents to DCF when residential treatment is
      Medically Necessary. The health plan shall not be responsible for providing
      any
      residential treatment for Children/Adolescents. The DCF, Substance Abuse and
      Mental Health ("SAMH") or DJJ District office shall coordinate the placement
      of
      the Enrolled Child/Adolescent with the health plan.

    

    f.
       The
      health plan's Case Management of Children/Adolescents shall include
      those persons, schools, programs, networks and agencies that figure importantly
      in the Child's/Adolescent's life.

    

    g.
       The
      health plan shall make determinations about care based on a comprehensive
      evaluation, consultation with those persons, schools, programs, networks and
      agencies that figure importantly in the Child's/Adolescent's life, and
      appropriate protocols for admission and retention.

    

    h.
      The
      health plan shall monitor services for adequacy in conformity with the
      cooperative agreement between the health plan and the facility.

    

    
      	 	
              C.

            	
              Psychiatric
                Evaluations for Enrollees Applying for Nursing Home
                Admission 

            

    

    

    The
      Health Plan shall, upon request from the Substance Abuse and Mental Health
      (SAMH) Offices, promptly arrange for and authorize psychiatric evaluations
      for
      enrollees who are applying for admission to a nursing facility pursuant to
      OBRA
      1987, and who, on the basis of a screening conducted by Comprehensive Assessment
      and Review for Long Term Care (CARES) workers, are thought to need mental health
      treatment. The examination shall be adequate to determine the need for
“specialized treatment” under the Act. Evaluations must be completed within five
      working days from the time the request from the DCF SAMH Program Office is
      received. State regulations have been interpreted by the state to permit any
      of
      the “mental health professionals” listed in Section 394.455, Florida Statutes,
      to make the observations preparatory to the evaluation, although a psychiatrist
      must sign such evaluations. The Health Plan will not be responsible for resident
      reviews or for providing services as a result of a Pre-Admission Screening
      and
      Resident Review (PASRR) evaluation.

    

    
      	 	
              D.

            	
              Assessment
                and Treatment of Mental Health Residents Who Reside in Assisted Living
                Facilities (ALF) that hold a Limited Mental Health
                License

            

    

    

    
      	 	 	
              The
                Health Plan must develop and implement a plan to ensure compliance
                with
                Section 394.4574, F.S., related to services provided to residents
                of
                licensed assisted living facilities that hold a limited mental health
                license. A cooperative agreement, as defined in 400.402, F.S., must
                be
                developed with the ALF if an enrollee is a resident of the ALF. The
                Health
                Plan must ensure that appropriate assessment services are provided
                to plan
                enrollees and that medically necessary mental health care services
                are
                available to all enrollees who reside in this type of
                setting.

            

    

    

    
      	 	 	
              A
                community living support plan, as defined in Section I, Definitions
                and
                Acronyms, must be developed for each enrollee who is a resident of
                an ALF,
                and it must be updated annually. The Health Plan case manager is
                responsible for ensuring that the community living support plan is
                implemented as written.

            

    

    

    
      	 	
              E.

            	
              Individuals
                with Special Health Care Needs:

            

    

    

    The
      plan
      shall implement mechanisms for identifying, assessing and ensuring the existence
      of an Individualized Treatment Plan for individuals with special health care
      needs as defined in Section I, Definitions and Acronyms. Mechanisms shall
      include evaluation of risk assessments, claims data, and CPT/ICD-9 codes.
      Additionally, the plan shall implement a process for receiving and considering
      provider and enrollee input.

    

    In
      accordance with this contract and 42 CFR 438.208(c)(3), an Individualized
      Treatment Plan for an enrollee determined to need a course of treatment or
      regular care monitoring must be:

    

    
      	·  	
              Developed
                by the enrollee's direct service mental health care professional
                with
                enrollee participation and in consultation with any specialists caring
                for
                the enrollee; 

            

    

    

    
      	·  	
              Approved
                by the plan in a timely manner if this approval is required;
                and

            

    

    

    
      	·  	
              Developed
                in accordance with any applicable Agency quality assurance and utilization
                review standards.

            

    

    

    Pursuant
      to 42 CFR 438.208(c)(4), for Enrollees with special health care needs determined
      through an assessment by appropriate mental health care professionals
      (consistent with 42 CFR 438.208(c)(2))
      to need a course of treatment or regular care monitoring, the plan must have
      a
      mechanism in place to allow Enrollees to directly access a mental health care
      specialist (for example, through a standing referral or an approved number
      of
      visits) as appropriate for the Enrollee's condition and identified
      needs.

    

    F. Crisis
      Support/Emergency Services 

    

    The
      health plan shall operate, as part of its Crisis Support/Emergency Services,
      a
      crisis emergency hotline available to all Enrollees twenty-four (24) hours
      a
      day, seven (7) days a week.

    

    
      	 	
              G.

            	
              Provision
                of Behavioral Health Services When Not Covered by the Health
                Plan

            

    

    

    1. If
      the
      Health Plan determines that an Enrollee is in need of behavioral health services
      that are not covered under the Contract, the Health Plan shall refer the
      Enrollee to the appropriate provider. The Health Plan may request the assistance
      of the Agency’s local field office or the local DCF District ADM Office for
      referral to the appropriate service setting.

    

    2. Long
      term
      care institutional services in a nursing facility, an institution for persons
      with developmental disabilities, specialized therapeutic foster care, children's
      residential treatment services or State Hospital services are not covered by
      the
      Health Plan. For Enrollees requiring those services, the Health Plan shall
      consult the Medicaid Field Office and/or the DCF District ADM Office to identify
      appropriate methods of assessment and referral.

    

    3. The
      Health Plan is responsible for transition and referral of the Enrollee to
      appropriate providers. The Health Plan shall request Disenrollment of all
      Enrollees receiving the services described in this Section VI.B.8., Provision
      of
      Behavioral Health Care Services When Not Covered by the Health
      Plan.

    

    
      	 	
              H.

            	
              Behavioral
                Health Services Care Coordination and Management
                

            

    

    

    The
      Health Plan shall be responsible for the coordination and management of
      Behavioral Health Services and continuity of care for all Enrollees. At a
      minimum, the Health Plan shall provide the following services to its
      Enrollees:

    

    1. Minimize
      disruption to the Enrollee as a result of any change in behavioral health care
      providers or behavioral health care case managers that occur as a result of
      this
      Contract. For new Enrollees who had been receiving Behavioral Health Services,
      the Health Plan shall continue to authorize all valid claims for services until
      the Health Plan has: 

    

    
      	 	
              a.

            	
              Reviewed
                the Enrollee's treatment plan;

            

    

    

    
      	 	
              b.

            	
              Developed
                an appropriate written transition plan;
                and

            

    

    

    c. Implemented
      the written transition plan.

    

    2. If
      the
      previous behavioral health care provider is unable to allow the Health Plan
      access to the Enrollee's Medical Records because the Enrollee refuses to release
      his/her records, then the Health Plan shall provide:

    

    
      	 	
              .a

            	
              Up
                to four (4) sessions of individual or group
                therapy;

            

    

    

    
      	 	
              .b

            	
              One
                (1) psychiatric medical session;

            

    

    

    
      	 	
              .c

            	
              Two
                (2) one-hour intensive therapeutic on-site;
                or

            

    

    

    
      	 	
              .d

            	
              Six
                (6) days of day treatment services.

            

    

    

    3.. Document
      all Emergency Behavioral Health Services received by an Enrollee, along with
      any
      follow-up services, in the Enrollee's behavioral health Medical Records. The
      Health Plan shall also assure the PCP receives the information about the
      Emergency Behavioral Health Services for filing in the PCP's Medical
      Record.

    

    4. Document
      all referral services in the Enrollees’ behavioral health Medical
      Records.

    

    5. Monitor
      Enrollees admitted to State mental health institutions by participating in
      discharge planning and community placement of Enrollees who are discharged
      within sixty (60) days of losing their Health Plan enrollment due to State
      institutionalization. The Agency shall sanction the Health Plan, as described
      in
      Section XIII, Sanctions, for any inappropriate over-utilization of State mental
      Hospital services for its Enrollees.

    

    6. Coordinate
      Hospital and institutional discharge planning for psychiatric admissions and
      substance abuse detoxification to ensure inclusion of appropriate post-discharge
      care. 

    

    
      	 	
              a.

            	
              Enrollees
                admitted to an acute care facility (inpatient Hospital or crisis
                stabilization unit) shall receive appropriate services upon discharge
                from
                the acute care facility.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall have follow-up services available to Enrollees
                within
                twenty-four (24) hours of discharge from an acute care facility,
                provided
                the acute care facility notified the Health Plan that it had provided
                services to the Enrollee.

            

    

    

    
      	 	
              c

            	
              The
                Health Plan shall continue the medication prescribed by a State mental
                health facility to the Enrollee for at least ninety (90) days after
                the
                State mental health facility discharges the Enrollee, unless the
                Health
                Plan's prescribing psychiatrist, in consultation and agreement with
                the
                State mental health facility's prescribing physician, determines
                that the
                medications: 

            

    

    

    (1) Are
      not
      Medically Necessary; or

    

    (2) Are
      potentially harmful to the Enrollee.

    

    7. Provide
      appropriate referral of the Enrollee for non-covered services to the appropriate
      service setting. The Health Plan shall request referral assistance, as needed,
      from the Medicaid Field Office. The Health Plan is encouraged to use the Florida
      Supplement to the American Society of Addictions Medicine Patient Placement
      Criteria for coordination and treatment of substance abuse related disorders
      with substance abuse providers. The Health Plan is encouraged to use the Florida
      Supplement to the American Society of Addictions Medicine Placement Criteria
      for
      coordination and treatment of substance-related disorders with substance abuse
      Providers. The Health Plan shall provide coordination of care with
      community-based substance abuse agencies as part of its policies and procedures
      developed for continuity of care for Enrollees who are diagnosed with mental
      illness and substance abuse or dependency.

    

    8. Provide
      court ordered mental health evaluations for Enrollees. The Health Plan shall
      also provide expert behavioral health testimony for Enrollees.

    

    9. Provide
      appropriate screening, assessment, and crisis intervention in support for
      Enrollees who are in the care and custody of the State. See Specifications
      listed in the Medicaid Community Mental Health Services Coverage &
Limitations Handbook.

    

    10. Upon
      a
      request from an ALF, the Health Plan shall provide procedures for the ALF to
      follow should an emergent condition arise with an Enrollee that resides at
      the
      ALF. (See Section 409.912, F.S.)

    

    11. The
      Health Plan shall participate in the SAMH planning process in each DCF district.
      (See Section 4098.912, F.S.)

    

    The
      Health Plan shall design and implement a Drug Utilization Review ("DUR")
      program. Once the Health Plan's pharmacy utilization indicates that an Enrollee
      is receiving an antipsychotic medication from a PCP or prescribing
      non-psychiatrist physician, the Health Plan shall request a consultation with
      the PCP or prescribing non-psychiatrist physician. Once the Health Plan's
      pharmacy utilization indicates that an Enrollee, who is being treated by a
      Behavioral Health Care Provider, receives medication for certain physical
      conditions (such as hypertension, diabetes, neurological disorders, cardiac
      problems, or any other serious medical condition) the Health Plan shall schedule
      a consultation with the PCP or prescribing physician to discuss coordination
      of
      care and concerns related to drug interactions. The Health Plan shall ensure
      coordination with the PCP or prescribing physician with regards to drug
      utilization and potential contraindications.

    

    
      	 	
              I.

            	
              Discharge
                Planning

            

    

    

    Discharge
      Planning is the evaluation of an Enrollee's medical care needs, including mental
      health service needs, substance abuse service needs, or both, in order to
      arrange for appropriate care after discharge from one level of care to another
      level of care. The Health Plan shall:

    

    1. Monitor
      all Enrollee discharge plans from behavioral health inpatient admissions to
      ensure that they incorporate the Enrollees’ needs for continuity in existing
      behavioral health therapeutic relationships.

    

    2. Ensure
      that Enrollees' family members, guardians, outpatient individual practitioners
      and other identified supports are given the opportunity to participate in
      Enrollee treatment to the maximum extent practicable and appropriate, including
      behavioral health treatment team meetings and developing the discharge plan.
      For
      adult Enrollees, family members and other identified supports may be involved
      in
      the development of the Discharge Plan only if the Enrollee consents to their
      involvement.

    

    3. Designate
      staff members who are responsible for identifying Enrollees who remain in the
      Hospital for non-clinical reasons (i.e., absence of appropriate treatment
      setting availability, high demand for appropriate treatment setting, high-risk
      Enrollees and Enrollees with multiple agency involvement).

    

    4. Develop
      and implement a plan that monitors and ensures that clinically indicated
      Behavioral Health Services are offered and available to Enrollees within
      twenty-four (24) hours of discharge from an inpatient setting.

    

    5. Ensure
      that a behavioral health program clinician provides medication management to
      Enrollees requiring medication monitoring within twenty-four (24) hours of
      discharge from a behavioral health program inpatient setting. The Health Plan
      shall ensure that the behavioral health program clinician is duly qualified
      and
      licensed to provide medication management.

    

    6. Upon
      the
      admission of an Enrollee, the Health Plan shall make its best efforts to ensure
      the Enrollee’s smooth transition to the next service or to the community; and
      shall require that Behavioral Health Care Providers:

    

    
      	 	
              (a)

            	
              Assign
                a case manager to oversee the care given to the
                Enrollee;

            

    

    

    
      	 	
              (b)

            	
              Develop
                an individualized discharge plan, in collaboration with the Enrollee
                where
                appropriate, for the next service or program or the Enrollee's discharge,
                anticipating the Enrollee's movement along a continuum of services;
                and

            

    

    

    
      	 	
              (c)

            	
              Make
                best efforts to ensure a smooth transition to the next service or
                community;

            

    

    

    
      	 	
              (d)

            	
              Document
                all significant efforts related to these activities, including the
                Enrollee's active participation in discharge
                planning.

            

    

    

    
      	 	
              J.

            	
              Transition
                Plan 

            

    

    

    A
      transition plan is a detailed description of the process of transferring
      Enrollees from providers to the Health Plan's Behavioral Health Care Provider
      network to ensure optimal continuity of care. The transition plan shall include,
      but not be limited to, a timeline for transferring Enrollees, description of
      provider medical record transfers, scheduling of appointments, propose
      prescription drug protocols and claims approval for existing providers during
      the transition period. The Health Plan shall document its efforts relating
      to
      the transition plan.

    

    1. The
      Health Plan shall minimize the disruption of treatment by an Enrollee's current
      behavioral health care provider by arranging for Enrollee use of services
      outside of the Health Plan's network. For Enrollees who have received Behavioral
      Health Services for at least six (6) months from a behavioral health care
      provider, whether the provider is in the Health Plan’s network or not, the
      Health Plan shall continue to authorize all valid claims until the Health Plan
      reviews the Enrollee's treatment plan and implements an appropriate written
      transition plan.

    

    2. During
      the first three (3) months that the Enrollee receives Behavioral Health Services
      under this Contract, the Health Plan shall not deny requests for Behavioral
      Health Services outside the network under the following conditions:

    

    
      	 	
              (1)

            	
              The
                Enrollee is a patient at a community behavioral health center and
                the
                center has discussed the Enrollee's care with the Health
                Plan.

            

    

    

    
      	 	
              (2)

            	
              If,
                following contact with the Health Plan, there is no Behavioral Health
                Care
                Provider readily available and the Enrollee's condition would not
                permit a
                delay in treatment.

            

    

    

    3. If
      the
      previous treating Provider is unable to allow the Health Plan access to the
      Enrollee's Medical Records because the Enrollee refuses to release the records,
      then the Health Plan shall approve the provider’s claims for:

    

    
      	 	
              (a)

            	
              Four
                (4) sessions of outpatient behavioral health counseling or
                therapy;

            

    

    

    
      	 	
              (b)

            	
              One
                (1) outpatient psychiatric physician session;

            

    

    

    
      	 	
              (c)

            	
              Two
                (2) one-hour intensive therapeutic on-site sessions;
                or

            

    

    

    
      	 	
              (d)

            	
              Six
                (6) days of day treatment services.

            

    

    

    

    4. Any
      disputes related to coverage of services necessary for the transition of
      Enrollees from their current behavioral health care provider to a Behavioral
      Health Care Provider shall follow the process set forth in Section IX, Grievance
      System, of this Contract.

    

    5. The
      Health Plan shall approve claims from providers for authorized out-of-plan
      non-emergency services, provided such claims are submitted within twelve (12)
      months of the date of service. The Plan must process such claims within the
      time
      period specified in section 641.3155, F.S.

    

    
      	 	
              K.

            	
              Functional
                Assessments 

            

    

    

    1. The
      Health Plan shall ensure that all Behavioral Health Care Providers administer
      functional assessments using the Functional Assessment Rating Scales (FARS)
      for
      all Enrollees over the age of eighteen (18) and Child Functional Assessment
      Rating Scale (CFARS) for all Enrollees age eighteen (18) and under.

    

    2. The
      Health Plan shall ensure that all Behavioral Health Care Providers administer
      and maintain the FARS and CFARS according to the FARS and CFARS manuals to
      all
      Enrollees receiving Behavioral Health Services and upon termination of providing
      such services. 

    

    3. The
      results of the FARS and CFARS assessments shall be maintained in each Enrollee's
      medical record, including a chart trending the results of the functional
      assessments.

    

    4. The
      Health Plan shall submit the FARS/CFARS reports as required in Section XI,
      Reporting Requirements.

    

    
      	 	
              L.

            	
              Outreach
                Program

            

    

    

    The
      Health Plan shall have an outreach program designed to encourage Enrollees
      to
      seek Behavioral Health Services through the Health Plan when the Health Plan,
      or
      Providers, perceive a need for Behavioral Health Services. In addition, the
      outreach program, at a minimum, shall provide for the following:

    

    1. Outreach
      program Enrollee communications that are written at the fourth (4th) grade
      reading level;

    

    2. Outreach
      program communications that are written the primary language spoken by the
      Enrollee;

    

    3. A
      program
      designed to assist PCP's in the identification and management, including
      referral and other resources, to aid in the treatment of:

    

    
      	 	
              (a)

            	
              Enrollees
                with severe and persistent mental illness;

            

    

    

    
      	 	
              (b)

            	
              Children/Adolescents
                with severe emotional disturbances;
                and

            

    

    

    
      	 	
              (c)

            	
              Enrollees
                with clinical depression.

            

    

    

    4. A
      program
      to identify and manage Enrollees who are homeless.

    

    
      	 	
              M.

            	
              Behavioral
                Health Subcontracts

            

    

    

    If
      the
      Health Plan subcontracts with a Managed Behavioral Health Organization ("MBHO")
      for the provision of Behavioral Health Services stipulated in this Section,
      the
      MBHO must be accredited by at least one (1) of the recognized national
      accreditation organizations. 

    

    1. The
      Health Plan shall submit to the Agency the staff psychiatrist subcontract,
      if
      any, and the model Provider contracts for each Behavioral Health Services
      specialist type or facility.

    

    2. All
      Provider contracts and subcontracts must adhere to the requirements set forth
      in
      this Contract, including Section XVI.Q., Terms and Conditions, Subcontracts,
      in
      this Contract.

    

    
      	 	
              N.

            	
              Optional
                Services

            

    

    

    The
      Health Plan is encouraged to provide additional services that will enhance
      the
      Health Plan’s Covered Services for Enrollees. To the degree possible, the Health
      Plan should use existing community resources. Below is a list of possible
      optional services that could be provided with the savings achieved or as
      downward substitutions. This list is not intended to be all-inclusive and the
      Health Plan is encouraged to use creativity in developing new and innovative
      services to expand the array of services and meet the needs of
      recipients.

    

    1.
       Respite
      Care Services

    

    2.
       Prevention
      Services in the Community

    

    3.
       Supportive
      Living Services

    

    4.
       Supported
      Employment Services

    

    5.
       Foster
      Homes for Adults

    

    6.
       Parental
      Education Programs

    
       

      7. 
        Drop-In
        Centers and other consumer operated programs (beyond the elements provided
        under
        the Opportunities for Recovery and Reintegration component)

       

    

    8.
       Intensive
      Therapeutic On-Site Services for Adults

    

    9.
       Home
      and
      Community Based Rehabilitation Services for Adults

     

    
      10. 
        Any
        other new and innovative interventions or services designed to benefit enrollees
        receiving Mental Health services

    

     

    
      	 	
              O.
                

            	
              Community
                Coordination and
                Collaboration

            

    

    

    The
      provider must be or become a vital part of the community services and support
      system. They must actively participate with and support community programs
      and
      coalitions that promote school readiness, that assist persons to return to
      work
      and provide for prevention programs. The provider must have linkages with
      numerous community programs that will assist enrollees in obtaining housing,
      economic assistance and other supports.

    

    
      	 	
              P.

            	
              Behavioral
                Health Managed Care Local Advisory
                Group

            

    

    

    1. There
      will be an advisory group for the Health Plan that convenes quarterly and
      reports to the Agency on advocacy and programmatic concerns. The local advisory
      group is responsible for providing technical and policy advice to the Agency
      regarding the Health Plan’s provision of services. The local advisory group does
      not have access to Enrollee Medical Records.

    

    2. The
      role
      of the local advisory group is to report to the Agency information related
      to
      practical and real events that occur related to the activities of Medicaid
      Health Plans. Concerns about services, program changes, Quality of care,
      difficulties, advocacy issues, and reports about positive outcomes are presented
      by members of the advisory group and are addressed by the agency as part of
      the
      ongoing monitoring of the Health Plan contracts. The Agency presents information
      about actions taken related to issues presented by the group. If the group
      determines that it is appropriate, the advisory group members also vote to
      present their issues to the Agency in writing.

    

    3. The
      group
      may request information to be presented at each meeting that will keep the
      group
      up-to-date regarding the contract and activities of each Health Plan. Minutes
      of
      the meetings are kept and distributed to all members and attendees. The voting
      membership of the group is updated periodically. This is a public meeting and
      may be attended by anyone in the community.

     

    4. The
      local
      advisory group is coordinated by Agency area staff (who are not part of the
      voting membership) and consists of providers, consumer representatives, advocacy
      groups, and other relevant groups as identified by the Agency, which represent
      the counties within the service area. Such relevant groups include the Agency’s
      Medicaid Office, including Health Plan representatives; SAMH and Family Safety
      representatives; representatives from any community based care Providers
      contracted with DCF; the Florida Drop-In Center Association; the Human Rights
      Advocacy Committee; the Alliance for the Mentally Ill; the Florida Consumer
      Action Council; and the Substance Abuse and Mental Health Planning Council.
      In
      addition, the Health Plan provides representation to the local advisory group.
      The advisory group elects a chairperson and vice-chairperson from the voting
      membership, who facilitates the meetings and prepares any written correspondence
      on behalf of the group.

    

    5. The
      Health Plan’s responsibility related to the advisory group is as
      follows:

    

    
      	·  	
              Assure
                representation at all scheduled
                meetings;

            

    

    

    
      	·  	
              Provide
                information requested by advisory group
                members;

            

    

    

    
      	·  	
              Follow
                up on identified issues of concern related to the provision of services
                or
                administration of the Health Plan;
                and

            

    

    

    
      	·  	
              Share
                pertinent information about Quality improvement findings and outreach
                activities with the group.

            

    

    

    

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    Section
      VII

    Provider
      Network

    

    
      	A.	
               General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall have sufficient facilities, service locations,
                service
                sites and personnel to provide the Covered Services described in
                Section V
                and Behavioral Health Care described in Section VI.
                

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall provide the Agency with adequate assurances that
                the
                Health Plan has the capacity to provide Covered Services to all Enrollees
                up to the maximum enrollment level in each county, including assurances
                that the Health Plan: 

            

    

    

    a. Offers
      an
      appropriate range of services and accessible preventive and primary care
      services such that the Health Plan can meet the needs of the maximum enrollment
      level in each county, and

    

    b. Maintains
      a sufficient number, mix and geographic distribution of Providers, including
      Providers who are accepting new Medicaid patients as specified in Section
      1932(b)(7) of the Social Security Act, as enacted by Section 4704(a) of the
      Balanced Budget Act of 1997.

    

    
      	 	
              3.

            	
              When
                designing the Provider network, the Health Plan shall take the following
                into consideration as required by 42 CFR
                438.206:

            

    

    

    a. The
      anticipated number of Enrollees;

    

    b. The
      expected utilization of services, taking into consideration the characteristics
      and health care needs of specific Medicaid populations represented;

    

    c. The
      numbers and types (in terms of training, experience, and specialization) of
      providers required to furnish the Covered Services;

    

    d. The
      numbers of network providers who are not accepting new Enrollees; 

    

    e. The
      geographic location of providers and Enrollees, considering distance, travel
      time, the means of transportation ordinarily used by Enrollees and whether
      the
      location provides physical access for Medicaid enrollees with disabilities;
      and

    

    f. There
      is
      to be no discrimination against particular providers that serve high-risk
      populations or specialize in conditions that require costly
      treatments.

    

    
      	 	
              4.

            	
              Health
                Maintenance Organizations and other licensed managed care organizations
                shall enroll all network providers with the Agency’s Fiscal Agent, no
                later than November 30, 2006, using the Agency’s streamlined Provider
                Enrollment process. All Capitated PSNs shall use the streamlined
                Provider
                Enrollment process to enroll network providers prior to contract
                execution.

            

    

    

    
      	 	
              5.

            	
              Each
                Provider shall maintain Hospital privileges if Hospital privileges
                are
                required for the delivery of Covered Services. The Health Plan may
                use
                admitting panels to comply with this
                requirement.

            

    

    

    
      	 	
              6.

            	
              If
                the Health Plan is unable to provide Medically Necessary services
                to an
                Enrollee, the Health Plan must cover these services by using providers
                and
                services that are not providers in the Health Plan's network, in
                an
                adequate and timely manner, for as long as the Health Plan is unable
                to
                provide the Medically Necessary services within the Health Plan's
                network.

            

    

    

    
      	 	
              7.

            	
              The
                Health Plan shall allow each Enrollee to choose his or her Providers
                to
                the extent possible and
                appropriate.

            

    

    

    
      	 	
              8.

            	
              The
                Health Plan shall require each Provider to have a unique Florida
                Medicaid
                Provider number, in accordance with the requirement of Section X,
                C. jj.,
                of this Contract. By May 2007, the Health Plan shall require each
                Provider
                to have a National Provider Identifier (NPI) in accordance with section
                1173(b) of the Social Security Act, as enacted by section
                4707(a) of the Balanced Budget Act of
                1997.

            

    

    

    
      	 	
              9.

            	
              The
                Health Plan shall provide the Agency with documentation of compliance
                with
                access requirements: 

            

    

    

    a. Upon
      the
      effective date of the Contract; and

    

    b. At
      any
      time there has been a significant change in the Health Plan's operations that
      would affect adequate capacity and services, including, but not limited to,
      the
      following:

    

    
      	 	
              (1)

            	
              Changes
                in Health Plan services or Service Area;
                and

            

    

    

    
      	 	
              (2)

            	
              Enrollment
                of a new population in the Health
                Plan.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan shall have procedures to inform Potential Enrollees and
                Enrollees of any changes to service delivery and/or the Provider
                network
                including the following:

            

    

    

    a. Inform
      Potential Enrollees and Enrollees of any restrictions to access to Providers,
      including Providers who are not taking new patients, upon request and, for
      Enrollees, at least on a six (6) month basis.

    

    b. An
      explanation to all Potential Enrollees that an enrolled family may choose to
      have all family members served by the same PCP or they may choose different
      PCPs
      based on each family member’s needs.

    

    c. Inform
      Potential Enrollees and Enrollees of objections to providing counseling and
      referral services based on moral or religious grounds within ninety (90) days
      after adopting the policy with respect to any service.

    

    
      	 	
              11.

            	
              The
                Health Plan shall have procedures to document when a decision is
                made to
                not include individual or groups of providers in its network and
                must give
                the affected providers written notice of the reason for its decision.
                

            

    

    

     

    
      	B.	
              Primary
                Care Providers

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan shall enter into agreements with a sufficient number
                of PCPs
                to ensure adequate accessibility for Enrollees of all ages. The Health
                Plan shall select and approve its PCPs. The Health Plan shall ensure
                its
                approved PCPs agree to the following: 

            

    

    

    (a) The
      PCP’s
      agreement to accept the associated Case Management
      responsibilities.

    

    (b) The
      PCP’s
      agreement to provide or arrange for coverage of services, consultation or
      approval for referrals twenty four (24) hours per day, seven days per week
      by
      Medicaid enrolled providers who will accept Medicaid reimbursement. This
      coverage must consist of an answering service, call forwarding, provider call
      coverage or other customary means approved by the Agency. The chosen method
      of
      twenty four (24) hour coverage must connect the caller to someone who can render
      a clinical decision or reach the PCP for a clinical decision. The after hours
      coverage must be accessible using the medical office’s daytime telephone number.
      The PCP or covering medical professional must return the call within thirty
      (30)
      minutes of the initial contact.

    

    (c) The
      PCP’s
      agreement to arrange for coverage of primary care services during absences
      due
      to vacation, illness or other situations which require the PCP to
      be
      unable to provide services. Coverage must be provided by a Medicaid enrolled
      PCP. 

    

    
      	 	
              2.
                

            	
              The
                Health Plan shall provide the
                following:

            

    

    

    a. At
      least
      one (1) FTE PCP per county including, but not limited to, the following
      specialties:

    

    
      	 	
              (1)

            	
              Family
                Practice;

            

    

    

    
      	 	
              (2)

            	
              General
                Practice;

            

    

    

    
      	 	
              (3)

            	
              Obstetrics
                or Gynecology;

            

    

    

    
      	 	
              (4)

            	
              Pediatrics;
                and

            

    

    

    
      	 	
              (5)

            	
              Internal
                Medicine.

            

    

    

    b. At
      least
      one (1) FTE PCP per 1,500 Enrollees. The Health Plan may increase the ratio
      by
      750 Enrollees for each FTE ARNP or FTE PA affiliated with a PCP.

    

    c. The
      Health Plan shall allow pregnant Enrollees to choose the Health Plan’s
      obstetricians as their PCPs to the extent that the obstetrician is willing
      to
      participate as a PCP.

    

    
      	 	
              3.

            	
              At
                least annually, the Health Plan shall review each PCPs average wait
                times
                to ensure services are in compliance with Section VII, D. Appointment
                Waiting Times and Geographic Access
                Standards.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall assign a pediatrician or other appropriate primary
                care
                physician to all pregnant Enrollees for the care of their newborn
                babies
                no later than the beginning of the last trimester of gestation. If
                the
                Health Plan was not aware that the Enrollee was pregnant until she
                presented for delivery, the Health Plan shall assign a pediatrician
                or a
                primary care physician to the newborn baby within one (1) Business
                Day
                after birth. The Health Plan shall advise all Enrollees of the Enrollees’
                responsibility to notify their Health Plan and their DCF public assistance
                specialists (case workers) of their pregnancies and the births of
                their
                babies.

            

    

    

    
      	C.	
               Minimum
                Standards

            

    

    

    
      	 	
              1.

            	
              Emergency
                Services and Emergency Services Facilities

            

    

    

    The
      Health Plan shall ensure the availability of Emergency Services and Care
      twenty-four (24) hours a day, seven (7) days a week. 

    

    
      	 	
              2.

            	
              General
                Acute Care Hospital 

            

    

    

    The
      Health Plan shall provide one
      (1)
      fully accredited general acute care Hospital bed
      per
      275 enrollees.
      The
      Agency may waive this accreditation requirement, in writing, for
      Rural
      areas.

    

    
      	 	
              3.

            	
              Birth
                Delivery Facility 

            

    

    

    The
      Health Plan shall provide one (1) birth delivery facility, licensed under
      Chpater 383, F.S., or a Hospital with birth delivery facilities, licensed under
      Chapter 395, F.S. The birth delivery facility may be part of a Hospital or
      a
      freestanding facility.

    

    
      	 	
              4.

            	
              Birthing
                Center

            

    

    

    The
      Health Plan shall provide a birthing center, licensed under Chapter 383, F.S.
      that is accessible to low risk Enrollees. 

    

    
      	 	
              5.

            	
              Regional
                Perinatal Intensive Care Centers (RPICC)

            

    

    

    The
      Health Plan shall assure access for Enrollees in one (1) or more of Florida's
      Regional Perinatal Intensive Care Centers (RPICC), (see sections 383.15 through
      383.21, F.S.) or a Hospital licensed by the Agency for Neonatal Intensive Care
      Unit (NICU) Level III beds.

    

    
      	 	
              6.

            	
              Neonatal
                Intensive Care Unit (NICU) 

            

    

    

    The
      Health Plan shall ensure that care for medically high risk perinatal Enrollees
      is provided in a facility with a NICU sufficient to meet the appropriate level
      of need for the Enrollee.

    

    
      	 	
              7.

            	
              Certified
                Nurse Midwife Services

            

    

    

    The
      Health Plan shall ensure access to certified nurse midwife services or licensed
      midwife services for low risk Enrollees. 

    

    
      	 	
              8.

            	
              Pharmacy
                

            

    

    

    If
      the
      Health Plan elects to use a more restrictive pharmacy network than the
      non-Medicaid Reform Fee-for-Service network, the Health Plan shall provide
      one
      (1) licensed pharmacy per 2,500 Enrollees. The Health Plan shall ensure that
      its
      contracted pharmacies comply with the Settlement Agreement to Hernandez, et.
      al.
      v. Medows (case number 02-20964 Civ-Gold/ Simonton) (HSA).

    

    
      	 	
              9.

            	
              Access
                for Persons with Disabilities

            

    

    

    The
      Health Plan shall ensure that all facilities have access for persons with
      disabilities. 

    

    
      	 	
              10.

            	
              Health,
                Cleanliness and Safety

            

    

    

    The
      Health Plan shall ensure adequate space, supplies, proper sanitation, and
      smoke-free facilities with proper fire and safety procedures in operation.
      

    

    
      	D.	
               Appointment
                Waiting Times and Geographic Access
                Standards

            

    

    

    
      	 	
              1.

            	
              The
                Health Plans must assure that PCP services and referrals to Participating
                Specialists are available on a timely basis, as
                follows:

            

    

    

    a. Urgent
      Care — within one (1) day,

    

    b. Routine
      Sick Patient Care — within one (1) week, and

    

    c. Well
      Care
      Visit — within one (1) month.

    

    
      	 	
              2.

            	
              All
                PCP's and Hospital services must be available within an average of
                thirty
                (30) minutes travel time from an Enrollee's residence. All Participating
                Specialists and ancillary services must be within an average of sixty
                (60)
                minutes travel time from an Enrollee's residence. The Agency may
                waive
                this requirement, in writing, for Rural areas and where there are
                no PCPs
                or Hospitals within the thirty (30) minute average travel
                time.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall provide a designated emergency services facility
                within
                an average of thirty (30) minutes travel time from an Enrollee's
                residence, that provides care on a twenty-four (24) hours a day,
                seven (7)
                days a week basis. Each designated emergency service facility shall
                have
                one (1) or more physicians and one (1) or more nurses on duty in
                the
                facility at all times. The Agency may waive the travel time requirement,
                in writing, in Rural areas. 

            

    

    
      	 	 	 

    

    
      	 	
              4.

            	
              For
                Rural areas, if the Health Plan is unable to enter into an agreement
                with
                specialty or ancillary service providers within the required sixty
                (60)
                minute average travel time, the Agency may waive, in writing, the
                requirement.

            

    

    

    
      	 	
              5.

            	
              At
                least one (1) pediatrician or one (1) CHD, FQHC or RHC within an
                average
                of thirty (30) minutes travel time from an Enrollee's residence,
                provided
                that this requirement remains consistent with the other minimum time
                requirements of this Contract. In order to meet this requirement,
                the
                pediatrician(s), CHD, FQHC, and/or RHC must provide access to care
                on a
                twenty-four (24) hours a day, seven days a week basis. The Agency
                may
                waive this requirement, in writing, for Rural areas and where there
                are no
                pediatricians, CHDs, FQHCs or RHCs within the thirty (30) minute
                average
                travel time. 

            

    

    

    
      	E.	
               Behavioral
                Health Services

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan shall have at least one (1) certified adult psychiatrist
                and
                at least one (1) board certified child psychiatrist (or one (1) child
                psychiatrist who meets all education and training criteria for Board
                Certification) that are available within thirty (30) minutes average
                travel time for Urban areas and sixty (60) minutes average travel
                time for
                Rural areas of all Enrollees. 

            

    

    

    
      	 	
              2.

            	
              For
                Rural areas, if the Health Plan does not have a Provider with the
                necessary experience, the Agency may waive, in writing, the requirements
                in E.1 above.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall ensure that outpatient staff includes at least
                one (1)
                FTE Direct Service Behavioral Health Provider per 1,500 Enrollees.
                The
                Agency expects the Health Plan’s staffing pattern for direct service
                Providers to reflect the ethnic and racial composition of the
                community.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan’s array of Direct Service Behavioral Health Providers for
                adults and Children/Adolescents shall include Providers that are
                licensed
                or eligible for licensure, and demonstrate two (2) years of clinical
                experience in the following specialty areas or with the following
                populations:

            

    

    

    a. Adoption;

    

    b. Child
      protection or foster care;

    

    c. Dual
      diagnosis (mental illness and substance abuse);

    

    d. Dual
      diagnosis (mental illness and developmental disability);

    

    e. Developmental
      disabilities;

    

    f. Behavior
      analysis;

    

    g. Behavior
      management and alternative therapies for Children/Adolescents;

    

    h. Separation
      and loss;

    

    i. Victims
      and perpetrators of sexual abuse (Children/Adolescents and adults);

    

    j. Victims
      and perpetrators of violence and violent crimes (Children/Adolescents and
      adults);

    

    k. Court
      ordered mental health evaluations including assessment of parental mental health
      issues and parental competency as it relates to mental health; and

    

    l. Expert
      witness testimony.

    

    
      	 	
              5.

            	
              All
                Direct Service Behavioral Health Providers and mental health targeted
                case
                managers serving the Children/Adolescent population shall be certified
                by
                DCF to administer CFARS (or other rating scale required by DCF or
                the
                Agency).

            

    

    

    
      	 	
              6.

            	
              Mental
                health targeted case managers shall not be counted as Direct Service
                Behavioral Health Providers.

            

    

    

    
      	 	
              7.

            	
              For
                Case Management services, the Health Plan shall provide staff that
                meets
                the following minimum requirements:

            

    

    

    a.
       Have
      a
      baccalaureate degree from an accredited university, with major course work
      in
      the areas of psychology, social work, health education or a related human
      service field and, if working with Children/Adolescents, have a minimum of
      one-(1) year full time experience or equivalent experience, working with the
      target population. Prior experience is not required if working with the adult
      population; or

    

    b.
       Have
      a
      baccalaureate degree from an accredited university and if working with
      Children/Adolescents, have at least three (3) years full time or equivalent
      experience, working with the target population. If working with adults, the
      case
      manager must have two (2) years of experience. (Note: case managers who were
      certified by the Department prior to July 1, 1999, who do not meet the degree
      requirements, may provide Case Management services if they meet the other
      requirements; and

    

    c. Have
      completed a training program within six (6) months of employment. The training
      program must be prior approved by the Agency. The training must include a review
      of the local resources and a thorough presentation of the applicable State
      and
      federal statutes and promote the knowledge, skills, and competency of all case
      managers through the presentation of key core elements relevant to the target
      population. The case manager must also be able to demonstrate an understanding
      of the Health Plan’s Case Management policies and procedures.

    

    
      	 	
              8.
                

            	
              Case
                Management supervision must be provided by a person who has a master’s
                degree in a human services field and three (3) years of professional
                full
                time experience serving this target population or a person with a
                bachelor’s degree and five (5) years of full time or equivalent Case
                Management experience. For supervising case managers who work only
                with
                adults, two (2) years of full time experience is required. The supervisors
                must have had the approved Health Plan training in Case Management
                or have
                documentation that they have prior equivalent
                training.

            

    

    

    
      	 	
              9.
                

            	
              The
                Health Plan shall have access to no less than one (1) fully accredited
                psychiatric community Hospital bed per 2,000 Enrollees, as appropriate
                for
                both Children/Adolescents and adults. Specialty psychiatric Hospital
                beds
                may be used to count toward this requirement when psychiatric community
                Hospital beds are not available within a particular community.
                Additionally, the Health Plan shall have access to sufficient numbers
                of
                accredited Hospital beds on a medical/surgical unit to meet the need
                for
                medical detoxification treatment.

            

    

    

    
      	 	
              10.

            	
              The
                Health Plan’s facilities must be licensed, as required by law and rule,
                accessible to the handicapped, in compliance with federal Americans
                with
                Disabilities Act guidelines, and have adequate space, supplies, good
                sanitation, and fire, safety, and disaster preparedness and recovery
                procedures in operation.

            

    

    

    
      	 	
              11.

            	
              The
                Health Plan shall ensure that it has Providers that are qualified
                to serve
                Enrollees and experienced in serving severely emotionally disturbed
                Children/Adolescents and severely and persistent mentally ill adults.
                The
                Health Plan shall maintain documentation of its Providers’ experience in
                the Providers' credentialing file.

            

    

    

    
      	 	
              12.

            	
              The
                Health Plan shall adhere to the staffing ratio of at least one (1)
                FTE
                Behavioral Health Care Case Manager for twenty (20) Children/Adolescents
                and at least one (1) FTE Behavioral Health Care Case Manager per
                forty
                (40) adults. Direct Service Behavioral Health Care Providers shall
                not
                count as Behavioral Health Care Case
                Managers.

            

    

    

    
      	 	
              13.

            	
              Prior
                to commencement of Behavioral Health Services, the Health Plan shall
                enter
                into agreements for coordination of care and treatment of Enrollees,
                jointly or sequentially served, with county community mental health
                care
                center(s) that are not a part of the Health Plan's Participating Provider
                network. The Health Plan shall enter into similar agreements with
                agencies
                funded pursuant to Chapter 394, F.S., 2004. The Agency shall approve
                all
                model agreements between the Health Plan and county community mental
                health center(s)/agencies before the Health Plan enters into the
                agreement. This requirement shall not apply if the Health Plan provides
                the Agency with documentation that shows the Health Plan has made
                a good
                faith effort to contract with county community mental health
                center(s)/agencies, but could not reach an
                agreement.

            

    

    

    
      	 	
              14.

            	
              The
                Health Plan shall request current behavioral health care provider
                information from all new Enrollees upon enrollment. The Health Plan
                shall
                solicit these behavioral health services providers to participate
                in the
                Health Plan's network. The Health Plan may request in writing that
                the
                Agency grant exemption to a Health Plan from soliciting a specific
                behavioral health services provider on a case-by-case
                basis.

            

    

    

    
      	 	
              15.

            	
              To
                the maximum extent possible, the Health Plan shall contract for the
                provision of Behavioral Health Services with the State's community
                mental
                health centers designated by the Agency and
                DCF.

            

    

    

    
      	F.	
               Specialists
                and Other Providers

            

    

    

    
      	 	
              1.

            	
              In
                addition to the above requirements, the Health Plan shall assure
                the
                availability of the following specialists, as appropriate for both
                adults
                and pediatric members, on at least a referral basis. The Health Plan
                shall
                use Participating Specialists with pediatric expertise for
                Children/Adolescents when the need for pediatric specialty care is
                significantly different from the need for adult specialty care (for
                example a pediatric cardiologist for Children/Adolescents with congenital
                heart defects).

            

    

    

    a. Allergist,

    

    b. Cardiologist,

    

    c. Endocrinologist,

    

    d. General
      Surgeon,

    

    e. Obstetrical/Gynecology
      (OB/GYN),

    

    f. Neurologist,

    

    g. Nephrologist,

    

    h. Orthopedist,

    

    i. Urologist,

    

    j. Dermatologist,

    

    k. Otolaryngologist,

    

    l. Pulmonologist,

    

    m. Chiropractic
      Physician,

    

    n. Podiatrist,

    

    o. Ophthalmologist,

    

    p. Optometrist,

    

    q. Neurosurgeon,

    

    r. Gastroenterologist,

    

    s. Oncologist,

    

    t. Radiologist,

    

    u. Pathologist,

    

    v. Anesthesiologist,

    

    w. Psychiatrist,

    

    x. Oral
      surgeon,

    

    y. Physical,
      respiratory, speech and occupational therapists, and

    

    z. Infectious
      disease specialist.

    

    
      	 	
              2.

            	
              If
                the infectious disease specialist does not have expertise in HIV
                and its
                treatment and care, then the Health Plan must have another Provider
                with
                such expertise.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall make a good faith effort to execute memoranda of
                agreement with the local CHDs to provide services which may include,
                but
                are not limited to, family planning services, services for the treatment
                of sexually transmitted diseases, other public health related diseases,
                tuberculosis, immunizations, foster care emergency shelter medical
                screenings, and services related to Healthy Start prenatal and post
                natal
                screenings. The Health Plan shall provide documentation of its good
                faith
                effort upon the Agency’s request.

            

    

    

    
      	 	
              4.

            	
              Notwithstanding
                Section VIII.B.2, Certain Public Providers, of this Contract, the
                Health
                Plan shall pay, without prior authorization, at the contracted rate
                or the
                Medicaid Fee-for-Service rate, all valid claims initiated by any
                CHD for
                office visits, prescribed drugs, laboratory services directly related
                to
                DCF emergency shelter medical screening, and tuberculosis. The Health
                Plan
                need not reimburse the CHD until the CHD notifies the Plan and provides
                the Plan with copies of the appropriate medical records and provides
                the
                Enrollee's PCP with the results of any tests and associated office
                visits.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall make a good faith effort to execute a contract
                with a
                Federally Qualified Health Center (FQHC), and if applicable, a Rural
                Health Clinic (RHC). The Health Plan shall reimburse FQHCs and RHCs
                at
                rates comparable to those rates paid for similar services in the
                FQHC's or
                RHC's community. The Health Plan shall report to the Agency, on a
                quarterly basis, the payment rates and the payment amounts made to
                FQHCs
                and RHCs for contractual services provided by these
                entities.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall permit female Enrollees to have direct access to
                a
                women's health specialist within the network for Covered Services
                necessary to provide women's routine and preventive health care services.
                This is in addition to an Enrollee's designated PCP, if that Provider
                is
                not a women's health specialist.

            

    

    

    G. Specialty
      Plan Provider Network

    

    A
      Health
      Plan that offers a Specialty Plan shall ensure its Provider network meets the
      following requirements:

    

    
      	 	
              1.

            	
              The
                Provider network will be integrated and consist of PCPs and specialists
                who are trained to provide services for a particular condition or
                population;

            

    

    

    
      	 	
              2.

            	
              If
                the Specialty Plan has been developed for individuals with a particular
                disease state, the network will contain a sufficient number of board
                certified specialists in the care and management of the disease.
                Because
                individuals have multiple diagnoses, there should be a sufficient
                number
                of specialists to manage different diagnoses as
                well;

            

    

    

    
      	 	
              3.

            	
              A
                defined network of facilities used for inpatient care shall be included
                with accredited tertiary hospitals and hospitals that have been designated
                for specific conditions, appropriate for the Specialty Plan population
                (e.g., end stage renal disease centers, comprehensive hemophilia
                centers;

            

    

    

    
      	 	
              4.

            	
              Specialty
                pharmacies when appropriate; and

            

    

    

    
      	 	
              5.

            	
              A
                range of community based care options as alternatives to hospitalization
                and institutionalization.

            

    

    

    
      	H.	
               Continuity
                of Care

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall allow Enrollees in active treatment to continue
                care
                with a terminated treating provider when such care is Medically Necessary,
                through completion of treatment of a condition for which the Enrollee
                was
                receiving care at the time of the termination, until the Enrollee
                selects
                another treating Provider, or during the next Open Enrollment period.
                None
                of the above may exceed six (6) months after the termination of the
                Provider's contract.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall allow pregnant Enrollees who have initiated a course
                of
                prenatal care, regardless of the trimester in which care was initiated,
                to
                continue care with a terminated treating provider until completion
                of
                postpartum care.

            

    

    

    
      	 	
              3.

            	
              Notwithstanding
                the provisions in this subsection, a terminated provider may refuse
                to
                continue to provide care to an Enrollee who is abusive or
                noncompliant.

            

    

    

    
      	 	
              4.

            	
              For
                continued care under this subsection, the Health Plan and the terminated
                provider shall continue to abide by the same terms and conditions
                as
                existed in the terminated contract.

            

    

    

    
      	 	
              5.

            	
              The
                requirements set forth in this subsection shall not apply to providers
                who
                have been terminated from the Health Plan for
                Cause.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall develop and maintain policies and procedures for
                the
                above requirements. 

            

    

    

    
      	I.	
              Network
                Changes

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall notify the Agency within seven (7) Business Days
                of any
                significant changes to the Health Plan network. A significant change
                is
                defined as:

            

    

    

    a. A
      decrease in the total number of PCPs by more than five percent
      (5%);

    

    b. A
      loss of
      all Participating Specialists in a specific specialty where another
      Participating Specialist in that specialty is not available within sixty (60)
      minutes;

    

    c. A
      loss of
      a Hospital in an area where another Health Plan Hospital of equal service
      ability is not available within thirty (30) minutes; or

    

    d. Other
      adverse changes to the composition of the network which impair or deny the
      Enrollee's adequate access to Providers.

    

    
      	 	
              2.

            	
              The
                Health Plan shall have procedures to address changes in the Health
                Plan
                network that negatively affect the ability of Enrollees to access
                services, including access to a culturally diverse Provider network.
                Significant changes in network composition that negatively impact
                Enrollee
                access to services may be grounds for Contract termination or Agency
                determined sanctions.

            

    

    

    
      	 	
              3.

            	
              If
                a PCP ceases participation in the Health Plan network, the Health
                Plan
                shall send written notice to the Enrollees who have chosen the Provider
                as
                their PCP. This notice shall be issued no less than ninety (90) Calendar
                Days prior to the effective date of the termination and no more than
                ten
                (10) Calendar Days after receipt or issuance of the termination notice.
                

            

    

    

    a. If
      an
      Enrollee is in a Prior Authorized ongoing course of treatment with any other
      Provider who becomes unavailable to continue to provide services, the Health
      Plan shall notify the Enrollee in writing within ten (10) Calendar Days from
      the
      date the Health Plan becomes aware of such unavailability.

    

    b. These
      requirements to provide notice prior to the effective dates of termination
      shall
      be waived in instances where a Provider becomes physically unable to care for
      Enrollees due to illness, a Provider dies, the Provider moves from the Service
      Area and fails to notify the Health Plan, or when a Provider fails
      credentialing. Under these circumstances, notice shall be issued immediately
      upon the Health Plan becoming aware of the circumstances.

    

    

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    Section
      VIII

    Quality
      Management

    

    
      	A.  	
              Quality
                Improvement

            

    

     

    
      	1.  	
              General
                Requirements

            

    

    

    a. The
      Health Plan shall have an ongoing Quality Improvement Program (QIP) that
      objectively and systematically monitors and evaluates the quality and
      appropriateness of care and services rendered, thereby promoting Quality of
      care
      and Quality patient outcomes in service performance to its
      Enrollees.

    

    b. The
      Health Plan’s written policies and procedures shall address components of
      effective health care management including, but not limited to anticipation,
      identification, monitoring, measurement, evaluation of Enrollee’s health care
      needs, and effective action to promote Quality of care. 

    

    c. The
      Health Plan shall define and implement improvements in processes that enhance
      clinical efficiency, provide effective utilization, and focus on improved
      outcome management achieving the highest level of success. 

    

    d. The
      Health Plan and its QIP shall demonstrate in its care management, specific
      interventions to better manage the care and promote healthier Enrollee outcomes.
      

    

    e. The
      Health Plan shall cooperate with the Agency and the External Quality Review
      Organization (EQRO). The Agency will set methodology and standards for QI (spell
      out first time) with advice from the EQRO.

    

    f. Prior
      to
      implementation, the Agency and/or the EQRO shall review the Health Plan
      QIP.

    

    g. The
      Health Plan must submit its QIP to the Agency no later than the execution date
      of the Contract. The QIP must be approved, in writing, by the Agency no later
      than three (3) months following the execution of this Contract. 

    

    
      	 	
              2.
                

            	
              Specific
                Required Components of the
                QIP

            

    

    

    a. The
      Health Plan’s governing body shall oversee and evaluate the QIP. The role of the
      Health Plan’s governing body shall include providing strategic direction to the
      QIP, as well as ensuring the QIP is incorporated into the operations throughout
      the Health Plan.

    

    b. The
      Health Plan shall have a QIP Committee. The Chairman of the Committee shall
      be
      the Health Plan Medical Director. Appropriate Health Plan staff representing
      the
      various departments of the organization shall have membership on the Committee.
      The Committee shall meet on a regular periodic basis. Its responsibilities
      shall
      include the following:

    

    (1) Development
      and implementation of a written QI plan, which incorporates the strategic
      direction provided by the governing body.

    

    (2) The
      QI
      plan shall reflect a coordinated strategy to implement the QIP including
      planning, decision making, intervention, and assessment of results.

    

    (3) The
      QI
      plan shall include a description of the Health Plan staff assigned to the QIP;
      their specific training regarding Medicaid; how they are organized; and their
      responsibilities.

    

    (4) The
      QI
      plan shall describe the role of its Providers in giving input to the QIP,
      whether that is by membership on the Committee, its Sub-Committees, or other
      means.

    

    (5) The
      Health Plan is encouraged to include an advocate representative on the QIP
      Committee.

    

    (6) The
      Health Plan shall submit its written QI plan to the Agency for written approval
      within thirty (30) days of the execution of the Contract.

    

    c. Direct
      and review QI activities, including, but not limited to:

    

    (1) Assure
      that QIP activities take place throughout the Health Plan;

    

    (2) Review
      and suggest new and/or improved QI activities;

    

    (3) Direct
      task forces/committees to review areas of concern in the provision of health
      care services to Enrollees;

    

    (4) Designate
      evaluation and study design procedures;

    

    (5) Report
      findings to appropriate executive authority, staff, and departments within
      the
      Health Plan; and 

    

    (6) Direct
      and analyze periodic reviews of Enrollees' service utilization
      patterns.

     

    d. Maintain
      minutes of all Committee and Sub-Committee meetings.

    

    
      	 	
              3.

            	
              Health
                Plan QI Activities

            

    

    

    The
      Health Plan shall monitor and evaluate the quality and appropriateness of care
      and service delivery (or the failure to provide care or deliver services) to
      Enrollees through performance improvement projects (PIPs), medical record
      audits, performance measures, surveys, and related activities. 

    

    a. PIPs

    

    The
      Health Plan shall perform no less than six (6) Agency approved performance
      improvement projects.

    

    (1) Each
      PIP
      must include a statistically significant sample of Enrollees.

    

    (2) At
      least
      one (1) of the PIPs must focus on Language and Culture, Clinical Health Care
      Disparities, or Culturally and Linguistically Appropriate Services.

    

    (3) At
      least
      two (2) of the PIPs must relate to Behavioral Health Services.

    

    (4) All
      PIPs
      by the Health Plan must achieve, through ongoing measurements and intervention,
      significant improvement to the Quality of care and service delivery, sustained
      over time, in both clinical care and non-clinical care areas that are expected
      to have a favorable effect on health outcomes and Enrollee
      satisfaction.

    

    (5) The
      PIPs
      must be completed in a reasonable time period so as to allow the Health Plan
      to
      evaluate the information drawn from them and to use the results of the analysis
      to improve Quality of care and service delivery every year.

    

    (6) Within
      three months of the execution of this Contract, the Health Plan shall submit,
      in
      writing, a description of each of the PIPs to the Agency for approval. The
      detailed description shall include: 

    

    
      	i.  	
              An
                overview explaining how and why the project was selected, as well
                as its
                relevance to the Health Plan Enrollees and
                Providers;

            

    

    

    
      	ii.  	
              The
                study question;

            

    

    

    
      	iii.  	
              The
                study population;

            

    

    

    
      	iv.  	
              The
                quantifiable measures to be used, including a goal or
                benchmark;

            

    

    

    
      	v.  	
              Baseline
                methodology;

            

    

    

    
      	vi.  	
              Data
                sources;

            

    

    

    
      	vii.  	
              Data
                collection methodology;

            

    

    

    
      	viii.  	
              Data
                collection cycle;

            

    

    

    
      	ix.  	
              Data
                analysis cycle;

            

    

    

    
      	x.  	
              Results
                with quantifiable measures;

            

    

    

    
      	xi.  	
              Analysis
                with time period and the measures
                covered;

            

    

    

    
      	xii.  	
              Analysis
                and identification of opportunities for improvement;
                and

            

    

    

    
      	xiii.  	
              An
                explanation of all interventions to be
                taken.

            

    

    

    b. Behavioral
      Health QI Requirements

    

    (1) 
      The
      Health Plan's QIP shall include a Behavioral Health component in order to
      monitor and assure that the Health Plan's Behavioral Health Services are
      sufficient in quantity, of acceptable Quality and meet the needs of the
      Enrollees. 

    

    (2) Treatment
      plans must:

    

    
      	i.  	
              Identify
                reasonable and appropriate
                objectives;

            

    

    

    
      	ii.  	
              Provide
                necessary services to meet the identified objectives;
                and

            

    

    

    
      	iii.  	
              Include
                retrospective reviews that confirm that the care provided, and its
                outcomes, were consistent with the approved treatment plans and
                appropriate for the Enrollees'
                needs.

            

    

    

    (3) In
      determining if Behavioral Health Services are acceptable according to current
      treatment standards, the Health Plan shall:

    

    
      	i.  	
              Perform
                a quarterly review of a random selection of ten percent (10%) or
                fifty
                (50) medical records, whichever is more, of Enrollees who received
                Behavioral Health Services during the previous quarter;
                and

            

    

    

    
      	ii.  	
              Elements
                of these reviews shall include, but not be limited to:
                

            

    

    

    
      	 	
              (a)

            	
              Management
                of specific diagnoses;

            

    

    

    
      	 	
              (b)

            	
              Appropriateness
                and timeliness of care;

            

    

    

    
      	 	
              (c)

            	
              Comprehensiveness
                of and compliance with the plan of
                care;

            

    

    

    
      	 	
              (d)

            	
              Evidence
                of special screening for high risk Enrollees and/or conditions;
                and

            

    

    

    
      	 	
              (e)

            	
              Evidence
                of appropriate coordination of
                care.

            

    

    

    (4) In
      areas
      in which there is not an established local advisory group, the Health Plan
      is
      responsible for the development of local advisory group meetings within sixty
      (60) days of the effective date of the Contract.

    

    (5) In
      areas
      where there is more than one (1) Health Plan authorized to provide Behavioral
      Health Services, the Health Plans shall work together in establishing an area
      local advisory group.

    

    (6) Composition
      of local advisory groups shall follow Section X. Administration and Management,
      I., Health Plan Local Advisory Group.

    

    (7) The
      Health Plan shall send representation to the local advisory group’s meetings
      that convene quarterly and report to the Agency on the Behavioral Health
      advocacy and programmatic concerns.

    

    (8) Local
      advisory groups shall provide technical and policy advice to the Agency
      regarding Behavioral Health Services.

    

    c. Performance
      Measures (PMs) 

    

    The
      Health Plan shall collect data on patient outcome PMs, as defined by the Health
      Plan Employee Data and Information Set (HEDIS) or otherwise defined by the
      Agency and report the results of the measures to the Agency annually. The Agency
      may add or remove reporting requirements with 30-days advance notice. At a
      minimum, the following PMs shall be measured by the Health Plan:

    

    (1) Breast
      Cancer Screening;

    

    (2) Cervical
      Cancer Screening;

    

    (3) Colorectal
      Cancer Screening;

    

    (4) Well
      Child Visits in the First 15 Months of Life;

    

    (5) Well
      Child Visits in the Third, Fourth, Fifth and Sixth Years of Life;

    

    (6) Adolescent
      Well Care Visits;

    

    (7) Childhood
      Immunization Status; 

    

    (8) Adolescent
      Immunization Status;

    

    (9) Preventive
      and Total Dental Visits for Children/Adolescents Between Three Years and Eleven
      Years and for Children/Adolescents Between Twelve Years and Twenty Years of
      Age;

    

    (10) Average
      number of days spent in the community by all Enrollees receiving Behavioral
      Health intensive case management services;

    

    (11) Number
      of
      enrollees admitted to the State Mental Hospital;

    

    (12) Amount
      of
      time between discharge from the State Mental Hospital and first date of service
      received from the Provider; and

    

    (13) Number
      of
      Enrollees who receive a psychiatric evaluation within required time frames
      prior
      to admission to a nursing facility.

    

    (14) Agency-specified
      data on the five Disease Management programs for chronic conditions specified
      in
      subsection B.6.a. of this Section.

    

    d. Consumer
      Assessment of Health Plans Survey (CAHPS)

    

    At
      the
      end of the first (1st) year under this Contract, the Agency shall conduct an
      annual Consumer Assessment of Health Plans Survey. The CAHPS survey shall be
      done on an annual basis thereafter. The Vendor shall a corrective action plan
      to
      address the results of the CAHPS Survey within two (2) months of the request
      from the Agency. 

    

    e. Provider
      Satisfaction Survey

    

    The
      Health Plan shall submit a Provider satisfaction survey plan, including the
      questions to be asked, to the Agency for written approval by the end of the
      eighth (8th) month of this Contract. The Health Plan shall conduct the survey
      at
      the end of the first (1st) year of this Contract. The results of the Provider
      satisfaction survey shall be reported to the Agency within four (4) months
      of
      the beginning of the second year of this Contract. 

     

    f. Medical
      Record Review

    

    (1) If
      the
      Health Plan is not accredited, or if the Health Plan is accredited by an entity,
      that does not review the Medical Records of the Health Plan's PCPs, then the
      Health Plan shall conduct reviews of Enrollees’ Medical Records to ensure that
      PCPs provide high Quality health care that is documented according to
      established standards. 

    

    (2) The
      standards, which must include all Medical Record documentation requirements
      addressed in this Contract, must be distributed to all Providers. 

    

    (3) The
      Health Plan must conduct these reviews at all PCP sites that serve fifty (50)
      or
      more Enrollees. 

    

    (4) Practice
      sites include both individual offices and large group facilities. 

    

    (5) The
      Health Plan must review each practice site at least one (1) time during each
      two
      (2) year period. 

    

    
      	 	
              (6)

            	
              The
                Health Plan must review a reasonable number of records at each site
                to
                determine compliance. Five (5) to ten (10) records per site is a
                generally-accepted target, though additional reviews must be completed
                for
                large group practices or when additional data is necessary in specific
                instances. 

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall report the results of all Medical Record reviews
                to the
                Agency within thirty (30) Calendar Days of the
                review.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan must submit to the Agency for written approval and maintain
                a
                written strategy for conducting Medical Record reviews. The strategy
                must
                include, at a minimum, the following:

            

    

    

    i. Designated
      staff to perform this duty; 

    

    ii. The
      method of case selection; 

    

    iii. The
      anticipated number of reviews by practice site; 

    

    iv. The
      tool
      that the Health Plan will use to review each site; and

    

    v. How
      the
      Health Plan will link the information compiled during the review to other Health
      Plan functions (e.g., QI, credentialing, Peer Review, etc.).

    

    g. Peer
      Review

    

    
      	 	
              (1)

            	
              The
                Health Plan shall have a Peer Review process which:
                

            

    

    

    i. Reviews
      a
      Provider's practice methods and patterns, morbidity/mortality rates, and all
      Grievances filed against the Provider relating to medical
      treatment.

    

    ii. Evaluates
      the appropriateness of care rendered by Providers.

    

    iii. Implements
      corrective action(s) when the Health Plan deems it necessary to do
      so.

    

    iv. Develops
      policy recommendations to maintain or enhance the Quality of care provided
      to
      Enrollees.

    

    v. Conducts
      reviews which include the appropriateness of diagnosis and subsequent treatment,
      maintenance of a Provider's Medical Records, adherence to standards generally
      accepted by a Provider's peers and the process and outcome of a Provider's
      care.

    

    vi. Appoints
      a Peer Review Committee, as a Sub-Committee to the QIP Committee, to review
      provider performance when appropriate. The Medical Director or his/her designee
      shall chair the Peer Review Committee, and its membership shall be drawn from
      the Provider Network and include peers of the Provider being
      reviewed.

    

    vii. Receive
      and review all written and oral allegations of inappropriate or aberrant service
      by a Provider.

    

    viii. Educate
      Enrollees and Health Plan staff about the Peer Review process, so that Enrollees
      and the Health Plan staff can notify the Peer Review authority of situations
      or
      problems relating to Providers.

    

    h. Credentialing
      and Recredentialing 

    

    
      	 	
              (1)

            	
              The
                Health Plan shall be responsible the credentialing and recredentialing
                of
                its Provider network. Hospital ancillary Providers are not required
                to be
                independently credentialed if those Providers only provide services
                to the
                Health Plan Enrollees through the
                Hospital.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall establish and verify credentialing and recredentialing
                criteria for all professional Providers that, at a minimum, meet
                the
                Agency's Medicaid participation standards. The Agency’s criterion
                includes:

            

    

    

    i. A
      completed Medicaid Agreement with a copy of each Provider's current medical
      license sent to the Agency’s Fiscal Agent and verification that the Provider is
      an approved Medicaid provider. The Provider’s active licensure shall suffice in
      lieu of verification of education, training, and professional liability coverage
      requirements.

    

    ii. No
      receipt of revocation or suspension of the Provider's State License by the
      Division of Medical Quality Assurance, Department of Health.

    

    iii. No
      ongoing investigation(s) by Medicaid Program Integrity, Medicaid Fraud and
      Control Unit, Medicare, Medical Quality Assurance, or other governmental
      entities.

    

    
      	 	
              (3)

            	
              The
                Health Plan's credentialing files must document the education, experience,
                prior training and ongoing service training for each staff member
                or
                Provider rendering Behavioral Health
                Services.

            

    

    

    
      	 	
              (4)

            	
              The
                following additional requirements apply to physicians and must ensure
                compliance with 42 CFR 438.214:

            

    

    

    i. Good
      standing of privileges at the Hospital designated as the primary admitting
      facility by the PCP or if the Provider does not have admitting privileges,
      good
      standing of privileges at the Hospital by another physician with whom the PCP
      has entered into an arrangement for Hospital coverage.

    

    ii. Valid
      Drug Enforcement Administration (DEA) certificates, where
      applicable.

    

    iii. Attestation
      that the total active patient load (all populations with Medicaid
      Fee-for-Service (FFS), CMS Network, Health Maintenance Organization (HMO),
      Health Plan, Medicare or commercial coverage) is no more than 3,000 patients
      per
      PCP. An active patient is, one that is, seen by the Provider a minimum of three
      (3) times per year.

    

    iv. Passage
      of a criminal background check, within the previous twelve (12) months from
      the
      date of the Enrollment application, by the Provider, any officer, director,
      agent managing employee, affiliated person, or any partner or shareholder having
      an ownership interest of five percent (5%) or greater in the Provider. (If
      the
      Provider is a corporation, partnership, or other business entity.)

    

    v. A
      good
      standing report on a credentialing site visit survey.

    

    vi. Attestation
      to the correctness/completeness of the Provider's application.

    

    vii. Statement
      regarding any history of loss or limitation of privileges or disciplinary
      activity.

    

    viii. Current
      curriculum vitae, which includes at least five (5) years of work
      history.

    

    
      	 	
              4.

            	
              Agency
                Oversight

            

    

    

    a. The
      Agency shall evaluate the Health Plan’s QIP and PMs at least one (1) time per
      year at dates to be determined by the Agency, or as otherwise specified by
      this
      Contract.

    

    b. The
      Health Plan, in conjunction with the Agency, shall participate in workgroups
      to
      design additional QI strategies and to learn to use the best practice methods
      for enhancing the Quality of health care provided to Enrollees.

    

    c. If
      the
      PIPs, CAHPS, the PMs, the annual Medical Record audit or the EQRO indicate
      that
      the Health Plan's performance is not acceptable, then the Agency may restrict
      the Health Plan’s Enrollment activities including, but not limited to,
      termination of Mandatory Assignments.

    

    d. If
      the
      Agency determines that the Health Plan’s performance is not acceptable, the
      Agency shall require the Health Plan to submit a corrective action plan (CAP).
      f
      the Health Plan fails to provide a CAP within the time specified by the Agency,
      the Agency shall sanction the Health Plan, in accordance with the provisions
      of
      Section XIV, Sanctions, and may immediately terminate all Enrollment activities
      and Mandatory Assignments. When considering whether to impose a limitation
      on
      Enrollment activities or Mandatory Assignment, the Agency may take into account
      the Health Plan’s cumulative performance on all QI activities.

    

    

    e. Annual
      Medical Record Audit

    

    
      	 	
              (1)

            	
              The
                Health Plan shall furnish specific data requested by the Agency in
                order
                to conduct the Medical Record
                audit.

            

    

    

    
      	 	
              (2)

            	
              If
                the Medical Record audit indicates that Quality of care is not acceptable,
                pursuant to contractual requirements, the Agency shall sanction the
                Health
                Plan, in accordance with the provisions of Section XIV, Sanctions,
                and may
                immediately terminate all Enrollment activities and Mandatory Assignments,
                until the Health Plan attains an acceptable level of Quality of care
                as
                determined by the Agency.

            

    

    

    f. Independent
      Medical Record Review by an EQRO

    

    
      	 	
              (1)

            	
              The
                Health Plan shall provide all information requested by the EQRO and/or
                the
                Agency, including, but not limited to quality outcomes concerning
                timeliness of, and Enrollee access to, Covered
                Services.

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan shall cooperate with the EQRO during the Medical Record
                review, which will be done at least one (1) time per year.
                

            

    

    

    
      	 	
              (3)

            	
              If
                the EQRO indicates that the Quality of care is not within acceptable
                limits set forth in this Contract, the Agency shall sanction the
                Health
                Plan, in accordance with the provisions of Section XIV, Sanctions
                and may
                immediately terminate all Enrollment activities and Mandatory Assignments
                until the Health Plan attains a satisfactory level of Quality of
                care as
                determined by the EQRO.

            

    

    

    

    
      	B.  	
              Utilization
                Management (UM)

            

    

     

    

    
      	 	
              1.

            	
              General
                Requirements

            

    

    

    The
      UM
      program shall be consistent with 42 CFR 456 and include, but not be limited
      to:

    

    a. Procedures
      for identifying patterns of over-utilization and under-utilization by Enrollees
      and for addressing potential problems identified as a result of these
      analyses.

    

    b. The
      Health Plan shall report Fraud and Abuse information identified through the
      Utilization Management program to the Agency’s contract manager, MPI and MFCU as
      described in Section X, and referenced in 42 C.F.R. 455.1(a)(1).

    

    c. A
      procedure for Enrollees to obtain a second medical opinion and that the Health
      Plan shall be responsible for authorizing claims for such services in accordance
      with section 641.51, F.S.

    

    d. Service
      Authorization protocols for Prior Authorization and denial of services; the
      process used to evaluate prior and con-current authorization; mechanisms to
      ensure consistent application of review criteria for authorization decisions;
      consultation with the requesting Provider when appropriate, Hospital discharge
      planning, physician profiling; and a retrospective review of both inpatient
      and
      ambulatory claims, meeting the predefined criteria below. The Health Plan shall
      be responsible for ensuring the consistent application of review criteria for
      authorization decisions and consulting with the requesting Provider when
      appropriate.

    

    
      	 	
              (1)

            	
              The
                Health Plan must have written approval from the Agency for its Service
                Authorization protocols and for any changes to the original protocols.
                

            

    

    

    
      	 	
              (2)

            	
              The
                Health Plan's Service Authorization systems shall provide the
                authorization number and effective dates for authorization to
                Participating Providers and non-participating
                Providers.

            

    

    

    
      	 	
              (3)

            	
              The
                Health Plan's Service Authorization systems shall provide written
                confirmation of all denials of authorization to providers. (See 42
                C.F.R.
                438.210(c)).

            

    

    

    i. The
      Health Plan may request to be notified, but shall not deny claims payment based
      solely on lack of notification, for the following:

    

    
      	 	
              (a)

            	
              Inpatient
                emergency admissions (within ten (10)
                days);

            

    

    

    
      	 	
              (b)

            	
              Obstetrical
                care (at first visit);

            

    

    

    
      	 	
              (c)

            	
              Obstetrical
                admissions exceeding forty-eight (48) hours for vaginal delivery
                and
                ninety-six (96) hours for caesarean section;
                and

            

    

    

    
      	 	
              (d)

            	
              Transplants.

            

    

    

    ii. The
      Health Plan shall ensure that all decisions to deny a Service Authorization
      request, or limit a service in amount, duration, or scope that is less than
      requested, are made by Health Care Professionals who have the appropriate
      clinical expertise in treating the Enrollee’s condition or disease. (See 42
      C.F.R. 438.210(b)(3))

    

    
      	 	
              (4)

            	
              Only
                a licensed psychiatrist may authorize a denial for an initial or
                concurrent authorization of any request for Behavioral Health Services.
                The psychiatrist's review shall be part of the UM process and not
                part of
                the clinical review, which may be requested by a Provider or the
                Enrollee,
                after the issuance of a denial.

            

    

    

    
      	 	
              (5)

            	
              The
                Health Plan shall provide post authorization to County Health Departments
                (CHD) for the provision of emergency shelter medical screenings provided
                for clients of DCF.

            

    

    

    
      	 	
              (6)

            	
              Health
                Plans with automated authorization systems may not require paper
                authorization as a condition of receiving
                treatment.

            

    

    

    
      	 	
              2.

            	
              Certain
                Public Providers 

            

    

    

    a. The
      Health Plan shall authorize all claims, from a CHD, a migrant health center
      funded under Section 329 of the Public Health Services Act or a community health
      center funded under Section 330 of the Public Health Services Act, without
      Prior
      Authorization for the following:

    

    
      	 	
              (1)

            	
              The
                diagnosis and treatment of sexually transmitted diseases and other
                communicable diseases, such as tuberculosis and human immunodeficiency
                syndrome;

            

    

    

    
      	 	
              (2)

            	
              The
                provision of immunizations;

            

    

    

    
      	 	
              (3)

            	
              Family
                planning services and related
                pharmaceuticals;

            

    

    

    
      	 	
              (4)

            	
              School
                health services listed in (1), (2) and (3) above, and for services
                rendered on an urgent basis by such Providers;
                and,

            

    

    

    
      	 	
              (5)

            	
              In
                the event that a vaccine-preventable disease emergency is declared,
                the
                Health Plan shall authorize claims from the County Health Department
                for
                the cost of the administration of
                vaccines.

            

    

    

    b. The
      providers specified in B.2.a. above, shall attempt to contact the Health Plan
      before providing health care services to Enrollees. Such providers shall provide
      the Health Plan with the results of the office visit, including test results,
      and shall be reimbursed by the Health Plan at the rate negotiated between the
      Health Plan and the public provider or the Medicaid Fee-for-Service
      rate.

    

    c. The
      Health Plan shall not deny claims for services delivered by the providers
      specified in B.2.a. above solely based on the period between the date of service
      and the date of clean claim submission, unless that period exceeds 365 Calendar
      Days.

    

    
      	 	
              3.

            	
              Notice
                of Action

            

    

    

    a. The
      Health Plan shall notify the Enrollee, in writing, using language at, or below
      the fourth grade reading level, of any Action taken by the Health Plan to deny
      a
      Service Authorization request, or limit a service in amount, duration, or scope
      that is less than requested. (See 42 C.F.R. 438.404(a) and (c) and 42 C.F.R.
      438.10(c) and (d))

     

    b. The
      Health Plan must provide notice to the Enrollee as set forth below: (See 42
      C.F.R. 438.404(a) and (c) and 42 C.F.R. 438.210(b) and (c)) 

    

    
      	 	
              (1)

            	
              The
                Action the Health Plan has taken or intends to
                take.

            

    

    

    
      	 	
              (2)

            	
              The
                reasons for the Action, customized for the circumstances of the
                Enrollee.

            

    

    

    
      	 	
              (3)

            	
              The
                Enrollee’s or the Provider's (with written permission of the Enrollee)
                right to file an Appeal.

            

    

    

    
      	 	
              (4)

            	
              The
                procedures for filing an Appeal.

            

    

    

    
      	 	
              (5)

            	
              The
                circumstances under which expedited resolution is available and how
                to
                request it.

            

    

    

    
      	 	
              (6)

            	
              Enrollee
                rights to request that Benefits continue pending the resolution of
                the
                Appeal, how to request that Benefits be continued, and the circumstances
                under which the Enrollee may be required to pay the costs of these
                services.

            

    

    

    c. The
      Health Plan must provide the notice of Action within the following time
      frames:

    

    
      	 	
              (1)

            	
              At
                least ten (10) Calendar Days before the date of the Action or fifteen
                (15)
                Calendar Days if the notice is sent by Surface Mail (five [5] Calendar
                Days if the Health Plan suspects Fraud on the part of the Enrollee.
                (See
                42 C.F.R. 431.211, 42 C.F.R. 431.213 and 42 C.F.R. 431.214)
                

            

    

    

    
      	 	
              (2)

            	
              For
                denial of the claim, at the time of any Action affecting the
                claim.

            

    

    

    
      	 	
              (3)

            	
              For
                standard Service Authorization decisions that deny or limit services,
                as
                quickly as the Enrollee’s health condition requires, but no later than
                fourteen (14) Calendar Days following receipt of the request for
                service.
                (See 42 C.F.R. 438.201(d)(1))

            

    

    

    
      	 	
              (4)

            	
              If
                the Health Plan extends the time frame for notification, it
                must:

            

    

    1.  

    i. Give
      the
      Enrollee written notice of the reason for the extension and inform the Enrollee
      of the right to file a Grievance if the Enrollee disagrees with the Health
      Plan’s decision to extend the time frame.

    

    ii. Carry
      out
      its determination as quickly as the Enrollee's health condition requires, but
      in
      no case later than the date upon which the fourteen (14) Calendar Day extension
      period expires. (See 42 C.F.R. 438.210(d)(1))

    2.  

    
      	 	
              (5)

            	
              If
                the Health Plan fails to reach a decision within the time frames
                described
                above, the failure on the part of the Health Plan shall be considered
                a
                denial and is an Action adverse to the Enrollee. (See 42 C.F.R.
                438.210(d))

            

    

    

    
      	 	
              (6)

            	
              For
                expedited Service Authorization decisions, within the three (3) Business
                Days (with the possibility of a fourteen (14) Calendar Day extension)
                (See
                42 C.F.R. 438.210(d)(2))

            

    

    

    
      	 	
              (7)

            	
              The
                Health Plan shall provide timely approval or denial of authorization
                of
                out-of-network use through the assignment of a Prior Authorization
                number,
                which refers to and documents the approval. The Health Plan shall
                provide
                written follow-up documentation of the approval or the denial to
                the
                out-of-network provider within five (5) Business Days from the request
                for
                approval.

            

    

    

    
      	 	
              (8)

            	
              The
                Health Plan shall determine when exceptional referrals to out-of-network
                specially qualified providers are needed to address the unique medical
                needs of an Enrollee (e.g., when an Enrollee’s medical condition requires
                testing by a geneticist). The Health Plan shall develop and maintain
                policies and procedures for such
                referrals.

            

    

    

    
      	 	
              4.

            	
              Care
                Management

            

    

    

    The
      Health Plan shall be responsible for the management of medical care and
      continuity of care for all Enrollees. The Health Plan shall maintain written
      Case Management and continuity of care protocols that include the following
      minimum functions:

    

    a. Appropriate
      referral and scheduling assistance of Enrollees needing specialty health
      care/Transportation services, including those identified through Child Health
      Check-Up Program (CHCUP) Screenings.

    

    b. Determination
      of the need for Non-Covered Services and referral of the Enrollee for assessment
      and referral to the appropriate service setting (to include referral to WIC
      and
      Healthy Start) utilizing assistance as needed by the area Medicaid
      office.

    

    c. Case
      Management follow-up services for children, who the Health Plan identifies
      through blood Screenings as having abnormal levels of lead.

    

    d. Coordinated
      Hospital/institutional discharge planning that includes post-discharge care,
      including skilled, short-term, skilled nursing facility care, as
      appropriate.

    

    e. A
      mechanism for direct access to specialists for Enrollees identified as having
      special health care needs, as is appropriate for their condition and identified
      needs.

    

    f. The
      Health Plan shall have an outreach program and other strategies for identifying
      every pregnant Enrollee. This shall include case management, claims analysis,
      and use of health risk assessment, etc. The Health Plan shall require its
      participating Providers to notify the Health Plans of any Medicaid Enrollee
      who
      is identified as being pregnant. 

    

    g. Documentation
      of referral services in Enrollees’ medical records, including results.

    

    h. Monitoring
      of Enrollees with ongoing medical conditions and coordination of services for
      high utilizers such that the following functions are addressed as appropriate:
      acting as a liaison between the Enrollee and Providers, ensuring the Enrollee
      is
      receiving routine medical care, ensuring that the Enrollee has adequate support
      at home, assisting Enrollees who are unable to access necessary care due to
      their medical or emotional conditions or who do not have adequate community
      resources to comply with their care, and assisting the Enrollee in developing
      community resources to manage the member’s medical condition. 

    

    i. Documentation
      of emergency care encounters in Enrollees’ records with appropriate medically
      indicated follow-up. 

    

    j. Coordination
      of hospital/institutional discharge planning that includes post-discharge care,
      including skilled short-term rehabilitation, and skilled nursing facility care,
      as appropriate. 

    

    k. Share
      with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its
      identification and assessment of any enrollee with special health care needs
      so
      that those activities need not be duplicated.

    

    l. Ensure
      that in the process of coordinating care, each Enrollee's privacy is protected
      consistent with the confidentiality requirements in 45 CFR parts 160 and 164.
      45
      CFR Part 164 specifically describes the requirements regarding the privacy
      of
      individually identifiable health information. 

    

    
      	 	
              5.

            	
              New
                Enrollee Procedures

            

    

    

    a. The
      Health Plan shall not delay Service Authorization if written documentation
      is
      not available in a timely manner.

    

    b. The
      Health Plan shall contact each new Enrollee at least two (2) times, if
      necessary, within ninety (90) Calendar Days of the Enrollee's Enrollment to
      schedule the Enrollee's initial appointment with the PCP for the purpose of
      obtaining a health risk assessment and/or CHCUP Screening. For this subsection,
      "contact" is defined as mailing a notice to, or telephoning, an Enrollee at
      the
      most recent address or telephone number available.

    

    c. The
      Health Plan shall urge Enrollees to see their PCPs within 180 Calendar Days
      of
      Enrollment.

    

    d. The
      Health Plan shall contact each new Enrollee within thirty (30) Calendar Days
      of
      Enrollment to request that the Enrollee authorize the release of his or her
      Medical Records (including those related to Behavioral Health Services) to
      the
      Health Plan, or the Health Plan's health services subcontractor, from those
      providers who treated the Enrollee prior to the Enrollee's Enrollment with
      the
      Health Plan. Also, the Health Plan shall request or assist the Enrollee's new
      PCP by requesting the Enrollee's Medical Records from the previous
      providers.

    

    e. The
      Health Plan shall use the Enrollee's health risk assessments and/or released
      Medical Records to identify Enrollee's who have not received CHCUP Screenings
      in
      accordance with the Agency approved periodicity schedule.

    

    f. The
      Health Plan shall contact, up to two (2) times if necessary, any Enrollee more
      than two (2) months behind in the Agency approved periodicity Screening schedule
      to urge those Enrollees, or their legal representatives, to make an appointment
      with the Enrollees' PCPs for a Screening visit.

    

    g. Within
      thirty (30) Calendar Days of Enrollment, the Health Plan shall notify Enrollees
      of, and ensures the availability of, a Screening for all Enrollees known to
      be
      pregnant or who advise the Health Plan that they may be pregnant. The Health
      Plan shall refer Enrollees who are, or may be, pregnant to the appropriate
      Provider stating that the Enrollee can obtain appropriate prenatal
      care.

    

    h. The
      Health Plan shall honor any written documentation of Prior Authorization of
      ongoing Covered Services for a period of thirty (30) Business Days after the
      effective date of Enrollment, or until the Enrollee's PCP reviews the Enrollee's
      treatment plan for the following types of Enrollees:

    

    
      	 	
              (1)

            	
              Enrollees
                who voluntarily enrolled; and

            

    

    

    
      	 	
              (2)

            	
              Those
                Enrollees who were automatically reenrolled after regaining Medicaid
                eligibility.

            

    

    

    i. For
      Mandatory Assignment Enrollees, the Health Plan shall honor any written
      documentation of Prior Authorization of ongoing services for a period of one
      (1)
      month after the effective date of Enrollment or until the Mandatory Assignment
      Enrollee's PCP reviews the Enrollee's treatment plan, whichever comes
      first.

    

    j. For
      all
      Enrollees, written documentation of Prior Authorization of ongoing services
      includes the following, provided that the services were prearranged prior to
      Enrollment with the Health Plan:

    

    
      	 	
              (1)

            	
              Prior
                existing orders;

            

    

    

    
      	 	
              (2)

            	
              Provider
                appointments, e.g. dental appointments, surgeries, etc.;
                and

            

    

    

    
      	 	
              (3)

            	
              Prescriptions
                (including prescriptions at non-participating
                pharmacies).

            

    

    

    k. The
      Health Plan shall not delay Service Authorization if written documentation
      is
      not available in a timely manner. The Health Plan is not required to approve
      claims for which it has received no written documentation. 

    

    l. The
      Health Plan shall not deny claims submitted by an out-of-network provider solely
      based on the period between the date of service and the date of clean claim
      submission, unless that period exceeds 365 days.

    

    m. The
      Enrollee's guardian, next of kin or legally authorized responsible person is
      permitted to act on the Enrollee's behalf in matters relating to the Enrollee's
      Enrollment, plan of care, and/or provision of services, if the
      Enrollee: 

    

    
      	 	
              (1)

            	
              Was
                adjudicated incompetent in accordance with the law;
                

            

    

    

    
      	 	
              (2)

            	
              Is
                found by his or her Provider to be medically incapable of understanding
                his or her rights; or

            

    

    

    
      	 	
              (3)

            	
              Exhibits
                a significant communication
                barrier.

            

    

    

    n. The
      Health Plan shall take immediate action to address any identified urgent medical
      needs. "Urgent medical needs" means any sudden or unforeseen situation which
      requires immediate action to prevent hospitalization or nursing home placement.
      Examples include hospitalization of spouse or caregiver or increased impairment
      of in Enrollee living alone who suddenly cannot manage basic needs without
      immediate help, hospitalization or nursing home placement.

    

    
      	 	
              6.

            	
              Disease
                Management

            

    

    

    a. The
      Health Plan shall develop and implement disease management programs for
      Enrollees living with chronic conditions. The disease management initiatives
      shall include, but are not limited to asthma, HIV/AIDS, diabetes, congestive
      heart failure, and hypertension. The Health Plan may develop and implement
      additional disease management programs for its Enrollees.

    

    b. The
      disease management programs shall include the following components:

    

    
      	 	
              (1)

            	
              Provider
                and Enrollee profiling;

            

    

    

    
      	 	
              (2)

            	
              Specialized
                disease-specific physician care;

            

    

    

    
      	 	
              (3)

            	
              Intensive
                care management;

            

    

    

    
      	 	
              (4)

            	
              Provider
                education;

            

    

    

    
      	 	
              (5)

            	
              Enrollee
                education; 

            

    

    

    
      	 	
              (6)

            	
              Clinical
                practice guidelines;

            

    

    

    
      	 	
              (7)

            	
              Severity
                and risk assessments of the Enrollee
                population;

            

    

    

    
      	 	
              (8)

            	
              Screening
                to verify the Enrollee’s initial diagnosis, any complications and the
                severity of the Enrollee’s illness;
                and

            

    

    

    
      	 	
              (9)

            	
              Interventions
                designed to improve compliance and prevent acute events, which may
                include:

            

    

    

    i. Implementation
      of standard clinical guidelines for recommended treatments for each disease
      process; and

    ii. Enrollee
      and Provider education focusing on self-management by the Enrollee.

    

    c. The
      Health Plan must develop and use a plan of treatment for chronic disease
      follow-up care that is tailored to the individual Enrollee. The purpose of
      the
      plan of treatment is to assure appropriate ongoing treatment reflecting the
      highest standards of medical care designed to minimize further deterioration
      and
      complications. The plan of treatment shall be on file for each Enrollee with
      a
      chronic disease and shall contain sufficient information to explain the progress
      of treatment.

    

    d. As
      indicated below, the Health Plan must conduct Agency-specified patient
      satisfaction surveys for each of the five chronic conditions specified in
      subsection a. above, for a statistically valid sample of the respective Enrollee
      population identified with each chronic conditions.  These patient
      satisfaction surveys must be completed on a quarterly-rotational basis so that
      the Health Plans submit the respective patient satisfaction surveys results
      by
      the 15th of the month following the quarter being reported. The Agency may
      use
      the results of these surveys in Health Plan comparison information provided
      by
      the Choice Counselor/Enrollment Broker to Potential Enrollees.

    

    i. 
      If the
      Health Plan implements Disease Management programs for other chronic conditions
      in addition to the five chronic conditions specified in subsection B.6.a. above,
      it may request approval from the Agency to replace no more than two of the
      required patient satisfaction surveys with patient satisfaction surveys on
      other
      Health Plan-implemented Disease Management programs for chronic
      conditions.

    

    ii. For
      the
      first (1st) Contract Year, the Health Plan must begin conducting the first
      patient satisfaction surveys by January 1, 2007, with a completion date no
      later
      than August 31, 2007. The Health Plan can choose how it divides the patient
      satisfaction surveys during the first (1st) Contract Year. For example, the
      Health Plan can conduct three (3) of the patient satisfaction surveys during
      the
      quarter beginning January 1, 2007 and the last two (2) patient satisfaction
      surveys during the quarter beginning April 1, 2007. 

    

    iii. For
      the
      second (2nd)
      and
      third (3rd)
      Contract Years, the Health Plan shall commence conducting patient satisfaction
      surveys on September 1, 2008 and September 1, 2009, respectively, with
      completion of the patient satisfaction surveys by August 31, 2009 and August
      31,
      2010, respectively. As
      with
      the first Contract Year, the Health Plan may choose which patient satisfaction
      surveys to conduct each quarter. For example, the Health Plan may choose to
      conduct 1 patient satisfaction survey for the first three quarters of the second
      Contract Year and two in the last quarter for a total of five. In the third
      Contract Year, the health Plan may choose to conduct one patient satisfaction
      survey in the first, third and fourth quarters of the Contract Year, and two
      during the second quarter of the third Contract Year.

    iv. By
      October 1, 2006, the Health Plan must submit its sampling methodology and
      patient satisfaction survey schedule for each of the Disease Management chronic
      conditions for the first Contract Year to the Agency for review and
      approval.  If the Health Plan is requesting to replace any of the required
      patient satisfaction surveys with patient satisfaction surveys on other Health
      Plan-implemented Disease Management programs, then it must submit its request
      with the October 1, 2006, sampling methodology and scheduling submittal. 
For each Contract Year thereafter, the Health Plan must submit to the Agency
      its
      sampling methodology, patient satisfaction survey schedule, and all requests
      for
      survey replacement by the April 1 prior to the beginning of the next Contract
      Year.

    

    v. The
      Health Plan shall submit patient satisfaction survey results must be submitted
      in the format and with the information prescribed by the Agency.

    

    
      	 	
              7.

            	
              Incentive
                Programs 

            

    

    

    a. The
      Health Plan may offer incentives for Enrollees to receive preventive care
      services. The incentives shall not duplicate those included in the Enhanced
      Benefits Program. The Health Plan shall receive written approval from the Agency
      before offering any incentives. The Health Plan shall make all incentives
      available to all Enrollees. The Health Plan shall not use incentives to direct
      individuals to select a particular Provider. 

    

    b. The
      Health Plan may inform Enrollees, once they are enrolled, about the specific
      incentives available.

    

    c. The
      Health Plan shall not include the provision of gambling, alcohol, tobacco or
      drugs in any of the Health Plan's incentives.

    

    d. The
      Health Plan's incentives shall have some health or child development related
      function (e.g., clothing, food, books, safety devices, infant care items,
      magazine subscriptions to publications which devote at least ten percent (10%)
      of their copy to health related subjects, membership in clubs advocating
      educational advancement and healthy lifestyles, etc.). Incentive dollar values
      shall be in proportion to the importance of the health service to be utilized
      (e.g., a T-shirt for attending one (1) prenatal class, but a car seat for
      completion of a series of classes).

    

    e. Incentives
      shall be limited to a dollar value of ten dollars ($10), except in the case
      of
      incentives for the completion of a series of services, health education classes
      or other educational activities, in which case the incentive shall be limited
      to
      a dollar value of fifty dollars ($50). The Agency will allow a special exception
      to the dollar value relating to infant car seats, strollers, and cloth baby
      carriers, or slings.

    

    f. The
      Health Plan shall not include in the dollar limits on incentives any money
      spent
      on the transportation of Enrollees to services or child care provided during
      the
      provision of services.

    

    g. The
      Health Plan may offer an Agency approved program for pregnant women in order
      to
      encourage the commencement of prenatal care visits in the first (1st) trimester
      of pregnancy. The Health Plan's prenatal and postpartum care Incentive Program
      must be aimed promoting early intervention and prenatal care to decrease infant
      mortality and low birth weight and to enhance healthy birth outcomes. The
      prenatal and postpartum incentives may include the provision of maternity and
      health related items and education as an incentive.

    

    h. The
      Health Plan's request for approval of all incentives shall contain a detailed
      description of the incentive and its mission.

    

    
      	 	
              8.

            	
              Practice
                Guidelines

            

    

    

    a. The
      Health Plan shall adopt practice guidelines that meet the following
      requirements:

    

    
      	 	
              (1)

            	
              Are
                based on valid and reliable clinical evidence or a consensus of Health
                Care Professionals in a particular
                field;

            

    

    

    
      	 	
              (2)

            	
              Consider
                the needs of the Enrollees;

            

    

    

    
      	 	
              (3)

            	
              Are
                adopted in consultation with Providers;
                and

            

    

    

    
      	 	
              (4)

            	
              Are
                reviewed and updated periodically, as appropriate. ( See 42 CFR
                438.236(b))

            

    

    

    b. The
      Health Plan shall disseminate any revised practice guidelines to all affected
      Providers and, upon request, to Enrollees and Potential Enrollees.

    

    c. The
      Health Plan shall ensure consistency with regard to all decisions relating
      to
      UM, Enrollee education, Covered Services and other areas to which the practice
      guidelines apply.

    

    9.
       Changes
      to Utilization Management Components 

    

    The
      Health Plan shall provide no less than thirty (30) Calendar Days written notice
      before making any changes to the administration and/or management procedures
      and/or authorization, denial or review procedures, including any delegations,
      as
      described in this section.

    

    
      	 	
              10.
                

            	
              Out-of-Plan
                Use of Non-Emergency
                Services

            

    

    

    Unless
      otherwise specified in this Contract, where an Enrollee utilizes services
      available under the Health Plan other than emergency services from a
      non-contract provider, the Health Plan shall not be liable for the cost of
      such
      utilization unless the Health Plan referred the Enrollee to the non-contract
      provider or authorized such out-of-plan utilization. The Health Plan shall
      provide timely approval or denial of authorization of out-of-plan use through
      the assignment of a prior authorization number, which refers to and documents
      the approval. A Health Plan may not require paper authorization as a condition
      of receiving treatment if the plan has an automated authorization system.
      Written follow up documentation of the approval must be provided to the
      out-of-plan provider within one (1) Business Day from the request for approval.
      The Enrollee shall be liable for the cost of such unauthorized use of
      contract-covered services from non-contract providers.

    

    In
      accordance with section 409.912, F.S., the Health Plan shall reimburse any
      hospital or physician that is outside the Health Plan’s authorized geographic
      service area for Health Plan authorized services provided by the hospital or
      physician to plan members at a rate negotiated with the hospital or physician
      for the provision of services or according to the lesser of the
      following:

    

    a. The
      usual
      and customary charge made to the general public by the hospital or physician;
      or

    

    b. The
      Florida Medicaid reimbursement rate established for the hospital or
      physician.

    

    The
      plan
      shall reimburse all out-of-plan providers pursuant to section 641.3155,
      F.S.

     

    

    
      
        
           

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    Section
      IX

    Grievance
      System

    

    
      	A.	
               General
                Requirements

            

    

    

    
      	1.  	
              The
                Health Plan must develop, implement, and maintain a Grievance System
                that
                complies with federal laws and regulations, including 42 CFR 431.200
                and
                438, Subpart F, “Grievance System.”

            

    

    

    
      	2.  	
              The
                Grievance System must include an external grievance resolution process
                modeled after the subscriber assistance program panel, as created
                in
                section 408.7056, F.S., and referred to in this contract as the
                Beneficiary Assistance Program.

            

    

    

    
      	3.  	
              The
                Grievance System must include written policies and procedures that
                are
                approved in writing, by the Agency.

            

    

    

    
      	4.  	
              The
                Health Plan must give Enrollees reasonable assistance in completing
                forms
                and other procedural steps, including, but not limited to, providing
                interpreter services and toll-free numbers with TTY/TDD and interpreter
                capability. 

            

    

    

    
      	5.  	
              The
                Health Plan must acknowledge receipt of each Grievance and
                Appeal.

            

    

    

    
      	6.  	
              The
                Health Plan must ensure that decision makers about Grievances and
                Appeals
                were not involved in previous levels of review or decision making
                and are
                Health Care Professionals with appropriate clinical expertise in
                treating
                the Enrollee’s condition or disease when deciding any of the
                following:

            

    

    

    a. An
      Appeal
      of a denial based on lack of Medical Necessity;

    

    b. A
      Grievance regarding denial of expedited resolution of an Appeal; or

    

    c. A
      Grievance or Appeal involving clinical issues.

    

    
      	7.  	
              The
                Health Plan shall provide information regarding the Grievance System
                to
                Enrollees as described in Section IV., A., 2. and 3. The information
                shall
                include, but not be limited to:

            

    

    

    
      	a.  	
              Enrollee
                rights to file Grievances and Appeals and requirements and time frames
                for
                filing.

            

    

    

    
      	b.  	
              The
                availability of assistance in the filing
                process.

            

    

    

    
      	c.  	
              The
                address, toll-free telephone number, and the office hours of the
                Grievance
                coordinator.

            

    

    

    
      	d.  	
              The
                method for obtaining a Medicaid fair hearing, the rules that govern
                representation at the hearing, and the DCF address for pursuing a
                fair
                hearing, which is:

            

    

    

    Office
      of
      Public Assistance Appeals Hearings 

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      Florida 32399-0700

    

    
      	e.  	
              A
                description of the Beneficiary Assistance Program, the types of Grievances
                and Appeals that can be forwarded to the Beneficiary Assistance Program
                and directions for doing so. 

            

    

    

    
      	f.  	
              A
                statement assuring Enrollees that the Health Plan, its Providers
                or the
                Agency will not retaliate against an Enrollee for submitting a Grievance,
                an Appeal or a request for a Medicaid fair hearing.
                

            

    

    

    
      	g.  	
              Enrollee
                rights to request continuation of Benefits during an Appeal or Medicaid
                fair hearing process and, if the Health Plan’s Action is upheld in a
                hearing, the fact that the Enrollee may be liable for the cost of
                said
                Benefits.

            

    

    

    
      	h.  	
              Notice
                that the Health Plan must continue Enrollee Benefits
                if:

            

    

    

    
      	 	
              (1)

            	
              The
                Appeal is filed timely, meaning on or before the later of the
                following:

            

    

    

    
      	i.  	
              Within
                ten (10) Calendar Days of the date on the notice of Action (Fifteen
                (15)
                Calendar Days if the notice is sent via Surface Mail),
                and

            

    

    

    
      	ii.  	
              The
                intended effective date of the Health Plan’s proposed Action.
                

            

    

    

    
      	 	
              (2)

            	
              The
                Appeal involves the termination, suspension, or reduction of a previously
                authorized course of treatment.

            

    

    

    
      	 	
              (3)

            	
              The
                services were ordered by an authorized
                provider.

            

    

    

    
      	 	
              (4)

            	
              The
                authorization period has not
                expired.

            

    

    

    
      	 	
              (5)

            	
              The
                Enrollee requests extension of
                Benefits.

            

    

    

    
      	i.  	
              The
                Health Plan must provide information about the Grievance System and
                its
                respective policies, procedures, and timeframes, to all Providers
                and
                subcontractors at the time they enter into a subcontract/Provider
                contract. The Health Plan must clearly specify all procedural steps
                in the
                Provider manual, including the address, telephone number, and office
                hours
                of the Grievance coordinator.

            

    

    

    
      	8.  	
              The
                Health Plan must maintain records of Grievances and Appeals for tracking
                and trending for QI and to fulfill reporting requirements as described
                in
                Section XII., Reporting
                Requirements.

            

    

    

    
      	B.	
               Grievance
                Process

            

    

    

    
      	1.  	
              Filing
                a Grievance

            

    

    

    
      	a.  	
              A
                Grievance is any expression of dissatisfaction by an Enrollee, about
                any
                matter other than an Action. A Provider, acting on behalf of the
                Enrollee
                and with the Enrollee’s written consent, may also file a
                Grievance.

            

    

    

    
      	b.  	
              A
                Grievance may be filed orally.

            

    

    

    
      	2.  	
              Grievance
                Resolution

            

    

    

    
      	a.  	
              The
                Health Plan must resolve each Grievance and provide the Enrollee
                with a
                notice of the Grievance disposition within ninety (90) days of its
                receipt.

            

    

    

    
      	b.  	
              The
                Grievance must be resolved more expeditiously, within twenty four
                (24)
                hours, if the Enrollee’s health condition requires, as found in
                s409.91211(3)(q), F.S.

            

    

    

    
      	c.  	
              The
                notice of disposition must be in writing and include the results
                and the
                date of Grievance resolution. 

            

    

    

    
      	d.  	
              The
                Health Plan must provide the Agency with a copy of the notice of
                disposition upon request.

            

    

    

    
      	e.  	
              The
                Health Plan must ensure that punitive action is not taken against
                a
                Provider who files a Grievance on an Enrollee’s behalf or supports an
                Enrollee’s Grievance as required in s. 409.9122(12),
                F.S.

            

    

    

    
      	3.  	
              Submission
                to the Beneficiary Assistance
                Program

            

    

    

    a. The
      original Grievance must be filed with the Health Plan in writing.

    

    b. The
      submission of the Grievance to the Beneficiary Assistance Program must be done
      within one (1) year of the date of the occurrence which initiated the
      Grievance.

    

    c. The
      Grievance may be filed if it concerns:

    

    
      	 	
              (1)

            	
              The
                quality of health care services; or

            

    

    

    
      	 	
              (2)

            	
              Matters
                pertaining to the contractual relationship between an Enrollee and
                the
                Health Plan.

            

    

    

    
      	C.	
               
                Appeal Process

            

    

    

    
      	1.  	
              Filing
                an Appeal

            

    

    

    a. An
      Enrollee may request a review of a Health Plan Action by filing an
      Appeal.

    

    b. An
      Enrollee may file an Appeal, and a Provider, acting on behalf of the Enrollee
      and with the Enrollee’s written consent, may file an Appeal. The Appeal
      procedure must be the same for all Enrollees.

    

    c. The
      Appeal must be filed within thirty (30) days of the date of the notice of
      Action. If the Health Plan fails to issue a written notice of Action, the
      Enrollee or Provider may file an Appeal within one (1) year of the
      Action.

    

    d. The
      Enrollee or Provider may file an Appeal either orally or in writing and must
      follow an oral filing with a written, signed Appeal. For oral filings, time
      frames for resolution begin on the date the Health Plan receives the oral
      filing.

    

    
      	2.  	
              Resolution
                of Appeals

            

    

    

    The
      Health Plan must:

    

    a. Ensure
      that oral inquiries seeking to appeal an Action are treated as Appeals and
      acknowledge receipt of those inquiries, as well as written Appeals, in writing,
      unless the Enrollee or the Provider requests expedited resolution.

    

    b. Provide
      a
      reasonable opportunity for the Enrollee/Provider to present evidence, and
      allegations of fact or law, in person as well as in writing.

     

    c. Allow
      the
      Enrollee and their representative the opportunity, before and during the Appeals
      process, to examine the Enrollee’s case file, including Medical Records and any
      other documents and records.

    

    d. Consider
      the Enrollee representative, or estate representative of a deceased Enrollee
      as
      parties to the Appeal.

    

    e. Resolve
      each Appeal and provide notice within forty-five (45) days from the day the
      Health Plan receives the Appeal. 

    

    f. Resolve
      the Appeal more expeditiously if the Enrollee’s health condition
      requires.

    

    g. The
      Health Plan may extend the resolution time frames by up to fourteen (14)
      Calendar Days if the Enrollee requests the extension or the Health Plan
      documents that there is need for additional information and that the delay
      is in
      the Enrollee’s interest. If the extension is not requested by the Enrollee, the
      Health Plan must give the Enrollee written notice of the reason for the
      delay.

    

    h. Continue
      the Enrollee's Benefits if:

    

    
      	 	
              (1)

            	
              The
                Appeal is filed timely, meaning on or before the later of the
                following:

            

    

    

    i. Within
      ten (10) Calendar Days of the date on the notice of Action or fifteen (15)
      Calendar Days if sent by Surface Mail, or

    

    ii. The
      intended effective date of the Health Plan’s proposed Action.

    

    
      	 	
              (2)

            	
              The
                Appeal involves the termination, suspension, or reduction of a previously
                authorized course of treatment.

            

    

    

    
      	 	
              (3)

            	
              The
                services were ordered by an authorized
                provider.

            

    

    

    
      	 	
              (4)

            	
              The
                Authorization period has not
                expired.

            

    

    

    
      	 	
              (5)

            	
              The
                Enrollee requests extension of
                Benefits.

            

    

    

    i. If
      the
      Health Plan continues or reinstates Enrollee Benefits while the Appeal is
      pending, the Benefits must be continued until one of following
      occurs:

    

    
      	 	
              (1)

            	
              The
                Enrollee withdraws the Appeal.

            

    

    

    
      	 	
              (2)

            	
              Ten
                (10) Calendar Days (Fifteen (15) Calendar Days if the notice is sent
                via
                Surface Mail) pass from the date of the Health Plan’s adverse decision,
                and the Enrollee has not requested a Medicaid fair hearing with
                continuation of Benefits. 

            

    

    

    
      	 	
              (3)

            	
              A
                Medicaid fair hearing decision adverse to the Enrollee is made.
                

            

    

    

    
      	 	
              (4)

            	
              The
                authorization expires or authorized service limits are
                met.

            

    

    

    

    j. Provide
      written notice of disposition that includes the results and date of Appeal
      resolution, and for decisions not wholly in the Enrollee’s favor, also
      includes:

    

    
      	 	
              (1)

            	
              Notice
                of the Enrollee’s right to request a Medicaid fair
                hearing.

            

    

    

    
      	 	
              (2)

            	
              Information
                about how to request a Medicaid fair hearing, including the DCF address
                for pursuing a Medicaid fair hearing, which
                is:

            

    

    

    Office
      of
      Public Assistance Appeals Hearings

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      Florida 32399

    

    
      	 	
              (3)

            	
              Notice
                of the right to continue to receive Benefits pending a Medicaid fair
                hearing.

            

    

    

    
      	 	
              (4)

            	
              Information
                about how to request the continuation of
                Benefits.

            

    

    

    
      	 	
              (5)

            	
              Notice
                that if the Health Plan’s action is upheld in a Medicaid fair hearing, the
                Enrollee may be liable for the cost of any continued
                Benefits.

            

    

    

    k. Provide
      the Agency with a copy of the written notice of disposition upon
      request.

    

    l. Ensure
      that punitive action is not taken against a Provider who files an Appeal on
      an
      Enrollee’s behalf or supports an Enrollee’s Appeal.

    

    
      	3.  	
              Post
                Appeal Resolution

            

    

    

    a. If
      the
      final resolution of the Appeal in a fair hearing is adverse to the Enrollee,
      the
      Agency may recover the cost of the services furnished while the Appeal was
      pending, to the extent that they were furnished solely because of the
      requirements of this section.

    

    b. The
      Health Plan must authorize or provide the disputed services promptly, and as
      expeditiously as the Enrollee's health condition requires, if the services
      were
      not furnished while the Appeal was pending and the disposition reverses a
      decision to deny, limit, or delay services.

    

    c. The
      Health Plan must pay for disputed services, in accordance with State policy
      and
      regulations, if the services were furnished while the Appeal was pending and
      the
      disposition reverses a decision to deny, limit, or delay services.

     

    
      	4.  	
              Expedited
                Process

            

    

    

    a. The
      Health Plan must establish and maintain an expedited review process for
      Grievances and Appeals when the Health Plan determines (if requested by the
      Enrollee) or the Provider indicates (in making the request on the Enrollee's
      behalf or supporting the Enrollee's request) that taking the time for a standard
      resolution could seriously jeopardize the Enrollee's life or health or ability
      to attain, maintain, or regain maximum function.

     

    b. The
      Enrollee or Provider may file an expedited Appeal either orally or in writing.
      No additional Enrollee follow-up is required.

    

    The
      Health Plan must:

    

    
      	 	
              (1)

            	
              Inform
                the Enrollee of the limited time available for the Enrollee to present
                evidence and allegations of fact or law, in person and/or in
                writing.

            

    

    

    
      	 	
              (2)

            	
              Resolve
                each expedited Appeal and provide notice, as expeditiously as the
                Enrollee’s health condition requires, not to exceed seventy-two (72) hours
                after the Health Plan receives the Appeal.

            

    

    

    
      	 	
              (3)

            	
              Provide
                written notice of disposition that includes the results and date
                of
                expedited Appeal resolution, and for decisions not wholly in the
                Enrollee’s favor, that includes:

            

    

    

    i. Notice
      of
      the Enrollee’s right to request a Medicaid fair hearing.

    

    ii. Information
      about how to request a Medicaid fair hearing, including the DCF address for
      pursuing a fair hearing, which is:

    

    Office
      of
      Public Assistance Appeals Hearings

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      Florida 32399-0700

    

    iii.
       Notice
      of
      the right to continue to receive Benefits pending a hearing.

    

    iv. Information
      about how to request the continuation of Benefits.

    

    v. Notice
      that if the Health Plan’s action is upheld in a hearing, the Enrollee may be
      liable for the cost of any continued Benefits.

    

    c. If
      the
      Health Plan denies a request for expedited resolution of an Appeal, the Health
      Plan must:

    

    
      	 	
              (1)

            	
              Transfer
                the Appeal to the standard time frame of no longer than forty-five
                (45)
                days from the day the Health Plan receives the Appeal with a possible
                fourteen (14) day extension.

            

    

    

    
      	 	
              (2)

            	
              Make
                reasonable efforts to provide prompt oral notice of the
                denial.

            

    

    

    
      	 	
              (3)

            	
              Provide
                written notice of the denial within two (2) Calendar
                Days.

            

    

    

    
      	 	
              (4)

            	
              Fulfill
                all general Health Plan duties listed
                above.

            

    

    

    
      	5.  	
              Submission
                to the Beneficiary Assistance
                Program

            

    

    

    a. The
      submission of the Appeal to the Beneficiary Assistance Program must be done
      within one (1) year of the date of the occurrence that initiated the
      Appeal.

    

    b. An
      Enrollee may submit an Appeal to the Beneficiary Assistance Program if it
      concerns: 

    

    
      	 	
              (1)

            	
              The
                availability of health care services or the coverage of Benefits,
                or an
                adverse determination about Benefits made pursuant to UM;
                or

            

    

    

    
      	 	
              (2)

            	
              Claims
                payment, handling, or reimbursement for
                Benefits.

            

    

    

    c. If
      the
      Enrollee has taken the Appeal to a Medicaid fair hearing, the Enrollee cannot
      submit the Appeal to the Beneficiary Assistance Program. 

    

    
      	D.	
               Medicaid
                Fair Hearing System

            

    

    

    
      	1.  	
              Request
                for a Medicaid Fair
                Hearing

            

    

     

    a. An
      Enrollee may request a Medicaid fair hearing either upon receipt of a notice
      of
      Action from the Health Plan or upon receiving an adverse decision from the
      Health Plan, after filing an Appeal with the Health Plan.

    

    b. A
      Provider, acting on behalf of the Enrollee and with the Enrollee’s written
      consent, may request a Medicaid fair hearing under the same circumstances as
      the
      Enrollee. 

    

    c. Parties
      to the Medicaid fair hearing include the Health Plan, as well as the Enrollee
      and his or her representative or the representative of a deceased Enrollee’s
      estate.

    

    d. The
      Enrollee or Provider may request a Medicaid fair hearing within ninety (90)
      Calendar Days of the date of the notice of Action from the Health Plan regarding
      an Enrollee Appeal. 

    

    e. The
      Enrollee or Provider may request a Medicaid fair hearing by contacting DCF
      at:

    

    The
      Office of Public Assistance Appeals Hearings

    1317
      Winewood Boulevard, Building 5, Room 203

    Tallahassee,
      Florida 32399-0700

    

    
      	2.  	
              Health
                Plan Responsibilities

            

    

    

    The
      Health Plan must:

    

    a. Continue
      the Enrollee's Benefits while the Medicaid fair hearing is pending
      if:

    

    
      	 	
              (1)

            	
              The
                Medicaid fair hearing is filed timely, meaning on or before the later
                of
                the following:

            

    

    

    i. Within
      ten (10) Calendar Days of the date on the notice of Action (Fifteen (15)
      Calendar Days if the notice is sent via Surface Mail); or

    

    ii. The
      intended effective date of the Health Plan’s proposed Action.

    

    
      	 	
              (2)

            	
              The
                Medicaid fair hearing involves the termination, suspension, or reduction
                of a previously authorized course of
                treatment.

            

    

    

    
      	 	
              (3)

            	
              The
                services were ordered by an authorized
                provider.

            

    

    

    
      	 	
              (4)

            	
              The
                authorization period has not
                expired.

            

    

    

    
      	 	
              (5)

            	
              The
                Enrollee requests extension of
                Benefits.

            

    

    

    b. Ensure
      that punitive action is not taken against a Provider who requests a Medicaid
      fair hearing on the Enrollee’s behalf or supports an Enrollee’s request for a
      Medicaid fair hearing.

    

    c. If
      the
      Health Plan continues or reinstates Enrollee Benefits while the Medicaid fair
      hearing is pending, the Benefits must be continued until one of following
      occurs:

    

    
      	 	
              (1)

            	
              The
                Enrollee withdraws the request for a Medicaid fair
                hearing.

            

    

    

    
      	 	
              (2)

            	
              Ten
                (10) Calendar Days pass from the date of the Health Plan’s adverse
                decision and the Enrollee has not requested a Medicaid fair hearing
                with
                continuation of Benefits until a Medicaid fair hearing decision is
                reached. (Fifteen (15) Calendar Days if the notice is sent via Surface
                Mail)

            

    

    

    
      	 	
              (3)

            	
              A
                Medicaid fair hearing decision adverse to the Enrollee is
                made.

            

    

    

    
      	 	
              (4)

            	
              The
                authorization expires or authorized service limits are
                met.

            

    

    

    
      	3.  	
              Post
                Medicaid Fair Hearing
                Decision

            

    

    

    a. If
      the
      final resolution of the Medicaid fair hearing is adverse to the Enrollee, the
      Health Plan may recover the cost of the services furnished while the Medicaid
      fair hearing was pending, to the extent that they were furnished solely because
      of the requirements of this section.

    

    b. The
      Health Plan must authorize or provide the disputed services promptly, and as
      expeditiously as the Enrollee's health condition requires, if the services
      were
      not furnished while the Medicaid fair hearing was pending and the Medicaid
      fair
      hearing officer reverses a decision to deny, limit, or delay
      services.

    

    c. The
      Health Plan must pay for disputed services, in accordance with State policy
      and
      regulations, if the services were furnished while the Medicaid fair hearing
      was
      pending and the Medicaid fair hearing officer reverses a decision to deny,
      limit, or delay services.

    

    

    

    REMAINDER
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    Section
      X

    Administration
      and Management

    

    
      	A.	
              General
                Provisions

            

    

    

    1. The
      Health Plan’s governing body shall set forth policy and has overall
      responsibility for the organization of the Health Plan. The Health Plan shall
      be
      responsible for the administration and management of all aspects of this
      Contract, including all Subcontracts, employees, agents and services performed
      by anyone acting for or on behalf of the Health Plan. The Health Plan shall
      have
      a centralized executive administration, which shall serve as the contact point
      for the Agency, except as otherwise specified in the Contract.

    2. The
      Health Plan shall be responsible for the administration and management of all
      aspects of this Contract, such as, but not limited to, the delivery of services,
      provider network, provider education, and claims resolution and assistance.
      

    

    
      	 	
              3.

            	
              The
                Health Plan must provide that compensation to individuals or entities
                that
                conduct utilization management activities is not structured so as
                to
                provide incentives for the individual or entity to deny, limit, or
                discontinue medically necessary services to any
                Enrollee.

            

    

    

    
      	B.	
              Staffing

            

    

    

    1. Minimum
      Staffing Requirements

    

    a. Contract
      Manager:
      The
      Health Plan shall designate a contract manager to work directly with the Agency.
      The contract manager shall be a full-time employee of the Health Plan with
      the
      authority to revise processes or procedures and assign additional resources
      as
      needed to maximize the efficiency and effectiveness of services required under
      the Contract. The Health Plan shall meet in person or by telephone at the
      request of Agency representatives, but at least monthly, to discuss the status
      of the Contract, Health Plan performance, benefits to the State, necessary
      revisions, reviews, reports and planning. Formal summary reports shall be
      developed and presented to the Agency, or its Agent, as specified.

    

    b. Full-Time
      Administrator:
      The
      Health Plan shall have a full-time administrator specifically identified to
      administer the day-to-day business activities of this Contract. The Health
      Plan
      may designate the same person as the Contract Manager, the Full-time
      Administrator, or the Medical Director, but such person cannot be designated
      to
      any other position in this section, including in other lines of business within
      the Health Plan, unless otherwise approved by the Agency.

    

    c. Medical
      and Professional Support Staff:
      The
      Health Plan shall have medical and professional support staff sufficient to
      conduct daily business in an orderly manner, including having Enrollee services
      staff directly available during business hours for Enrollee services
      consultation, as determined through management and medical reviews. The Health
      Plan shall maintain sufficient medical staff, available twenty-four (24) hours
      per day, seven (7) days per week, to handle Emergency Services and Care
      inquiries. The Health Plan shall maintain sufficient medical staff during
      non-business hours, unless the Health Plan's computer system automatically
      approves all Emergency Services and care claims relating to Screening and
      treatment.

    

    d. Medical
      Director:
      The
      Health Plan shall have a full-time licensed physician to serve as medical
      director to oversee and be responsible for the proper provision of Covered
      Services to Enrollees, the Quality Management Program, and the Grievance System.
      The medical director shall be licensed in accordance with chapter 458 or 459,
      F.S. The medical director cannot be designated to serve in any other
      non-administrative position. 

    

    e. Medical
      Records Review Coordinator:
      A
      designated person, qualified by training and experience, to ensure compliance
      with the Medical Records requirements as described in this Contract. The medical
      records review coordinator shall maintain Medical Record standards and conduct
      Medical Record reviews according to the terms of this Contract. 

    

    f. Data
      Processing and Data Reporting Coordinator:
      The
      Health Plan shall have a person trained and experienced in data processing,
      data
      reporting, and claims resolution, as required to ensure that computer system
      reports that that the Health Plan provides to the Agency and its Agent are
      accurate, and that computer systems operate in an accurate and timely
      manner.

    

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

    

    h. QI
      and
      UM Professional:
      The
      Health Plan shall have a designated person, qualified by training and experience
      in QI and UM and who holds the appropriate clinical certification and/or
      license.

    

    i. Grievance
      System Coordinator:
      The
      Health Plan shall have a designated person, qualified by training and
      experience, to process and resolve Appeals and Grievances and to be responsible
      for the Grievance System.

    

    j. Compliance
      Officer:
      The
      Health Plan shall have a designated person qualified by training and experience,
      to oversee a Fraud and Abuse program to prevent and detect potential Fraud
      and
      Abuse activities pursuant to State and federal rules and
      regulations.

    

    k. Case
      Management Staff:
      The
      Health Plan shall have sufficient Case Management staff, qualified by training,
      experience and certification/licensure to conduct the Health Plan's Case
      Management functions.

    

    l. Claims/Encounter
      Manager:
      The
      Health Plan shall have a designated person qualified by training and experience
      to oversee claims and encounter submittal and processing and to ensure the
      accuracy, timeliness and completeness of processing payment and
      reporting.

    

    2. Behavioral
      Health Staff Requirements 

    

    a. The
      Health Plan must name a staff member to maintain oversight responsibility for
      Behavioral Health Services and to act as a liaison to the Agency. 

    

    b. The
      Health Plan's Medical Director shall appoint a board certified, or board
      eligible, licensed psychiatrist (staff psychiatrist) to oversee the provision
      of
      Behavioral Health Services to Enrollees. The Health Plan may delegate this
      duty,
      by way of a written subcontract, to a third party.

    

    c. The
      Agency shall review and approve the Health Plan's Behavioral Health Services
      staff and any subcontracted Behavioral Health Care Providers in order to
      determine the Health Plan's compliance with all licensure
      requirements.

    

    
      	C.	
               Provider
                Contracts Requirements

            

    

    

    1. The
      Health Plan shall comply with all Agency procedures for Provider Contract review
      and approval submission. 

    

    a. All
      Provider Contracts must comply with 42 CFR 438.230. 

    

    b. All
      Providers must be eligible for participation in the Medicaid program. Any
      provider of service who has been involuntarily terminated from the Florida
      Medicaid program, other than those terminated for inactivity, is not considered
      to be an eligible Medicaid provider.

    

    c.
       The
      Health Plan shall not employ or contract with individuals on the State or
      federal exclusions list.

    

    d. No
      Provider Contract which the Health Plan enters into with respect to performance
      under the Contract shall in any way relieve the Health Plan of any
      responsibility for the provision of services duties under this Contract. The
      Health Plan shall assure that all services and tasks related to the Provider
      Contract are performed in accordance with the terms of this Contract. The Health
      Plan shall identify in its Provider Contracts any aspect of service that may
      be
      subcontracted by the Provider.

    

    e. All
      model
      Provider Contracts and amendments must be submitted by the Health Plan to the
      Agency for approval and the Health Plan must receive approval by the Agency
      prior to use.

    

    2. All
      Provider Contracts and amendments executed by the Health Plan must be in
      writing, signed, and dated by the Health Plan and the Provider. All model and
      executed Provider Contracts and amendments shall meet the following
      requirements:

    

    a. Prohibit
      the Provider from seeking payment from the Enrollee for any Covered Services
      provided to the Enrollee within the terms of the Contract;

    

    b. Require
      the Provider to look solely to the Agency or its Agent for compensation for
      services rendered, with the exception of nominal cost sharing, pursuant to
      the
      Florida State Medicaid Plan and the Florida Coverages and Limitations Handbooks,
      

    

    c. If
      there
      is a Health Plan physician incentive plan, include a statement that the Health
      Plan shall make no specific payment directly or indirectly under a physician
      incentive plan to a Provider as an inducement to reduce or limit Medically
      Necessary services to an Enrollee, and that all incentive plans shall not
      contain provisions which provide incentives, monetary or otherwise, for the
      withholding of Medically Necessary care;

    

    d. Specify
      that any contracts, agreements, or subcontracts entered into by the Provider
      for
      the purposes of carrying out any aspect of this contract must include assurances
      that the individuals who are signing the contract, agreement or subcontract
      are
      so authorized and that it includes all the requirements of this
      Contract;

    

    e. Require
      the Provider to cooperate with the Health Plan's peer review, grievance, QIP
      and
      UM activities, and provide for monitoring and oversight, including monitoring
      of
      services rendered to Enrollees, by the Health Plan (or its subcontractor) and
      for the Provider to provide assurance that all licensed Providers are
      Credentialed in accordance with the Health Plan’s and the Agency’s Credentialing
      requirements as found in Section VIII.A.3.h Credentialing and Recredentialing,
      of this Contract, if the Health Plan has delegated the Credentialing to a
      Subcontractor;

    

    f. Include
      provisions for the immediate transfer to another PCP or Health Plan if the
      Enrollee's health or safety is in jeopardy;

    

    g. Not
      prohibit a Provider from discussing treatment or non-treatment options with
      Enrollees that may not reflect the Health Plan's position or may not be covered
      by the Health Plan;

    

    h. Not
      prohibit a Provider from acting within the lawful scope of practice, from
      advising or advocating on behalf of an Enrollee for the Enrollee's health
      status, medical care, or treatment or non-treatment options, including any
      alternative treatments that might be self-administered;

    

    i. Not
      prohibit a Provider from advocating on behalf of the Enrollee in any Grievance
      System or UM process, or individual authorization process to obtain necessary
      health care services;

    

    j. Require
      Providers to meet appointment waiting time standards pursuant to this
      Contract;

    

    k. Provide
      for continuity of treatment in the event a Provider's agreement terminates
      during the course of an Enrollee's treatment by that Provider;

    

    l. Prohibit
      discrimination with respect to participation, reimbursement, or indemnification
      of any Provider who is acting within the scope of his or her license or
      certification under applicable State law, solely on the basis of such license
      or
      certification. This provision should not be construed as a willing Provider
      law,
      as it does not prohibit the Health Plan from limiting provider participation
      to
      the extent necessary to meet the needs of the Enrollees. This provision does
      not
      interfere with measures established by the Health Plan that are designed to
      maintain quality and control costs;

    

    m. Prohibit
      discrimination against Providers serving high-risk populations or those that
      specialize in conditions requiring costly treatments;

    

    n. Require
      an adequate record system be maintained for recording services, charges, dates
      and all other commonly accepted information elements for services rendered
      to
      the Health Plan.

    

    o. Require
      that records be maintained for a period not less than five (5) years from the
      close of the Contract and retained further if the records are under review
      or
      audit until the review or audit is complete. (Prior approval for the disposition
      of records must be requested and approved by the Health Plan if the Provider
      Contract is continuous.)

    

    p. Specify
      that DHHS, the Agency, including MPI and MFCU, shall have the right to inspect,
      evaluate, and audit all of the following related to the contract:

    

    i. Pertinent
      books, 

    

    ii. Financial
      records, 

    

    iii. Medical
      Records, and

    

    iv. Documents,
      papers, and records of any Provider involving transactions, financial or
      otherwise, related to this Contract;

    

    q. Specify
      Covered Services and populations to be served under the contract;

    

    r. Require
      that Providers comply with the Health Plan's cultural competency
      plan;

    

    s. Require
      that any marketing materials related to this Contract that are distributed
      by
      the Provider be submitted to the Agency for written approval before
      use;

    

    t. Provide
      for submission of all reports and clinical information required by the Health
      Plan, including Child Health Check-Up reporting (if applicable);

    

    u. Prohibit
      Providers from making referrals for designated health services to health care
      entities with which the Provider or a member of the Provider's family has a
      financial relationship; 

    

    v. Require
      Providers of transitioning Enrollees to cooperate in all respects with providers
      of other Health Plans to assure maximum health outcomes for
      Enrollees;

    

    w. Require
      Providers to submit notice of withdrawal from the network at least ninety (90)
      Calendar Days prior to the effective date of such withdrawal;

    

    x. Require
      that all Providers agreeing to participate in the network as PCPs fully accept
      and agree to perform the Case Management responsibilities and duties associated
      with the PCP designation;

    

    y. Require
      all Providers to notify the Health Plan in the event of a lapse in general
      liability or medical malpractice insurance, or if assets fall below the amount
      necessary for licensure under Florida Statute; 

    

    z. Require
      Providers to offer hours of operation that are no less than the hours of
      operation offered to commercial enrollees or comparable to non-Reform Medicaid
      FFS Recipients if the Provider serves only Medicaid Recipients.

    

    aa. Require
      safeguarding of information about Enrollees according to 42 CFR, Part
      438.224.

    

    bb. Require
      compliance with HIPAA privacy and security provisions.

    

    cc. Require
      an exculpatory clause, which survives Subcontract termination including breach
      of Subcontract due to insolvency, that assures that Medicaid Recipients or
      the
      Agency may not be held liable for any debts of the Subcontractor. 

    

    dd. Contain
      a
      clause indemnifying, defending and holding the Agency and the Health Plan
      Enrollees harmless from and against all claims, damages, causes of action,
      costs
      or expense, including court costs and reasonable attorney fees to the extent
      proximately caused by any negligent act or other wrongful conduct arising from
      the Provider Contract: 

    

    
      	 	
              i.

            	
              This
                clause must survive the termination of the Provider Contract, including
                breach due to Insolvency, and 

            

    

    

    
      	 	
              ii.

            	
              The
                Agency may waive this requirement for itself, but not Health Plan
                Enrollees, for damages in excess of the statutory cap on damages
                for
                public entities if the Provider is a public health entity with statutory
                immunity (all such waivers must be approved in writing by the
                Agency);

            

    

    

    
      	ee.  	
              Require
                that the Provider secure and maintain during the life of the Provider
                Contract worker's compensation insurance (complying with the Florida's
                Worker's Compensation Law) for all of its employees connected with
                the
                work under this Contract unless such employees are covered by the
                protection afforded by the Health
                Plan;

            

    

    

    
      	ff.  	
              Make
                provisions for a waiver of those terms of the Provider Contract,
                which, as
                they pertain to Medicaid Recipients, are in conflict with the
                specifications of this Contract; 

            

    

    

    
      	gg.  	
              Contain
                no provision that in any way prohibits or restricts the Provider
                from
                entering into a commercial contract with any other plan (pursuant
                to s.
                641.315, F.S.);

            

    

    

    
      	hh.  	
              Contain
                no provision requiring the Provider to contract for more than one
                Health
                Plan product or otherwise be excluded (pursuant to s. 641.315, F.S.);
                

            

    

    

    
      	ii.  	
              Contain
                no provision that prohibits the Provider from providing inpatient
                services
                in a contracted hospital to an Enrollee if such services are determined
                to
                be medically necessary and covered services under this
                Contract;.

            

    

    

    
      	jj.  	
              Require
                all Providers to apply for a National Provider Identification number
                (NPI)
                within ninety (90) days of final execution of this Contract or within
                ninety (90) days of final execution of the Provider contract, whichever
                is
                later. Providers can obtain their NPIs through the National Plan
                and
                Provider Enumerator System located at: .
                Additionally, the Provider contract shall require the Provider to
                submit
                all NPIs for its physicians and other health care providers to the
                Health
                Plan within fifteen (15) Business Days of receipt. The Health Plan
                shall
                report the Providers’ NPIs as part of its Provider Network Report, in a
                manner to be determined by the Agency, and in its Provider Directory,
                to
                the Agency or its Choice Counselor/Enrollment Broker, as set forth
                in
                Section XII, Reporting
                Requirements.

            

    

    

    a. The
      Health Plan need not obtain an NPI from the following Providers:

    

    (1) Individuals
      or organizations that furnish atypical or nontraditional services that are
      only
      indirectly related to the provision of health care (examples include taxis,
      home
      and vehicle modifications, insect control, habilitation and respite services);
      and

    

    (2) Individuals
      ore businesses that only bill or receive payment for, but do not furnish, health
      care services or supplies (examples include billing services, repricers and
      value-added networks).

    

    
      	kk.  	
              Require
                Providers to cooperate fully in any investigation by the Agency,
                Medicaid
                Program Integrity (MPI), or Medicaid Fraud Control Unit (MFCU), or
                any
                subsequent legal action that may result from such an
                investigation.

            

    

    

    

    
      	D.	
               Provider
                Termination 

            

    

    

    1. The
      Health Plan shall comply with all State and federal laws regarding Provider
      termination. In its Provider contracts, the Health Plan shall:

    

    a. Specify
      that in addition to any other right to terminate the Provider contract, and
      not
      withstanding any other provision of this Contract, the Agency or the Health
      Plan
      may request immediate termination of a Provider contract if, as determined
      by
      the Agency, a Provider fails to abide by the terms and conditions of the
      Provider contract, or in the sole discretion of the Agency, the Provider fails
      to come into compliance with the Provider contract within fifteen (15) Calendar
      Days after receipt of notice from the Health Plan specifying such failure and
      requesting such Provider abide by the terms and conditions thereof;
      and

    

    b. Specify
      that any Provider whose participation is terminated pursuant to the Provider
      contract for any reason shall utilize the applicable appeals procedures outlined
      in the Provider contract. No additional or separate right of appeal to the
      Agency or the Health Plan is created as a result of the Health Plan's act of
      terminating, or decision to terminate any Provider under this Contract.
      Notwithstanding the termination of the Provider contract with respect to any
      particular Provider, this Contract shall remain in full force and effect with
      respect to all other Providers; and

    

    2. The
      Health Plan shall notify the Agency at least ninety (90) Calendar Days prior
      to
      the effective date of the suspension, termination, or withdrawal of a Provider
      from participation in the Health Plan network. If the termination was for
      "Cause" the Health Plan shall provide to the Agency the reasons for termination;
      and

    

    3. The
      Health Plan shall notify Enrollees in accordance with the provisions of this
      Contract;
      and

    

    4. The
      Health Plan shall provide sixty (60) Calendar Days’ advance written notice to
      the Provider before canceling, without cause, the contract with the Provider,
      except in a case in which a patient's health is subject to imminent danger
      or a
      physician's ability to practice medicine is effectively impaired by an action
      by
      the Board of Medicine or other governmental Agency, in which case notification
      shall be provided to the Agency immediately. A copy of the notice shall be
      submitted simultaneously to the Agency.

    

    REMAINDER
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      	E.	
               Provider
                Services

            

    

    

    
      	 	
              1.

            	
              General
                Provisions

            

    

    

    a. The
      Health Plan shall provide sufficient information to all Providers in order
      to
      operate in full compliance with this Contract and all applicable federal and
      State laws and regulations. 

    

    b. The
      Health Plan shall monitor Provider knowledge and understanding of Provider
      requirements, and take corrective actions to ensure compliance with such
      requirements.

    

    c. The
      Health Plan shall submit to the Agency for written approval all materials and
      information to be distributed and/or made available to Providers.

    

    
      	 	
              2.

            	
              Provider
                Handbooks

            

    

    

    The
      Health Plan shall develop and issue a Provider handbook to all Providers at
      the
      time the Provider contract is signed. The Health Plan may choose not to
      distribute the Provider handbook via Surface Mail, provided it submits a written
      notification to all Providers that explains how to obtain the Provider handbook
      from the Health Plan’s Web site. This notification shall also detail how the
      Provider can request a hard-copy from the Health Plan at no charge to the
      Provider. All Provider handbooks and bulletins shall be in compliance with
      State
      and federal laws. The Provider handbook shall serve as a source of information
      regarding Health Plan Covered Services, policies and procedures, statutes,
      regulations, telephone access and special requirements to ensure all Contract
      requirements are met. At a minimum, the Provider handbook shall include the
      following information:

    

    a. Description
      of the program;

    

    b. Covered
      Services;

    

    c. Emergency
      Service responsibilities;

    

    d. Child
      Health Check-Up program services and standards;

    

    e. Policies
      and procedures that cover the Provider complaint system. This information shall
      include, but not be limited to, specific instructions regarding how to contact
      the Health Plan’s Provider services to file a Provider complaint and which
      individual(s) has the authority to review a Provider complaint;

    

    f. Information
      about the Grievance System, the timeframes and requirements, the availability
      of
      assistance in filing, the toll-free numbers and the Enrollee’s right to request
      continuation of Benefits while utilizing the Grievance System;

    

    g. Medical
      Necessity standards and practice guidelines; 

    

    h. Practice
      protocols, including guidelines pertaining to the treatment of chronic and
      complex conditions;

    

    i. PCP
      responsibilities;

    

    j. Other
      Provider or Subcontractor responsibilities;

    

    k. Prior
      Authorization and referral procedures;

    

    l. Medical
      Records standards;

    

    m. Claims
      submission protocols and standards, including instructions and all information
      necessary for a clean or complete claim;

    

    n. Notice
      that the amount paid to Providers by the Agency shall be the Medicaid fee
      schedule amount less any applicable co-payments;

    

    o. Notice
      that Provider complaints regarding claims payment should be sent to the Health
      Plan;

    

    p. The
      Health Plan’s cultural competency plan; 

    

    q. Enrollee
      rights and responsibilities; and

    

    r. The
      Health Plan shall disseminate bulletins as needed to incorporate any needed
      changes to the Provider handbook.

    

    
      	 	
              3.

            	
              Education
                and Training

            

    

    

    a. The
      Health Plan shall provide training to all Providers and their staff regarding
      the requirements of this Contract and special needs of Enrollees. The Health
      Plan shall conduct initial training within thirty (30) Calendar Days of placing
      a newly Contracted Provider on active status. The Health Plan shall also conduct
      ongoing training as deemed necessary by the Health Plan or the Agency in order
      to ensure compliance with program standards and this Contract.

    

    b. The
      Health Plan shall submit the Provider training manual and training schedule
      to
      the Agency for written approval. 

    

    
      	 	
              4.

            	
              Provider
                Relations

            

    

    

    The
      Health Plan shall establish and maintain a formal Provider relations function
      to
      timely and adequately respond to inquiries, questions and concerns from network
      Providers. The Health Plan shall implement policies addressing the compliance
      of
      Providers with the requirements of this Contract, institute a mechanism for
      Provider dispute resolution and execute a formal system of terminating Providers
      from the Health Plan’s network.

    

    
      	 	
              5.

            	
              Toll-free
                Provider Telephone Help
                Line

            

    

    

    a. The
      Health Plan shall operate a toll-free telephone help line to respond to Provider
      questions, comments and inquiries. 

    

    b. The
      Health Plan shall develop telephone help line policies and procedures that
      address staffing, personnel, hours of operation, access and response standards,
      monitoring of calls via recording or other means, and compliance with standards.
      

    

    c. The
      Health Plan shall submit these telephone help line policies and procedures,
      including performance standards, to the Agency for written approval.

    

    d. The
      Health Plan’s call center systems shall have the capability to track call
      management metrics identified in Section IV.6., Enrollee Services and Marketing,
      Toll-free Enrollee Help Line.

    

    e. The
      telephone help line shall be staffed twenty-four (24) hours a day, seven (7)
      days a week to respond to Prior Authorization requests. This telephone help
      line
      shall have staff to respond to Provider questions in all other areas, including
      the Provider complaint system, Provider responsibilities, etc., between the
      hours of 7:00 am and 7:00 pm EST or EDT as appropriate, Monday through Friday,
      excluding State holidays.

    

    f. The
      Health Plan shall develop performance standards and monitor telephone help
      line
      performance by recording calls and employing other monitoring activities. All
      performance standards shall be submitted to the Agency for approval.

    

    g. The
      Health Plan shall ensure that after regular business hours the Provider services
      line (not the Prior Authorization line) is answered by an automated system
      with
      the capability to provide callers with information about operating hours and
      instructions about how to verify Enrollment for an Enrollee with an Emergency
      or
      Urgent Medical Condition. The requirement that the Health Plan shall provide
      information to providers about how to verify Enrollment for an Enrollee with
      an
      Emergency or Urgent Medical Condition shall not be construed to mean that the
      provider must obtain verification before providing Emergency Services and
      Care.

    

    
      	 	
              6.

            	
              Provider
                Complaint System 

            

    

    

    a. The
      Health Plan shall establish a Provider complaint system that permits a Provider
      to dispute the Health Plan’s policies, procedures, or any aspect of a Health
      Plan’s administrative functions, including proposed Actions. 

    

    b. The
      Health Plan shall submit its Provider complaint system policies and procedures
      to the Agency for written approval.

     

    

    c. The
      Health Plan shall include its Provider complaint system policies and procedures
      in its Provider handbook as described above.

    

    d. The
      Health Plan shall also distribute the Provider complaint system policies and
      procedures to out of network providers upon written or oral request. The Health
      Plan may distribute a summary of these policies and procedures, if the summary
      includes information about how the provider may access the full policies and
      procedures on the Health Plan’s Web site. This summary shall also detail how the
      provider can request a hard-copy from the Health Plan at no charge to the
      provider.

    

    e. As
      a part
      of the Provider complaint system, the Health Plan shall:

    

    
      	
              (1)

            	
              Allow
                providers forty-five (45) Calendar Days to file a written
                complaint;

            

    

    

    
      	
              (2)

            	
              Have
                dedicated staff for providers to contact via telephone, electronic
                mail,
                or in person, to ask questions, file a Provider complaint and resolve
                problems;

            

    

    

    
      	
              (3)

            	
              Identify
                a staff person specifically designated to receive and process provider
                complaints; 

            

    

    

    
      	
              (4)

            	
              Thoroughly
                investigate each provider complaint using applicable statutory,
                regulatory, Contractual and Provider contract provisions, collecting
                all
                pertinent facts from all parties and applying the Health Plan’s written
                policies and procedures; and

            

    

    

    
      	
              (5)

            	
              Ensure
                that Health Plan executives with the authority to require corrective
                action are involved in the provider complaint
                process.

            

    

    

    f. In
      the
      event the outcome of the review of the provider complaint is adverse to the
      provider, the Health Plan shall provide a written notice of adverse action
      to
      the provider. 

    

    
      	F.	
               Medical
                Records Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall maintain Medical Records for each Enrollee in accordance
                with this section. Medical Records shall include the Quality, quantity,
                appropriateness, and timeliness of services performed under this
                Contract.

            

    

    

    a. The
      Health Plan must include/follow the Medical Record standards set forth below
      for
      each Enrollee's Medical Records, as appropriate:

    

    (1) The
      Enrollee’s identifying information, including name, Enrollee identification
      number, date of birth, sex and legal guardianship (if any).

    

    (2) Each
      record must be legible and maintained in detail.

    

    (3) A
      summary
      of significant surgical procedures, past and current diagnoses or problems,
      allergies, untoward reactions to drugs and current medications.

    

    (4) All
      entries must be dated and signed by the appropriate party.

    

    (5) All
      entries must indicate the chief complaint or purpose of the visit, the
      objective, diagnoses, medical findings or impression of the
      provider.

    

    (6) All
      entries must indicate studies ordered (e.g., laboratory, x-ray, EKG) and
      referral reports.

    

    (7) All
      entries must indicate therapies administered and prescribed.

    

    (8) All
      entries must include the name and profession of the provider rendering services
      (e.g., MD, DO, OD), including the signature or initials of the
      provider.

    

    (9) All
      entries must include the disposition, recommendations, instructions to the
      Enrollee, evidence of whether there was follow-up and outcome of
      services.

    

    (10) All
      records must contain an immunization history.

    

    (11) All
      records must contain information relating to the Enrollee’s use of tobacco
      products and alcohol/substance abuse.

    

    (12) All
      records must contain summaries of all Emergency Services and Care and Hospital
      discharges with appropriate medically indicated follow up.

    

    (13) Documentation
      of referral services in Enrollees' Medical Records.

    

    (14) All
      services provided by providers. Such services must include, but not necessarily
      be limited to, family planning services, preventive services and services for
      the treatment of sexually transmitted diseases.

    

    (15) All
      records must reflect the primary language spoken by the Enrollee and any
      translation needs of the Enrollee.

    

    (16) All
      records must identify Enrollees needing communication assistance in the delivery
      of health care services.

    

    (17) All
      records must contain documentation that the Enrollee was provided written
      information concerning the Enrollee’s rights regarding advance directives
      (written instructions for living will or power of attorney) and whether or
      not
      the Enrollee has executed an advance directive. Neither the Health Plan, nor
      any
      of its Providers shall, as a condition of treatment, require the Enrollee to
      execute or waive an advance directive. The Health Plan must maintain written
      policies and procedures for advance directives.

    

    b. Confidentiality
      of Medical Records

    

    (1) The
      Health Plan shall have a policy to ensure the confidentiality of Medical Records
      in accordance with 42 CFR, Part 431, Subpart F. This policy shall also include
      confidentiality of a minor’s consultation, examination, and treatment for a
      sexually transmissible disease in accordance with section 384.30(2),
      F.S.

    

    (2) The
      Health Plan shall have a policy to ensure compliance with the Privacy and
      Security provisions of the Health Insurance Portability and Accountability
      Act
      (HIPAA).

    

    
      	 	
              2.

            	
              The
                Health Plan shall maintain a behavioral health Medical Record for
                each
                Enrollee. Each Enrollee's behavioral health Medical Record shall
                include:

            

    

    

    a. Documentation
      sufficient to disclose the Quality, quantity, appropriateness and timeliness
      of
      Behavioral Health Services performed;

    

    b. Must
      be
      legible and maintained in detail consistent with the clinical and professional
      practice which facilitates effective internal and external purity, medical
      audit
      and adequate follow-up treatment; and

    

    c. For
      each
      service provided, clear identification as to

    

    
      	 	
              (1)

            	
              The
                physician or other service provider;

            

    

    

    
      	 	
              (2)

            	
              Date
                of service;

            

    

    

    
      	 	
              (3)

            	
              The
                units of service provided; and

            

    

    

    
      	 	
              (4)

            	
              The
                type of service provided.

            

    

    

    
      	G.
              	
               Claims
                Payment

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall reimburse providers for the delivery of authorized
                services pursuant to section 641.3155 F.S. including, but not limited
                to:

            

    

    

    a. Claims
      are considered received on the date the claims are received by the Health Plan
      at its designated claims receipt location.

    

    b. The
      provider must mail or electronically transfer (submit) the claim to the Health
      Plan within six (6) months of:

    

    
      	 	
              (1)

            	
              The
                date of service or discharge from an inpatient setting;
                or

            

    

    

    
      	 	
              (2)

            	
              The
                provider has been furnished with the correct name and address of
                the
                Enrollee’s Health Plan.

            

    

    

    c. When
      the
      Health Plan is the secondary payor, the provider must submit the claim to the
      Health Plan within ninety (90) days of the final determination of the primary
      payor.

    

    
      	 	
              2.

            	
              The
                Health Plan shall reimburse providers for Medicare deductibles and
                co-insurance payments for Medicare dually eligible members according
                to
                the lesser of the following:

            

    

    

    a. The
      rate
      negotiated with the provider; or

    

    b. The
      reimbursement amount as stipulated in section 409.908 F.S.

    

    
      	 	
              3.

            	
              In
                accordance with section 409.912 F.S., the Health Plan shall reimburse
                any
                Hospital or physician that is outside the Health Plan’s authorized
                geographic service area for Health Plan authorized services provided
                by
                the Hospital or physician to
                Enrollees:

            

    

    

    a. At
      a rate
      negotiated with the Hospital or physician; or

    

    b. The
      lesser of the following:

    

    
      	 	
              (1)

            	
              The
                usual and customary charge made to the general public by the Hospital
                or
                physician; or

            

    

    

    
      	 	
              (2)

            	
              The
                Florida Medicaid reimbursement rate established for the Hospital
                or
                physician.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall have a process for handling and addressing the
                resolution of provider complaints concerning claims issues. The process
                shall be in compliance with 641 .3155
                F.S.

            

    

    

    
      	 	
              5.

            	
              The
                Health Plan shall have claims processing and payment performance
                metrics
                including those for quality, accuracy and timeliness and include
                a process
                for measurement and monitoring, and for the development and implementation
                of interventions for improvement. These metrics must be approved
                in
                writing by the Agency.

            

    

    

    
      	 	
              6.

            	
              Pursuant
                to 42CFR447.45, the Health Plan shall have a claims processing and
                payment
                system, such that:

            

    

    

    a. Ninety
      percent (90%) of clean claims are paid within thirty (30) days from receipt
      at
      the Health Plan;

    

    b. Ninety-nine
      percent (99%) of clean claims are paid within ninety (90) days of receipt a
      the
      Health Plan; and

    

    c. All
      clean
      claims are paid within twelve (12) months of receipt by the Health
      Plan.

    

    
      	H.	
               Encounter
                Data 

            

    

    

    The
      Agency is developing a Medicaid Encounter Data System (MEDS) to collect all
      encounter data from health plans reimbursed on a capitated basis. Encounter
      data
      collection will be required from all Florida capitated health plans for all
      health care services rendered to its members. 

    

    The
      information required to support encounter reporting and submission will be
      defined by the Agency in the MEDS Companion Guide and MEDS Operations Manual.
      Other information contained within the MEDS Companion Guide and MEDS Operations
      Manual will be Managed Care Organization testing requirements for SFY 06-07
      and
      thereafter. The Companion Guide and Operations Manual will be distributed to
      Health Plans in a manner that makes them easily accessible. 

    

    Upon
      the
      request of the Agency, Health Plans shall be prepared to submit encounter data
      to the Agency or its designee. Health Plans shall have a comprehensive automated
      and integrated Encounter Data System that is capable of meeting the requirements
      listed below:

    

    
      	1.  	
              All
                encounters shall be submitted in the standard HIPAA transaction formats,
                namely the ANSI X12N 837 Transaction formats (P - Professional, I
                -
                Institutional, and D - Dental), and the National Council for Prescription
                Drug Programs NCPDP format (for Pharmacy
                services).

            

    

    

    
      	2.  	
              Health
                Plans shall collect and submit to the Agency or its designee, enrollee
                service level encounter data for all covered services. Health Plans
                will
                be held responsible for errors or noncompliance resulting from their
                own
                actions or the actions of an agent authorized to act on their
                behalf.

            

    

    

    
      	3.  	
              Health
                Plans shall have the capability to convert all information that enters
                their claims systems via hard copy paper claims to encounter data
                to be
                submitted in the appropriate HIPAA compliant
                formats.

            

    

    

    
      	4.  	
              Complete
                and accurate encounters shall be provided to the Agency. Health Plans
                will
                implement review procedures to validate encounter data submitted
                by
                providers. The historical encounter data submission shall be retained
                for
                a period not less than five years following generally accepted retention
                guidelines.

            

    

    

    
      	5.  	
              Health
                Plans shall require each Provider to have a unique Florida Medicaid
                Provider number, in accordance with the requirement of Section X,
                C. jj.
                of this Contract.

            

    

    

    
      	6.  	
              Health
                Plans will designate sufficient IT and staffing resources to perform
                these
                encounter functions as determined by generally accepted best industry
                practices. 

            

    

    

    
      	I.	
              Fraud
                Prevention

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall establish functions and activities governing program
                integrity in order to reduce the incidence of Fraud and Abuse and
                shall
                comply with all State and federal program integrity requirements,
                including the applicable provisions of chapters 358, 414, 641 and
                932 in
                Florida law and s. 409.912 (21) and (22). (See 42 CFR
                438.608)

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall designate a compliance officer with sufficient
                experience in health care, who shall have the responsibility and
                authority
                for carrying out the provisions of the Fraud and Abuse policies and
                procedures. The Health Plan shall have adequate staffing and resources
                to
                investigate unusual incidents and develop and implement corrective
                action
                plans to assist the Health Plan in preventing and detecting potential
                Fraud and Abuse activities.

            

    

    

    
      	 	
              3.

            	
              The
                Health Plan shall have internal controls and policies and procedures
                in
                place that are designed to prevent, detect and report known or suspected
                Fraud and Abuse activities.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall submit its Fraud and Abuse policies and procedures
                to
                the Bureau of Managed Health Care for written approval before
                implementation. At a minimum, the policies and procedures
                shall:

            

    

    

    a. Ensure
      that all officers, directors, managers and employees know and understand the
      provision of the Health Plan's Fraud and Abuse policies and
      procedures;

    

    b. Include
      procedures designed to prevent and detect potential or suspected abuse and
      fraud
      in the administration and delivery of services under this Contract. The Health
      Plan is responsible for reporting suspected fraud and abuse by participating
      and
      non-participating providers, as well as enrollees, when detected. 

    

    c. Incorporate
      a description of the specific controls in place for prevention and detection
      of
      potential or suspected Fraud and Abuse, including, but not limited
      to:

    

    
      	 	
              (1)

            	
              Claims
                edits;

            

    

    

    
      	 	
              (2)

            	
              Post-processing
                review of claims;

            

    

    

    
      	 	
              (3)

            	
              Provider
                profiling and credentialing, including a review process for claims
                that
                shall include Providers and nonparticipating
                providers:

            

    

    

    i. Who
      consistently demonstrate a pattern of submitting falsified encounter or service
      reports;

    

    ii. Who
      consistently demonstrate a pattern of overstated reports or up-coded levels
      of
      service;

    

    iii. Who
      alter, falsify or destroy clinical record documentation;

    

    iv. Who
      make
      false statements relating to credentials;

    

    v. Who
      misrepresent medical information to justify Enrollee referrals;

    

    vi. Who
      fail
      to render Medically Necessary Covered Services that they are obligated to
      provide according to their Provider contracts; and

    

    vii. Who
      charge Enrollees for Covered Services.

    

    
      	 	
              (4)

            	
              Prior
                Authorization;

            

    

    

    
      	 	
              (5)

            	
              Utilization
                Management;

            

    

    

    
      	 	
              (6)

            	
              Relevant
                Subcontract and Provider contract provisions;
                and

            

    

    
      	 	
              (7)

            	
              Pertinent
                provisions from the Provider handbook and the Enrollee
                handbook.

            

    

    

    d. Contain
      provisions for the confidential reporting of Health Plan violations to the
      Health Plan's analyst with the Bureau of Managed Health Care, MPI and
      MFCU;

    

    e. Include
      provisions for the investigation and follow-up of any reports;

    

    f. Ensure
      that the identities of individuals reporting acts of Fraud and Abuse are
      protected;

    

    g. Require
      all instances of provider or Enrollee Fraud and Abuse under State and/or federal
      law be reported to the Health Plan's analyst with the Bureau of Managed Health
      Care and MPI. The Health Plan shall not cease an investigation or resolve the
      suspicion, knowledge or action without first informing the Agency and MPI.
      Additionally, any final resolution must include a written statement that
      provides notice to the provider or enrollee that the resolution in no way binds
      the State of Florida nor precludes the State of Florida from taking further
      action for the circumstances that brought rise to the matter;

    

    h. The
      Health Plan and all providers, upon request, and as required by State and/or
      federal law, shall:

    

    
      	 	
              (1)

            	
              Make
                available to the Agency, MPI and/or MFCU any and all administrative,
                contractual, financial and Medical Records relating to the delivery
                of
                items or services for which Medicaid monies are expended;
                and

            

    

    

    
      	 	
              (2)

            	
              Allow
                access to the Agency, MPI and/or MFCU to any place of business and
                all
                Medical Records, as required by State and/or federal law. The Agency,
                MPI
                and MFCU shall have access during normal business hours, except under
                special circumstances when the Agency, MPI and MFCU shall have after
                hour
                admission. The Agency, MPI and/or MFCU shall determine the need for
                special circumstances.

            

    

    

    i. The
      Health Plan shall cooperate fully in any investigation by the Agency, MPI,
      MFCU
      or any subsequent legal action that may result from such an
      investigation.

    

    j. The
      Health Plan shall ensure that the Health Plan does not retaliate against any
      individual who reports violations of the Health Plan's Fraud and Abuse policies
      and procedures or suspected Fraud and Abuse.

    

    k. The
      Health Plan shall provide for the use of the List of Excluded Individuals and
      Entities (LEIE), or its equivalent, to identify excluded parties during the
      process of an engaging the services of new Providers to ensure that the
      Providers are not in a nonpayment status or sanctioned from participation in
      federal health care programs. The Health Plan shall not engage the services
      of a
      provider if that provider is in nonpayment status or salute from participation
      in federal health care programs under sections 1128 and/or 1128A of the Social
      Security Act. The Health Plan shall not employ or contract the services of
      excluded Providers and must terminate the Provider contract immediately between
      the Health Plan and a Provider that becomes an excluded provider.

    

    
      	 	
              5.

            	
              The
                Health Plan shall comply with all reporting requirements set forth
                in
                Section XII., Reporting
                Requirements.

            

    

    

    
      	 	
              6.

            	
              The
                Health Plan shall meet with the Agency periodically, at the Agency’s
                request, to discuss fraud, abuse, neglect and overpayment issues.
                For
                purpose of this section, the Health Plan Compliance Officer shall
                be the
                point of contact for the Health Plan and the Agency’s Medicaid Fraud and
                Abuse Liaison shall be the point of contact for the
                Agency.

            

    

    

    

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    Section
      XI

    Information
      Management and Systems 

    

    

    
      	A.	
               General
                Provisions

            

    

    

    
      	1.  	
              Systems
                Functions.
                The Health Plan shall have Information management processes and
                Information Systems (hereafter referred to as Systems) that enable
                it to
                meet Agency and federal reporting requirements and other Contract
                requirements and that are in compliance with this Contract and all
                applicable State and federal laws, rules and regulations including
                HIPAA.

            

    

    

    
      	2.  	
              Systems
                Capacity.
                The Health Plan’s Systems shall possess capacity sufficient to handle the
                workload projected for the begin date of operations and will be scaleable
                and flexible so they can be adapted as needed, within negotiated
                timeframes, in response to changes in Contract requirements, increases
                in
                enrollment estimates, etc. 

            

    

    

    
      	3.  	
              E-Mail
                System.
                The Health Plan shall provide a continuously available electronic
                mail
                communication link (E-mail system) with the Agency. This system shall
                be:
                available from the workstations of the designated Health Plan contacts;
                and capable of attaching and sending documents created using software
                products other than Health Plan’s systems, including the Agency’s
                currently installed version of Microsoft Office and any subsequent
                upgrades as adopted.

            

    

    

    
      	4.  	
              Participation
                in Information Systems Work Groups/Committees.
                The Health Plan shall meet as requested by the Agency to coordinate
                activities and develop cohesive systems strategies across vendors
                and
                agencies that actively participate in the reform initiative.
                

            

    

    

    
      	5.  	
              Connectivity
                to the Agency/State Network and Systems.
                The Health Plan shall be responsible for establishing connectivity
                to the
                Agency’s/the State’s wide area data communications network, and the
                relevant information systems attached to this network, in accordance
                to
                all applicable Agency and/or State policies, standards and guidelines.
                

            

    

    

    
      	B.	
               Data
                and Document Management
                Requirements

            

    

    

    1. Adherence
      to Data and Document Management Standards 

    

    
      	a.  	
              Health
                Plan Systems shall conform to the standard transaction code sets
                specified
                in Section XI.I. 

            

    

    

    
      	b.  	
              The
                Health Plan’s Systems shall conform to HIPAA standards for data and
                document management that are currently under development within one
                hundred twenty (120) Calendar Days of the standard’s effective date or, if
                earlier, the date stipulated by CMS or the
                Agency.

            

    

    

    
      	c.  	
              The
                Health Plan shall partner with the Agency in the management of standard
                transaction code sets specific to the Agency. Furthermore, the Health
                Plan
                shall partner with the Agency in the development and implementation
                planning of future standard code sets not specific to HIPAA or other
                federal efforts and shall conform to these standards as stipulated
                in the
                plan to implement the standards. 

            

    

    

    
      	2.  	
              Data
                Model and Accessibility.
                Health Plan Systems shall be Structured Query Language (SQL) and/or
                Open
                Database Connectivity (ODBC) compliant; alternatively, Health Plan
                Systems
                shall employ a relational data model in the architecture of its databases
                in addition to a relational database management system (RDBMS) to
                operate
                and maintain them. 

            

    

    

    
      	3.  	
              Data
                and Document Relationships.
                The Health Plan shall house indexed images of documents used by Enrollees
                and providers to transact with the Health Plan in the appropriate
                database(s) and document management systems so as to maintain the
                logical
                relationships between certain documents and certain data.
                

            

    

    

    
      	4.  	
              Information
                Retention.
                Information in Health Plan systems shall be maintained in electronic
                form
                for three years in live Systems and, for audit and reporting purposes,
                for
                seven years in live and/or archival
                Systems.

            

    

    

    
      	5.  	
              Information
                Ownership.
                All Information, whether data or documents, and reports that contain
                or
                make references to said Information, involving or arising out of
                this
                Contract is owned by the Agency. The Health Plan is expressly prohibited
                from sharing or publishing the Agency information and reports without
                the
                prior written consent of the Agency. In the event of a dispute regarding
                the sharing or publishing of information and reports, the Agency’s
                decision on this matter shall be final and not subject to change.
                

            

    

    

    
      	C.	
               System
                and Data Integration
                Requirements

            

    

     

    1. Adherence
      to Standards for Data Exchange 

    

    
      	a.  	
              Health
                Plan Systems shall be able to transmit, receive and process data
                in
                HIPAA-compliant formats that are in use as of the Contract Execution
                Date;
                these formats are detailed in Section
                XI.J.

            

    

    

    
      	b.  	
              Health
                Plan Systems shall be able to transmit, receive and process data
                in the
                Agency-specific formats and/or methods that are in use on the Contract
                Execution Date, as specified in Section
                XI.J.

            

    

    

    
      	c.  	
              Health
                Plan Systems shall conform to future federal and/or Agency specific
                standards for data exchange within one hundred twenty (120) Calendar
                Days
                of the standard’s effective date or, if earlier, the date stipulated by
                CMS or the Agency. The Health Plan shall partner with the Agency
                in the
                management of current and future data exchange formats and methods
                and in
                the development and implementation planning of future data exchange
                methods not specific to HIPAA or other Federal effort. Furthermore,
                the
                Health Plan shall conform to these standards as stipulated in the
                plan to
                implement such standards.

            

    

    

    2. HIPAA
      Compliance Checker.
      

    

    All
      HIPAA-conforming exchanges of data between the Agency and the Health Plan shall
      be subjected to the highest level of compliance as measured using an
      industry-standard HIPAA compliance checker application.

    

    3. Data
      and Report Validity and Completeness. 

    

    The
      Health Plan shall institute processes to ensure the validity and completeness
      of
      the data, including reports, it submits to the Agency. At its discretion, the
      Agency will conduct general data validity and completeness audits using
      industry-accepted statistical sampling methods. Data elements that will be
      audited include but are not limited to: Enrollee ID, date of service, assigned
      Medicaid Provider ID, category and sub category (if applicable) of service,
      diagnosis codes, procedure codes, revenue codes, date of claim processing,
      and
      (if and when applicable) date of claim payment. Control totals shall also be
      reviewed and verified.

    

    4. State/Agency
      Website/Portal Integration. 

    

    Where
      deemed that the Health Plan’s Web presence will be incorporated to any degree to
      the Agency’s or the State’s Web presence (also known as Portal), the Health Plan
      shall conform to any applicable Agency or State standard for Website structure,
      coding and presentation. 

    

    5. Connectivity
      to and Compatibility/Interoperability with Agency Systems and IT Infrastructure.
      

    

    The
      Health Plan shall be responsible for establishing connectivity to the
      Agency’s/State’s wide area data communications network, and the relevant
      information systems attached to this network, in accordance with all applicable
      Agency and/or State policies, standards and guidelines.

    

    6. Functional
      Redundancy with FMMIS. 

    

    The
      Health Plan’s Systems shall be able to transmit and receive transaction data to
      and from FMMIS as required for the appropriate processing of claims and any
      other transaction that could be performed by either System. 

    

    7. Data
      Exchange in Support of the Agency’s Program Integrity and Compliance Functions.

    

    The
      Health Plan’s System(s) shall be capable of generating files in the prescribed
      formats for upload into Agency Systems used specifically for program integrity
      and compliance purposes.

    

    8. Address
      Standardization. 

    

    The
      Health Plan’s System(s) shall possess mailing address standardization
      functionality in accordance with US Postal Service conventions.

    

    9. Eligibility
      and Enrollment Data Exchange Requirements

    

    
      	a.  	
              The
                Health Plan shall receive, process and update enrollment files sent
                daily
                by the Agency or its Agent.

            

    

    

    
      	b.  	
              The
                Health Plan shall update its eligibility/Enrollment databases within
                twenty-four (24) hours of receipt of said files.
                

            

    

    

    
      	c.  	
              The
                Health Plan shall transmit to the Agency or its Agent, in a periodicity
                schedule, format and data exchange method to be determined by the
                Agency,
                specific data it may garner from an Enrollee including third party
                liability data.

            

    

    

    
      	d.  	
              The
                Health Plan shall be capable of uniquely identifying a distinct Medicaid
                Recipient across multiple Systems within its Span of
                Control.

            

    

    

    
      	D.	
               
                Systems Availability, Performance and Problem Management
                Requirements

            

    

     

    
      	1.  	
              Availability
                of Critical Systems Functions. 

            

    

    

    The
      Health Plan will ensure that critical systems functions available to Health
      Plan
      Enrollees and Providers - functions that if unavailable would have an immediate
      detrimental impact on enrollees and providers - are available twenty-four (24)
      hours a day, seven (7) days a week, except during periods of scheduled System
      Unavailability agreed upon by the Agency and the Health Plan. Unavailability
      caused by events outside of a Health Plan’s Span of Control is outside of the
      scope of this requirement. 

    

    
      	2.  	
              Availability
                of Data Exchange Functions. 

            

    

    

    The
      Health Plan shall ensure that the systems and processes within its Span of
      Control associated with its data exchanges with the Agency and/or its Agent(s)
      are available and operational according to specifications and the data exchange
      schedule. 

    

    
      	3.  	
              Availability
                of Other Systems Functions.
                

            

    

    

    The
      Health Plan shall ensure that at a minimum all other System functions and
      Information are available to the applicable System users between the hours
      of
      7:00 a.m. and 7:00 p.m., EST or EDT as appropriate, Monday through Friday.
      

    

    
      	4.  	
              Problem
                Notification. 

            

    

    

    
      	a.  	
              Upon
                discovery of any problem within its Span of Control that may jeopardize
                or
                is jeopardizing the availability and performance of all Systems functions
                and the availability of information in said Systems, including any
                problems impacting scheduled exchanges of data between the Health
                Plan and
                the Agency and/or its Agent(s), the Health Plan shall notify the
                applicable Agency staff via phone, fax and/or electronic mail within
                fifteen (15) minutes of such discovery. In its notification the Health
                Plan shall explain in detail the impact to critical path processes
                such as
                enrollment management and claims submission
                processes.

            

    

    

    
      	b.  	
              The
                Health Plan shall provide to appropriate Agency staff information
                on
                System Unavailability events, as well as status updates on problem
                resolution. At a minimum these up-dates shall be provided on an hourly
                basis and made available via electronic mail and/or telephone.
                

            

    

    

    

    
      	5.  	
              Recovery
                from Unscheduled System Unavailability.
                

            

    

    

    Unscheduled
      System unavailability caused by the failure of systems and telecommunications
      technologies within the Health Plan’s Span of Control will be resolved, and the
      restoration of services implemented, within forty-eight (48) hours of the
      official declaration of System Unavailability.

     

    
      	6.  	
              Exceptions
                to System Availability Requirement.
                

            

    

    

    The
      Health Plan shall not be responsible for the availability and performance of
      systems and IT infrastructure technologies outside of the Health Plan’s span of
      control. 

    

    
      	7.  	
              Corrective
                Action Plan.
                

            

    

    

    Full
      written documentation that includes a Corrective Action Plan, that describes
      how
      problems with critical Systems functions will be prevented from occurring again,
      shall be delivered within five (5) Business Days of the problem’s
      occurrence.

    

    
      	8.  	
              Business
                Continuity-Disaster Recovery (BC-DR) Plan
                

            

    

    

    
      	a.  	
              Regardless
                of the architecture of its Systems, the Health Plan shall develop
                and be
                continually ready to invoke a business continuity and disaster recovery
                (BC-DR) plan that is reviewed and prior-approved by the Agency.
                

            

    

    

    
      	b.  	
              At
                a minimum the Health Plan’s BC-DR plan shall address the following
                scenarios: (1) the central computer installation and resident software
                are
                destroyed or damaged, (2) System interruption or failure resulting
                from
                network, operating hardware, software, or operational errors that
                compromises the integrity of transactions that are active in a live
                system
                at the time of the outage, (3) System interruption or failure resulting
                from network, operating hardware, software or operational errors
                that
                compromises the integrity of data maintained in a live or archival
                system,
                (4) System interruption or failure resulting from network, operating
                hardware, software or operational errors that does not compromise
                the
                integrity of transactions or data maintained in a live or archival
                system
                but does prevent access to the System, i.e. causes unscheduled System
                Unavailability.

            

    

    
      	c.  	
              The
                Health Plan shall periodically, but no less than annually, perform
                comprehensive tests of its BC-DR plan through simulated disasters
                and
                lower level failures in order to demonstrate to the Agency that it
                can
                restore System functions per the standards outlined elsewhere in
                this
                Section of the Contract.

            

    

    

    
      	d.  	
              In
                the event that the Health Plan fails to demonstrate in the tests
                of its
                BC-DR plan that it can restore system functions per the standards
                outlined
                in this Contract, the Health Plan shall be required to submit to
                the
                Agency a corrective action plan in accordance with Section XIV (Sanctions)
                of this Contract that describes how the failure will be resolved.
                The
                corrective action plan shall be delivered within ten (10) Business
                Days of
                the conclusion of the test.

            

    

     

    
      	E.	
               
                System Testing and Change Management Requirements 

            

    

    

    
      	1.  	
              Notification
                and Discussion of Potential System Changes.
                

            

    

    

    The
      Health Plan shall notify the applicable Agency staff person of the following
      changes to Systems within its Span of Control within at least ninety (90)
      Calendar Days of the projected date of the change; if so directed by the Agency,
      the Health Plan shall discuss the proposed change with the applicable Agency
      staff: (1) software release updates of core transaction Systems: claims
      processing, eligibility and Enrollment processing, service authorization
      management, Provider enrollment and data management; (2) conversions of core
      transaction management Systems. 

    

    
      	2.  	
              Response
                to Agency Reports of Systems Problems not Resulting in System
                Unavailability.
                

            

    

    

    The
      Health Plan shall respond to Agency reports of System problems not resulting
      in
      System Unavailability according to the following timeframes: 

    

    
      	a.  	
              Within
                seven (7) Calendar Days of receipt the Health Plan shall respond
                in
                writing to notices of system problems.

            

    

    

    
      	b.  	
              Within
                twenty (20) Calendar Days, the correction will be made or a Requirements
                Analysis and Specifications document will be due.
                

            

    

    

    
      	c.  	
              The
                Health Plan will correct the deficiency by an effective date to be
                determined by the Agency. 

            

    

    

    
      	3.  	
              Valid
                Window for Certain System Changes.
                

            

    

    

    Unless
      otherwise agreed to in advance by the Agency as part of the activities described
      in this Contract Section, scheduled System Unavailability to perform System
      maintenance, repair and/or upgrade activities shall not take place during hours
      that could compromise or prevent critical business operations. 

    

    
      	4.  	
              Testing

            

    

    

    
      	a.  	
              The
                Health Plan shall work with the Agency pertaining to any testing
                initiative as required by the Agency.

            

    

    

    
      	b.  	
              The
                Health Plan shall provide sufficient system access to allow the Agency
                and/or independent testing of the Health Plan’s systems during and
                subsequent to readiness review. 

            

    

    

    

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      	F.	
               Information
                Systems Documentation Requirements 

            

    

    

    
      	1.  	
              Types
                of Documentation.
                

            

    

    

    The
      Health Plan shall develop, prepare, print, maintain, produce, and distribute
      distinct System Process and Procedure Manuals, User Manuals and Quick/Reference
      Guides, and any updates thereafter, for the Agency and other applicable Agency
      staff.

    

    
      	2.  	
              Content
                of System Process and Procedure Manuals.
                

            

    

    

    The
      Health Plan shall ensure that written System Process and Procedure Manuals
      document and describe all manual and automated system procedures for its
      information management processes and information systems. 

    

    
      	3.  	
              Content
                of System User Manuals.
                

            

    

    

    The
      System User Manuals shall contain information about, and instructions for,
      using
      applicable System functions and accessing applicable system data. 

    

    
      	4.  	
              Changes
                to Manuals. 

            

    

    

    
      	a.  	
              When
                a System change is subject to Agency sign off, the Health Plan shall
                draft
                revisions to the appropriate manuals prior to Agency sign off of
                the
                change. 

            

    

    

    
      	b.  	
              Updates
                to the electronic version of these manuals shall occur in real time;
                updates to the printed version of these manuals shall occur within
                ten
                (10) Business Days of the update taking
                effect.

            

    

    

    
      	5.  	
              Availability
                of/Access to Documentation.
                

            

    

    

    All
      of
      the aforementioned manuals and reference guides shall be available in printed
      form and/or on-line. If so prescribed, the manuals will be published in
      accordance to the appropriate Agency and/or State standard. 

    

    
      	G.	
               
                Reporting Requirements - Specific to Information Management and Systems
                Functions and Capabilities - and Technological Capabilities 

            

    

    

    
      	1.  	
              Reporting
                Requirements.
                

            

    

    

    The
      Health Plan shall submit a monthly Systems
      Availability and Performance Report
      to the
      Agency as described in Section XII (Reporting) of this Contract. 

    

    
      	2.  	
              Reporting
                Capabilities.
                

            

    

    

    The
      Health Plan shall provide systems-based capabilities to access to authorized
      Agency personnel, on a secure and read-only basis, to data that can be used
      in
      ad hoc reports.

    

    
      	H.	
               Other
                Requirements

            

    

    

    Community
      Health Record/Electronic Medical Record and
      Related Efforts 

    

    
      	a.  	
              At
                such time that the Agency requires, the Health Plan shall participate
                and
                cooperate with the Agency to implement, within a reasonable timeframe,
                a
                secure, Web-accessible Community Health Records for
                Enrollees.

            

    

    

    
      	b.  	
              The
                design of the vehicle(s) for accessing the Community Health Record,
                the
                health record format and design shall comply with all HIPAA and related
                regulations.

            

    

    

    
      	c.  	
              The
                Health Plan shall also cooperate with the Agency in the continuing
                development of the state’s health care data site (FloridaHealthStat).
                

            

    

    

    
      	I.	
               Compliance
                with Standard Coding
                Schemes

            

    

    

    
      	1.  	
              Compliance
                with HIPAA-Based Code Sets. 

            

    

    

    A
      Health
      Plan System that is required to or otherwise contains the applicable data type
      shall conform to the following HIPAA-based standard code sets; the processes
      through which the data are generated should conform to the same standards as
      needed: 

    

    
      	a.  	
              Logical
                Observation Identifier Names and Codes
                (LOINC)

            

    

    

    
      	b.  	
              Health
                Care Financing Administration Common Procedural Coding System
                (HCPCS)

            

    

    

    
      	c.  	
              Home
                Infusion EDI Coalition (HEIC) Product Codes

            

    

    

    
      	d.  	
              National
                Drug Code (NDC)

            

    

    

    
      	e.  	
              National
                Council for Prescription Drug Programs
                (NCPDP)

            

    

    

    
      	f.  	
              International
                Classification of Diseases (ICD-9)

            

    

    

    
      	g.  	
              Diagnosis
                Related Group (DRG)

            

    

    

    
      	h.  	
              Claim
                Adjustment Reason Codes

            

    

    

    
      	i.  	
              Remittance
                Remarks Codes

            

    

    

    
      	2.  	
              Compliance
                with Other Code Sets. 

            

    

    

    A
      Health
      Plan System that is required to or otherwise contains the applicable data type
      shall conform to the following non-HIPAA-based standard code sets:

    

    
      	 	
              a.
                

            	
              As
                described in all AHCA Medicaid Reimbursement Handbooks, for all "Covered
                Entities", as defined under the HIPAA, and which submit transactions
                in
                paper format (non-electronic
                format).

            

    

    

    
      	 	
              b.

            	
              As
                described in all AHCA Medicaid Reimbursement Handbooks for all
                "Non-covered Entities", as defined under the
                HIPAA.

            

    

    

    

    

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      	J.	
               Data
                Exchange and Formats and Methods Applicable to Health
                Plans 

            

    

    

    
      	1.  	
              HIPAA-Based
                Formatting Standards. 

            

    

    

    Health
      Plan Systems shall conform to the following HIPAA-compliant standards for
      information exchange effective the first day of operations in the applicable
      service region:

    

    Batch
      transaction types

    - ASC
      X12N
      834 Enrollment and Audit Transaction

    - ASC
      X12N
      835 Claims Payment Remittance Advice Transaction

    - ASC
      X12N
      837I Institutional Claim/Encounter Transaction 

    - ASC
      X12N
      837P Professional Claim/Encounter Transaction

    - ASC
      X12N
      837D Dental Claim/Encounter Transaction

    - NCPDP
      1.1 Pharmacy
      Claim/Encounter Transaction

     

    

    Online
      transaction types

    - ASC
      X12N
      270/271 Eligibility/Benefit Inquiry/Response

    - ASC
      X12N
      276 Claims Status Inquiry 

    - ASC
      X12N
      277 Claims Status Response 

    - ASC
      X12N
      278/279 Utilization Review Inquiry/Response 

    - NCPDP
      5.1 Pharmacy
      Claim/Encounter Transaction

    

    
      	2.  	
              Methods
                for Data Exchange. 

            

    

    

    The
      Health Plans and the Agency and/or its Agent(s) shall made predominant use
      of
      Secure File Transfer Protocol (SFTP) and Electronic Data Interchange (EDI)
      in
      their exchanges of data. 

    

    
      	3.  	
              Agency-Based
                Formatting Standards and Methods. 

            

    

    

    Health
      Plan Systems shall exchange the following data with the Agency and/or its
      Agent(s) in a format to be jointly agreed upon by the Health Plan and the
      Agency: 

    

    
      	a.  	
              Provider
                network data

            

    

    

    
      	b.  	
              Case
                management fees

            

    

    

    
      	c.  	
              Administrative
                payments 

            

    

    

    

    

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    Section
      XII

    Reporting
      Requirements

    

    
      	A.	
               Health
                Plan Reporting
                Requirements

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all Reporting Requirements set forth
                by the
                Agency in this Contract.

            

    

    

    
      	 	
              a.

            	
              The
                Health Plan is responsible for assuring the accuracy, completeness,
                and
                timely submission of each report.

            

    

     

    
      	 	
              b.

            	
              The
                Health Plan’s chief executive officer (CEO), chief financial officer
                (CFO), or an individual who reports to the CEO or CFO and who has
                delegated authority to certify the Health Plan’s reports, must attest,
                based on his/her best knowledge, information, and belief, that all
                data
                submitted in conjunction with the reports and all documents requested
                by
                the Agency are accurate, truthful, and complete. (42 C.F.R. 438.606(a)
                and
                (b))

            

    

     

    
      	 	
              c.

            	
              The
                Health Plan must submit its certification at the same time it submits
                the
                certified data reports. (42 C.F.R.
                438.606(c))

            

    

    

    
      	 	
              d.

            	
              Before
                October 1 of each year, the Health Plan shall deliver to the Agency
                a
                certification by an Agency-approved independent auditor that the
                Performance Measure data reported for the previous calendar year
                have been
                fairly and accurately presented.

            

    

    

    
      	 	
              e.

            	
              Deadlines
                for report submission referred to in this Contract specify the actual
                time
                of receipt at the Agency, not the date the file was postmarked or
                transmitted. 

            

    

    

    
      	 	
              f.

            	
              If
                a reporting due date falls on a weekend, the report shall be due
                to the
                Agency on the following Monday. 

            

    

    

    
      	 	
              g.

            	
              All
                reports to be filed on a quarterly basis shall be filed on a calendar
                year
                quarter.

            

    

    

    
      	 	
              2.

            	
              The
                Agency shall furnish the Health Plan with the appropriate reporting
                formats, instructions, submission timetables, and technical assistance,
                as
                required.

            

    

    

    
      	 	
              3.

            	
              The
                Agency reserves the right to modify the Reporting Requirements, with
                a
                ninety (90) Calendar Day notice to allow the Health Plan to complete
                implementation, unless otherwise required by law.
                

            

    

    

    
      	 	
              4.

            	
              The
                Agency shall provide the Health Plan with written notification of
                any
                modifications to the Reporting Requirements.

            

    

    

    5. The
      Reporting Requirements specifications are outlined in detail below.

    

    
      	 	
              6.

            	
              If
                the Health Plan fails to submit the required reports accurately and
                within
                the timeframes specified below, the Agency shall fine or otherwise
                sanction the Health Plan in accordance with Section XIV,
                Sanctions.

            

    

    

    
      	7.  	
              The
                Health Plan must use the following naming convention for all submitted
                reports. Unless otherwise noted, each report will have an 8-digit
                file
                name, constructed as follows:

            

    

    

    
      	
              Digit
                1

            	
              Report
                Identifier

            	
              Indicates
                the report type. Use G for grievance report; 

            
	
              Digits
                2, 3, and 4

               

            	
              Plan
                Identifier

               

            	
              Indicates
                the specific Health Plan submitting the data by the use of three
                (3)
                unique alpha digits. Comports to the Health Plan identifier used
                in
                exchanging data with the enrollment broker.

            
	
              Digits
                5 and 6

            	
              Year

            	
              Indicates
                the year. For example, reports submitted in 2006 should indicate
                06.

            
	
              Digits
                7 and 8

            	
              Time
                Period

               

            	
              For
                reports submitted on a quarterly basis, use Q1, Q2, Q3 or Q4. For
                reports
                submitted monthly, use the appropriate month, such as 01, 02, 03,
                etc.

            

    

    

    8. These
      files can be: 

    

    a. Mailed
      to
      the following address:

    

    Agency
      for Health Care Administration

    Bureau
      of
      Managed Health Care

    2727
      Mahan Drive, MS #26

    Tallahassee,
      FL 32308

    

    or

    

    b. Transmitted
      electronically to the Agency at the following address:

    

    MMCDATA@ahca.myflorida.com

    

    

    
      	 	
              9.

            	
              For
                financial reporting, the Health Plan shall complete the spreadsheets
                and
                mail the diskette or compact disk to the address indicated above
                or
                transmit it electronically to the Agency at the email address noted
                above.
                Additionally, the Health Plan must also send financial reports to
                the
                following e-mail address:

            

    

    

    MMCDATA@ahca.myflorida.com

    

    

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    Table
      1

    Summary
      of Reporting Requirements

    

    
      	
              Health
                Plan Reports Required by AHCA

            
	
              Report
                Name

            	
              Level
                of Analysis

            	
              Frequency

            	
              Submission
                Media

            
	
              834
                Transaction

              Enrollment/Disenrollment

            	
              Location
                Level

            	
              Monthly

            	
              File
                Transfer Protocol (FTP) to the Agency or its Agent via a secure Internet
                site

            
	
              Grievance
                System Reporting

              Table
                2

            	
              Individual
                Level

            	
              Quarterly,
                within 45 Calendar Days of end of reporting quarter

            	
              Electronic
                mail or diskette

            
	
              Provider
                Network Report

              Table
                3

            	
              Location
                Level

            	
              At
                least monthly

            	
              FTP
                to Choice Counselor vendor

            
	
              Marketing
                Representative Report

              Table
                4

            	
              Health
                Plan Level

            	
              Monthly

            	
              Electronic
                mail

            
	
              Enhanced
                Benefit Report

              Table
                5

            	
              Enrollee
                Level

            	
              Monthly

            	
              Electronic
                Mail

            
	
              Catastrophic
                Costs Report

              Table
                6

            	
              Enrollee
                Level

            	
              Monthly,
                as needed

            	
              Electronic
                Mail

            
	
              Critical
                Incidents

            	
              Enrollee
                Level

            	
              Daily
                , as needed

            	
              Electronic
                Mail

            
	
              Results
                of the HSA Survey

            	
              Health
                Plan Level

            	
              Biannually,
                on February 1 and August 1

            	
              Electronic
                mail or diskette

            
	
              Performance
                Measures

            	
              Health
                Plan Level

            	
              Annually,
                for previous calendar year, due October 1

            	
              Electronic
                mail, CD ROM or diskette submission

            
	
              Financial
                Reporting

            	
              Health
                Plan Level

            	
              Quarterly,
                within 45 Calendar Days of end of reporting quarter

            	
              Diskette

            
	
              Audited
                Financial Report

            	
              Health
                Plan Level

            	
              Annually,
                within 90 Calendar Days of end of Health Plan Fiscal Year

            	
              Electronic
                mail or diskette

            
	
              Suspected
                Fraud Reporting

            	
              Individual
                Level

            	
              As
                described in 

              Section
                X, H.

            	
              Electronic
                Mail

            
	
              Denials
                of Authorization

              Tables
                7 and 7A

            	
              Enrollee
                Level

            	
              Monthly
                within 14 Calendar Days of the end of the month being
                reported

            	
              Electronic
                mail or diskette

            
	
              Systems
                Availability and Performance Report

              Table
                8

            	
              Health
                Plan Level

            	
              Monthly,
                within fifteen (15) Calendar Days of the end of the reporting
                month

            	
              Electronic
                Mail

            
	
              Claims
                Inventory Summary Reports

              Tables
                9, 9a, 9b and 9c

            	
              Health
                Plan Level

            	
              Quarterly,
                within forty five (45) Calendar Days of the end of the reporting
                quarter

            	
              Electronic
                Mail

            
	
              Child
                Health Check Up Reports

              Tables
                10 and 10a

            	
              Health
                Plan Level

            	
              Annually
                for previous federal fiscal year (Oct.-Sept.) due by January 15.
                Audited
                report due by Oct. 1

            	
              Electronic
                Mail

            
	
              Pharmacy
                Encounter Data

            	
              Health
                Plan Level

            	
              Quarterly,
                within 30 days of the end of the quarter

            	
              Electronic
                Mail

            
	
              Health
                Plan Benefit Package

              Table
                11

            	
              Health
                Plan Level

            	
              Annual
                re-certification by 

              June
                30

            	
              Electronic
                Mail

            
	
              Transportation
                Services

            	
              Health
                Plan Level

            	 	 
	
              Behavioral
                Health Specific Reporting

            
	
              Enrollee
                Satisfaction Survey Summary 

              Table
                12

            	
              Health
                Plan Level

            	
              Semi-annually,
                due sixty (60) days after the end of the six months being reported.
                

            	
              Hard
                Copy

            
	
              Stakeholders
                Satisfaction Survey Summary 

              Table
                13

            	
              Health
                Plan Level

            	
              Semi-annually,
                due sixty (60) days after the end of the six months being reported.
                

            	
              Hard
                Copy

            
	
              Grievance
                System Report

              Table
                2 

            	
              Individual
                Level

            	
              Quarterly,
                within 45 days of end of reporting quarter

            	
              Via
                AHCA secure RTP site

            
	
              Critical
                Incident

              Summary
                

              Table
                14

            	
              Health
                Plan Level

            	
              Monthly
                — Due on the 15th of the month- Contains previous calendar month’s
                data

            	
              Via
                AHCA secure FTP site

            
	
              Critical
                Incidents 

              Table
                14a

            	
              Individual

            	
              Immediately
                upon occurrence

            	
              Via
                AHCA secure FTP site

            
	
              Required
                Staff/Providers 

              Table
                15

            	
              Health
                Plan Level

            	
              Quarterly
                — Due forty-five (45) after the end of the quarter being reported -
                Contains data for the entire quarter

            	
              Via
                AHCA secure FTP site.

            
	
              FARS/CFARS
                

              Table
                16

            	 	
              Biannually,
                due no later than forty-five (45) days after the reporting
                period.

            	
              Via
                AHCA secure FTP site

            
	
              Encounter
                Data 

              Table
                17

            	
              Individual
                Level

            	
              Quarterly
                - Due forty five (45) days after the end of the quarter being
                reported.

            	
              Via
                AHCA secure FTP site

            
	
              Minority
                Reporting

            	
              Health
                Plan Level

            	
              Monthly
                - Due 15 days after the end of the month being reported

            	
              Electronic
                Mail 

            

    

    

    

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      	B.	
               Enrollment/Disenrollment
                Reports:

            

    

    

    
      	 	
              1.

            	
              The
                Agency or its Agent will report Enrollment/Disenrollment information
                to
                the PSN.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall review the Enrollment/Disenrollment reports for
                accuracy
                and will notify the Agency within three (3) Business Days of any
                discrepancies. Failure to notify the Agency of any discrepancies
                within
                three (3) Business Days shall lead
                to fines and other sanctions as detailed in Section XIV,
                Sanctions.

            

    

    

    
      	 	
              3.

            	
              The
                Enrollment/Disenrollment Reports will use HIPAA-compliant standard
                transactions. The Agency or its Agent will use the X12N 834 transaction
                for all Enrollee maintenance and reporting. The PSN must be capable
                of
                receiving and processing X12N 834 transactions.

            

    

    

    During
      the transition period from proprietary to standard formats, the PSN shall
      cooperatively participate with the Agency in the transition process, including
      formal testing when asked to do so by the Agency. 

    

    
      	C.	
               Grievance
                System

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan shall submit the Grievance System report to the Agency
                for
                Health Care Administration via the Agency’s secure FTP server or
                on a diskette or CD.

            

    

    

    
      	 	
              2.

            	
              The
                report is due forty-five (45) Calendar Days following the end of
                the
                reported quarter. 

            

    

    

    
      	3.  	
              The
                Health
                Plan must
                submit the Grievance System report each quarter. If no new Grievances
                or
                Appeals have been filed with the Health
                Plan,
                or if the status of an unresolved Appeal has not changed to 'Resolved,'
                please submit one (1) record only. This record must contain the PLAN_ID
                field only, with the first 7-digits of the 9-digit Medicaid provider
                number. 

            

    

    

    
      	 	
              4.

            	
              The
                report shall contain information about Grievances and Appeals concerning
                both medical and behavioral health
                issues.

            

    

     

    

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    Table
      2

    Structure
      for Grievance/Appeal Reporting File

    

    
      	
              Field
                Name

            	
               

              Length

            	
               

              Start
                Column

            	
               

              End
                Column

            	
               

              Description

            
	
              PLAN_ID

               

            	
              9

            	
              1

            	
              9

            	
               

              The
                nine digit Medicaid provider number.

            
	
               

              RECIP_ID

               

            	
               

              9

               

            	
               

              10

               

            	
               

              18

               

            	
               

              The
                recipient’s 9 digit Medicaid ID number

               

            
	
               

              LAST_NAME

               

            	
               

              20

               

            	
               

              19

               

            	
               

              38

               

            	
               

              The
                recipient’s last name

               

            
	
               

              FIRST_NAME

               

            	
               

              10

               

            	
               

              39

               

            	
               

              48

               

            	
               

              The
                recipient’s first name

               

            
	
               

              MID_INIT

               

            	
               

              1

               

            	
               

              49

               

            	
               

              49

               

            	
               

              The
                recipient’s middle initial

               

            
	
               

              GRV_DATE

               

            	
               

              10

               

            	
               

              50

               

            	
               

              59

               

            	
               

              The
                date of the grievance (MM/DD/CCYY)

               

            
	
               

              GRV_TYPE

               

            	
               

              2

               

            	
               

              60

               

            	
               

              61

               

            	
              1. Quality
                of Care

              2. Access
                to Care

              3. Emergency
                Services

              4. Not
                Medically Necessary

              5. Pre-Existing
                Condition

              6. Excluded
                Benefit

              7. Billing
                Dispute

              8. Contract
                Interpretation

               

            	
              1.
                Enrollment/Disenrollment

              2.
                Termination of Contract

              3.
                Services after termination

              4.
                Unauthorized out of plan svcs

              5.
                Unauthorized in-plan svcs

              6.
                Benefits available in plan

              7.
                Experimental/ Investigational

              8.
                Other

               

            
	
               

              APP_DATE

               

            	
               

              10

               

            	
               

              62

               

            	
               

              71

               

            	
               

              The
                date of the appeal (MM/DD/CCYY)

               

            
	
               

              APP_ACTION

               

            	
               

              1

               

            	
               

              72

               

            	
               

              72

               

            	
               

              The
                type of action (42 CFR 438.400):

               

            
	 	 	 	 	
              1. The
                denial or limited authorization of a requested service, including
                the type
                or level of service.

              2. The
                reduction, suspension, or termination of a previously authorized
                service.

              3. The
                denial, in whole or in part, of payment for a service.

              4. The
                failure to provide services in a timely manner, as defined by the
                state.

              5. The
                failure of the plan to act within the time frames provided in Sec.
                438.408(b).

              6. For
                a resident of a rural area with only one managed care entity, the
                denial
                of a Medicaid enrollee’s request to exercise his or her right, under Sec.
                438.52(b)(2)(ii), to obtain services outside the network.

               

            
	
               

              DISP_DATE

               

            	
               

              10

               

            	
               

              73

               

            	
               

              82

               

            	
               

              The
                date of the Disposition (MM/DD/CCYY)

               

            
	
               

              DISP_TYPE

               

            	
               

              2

               

            	
               

              83

               

            	
               

              84

               

            	
               

              The
                Disposition of the Appeal / Grievance:

               

            
	 	 	 	 	
              1. Referral
                made to specialist

              2. PCP
                Appointment made

              3. Bill
                Paid

              4. Procedure
                scheduled

              5. Reassigned
                PCP

              6. Reassigned
                Center

              7. Disenrolled
                Self

              8. Disenrolled
                by plan

               

            	
              1. In
                HMO QA Review

              2. In
                HMO Grievance System

              3. Referred
                to Area Office

              4. Member
                sent OLC form

              5. Lost
                contact with member

              6. Hospitalized
                / Institutionalized

              7. Confirmed
                original decision

              8. Reinstated
                in HMO

              9. Other

            
	
               

              DISP_STAT

               

            	
               

              1

               

            	
               

              85

               

            	
               

              85

               

            	
               

              R
                =
                Resolved

               

            	
               

              U
                =
                Unresolved

               

            
	 	 	 	 	
              Note:
                Any grievance or appeal first reported as unresolved must be reported
                again when resolved. Grievances and appeals that are resolved in
                the
                quarter prior to reporting should be reported for the first time
                as
                resolved.

            
	
               

              EXPED_REQ

               

            	
               

              1

               

            	
               

              86

               

            	
               

              86

               

            	
              Indicate
                whether the appeal was an expedited request

              Y
                =Yes N = No Note: This field is required for all reported
                appeals.

            
	
               

              FILE_TYPE

               

            	
               

              2

               

            	
               

              87

               

            	
               

              88

               

            	
              Indicate
                whether the report is related to Grievance or Appeal and a behavioral
                health service respectively

              G
                =
                Grievance Report GB = Grievance Behavioral Report

              A
                =
                Appeal Report AB = Appeal Behavioral Report

            
	
               

              ORIGINATOR

               

            	
               

              1

               

            	
               

              89

               

            	
               

              89

               

            	
              1
                =
                An enrollee

              2
                =
                A provider, acting on behalf of the enrollee and with the enrollee’s
                written consent

            

    

    

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      	D.	
               Provider
                Reporting

            

    

    

    
      	 	
              1.

            	
              The
                Health
                Plan shall
                submit its provider directory as described in Section IV, A.5, Provider
                Directory, of this Contract, to the Agency or its Choice
                Counselor/Enrollment Broker at least on a monthly basis via FTP.
                

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall ensure that the Provider Network Report as described
                in
                Table 3 of this Section is an electronic representation of the Health
                Plan’s complete network of Providers, not a listing of entities for whom
                the Health Plan has paid claims.

            

    

    

    
      	 	
              3.

            	
              The
                Provider Network Report shall be in an ASCII flat file and must be
                a
                complete refresh of the Health Plan’s Provider information. Plans will
                receive final instructions regarding file naming, Plan Code (see
                layout
                below), file transfers, file submission frequency and schedule and
                other
                issues prior to implementation.

            

    

    

    
      	 	
              4.

            	
              The
                Health Plan shall submit the Provider Network Report on the Monday
                preceding the second to the last Saturday of each month. If the Monday
                deadline falls on a holiday, the PSN shall submit the file on the
                Friday
                before the holiday. The Health Plan may choose to submit the Provider
                Network Report a second time each month, on the third Business Day
                before
                the end of the month. This reporting schedule is subject to change
                upon
                notice from the Agency.

            

    

    

    

    NOTE:
      The following reporting material is proprietary information of ACS Inc. and
      may
      not be used, duplicated, or altered without the written permission of Corporate
      Management.

    

    

    

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                  Field
                    Name

                	
                  Field
                    Length

                	
                  Required
                    Field

                	
                  Field
                    Format

                	
                  Justification

                	
                  Comments

                
	
                  Plan
                    Code

                	
                  9

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  This
                    is the 9 digit Medicaid Provider ID number specific to the county
                    of HMO/
                    operation.

                
	
                  Provider
                    Type 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Identifies
                    the provider’s general area of service with an alpha character, as
                    follows:

                  P
                    =
                    Primary Care Provider (PCP)

                  I
                    =
                    Individual Practitioner other than a PCP

                  B
                    =
                    Birthing Center

                  T
                    =
                    Therapy

                  G
                    =
                    Group Practice (includes FQHCs and RHCs)

                  H
                    =
                    Hospital

                  C
                    =
                    Crisis Stabilization Unit

                  D
                    =
                    Dentist

                  R
                    =
                    Pharmacy

                  A
                    =
                    Ancillary Provider (DME providers, Home Health Care 

                  Agencies,
                    etc.)

                
	
                  Plan
                    Provider Number

                	
                  15

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  Unique
                    number assigned to the provider by the plan.

                
	
                  Group
                    Affiliation 

                	
                  15

                	
                  Required
                    for all groups and providers who are members of a group

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  The
                    unique provider number assigned by the HMO/ to the group practice.
                    This
                    field is required for all providers who are members of a group,
                    such as
                    PCPs and specialists. The group affiliation number must be the
                    same for
                    all providers who are members of that group. A record is also
                    required for
                    each group practice being reported. For groups, this identification
                    number
                    must be the same as the plan provider number.

                
	
                  SSN
                    or FEIN 

                	
                  9

                	
                  X

                	
                  alpha

                	
                  Left
                    with leading zeros

                	
                  Social
                    Security Number of Federal Identification Number for the individual
                    provider or the group practice.

                
	
                  Provider
                    last name

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  The
                    last name of the provider, or the first 30 characters of the
                    name of the
                    group. (Please do not include courtesy titles such as Dr., Mr.,
                    Ms., since
                    this titles can interfere with electronic searches of the data.)
                    This
                    field should also be used to note hospital name. UPPER CASE ONLY
                    PLEASE.

                
	
                  Provider
                    first name

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  The
                    first name of the provider, or the continuation of the name of
                    the group.
                    Please do not include provider middle name in this field. Middle
                    name
                    field has been added at the end of the file for this purpose.
                    UPPER CASE
                    ONLY PLEASE.

                
	
                  Address
                    line 1

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Physical
                    location of the provider or practice. Do not use P.O. Box or
                    mailing
                    address is different from practice location. UPPER CASE ONLY
                    PLEASE.
                    

                
	
                  Address
                    line 2

                	
                  30

                	 	
                  alpha

                	
                  Left

                	 
	
                  City
                    

                	
                  30

                	
                  X

                	
                  alpha

                	
                  Left

                  Left

                	
                  Physical
                    city location of the provider or practice. UPPER CASE ONLY
                    PLEASE

                
	
                  Zip
                    Code

                	
                  9

                	
                  X

                	
                  numeric

                	
                  Left
                    with trailing zeros

                	
                  Physical
                    zip code location of the provider or practice. Accuracy is important,
                    since address information is one of the standard items used to
                    search for
                    providers that are located in close proximity to the member.
                    

                
	
                  Phone
                    area code

                	
                  3

                	 	
                  numeric

                	
                  Left

                	 
	
                  Phone
                    number

                	
                  7

                	 	
                  numeric

                	
                  Left

                	
                  Please
                    note that the format does not allow for use of a
                    hyphen.

                
	
                  Phone
                    extension

                	
                  4

                	 	
                  numeric

                	
                  Left

                	 
	
                  Sex

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  The
                    gender of the provider. Valid values: M = male; F = Female; U
                    =
                    Unknown

                
	
                  PCP
                    Indicator 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  Used
                    to indicate if an individual provider is a primary care physician,
                    or for
                    the , a medical home. Valid values: P = Yes, the provider is
                    a PCP/medical
                    home; N = No, the provider is not a PCP/medical home. This field
                    should
                    not be used to note group providers as PCPs, since members must
                    be
                    assigned to specific providers, not group practices. 

                
	
                  Provider
                    Limitation 

                	
                  1

                	
                  Required
                    if PCP Indicator = P 

                	
                  alpha

                	
                  Left

                	
                  X
                    =
                    Accepting new patients

                  N
                    =
                    Not accepting new patients but remaining a contracted network
                    provider

                  L
                    =
                    Not accepting new patients; leaving the network (Please note
                    the “L”
                    designation at the earliest opportunity)

                  P
                    =
                    Only accepting current patients

                  C
                    =
                    Accepting children only

                  A
                    =
                    Accepting adults only

                  R
                    =
                    Refer member to HMO/ member services

                  F
                    =
                    Only accepting female patients

                  S
                    =
                    Only serving children through CMS (MediPass/PSN only)

                
	
                  HMO//MediPass
                    Indicator 

                	
                  1

                	
                  X

                	
                  alpha

                	
                  Left

                	
                  H
                    =
                    HMO/

                  This
                    field must be completed with this designation for each record
                    submitted by
                    the HMO/.

                
	
                  Evening
                    hours 

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  Y
                    =
                    Yes; N = No

                
	
                  Saturday
                    hours

                	
                  1

                	 	
                  alpha

                	
                  Left

                	
                  Y
                    =
                    Yes; N = No

                
	
                  Age
                    restrictions

                	
                  20

                	 	
                  alpha

                	
                  Left

                	
                  Populate
                    this field with free-form text, to identify any age restriction
                    the
                    provider may have on their practice.

                
	
                  Primary
                    Specialty 

                	
                  3

                	
                  Required
                    if Provider Type = P or I

                	
                  numeric

                	
                  Left
                    with leading zeros

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                   

                	
                  Insert
                    the 3 digit code that most closely describes

                  001
                    Adolescent Medicine

                  002
                    Allergy

                  003
                    Anesthesiology

                  004
                    Cardiovascular Medicine

                  005
                    Dermatology

                  006
                    Diabetes

                  007
                    Emergency Medicine

                  008
                    Endocrinology

                  009
                    Family Practice

                  010
                    Gastroenterology

                  011
                    General Practice

                  012
                    Preventative Medicine

                  013
                    Geriatrics

                  014
                    Gynecology

                  015
                    Hematology

                  016
                    Immunology

                  017
                    Infectious Diseases

                  018
                    Internal Medicine

                  019
                    Neonatal/Perinatal

                  020
                    Neoplastic Diseases

                  021
                    Nephrology

                  022
                    Neurology

                  023
                    Neurology/Children

                  024
                    Neuropathology

                  025
                    Nutrition

                  026
                    Obstetrics

                  027
                    OB-GYN

                  028
                    Occupational Medicine

                  029
                    Oncology

                  030
                    Ophthalmology

                  031
                    Otolaryngology

                  032
                    Pathology

                  033
                    Pathology, Clinical

                  034
                    Pathology, Forensic

                  035
                    Pediatrics

                  036
                    Pediatric Allergy

                  037
                    Pediatric Cardiology

                  038
                    Pediatric Oncology &Hematology

                  039
                    Pediatric Nephrology

                  040
                    Pharmacology

                  041
                    Physical Medicine and Rehab

                  042
                    Psychiatry 

                  043
                    Psychiatry, Child

                  044
                    Psychoanalysis

                  045
                    Public Health

                  046
                    Pulmonary Diseases

                  047
                    Radiology

                  048
                    Radiology, Diagnostic

                  049
                    Radiology, Pediatric

                  050
                    Radiology, Therapeutic

                  051
                    Rheumatology

                  052
                    Surgery, Abdominal

                  053
                    Surgery, Cardiovascular

                  054
                    Surgery, Colon / Rectal

                  055
                    Surgery, General

                  056
                    Surgery, Hand

                  057
                    Surgery, Neurological

                  058
                    Surgery, Orthopedic

                  059
                    Surgery, Pediatric

                  060
                    Surgery, Plastic

                  061
                    Surgery, Thoracic

                  062
                    Surgery, Traumatic

                  063
                    Surgery, Urological

                  064
                    Other Physician Specialty

                  065
                    Maternal/Fetal

                  066
                    Assessment Practitioner

                  067
                    Therapeutic Practitioner

                  068
                    Consumer Directed Care

                  069
                    Medical
                    Oxygen Retailer 

                  070
                    Adult Dentures Only

                  071
                    General Dentistry

                  072
                    Oral Surgeon (Dentist)

                  073
                    Pedodontist

                  074
                    Other Dentist

                  075
                    Adult Primary Care Nurse Practitioner

                  076
                    Clinical Nurse Spec

                  077
                    College Health Nurse Practitioner

                  078
                    Diabetic Nurse Practitioner

                  079
                    Brain
                    & Spinal Injury Medicine 

                  080
                    Family/Emergency Nurse Practitioner

                  081
                    Family Planning Nurse Practitioner

                  082
                    Geriatric Nurse Practitioner

                  083
                    Maternal/Child Family Planning Nurse Practitioner

                  084
                    Reg. Nurse Anesthetist

                  085
                    Certified Registered Nurse Midwife

                  086
                    OB/GYN Nurse Practitioner

                  087
                    Pediatric Neonatal 

                  088
                    Orthodontist

                  089
                    Assisted Living for the Elderly

                  090
                    Occupational Therapist

                  091
                    Physical Therapist

                  092
                    Speech Therapist

                  093
                    Respiratory Therapist

                   

                   

                  100
                    Chiropractor

                  101
                    Optometrist

                  102
                    Podiatrist

                  103
                    Urologist

                  104
                    Hospitalist

                  BH1
                    Psychology, Adult

                  BH2
                    Psychology, Child

                  BH3
                    Mental Health Counselor

                  BH4
                    Community Mental Health Center

                  BH5
                    Clubhouse (TBD)

                
	
                  Specialty
                    2 

                	
                  3

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  Use
                    codes listed above.

                
	
                  Specialty
                    3 

                	
                  3

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  Use
                    codes listed above.

                
	
                  Language
                    1 

                	
                  2

                	 	
                  numeric

                	
                  Left
                    with leading

                	
                  01
                    = English

                  02
                    = Spanish

                  03
                    = Haitian Creole

                  04
                    = Vietnamese

                  05
                    = Cambodian

                  06
                    = Russian

                  07
                    = Laotian

                  08
                    = Polish

                  09
                    = French

                  10
                    = Other

                
	
                  Language
                    2 

                	
                  2

                	 	
                  numeric

                	 	
                  Use
                    codes listed above.

                
	
                  Language
                    3 

                	
                  2

                	 	
                  numeric

                	 	
                  Use
                    codes listed above.

                
	
                  Hospital
                    Affiliation 1 

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Hospital
                    with which the provider is affiliated. Use the AHCA ID for accurate
                    identification, 

                
	
                  Hospital
                    Affiliation 2

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 3

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 4

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Hospital
                    Affiliation 5

                	
                  9

                	 	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  as
                    above

                
	
                  Wheel
                    Chair Access 

                	
                  1

                	 	
                  alpha

                	 	
                  Indicates
                    if the provider’s office is wheelchair accessible. Use Y = Yes or N =
                    No.

                
	
                  #
                    of HMO/ Members

                	
                  4

                	
                  X

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Information
                    must be provided for PCPs only. Indicates the total number of
                    patients who
                    are enrolled in submitting plan. For providers who practice at
                    multiple
                    locations, the number of HMO/ members specific to each physical
                    location
                    must be specified.

                
	
                  Active
                    Patient Load

                	
                  4

                	
                  X

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  Total
                    Active Patient Load, as defined in contract

                
	
                  Professional
                    License Number

                	
                  10

                	
                  X

                	
                  alpha/
                    numeric

                	 	
                  Must
                    be included for all health care professionals. License number
                    is formatted
                    with up to 3 alpha characters followed by up to 7 numeric digits.
                    

                
	
                  AHCA
                    Hospital ID1 
                    AHCA provided the list of AHCA IDs for hospitals to plans on
                    8-26-05.
                    

                	
                  8

                	
                  Required
                    if Provider Type = “H”

                	
                  numeric

                	
                  Left
                    with leading zeros

                	
                  The
                    number assigned by the Agency to uniquely identify each specific
                    hospital
                    by physical location. Any out of state hospital for which an
                    AHCA ID is
                    not included should be designated with the pseudo-number
                    99999999.

                
	
                  County
                    Health Department (CHD) Indicator

                	
                  1

                	
                  X

                	
                  alpha

                	 	
                  Used
                    to designate whether the individual or group provider is associated
                    only
                    with a county health department. Y = Yes; N = No. This field
                    must be
                    completed for all PCP and specialty providers.

                
	
                  Filler

                	
                  47

                	
                  X

                	 	 	 

        

        

          
            
              

            

          

        

      

      
        
          1 
            AHCA
            provided the list of AHCA IDs for hospitals to plans on 8-26-05.

        

      

    

     

    
 

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    

    

    
      	E.	
              Marketing
                Representative Report

            

    

    

    The
      Health Plan shall register each marketing representative with the Agency as
      outlined in Section IV, Enrollee Services and Marketing. The file will be
      submitted within five days of the reporting month to the Agency at the following
      e-mail address: petrieg@ahca.myflorida.com.
      The
      Agency-supplied spreadsheet template must be used. This template contains the
      following data elements:

    

     

    Table
      4

    

    Required
      Information for Marketing Representative Report Template

    

    
      	
              Plan
                Information

            	
              Marketing
                Representative Information

            
	
              Plan
                Name

            	
              Last
                Name

            
	
              Address

            	
              First
                Name

            
	
              Contact
                Person

            	
              DOI
                License Number

            
	
              Phone

            	
              Address

            
	
              Fax

            	
              City

            

    

    

     

     

    
      	F.	
               
                Enhanced Benefits Report

            

    

     

     

    Table
      5

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      	G.	
               
                Catastrophic Component Threshold and Benefit Maximum
                Report

            

    

     

    Health
      Plans that choose to cover the comprehensive component shall submit this report
      for each Enrollee, whose costs for Covered Services reach $25,000 in a Contract
      Year. The report shall be in the format shown in Table 6 below. The report
      shall
      be submitted monthly from the time the Enrollee’s costs reach $25,000 through
      the end of the Contract Year.

    

    Health
      Plans that choose to cover the comprehensive and catastrophic component shall
      submit this report for each Enrollee, whose costs for Covered Services reach
      $450,000 in a Contract Year. The report shall be in the format shown in Table
      6
      below. The report shall be submitted monthly from the time the Enrollee’s costs
      reach $450,000 through the end of the Contract Year.

    

    

    Table
      6

    

    

    
      	
              $25,000
                or $450,000 Thresholds Reached/Report to AHCA

               

            
	
              RECIP

            	
              DOS

            	
              DOP

            	
              UNIT/DAY

            	
              AMOUNT

            	
              APPCD

            	
              TRPROV

            	
              TRTYPE

            	
              DIAG1

            	
              DIAG2

            	
              DIAG3

            	
              DIAG4

            	
              DIAG5

            	
              PROCD

            	
              MOD1

            	
              MOD
                2

            	
              NDC

            	
              DRUGQTY

            	
              P2PROV

            	
              P2TYPE

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

    

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      	H.	
               
                Critical Incidents

            

    

    

    The
      Health Plan shall report all serious Enrollee injuries occurring through health
      care services within 15 days of the Health Plan receiving information about
      the
      injury. The Health Plan will use the Florida Agency for Health Care
      Administration, Division of Health Quality Assurance’s Code 15 Report for
      Florida Ambulatory Surgical Centers, Hospitals and HMOs to document the
      incident. The Code 15 Report shall be sent to the Health Plan’s analyst in the
      Bureau of Managed Health Care. The Code 15 Report can be found at
      www.ahca.myflorida/MCHQ/Health_Facility_Regulation/Risk/reporting.

    

    
      	I.	
               Hernandez
                Settlement Agreement (HAS)
                Report

            

    

    

    If
      the
      Health Plan has authorization requirements for prescribed drug services, the
      Health Plan shall file reports biannually to the Bureau of Managed Health Care,
      to include the following:

    

    1. The
      results of the HSA survey with:

    (a) The
      total
      number of pharmacy locations surveyed;

    (b) The
      HSA
      areas surveyed;

    
      	 	
              (c)

            	
              Those
                HSA areas in which the pharmacy locations were delinquent;
                and

            

    

    
      	 	
              (d)

            	
              The
                process by which the Health Plan selected the pharmacy
                locations.

            

    

    

    2. A
      copy of
      the Hernandez Ombudsman Log.

    

    
      	J.	
               
                Performance Measure Report

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report the performance measures described in Section
                VIII, A.3.c.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall calculate the performance measures based on the
                calendar
                year (January 1 through December 31), unless otherwise
                specified.

            

    

    

    
      	 	
              3.

            	
              The
                performance measure report is due by October 1 after the measurement
                year.

            

    

    

    
      	K.	
               Financial
                Reporting

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall complete the spreadsheet supplied by the
                Agency.

            

    

    

    
      	 	
              2.

            	
              Audited
                financial reports — The Health Plan shall submit to the Agency annual
                audited financial statements and four (4) quarterly unaudited financial
                statements.

            

    

    

    
      	 	
              a.

            	
              The
                audited financial statements are due no later than three (3) calendar
                months after the end of the Health Plan’s fiscal
                year.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall submit the quarterly unaudited financial statements
                no
                later than forty-five (45) days after each calendar quarter and shall
                use
                generally accepted accounting principles in preparing the unaudited
                quarterly financial statements, which shall include, but not be limited
                to, the following:

            

    

    

    (1) A
      Balance
      Sheet;

    

    (2) A
      Statement of Revenues and Expenses;

    

    
      	(2)  	
              A
                Statement of Cash Flows; and 

            

    

    

    (4) Footnotes.

    

    
      	 	
              c.

            	
              The
                Health Plan shall submit the annual and quarterly financial statements
                using, an Agency-supplied template, by electronic transmission to
                the
                following e-mail address:

            

    

    

    MMCFIN@AHCA.MYFLORIDA.COM

    

    
      	 	
              d.

            	
              The
                Health Plan shall submit annual and quarterly financial statements
                that
                are specific to the operations of the Health Plan rather than to
                a parent
                or umbrella organization.

            

    

    

    
      	L.	
               Suspected
                Fraud Reporting

            

    

    

    
      	 	
              1.

            	
              Provider
                Fraud and Abuse

            

    

    

    Upon
      detection of a potential or suspected fraudulent claim submitted by a provider,
      the Health Plan shall file a report with the Agency, MPI and MFCU..
      The
      report shall contain at a minimum:

    

    
      	 	
              a.

            	
              The
                name of the provider;

            

    

    

    
      	 	
              b.

            	
              The
                assigned Medicaid provider number and the tax identification
                number;

            

    

    

    
      	 	
              c

            	
              A
                description of the suspected fraudulent act;
                and

            

    

    

    
      	 	
              d.

            	
              The
                narrative report must be sent to the Health Plan’s analyst at the Bureau
                of Managed Health Care, MPI and
                MFCU.

            

    

    

    2. Enrollee
      Fraud

    

    
      	 	
              a.

            	
              Upon
                detection of all instances of fraudulent claims or acts by an Enrollee,
                the Health Plan shall file a report with the Agency and MPI.
                

            

    

    

    
      	 	
              b.

            	
              The
                report shall contain, at a minimum:

            

    

    

    (1) The
      name
      of the Enrollee,

    

    (2) The
      Enrollee’s Health Plan identification number,

    

    (3) The
      Enrollee’s Medicaid identification number,

    

    (4) A
      description of the suspected fraudulent act, and

    

    
      	 	
              (5)

            	
              The
                narrative report must be sent to the Health Plan’s analyst at the Bureau
                of Managed Health Care and MPI.

            

    

    

    
      	 	
              3.

            	
              Failure
                to report instances of suspected Fraud and Abuse is a violation of
                law and
                subject to the penalties provided by
                law.

            

    

    

    
      	M.	
               
                Denials of Authorization Reporting Requirements 

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall report, on a monthly basis, denials of authorization
                for
                services in the following
                categories:

            

    

    

    a. Inpatient
      care (pre-certification and concurrent denials);

    

    b. Specialty
      care; and

    

    c. Ancillary
      Services.

    

    
      	3.  	
              The
                Health Plan shall report all Denials of Authorization in accordance
                with
                the format set forth in Table 7 and 7-A,
                below.

            

    

    

     

    Table
      7

    Denials
      of Authorization Report

    

    
      	 	
              Inpatient

              Pre-Certification

            	
              Inpatient

              Concurrent

            	
              Specialty
                Care

            	
              Ancillary
                Services

            
	 	 	 	 	 
	
              Enrollee
                ID #

            	 	 	 	 
	
              Service
                Requested

            	 	 	 	 
	
              Date
                of Request

            	 	 	 	 
	
              Date
                of Denial

            	 	 	 	 
	
              Denial
                Reason

            	 	 	 	 
	
              Denial
                Appealed Yes/No

            	 	 	 	 

    

    

    

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    Table
      7-A

    Summary
      of Authorization Denials

    

    
      	 	
              Inpatient
                Pre-Certification

            	
              Inpatient
                Con-Current

            	
              Specialty
                Care

            	
              Ancillary
                Services

            
	
               

              Total
                Authorizations Requested

            	 	 	 	 
	
               

              Total
                Authorizations Denied

            	 	 	 	 
	
               

              Average
                Number of Calendar Days Between Request and Denial

            	 	 	 	 
	
               

              Longest
                Number of Calendar Days Between Request and Denial

            	 	 	 	 
	
               

              Total
                Number of Denials Appealed

            	 	 	 	 

    

    

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      	N.	
               
                Systems Availability and Performance
                Report

            

    

    

    The
      Systems Availability and Performance Report should be formatted as shown in
      Table 8, below. The Health Plan shall provide average uptime, downtime and
      unscheduled downtime, i.e. outage and data by system (application/operating
      environment cohort) in tabular form.

    

    

    Table
      8

    

    Systems
      Availability and Performance Report

    

    
      	
              System
                Availability and Performance Report

            
	
              System

            	
               

            	
              Total
                Up Time

            	
              Total
                Down Time

            	
              Total
                UNSCHEDULED Down Time ("Outage Time")

            	
               

            
	
              Measurement
                Period

            	
              Up
                Time During Period

            	
              Up
                Time During Period

            	
              During
                Period

            	
              Notes/Comments

            
	
               system
                1

            	 	 	 	 	 	 
	
              system2

            	 	 	 	 	
               

            	
               

            
	
              system3

            	 	 	 	 	
               

            	
               

            
	
              system4

            	 	 	 	 	
               

            	
               

            
	
              system5

            	 	 	 	 	 	 
	
              system6

            	 	 	 	 	
               

            	
               

            
	
              system7

            	 	 	 	 	
               

            	
               

            
	
              system8

            	 	 	 	 	
               

            	
               

            
	
              system9

            	 	 	 	 	
               

            	
               

            
	
              system10

            	 	 	 	 	
               

            	
               

            

    

    

    

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      	O.	
               
                Claims Inventory Summary
                Report

            

    

    

    The
      Health Plan shall file an Aging Claims Summary Report quarterly, noting paid,
      denied and unpaid claims by provider type. The Health Plan will submit this
      report using the CLAIMS
      AGING TEMPLATE.xls
      file
      supplied by the Agency and presented in Tables 10, 10a, 10b and 10c. This file
      is an Excel spreadsheet and may be submitted to the following email address:
      mmcclms@ahca.myflorida.com.

    

    Table
      9

    

    Total
      Claims Aging By Provider Type

     

    
      NOTE:
        List
        ALL
        claims including those contained in the beginning inventory on this
        page.

    
      	
              00/00/00

            	 	
               

            	
            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    

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    Table
      9a

    

    Paid
      Claims Aging by Provider Type Report

    

    
      	
              00/00/00

            	 	
               

            	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    

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    Table
      9b

    Denied
      Claims Aging By Provider Type

    

    
      	
              00/00/00

            	 	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
              OTHER

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
               

            	
              0%

            	
              0
                

            

    

    

    

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    Table
      9c

    

    Unpaid
      Claims Aging by Provider Type Report

    

    

    
      	
               

            	
              00/00/00

            	
               

            	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              days

            	
               

            	
              TOTAL

            
	
              PROVIDER

            	
              1-30

            	
              %

            	
              31-60

            	
              %

            	
              61-90

            	
              %

            	
              91-120

            	
              %

            	
              120+

            	
              %

            	
              CLAIMS

            
	
              PRIMARY
                CARE

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
              SPECIALTY

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
              OTHER

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            
	
               

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            	
              0%

            	
              0
                

            

    

    

    

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    Table
      9d

    

    Claims
      Inventory by Provider Type

    

    

    
      	
              00/00/00

            	 	
              Inventory

            	
               

            	
               

            	
               

            
	
               

            	
              (Ending
                Inventory from Previous quarter) 

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
              Beginning
                

            	
              Claims

            	
               

            	
               

            	
              Ending
                

            
	
              PROVIDER

            	
              Inventory

            	
              Received

            	
              Claims
                Paid

            	
              Claims
                Denied

            	
              Inventory

            
	
              PRIMARY
                CARE

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
              SPECIALTY

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
              OTHER

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              HOSPITALS:

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            
	
               

            	
               

            	
              0

            	
              0

            	
              0

            	
              0

            

    

    

    

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      	P.	
               
                Child Health Check-Up
                Reports

            

    

    

    The
      Agency will supply the Excel spreadsheets necessary to create these
      reports.

    

    CMS
      416
      Report

    

    
      	 	
              1.

            	
              The
                Child Health Check Up, CMS 416 Report shall be submitted annually
                and in
                the formats as presented in Tables 10. The reporting period is the
                federal
                fiscal year. The report is due on January 1, following the reporting
                period. Before October 1 following each reporting period, the Health
                Plan
                shall deliver to the Agency a certification by an Agency approved
                independent auditor that the Child Health Check-Up data has been
                fairly
                and accurately presented. This filing requires a copy of the audited
                reports and a copy of the auditors' letter of
                opinion.

            

    

    

    
      	 	
              2.

            	
              For
                each of the following line items, report total counts by the age
                groups
                indicated. In cases where calculations are necessary, perform separate
                calculations for the total column and each age group. Report age
                based
                upon the child's age as of September 30 of the federal fiscal
                year.

            

    

    

    Medicaid
      Provider ID Number:
      Enter
      the plan's seven digit Medicaid Provider ID number, i.e., 015----

    

    Plan
      Name:
      Enter
      the name of the Health Plan.

    

    Fiscal
      Year:
      Entered
      is the federal fiscal year being reported. Given

    

    Line
      1 - Total Individuals Eligible for Child Health Check-Up
      (CHCUP):  Enter
      the
      total unduplicated number of all Enrollees under the age of 21, distributed
      by
      age and by basis of Medicaid Eligibility category.
      Unduplicated
      means
      that an Enrollee is reported
      only once,
      although
      he or she may have had more than one period of Eligibility during the year.
      All
      Enrollees under age 21 (except MediKids Enrollees) are considered eligible
      for
      CHCUP services, regardless of whether they have been informed about the
      availability of CHCUP services or whether they accept CHCUP services at the
      time
      of informing. Do
      not count Enrollees in the MediKids populations.

    

    Line
      2a - State Periodicity Schedules
      -
      Given.

    

    Line
      2b - Number of Years in Age Group
      -
      Given.

    

    Line
      2c - Annualized State Periodicity Schedule
      -
      Given.

    

    Line
      3a - Total Months Eligibility
      - Enter
      the total months of Eligibility for the Enrollees in each age group in Line
      1
      during the reporting year.

    Line
      3b - Average Period of Eligibility
      -
      Pre-calculated by dividing the total months of Eligibility by Line 1, then
      by
      dividing that number by 12. This number represents the portion of the year
      that
      Enrollees remain Medicaid Eligible during the reporting year, regardless of
      whether Eligibility was maintained continuously.

    

    Line
      4 - Expected Number of Screenings per Eligible
      Multiply
      -
      Pre-calculated by multiplying Line 2c by Line 3b. This number reflects the
      expected number of initial or periodic screenings per Child/Adolescent per
      year
      based on the number required by the State-specific periodicity schedule and
      the
      average period of Eligibility.

    

    Line
      5 - Expected Number of Screenings
      -
      Pre-calculated by multiplying Line 4 by Line 1. This reflects the total number
      of initial or periodic screenings expected to be provided to the Enrollees
      in
      Line 1.

    

    Line
      6 - Total Screenings Received
      - Enter
      the total number of initial or periodic screens furnished to Enrollees. Use
      the
      CPT codes listed below or any Health Plan-specific CHCUP codes developed for
      these screens. Use of these proxy codes is for reporting purposes
      only.

    

    
      	 	
              3.

            	
              Health
                Plans must continue to ensure that all five age-appropriate elements
                of an
                CHCUP screen, as defined by law, are provided to CHCUP eligible
                Enrollees

            

    

    

    
      	 	
              4.

            	
              This
                number should not
                reflect sick visits or episodic visits provided to children unless
                an
                initial or periodic screen was also performed during the visit. However,
                it may reflect a screen outside of the normal state periodicity schedule
                that is used as a "catch-up" CHCUP screening. (A catch-up CHCUP screening
                is defined as a complete
                screening that is provided to bring a child up-to-date with the State's
                screening periodicity schedule.) Use data reflecting date
                of service
                within the fiscal year for such screening services or other documentation
                of such services. Do
                not count MediKids Enrollees, who have had a
                check-up.
                The
                CPT-4 codes to be used to document the receipt of an initial or periodic
                screen are as follows:

            

    

    

    Codes
      for Preventive Medicine Services

    

    99381
      New
      Patient Under One Year

    99382
      New
      Patient Ages 1 - 4 Years

    99383
      New
      Patient Ages 5 - 11 Years

    99384
      New
      Patient Ages 12 - 17 Years

    99385EP
      New
      Patient Ages 18 - 39 Years 

    99391
      Established Patient Under One Year

    99392
      Established Patient Ages 1 - 4 Years

    99393
      Established Patient Ages 5 - 11 Years

    99394
      Established Patient Ages 12 - 17 Years

    99395EP
      Established Patient Ages 18 - 39 Years

    99431
      Newborn
      Care - History and Examination

    99432
      Normal
      Newborn Care 

    99435
      Newborn
      Care (history and examination)

    

    Codes
      For Evaluation and Management Services (must
      be used in conjunction withV codes V20-V20.2 and/or V70.0 and/or
      V70.3-V70.9)

    

    99201-99205
      New
      Patient

    99211-99215
      Established
      Patient

    

    Line
      7 - Screening Ratio
      -
      Pre-calculated by dividing the actual number of initial and periodic screening
      services received (Line 6) by the expected number of initial and periodic
      screening services (Line 5). This ratio indicates the extent to which CHCUP
      eligible Enrollees receive the number of initial and periodic screening services
      required by the State's periodicity schedule, adjusted by the proportion of
      the
      year for which they are Medicaid Eligible. This
      ratio should not be over 100%. Any data submitted which exceeds 100% will be
      reflected as 100% on the final report.

    

    Line
      8 - Total Eligibles Who Should Receive at Least One Initial or Periodic
      Screen
      - The
      number of Enrollees who should receive at least one initial or periodic screen
      is dependent on the State's periodicity schedule. The following calculations
      were used:

    

    
      	 	 	
              a.

            	
              If
                the number entered in Line 4 is greater than 1, the number 1 is used.
                If
                the number in Line 4 is less than or equal to 1, the number in Line
                4 is
                used. This eliminates situations where more than one visit is expected
                in
                any age group in a year.

            

    

    

    
      	 	 	
              b.

            	
              The
                number from calculation 1 is multiplied by the number in Line 1 and
                entered on Line 8.

            

    

    

    Line
      9 - Total Eligibles Receiving at Least One Initial or Periodic
      Screen
      - Enter
      the unduplicated count of Enrollees who received at least one
      documented initial or periodic screen during the year. Refer to codes in Line
      6
      and count
      Enrollees where you have received a claim. Do
      not count MediKids Enrollees who have had a check-up.

    

    Line
      10 - Participant Ratio
      -
      Pre-Calculated by dividing Line 9 by Line 8. This ratio indicates the extent
      to
      which Enrollees are receiving any initial and periodic screening services during
      the year. NOTE:
      The
      Health Plan shall adopt annual participation goals to achieve at least a eighty
      percent (80%) CHCUP participation rate pursuant to Section 5360, Annual
      Participation Goals, of the State Medicaid Manual.

    

    Line
      11 - Total Eligibles Referred for Corrective
      Treatment
      - Enter
      the unduplicated
      number
      of Enrollees who, as a result of at least one health problem identified during
      an initial or periodic screening service, including
      vision and hearing screenings,
      were
      scheduled for another appointment with the screening provider or referred to
      another provider for further needed diagnostic or treatment services. This
      element does not include correction of health problems during the course of
      a
      screening examination. This element is required. The new federally required
      referral codes should be provided in Line 11.

    

    

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              For
                reporting on the CMS-416 only count the referral codes "T" and
                "V". 
                

            
	
              U

            	
              Complete
                Normal

            
	
              Indicator
                is used when there are no referrals made.

            
	
              2

            	
              Abnormal,
                Treatment Initiated

            	
               

            
	
              Indicator
                is used when a child is currently under treatment for referred diagnostic
                or corrective health problem.

            
	
              T

            	
              Abnormal,
                Recipient Referred

            
	
              Indicator
                is used for referrals to another provider for diagnostic or corrective
                treatments or scheduled for another appointment with check-up provider
                for
                diagnostic or corrective treatment for at least one health problem
                identified during an initial or 

            
	
              V

            	
              Patient
                Refused Referral

            
	
              Indicator
                is used when the patient refused a referral.

            

    

    

    

    
      	 	
              5.

            	
              For
                purposes of reporting information on dental services, unduplicated
                means that each child is counted once for each
                line of data
                requested. Example: a child would be counted once on Line 12a for
                receiving any dental service and would be counted again for Line
                12b
                and/or 12c if the child received a preventive and/or treatment dental
                service. These numbers should reflect services received in managed
                care.
                Lines 12b and 12c do not
                equal total services reflected on Line
                12a.

            

    

    

    Line
      12a - Total Eligibles Receiving Any Dental
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving any
      dental
      services as defined by CDT Codes D0100 - D9999.

    

    Line
      12b - Total Eligibles Receiving Preventive Dental
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving a preventive dental service as defined by
      CDT
      Codes D1000 - D1999.

    

    Line
      12c - Total Eligibles Receiving Dental Treatment
      Services
      - Enter
      the unduplicated
      number
      of Children/Adolescents receiving treatment services as defined by CDT Codes
      D2000 - D9999.

    

    Line
      13 - Total Eligibles Enrolled in Managed Care
      - This
      number is reported for informational purposes only. This number represents
      all
      Enrollees eligible for CHCUP services, who were Enrolled at any time during
      the
      reporting year. These Enrollees should be included in the total number of
      unduplicated eligibles on Line 1 and the number of initial or periodic
      screenings provided to these Enrollees should be included in Lines 6 and 8
      for
      purposes of determining the State's screening and participation rates. The
      number of Enrollees referred for corrective treatment and receiving dental
      services should be reflected in Lines 11 and 12, respectively. Do
      not count
      MediKids Enrollees.

    

    
      	 	
              6.

            	
              To
                report the number of screening blood lead tests do the following:
                Count
                the number of times CPT code 83655 ("lead") or any State-specific
                (local)
                codes used for a blood lead test reported with any ICD-9-CM except
                with
                diagnosis codes 984 (.0 - .9) ("Toxic Effects of Lead and Its Compounds"),
                E861.5 ("Accidental Poisoning by Petroleum Products, Other Solvents
                and
                Their Vapors NEC: Lead Paints"), and E866.0 (Accidental Poisoning
                by Other
                Unspecified Solid and Liquid Substances: Lead and Its Compounds and
                Fumes"). These specific ICD-9-CM diagnosis codes are used to identify
                people who are lead poisoned. Blood lead tests done in these individuals
                should not be counted as a screening blood lead test. This
                is a federally mandated test for ages 12 months, 24 months and between
                the
                ages of 36 - 72 months
                who have not been previously screened for lead
                poisoning.

            

    

    

    

    Line
      14 - Total Number of Screening Blood Lead Tests
      - Enter
      the total number of screening blood lead tests furnished to eligible Enrollees.
      Blood lead tests done on Enrollees who have been diagnosed or treated for lead
      poisoning should not be counted. Do not make entries in the shaded
      columns.

    

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    Table
      10

    

    Child
      Health Check Up Report 

    

    
      	
               

            	
              Enter
                Data in Blue Colored Out-Lined Cells Only

            	
              CHILD
                HEALTH CHECK-UP REPORT (CHCUP) [CMS-416]

            
	 	
              Seven
                Digit Medicaid Provider Number :

            	
               

            	
              This
                report is due to the Agency no later than January
                15.

            
	 	
              Plan
                Name :

            	
               

            	
               

            	
               

            
	
               

            	
              Federal
                Fiscal Year :

            	
              October
                1, 2004 - September 30, 2005

            	
               

            	
               

            	
              The
                Audited Report is due October 1.

            
	
               

            	
              Age
                Groups

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              Less
                than 1 Year

            	
              1-2
                Years *

            	
              3-5
                Years

            	
              6-9
                Years

            	
              10-14
                Years

            	
              15-18
                Years

            	
              19-20
                Years

            	
              Total
                All Years

            
	
              1.

            	
              Total
                Individuals Eligible for CHCUP (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              2a.

            	
              State
                Periodicity Schedule

            	
              6

            	
              4

            	
              3

            	
              2

            	
              5

            	
              4

            	
              2

            	
              26

            
	
              2b.

            	
              Number
                of Years in Age Group

            	
              1

            	
              2

            	
              3

            	
              4

            	
              5

            	
              4

            	
              2

            	
              21

            
	
              2c.

            	
              Annualized
                State Periodicity Schedule

            	
              6.00

            	
              2.00

            	
              1.00

            	
              0.50

            	
              1.00

            	
              1.00

            	
              1.00

            	
              1.24

            
	
              3a.

            	
              Total
                Months of Eligibility

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              3b.

            	
              Average
                Period of Eligibility

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              4.

            	
              Expected
                Number of screenings per Eligible

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              5.

            	
              Expected
                Number of screenings

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              6.

            	
              Total
                Screens Received

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            

    

     

    
      	
              7.

            	
              Screening
                Ratio

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              8.

            	
              Total
                Eligible who should receive at least one Initial or periodic
                screening

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              #VALUE!

            
	
              9.

            	
              Total
                Eligibles receiving at least one Initial or periodic screen
                (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              10.

            	
              Participation
                Ratio

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              11.

            	
              Total
                eligibles referred for corrective treatment (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              12a.

            	
              Total
                Eligibles receiving any dental services (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              0
                

            
	
              12b.

            	
              Total
                Eligibles receiving preventative dental services (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              0
                

            
	
              12c.

            	
              Total
                Eligibles receiving dental treatment services (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              0
                

            
	
              13.

            	
              Total
                Eligibles Enrolled in Plan

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              14.

            	
              Total
                number of Screening Blood Lead Tests

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	 	
              *
                Includes 12-month visit

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 

    

    

    

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    Florida
      Sixty Percent Ratio

    

    
      	 	
              1.

            	
              The
                Child Health Check Up, CMS 416 Report shall be submitted annually
                and in
                the formats as presented in Tables 10 and 10a. The reporting period
                is the
                federal fiscal year. The report is due on January 1, following the
                reporting period. Before October 1 following each reporting period,
                the
                Health Plan shall deliver to the Agency a certification by an Agency
                approved independent auditor that the Child Health Check-Up data
                has been
                fairly and accurately presented. This filing requires a copy of the
                audited reports and a copy of the auditors' letter of
                opinion.

            

    

    

    
      	 	
              2.

            	
              For
                each of the following line items, report total counts by the age
                groups
                indicated. In cases where calculations are necessary, formulas have
                been
                inserted to pre-calculate the field. Report age based
                upon the child's age as of September 30 of the Federal fiscal
                year.

            

    

    

    Medicaid
      Provider ID Number:
      Enter
      the Health Plan's basic seven digit Medicaid Provider ID number, i.e.,
      015----

    

    Plan
      Name:
      Enter
      the name of the Health Plan.

    

    Fiscal
      Year:
      Entered
      is the federal fiscal year being reported.

    

    Line
      1 - Total Individuals Eligible for Child Health Check-Up
      (CHCUP):
      Enter
      the total unduplicated number of all Enrollees under the age of 21 Enrolled
      continuously
      for 8 months,
      distributed by age and by basis of Medicaid Eligibility.
      Unduplicated
      means
      that an Enrollee is reported
      only once
      although
      he or she may have had more than one period of Eligibility during the year.
      All
      Enrollees under age 21 (except MediKids Enrollees) are considered eligible
      for
      CHCUP services, regardless of whether they have been informed about the
      availability of CHCUP services or whether they accept CHCUP services at the
      time
      of informing. Do
      not count MediKids Enrollees.

    

    Line
      2a - State Periodicity Schedules
      -
      Given.

    

    Line
      2b - Number of Years in Age Group
      -
      Given.

    

    Line
      2c - Annualized State Periodicity Schedule
      -
      Given.

    

    Line
      3a - Total Months Eligibility
      - Enter
      the total months of eligibility for the Enrollees in each age group in Line
      1
      during the reporting year.

    

    Line
      3b - Average Period Eligibility
      -
      Calculated by dividing the total months of eligibility by Line 1, then by
      dividing that number by 12. This number represents the portion of the year
      that
      Enrollees remain Medicaid Eligible during the reporting year, regardless of
      whether Eligibility was maintained continuously.

    

    Line
      4 - Expected Number of Screenings per Eligible
      Multiply
      -
      Calculated by multiplying Line 2c by Line 3b. This number reflects the expected
      number of initial or periodic screenings per Child/Adolescent per year based
      on
      the number required by the State-specific periodicity schedule and the average
      period of Eligibility.

    

    Line
      5 - Expected Number of Screenings
      -
      Calculated by multiplying Line 4 by Line 1. This reflects the total number
      of
      initial or periodic screenings expected to be provided to the Enrollees in
      Line
      1.

    

    Line
      6 - Total Screenings Received
      - Enter
      the total number of initial or periodic screens furnished to Enrollees. Use
      the
      CPT codes listed below or any Health Plan-specific CHCUP codes developed for
      these screens. Use
      of these proxy codes is for reporting purposes only.

    

    
      	 	
              3.

            	
              Health
                Plans must continue to ensure that all five age-appropriate elements
                of an
                CHCUP screen, as defined by law, are provided to CHCUP eligible
                Enrollees.

            

    

    

    
      	 	
              4.

            	
              This
                number should not
                reflect sick visits or episodic visits provided to Children/Adolescents
                unless an initial or periodic screen was also performed during the
                visit.
                However, it may reflect a screen outside of the normal State periodicity
                schedule that is used as a "catch-up" CHCUP screening. (A catch-up
                CHCUP
                screening is defined as a complete
                screening that is provided to bring a Child/Adolescent up-to-date
                with the
                State's screening periodicity schedule.) Use data reflecting date
                of service
                within the fiscal year for such screening services or other documentation
                of such services. Do
                not
                count MediKids Enrollees, who have had a check-up. The
                CPT-4 codes to be used to document the receipt of an initial or periodic
                screen are as follows:

            

    

    

    Codes
      for Preventive Medicine Services

    

    99381
      New
      Patient Under One Year

    99382
      New
      Patient Ages 1 - 4 Years

    99383
      New
      Patient Ages 5 - 11 Years

    99384
      New
      Patient Ages 12 - 17 Years

    99385EP
      New
      Patient Ages 18 - 39 Years

    99391
      Established Patient Under One Year

    99392
      Established Patient Ages 1 - 4 Years

    99393
      Established Patient Ages 5 - 11 Years

    99394
      Established Patient Ages 12 - 17 Years

    99395EP
      Established Patient Ages 18 - 39 Years

    99431
      Newborn
      Care - History and Examination

    99432
      Normal
      Newborn Care 

    99435
      Newborn
      Care (history and examination)

    

    Codes
      for Evaluation and Management
      (must be used in conjunction with V codes V20-V20.2 and/or V70.0 and/or
      V70.3-V70.9)

    

    99201-99205
      New
      Patient

    99211-99215
      Established
      Patient

    

    Line
      7 - Screening Ratio
      -
      Calculated by dividing the actual number of initial and periodic screening
      services received (Line 6) by the expected number of initial and periodic
      screening services (Line 5). This ratio indicates the extent to which CHCUP
      eligible Enrollees receive the number of initial and periodic screening services
      required by the State's periodicity schedule, adjusted by the proportion of
      the
      year for which they are Medicaid eligible. This
      ratio should not
      be over 100%. Any data submitted which exceeds 100% will be reflected as 100%
      on
      the final report. The goal ratio is 60% or higher under State
      requirements.

    

    

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    

    Table
      10a

    Child
      Health Check Up Report

     

    
      COMPLETE
        THIS 60% TEMPLATE TO MEET THE 60% SCREENING RATIO PURSUANT TO SECTION 409.912,
        FLORIDA STATUTES AND SECTIONS 10.8.1 AND 60.0, 2004-2006 MEDICAID HMO
        CONTRACT

       

       

      
        	 Enter
                Data in Blue Colored Out-Lined Cells ONLY - This report reflects
                only
                those eligibles that have at least 8 months of continuous enrollment
                -
                State
                Required	 FL
                60% SCREENING RATIO - CHILD HEALTH CHECK-UP REPORT (CHCUP) - 8 MONTHS
                CONTINUOUS ENROLLMENT

      

    

    

    
      	
               

            
	
               

            	
               

            
	 	
              Seven
                Digit Medicaid Provider ID Number :

            	
               

            	
              The
                unaudited report is due to the Agency no later than January
                15.
                The audited report is due October 1.

            
	 	
              Plan
                Name :

            	
               

            	
              F.S.
                409.912 & Section 10.8.1, Medicaid HMO Contract

            
	
               

            	
              Federal
                Fiscal Year :

            	
              October
                1, 2004 - September 30, 2005

            	
              REQUIRED
                FILING

            
	
               

            	
              Age
                Groups

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
               

            	
               

            	
              Less
                than 1 Year

            	
              1-2
                Years *

            	
              3-5
                Years

            	
              6-9
                Years

            	
              10-14
                Years

            	
              15-18
                Years

            	
              19-20
                Years

            	
              Total
                All Years

            
	
              1.

            	
              Total
                Individuals Eligible for CHCUP with 8 months continuous enrollment
                (Unduplicated)

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              2a.

            	
              State
                Periodicity Schedule

            	
              6

            	
              4

            	
              3

            	
              2

            	
              5

            	
              4

            	
              2

            	
              26

            
	
              2b.

            	
              Number
                of Years in Age Group

            	
              1

            	
              2

            	
              3

            	
              4

            	
              5

            	
              4

            	
              2

            	
              21

            
	
              2c.

            	
              Annualized
                State Periodicity Schedule

            	
              6.00

            	
              2.00

            	
              1.00

            	
              0.50

            	
              1.00

            	
              1.00

            	
              1.00

            	
              1.24

            
	
              3a.

            	
              Total
                Months of Eligibility

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              3b.

            	
              Average
                Period of Eligibility

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	
              4.

            	
              Expected
                Number of screenings per Eligible

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            
	 

              5.

            	 

              Expected
                Number of screenings

            	 	 	 	 	 	 	 	 
	 

              6.

            	 

              Total
                Screens Received

            	 	 	 	 	 	 	 	 
	 

              7.

            	 

              Screening
                Ratio - F.S. 409.912 & Section 10.8.1, Medicaid HMO
                Contract

            	 	 	 	 	 	 	 	 

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    

    Q.  Pharmacy
      Encounter Data

     

    Health
      Plans shall submit pharmacy encounter data on an ongoing quarterly payment
      schedule. For example, all claims paid during 04/01/06 and 06/30/06 is due
      to
      the Agency by 07/31/06. The following should be used when submitting the
      data:

    

    
      	1.  	
              Any
                claims paid during the payment period should be submitted within
                30 days
                after the end of the quarter.

            

    

    
      	2.  	
              Only
                the final adjudication of claims should be
                submitted.

            

    

    
      	3.  	
              The
                File Naming Convention is: [health plan abbreviation]_[current date]_[file
                type]_[Production]_[file#]_[total # of files].format. For example:
                ABC_07312006_Rx_Production_1_7.txt

            

    

    
      	4.  	
              The
                files must be accompanied by a field layout and the records must
                have
                carriage-returns and line-feeds for record/file
                separation.

            

    

    
      	5.  	
              All
                Medicaid pharmacy data should be submitted via CD to Bureau of Health
                Systems Development and shall be timely, accurate, complete, and
                certified. Each submission requires a concurrent certification
                letter.

            

    

    
      	6.  	
              The
                minimal data requirements include the Plan ID, Transaction Reference
                number (claim identifier), NDC code, Date of Service (CCYYMMDD),
                Medicaid
                ID as assigned by the state, and Process/payment date
                (CCYYMMDD).

            

    

    
      	7.  	
              The
                format is expected to change to NCPDP as the Agency is developing
                the
                companion guide and the Plans shall conform to this change upon
                notification.

            

    

     

    R.
      Health Plan Benefit Package

    The
      Benefit Grid (Grid) below describes the Health Plan’s Customized Benefit Package
      (CBP). The Health Plan’s CBP must meet actuarial equivalency and sufficiency
      standards for the population or populations which will be covered by the CBP.
      The Health Plan shall submit its CBP for recertification of actuarial
      equivalency and sufficiency standards on an annual basis. 

    

    The
      Grid
      displays the services to be covered and the areas that are customized by the
      Prepaid Health Plan, whether that is co-pays, or the amount, duration or scope
      of the services. The shaded areas indicate that no changes to the services
      in
      that part of the Grid can be changed from the Medicaid fee-for-service coverage
      limits.

    

    If
      the
      Health Plan submits a Benefit Grid with any input cells left blank, that
      indicates the coverage level of the respective benefit is at the fee-for-service
      coverage limits.

    

    If
      the
      CBP includes expanded services, beginning with #10 of the Grid, the Prepaid
      Health Plan must submit additional information with the Grid including projected
      PMPM costs for the target population, as well as the actuarial rationale for
      them. This rationale shall include utilization and unit cost expectations for
      services provided in the benefit.

    

    The
      Health Plan shall submit its CBP for recertification of actuarial equivalency
      and sufficiency standards no later than June 30th
      of each
      year. 

    

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

     

    Health
      Plan:________________________________

    Target
      Population:___________________________

     

     

    All
      Listed Services must be covered for Children and Pregnant Adults
      if medically necessary with no co-pay

    

      
        	 	
                Covered
                  Service Category

              	
                AHCA
                  Standard for Adult Coverage

              	
                Day/Visit
                  Limit

              	
                Limit
                  Period

                (Annual/Monthly)

              	
                Dollar
                  Limit

              	
                Limit
                  Period

                (Annual/Monthly)

              	
                Copay
                  Amount

              	
                Copay
                  Application

              
	
                1

              	
                Hospital
                  Inpatient

              	 	
                45
                  days

              	 	 	 	 	 	 
	 	
                Behavioral
                  Health

              	 	 	 	 	 	 	
                day
                  or admit

              
	 	
                Physical
                  Health

              	 	 	 	 	 	 	
                day
                  or admit

              
	 	
                 

              	 	 	 	 	 	 	 	 
	
                2

              	
                Transplant
                  Services

              	 	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                 

              	 	 	 	 	 	 	 	 
	
                3

              	
                Outpatient Services

              	 	 	 	 	 	 	 	 
	 	
                Emergency
                  Room

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Medical/Drug
                  Therapies (Chemo, Dialysis)

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Ambulatory
                  Surgery - ASC

              	
                all
                  mecially nec.

              	 	 	 	 	 	 
	 	
                Hospital
                  Outpatient Surgery

              	
                all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	
                Independent
                  Lab / Portable X-ray

              	
                all
                  medically nec

              	 	 	 	 	 	
                day

              
	 	
                Hospital
                  Outpatient Services NOS

              	
                sufficiency
                  tested

              	 	 	 	 	 	
                visit

              
	 	
                Outpatient
                  Therapy (PT/RT)

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	
                Outpatient
                  Therapy (OT/ST)

              	
                not
                  applicable

              	 	 	 	 	 	 
	 	
                 

              	 	 	 	 	 	 	 	 
	
                4

              	
                Maternity
                  and Family Planning Services

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Inpatient
                  Hospital

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Birthing
                  Centers

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Physician
                  Care

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Family
                  Planning

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Pharmacy

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	
                5

              	
                Physician
                  and Phys Extender Services (non maternity)

              	 	 	 	 	 	 	 
	 	
                EPSDT

              	
                not
                  applicable

              	 	 	 	 	 	 
	 	
                Primary
                  Care Physician

              	
                all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	
                Specialty
                  Physician

              	
                all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	
                ARNP
                  / Physician Assistant

              	
                 all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	
                Clinic
                  (FQHC, RHC)

              	
                all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	
                Clinic
                  (CHD)

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Other

              	
                 all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	 	 	 	 	 	 	 	 	 
	
                6

              	
                Other
                  Outpatient Professional Services

              	 	 	 	 	 	 	 
	 	
                Home
                  Health Services

              	
                sufficiency
                  tested

              	 	 	 	 	 	
                visit

              
	 	
                Chiropractor

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	
                Podiatrist

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	
                Dental
                  Services

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	
                Vision
                  Services

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	
                Hearing
                  Services

              	
                coverage

              	 	 	 	 	 	
                visit

              
	 	 	 	
                 

              	 	 	 	 	 	 
	
                7

              	
                Outpatient
                  Mental Health

              	
                all
                  medically nec

              	 	 	 	 	 	
                visit

              
	 	 	 	 	 	 	 	 	 	 
	
                8

              	
                Outpatient
                  Pharmacy

              	
                sufficiency
                  tested

              	 	 	 	 	 	 
	 	
                Generic
                  Pharmacy

              	 	 	 	 	 	 	 
	 	
                Brand
                  Pharmacy

              	 	 	 	 	 	 	 
	 	
                 

              	 	 	 	 	 	 	 	 
	
                9

              	
                Other
                  Services

              	 	 	 	 	 	 	 
	 	
                Ambulance

              	
                all
                  medically nec

              	 	 	 	 	 	 
	 	
                Non-emergent
                  Transportation

              	
                all
                  medically nec

              	 	 	 	 	 	
                trip

              
	 	
                Durable
                  Medical Equipment

              	
                 sufficiency
                  tested

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 
	 	
                Additional
                  Services (if applicable)*

              	
                Projected
                  PMPM

              	 	 	 	 	 	 
	
                10

              	 	 	 	 	 	 	 	 	 
	
                11

              	 	 	 	 	 	 	 	 	 
	
                12

              	 	 	 	 	 	 	 	 	 
	
                13

              	 	 	 	 	 	 	 	 	 
	
                14

              	 	 	 	 	 	 	 	 	 
	 	
                *
                  Attach benefit description and supporting documentation.

              	 	 	 	 	 

      

    

     

     

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      S. 
        Transportation Services

    

    1. The
      Health Plan shall report the following encounter data on a quarterly
      basis:

    

    
      	a.  	
              A
                call log broken down by month that includes the following
                information:

            

    

    

    
      	i.  	
              Number
                of calls received;

            

    

    
      	ii.  	
              Average
                time required to answer a call;

            

    

    
      	iii.  	
              Number
                of abandoned calls;

            

    

    
      	iv.  	
              Percentage
                of calls that are abandoned;

            

    

    
      	v.  	
              Average
                abandonment time; and

            

    

    
      	vi.  	
              Average
                call time.

            

    

    

    
      	b.  	
              A
                listing of the total number of reservations of Transportation Services
                by
                month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    
      	i.  	
              Ambulatory
                transportation;

            

    

    
      	ii.  	
              Long
                haul ambulatory transportation;

            

    

    
      	iii.  	
              Wheelchair
                transportation;

            

    

    
      	iv.  	
              Stretcher
                transportation;

            

    

    
      	v.  	
              Ambulatory
                multiload transportation;

            

    

    
      	vi.  	
              Wheelchair
                multiload transportation;

            

    

    
      	vii.  	
              Mass
                transit pending transportation;

            

    

    
      	viii.  	
              Mass
                transit transportation;

            

    

    
      	ix.  	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    
      	x.  	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    

    
      	c.  	
              A
                listing of the total number of authorized uses of Transportation
                Services,
                by month, level of service and percentage of level of service utilized,
                to
                include, but not be limited to, the
                following:

            

    

    

    
      	i.  	
              Ambulatory
                transportation;

            

    

    
      	ii.  	
              Long
                haul ambulatory transportation;

            

    

    
      	iii.  	
              Wheelchair
                transportation;

            

    

    
      	iv.  	
              Stretcher
                transportation;

            

    

    
      	v.  	
              Ambulatory
                multiload transportation;

            

    

    
      	vi.  	
              Wheelchair
                multiload transportation;

            

    

    
      	vii.  	
              Mass
                transit pending transportation;

            

    

    
      	viii.  	
              Mass
                transit transportation;

            

    

    
      	ix.  	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    
      	x.  	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	d.  	
              A
                listing of the total number of canceled trips, by month, level of
                service
                and percentage of level of service utilized, to include, but not
                be
                limited to, the following:

            

    

    

    
      	i.  	
              Ambulatory
                transportation;

            

    

    
      	ii.  	
              Long
                haul ambulatory transportation;

            

    

    
      	iii.  	
              Wheelchair
                transportation;

            

    

    
      	iv.  	
              Stretcher
                transportation;

            

    

    
      	v.  	
              Ambulatory
                multiload transportation;

            

    

    
      	vi.  	
              Wheelchair
                multiload transportation;

            

    

    
      	vii.  	
              Mass
                transit pending transportation;

            

    

    
      	viii.  	
              Mass
                transit transportation;

            

    

    
      	ix.  	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    
      	x.  	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	e.  	
              A
                listing of the total number of denied Transportation Services, by
                month,
                and a detailed description of why the Plan denied the Transportation
                Service request.

            

    

    

    
      	f.  	
              A
                listing of the total number of authorized trips, by facility type,
                for
                each month and level of service.

            

    

    

    
      	g.  	
              A
                listing of the total number of Transportation Service claims and
                payments,
                by facility type, for each month and level of
                service.

            

    

    

    
      	2.  	
              Establish
                a performance measure to evaluate the safety of the Transportation
                Services provided by Participating Transportation Providers. The
                Plan
                shall report the results of the evaluation to the Agency on August
                15th of
                each year;

            

    

    

    
      	3.  	
              Establish
                a performance measure to evaluate the reliability of the vehicles
                utilized
                by Participating Transportation Providers. The Plan shall report
                the
                results of the evaluation to the Agency on August 15th of each year;
                and

            

    

    

    
      	4.  	
              Establish
                a performance measure to evaluate the quality of service provided
                by a
                Participating Transportation Provider. The Plan shall report the
                results
                of the evaluation to the Agency on August 15th of each
                year.

            

    

    

    
      	5.  	
              Certification
                - Each Health Plan/Participating Transportation Provider shall submit
                an
                annual safety and security certification in accordance with 14-90.10,
                F.A.C., 2004 and shall submit to any and all Safety and Security
                Inspections and Reviews in accordance with 14-90.12, F.A.C.,
                2004.

            

    

    

    
      	6.  	
              The
                Plan shall report the following by August 15th
                of
                each year:

            

    

    

    
      	a.  	
              The
                estimated number of one-way passenger trips to be provided in the
                following categories:

            

    

    

    
      	i.  	
              Ambulatory
                transportation;

            

    

    
      	ii.  	
              Long
                haul ambulatory transportation;

            

    

    
      	iii.  	
              Wheelchair
                transportation;

            

    

    
      	iv.  	
              Stretcher
                transportation;

            

    

    
      	v.  	
              Ambulatory
                multiload transportation;

            

    

    
      	vi.  	
              Wheelchair
                multiload transportation;

            

    

    
      	vii.  	
              Mass
                transit pending transportation;

            

    

    
      	viii.  	
              Mass
                transit transportation;

            

    

    
      	ix.  	
              Mass
                transit transportation (Enrollee has pass);
                and

            

    

    
      	x.  	
              Mass
                transit transportation (sent pass to
                Enrollee).

            

    

    

    
      	b.  	
              The
                actual amount of funds expended and the total number of trips provided
                during the previous fiscal year;
                and

            

    

     

    
      	c.  	
              The
                operating financial statistics for the previous fiscal
                year.

            

    

    

    

    

    

    

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T. Enrollee
      Satisfaction Survey Summary

    
      	 	
              a.

            	
              In
                all
                areas in which the Health Plan provides Behavioral Health
                Services,
                the Health Plan shall conduct a Behavioral Health Services Enrollee
                Satisfaction Survey in both English and
                Spanish.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall report the Enrollee Satisfaction Survey Summary
                to the
                Agency in accordance with the requirements set forth in Table 9,
                Enrollee
                Satisfaction Survey Summary, below.

            

    

    

    Table
      12

    

    Enrollee
      Satisfaction Survey Summary

    

    
      	
              Number
                of surveys distributed

            	 
	
              Number
                of surveys completed

            	 
	
              Method
                used 

            	 
	
              
                Number
                  of Responses for each item on the survey

              

               

            

    

    

    
      	
              Item
                Numbers

            	
              Agree

            	
              Disagree

            	
              No
                Response

            
	
              1

            	 	 	 
	
              2

            	 	 	 
	
              3

            	 	 	 
	
              4

            	 	 	 
	
              5

            	 	 	 
	
              6

            	 	 	 
	
              7

            	 	 	 
	
              8

            	 	 	 
	
              9

            	 	 	 
	
              10

            	 	 	 
	 	 	 	 
	
               

              Significant
                findings or results that will be addressed: 

               

            
	 
	 
	 
	 
	 

    

    

    

    

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    
U.  Stakeholders’
      Satisfaction Survey Summary

    
 

    
      	 	
              a.

            	
              The
                Health Plan shall submit to the Agency the results of a Stakeholders’
                Satisfaction Survey Summary. 

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan shall report the results from the survey in accordance
                with
                Table 10, Stakeholders’ Satisfaction Survey Summary,
                below.

            

    

    

    Table
      13

    

    Stakeholders
      Satisfaction Survey Summary

    

    
      	
              Types
                of Stakeholders Surveyed

            	
              DCF

              Counselors

            	
              Community
                Based Care Providers

            	
              Foster
                Parents

            	
              Consumer
                Advocacy Groups

            	
              Parents
                of SED Children

            	
              Out-of-Plan
                Providers (specify)

            	
              Others

            
	
               

              Number
                of Surveys Distributed

               

            	 	 	 	 	 	 	 
	
               

              Number
                of surveys completed in each type

               

            	 	 	 	 	 	 	 
	
               

              Method
                used for distribution

               

            	 	 	 	 	 	 	 

    

    

    

    
      	
              Summary
                of Responses:

               

               

            
	
              Significant
                findings or results that will be addressed:

               

               

            

    

    

     

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      V.
        Behavioral Health Services Grievance and Appeals Reporting
        Requirements

    

    

    See
      C.
      Grievance System of this section, Section XII.

    

    W. 
Critical
      Incident Reporting

     

    
      	 	
              a.

            	
              For
                Providers and providers under contract with DCF, the State’s operating
                procedures for incident reporting and client risk protection establishes
                departmental procedures and guidelines for reporting information
                related
                to the incidents specified in this Section. See CF Operating Procedure
                No.
                215-6, November 1, 1998.

            

    

    

    
      	 	
              b.

            	
              The
                critical incident reporting requirements set forth in this section
                do not
                replace the abuse, neglect and exploitation reporting system established
                by the State. Additionally, the Health Plan must report to the Agency
                in
                accordance with the format in Table 14, Critical Incidents Summary,
                and
                Table 14-A, Critical Incident Individual,
                below.

            

    

    

    
      	 	
              c.

            	
              The
                definitions of reportable critical incidents apply to the Health
                Plan,
                Providers (participating and non-participating) and any
                subcontractees/delgatees providing services to
                Enrollees.

            

    

    

    
      	 	
              d.

            	
              The
                Health Plan shall report the following events immediately to the
                Agency,
                in accordance with the format set forth in Table 10-A, Critical Incident
                Individual, below:

            

    

    

    (1) Death
      of
      an Enrollee due to one (1) of the following:

    

    (a) Suicide;

    

    (b) Homicide;

    

    (c) Abuse;

    

    (d) Neglect;
      or

    

    
      	 	
              (e)

            	
              An
                accident or other incident that occurs while the Enrollee is in a
                facility
                operated or contracted by the Health Plan or in an acute care
                facility.

            

    

    

    
      	 	
              (2)

            	
              Enrollee
                Injury or Illness - A medical condition that requires medical treatment
                by
                a licensed health care professional and which is sustained, or allegedly
                is sustained, due to an accident, act of abuse, neglect or other
                incident
                occurring while an Enrollee is in a Facility operated or contracted
                by the
                Health Plan or while the Enrollee is in an acute care
                facility.

            

    

    

    
      	 	
              (3)

            	
              Sexual
                Battery - An allegation of sexual battery, as determined by medical
                evidence or law enforcement involvement, by:

            

    

    

    (a) An
      Enrollee on another Enrollee;

    

    
      	 	
              (b)

            	
              An
                employee of the Health Plan, a provider or a subcontractee, an Enrollee;
                and/or 

            

    

    

    
      	 	
              (c)

            	
              An
                Enrollee on an employee of the Health Plan, a provider or a
                subcontractee.

            

    

    

    
      	 	
              e.

            	
              The
                Health Plan shall immediately report to the Agency, in accordance
                with the
                format in Table 14-A, Critical Incident Individual, below, if one
                (1) or
                more of the following events occur:

            

    

    

    (1) Medication
      errors in an acute care setting; and/or

    

    
      	 	
              (2)

            	
              Medication
                errors involving Children/Adolescents in the care or custody of DCF.
                

            

    

    

    
      	 	
              f.

            	
              The
                Health Plan shall report monthly to the Agency, in accordance with
                the
                format in Table 14 Critical Incidents Summary, below, a summary of
                all
                critical incidents.

            

    

    

    
      	 	
              g.

            	
              In
                addition to supplying a quarterly Critical Incidents Summary, the
                Health
                Plan shall also report Critical Incidents in the manner prescribed
                by the
                appropriate district’s DCF Alcohol, Drug Abuse Mental Health office, using
                the appropriate DCF reporting forms and
                procedures.

            

    

    

     

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    Table
      14

    

    Critical
      Incidents Summary

    

    
      	
              Incident
                Type

            	
              # of
                Events

            
	
              Enrollee
                Death - Suicide

            	 
	
              Enrollee
                Death - Homicide

            	 
	
              Enrollee
                Death - Abuse/Neglect

            	 
	
              Enrollee
                Death - other

            	 
	
              Enrollee
                Injury or Illness

            	 
	
              Sexual
                Battery

            	 
	
              Medication
                Errors - acute care

            	 
	
              Medication
                Errors - children

            	 
	
              Enrollee
                Suicide Attempt

            	 
	
              Altercations
                requiring Medical Interventions

            	 
	
              Enrollee
                Escape

            	 
	
              Enrollee
                Elopement

            	 
	
              Other
                reportable incidents

            	 
	
              Total

            	 

    

    

    

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    Table
      14-A

    

    Critical
      Incident Individual

    

    
      	
               

              Enrollee
                Medicaid ID#:

            	 
	
               

              Date
                of Incident:

            	 
	
               

              Location
                of Incident:

            	 
	
               

              Critical
                Incident Type:

            	 
	
               

              Details
                of Incident: (Include
                enrollee’s age, gender, diagnosis, current medication, source of
                information, all reported details about the event, action taken by
                Health
                Plan or provider, and any other pertinent information)

            	 
	
               

              Follow
                up planned or required: (Include
                information related to any Health Plan or provider protocol that
                applies
                to event.)

            	 
	
               

              Assigned
                provider:

            	 
	
               

              Report
                submitted by:

            	 
	
               

              Date
                of submission:

            	 

    

    

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      X. 
        Required Staff/Providers

    

    

    The
      Health Plan shall submit contracted and subcontracted staffing information
      by
      position, name and FTE for all direct service positions on a quarterly basis
      in
      accordance with the format of Table 15 below.

    

    

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    Table
      15

    Required
      Staff/Providers

    

    
      	 	 	
              Non-Clinical
                Specialties

            	
              Therapeutic
                Specialty Areas With 2 Years Clinical
                Experience

            
	
              Positions

            	
              Total

            	
              Bi-Lingual

            	
              Expert
                Witness

            	
              Court
                Ordered Evals

            	
              Adoption/

              Attachment
                Issues

            	
              Post
                Traumatic Stress Syndrome

            	
              Dual
                Diagnosis (Mental Disorder/ Substance Abuse)

            	
              Gender/
                Sexual Issues

            	
              Geriatrics/
                Aging Issues

            	
              Separation,
                Grief & Loss

            	
              Easting
                Disorders

            	
              Adolescent/
                Children’s Issues

            	
              Sexual
                / Physical Abuse 

              —Child

            	
              Sexual
                Physical Abuse 

              —
                Adult

            	
              Domestic
                Violence

              —
                Child

            	
              Domestic
                Violence 

              —
                Adult

            
	
              Adult
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Child
                Psychiatrists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Other
                Physicians

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychiatric
                ARNPs

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Psychologists

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Master
                Level Clinicians (LCSW, LMFT, LMHC, MFCC)_

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Bachelor
                Level

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              RN

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
              Unduplicated
                Totals

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

    

     

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    
Y.  FARS/CFARS

     

    The
      reports shall be submitted in accordance with the format of Table 16 and 16-A
      below.

    

    

    
      	
              Table
                16

              FARS/CFARS
                Reporting

            
	
               

              O***YY06.txt
                (January through June, due August 15) OR

               

            
	
               

              O***YY12.txt
                (July through December, due February 15)

               

            
	
              Data
                Element Name

            	
               

              Length

            	
               

              Start
                Column

            	
              End
                Column

            	
               

              Description

            
	
               

              Recipient
                ID

            	
               

              9

            	
               

              1

            	
               

              9

            	
               

              9-Digit
                Medicaid ID Number of plan member

            
	
               

              Recipient
                DOB

            	
               

              10

            	
               

              10

            	
               

              19

            	
               

              Plan
                member’s date of birth (MM/DD/CCYY)

            
	
               

              Provider
                ID

            	
               

              9

            	
               

              20

            	
               

              28

            	
               

              9-Digit
                Medicaid HMO ID Number

            
	
               

              Assessment
                Type

            	
               

              1

            	
               

              29

            	
               

              29

            	
               

              Designate
                the type of functional assessment that was done using “F: for FARS or “C”
                for CFARS

            
	
               

              Initial
                Date

            	
               

              10

            	
               

              30

            	
               

              39

            	
               

              Date
                of initial assessment (MM/DD/CCYY)

            
	
               

              Initial
                Score

            	
               

              2

            	
               

              40

            	
               

              41

            	
               

              Initial
                overall assessment score

            
	
               

              6
                Month Date

            	
               

              10

            	
               

              42

            	
               

              51

            	
               

              Date
                of 6 month assessment, if applicable** (MM/DD/CCYY)

            
	
               

              6
                Month Score

            	
               

              2

            	
               

              52

            	
               

              53

            	
               

              6
                month overall assessment score, if applicable**

            
	
               

              Discharge
                Date

            	
               

              10

            	
               

              54

            	
               

              63

            	
               

              Date
                of Discharge (MM/DD/CCYY)

            
	
               

              Discharge
                Score

            	
               

              2

            	
               

              64

            	
               

              65

            	
               

              Overall
                assessment score at discharge

            
	 	 	 	 	 
	
               

              **
                Note: Discharge date may occur prior to the 6 month
                assessment.

               

            

    

    

    

    

    Placeholder
      for Table 16-A, Summary FARS/CFARS Outcomes and Trending
      Report

     

    

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    
Z.
Behavioral
      Health Encounter Report

    
The
      Behavioral Health encounter data shall be reported in the format given in Table
      17, below. The following should be used when completing the report.

    

    1. Diagnostic
      Criteria

    All
      provider claims are restricted to claims for beneficiaries with an ICD-9CM
      diagnosis code of 290 through 290.43; 293 through 298.9; 300 through 301.9;
      302.7, 306.51 through 312.4; 312.81 through 314.9; 315.3, 315.31, 315.5, 315.8,
      and 315.9.

    

    2. Provider
      and Coding Criteria

    a. General
      Hospital Services - Provider Type 01, Claim Input Indicator “I”

    Use
      Revenue Codes 0114, 0124, 0134, 0144, 0154, or 0204 on the UB-92 or
      837-I

    

    
      	 	
              b.

            	
              Hospital
                Outpatient Services - Provider Type 01, Claim Input Indicator
                “O”

            

    

    Use
      Revenue Center Codes 0450, 0513, 0901, 0914, or 0918
      on
      the UB-92 or 837-I

    

    3. Community
      Mental Health Services

    

    Provider
      Type - 05, Community Alcohol, Drug and Mental Health, or 

    Provider
      Type - 07, Mental Health Practitioner

    Both
      are
      Claim Input Indicator “J”

    

    Use
      Procedure code H0001; H000lHN; H0001H0; H0001TS; H0031; H0031 HO; H003lHN;
      H0031TS; H0032; H0032TS; H0046; H0047; H2000; H2000HO; H2000HP;
      H2010HO;
      H2010HE; H2010HF; H2010HQ; H2012; H2012HF; H2017; H2019; H2019HM; M2019HN;
      H2019HO; H2019HQ; H2019HR; H2030; T1007; T1007TS; T1015; T1015HE; T1015HF;
      Tl023HE; or T1023HF 

    

    
      	 	
              4.

            	
              Physician
                Services - Provider Type 25 (MD) or 26 (DO) with a specialty code
                of
                "42"Psychiatrist, "43”Child Psychiatrist, or "44"
                Psychoanalysis

            

    

    

    All
      claims submitted by these specialists apply

    

    
      	 	
              5.

            	
              Advanced
                Nurse Practitioner Provider Type 30 (ARNP) with a specialty Code
                of “76” -
                Clinical Nurse Specialist.

            

    

    

    All
      claims submitted by these specialists apply

    

    6. Case
      Management Agency - Provider Type 91 

    

    Procedure
      code T1017 (Targeted Case Management for Adults); T1017HA (Targeted Case
      Management for Children (birth through 17); and T1017HK (Intensive Team Targeted
      Case Management, Adults 18 an over).

    

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    Table
      17

    Behavioral
      Health Encounter Data

    

      
        	
                Field
                  Name

              	
                Field
                  Length

              	
                Comments

              
	
                Medicaid
                  ID

              	
                9

              	
                First
                  9 digits of the Enrollee ID number 

              
	
                Plan
                  ID

              	
                9

              	
                9
                  digit Medicaid ID of the Health Plan in which Enrollee was Enrolled
                  on the
                  first date of service

              
	
                Service
                  Type

              	
                1

              	
                I Hospital
                  Inpatient

                C CSU

                O Hospital
                  Outpatient

                P Physician
                  (MD or DO)

                A Advanced
                  Nurse Practitioner, ARNP

                H Comm.
                  Mental Health, Mental Health Practitioner

                T Targeted
                  Case Management

                L Locally
                  Defined or Optional Service

              
	
                First
                  Date of Service

              	
                8

              	
                For
                  Inpatient and CSU encounters, this equals the admit date. Use YYYYMMDD
                  format.

              
	
                Revenue
                  Code

              	
                4

              	
                Use
                  only for Hospital Inpatient and Hospital Outpatient
                  Encounters

              
	
                Procedure
                  Code

              	
                5

              	
                5
                  digit CPT or HCPCS Procedure Code (For Inpatient Claims only, use
                  the
                  ICD9-CM Procedure Code.) 

              
	
                Procedure
                  Modifier 1

              	
                2

              	 
	
                Procedure
                  Modifier 2

              	
                2

              	 
	
                Units
                  of Service

              	
                3

              	
                For
                  Inpatient and CSU encounters, report the number of covered days.
                  For all
                  other encounters, use the units of service referenced in the appropriate
                  Medicaid Coverage and Limitations Handbook.

              
	
                Diagnosis

              	
                6

              	
                Primary
                  Diagnosis Code

              
	
                Provider
                  Type

              	
                1

              	
                1 M.D.

                2 D.O.

                3 A.R.N.P.

                4 P.A.

                5 Community
                  Mental Health Center

                6 Licensed
                  Psychologist, LCSW, LMFT, LMHC

                7 Other

              
	
                Provider
                  ID Type

              	
                1

              	
                Type
                  of unique identifier for the direct service provider:

                A
                  =
                  AHCA ID 

                M
                  =
                  Medicaid Provider ID

                L
                  =
                  Professional License Number

              
	
                Provider
                  ID

              	
                9

              	
                Unique
                  identifier for the direct service provider

              
	
                Amount
                  Paid

              	
                10

              	
                Costs
                  associated with the claim. Format with an explicit decimal point
                  and 2
                  decimal places but no explicit commas. Optional.

              
	
                Run
                  Date

              	
                8

              	
                The
                  date the file was prepared. Use YYYYMMDD format

              
	
                Claim
                  Reference Number

              	
                25

              	
                The
                  Health Plan’s internal unique claim record
                  identifier

              

      

    

    
      
        
          
            

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
            

          

        

      

    

    

    

    AA. Minority
      Participation Report

    

    The
      Agency for Health Care Administration encourages the Vendor to use Minority
      and
      Certified Minority businesses as subcontractors when procuring commodities
      or
      services to meet the requirement of this Contract.

    

    The
      Agency requires information regarding the Vendor’s use of minority owned
      businesses as subcontractors under this contract. This information will be
      used
      for assessment and evaluation of the Agency’s Minority Business Utilization
      Plan. During the term of the contract, it will be necessary to provide this
      information monthly by the 15th
      of each
      subsequent month. A minority owned business is defined as any business
      enterprise owned and operated by the following ethnic groups: African
      American (Certified Minority Code H or Non-Certified Minority Code N), Hispanic
      American (Certified Minority Code I or Non-Certified Minority O), Asian American
      (Certified Minority Code J or Non-Certified Minority Code P), Native American
      (Certified Minority Code K or Non-Certified Minority Code Q), or American Woman
      (Certified Minority Code M or Non-Certified Minority Code R). This
      requirement can be waived by the agency if the plan demonstrates that it is
      either at least 51 percent minority owned, at least 51 percent of its board
      of
      directors are a minority, at least 51 percent of its officers are a minority,
      or
      if the plan is not for profit corporation and at least 51 percent of the
      population it serves belong to a minority.

    

    The
      Vendor is required to provide the following information on company
      letterhead:

    

    1) Minority
      subvendor's company name and Minority Code (see above); 

    
      	 	
              2)

            	
              Services
                subcontracted related to this
                Contract;

            

    

    
      	 	
              3)

            	
              Dates
                of services (beginning and ending);

            

    

    
      	 	
              4)
                

            	
              Total
                dollar amount paid to subvendor for services related to this Contract;
                or

            

    

    
      	 	
              5)

            	
              A
                statement that no minority subvendors were used during this
                period.

            

    

    

    

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    Section
      XIII

    Method
      of Payment

    

    
      	
              A.

            	
              Payment
                Overview. This
                is a fixed price (unit cost) Contract. The Agency will manage this
                fixed
                price Contract for the delivery of Covered Services to Enrollees.
                The
                Agency or its Fiscal Agent shall make payment to the Health Plan
                on a
                monthly basis for the Health Plan’s satisfactory performance of its duties
                and responsibilities as set forth in this Contract. To accommodate
                payments, the Health Plan is enrolled as a Medicaid provider with
                the
                Fiscal Agent. Payments
                made to the Health Plan resulting from this Contract include monthly
                Capitation Rate payments for either a Comprehensive Component or
                a
                Comprehensive Component and Catastrophic Component, both of which
                contain
                risk adjustments, and were developed for particular Medicaid populations,
                and may contain an adjustment to collect amounts for the Enhanced
                Benefit
                Accounts fund. The Agency may also pay Health Plans for obstetrical
                delivery and transplant services through Kick Payments; for Covered
                Services that are over the Catastrophic Component Threshold, if the
                Health
                Plan has contracted for the Comprehensive Component only; and for Child
                Health Check-Up (CHCUP) incentive payments, if any, as specified
                below.
                

            

    

    

    B. Capitation
      Rate Payments

    

     

    
      	1.  	
              The
                Agency’s Capitation Rate payments shall meet the following
                requirements:

            

    

     

    
      	a.  	
              Medicaid
                Reform Capitation Rates will begin with the September 1, 2006 Capitation
                Rate payments. 

            

    

    (1) For
      the
      first (1st)
      two (2)
      years of Medicaid Reform, the Health Plan’s Risk-Adjusted Capitation Rates (for
      the Children and Families and Aged and Disabled Enrollee population) will
      consist of two (2) components for the eligibility categories listed in Tables
      2
      and 3 in Attachment I. The two components are: a current Capitation Rate
      methodology component and a Risk-Adjusted Capitation Rate methodology component.
      

     

    (2) For
      SSI
      Medicare Part B Only Enrollees and SSI Medicare Parts A and B Enrollees, the
      Capitation Rates are based on the current Capitation Rate methodology for the
      age groups listed in Table 4 in Attachment I.

     

    (3) For
      Enrollees diagnosed with HIV/AIDS and for Children with Chronic Conditions,
      the
      Capitation Rates are fully Risk-Adjusted. 

     

    
      	 	
              (a)

            	
              The
                Agency will pay the Health Plan the HIV/AIDS Capitation Rate only
                for
                those Enrollees who have been identified and verified as having an
                HIV/AIDS diagnosis. The HIV/AIDS Capitation Rate is provided in the
                Capitation Rate Table 5 in Attachment I.

            

    

     

    (i) The
      Agency will pay the HIV/AIDS Capitation Rate for those Enrollees who have been
      identified as having an HIV/AIDS diagnosis, regardless of whether or not the
      Health Plan is a Specialty Plan.

     

    (ii) Enrollees
      with an HIV/AIDS diagnosis may be identified by either the Agency or the Health
      Plan. For the Health Plan to identify that an Enrollee has an HIV/AIDS
      diagnosis, the Health Plan must have completed lab testing as interpreted by
      a
      licensed physician prior to reporting the Enrollee to the Agency as an
      identified Enrollee with an HIV/AIDS diagnosis. The Health Plan must provide
      the
      Agency with such Enrollee’s test results upon request.

     

    (iii) The
      Health Plan may submit Enrollees identified with an HIV/AIDS diagnosis to the
      Agency in a format and transmittal method approved by the Agency.

     

    (iv) The
      Agency shall not pay the HIV/AIDS Capitation Rate for any Enrollee who was
      not
      identified as HIV/AIDS prior to Enrollment processing for the month for which
      the capitation payment is made, nor shall the Agency make a retroactive
      capitation payment at the HIV/AIDS Capitation Rate if the Enrollee was
      identified as HIV/AIDS after Enrollment processing.

     

    
      	 	
              (b)

            	
              The
                Agency will pay the Health Plan the Capitation Rate for Children
                with
                Chronic Conditions only if the Enrollee meets the requirements for
                the
                Children with Chronic Conditions and is enrolled in a Specialty Plan
                for
                for Children with Chronic Conditions based on the rates specified
                in Table
                6. 

            

    

     

     

    
      	b.  	
              For
                each eligibility category indicated, and for each age group indicated,
                the
                Agency will make a capitation payment for Enrollees as provided for
                in the
                Capitation Rate tables in Attachment I and as described below.
                

            

    

     

    (1) For
      Enrollees who are in the Children and Families and the Aged and Disabled
      eligibility categories, not identified as diagnosed with HIV/AIDS and not
      enrolled in a Specialty Plan as identified Children with Chronic Conditions,
      their Capitation Rates are provided in Capitation Rate Tables 2 and 3 of
      Attachment I. The columns in Capitation Rate Tables 2 and 3 of Attachment I
      are
      defined below: 

     

    
      	 	
              (a)

            	
              Age
                ranges for the eligibility categories for which the Capitation Rates
                are
                calculated.

            

    

     

    
      	 	
              (b)

            	
              Contract
                Year 2006-2007 Medicaid Reform rates under current Capitation Rate
                methodology.

            

    

     

    
      	 	
              (c)

            	
              Percentage
                of current methodology used for determining
                rates.

            

    

     

    
      	 	
              (d)

            	
              Current
                methodology capitation amount (component) based on the percentage
                of
                current methodology Capitation Rates
                used.

            

    

     

    
      	 	
              (e)

            	
              Preliminary
                base rate for Contract Year Risk-Adjusted methodology with Enhanced
                Benefit adjustment. The Enhanced Benefit adjustment is a per Health
                Plan
                percentage amount that is deposited into the Enhanced Benefit Accounts
                fund (see also subsection F.2. of this Attachment).
                

            

    

     

    
      	 	
              (f)

            	
              Budget
                neutrality factor: an actuarially-derived factor to ensure that aggregate
                costs do not increase or decrease.

            

    

     

    
      	 	
              (g)

            	
              Base
                rates for Risk-Adjusted Methodology after Budget Neutrality: Capitation
                amount based on the percentage of Risk-Adjusted methodology Capitation
                Rates used multiplied by the budget neutrality factor
                (f).

            

    

     

    
      	 	
              (h)

            	
              Percentage
                of Risk-Adjusted methodology used for determining rates (the Agency’s
                Risk-Adjusted Capitation Rate methodology is based on eligibility,
                claims
                and encounter data).

            

    

     

    
      	 	
              (i)

            	
              25%
                of Risk Adjusted Methodology: The capitation amount based on the
                percentage of Risk-Adjusted methodology (h) multiplied by the Base
                Rates
                column for Risk-Adjusted methodology after budget neutrality factor
                (g).

            

    

     

    
      	i.  	
              The
                Agency assigns the Health Plan a Risk-Adjusted Plan Factor which
                designates the aggregated risk of the Health Plan’s enrolled population.
                

            

    

     

    
      	ii.  	
              During
                the first (1st)
                two (2) Contract years, the Health Plan’s Risk-Adjusted Plan Factor will
                not vary more than ten percent (10%) from the aggregate weighted
                mean of
                all Medicaid Reform Health Plans within the same Service Area for
                the
                respective eligibility categories. 

            

    

     

    
      	 	
              (j)

            	
              Final
                Rate (with Enhanced Benefit Adjustment): The current methodology
                capitation amount (d) added to the 25% of Risk-Adjusted methodology
                amount
                (i). The final rate provided in Attachment I is an estimate based
                on a
                Plan Factor of 1.0. Note: The actual final monthly Capitation Rate(s)
                paid
                to the Health Plan will be based on the Health Plan’s actual Plan Factor
                and reduced by the actual percentage deducted to fund the Enhanced
                Benefit
                Accounts.

            

    

     

    (2) For
      Enrollees who in the SSI Medicare Part B Only and the SSI Medicare Parts A
      and B
      eligibility categories, and who are not identified as diagnosed with HIV/AIDS
      or
      enrolled in a Specialty Plan as identified Children with Chronic Conditions
      Enrollees, their Capitation Rates are provided in Table 4 of Attachment I.
      

     

    (3) For
      Enrollees who are identified as diagnosed with HIV/AIDS, their Capitation Rates
      are provided in Table 5 of Attachment I. 

     

    
      	 	
              (i)

            	
              HIV/AIDS
                Specialty Plan Enrollees who are family members of Enrollees identified
                as
                diagnosed with HIV/AIDS, and who are not identified as diagnosed
                with
                HIV/AIDS, will receive a Capitation Rate based on their respective
                eligibility categories in Capitation Rate Tables 2 or 3 in Attachment
                I.
                In developing the capitation rates for these family members, a Plan
                Factor
                of 1.0 will be assigned until the Agency determines that the Health
                Plan
                has enough of population of such Enrollees as to warrant its own
                Plan
                Factor.

               

            

    

    (4) For
      Enrollees who are in the Children with Chronic Conditions Speciality Plan,
      their
      Capitation Rates are provided in Table 6 of Attachment I. Sibling Enrollees
      who
      are enrolled in the Children with Chronic Conditions Speciality Plan, and are
      not identified as Children with Chronic Conditions, will receive a Capitation
      Rate based on their respective eligibility categories in Capitation Rate Tables
      2 or 3 in Attachment I. In developing the capitation rates for these family
      members, a Plan Factor of 1.0 will be assigned until the Agency determines
      that
      the Health Plan has enough of population of such Enrollees as to warrant its
      own
      Plan Factor.

     

    
      	 	
              c.

            	
              The
                Risk-Adjusted Capitation Rates paid by the Agency are either for
                the
                Comprehensive Component or Comprehensive Component and Catastrophic
                Component as specified below. 

            

    

     

    
      	(1)  	
              Health
                Plans are required to provide the Comprehensive Component and the
                Catastrophic Component to Enrollees in the following
                manner:

            

    

     

    
      	 	
              (a)

            	
              For
                Contracts serving Broward County and/or Duval County, Health Plans
                that
                are not Capitated PSNs are required to provide both the Comprehensive
                Component and Catastrophic Components. This means that the Health
                Plan is
                responsible for the cost of providing Covered Services up to the
                Benefit
                Maximum determined by the Agency for the Contract Year.
                

            

    

     

    
      	 	
              (b)

            	
              For
                Contracts serving Broward County and/or Duval County, Health Plans
                that
                are Capitated PSNs must provide the Comprehensive Component and may
                choose
                to provide the Catastrophic Component. The Capitated PSN’s choice will be
                documented in Attachment I. 

            

    

     

    i. If
      the
      Capitated PSN has chosen to provide both the Comprehensive Component and the
      Catastrophic Component, the Health Plan is responsible for the cost of providing
      Covered Services up to the Benefit Maximum determined by the Agency for the
      Contract Year. 

     

    ii. If
      the
      Capitated PSN has chosen to provide the Comprehensive Component only, the Health
      Plan is responsible for the cost of providing Covered Services up to the
      Catastrophic Component Threshold by the Agency for the Contract Year. Such
      a
      Health Plan will receive reimbursement from the Agency for its costs beyond
      the
      Catastrophic Threshold up to the Benefit Maximum in accordance with Subsection
      D. 

     

    
      	 	
              (c)

            	
              For
                Contracts serving Baker County, Clay County and/or Nassau County,
                the
                Health Plan is required to provide the Comprehensive Component and
                may
                choose to provide the Catastrophic Component to its Enrollees in
                those
                counties. 

            

    

     

    i. If
      by
      this Contract, as specified in Attachment I, the Health Plan has agreed to
      provide both the Comprehensive Component and the Catastrophic Component, then
      the Health Plan is responsible for the cost of providing the Enrollee with
      Covered Services up to the Benefit Maximum determined by the Agency for the
      Contract Year. 

     

    ii. If
      by
      this Contract, as specified in Attachment I, the Health Plan has agreed to
      provide the Comprehensive Component only, then the Health Plan is financially
      responsible for the provision of Covered Services up to the Catastrophic
      Component Threshold determined by the Agency for the Contract Year.

     

    (2) For
      purposes of calculating whether an Enrollee has met the Catastrophic Component
      Threshold and the Benefit Maximum, a Health Plan’s costs will be converted to
      the Medicaid Fee-for-Service payment levels as indicated in subsection D. below.
      For services covered by the Health Plan for which there is no Medicaid fee,
      the
      Agency will use the amount the Health Plan paid for the service. Upon the
      Agency’s request, the plan shall provide documentation to validate payment and
      services rendered. In addition, if the Health Plan receives payment from the
      Agency for Kick Payment services, the Kick Payment made by the Agency will
      be
      included toward the Catastrophic Component Threshold and toward the Benefit
      Maximum.

     

    (3) Health
      Plans will be paid Capitation Rates for the Comprehensive Component and the
      Catastrophic Component or for the Comprehensive Component only, in accordance
      with whether the Health Plan agreed, by this Contract, to provide both the
      Comprehensive Component and Catastrophic Component or to provide only the
      Comprehensive Component. 

     

    2. The
      Agency’s Capitation Rates are included as Attachment I,
      titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY
      CMS.”
      The
      Agency may use, or may amend and use these rates, only after certification
      by
      its actuary and approval by the Centers for Medicare and Medicaid Services.
      Inclusion of these rates is not intended to convey or imply any rights, duties
      or obligations of either party, nor is it intended to restrict, restrain or
      control the rights of either party that may have existed independently of this
      Section of the Contract. 

     

    

    
      	 	
              a.

            	
              By
                signature on this Contract, the parties explicitly agree that this
                Section
                shall not independently convey any inherent rights, responsibilities
                or
                obligations of either party, relative to these rates, and shall not
                itself
                be the basis for any cause of administrative, legal or equitable
                action
                brought by either party. In the event that the rates certified by
                the
                actuary and approved by CMS are different from the rates included
                in this
                Contract, the Health Plan agrees to accept a reconciliation performed
                by
                the Agency to bring payments to the Health Plan in line with the
                approved
                rates. The Agency may amend and use the CMS-approved rates by notice
                in a
                Contract amendment to the Health Plan.

            

    

    

    
      	 	
              b.

            	
              Upon
                receipt of CMS approval of the September 1, 2006 - August 31, 2007
                Capitation Rates (remainder of the 2006-2007 Contract year), the
                Agency
                shall amend this Contract to reflect CMS-approved and actuarially
                certified Capitation Rates effective September 1, 2006. The Health
                Plan’s
                Capitation Rates for this Contract period (September 1, 2006 - August
                31,
                2007) will be weighted so that seventy-five percent (75%) is based
                on
                current Capitation Rate methodology and twenty-five percent (25%)
                is based
                on the Risk-Adjusted Capitation Rate
                methodology.

            

    

    

    
      	 	
              c.

            	
              Upon
                CMS approval of the September 1, 2007 - August 31, 2008 Capitation
                Rates,
                the Agency shall amend this Contract to reflect CMS-approved and
                actuarially certified Capitation Rates effective September 1, 2007.
                The
                Health Plan’s Capitation Rates for the September 1, 2007 - August 31, 2008
                Contract Year will be weighted so that fifty percent (50%) is based
                on
                current Capitation Rate methodology and fifty percent (50%) is based
                on
                the Risk-Adjusted Capitation Rate
                methodology.

            

    

    

    
      	 	
              d.

            	
              Upon
                CMS approval of the September 1, 2008 - August 31, 2009 Capitation
                Rates,
                the Agency shall amend this Contract to reflect CMS-approved and
                actuarially certified Capitation Rates effective September 1, 2008.
                The
                Health Plan’s Capitation Rates shall be fully Risk-Adjusted for the
                September 1, 2008 - August 31, 2009 Contract
                Year.

            

    

    

    3. The
      Agency shall pay the applicable Capitation Rate for each Enrollee whose name
      appears on the ONGOING REPORT (FLMR 8200-R004) and the REINSTATEMENT
      REPORT
      (FLMR
      8200-R009) for each month, except that the Agency shall not pay for, and, in
      accordance with subsections F. and G. of this Attachment, shall recoup payment
      for, any part of the total Enrollment that exceeds the maximum authorized
      Enrollment level(s) expressed in this Contract in Attachment I. The total
      payment amount to the Health Plan shall depend on the number of Enrollees in
      each eligibility category and each rate group, and whether the Health Plan
      is
      providing the Comprehensive Component only or the Comprehensive Component and
      the Catastrophic Component, and at a rate that has been Risk-Adjusted pursuant
      to this Contract, or as adjusted pursuant to the Contract, where necessary
      in
      accordance with subsection F. of this Attachment. 

    

    
      	 	
              a.

            	
              The
                Health Plan is obligated to provide services pursuant to the terms
                of this
                Contract for all Enrollees for whom the Health Plan has received
                capitation payment or for whom the Agency has assured the Health
                Plan that
                the capitation payment is
                forthcoming.

            

    

    

    
      	 	
              b.

            	
              To
                ensure a seamless health care delivery system for the Enrollee, if
                the
                Health Plan contracts for the Comprehensive Component only, the Health
                Plan continues to be responsible for coordinating, managing, and
                delivering all Enrollee care up to the Benefit Maximum regardless
                of
                whether the cost of the Enrollee’s Covered Services is above and beyond
                the Catastrophic Component
                Threshold.

            

    

    

    
      	 	
              c.

            	
              Regardless
                of whether the Health Plan is at risk for the Comprehensive Component
                only
                or for both the Comprehensive Component and the Catastrophic Component,
                the Health Plan continues to be responsible for the coordinating
                and
                managing all Enrollee care even if the cost of the Enrollee’s Covered
                Services is above and beyond the Benefit Maximum.

            

    

    

    4. The
      Capitation Rates to be paid specific to the Health Plan shall be as indicated
      in
      the Payment Tables in Attachment I, and adjusted monthly based on the Health
      Plan’s Plan Factor in accordance with subsection B.1.b.(1)(g)(i) through (ii) of
      this Section. 

    

    5. Unless
      otherwise specified in this Contract, the
      Health Plan shall accept the capitation payment received each month as payment
      in full by the Agency for all services provided to Enrollees covered under
      this
      Contract and the administrative costs incurred by the Health Plan in providing
      or arranging for such services. Any and all costs incurred by the Health Plan
      in
      excess of the capitation payment shall be borne in total by the Health Plan.
      

    

    6. The
      Agency shall pay a retroactive Capitation Rate for each Newborn enrolled in
      the
      Health Plan for up to the first (1st)
      three
      (3) months of life provided the Newborn was enrolled through the Unborn
      Activation Process. 

    

    
      	 	
              a.

            	
              The
                Health Plan shall use the Unborn Activation Process to enroll all
                babies
                born to pregnant Enrollees as specified in Section III, Eligibility
                and
                Enrollment, B.3.

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan is responsible for payment of all Covered Services provided
                to
                Newborns enrolled through the Unborn Activation
                Process.

            

    

    

    C. Kick
      Payments

    

    Beginning
      September 1, 2006, the Agency shall pay Health Plans one (1) Kick Payment for
      each covered transplant for the Health Plan’s Enrollees who are not dually
      eligible for Medicare, and for each obstetrical delivery performed for each
      obstetrical delivery performed for the Health Plan’s Enrollees. Kick Payments
      are not made for Enrollees dually eligible for Medicare. 

    

    1. The
      Agency shall pay Kick Payments in the amounts indicated for children and adults
      in Attachment I, Tables 7 and 8. 

    

    
      	 	
              a.

            	
              For
                Health Plans under Contract to provide the Comprehensive Component
                only,
                Agency reimbursements to the Health Plan for Kick Payment services
                will be
                counted toward the Health Plan’s Catastrophic Component Threshold. Once
                the Catastrophic Component Threshold has been met, the Agency will
                continue to reimburse the Health Plan any Kick Payment services delivered
                by the Health Plan at the Kick Payment
                amounts.

            

    

    

    
      	 	
              b.

            	
              For
                purposes of Kick Payments, an obstetrical delivery includes all births
                resulting from the delivery; therefore, if an obstetrical delivery
                results
                in multiple births, the Agency will reimburse the Health Plan through
                one
                Kick Payment only. Obstetrical deliveries also include still births
                as
                specified in the Medicaid Physicians Services
                Handbook.

            

    

    
      	 	
              c.

            	
              For
                Health Plans under Contract as a Specialty Plan, Agency reimbursements
                to
                the Health Plans for Kick Payment services will be counted toward
                the
                Enrollee’s Benefit Maximum. 

            

    

    

    2. To
      receive a Kick Payment, the Health Plan must adhere to specific requirements
      listed in subsections 3. and 4. below and adhere to the following
      requirements:

    

    
      	 	
              a.

            	
              The
                Health Plan must have provided the covered Kick Payment service to
                the
                recipient while he or she was enrolled in the Health Plan;
                and

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan must submit any required documentation to the Agency
                upon its
                request in order to receive the Kick Payment applicable to the Covered
                Service provided.

            

    

    

    3. In
      addition to subsection 2. above, to receive a Kick Payment for covered
      transplants provided to an Enrollee without Medicare, the Health Plan must
      also
      comply with the following requirements: 

    

    
      	 	
              a.

            	
              For
                each transplant provided, the Health Plan must submit an accurate
                and
                complete CMS-1500 Claim Form and (“CMS-1500”) Operative Report to the
                Fiscal Agent within the required Medicaid Fee-for-Service claims
                submittal
                timeframes 

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan must list itself as both the Pay-to and the Treating
                Provider
                on the CMS-1500 Claim Form; and

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan must use the following list of transplant procedure codes
                relative to the type of transplant performed when completing Field
                24 D on
                the CMS-1500:

            

    

    

    
      	
              CPT
                Code

            	
              Transplant
                CPT Code Description

            
	
              32851

            	
              lung
                single, without bypass

            
	
              32852

            	
              lung
                single, with bypass

            
	
              32853

            	
              lung
                double, without bypass

            
	
              32854

            	
              lung
                double, with bypass

            
	
              33945

            	
              heart
                transplant with or without recipient cardiectomy

            
	
              47135

            	
              liver,
                allotransplation, orthotopic, partial or whole from cadaver or living
                donor

            
	
              47136

            	
              liver,
                heterotopic, partial or whole from cadaver or living donor any
                age

            

    

    

    4. In
      addition to subsection 2. above, to receive a Kick Payment for the covered
      obstetrical delivery provided to an Enrollee, the Health Plan must also comply
      with the following requirements:

    

    
      	 	
              a.

            	
              The
                Health Plan must submit an accurate and complete CMS-1500 Claim Form
                in
                sufficient time to be received by the Fiscal Agent within six (6)
                months
                following the date of service
                (delivery);

            

    

    

    
      	 	
              b.

            	
              The
                Health Plan must list itself as both the Pay-to and the Treating
                Provider
                on the CMS-1500 Claim Form; and

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan must use the following list of delivery procedure codes
                relative to the type of delivery performed when completing Field
                24 D on
                the CMS-1500:

            

    

    

    

    

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              CPT
                Code

            	
              Obstetrical
                Delivery CPT Code Description

            
	
              59409

            	
              Vaginal
                delivery only

            
	
              59410

            	
              Vaginal
                delivery including postpartum care

            
	
              59515

            	
              Cesarean
                delivery including postpartum care

            
	
              59612

            	
              Vaginal
                delivery only, after previous cesarean delivery

            
	
              59614

            	
              Vaginal
                delivery only, after previous cesarean delivery including postpartum
                care

            
	
              59622

               

            	
              Cesarean
                delivery only, following attempted vaginal delivery after previous
                cesarean delivery including postpartum
                care

            

    

    

    

    
      	
              D.

            	
              Claims
                Payment for Health Plans Accepting Financial Risk for the Comprehensive
                Component Only

            

    

    

    1. In
      order
      for Health Plans accepting financial risk for only the Comprehensive Component
      to receive reimbursement from the Agency for incurred expenditures for Covered
      Services for an Enrollee who has reached the annual Catastrophic Component
      Threshold, the Health Plan shall adhere to the following
      requirements:

    

    a.The
      Health Plan must notify the Agency in writing, in an Agency-specified format,
      when expenditures it has paid for an Enrollee’s Covered Services exceed $25,000
      prior to the end of a Contract Year. 

    

    b.For
      Enrollee’s whose Health Plan expenditures for Covered Services costs exceed
      $25,000, the Health Plan must update the Agency in writing, as specified in
      Section XII, and on a monthly basis, of the Health Plan’s additional
      expenditures for Covered Services for the Enrollee until the Enrollee has
      exceeded the Catastrophic Component Threshold or for the remainder of the
      Contract Year, whichever occurs first;

    

    c.Once
      the
      Agency has reviewed the Covered Services expenditure information provided by
      the
      Health Plan and has determined that a Health Plan’s expenditures for an Enrollee
      have exceeded the Catastrophic Component Threshold for the Medicaid Covered
      Services received based on Florida Medicaid’s fee schedules and as indicated in
      subsection B.1.c.(2) of this Attachment, and the Health Plan has received Agency
      notification that the Enrollee has met the Catastrophic Component Threshold,
      the
      Health Plan must submit the following in order to receive reimbursement for
      Covered Services provided: 

    

    (1)An
      accurate and fully-completed claim form in the Agency’s designated format and
      within the Medicaid FFS time frames for claims submission. The Health Plan
      must
      list itself as both the Pay to and Treating Provider.

    

    (2)Any
      specified data requested by the Agency regarding treating providers unknown
      to
      FMMIS.

    

    (3)Health
      Plan claims data, for an Agency-specified data set in an Agency-specified format
      and transmittal method, that documents that the Health Plan’s expenditures,
      after conversion to the appropriate Medicaid fee (as applicable) are an amount
      equal to the Catastrophic Component Threshold.

    

    2.For
      Health Plans providing the Comprehensive Component only, the Agency will be
      responsible for payment to the Health Plan for Medicaid Covered Services
      provided in excess of the Catastrophic Component Threshold up to the Enrollee’s
      Benefit Maximum.

    

    a.With
      the
      exception of Kick Payment services, such payment will be made at ninety-five
      percent (95%) of the Medicaid FFS payment rate, less co-payment or coinsurance
      required under the Medicaid fee schedule, for the respective Medicaid Covered
      Service provided and paid for by the Health Plan.

    

    b.For
      Kick
      Payment services provided by the Health Plan, the Agency’s payment to the Health
      Plan will be the Kick Payment amount specified in Attachment I, Tables 7 and
      8.

    

    c.For
      Covered Services provided by the Health Plan for which there is not a Medicaid
      payment rate, the Agency will pay the actual amount the Health Plan paid to
      the
      Provider less five percent (5%).

    

    d.If
      the
      Health Plan submits claims to the Agency for Covered Services that are not
      in
      excess of the Catastrophic Component Threshold, or claims for Covered Services
      beyond the benefit maximum, and the Agency reimburses the plan for those claims,
      the Agency will recoup such reimbursement or the Health Plan will be responsible
      for repayment in accordance with the Payment Assessments and Errors subsections
      below.

    

    E. Child
      Health Check-UP (CHCUP) Incentive Payments

    

    Health
      Plans will be eligible to participate in the Child Health Check-Up (CHCUP)
      incentive program when the Health Plan has exceeded both the sixty percent
      (60%)
      State screening rate and the federal eighty percent (80%) participation and
      screening ratio goals as outlined in Section V, Covered Services, E.2. The
      Agency will determine which Health Plans will participate based upon the audited
      CHCUP reports submitted.

    

    
      	1.  	
              The
                amount of the incentive payment shall be calculated as follows: the
                ratio
                of a qualified Health Plan’s screenings to the total of all Health Plans’
                screenings will be multiplied by the total amount in the fund for
                the
                incentive payment. The ratios will be based on the Health Plans’ audited
                CHCUP reports. The total amount in the fund will be determined at
                the
                discretion of the Agency. In no event shall the total monies allotted
                to
                the incentive program be in excess of the incentive payment fund.
                

            

    

    

    2. Pursuant
      to 42 CFR 438.6, I(1)(iv) and (5)(iii), the payment to any one (1) Health Plan
      shall not be in excess of five percent (5%) of the capitation amount paid to
      all
      Health Plans for CHCUP services provided pursuant to this Contract

    

    

    

    
      
        
          
             

          

          
          

        

        
          
          

          
          

        

        
          
          

          
            

          

        

      

    

    

    

    F. Payment
      Assessments

    

    1. Choice
      Counseling/Enrollment and Disenrollment

    

    In
      accordance with s 409.912 (29), F.S., at such time as the Agency receives
      legislative direction to assess Health Plans for Enrollment and Disenrollment
      services costs,
      the Agency shall apply assessments, in quarterly installments each year, against
      the Health Plan’s next capitation payment to pay for the Enrollment and
      Disenrollment services costs of the Choice Counselor/Enrollment Broker as
      follows:

    

    
      	 	
              a.

            	
              July
                1, for costs estimated for the Enrollment and Disenrollment services
                rendered by the Choice Counselor/Enrollment Broker for July and the
                following two (2) months;

            

    

    

    
      	 	
              b.

            	
              October
                1, for costs related to the Enrollment and Disenrollment services
                rendered
                by the Choice Counselor/Enrollment Broker for October and the
                following two (2) months;

            

    

    

    
      	 	
              c.

            	
              January
                1, for costs related to the Enrollment and Disenrollment services
                rendered
                by the Choice Counselor/Enrollment Broker for January and the
                following two (2) months; and

            

    

    

    
      	 	
              d.

            	
              April
                1, for costs related to maintaining the third party Enrollment and
                Disenrollment services contract for April and the following two (2)
                months.

            

    

    

    2. Rate
      Adjustments

    

    The
      Health Plan and the Agency acknowledge that the Capitation Rates paid under
      this
      Contract, as specified in Payment and Maximum Authorized Enrollment Levels
      of
      this Contract, are subject to approval by the federal government.

    

    
      	 	
              a.

            	
              Adjustments
                to funds previously paid and to be paid may be required. Funds previously
                paid shall be adjusted when Capitation Rate calculations are determined
                to
                have been in error, or when capitation payments have been made for
                Medicaid Recipients who are determined to be ineligible for Health
                Plan
                Enrollment during the period for which the capitation payments were
                made.
                In such events, the Health Plan agrees to refund any overpayment
                and the
                Agency agrees to pay any
                underpayment.

            

    

    

    
      	 	
              b.

            	
              If
                the Agency receives legislative direction as specified in Section
                XIII,
                subsection F.1., Payment Assessments, Choice Counseling, respectively,
                the
                Agency shall annually, or more frequently, determine the actual
                expenditures for Enrollment and Disenrollment services rendered by
                the
                Choice Counselor/Enrollment Broker. The Agency will compare Capitation
                Rate assessments to the actual expenditures for such Enrollment and
                Disenrollment services. The following factors will enter into the
                cost
                settlement process:

            

    

    

    
      	 	
              (1)

            	
              If
                the amount of Capitation Rate assessments are less than the actual
                cost of
                providing Enrollment and Disenrollment services rendered by the Choice
                Counselor/Enrollment Broker, the Health Plan shall pay the difference
                to
                the Agency within thirty (30) Calendar Days of
                settlement.

            

    

    

    
      	 	
              (2)

            	
              If
                the amount of capitation assessments exceeds the actual cost of providing
                Enrollment, and Disenrollment services, the Agency will pay the difference
                to the Health Plan within thirty (30) Calendar Days of the
                settlement.

            

    

    

    
      	 	
              c.

            	
              As
                the Agency adjusts the Plan Factor based on updated historical data,
                the
                Health Plan’s Capitation Rates will be adjusted according to the
                methodology indicated in the Capitation Rate
                tables.

            

    

    

    
      	 	
              d.

            	
              The
                Agency may adjust the Health Plan’s Capitation Rates if the percentage
                deducted for the Enhanced Benefit Accounts fund is modified due to
                program
                needs.

            

    

    

    G. Errors

    

    Health
      Plans are expected to carefully prepare all reports and monthly payment requests
      for submission to the Agency. 

    

    If
      after
      preparation and electronic submission, either the Health Plan or the Agency
      discover an error, including but not limited to errors resulting in incorrect
      Kick Payments, errors resulting in incorrect identification of Enrollees
      (including but not limited to specific identification of Enrollees with HIV/AIDS
      diagnoses), errors resulting in incorrect claims payments, and errors resulting
      in Capitation Rate payments above the Health Plan’s authorized Enrollment
      levels, the Health Plan has thirty (30) Calendar Days after its discovery of
      the
      error, or from its receipt of Agency notice of the error, to correct the error
      and re-submit accurate reports and/or invoices. Failure to respond within the
      thirty (30) Calendar Day period shall result in a loss of any money due the
      Health Plan for such errors and/or a sanction against the Health Plan pursuant
      to Section XIV of this Contract.

    

    H. Enrollment
      Levels

    

    The
      Health Plan is assigned an authorized maximum Enrollment level for each
      operational county. The authorized maximum Enrollment level is in effect on
      September 1, 2006, or upon Contract execution, whichever is later. 

    

    1. The
      Agency must approve in writing any increase in the Health Plan’s maximum
      Enrollment level for each operational county and subpopulation to be served,
      as
      applicable. Such approval shall not be unreasonably withheld, and shall be
      based
      on the Health Plan’s satisfactory performance of terms of the Contract and
      approval of the Health Plan’s administrative and service resources, as specified
      in this Contract, in support of each Enrollment level

    

    2. Authorized
      Enrollment Levels in Attachment I indicate the Health Plan’s maximum authorized
      Enrollment levels for each Medicaid Reform county and each applicable authorized
      eligibility category.

    

    

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    Section
      XIV

    Sanctions

    

    
      	
              A.

            	
              General
                Provisions

            

    

    

    
      	 	
              1.

            	
              The
                Health Plan shall comply with all requirements and performance standards
                set forth in this Contract. In the event the Agency identifies a
                violation
                of this Contract, or other non-compliance with this Contract, the
                Health
                Plan shall submit a corrective action plan (CAP) within three (3)
                Calendar
                Days of the date of receiving notification of the violation or
                non-compliance from the Agency.

            

    

    

    
      	 	
              2.

            	
              Within
                five (5) Business Days of receiving the CAP the Agency will either
                approve
                or disapprove the CAP. If disapproved, the Health Plan shall resubmit,
                within ten (10) Business Days, a new CAP that addresses the concerns
                identified by the Agency. 

            

    

    

    
      	 	
              3.

            	
              Upon
                approval of the CAP, whether the initial CAP or the revised CAP,
                the
                Health Plan shall implement the CAP within the time frames specified
                by
                the Agency. 

            

    

    

    
      	 	
              4.

            	
              Except
                where specified below, the Agency shall impose a monetary sanction
                of $100
                per day on the Health Plan for each Calendar Day that the approved
                CAP is
                not implemented to the satisfaction of the
                Agency

            

    

    

    
      	
              B.

            	
              Specific
                Sanctions

            

    

    

    
      	 	
              As
                described in 42 CFR 438.700, the Agency may impose any of the following
                sanctions against a Health Plan if it determines that a Health Plan
                has
                violated any provision of this Contract, or any applicable
                statutes.

            

    

    

    
      	 	
              1.

            	
              Suspension
                of the Health Plan’s Voluntary Enrollments and participation in the
                Mandatory Assignment process for
                Enrollment.

            

    

    

    
      	 	
              2.

            	
              Suspension
                or revocation of payments to the Health Plan for Enrollees during
                the
                sanction period. 

            

    

    

    
      	 	
              3.

            	
              For
                any nonwillful violation of the Contract, the Agency shall impose
                a fine,
                not to exceed $2,500 per Violation. In no event shall such fine exceed
                an
                aggregate amount of $10,000 for all nonwillful Violations arising
                out of
                the same action.

            

    

    

    
      	 	
              4.

            	
              With
                respect to any knowing and willful violation of the Contract the
                Agency
                shall impose a fine upon the Health Plan in an amount not to exceed
                $20,000 for each such violation. In no event shall such fine exceed
                an
                aggregate amount of $100,000 for all knowing and willful violations
                arising out of the same action.

            

    

    

    
      	 	
              5.

            	
              If
                the Health Plan fails to carry out substantive terms of the Contract
                or
                fails to meet applicable requirements in 42 CFR 438.700, the Agency
                shall
                terminate the Contract. After the Agency notifies the Health Plan
                that it
                intends to terminate the Contract, the Agency shall give the Health
                Plan's
                Enrollees written notice of the State's intent to terminate the Contract
                and allow the Enrollees to disenroll immediately without
                Cause.

            

    

    

    
      	 	
              6.

            	
              The
                Agency may impose intermediate sanctions in accordance with 42 CFR
                438.702, including, but not limited
                to:

            

    

    

    
      	 	
              a.

            	
              Civil
                monetary penalties in the amounts specified in this
                contract.

            

    

    

    
      	 	
              b.

            	
              Appointment
                of temporary management for the Health Plan. Rules for temporary
                management pursuant to 42 CFR 438.706 are as
                follows:

            

    

    

    
      	 	
              (1)

            	
              The
                State may impose temporary management only if it finds (through on-site
                survey, Enrollee Grievances, financial audits, or any other means)
                that:

            

    

    

    
      	 	
              i.

            	
              There
                is continued egregious behavior by the Health Plan, including but
                not
                limited to behavior that is described in 42 CFR
                438.700;

            

    

    

    
      	 	
              ii.

            	
              There
                is substantial risk to Enrollees'
                health;

            

    

    

    
      	 	
              iii.

            	
              The
                sanction is necessary to ensure the health of the Health Plan’s
                Enrollees;

            

    

    

    
      	 	
              iv.

            	
              While
                improvements are made to remedy the Health Plan’s violation(s) under 42
                CFR 438.700; or

            

    

    

    
      	 	
              v.

            	
              Until
                there is an orderly termination or reorganization of the Health
                Plan.

            

    

    

    
      	 	
              (2)

            	
              The
                State must impose temporary management (regardless of any other sanction
                that may be imposed) if it finds that the Health Plan has repeatedly
                failed to meet substantive requirements in 42 CFR 438.706. The State
                must
                also grant Enrollees the right to terminate Enrollment without Cause,
                as
                described in 42 CFR 438.702(a)(3), and must notify the affected Enrollees
                of their right to terminate
                Enrollment.

            

    

    

    
      	 	
              (3)

            	
              The
                State shall not delay imposition of temporary management to provide
                a
                hearing before imposing this
                sanction.

            

    

    

    
      	 	
              (4)

            	
              The
                State shall not terminate temporary management until it determines
                that
                the Health Plan can ensure that the sanctioned behavior will not
                recur.

            

    

    

    
      	 	
              c.

            	
              Granting
                Enrollees the right to terminate Enrollment without Cause and notifying
                affected Enrollees of their right to
                disenroll.

            

    

    

    
      	 	
              d.

            	
              Suspension
                or limitation of all new Enrollment, including Mandatory Enrollment,
                after
                the effective date of the sanction.

            

    

    

    
      	 	
              e.

            	
              Suspension
                of payment for Enrollees after the effective date of the sanction
                and
                until CMS or the Agency is satisfied that the reason for imposition
                of the
                sanction no longer exists and is not likely to
                recur.

            

    

    

    
      	 	
              f.

            	
              Before
                imposing any intermediate sanctions, the State must give the Health
                Plan
                timely notice according to 42 CFR
                438.710.

            

    

    

    
      	 	
              7.

            	
              If
                the Health Plan’s CHCUP Screening compliance rate is below sixty percent
                (60%), it must submit to the Agency, and implement, an Agency accepted
                CAP. If the Health Plan does not meet the standard established in
                the CAP
                during the time period indicated in the plan, the Agency has the
                authority
                to impose sanctions in accordance with this
                section.

            

    

    

    
      	 	
              8.

            	
              Unless
                the duration of a sanction is specified, a sanction shall remain
                in effect
                until the Agency is satisfied that the basis for imposing the sanction
                has
                been corrected and is not likely to
                recur.

            

    

    

    
      	 	
              9.

            	
              The
                Agency reserves the right to withhold all or a portion of the Health
                Plans
                monthly administrative allocation for any amount owed pursuant to
                this
                section.

            

    

    

    

    

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    Section
      XV

    Financial
      Requirements

    

    
      	A.  	
              Insolvency
                Protection 

            

    

     

    The
      Health Plan shall establish a restricted Insolvency protection account with
      a
      federally guaranteed financial institution licensed to do business in Florida
      in
      accordance with section 1903(m)(1) of the Social Security Act (amended by
      section 4706 of the Balanced Budget Act of 1997), and section 409.912, F.S.
      The
      Health Plan shall deposit into that account five percent of the capitation
      payments made by the Agency each month until a maximum total of two percent
      of
      the annualized total current contract amount is reached. No interest may be
      withdrawn from this account until the maximum contract amount is reached. This
      provision shall remain in effect as long as the Health Plan continues to
      contract with the Agency. The restricted Insolvency protection account may
      be
      drawn upon with the authorized signatures of two persons designated by the
      Health Plan and two representatives of the Agency. The signature card shall
      be
      resubmitted when a change in authorized personnel occurs. If the authorized
      persons remain the same, the Health Plan shall submit an attestation to this
      effect annually. A sample form (Multiple Signature Verification Agreement)
      is
      available from the Agency upon request. 
      All such
      agreements or other signature cards must be approved in advance by the
      Agency.

    

    1. In
      the
      event that a determination is made by the Agency that the Health Plan is
      Insolvent, as defined in Section I Definitions, of this Contract, the Agency
      may
      draw upon the amount solely with the two authorized signatures of
      representatives of the Agency and funds may be disbursed to meet financial
      obligations incurred by the Health Plan under this Contract. A statement of
      account balance shall be provided by the Health Plan within fifteen (15)
      Calendar Days of request of the Agency.

     

    2. If
      the
      Contract is terminated, expired, or not continued, the account balance shall
      be
      released by the Agency to the Health Plan upon receipt of proof of satisfaction
      of all outstanding obligations incurred under this Contract.

    

    3. In
      the
      event the Contract is terminated or not renewed and the Health Plan is
      Insolvent, the Agency may draw upon the Insolvency protection account to pay
      any
      outstanding debts the Health Plan owes the Agency including, but not limited
      to,
      overpayments made to the Health Plan, and fines imposed under the Contract
      or
      section 641.52, F.S., for which a final order has been issued. In addition,
      if
      the Contract is terminated or not renewed and the Health Plan is unable to
      pay
      all of its outstanding debts to health care providers, the Agency and the Health
      Plan agree to the court appointment of an impartial receiver for the purpose
      of
      administering and distributing the funds contained in the Insolvency protection
      account. Should a receiver be appointed, he shall give outstanding debts owed
      to
      the Agency priority over other claims.

    

    
      	B.  	
              Insolvency
                Protection for a Capitated Provider Service Network
                (PSN) 

            

    

     

    1. A
      capitated PSN is required to assume responsibility for comprehensive coverage
      and meet the following financial reserve requirements: 

    

    
      	a.  	
              The
                capitated PSN shall maintain a minimum surplus in an amount that
                is the
                greater of $1 million or 1.5 percent of projected annual
                premiums.

            

    

    

    
      	b.  	
              In
                lieu of the requirements above, the Agency consider the following:
                

            

    

    
      	i.  	
              If
                the organization is a public entity, the Agency may take under advisement
                a statement from the public entity that a county supports the managed
                care
                plan with the county’s full faith and credit. In order to qualify for the
                Agency’s consideration, the county must own, operate, manage, administer,
                or oversee the managed care plan, either partly or wholly, through
                a
                county department or agency;

            

    

    
      	ii.  	
              The
                state guarantees the solvency of the
                organization;

            

    

    
      	iii.  	
              The
                organization is a federally qualified health center or is controlled
                by
                one or more federally qualified health centers and meets the solvency
                standards established by the state for such organization pursuant
                to s.
                409.912(4)(c), Florida Statutes; or

            

    

    
      	iv.  	
              The
                entity meets the financial standards for federally approved
                provider-sponsored organizations as defined in 42CFR ss. 422.380
                -
                422.390.

            

    

    

    2. Capitated
      PSNs have the option to assume responsibility for catastrophic coverage, but
      will be required to meet more stringent financial standards consistent with
      licensed HMOs in Chapter 641, F.S. and s. 409.912, F.S. At a minimum, the
      Capitated PSN shall at all times maintain a minimum surplus in an amount that
      is
      the greater $1,500,000, or 10 percent of total liabilities, or 2 percent of
      total contract amount. 

    

    
      	C.  	
              Surplus
                Start Up Account 

            

    

     

    All
      new
      Health Plans, after initial Contract execution but prior to initial Enrollee
      enrollment, shall submit to the Agency, if a private entity, proof of working
      capital in the form of cash or liquid assets excluding revenues from Medicaid
      premium payments equal to at least the first three (3) months of operating
      expenses or $200,000, whichever is greater. This provision shall not apply
      to
      Health Plans that have been providing services to Enrollees for a period
      exceeding three (3) continuous months.

     

    
      	D.  	
              Surplus
                Requirement 

            

    

     

    

    In
      accordance with section 409.912, F.S., the Health Plan shall maintain at all
      times in the form of cash, investments that mature in less than 180 Calendar
      Days allowable as admitted assets by the Department of Financial Services,
      and
      restricted funds of deposits controlled by the Agency (including the Health
      Plan’s Insolvency protection account) or the Department of Financial Services, a
      Surplus amount equal to one and one half (1 1⁄2) times the Health Plan’s monthly
      Medicaid prepaid revenues. In the event that the plan’s Surplus (as defined in
      Section I Definitions, of this Contract) falls below an amount equal to one
      and
      one half (1 1⁄2) times the Health Plan’s monthly Medicaid prepaid revenues, the
      Agency shall prohibit the Health Plan from engaging in Marketing and Request
      for
      Benefit Information activities, shall cease to process new Enrollments until
      the
      required balance is achieved, or may terminate the Health Plan’s Contract.

    

    
      	E.  	
              Interest

            

    

     

    

    Interest
      generated through investments made by the Health Plan under this Contract shall
      be the property of the Health Plan and shall be used at the Health Plan’s
      discretion.

    

    
      	F.  	
              Inspection
                and Audit of Financial
                Records

            

    

     

    

    The
      state
      and DHHS may inspect and audit any financial records of the plan or its
      subcontractors. Pursuant to section 1903(m)(4)(A) of the Social Security Act
      and
      State Medicaid Manual 2087.6(A-B), non-federally qualified plans must report
      to
      the state, upon request, and to the Secretary and the Inspector General of
      DHHS,
      a description of certain transactions with parties of interest as defined in
      section 1318(b) of the Social Security Act.

    

    
      	G.  	
              Physician
                Incentive Plans

            

    

     

    
      	 	
              1.

            	
              Physician
                incentive plans shall comply with 42 CFR 417.479, 42 CFR 438.6(h),
                42 CFR
                422.208 and 42 CFR 422.210. Health Plans shall make no specific payment
                directly or indirectly under a physician incentive plan to a physician
                or
                physician group as an inducement to reduce or limit medically necessary
                services furnished to an individual Enrollee. Incentive plans must
                not
                contain provisions which provide incentives, monetary or otherwise,
                for
                the withholding of medically necessary
                care.

            

    

    

    
      	 	
              2.

            	
              The
                Health Plan shall disclose information on physician incentive plans
                listed
                in 42 CFR 417.479(h)(1) and 417.479(i) at the times indicated in
                42 CFR
                417.479(d)-(g). All such arrangements must be submitted to the Agency
                for
                approval, in writing, prior to use. If any other type of withhold
                arrangement currently exists, it must be omitted from all
                subcontracts.

            

    

    
      	
               

              H.  

            	
               

              Third
                Party Resources 

            

    

     

    

    1. The
      Health Plan must specify whether it will assume full responsibility for third
      party collections in accordance with this section.

    

    2. The
      Health Plan shall be responsible for making every reasonable effort to determine
      the legal liability of third parties to pay for services rendered to members
      under this contract. The plan has the same rights to recovery of the full value
      of services as the Agency (See section 409.910, F.S. The following standards
      govern recovery.

    

    
      	 	
              a.

            	
              If
                the Health Plan has determined that third party liability exists
                for part
                or all of the services provided directly by the Health Plan to an
                Enrollee, the Health Plan shall make reasonable efforts to recover
                from
                third party liable sources the value of services
                rendered.

            

    

    

    
      	 	
              b.

            	
              If
                the Health Plan has determined that third party liability exists
                for part
                or all of the services provided to an Enrollee by a Subcontractor
                or
                referral Provider, and the third party is reasonably expected to
                make
                payment within 120 Calendar Days, the Health Plan may pay the
                Subcontractor or referral Provider only the amount, if any, by which
                the
                Subcontractor's allowable claim exceeds the amount of the anticipated
                third party payment; or, the Health Plan may assume full responsibility
                for third party collections for service provided through the Subcontractor
                or referral Provider.

            

    

    

    
      	 	
              c.

            	
              The
                Health Plan may not withhold payment for services provided to an
                Enrollee
                if third party liability or the amount of liability cannot be determined,
                or if payment shall not be available within a reasonable time, beyond
                120
                calendar days from the date of
                receipt.

            

    

    

    
      	 	
              d.

            	
              When
                both the Agency and the Health Plan have liens against the proceeds
                of a
                third party resource, the Agency shall prorate the amount due to
                Medicaid
                to satisfy such liens under section 409.910, F.S., between the Agency
                and
                the Health Plan. This prorated amount shall satisfy both liens in
                full.

            

    

    

    
      	 	
              e.

            	
              The
                Agency may, at its sole discretion, offer to provide third party
                recovery
                services to the Health Plan. If the Health Plan elects to authorize
                the
                Agency to recover on its behalf, the Health Plan shall be required
                to
                provide the necessary data for recovery in the format prescribed
                by the
                Agency. All recoveries, less the Agency’s cost to recover shall be income
                to the plan. The cost to recover shall be expressed as a percentage
                of
                recoveries and shall be fixed at the time the plan elects to authorize
                the
                Agency to recover on its behalf.

            

    

    

    
      	 	
              f.

            	
              All
                funds recovered from third parties shall be treated as income for
                the
                Health Plan.

            

    

    

    
      	I.  	
              Fidelity
                Bonds

            

    

     

    

    The
      Health Plan shall secure and maintain during the life of this Contract a blanket
      fidelity bond from a company doing business in the State of Florida on all
      personnel in its employment. The bond shall be issued in the amount of at least
      $250,000 per occurrence. Said bond shall protect the Agency from any losses
      sustained through any fraudulent or dishonest act or acts committed by any
      employees of the Health Plan and Subcontractors, if any. Proof of coverage
      must
      be submitted to the Agency’s contract manager within sixty (60) Calendar Days
      after execution of the Contract and prior to the delivery of health care. To
      be
      acceptable to the Agency for fidelity bonds, a surety company shall comply
      with
      the provisions of chapter 624, F.S. 

    

    

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    Section
      XVI

    Terms
      and Conditions

    

    
      	A.  	
              Agency
                Contract Management

            

    

    

    
      	 	
              1.

            	
              The
                Division of Medicaid within the Agency shall be responsible for management
                of the Contract. The Division of Medicaid shall make all statewide
                policy
                decision-making or contract interpretation. In addition, the Division
                of
                Medicaid shall be responsible for the interpretation of all federal
                and
                State laws, rules and regulations governing or in any way affecting
                this
                Contract. Management shall be conducted in good faith with the best
                interest of the State and the Medicaid Recipients it serves being
                the
                prime consideration. The Agency shall provide final interpretation
                of
                general Medicaid policy. When interpretations are required, the Health
                Plan shall submit written requests to the Agency’s contract
                manager.

            

    

    

    
      	 	
              2.

            	
              The
                terms of this Contract do not limit or waive the ability, authority
                or
                obligation of the Office of Inspector General, Bureau of Medicaid
                Program
                Integrity, its contractors, or other duly constituted government
                units
                (State or federal) to audit or investigate matters related to, or
                arising
                out of this Contract. 

            

    

    

    
      	 	
              3.

            	
              The
                Contract shall only be amended as
                follows:

            

    

    

    a. The
      parties cannot amend or alter the terms of this Contract without a written
      amendment.

    

    b. The
      Agency and the Health Plan understand that any such written amendment to amend
      or alter the terms of this Contract shall be executed by an officer of both
      parties, who is duly authorized to bind the Agency and the Health
      Plan.

    

    c. Only
      a
      person authorized by the Agency and a person authorized by the Health Plan
      may
      amend or alter the terms of this Contract. 

     

    
      	B.  	
              Applicable
                Laws and Regulations

            

    

    

    The
      Health Plan agrees to comply with all applicable federal and State laws, rules
      and regulations including but not limited to: Title 42 Code of Federal
      Regulations (CFR) chapter IV, subchapter C; Title 45 CFR, Part 74, General
      Grants Administration Requirements; chapters 409 and 641, Florida Statutes;
      all
      applicable standards, orders, or regulations issued pursuant to the Clean Air
      Act of 1970 as amended (42 USC 1857, et seq.); Title VI of the Civil Rights
      Act
      of 1964 (42 USC 2000d) in regard to persons served; Title IX of the education
      amendments of 1972 (regarding education programs and activities); 42 CFR 431,
      subpart F, section 409.907(3)(d), F.S., and Rule 59G-8.100 (24)(b), F.A.C.
      in
      regard to the contractor safeguarding information about beneficiaries; Title
      VII
      of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
      applicants for employment; Rule 59G-8.100, F.A.C.; section 504 of the
      Rehabilitation Act of 1973, as amended, 29 USC. 794, which prohibits
      discrimination on the basis of handicap in programs and activities receiving
      or
      benefiting from federal financial assistance; the Age Discrimination Act of
      1975, as amended, 42 USC. 6101 et. seq., which prohibits discrimination on
      the
      basis of age in programs or activities receiving or benefiting from federal
      financial assistance; the Omnibus Budget Reconciliation Act of 1981, P.L. 97-35,
      which prohibits discrimination on the basis of sex and religion in programs
      and
      activities receiving or benefiting from federal financial assistance; Medicare
      -
      Medicaid Fraud and Abuse Act of 1978; the federal Omnibus Budget Reconciliation
      Acts; Americans with Disabilities Act (42 USC 12101, et seq.); the Newborns’ and
      Mothers’ Health Protection Act of 1996; and the Balanced Budget Act of 1997 and
      the Health Insurance Portability and Accountability Act of 1996. The Health
      Plan
      is subject to any changes in federal and state law, rules, or
      regulations.

    

    
      	C.  	
              Assignment

            

    

    

    
      	 	
              1.

            	
              Except
                as provided below or with the prior written approval of the Agency,
                which
                approval shall not be unreasonably withheld, this Contract and the
                monies
                which may become due are not to be assigned, transferred, pledged
                or
                hypothecated in any way by the Health Plan, including by way of an
                asset
                or stock purchase of the Health Plan and shall not be subject to
                execution, attachment or similar process by the Health
                Plan.

            

    

    .

    a. As
      provided by section 409.912, F.S., when a merger or acquisition of a Health
      Plan
      has been approved by the Department of Financial Services pursuant to section
      628.4615, F.S., the Agency shall approve the assignment or transfer of the
      appropriate Contract upon the request of the surviving entity of the merger
      or
      acquisition if the Health Plan and the surviving entity have been in good
      standing with the Agency for the most recent 12 month period, unless the Agency
      determines that the assignment or transfer would be detrimental to the Medicaid
      Recipients or the Medicaid program. The entity requesting the assignment or
      transfer shall notify the Agency of the request ninety (90) days prior to the
      anticipated effective date.

    

    b. To
      be in
      good standing, a Health Plan or Plan must not have failed accreditation or
      committed any material violation of the requirements of section 641.52, F.S.,
      and must meet the Contract requirements.

    

    c. For
      the
      purposes of this section, a merger or acquisition means a change in controlling
      interest of an Entity, including an asset or stock purchase.

    

    
      	D.  	
              Attorney's
                Fees

            

    

    

    In
      the
      event of a dispute, each party to the Contract shall be responsible for its
      own
      attorneys’ fees except as otherwise provided by law.

    

    
      	E.  	
              Conflict
                of Interest

            

    

     

    The
      Contract is subject to the provisions of chapter 112, Florida Statutes. The
      Health Plan shall disclose the name of any officer, director, or agent who
      is an
      employee of the State of Florida, or any of its agencies. Further, the Health
      Plan shall disclose the name of any State employee who owns, directly or
      indirectly, an interest of five percent (5%) or more in the offerer's firm
      or
      any of its branches. The Health Plan covenants that it presently has no interest
      and shall not acquire any interest, direct or indirect, which would conflict
      in
      any manner or degree with the performance of the services hereunder. The Health
      Plan further covenants that in the performance of the Contract no person having
      any such known interest shall be employed. No official or employee of the Agency
      and no other public official of the State of Florida or the federal government
      who exercises any functions or responsibilities in the review or approval of
      the
      undertaking of carrying out the Contract shall, prior to completion of this
      Contract, voluntarily acquire any personal interest, direct or indirect, in
      this
      Contract or proposed Contract.

    

    

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      	F.  	
              Contract
                Variation

            

    

     

     

    If
      any
      provision of the Contract (including items incorporated by reference) is
      declared or found to be illegal, unenforceable, or void, then both the Agency
      and the Health Plan shall be relieved of all obligations arising under such
      provisions. If the remainder of the Contract is capable of performance, it
      shall
      not be affected by such declaration or finding and shall be fully performed.
      In
      addition, if the laws or regulations governing this Contract should be amended
      or judicially interpreted as to render the fulfillment of the Contract
      impossible or economically infeasible, both the Agency and the Health Plan
      shall
      be discharged from further obligations created under the terms of the Contract.
      However, such declaration or finding shall not affect any rights or obligations
      of either party to the extent that such rights or obligations arise from acts
      performed or events occurring prior to the effective date of such declaration
      or
      finding.

    

    
      	G.  	
              Court
                of Jurisdiction or Venue

            

    

     

    For
      purposes of any legal action occurring as a result of or under this Contract,
      between the Health Plan and the Agency, the place of proper venue shall be
      Leon
      County.

    

    
      	H.  	
              Damages
                for Failure to Meet Contract
                Requirements

            

    

     

     

    In
      addition to any remedies available through this Contract, in law or equity,
      the
      Health Plan shall reimburse the Agency for any federal disallowances or
      sanctions imposed on the Agency as a result of the Health Plan's failure to
      abide by the terms of this contract.

    

    
      	I.  	
              Disputes 

            

    

     

    The
      Health Plan may request in writing an interpretation of the Contract from the
      Contract manager. In the event the Health Plan disputes this interpretation,
      the
      Health Plan may request that the dispute be decided by the Division of Medicaid.
      The ability to dispute an interpretation does not apply to issues that are
      a
      matter of law or fact. Any disputes shall be decided by the Agency’s Division of
      Medicaid which shall reduce the decision to writing and serve a copy on the
      Health Plan. The written decision of the Agency’s Division of Medicaid shall be
      final and conclusive. The division will render its final decision based upon
      the
      written submission of the Health Plan and the Agency, unless, at the sole
      discretion of the Division director, the division allows an oral presentation
      by
      the Health Plan and the Agency. If such a presentation is allowed, the
      information presented will be considered in rendering the division’s decision.
      Should the Health Plan challenge an Agency decision through arbitration as
      provided below, the Agency action shall not be stayed except by order of an
      arbitrator. Thereafter, a Health Plan shall resolve any controversy or claim
      arising out of or relating to the Contract, or the breach thereof, by
      arbitration. Said arbitration shall be held in the City of Tallahassee, Florida,
      and administered by the American Arbitration Association in accordance with
      its
      applicable rules and the Florida Arbitration Code (chapter 682, F.S.). Judgment
      upon any award rendered by the arbitrator may be entered by the Circuit Court
      in
      and for the Second Judicial Circuit, Leon County, Florida. The chosen arbitrator
      must be a member of the Florida Bar actively engaged in the practice of law
      with
      expertise in the process of deciding disputes and interpreting contracts in
      the
      health care field. Any arbitration award shall be in writing and shall specify
      the factual and legal bases for the award. Either party may appeal a judgment
      entered pursuant to an arbitration award to the First District Court of Appeal.
      The parties shall bear their own costs and expenses relating to the preparation
      and presentation of a case in arbitration. The arbitrator shall award to the
      prevailing party all administrative fees and expenses of the arbitration,
      including the arbitrator’s fee. This Contract with numbered attachments
      represents the entire agreement between the Health Plan and the Agency with
      respect to the subject matter in it and supersedes all other contracts between
      the parties when it is duly signed and authorized by the Health Plan and the
      Agency. Correspondence and memoranda of understanding do not constitute part
      of
      this Contract. In the event of a conflict of language between the Contract
      and
      the attachments, the provisions of the Contract shall govern. However, the
      Agency reserves the right to clarify any contractual relationship in writing
      with the concurrence of the Health Plan and such clarification shall govern.
      Pending final determination of any dispute over an Agency decision, the Health
      Plan shall proceed diligently with the performance of the contract and in
      accordance with the Agency’s Division of Medicaid direction.

    

    
      	J.  	
              Force
                Majeure

            

    

     

    

    The
      Agency shall not be liable for any excess cost to the Health Plan if the
      Agency's failure to perform the Contract arises out of causes beyond the control
      and without the result of fault or negligence on the part of the Agency. In
      all
      cases, the failure to perform must be beyond the control without the fault
      or
      negligence of the Agency. The Health Plan shall not be liable for performance
      of
      the duties and responsibilities of the Contract when its ability to perform
      is
      prevented by causes beyond its control. These acts must occur without the fault
      or negligence of the Health Plan. These include destruction to the facilities
      due to hurricanes, fires, war, riots, and other similar acts. Annually by May
      31, the Health Plan shall submit to the Agency for approval an emergency
      management plan specifying what actions the Health Plan shall conduct to ensure
      the ongoing provisions of health services in a disaster or man-made
      emergency.

    

    
      	K.  	
              Legal
                Action Notification

            

    

     

    The
      Health Plan shall give the Agency by certified mail immediate written
      notification (no later than thirty (30) Calendar Days after service of process)
      of any action or suit filed or of any claim made against the Health Plan by
      any
      subcontractor, vendor, or other party which results in litigation related to
      this Contract for disputes or damages exceeding the amount of $50,000. In
      addition, the Health Plan shall immediately advise the Agency of the insolvency
      of a Subcontractor or of the filing of a petition in bankruptcy by or against
      a
      principal Subcontractor.

    

    
      	L.  	
              Licensing

            

    

     

    For
      the
      purposes of this Contract, a Health Plan includes health maintenance
      organizations authorized under chapter 641 of the Florida Statutes, exclusive
      provider organizations as defined in chapter 627 of the Florida Statutes, health
      insurers authorized under chapter 624 of the Florida Statutes, and Provider
      Service Networks as defined in Section 409.912, Florida Statutes. For purposes
      of this Contract, a PSN shall operate in accordance with section
      409.91211(3)(e), F.S., and is exempt from licensure under Chapter 641, F.S.,
      however, shall be responsible for meeting certain standards in Chapter 641,
      F.S.
      as required in this Contract. A
      Health
      Plan must be licensed under Chapter 641, Florida Statutes in order to offer
      a
      Specialty Plan for the population with HIV/AIDS.

    

    
      	M.  	
              Misuse
                of Symbols, Emblems, or Names in Reference to
                Medicaid

            

    

     

    No
      person
      or Health Plan may use, in connection with any item constituting an
      advertisement, solicitation, circular, book, pamphlet or other communication,
      or
      a broadcast, telecast, or other production, alone or with other words, letters,
      symbols or emblems the words “Medicaid,” or “Agency for Health Care
      Administration,” except as required in the Agency’s core contract, page two (2),
      unless prior written approval is obtained from the Agency. Specific written
      authorization from the Agency is required to reproduce, reprint, or distribute
      any Agency form, application, or publication for a fee. State and local
      governments are exempt from this prohibition. A disclaimer that accompanies
      the
      inappropriate use of program or Agency terms does not provide a defense. Each
      piece of mail or information constitutes a violation.

    

    
      	N.  	
              Offer
                of Gratuities

            

    

     

    By
      signing this agreement, the Health Plan signifies that no member of or a
      delegate of Congress, nor any elected or appointed official or employee of
      the
      State of Florida, the General Accounting Office, Department of Health and Human
      Services, CMS, or any other federal Agency has or shall benefit financially
      or
      materially from this procurement. The Contract may be terminated by the Agency
      if it is determined that gratuities of any kind were offered to or received
      by
      any officials or employees from the offeror, his agent, or
      employees.

     

    
      	O.  	
              Subcontracts

            

    

     

    
      	 	
              1.

            	
              The
                Health Plan is responsible for all work performed under this Contract,
                but
                may, with the written prior approval of the Agency, enter into
                Subcontracts for the performance of work required under this Contract.
                All
                Subcontracts must comply with 42 CFR 438.230. All Subcontracts and
                amendments executed by the Health Plan shall meet the following
                requirements. All Subcontractors must be eligible for participation
                in the
                Medicaid program; however, the Subcontractor is not required to
                participate in the Medicaid program as a provider. The Agency encourages
                use of minority business enterprise Subcontractors. See Section X.C.,
                Administration and Management, Provider Contracts, of this Contract,
                for
                provisions and requirements specific to Provider
                contracts.

            

    

    

    
      	 	
              2.

            	
              No
                Subcontract which the Health Plan enters into with respect to performance
                under the Contract shall in any way relieve the Health Plan of any
                responsibility for the performance of duties under this Contract.
                The
                Health Plan shall assure that all tasks related to the Subcontract
                are
                performed in accordance with the terms of this Contract. The Health
                Plan
                shall identify in its Subcontracts any aspect of service that may
                be
                further subcontracted by the
                Subcontractor.

            

    

    

    
      	 	
              3.

            	
              All
                model and executed Subcontracts and amendments used by the Health
                Plan
                under this Contract must be in writing, signed, and dated by the
                Health
                Plan and the Subcontractor and meet the following
                requirements:

            

    

    

    a. Identification
      of conditions and method of payment: 

    

    
      	 	
              i.

            	
              The
                Health Plan agrees to make payment to all subcontractors in a timely
                fashion. 

            

    

    

    
      	 	
              ii.

            	
              Provide
                for prompt submission of information needed to make
                payment.

            

    

    

    
      	 	
              iii.

            	
              Make
                full disclosure of the method and amount of compensation or other
                consideration to be received from the Health Plan.
                

            

    

    

    
      	 	
              iv.

            	
              Require
                an adequate record system be maintained for recording services, charges,
                dates and all other commonly accepted information elements for services
                rendered to the Health Plan.

            

    

    

    
      	 	
              v.

            	
              Specify
                that the Health Plan shall assume responsibility for cost avoidance
                measures for third party collections in accordance with Section XV.
                F.,
                Financial Requirements, Third Party Liability.

            

    

    

    b. Provisions
      for monitoring and inspections:

    

    
      	 	
              i.

            	
              Provide
                that the Agency and DHHS may evaluate through inspection or other
                means
                the quality, appropriateness and timeliness of services
                performed.

            

    

    

    
      	 	
              ii.

            	
              Provide
                for inspections of any records pertinent to the contract by the Agency
                and
                DHHS.

            

    

    

    
      	 	
              iii.

            	
              Require
                that records be maintained for a period not less than five (5) years
                from
                the close of the Contract and retained further if the records are
                under
                review or audit until the review or audit is complete. (Prior approval
                for
                the disposition of records must be requested and approved by the
                Health
                Plan if the Subcontract is
                continuous.)

            

    

    

    
      	 	
              iv.

            	
              Provide
                for monitoring and oversight by the Health Plan and the Subcontractor
                to
                provide assurance that all licensed medical professionals are Credentialed
                in accordance with the Health Plan’s and the Agency’s Credentialing
                requirements as found in Section VIII.A.3.h Credentialing and
                Recredentialing, of this Contract, if the Health Plan has delegated
                the
                Credentialing to a Subcontractor.

            

    

    

    
      	 	
              v.

            	
              Provide
                for monitoring of services rendered to Enrollees sponsored by the
                Provider.

            

    

    

    c. Specification
      of functions of the Subcontractor:

    

    
      	 	
              i.

            	
              Identify
                the population covered by the
                Subcontract.

            

    

    

    
      	 	
              ii.

            	
              Provide
                for submission of all reports and clinical information required by
                the
                Health Plan, including Child Health Check-Up reporting (if
                applicable).

            

    

    

    
      	 	
              iii.

            	
              Provide
                for the participation in any internal and external quality improvement,
                utilization review, peer review, and grievance procedures established
                by
                the Health Plan.

            

    

    

    d. Protective
      clauses:

    

    
      	 	
              i.

            	
              Require
                safeguarding of information about Enrollees according to 42 CFR,
                Part
                438.224.

            

    

    

    
      	 	
              ii.

            	
              Require
                compliance with HIPAA privacy and security
                provisions.

            

    

    

    
      	 	
              iii.

            	
              Require
                an exculpatory clause, which survives Subcontract termination including
                breach of Subcontract due to insolvency, that assures that Medicaid
                Recipients or the Agency may not be held liable for any debts of
                the
                Subcontractor. 

            

    

    

    
      	 	
              iv.

            	
              If
                there is a Health Plan physician incentive plan, include a statement
                that
                the Health Plan shall make no specific payment directly or indirectly
                under a physician incentive plan to a Subcontractor as an inducement
                to
                reduce or limit Medically Necessary services to an Enrollee, and
                that all
                incentive plans shall not contain provisions which provide incentives,
                monetary or otherwise, for the withholding of Medically Necessary
                care;

            

    

    

    
      	 	
              4.

            	
              Contain
                a clause indemnifying, defending and holding the Agency and the Health
                Plan Enrollees harmless from and against all claims, damages, causes
                of
                action, costs or expense, including court costs and reasonable attorney
                fees to the extent proximately caused by any negligent act or other
                wrongful conduct arising from the Subcontract agreement. This clause
                must
                survive the termination of the Subcontract, including breach due
                to
                Insolvency. The Agency may waive this requirement for itself, but
                not
                Health Plan Enrollees, for damages in excess of the statutory cap
                on
                damages for public entities if the Subcontractor is a public health
                entity
                with statutory immunity. All such waivers must be approved in writing
                by
                the Agency.

            

    

    

    
      	 	
              5.

            	
              Require
                that the Subcontractor secure and maintain during the life of the
                Subcontract worker's compensation insurance for all of its employees
                connected with the work under this Contract unless such employees
                are
                covered by the protection afforded by the Health Plan. Such insurance
                shall comply with the Florida's Worker's Compensation
                Law.

            

    

    

    
      	 	
              6.

            	
              Specify
                that if the Subcontractor delegates or Subcontracts any functions
                of the
                Health Plan, that the Subcontract or delegation includes all the
                requirements of this Contract.

            

    

    

    
      	 	
              7.

            	
              Make
                provisions for a waiver of those terms of the Subcontract, which,
                as they
                pertain to Medicaid Recipients, are in conflict with the specifications
                of
                this Contract.

            

    

    

    
      	 	
              8.

            	
              Provide
                for revoking delegation or imposing other sanctions if the Subcontractor's
                performance is inadequate.

            

    

    

    
      	 	
              9.

            	
              The
                Health Plan must provide that compensation to individuals or entities
                that
                conduct utilization management activities is not structured so as
                to
                provide incentives for the individual or entity to deny, limit, or
                discontinue medically necessary services to any
                Enrollee.

            

    

    

    
      	P.  	
              Hospital
                Subcontracts

            

    

     

    

    All
      hospital Subcontracts must meet the requirements outlined in Section XV.I.Q.,
      Terms and Conditions, Subcontracts, of this Contract. In addition such
      Subcontracts shall require that the hospitals notify the Health Plan of births
      where the mother is a Health Plan Enrollee. The Subcontract must also specify
      which entity (Health Plan or hospital) is responsible for completing form DCF-ES
      2039 and submitting it to the local DCF Economic Self-Sufficiency Services
      office. The Subcontract must also indicate that the plan’s name must be
      indicated as the referring Agency when the form DCF-ES 2039 is
      completed.

    

    
      	Q.  	
              Termination
                Procedures

            

    

     

    

    
      	 	
              1.

            	
              In
                conjunction with section III.B., Termination, on page eight (8) of
                the
                Agency's Standard Contract, termination procedures are required.
                The
                Health Plan agrees to extend the thirty (30) Calendar Days notice
                found in
                section III.B.1., Termination at Will, on page eight (8) of the Agency's
                Standard Contract to ninety (90) Calendar Days notice. The party
                initiating the termination shall render written notice of termination
                to
                the other party by certified mail, return receipt requested, or in
                person
                with proof of delivery, or by facsimile letter followed by certified
                mail,
                return receipt requested. The notice of termination shall specify
                the
                nature of termination, the extent to which performance of work under
                the
                Contract is terminated, and the date on which such termination shall
                become effective. In accordance with 1932(e)(4), Social Security
                Act, the
                Agency shall provide the plan with an opportunity for a hearing prior
                to
                termination for cause. This does not preclude the Agency from terminating
                without cause.

            

    

    

    
      	 	
              2.

            	
              Upon
                receipt of final notice of termination, on the date and to the extent
                specified in the notice of termination, the Health Plan
                shall:

            

    

    

    a. Stop
      work
      under the Contract, but not before the termination date.

    

    b. Cease
      enrollment of new Enrollees under the Contract.

    

    c. Terminate
      all Marketing activities and Subcontracts relating to Marketing.

    

    d. Assign
      to
      the State those Subcontracts as directed by the Agency's contracting officer
      including all the rights, title and interest of the Health Plan for performance
      of those Subcontracts.

    

    e. In
      the
      event the Agency has terminated this Contract in one or more Agency areas of
      the
      State, complete the performance of this Contract in all other areas in which
      the
      Health Plan has not been terminated.

    

    f. Take
      such
      action as may be necessary, or as the Agency's contracting officer may direct,
      for the protection of property related to the contract which is in the
      possession of the Health Plan and in which the Agency has been granted or may
      acquire an interest.

    

    g. Not
      accept any payment after the Contract ends unless the payment is for the time
      period covered under the Contract. Any payments due under the terms of this
      Contract may be withheld until the Agency receives from the Health Plan all
      written and properly executed documents as required by the written instructions
      of the Agency.

    

    h. At
      least
      sixty (60) Calendar Days prior to the termination effective date, provide
      written notification to all Enrollees of the following information: the date
      on
      which the Health Plan will no longer participate in the State’s Medicaid
      program; and instructions on contacting the Agency’s Choice Counselor/Enrollment
      Broker help line to obtain information on Enrollee’ enrollment options and to
      request a change in Health Plans.

    

    
      	R.  	
              Waiver

            

    

     

    

    No
      covenant, condition, duty, obligation, or undertaking contained in or made
      a
      part of the Contract shall be waived except by written agreement of the parties,
      and forbearance or indulgence in any other form or manner by either party in
      any
      regard whatsoever shall not constitute a waiver of the covenant, condition,
      duty, obligation, or undertaking to be kept, performed, or discharged by the
      party to which the same may apply. Until complete performance or satisfaction
      of
      all such covenants, conditions, duties, obligations, or undertakings, the other
      party shall have the right to invoke any remedy available under law or equity
      not withstanding any such forbearance or indulgence.

    

    
      	S.  	
              Withdrawing
                Services from a County

            

    

     

    

    If
      the
      Health Plan intends to withdraw services from a county, it shall provide written
      notice to its members in that county at least sixty (60) Calendar Days prior
      to
      the last day of service. The notice shall contain the same information as
      required for a notice of termination according to Section XVI.S.2.h., Terms
      and
      Conditions, Termination Procedures, of this Contract. The Health Plan shall
      also
      provide written notice of the withdrawal to all Subcontractors in the
      county.

    

    
      
        
          

          
          

        

        
          
          

          
          

        

        
          
          

        

      

    

     

    
      	T.  	
              MyFloridaMarketPlace
                Vendor Registration

            

    

     

    

    This
      Vendor is exempt under Rule 60A-1.030(3)d(ii), Florida Administrative Code,
      from
      being required to register in MyFloridaMarketPlace for this
      Contract.

    

    
      	U.  	
              MyFloridaMarketplace
                Vendor Registration and Transaction Fee Exemption 

            

    

     

    

    The
      Vendor is exempted from paying the 1% transaction fee per 60A-1.032(1)(g) of
      the
      Florida Administrative Code for this Contract.

    

    
      	V.  	
              Ownership
                and Management Disclosure 

            

    

     

    

    
      	 	
              1.

            	
              Federal
                and State laws require full disclosure of ownership, management and
                control of Disclosing Entities. 

            

    

    

    a. Disclosure
      shall be made on forms prescribed by the Agency for the areas of ownership
      and
      control interest (42 CFR 455.104 Form CMS 1513), business transactions (42
      CFR
      455.105), public entity crimes (section 287.133(3)(a), F.S.), and disbarment
      and
      suspension (52 Fed. Reg., pages 20360-20369, and section 4707 of the Balanced
      Budget Act of 1997). The forms are available through the Agency and are to
      be
      submitted to the Agency with the initial application for a Medicaid HMO or
      Health Plan and then submitted on an annual basis. The Health Plan shall
      disclose any changes in management as soon as those occur. In addition, the
      Health Plan shall submit to the Agency full disclosure of ownership and control
      of Medicaid HMOs and Health Plans at least sixty (60) Calendar Days before
      any
      change in the Health Plan's ownership or control occurs.

    

    b. The
      following definitions apply to ownership disclosure:

    

    
      	 	
              (1)

            	
              A
                person with an ownership interest or control interest means a person
                or
                corporation that:

            

    

    

    (a) Owns,
      indirectly or directly 5 percent (5%) or more of the Health Plan's capital
      or
      stock, or receives 5 percent (5%) or more of its profits;

    

    (b) Has
      an
      interest in any mortgage, deed of trust, note, or other obligation secured
      in
      whole or in part by the plan or by its property or assets and that interest
      is
      equal to or exceeds 5 percent (5%) of the total property or assets;
      or

    

    (c) Is
      an
      officer or director of the Health Plan if organized as a corporation, or is
      a
      partner in the plan if organized as a partnership.

    

    
      	 	
              (2)

            	
              The
                percentage of direct ownership or control is calculated by multiplying
                the
                percent of interest which a person owns, by the percent of the Health
                Plan's assets used to secure the obligation. Thus, if a person owns
                ten
                percent (10%) of a note secured by sixty percent (60%) of the Health
                Plan's assets, the person owns six percent (6%) of the Health
                Plan.

            

    

    

    
      	 	
              (3)

            	
              The
                percent of indirect ownership or control is calculated by multiplying
                the
                percentage of ownership in each organization. Thus, if a person owns
                ten
                percent (10%) of the stock in a corporation, which owns eighty percent
                (80%) of the Health Plan stock, the person owns 8 percent (8%) of
                the
                Health Plan.

            

    

    

    c. The
      following definitions apply to management disclosure:

    

    
      	 	
              (1)

            	
              Changes
                in management are defined as any change in the management control
                of the
                Health Plan. Examples of such changes are those listed below or equivalent
                positions by another title.

            

    

    

    (a) Changes
      in the board of directors or officers of the Health Plan, medical director,
      chief executive officer, administrator, and chief financial
      officer.

    

    (b) Changes
      in the management of the Health Plan where the Health Plan has decided to
      contract out the operation of the Health Plan to a management corporation.
      The
      Health Plan shall disclose such changes in management control and provide a
      copy
      of the contract to the Agency for approval at least sixty (60) Calendar Days
      prior to the management contract start date.

    

    d. In
      accordance with section 409.912, F.S., the Health Plan shall annually conduct
      a
      background check with the Florida Department of Law Enforcement on all persons
      with five percent (5%) or more ownership interest in the Health Plan, or who
      have executive management responsibility for the Health Plan, or have the
      ability to exercise effective control of the Health Plan. The Health Plan shall
      submit information to the Agency for such persons who have a record of illegal
      conduct according to the background check. The Health Plan shall keep a record
      of all background checks to be available for Agency review upon
      request.

    

    
      	 	
              (1)

            	
              In
                accordance with section 409.907, F.S., Health Plans with an initial
                contract beginning on or after July 1, 1997, shall submit, prior
                to
                execution of a contract, complete sets of fingerprints of principals
                of
                the plan to the Agency for the purpose of conducting a criminal history
                record check.

            

    

    

    
      	 	
              (2)

            	
              Principals
                of the Health Plan shall be as defined in section 409.907,
                F.S.

            

    

    

    e. The
      Health Plan shall submit to the Agency, within five (5) Business Days, any
      information on any officer, director, agent, managing employee, or owner of
      stock or beneficial interest in excess of five percent (5%) of the Health Plan
      who has been found guilty of, regardless of adjudication, or who entered a
      plea
      of nolo contendere or guilty to, any of the offenses listed in section 435.03,
      F.S.

    

    f. In
      accordance with section 409.912, F.S., the Agency shall not contract with a
      Health Plan that has an officer, director, agent, managing employee, or owner
      of
      stock or beneficial interest in excess of five percent (5%) of the Health Plan,
      who has committed any of the above listed offenses. In order to avoid
      termination, the Health Plan must submit a corrective action plan, acceptable
      to
      the Agency, which ensures that such person is divested of all interest and/or
      control and has no role in the operation and management of the Health
      Plan.

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    

    

    

    
      	W.  	
              Minority
                Recruitment and Retention
                Plan

            

    

     

    

    The
      Health Plan shall implement and maintain a minority recruitment and retention
      plan in accordance with section 641.217, F.S. The Health Plan shall have
      policies and procedures for the implementation and maintenance of such a plan.
      The minority recruitment and retention plan may be company-wide for all product
      lines.

    

    
      	X.  	
              Independent
                Provider

            

    

     

    

    It
      is
      expressly agreed that the Health Plan and any Subcontractors and agents,
      officers, and employees of the Health Plan or any Subcontractors, in the
      performance of this Contract shall act in an independent capacity and not as
      officers and employees of the Agency or the State of Florida. It is further
      expressly agreed that this Contract shall not be construed as a partnership
      or
      joint venture between the Health Plan or any Subcontractor and the Agency and
      the State of Florida.

    

    
      	Y.  	
              General
                Insurance Requirements

            

    

     

    

    The
      Health Plan shall obtain and maintain the same adequate insurance coverage
      including general liability insurance, professional liability and malpractice
      insurance, fire and property insurance, and directors’ omission and error
      insurance. All insurance coverage must comply with the provisions set forth
      for
      HMOs in Rule 69O-191.069, F.A.C.; excepting that the reporting, administrative,
      and approval requirements shall be to the Agency rather than to the Department
      of Financial Services. All insurance policies must be written by insurers
      licensed to do business in the State of Florida and in good standing with the
      Department of Financial Services. All policy declaration pages must be submitted
      to the Agency annually. Each certificate of insurance shall provide for
      notification to the Agency in the event of termination of the
      policy.

    

    
      	Z.  	
              Worker's
                Compensation Insurance

            

    

     

    

    The
      Health Plan shall secure and maintain during the life of the Contract, worker's
      compensation insurance for all of its employees connected with the work under
      this Contract. Such insurance shall comply with the Florida Worker's
      Compensation Law, chapter 440, F.S. Policy declaration pages must be submitted
      to the Agency annually.

    

    
      	AA.  	
              State
                Ownership

            

    

     

    

    The
      Agency shall have the right to use, disclose, or duplicate all information
      and
      data developed, derived, documented, or furnished by the plan resulting from
      this contract. Nothing herein shall entitle the Agency to disclose to third
      parties data or information which would otherwise be protected from disclosure
      by State or federal law.

    

    
      	BB.  	
              Disaster
                Plan

            

    

     

    The
      Health Plan shall submit a plan describing procedures guaranteeing the
      continuation of services during an emergency, including but not limited to
      localized acts of nature, accidents, and technological and/or attack-related
      emergencies.

    

    

    
      

      

      
        
          
            
            

            
            

          

          
            
            

            
              

            

          

          
            
            

            
              ATTACHMENT
                III

            

          

        

      

      

      BUSINESS
        ASSOCIATE AGREEMENT

      

      The
        parties to this Attachment agree that the following provisions constitute
        a
        business associate agreement for purposes of complying with the requirements
        of
        the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
        This
        Attachment is applicable if the Vendor is a business associate within the
        meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.

      

      The
        Vendor certifies and agrees as to abide by the following:

      

      
        	1.  	
                Definitions.
                  Unless specifically stated in this Attachment, the definition of
                  the terms
                  contained herein shall have the same meaning and effect as defined
                  in 45
                  C.F.R. 160 and 164.

              

      

      

      1.a.
        Protected
        Health Information.
        For
        purposes of this Attachment, protected health information shall have the
        same
        meaning and effect as defined in 45 C.F.R.
        160 and
164,
        limited to the information created, received, maintained or transmitted by
        the
        Vendor from, or on behalf of, the Agency. 

      

      1.b.
        Security
        Incident.
        For
        purposes of this Attachment, security incident shall mean any
        event
        resulting in computer systems, networks, or data being viewed, manipulated,
        damaged, destroyed or made inaccessible by an unauthorized activity. See
        National Institute of Standards and Technology (NIST) Special Publication
        800-61, "Computer Security Incident Handling Guide,” for more
        information.

      

      
        	2.  	
                Use
                  and Disclosure of Protected Health Information.
                  The Vendor shall not use or disclose protected health information
                  other
                  than as permitted by this Contract or by federal and state law.
                  The Vendor
                  will use appropriate safeguards to prevent the use or disclosure
                  of
                  protected health information for any purpose not in conformity
                  with this
                  Contract and federal and state law. The Vendor will implement
                  administrative, physical, and technical safeguards that reasonably
                  and
                  appropriately protect the confidentiality, integrity, and availability
                  of
                  electronic protected health information the Vendor creates, receives,
                  maintains, or transmits on behalf of the Agency.
                  

              

      

      

      
        	
                3.

              	
                Use
                  and Disclosure of Information for Management, Administration, and
                  Legal
                  Responsibilities.
                  The Vendor is permitted to use and disclose protected health information
                  received from the Agency for the proper management and administration
                  of
                  the Vendor or to carry out the legal responsibilities of the Vendor,
                  in
                  accordance with 45 C.F.R. 164.504(e)(4). Such disclosure is only
                  permissible where required by law, or where the
                  Vendor obtains reasonable assurances from the person to whom the
                  protected
                  health information is disclosed that: (1) the protected health
                  information
                  will be held confidentially, (2) the protected health information
                  will be
                  used or further disclosed only as required by law or for the purposes
                  for
                  which it was disclosed to the person, and (3) the person notifies
                  the
                  Vendor of any instance of which it is aware in which the confidentiality
                  of the protected health information has been
                  breached.

              

      

      

      
        	
                4.

              	
                Disclosure
                  to Third Parties.
                  The Vendor will not divulge, disclose, or communicate protected
                  health
                  information to any third party for any purpose not in conformity
                  with this
                  Contract without prior written approval from the Agency. The Vendor
                  shall
                  ensure that any agent, including a subcontractor, to whom it provides
                  protected health information received from, or created or received
                  by the
                  Vendor on behalf of, the Agency agrees to the same terms, conditions,
                  and
                  restrictions that apply to the Vendor with respect to protected
                  health
                  information.

              

      

      

      5. Access
        to Information.
        The
        Vendor shall make protected health information available in accordance with
        federal and state law, including providing a right of access to persons who
        are
        the subjects of the protected health information in accordance with 45 C.F.R.
        164.524. 

      

      6. Amendment
        and Incorporation of Amendments.
        The
        Vendor shall make protected health information available for amendment and
        to
        incorporate any amendments to the protected health information in accordance
        with 45 C.F.R. § 164.526.

      

      7. Accounting
        for Disclosures.
        The
        Vendor shall make protected health information available as required to provide
        an accounting of disclosures in accordance with 45 C.F.R. § 164.528. The Vendor
        shall document all disclosures of protected health information as needed
        for the
        Agency to respond to a request for an accounting of disclosures in accordance
        with 45 C.F.R. § 164.528.

      

      8. Access
        to Books and Records.
        The
        Vendor shall make its internal practices, books, and records relating to
        the use
        and disclosure of protected health information received from, or created
        or
        received by the Vendor on behalf of the Agency, available to the Secretary
        of
        the Department of Health and Human Services or the Secretary’s designee for
        purposes of determining compliance with the Department of Health and Human
        Services Privacy Regulations.

      

      9. Reporting.
        The
        Vendor shall make a good faith effort to identify any use or disclosure of
        protected health information not provided for in this Contract. The Vendor
        will
        report to the Agency, within ten (10) business days of discovery, any use
        or
        disclosure of protected health information not provided for in this Contract
        of
        which the Vendor is aware. The Vendor will report to the Agency, within
        twenty-four (24) hours of discovery, any security incident of which the Vendor
        is aware. A violation of this paragraph shall be a material violation of
        this
        Contract.

      

      10.
        Termination.
        Upon the
        Agency’s discovery of a material breach of this Attachment, the Agency shall
        have the right to terminate this Contract. 

      

      10.a.
        Effect
        of Termination.
        At the
        termination of this Contract, the Vendor shall return all protected health
        information that the Vendor still maintains in any form, including any copies
        or
        hybrid or merged databases made by the Vendor; or with prior written approval
        of
        the Agency, the protected health information may be destroyed by the Vendor
        after its use. If the protected health information is destroyed pursuant
        to the
        Agency’s prior written approval, the Vendor must provide a written confirmation
        of such destruction to the Agency. If return or destruction of the protected
        health information is determined not feasible by the Agency, the Vendor agrees
        to protect the protected health information and treat it as strictly
        confidential.

      

      

      

      The
        Vendor has caused this Attachment to be signed and delivered by its duly
        authorized representative, as of the date set forth below.

      

      Vendor
        Name:

       

       
/s/ 
Todd
        S.
        Farha           

      Signature

       

      6/26/06

      Date

        

      Todd
        S. Farha, President &
CEO          

      Name
        and
        Title of Authorized Signer

    

    
      
        
          
             

          

          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

      

      CERTIFICATION
        REGARDING

      DEBARMENT,
        SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION

      CONTRACTS/SUBCONTRACTS

      

      This
        certification is required by the regulations implementing Executive Order
        12549,
        Debarment and Suspension, signed February 18, 1986. The guidelines were
        published in the May 29, 1987, Federal Register (52 Fed. Reg., pages
        20360-20369).

      

      INSTRUCTIONS

      

      
        	
                1.

              	
                Each
                  Vendor whose contract/subcontract equals or exceeds $25,000 in
                  federal
                  monies must sign this certification prior to execution of each
                  contract/subcontract. Additionally, Vendors who audit federal programs
                  must also sign, regardless of the contract amount. The
                  Agency for Health Care Administration cannot contract with these
                  types of
                  Vendors if they are debarred or suspended by the federal
                  government.

              

      

      

      
        	
                2.

              	
                This
                  certification is a material representation of fact upon which reliance
                  is
                  placed when this contract/subcontract is entered into. If it is
                  later
                  determined that the signer knowingly rendered an erroneous certification,
                  the Federal Government may pursue available remedies, including
                  suspension
                  and/or debarment.

              

      

      

      
        	
                3.

              	
                The
                  Vendor shall provide immediate written notice to the contract manager
                  at
                  any time the Vendor learns that its certification was erroneous
                  when
                  submitted or has become erroneous by reason of changed
                  circumstances.

              

      

      

      
        	
                4.

              	
                The
                  terms "debarred," "suspended," "ineligible," "person," "principal,"
                  and
                  "voluntarily excluded," as used in this certification, have the
                  meanings
                  set out in the Definitions and Coverage sections of rules implementing
                  Executive Order 12549. You may contact the contract manager for
                  assistance
                  in obtaining a copy of those
                  regulations.

              

      

      

      
        	
                5.

              	
                The
                  Vendor agrees by submitting this certification that, it shall not
                  knowingly enter into any subcontract with a person who is debarred,
                  suspended, declared ineligible, or voluntarily excluded from participation
                  in this contract/subcontract unless authorized by the Federal
                  Government.

              

      

      

      
        	
                6.

              	
                The
                  Vendor further agrees by submitting this certification that it
                  will
                  require each subcontractor of this contract/subcontract, whose
                  payment
                  will equal or exceed $25,000 in federal monies, to submit a signed
                  copy of
                  this certification.

              

      

      

      
        	
                7.

              	
                The
                  Agency for Health Care Administration may rely upon a certification
                  of a
                  Vendor that it is not debarred, suspended, ineligible, or voluntarily
                  excluded from contracting/subcontracting unless it knows that the
                  certification is erroneous.

              

      

      

      
        	
                8.

              	
                This
                  signed certification must be kept in the contract manager's contract
                  file.
                  Subcontractor's certifications must be kept at the contractor's
                  business
                  location.

              

      

      

      CERTIFICATION

      

      
        	(1)	 	
                The
                  prospective Vendor certifies, by signing this certification, that
                  neither
                  he nor his principals is presently debarred, suspended, proposed
                  for
                  debarment, declared ineligible, or voluntarily excluded from participation
                  in this contract/subcontract by any federal department or
                  agency.

              

      

      

      
        	
                (2)

              	
                Where
                  the prospective Vendor is unable to certify to any of the statements
                  in
                  this certification, such prospective Vendor shall attach an explanation
                  to
                  this certification.

              

      

       

      
         
/s/ 
Todd
          S.
          Farha           

        Signature

         

        6/26/06

        Date

          

        Todd
          S. Farha, President &
CEO          

        Name
          and
          Title of Authorized Signer

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    CERTIFICATION
      REGARDING LOBBYING

    CERTIFICATION
      FOR CONTRACTS, GRANTS, LOANS AND COOPERATIVE AGREEMENTS

    

    

    The
      undersigned certifies, to the best of his or her knowledge and belief,
      that:

    

    
      	(1)  	
              No
                federal appropriated funds have been paid or will be paid, by or
                on behalf
                of the undersigned, to any person for influencing or attempting to
                influence an officer or employee of any agency, a member of congress,
                an
                officer or employee of congress, or an employee of a member of congress
                in
                connection with the awarding of any federal contract, the making
                of any
                federal grant, the making of any federal loan, the entering into
                of any
                cooperative agreement, and the extension, continuation, renewal,
                amendment, or modification of any federal contract, grant, loan,
                or
                cooperative agreement.

            

    

     

    
      	(2)  	
              If
                any funds other than federal appropriated funds have been paid or
                will be
                paid to any person for influencing or attempting to influence an
                officer
                or employee of any agency, a member of congress, an officer or employee
                of
                congress, or an employee of a member of congress in connection with
                this
                federal contract, grant, loan, or cooperative agreement, the undersigned
                shall complete and submit Standard Form-LLL, “Disclosure Form to Report
                Lobbying,” in accordance with its
                instructions.

            

    

     

    
      	(3)  	
              The
                undersigned shall require that the language of this certification
                be
                included in the award documents for all sub-awards at all tiers (including
                subcontracts, sub-grants, and contracts under grants, loans, and
                cooperative agreements) and that all sub-recipients shall certify
                and
                disclose accordingly.

            

    

    

    This
      certification is a material representation of fact upon which reliance was
      placed when this transaction was made or entered into. Submission of this
      certification is a prerequisite for making or entering into this transaction
      imposed by section 1352, Title 31, U.S. Code. Any person who fails to file
      the
      required certification shall be subject to a civil penalty of not less than
      $10,000 and not more than $100,000 for each such failure.

    

     

    
      	 

               
/s/ 
Todd
                S.
                Farha           
                

              Signature

            	 

              6/26/06

              Date

            
	 

              Todd
                S.
                Farha                             
                

              Name
                of Authorized Individual

               

            	
               FAR 001

              Application or Contract Number

            
	
               HealthEase Health Plan of Florida, Inc.  P.O. Box
                26011, Tampa, FL 33623

              Name and Address of Organziation

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