Document:

exv10w25

 

Exhibit 10.25

Contract No. FA523

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 AMERIGROUP OF FLORIDA, INC.,
hereinafter referred to as the “Vendor”, whose address is 4425 Corporation
Lane, Virginia Beach, VA 23462, a Florida Profit Corporation, to provide Health
Care Services to Medicaid benefeciaries.

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.	 	If this Contract contains federal funds, 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
Attachment I.
	 
	2.	 	If this Contract contains federal funding in excess of
$100,000, the Vendor must, upon Contract execution, complete the
Certification Regarding Lobbying form, Attachment IV. 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.
	 
	3.	 	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 V.

     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.

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Exhibit 10.25

	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 I, 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 provide a financial and compliance audit to the Agency as
specified in Attachment II and to ensure that all related party
transactions are disclosed to the auditor. Additional audit
requirements are specified in Attachment I.
	 
	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 I. These reports
will be used for monitoring progress or performance of the
contractual services as specified in Attachment I.
	 
	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 Contractor 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.

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Exhibit 10.25

     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

	 	 	 	To neither 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.
	 
	 	 	 	Financial Reports
	 
	 	 	 	To provide fmancial reports to the Agency as specified in
Attachment I.

     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

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Exhibit 10.25

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.

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Exhibit 10.25

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

An entity 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. The Agency may,
when specified

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Exhibit 10.25

in N/A, establish rates lower than the maximum provided in 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 I, 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.
	 
	6.	 	In accordance with Section 287.057 (14), this Contract may be
renewed for a period that may not exceed three (3) years or the term
of the original Contract, whichever period is longer, unless
otherwise specified in Attachment I. Renewal of this Contract shall
be in writing and subject to the same terms and conditions set forth
in the initial Contract prior to Contract termination. A renewal
contract may not include any compensation for costs associated with
the renewal. Renewals are contingent upon satisfactory performance
evaluations by the Agency and subject to the availability of funds.
A renewal clause, including terms under which the cost may change,
must be specified in the invitation to bid, request for proposal, or
other bid instrument, if applicable. This Contract may not be
renewed if it is the result of an emergency or single source method
of procurement.

0. 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 AMERIGROUP 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

The Vendor must submit the final invoice for payment to the Agency no
more than 90 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.

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Exhibit 10.25

     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 I, 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 $658,826,195.00, 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.

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Exhibit 10.25

     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 July 1,
2004, (whichever is later) and end June 30, 2006, 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 fmal
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.

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Exhibit 10.25

     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:

Christina Lopez

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:

Mitch Wright

Amerigroup of Florida, Inc.

4425 Corporation Lane

Virginia Beach, VA 23462

(757) 490-6900

	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:

Amerigroup of Florida, Inc.

4200 West Cypress Street, Suite 900

Tallahassee, FL 33607

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Exhibit 10.25

	2.	 	The name of the contact person
and street address where financial and
administrative records are maintained:
	 
	 	 	Kathleen K. Toth

Amerigroup of Florida,

Inc. 4425 Corporation

Lane Virginia Beach,

VA 23462

	 	 	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 185
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.

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

	 	 	 	 	 	 	 	 
	 	 	SIGNED	 	SIGNED
	

	 	BY:
	 	 	 	BY:
	 	/s/ Alan Levine
	

	 	 	 	
 
	 	 	 	
 
	

	 	 	 	 	 	 	 	 
	 	 	NAME: Karen Bornhanser	 	NAME: Alan Levine
	

	 	 	 	
 
	 	 	 	
 
	

	 	 	 	 	 	 	 	 
	 	 	TITLE: Chief Operating Officer	 	TITLE: Secretary
	

	 	 	 	
 
	 	 	 	
 
	

	 	 	 	 	 	 	 	 
	 	 	DATE: 7/1/04	 	DATE: 7/1/04
	

	 	 	 	
 
	 	 	 	
 

FEDERAL ID NUMBER (or SS Number for an individual): 65-0318864

VENDOR FISCAL YEAR ENDING DATE: DECEMBER 31, 2004

List of attachments included as part of this Contract:

	 	 	 	 	 
	Specify	 	 	 	 
	Type
	 	Number
	 	Description (include number of pages)

	Attachment

	 	I
	 	Scope of Services (166 Pages)
	Attachment

	 	II
	 	Financial and Compliance Audit (3 Pages)
	Attachment

	 	III
	 	Health Insurance Portability and Accountability Act of
1996 Compliance (2 Pages)
	Attachment

	 	N
	 	Certification Regarding Lobbying (1 Page)
	Attachment

	 	V
	 	Certification Regarding Debarment (1 Page)
	Attachment

	 	VI
	 	2004-2005 HMO Rates (2 Pages)

AHCA Contract No. FA523, Page 10 of 10

AHCA Form 2100-0007 (Rev. FEB04)

 

 

Exhibit 10.25

	2.	 	The name of the contact person and street
address where financial and administrative records
are maintained:
	 
	 	 	Kathleen K. Toth

Amerigroup of Florida,

Inc. 4425 Corporation

Lane Virginia Beach, VA 23462

	 	 	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 185 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.

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

	 	 	 	 	 	 	 	 
	 	 	SIGNED	 	SIGNED
	

	 	BY:
	 	/s/ Karen Bornhauser
	 	BY:	 	 
	

	 	 	 	
 
	 	 	 	
 
	

	 	 	 	 	 	 	 	 
	 	 	NAME: Karen Bornhauser	 	NAME: Alan Levine
	 	 	TITLE: Chief
Operating Officer	 	TITLE: Secretary
	

	 	 	 	
 	 	 	 	 
	

	 	 	 	 	 	 	 	 
	 	 	DATE: 7/1/04	 	DATE:

FEDERAL ID NUMBER (or SS Number for an individual):

65-0318864 VENDOR FISCAL YEAR ENDING DATE: DECEMBER 31, 2004

List of attachments included as part of this Contract:

	 	 	 	 	 
	Specify	 	 	 	 
	Type
	 	Number
	 	Description (include number of pages)

	Attachment

	 	I
	 	Scope of Services (166 Pages)
	Attachment

	 	II
	 	Financial and Compliance Audit (3 Pages)
	Attachment

	 	III
	 	Health Insurance Portability and Accountability
Act of 1996 Compliance (2 Pages)
	Attachment

	 	W
	 	Certification Regarding Lobbying (1 Page)
	Attachment

	 	V
	 	Certification Regarding Debarment (1 Page)
	Attachment

	 	VI
	 	2004-2005 HMO Rates (2 Pages)

AHCA Contract No. FA523, Page 10 of 10

AHCA Form 2100-0007 (Rev. FEB04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

ATTACHMENT I

SCOPE OF SERVICES

	10.0	 	  COVERED SERVICES AND ELIGIBLE BENEFICIARIES
	 
	10.1	 	  General
	 
	 	 	The health maintenance organization vendor, hereinafter referred to as
the plan, shall comply with all the provisions of this contract and its
amendments, if any, and shall act in good faith in the performance of
the contract provisions. The plan shall develop and maintain written
policies and procedures to implement the provisions of this contract.
The plan agrees that failure to comply with these provisions may result
in the assessment of penalties and/or termination of the contract in
whole or in part, as set forth in this contract.
	 
	 	 	The plan shall comply with all pertinent Agency rules in effect
throughout the duration of the contract.
	 
	 	 	The plan shall comply with all current Agency handbooks noticed in or
incorporated by reference in rules relating to the provision of
services set forth in sections 10.4, Covered Services, and 10.5,
Optional Services, except where the provisions of the contract alter
the requirements set forth in the handbooks. In addition, the plan
shall comply with the limitations and exclusions in the Agency
handbooks unless otherwise specified by this contract. In no instance
may the limitations or exclusions imposed by the plan be more
stringent than those specified in the handbooks. Pursuant to 42 CFR
438.210(a) the plan must furnish services up to the limits specified
by the Medicaid program. The plan may exceed these limits. However,
service limitations shall not be more restrictive than the Florida
fee-for-service program, pursuant to 42 CFR 438.210(a).
	 
	 	 	Upon implementation of the Medicaid Prepaid Mental Health program in
each Area the plan shall provide community mental health services and
mental health targeted case management services in accordance with
section 10.11, Behavioral Health Care, of this contract. Sections 2.2,
2.3 and 2.5 of the Area specific Prepaid Mental Health Plan (PMHP)
requests for proposals (RFP) will apply to the respective Area members.
All other general behavioral health service requirements shall also
apply.
	 
	 	 	The plan may offer services to enrolled Medicaid beneficiaries in
addition to those covered services specified in sections 10.4,
Covered Services, 10.8, Manner of Service Provision, and 10.9,
Quality and Benefit Enhancements. These services must be
specifically defined in regards to amount, duration and scope, and
must be approved in writing by the Agency prior to implementation.
	 
	 	 	The plan shall have a quality improvement program that ensures
enhancement of quality of care and emphasize quality patient outcomes.
The Agency may restrict the plan’s enrollment activities if acceptable
quality improvement and performance indicators based on HEDIS and other
outcome measures to be determined by the Agency are not met. Such
restrictions may include the termination of mandatory assignments.
	 
	10.2	 	  Eligible Beneficiaries
	 
	 	 	The categories of eligible beneficiaries authorized to be enrolled in
the plan are: Low Income Families and Children; Foster Care; Sixth
Omnibus Budget Reconciliation Act (SOBRA) Children; Supplemental
Security Income (SSI) Medicaid Only; SSI Medicare Part B Only; and SSI
Medicare Parts A & B. Beneficiaries who are residents of Assisted
Living Facilities (ALFs) and not enrolled in an ALF waiver program are
eligible for enrollment in the plan. 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. In addition,
women enrolled in the plan who change eligibility categories to the
SOBRA eligibility category due to their pregnancy will remain eligible
for enrollment in the plan. -

AHCA Contract No. FA523, Attachment I, Page 1 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	10.3	 	  Ineligible Beneficiaries
	 
	 	 	The following categories describe beneficiaries who are not eligible to
enroll in the plan:

	a.	 	Medicaid eligible beneficiaries 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 (because the beneficiary was assessed by Comprehensive
Assessment and Review for Long Term Care (CARES) and found to be at
a custodial level of care), intermediate care facilities for
persons with developmental disabilities, state hospitals or
correctional institutions.
	 
	b.	 	Medicaid eligible beneficiaries who are receiving services
through a hospice program, the Medicaid AIDS waiver (Project AIDS
Care) program, a prescribed pediatric extended care center, or
enrolled in Children’s Medical Services.
	 
	c.	 	Medicaid eligible beneficiaries who are also members
of a Medicare-funded health maintenance organization (HMO).
	 
	d.	 	Medicaid eligible beneficiaries whose Medicaid eligibility
has been determined through the medically needy program.
	 
	e.	 	Qualified Medicare beneficiaries (QMBs).
	 
	f.	 	Medicaid eligible beneficiaries who have other credible
health care coverage like TriCare or a private HMO.
	 
	g.	 	Medicaid eligible beneficiaries 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
and Preservation Program in the Department of Children and
Families (DCF).
	 
	3.	 	Children’s residential treatment facilities purchased
through the Alcohol, Drug Abuse, and Mental Health Program
Office (ADM) in DCF (Purchased Residential Treatment Services -
PRTS).
	 
	4.	 	ADM residential treatment facilities licensed as Level I
and II facilities.
	 
	5.	 	Residential Level I and Level II substance abuse
treatment programs pursuant to section 65D-30.007(2)(a) and
(b), F.A.C.

	h.	 	Family Planning waiver beneficiaries.
	 
	i.	 	Medicaid eligible beneficiaries in the following programs
may not enroll in a frail/elderly component of a Medicaid HMO:

	1.	 	An aged/disabled waiver program
	 
	2.	 	The Channeling program
	 
	3.	 	Developmental Services Waiver
	 
	4.	 	TANF beneficiaries
	 
	5.	 	The Assisted Living for the Elderly waiver, or

AHCA Contract No. FA523, Attachment I, Page 2 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	j.	 	Medicaid eligible beneficiaries who are members of the Florida Assertive
Community Treatment Team (FACT team) in those areas in which the HMO is
responsible for community mental health and targeted case management services.
	 
	k.	 	Participants in the Sub-acute Inpatient Psychiatric Program (SIPP).
	 
	l.	 	Pregnant women not enrolled in the plan prior to the effective
date of their SOBRA eligibility.

	10.4	 	Covered Services
	 
	 	 	The plan shall ensure the provision of the following covered services
as defined and specified in sections 10.1, General and 10.8, Manner of
Service Provision:

	 	 	 
	Child Health Check-Up

	 	Inpatient Hospital Services
	 
	 	 
	Community Mental Health Services.

	 	Mental Health Targeted Case Management
	 
	 	 
	Family Planning Services

	 	Outpatient Hospital and Emergency Services
	 
	 	 
	Freestanding Dialysis Centers

	 	Physician Services
	 
	 	 
	Hearing Services

	 	Prescribed Drug Services
	 
	 	 
	Home Health Services and Durable Medical Equipment

	 	Therapy Services
	 
	 	 
	Independent Laboratory and X-Ray Services

	 	Visual Services

     THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 3 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	Amerigroup of Florida, Inc.

	 	Medicaid HMO Contract
	July 1, 2004
	 	 

	10.5	 	Optional Services
	 
	 	 	These services are rendered within Medicaid guidelines at
the option of the plan and the Agency.

	 	 	 	 	 
	 	 	Covered
	 	Not Covered

	Dental Services

	 	X	 	 
	Transportation Services

	 	 	 	X
	Frail/Elderly Program

	 	 	 	X
	(in accordance with Exhibit 110.4 of this contract)
	 	 	 	 

	10.6	 	Expanded Services
	 
	 	 	These services are defined as those offered by the plan and approved
by the Agency, which are as follows:

	a.	 	Services in excess of the amount, duration and scope of
those listed in sections 10.4, Covered Services, and 10.5,
Optional Services.
	 
	b.	 	Services and benefits not listed in sections 10.4 and 10.5.
	 
	c.	 	The plan may offer an Agency approved over-the-counter
expanded drug benefit, not to exceed $10.00 per household, per
month. Such benefits shall be limited to non-prescription drugs
containing a National Drug Code (NDC) number, and first aid and
birth control supplies. Such benefits must be offered through a
plan’s pharmacy or plan’s subcontract with a pharmacy. The plan
shall make payments for the over-the-counter drug benefit directly
to the pharmacy.

	 	 	The following is a list of expanded services:

	1.	 	Adult preventative dental services
	 
	2.	 	Over the counter drug service not to exceed $10 per family
	 
	3.	 	Vision services — unlimited eye exams, eyeglasses and contact lenses

     THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 4 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	10.7	 	Excluded Services
	 
	 	 	The plan is not obligated to provide for the services that are not
specified in sections 10.4, Covered Services, 10.5, Optional Services,
10.6, Expanded Services and 10.9, Quality and Benefit Enhancements.
Plan members who require services available through Medicaid but not
covered by this contract shall receive these services through the
existing Medicaid fee-for-service reimbursement system. The plan shall
determine the need for these services and refer the member to the
appropriate service provider. The plan may request the assistance of
the local Medicaid Field Office for referral to the appropriate
service setting.
	 
	 	 	For members requiring long term care institutional services,
institutional services for persons with developmental disabilities or
state hospital services, the plan shall consult the DCF office to
identify appropriate methods of assessment and referral. The plan is
responsible for transition and referral to appropriate service
providers, including helping the member to obtain an attending
physician. Members requiring these services shall be disenrolled from
the plan in accordance with section 30.11, Disenrollment, of this
contract, except as required by Frail Elderly Program component
requirements, see Exhibit 110.4.
	 
	10.8	 	Manner of Service Provision
	 
	 	 	The Florida Medicaid Program provides multiple services/programs for
Medicaid eligible beneficiaries. The service definitions that follow
are those required by federal or state rule. The plan must furnish
services up to the limits specified by the Medicaid program. The plan
is responsible for contracting with providers who meet all provider
and service and product standards specified in the Agency’s Medicaid
Services Coverage and Limitations handbooks and the plan’s provider
handbooks, which must be incorporated in all plan subcontracts by
reference, for each service category covered by the plan. Exceptions
exist where different standards are specified elsewhere in this
contract or if the standard is waived in writing by the Division of
Medicaid on a case-by-case basis when the member’s medical needs
would be equally or better served in an alternative care setting or
using alternative therapies or devices within the prevailing medical
community.
	 
	10.8.1	 	Child Health Check-Up
	 
	 	 	Child Health Check-Up (CHCUP) services are comprehensive and preventive
health examinations provided on a periodic basis that are aimed at
identifying and correcting medical conditions in children and young
people (birth through 20 years of age). Policies and procedures are
described in the Child Health Check-Up Services Coverage and
Limitations Handbook. Policy requirements include:

	a.	 	The health screening examination 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 test where required; for children
who the plan identifies through blood lead screenings as having
abnormal levels of lead, the plan shall provide case management
follow-up services as required in chapter 2 of the Child Health
Check-Up Services Coverage and Limitations Handbook.); health
education (including anticipatory guidance); dental screening
(including a direct referral to a dentist, or to a Prepaid Dental
Health Plan (PDHP) where applicable for members beginning at 3
years of age or earlier as indicated); vision screening including
objective testing when required; and hearing screening including
objective testing, when required; diagnosis and treatment; and
referral and follow-up, as appropriate.
	 
	b.	 	Members shall be informed by the Agency through its
fiscal agent, of screenings due in accordance with the periodicity
schedule as specified in the Medicaid Child Health Check-Up
Services Coverage and Limitations Handbook. The plan is required
to contact members and follow-up on the state-issued CHCUP letter
to encourage the member to come in for a health assessment and
preventive care.
	 
	c.	 	Members must be referred to appropriate service
providers for further assessment and treatment of conditions
found in the examination within six months after the request
for a CHCUP.

AHCA Contract No. FA523, Attachment I, Page 5 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	d.	 	Members must be offered scheduling assistance to
make medical appointments and to obtain transportation.
	 
	e.	 	This service includes the maintenance of a coordinated
system to follow the member through the entire range of screening
and treatment, as well as supplying CHCUP training to providers.
	 
	f.	 	In accordance with section 409.912, F.S., the plan shall
achieve a CHCUP screening rate of at least 60 percent for those
members who are continuously enrolled for at least eight (8)
months. This screening compliance rate shall be based on the CHCUP
screening data reported by the plan pursuant to section 60.0,
Reporting Requirements of this contract, and the data reported
shall be monitored by the Agency for accuracy. The plan must
complete both the CHCUP Report template and the — 60 percent
Screening Ratio Template. If the plan does not achieve the 60
percent screening ratio, a corrective action plan is required to
be filed with the Agency no later than February 15th. Any data
reported that is found to be inaccurate shall be disallowed by the
Agency and the Agency may consider such findings as being in
violation of the contract (refer to section 70.17, Sanctions).
	 
	 	 	In addition to the above requirement, the plan shall adopt annual
screening and participation goals to achieve at least an 80 percent
CHCUP screening and participation rate in accordance with section
5360, Annual Participation Goals, of the State Medicaid Manual. If
the plan does not meet the 80 percent screening and participation
ratios, a corrective action plan must be filed with the Agency no
later than February 15`h

	10.8.2	 	Dental Services (optional)
	 
	 	 	Dental services are defined in the Medicaid Dental Services Coverage
and Limitations Handbook. Children’s Medicaid dental services include
diagnostic services, preventive treatment, restorative treatment,
endodontic treatment, periodontal treatment, restorative treatment,
surgical procedures and/or extractions, orthodontic treatment and
complete and partial dentures for beneficiaries under age 21. Complete
and partial denture relines and repairs are also included, as well as
adjunctive and emergency services. 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 incision and drainage of
abscess.
	 
	10.8.3	 	Diabetes Supplies and Education
	 
	 	 	In the same manner as specified in section 641.31, F.S., the plan
shall provide coverage for medically appropriate and necessary
equipment, supplies, and services used to treat diabetes, including
outpatient self-management training and educational services, if the
member’s primary care physician, or the physician to whom the
patient has been referred who specializes in treating diabetes,
certifies that the equipment, supplies and services are necessary.
	 
	10.8.4	 	Family Planning Services
	 
	 	 	These services are rendered for the purposes of enabling eligible
beneficiaries to make comprehensive, informed decisions about family
size and/or spacing of births as specified in the Medicaid Services
Coverage and Limitations handbooks. The provider provides the
following minimum services: plan 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 plan shall furnish the services on a voluntary and
confidential basis.
	 
	b.	 	The plan shall allow members full freedom of choice of
family planning methods covered under the Medicaid program,
including Medicaid covered implants, when there are no medical
contra-indications.

AHCA Contract No. FA523, Attachment I, Page 6 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	c.	 	In accordance with section 381.0051, F.S., the plan shall
render these services to eligible members under the age of 18
provided the member is married, a parent, pregnant, has written
consent by a parent or legal guardian, or in the opinion of a
physician, the member may suffer health hazards if the service is
not provided.
	 
	d.	 	The provisions of this subsection shall not be
interpreted so as to prevent a provider or other person from
refusing to furnish any contraceptive or family planning service,
supplies, or information for medical or religious reasons; and
the provider or other person shall not be held liable for such
refusal.
	 
	e.	 	Pursuant to 42 CFR 431.51 (b), the plan shall allow each
member to obtain family planning services from any participating
Medicaid provider and require no prior authorization for such
services. If the member receives services from a non-plan
Medicaid provider, then the plan must reimburse at the Medicaid
reimbursement rate, unless another payment rate is negotiated.
	 
	f.	 	In accordance with section, 409.912, F.S. the plan shall
make available and encourage all pregnant women and mothers with
infants to receive, scheduled postpartum visits for the purpose
of voluntary family planning, including discussion of all methods
of contraception, as appropriate, and counseling and services for
family planning to all women and their partners. The plan shall
direct providers to maintain documentation in the medical records
to reflect this.

	10.8.5	 	Freestanding Dialysis Facility Services
	 
	 	 	Program requirements are specified in section 409.906, F.S., and the
Freestanding Dialysis Center Services Coverage and Limitations Handbook.
Such services must be provided in accordance with the policy and service
provisions specified by fee-for-service Medicaid.
	 
	10.8.6	 	Hearing Services
	 
	 	 	These services include a hearing evaluation, diagnostic testing and
selective amplification procedures necessary to certify an individual
for a hearing aid device, and fitting and dispensing of hearing aids
and repair services as specified in the Medicaid Hearing Services
Coverage and Limitations Handbook. Medical and surgical treatment for
hearing disorders is part of physician services.
	 
	10.8.7	 	Home Health Care Services and Durable Medical Equipment
	 
	 	 	These services are intermittent nursing services by a registered nurse
or licensed practical nurse and/or personal care services by a home
health aide with accompanying necessary medical supplies, appliances and
durable equipment appropriate for use in the beneficiary’s place of
residence. These services are provided for eligible beneficiaries
primarily to maintain physical and emotional comfort and to assist the
beneficiary toward independent living in a safe environment as specified
in the Medicaid Home Health Services Coverage and Limitations and the
Durable Medical Equipment (DME)/Medical Supplies Services Coverage and
Limitations Handbook. Policy requirements include, but are not limited
to:

	a.	 	All services and medical equipment furnished by the plan
shall be contained in an individualized written plan of care
developed by health care professionals, including the attending
physician. The plan of care is designed to meet the medical,
health, and rehabilitative needs of the recipient and is approved
by the attending physician as evidenced by his or her original
signature and re-approved at least:

	•	 	Every 60 days or whenever the beneficiary’s
condition for home health services changes.
	 
	•	 	For disposable medical supplies, the
medical necessity must be re-determined every 6 months
and the prescription cannot be dated more than 14 days
after initiation.
	 
	•	 	For oxygen services, the medical necessity renewal time
frame is 12 months.

AHCA Contract No. FA523, Attachment I, Page 7 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	b.	 	Services rendered by a home health aide shall be
under the continuous supervision of a registered nurse.
	 
	c.	 	All services provided to Medicaid beneficiaries in
their place of residence shall be prescribed by a physician.
Provision of medically necessary supplies/DME does not
require a beneficiary to be homebound.
	 
	d.	 	Medical equipment as specified in the DME/Medical
Supplies Services Coverage and Limitations Handbook.

	10.8.8	 	Hospital Services
	 
	10.8.8.1	 	Inpatient
	 
	 	 	These services are 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 hospital services include but are not limited to 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 as specified in the
Medicaid Hospital Services Coverage and Limitations Handbook. This
service includes 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. Inpatient
hospital services include rehab hospital care. Rehab inpatient care
days are also counted as inpatient hospital days. The plan may
provide services in a nursing home as downward substitution for
inpatient care. Such services shall not be counted as inpatient
hospital days.
	 
	 	 	The service also includes the following:

	a.	 	Medically necessary and appropriate transplants: bone
marrow, all ages; cornea, all ages; and kidney, all ages. For
other transplants not covered by Medicaid, the evaluations,
pre-transplant care and post-transplant follow-up care are
covered by Medicaid and, therefore, must be covered by the plan
even though the transplant procedure is not covered. Transplant
service components are also covered under outpatient services,
physician services and prescribed drug services per the
applicable Medicaid Services Coverage and Limitations handbooks.
	 
	 	 	The plan is not responsible for the cost of transplant
evaluations, pre-transplant care and post transplant follow-up,
when an adult member (age 21 and over) is listed with the United
Network for Organ Sharing (UNOS) as a level IA, 1B, or 2 candidate
for heart transplant. The plan must disenroll these members at the
conclusion of the transplant evaluation and cannot re-enroll the
member until at least one-year post transplant.
	 
	 	 	The plan is not responsible for the cost of a completed adult
heart transplant evaluation regardless of whether or not the
beneficiary was determined a candidate for a transplant. The plan
is responsible for the cost of adult heart transplant evaluations
that are not completed for any reason.
	 
	 	 	The plan is not responsible for the cost of pre-transplant care
and post transplant follow-up when a member has been listed as a
candidate for a pediatric heart, lung or heart/lung transplant
(ages 20 and under) or a liver transplant (all ages). If, at the
conclusion of the transplant evaluation, the beneficiary is
listed with UNOS as a level
IA, 1B or 2 for heart, lung or heart/lung or 1, Model End Stage
Renal Disease (meld) score of 11-25, for a liver transplant, the
plan will disenroll the beneficiary. The beneficiary will have
the option to re-enroll at one-year post transplant. The plan is
responsible for the cost of the above transplant evaluations.
	 
	b.	 	Physical therapy services when necessary and provided during a
member’s inpatient stay.

AHCA Contract No. FA523, Attachment I, Page 8 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	c.	 	The plan shall be at risk for the provision of up to 45 days of
inpatient hospital care for each enrolled member, as determined
necessary by the physician responsible for discharging an enrolled
member from the hospital.
	 
	 	d.	 	The plan shall provide up to 45 days of inpatient coverage per
member from July 1 or the initial date of enrollment whichever comes
later, continuing through June 30.
	 
	 	d.	 	The plan shall provide up to 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 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. Such inpatient hospital care shall be included in the 45
days of inpatient hospital care for which the plan is at risk, as
specified in c. and d. above.
	 
	 	f.	 	The plan is responsible for the cost of transporting a
member from a non-participating facility or hospital to a
participating facility or hospital if the reason for transport
is solely for the plan’s convenience, regardless of whether the
plan covers Medicaid transportation services.
	 
	 	g.	 	The 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 and comply
with the provisions of section 641.31, F.S.

	 	1.	 	The plan shall provide for at least a 48-hour hospital
length of stay following a normal vaginal delivery, and at least a
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 provider in
consultation with the mother.
	 
	 	2.	 	The plan shall prohibit the following practices:
	 
	 	 	 	Denying the mother or newborn child eligibility, or continued
eligibility, to enroll or renew coverage under the terms of the
plan, solely for the purpose of avoiding the NMHPA
requirements;
	 
	 	 	 	Providing monetary payments or rebates to mothers to encourage
them to accept less than the minimum protections available under
NMHPA;
	 
	 	 	 	Penalizing or otherwise reducing or limiting the reimbursement of
an attending provider because the provider provided care in a
manner consistent with NMHPA;
	 
	 	 	 	Providing incentives (monetary or otherwise) to an attending
provider to induce the provider to provide care in a manner
inconsistent with NMHPA;
	 
	 	 	 	Restricting benefits for any portion of the 48-hour (or 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.

AHCA Contract No. FA523, Attachment I, Page 9 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

10.8.8.2 Outpatient

Outpatient hospital services are preventive, diagnostic, therapeutic,
or palliative care under the direction of a physician at a licensed
acute care hospital. Such outpatient hospital services include
emergency room, dressings, splints, oxygen and physician ordered
services and supplies necessary for the clinical treatment of a
specific diagnosis or treatment as specified in the Medicaid Hospital
Services Coverage and Limitations Handbook. Emergency medical services
as defined in section 100.0, Glossary, of this contract, are specified
in the Medicaid Hospital Services Coverage and Limitations Handbook
and section 20.10, Emergency Care Requirements. Policy requirements
include:

	a.	 	The plan shall provide outpatient hospital services and
emergency medical care services as medically necessary and
appropriate and without any specified dollar limitation.
	 
	b.	 	The plan shall cover the cost to all members of any
medically necessary duration of stay in a non-designated
facility, which resulted from a medical emergency until such
time as they can be safely transported to a plan facility.
	 
	c.	 	The plan shall have a procedure for the authorization of
dental care and associated ancillary services provided in an
outpatient hospital setting if that care meets the following
requirements;

	 	•	 	Is provided under the direction of a dentist at a licensed
hospital;
	 
	 	•	 	Is medically necessary or, if not
usually considered medically necessary, is considered
medically necessary in a hospital setting due to the
beneficiary’s disability, the beneficiary’s mental
health condition, or the beneficiary’s abnormal behavior
due to emotional instability or a developmental
disability, which necessitates the services being
provided in a hospital.

10.8.8.3 Hospital Ancillary Services

Ancillary services that are provided by the hospital include, but are
not limited to, radiology, pathology, neurology, neonatology and
anesthesiology. When the plan or plan’s authorized physician authorizes
these services (either inpatient or outpatient), the plan must
reimburse the professional component of the service at the Medicaid
line item rate, unless another reimbursement rate has been negotiated.
This is also required for emergency services rendered by non-plan
physicians for ancillary services provided in a hospital setting.

10.8.9 Immunizations

In accordance with section 1905(r)(1) of the Social Security Act, the
plan shall participate or direct its providers to participate in the
Vaccines For Children Program (VFC), the program administered by the
Department of Health (DOH), Bureau of Immunizations, which provides
vaccines at no charge to physicians, and eliminates any need to refer
children to county health departments (CHD) for immunizations. For
immunizations covered by Medicaid but not provided through VFC the
plan shall be responsible for coverage and reimbursement to the
provider. The plan is required to:

	a.	 	Provide immunizations in accordance with the childhood
immunization schedule as approved by the appropriate Recommended
Childhood Immunization Schedule for the United States or when it
is shown to be medically necessary for the child’s health in
accordance with section 409.912, F.S.
	 
	b.	 	Document that the plan is enrolled in the VFC program or that its
physicians have directly enrolled.
	 
	c.	 	Ensure its physicians have a sufficient supply of vaccines
from the plan if the plan is the VFC enrollee. If the plan’s
physicians are directly enrolled in the VFC program, they shall be
directed to maintain adequate vaccine supplies.
	 
	d.	 	Pay no more than the Medicaid program vaccine
administration fee of $10.00 per administration unless another rate
is negotiated with the provider.

AHCA Contract No. FA523, Attachment I, Page 10 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Title XXI MediKids participants do not qualify for the Vaccines for
Children Program as specified in this section. For immunizations
provided to Title XXI MediKids participants, the plan shall advise
providers to bill Medicaid fee-for-service directly at a rate
determined by the Agency. The administration fee is included in the
capitation rates for both Title XXI MediKids and Title XIX Medicaid
programs.

10.8.10 Independent Laboratory and Portable X-Ray Services

These services are medically necessary and appropriate diagnostic
laboratory procedures and portable x-rays ordered by a physician or
other licensed practitioner of the healing arts. Policies, procedures
and services covered by each program are described in the Medicaid
Independent Laboratory Services Coverage and Limitations Handbook;
and the Portable X-Ray Services Coverage and Limitations Handbook.
The programs encompass only those services approved by Medicaid for a
licensed independent laboratory or portable x-ray company under the
related service requirements and limitations described in the services
coverage and limitations handbooks. Laboratory and x-ray services
provided by a hospital, clinic or Medicaid provider enrolled as
physician services providers are not included in these programs. Such
services provided by a hospital, physician or clinic is included in
the definition of hospital, physician or clinic, as appropriate. In
addition, such services provided via a hospital setting are also
discussed under section 10.8.8.3, Hospital Ancillary Services. Policy
requirements include:

	a.	 	The plan must furnish, at a minimum, those laboratory and
portable x-ray procedures currently covered by the independent
laboratory and portable x-ray programs as described in their
respective handbooks.
	 
	b.	 	The plan shall pay for laboratory tests provided by
public providers as specified in section 20.8.9, Public Provider
Claims, without prior authorization as specified in section
110.1, Laboratory Tests And Associated Office Visits To Be Paid
By Plan Without Prior Authorization When Initiated By County
Health Department.

10.8.11 Physician Services

Physician services are those services and procedures rendered by a
licensed physician at a physician’s office, patient’s home, hospital,
nursing facility or elsewhere when dictated by the need for preventive,
diagnostic, therapeutic or palliative care, or for the treatment of a
particular injury, illness or disease as specified in the Medicaid
Physician Services Coverage and Limitations Handbook. For purposes of
this contract advanced registered nurse practitioner (ARNP) services,
physician assistant services (PA), podiatry services, ambulatory
surgical centers service, CHD services, rural health clinic services,
federally qualified health center (FQHC) services, birthing center
services (including the services of certified nurse midwives licensed
under chapter 464, F.S., and midwives licensed under chapter 467, F.S.),
and chiropractic services are included as physician services because
they can be provided by a physician and, as such, are included in the
capitation rate paid to the plan. These services must be provided as
specified in the appropriate Medicaid Services Coverage and Limitations
handbook. Their listing does not mean that the services must be
performed by the indicated professional category or at the indicated
location. Policy requirements include:

	a.	 	The plan shall furnish the full range of the
preventive medicine services program components as described
in the Medicaid Coverage and Limitations handbooks.
	 
	b.	 	The plan shall furnish psychiatrist services as medically
necessary for Medicaid beneficiaries, which may be rendered in
the psychiatrist’s office or in an outpatient or inpatient
setting.
	 
	c.	 	The plan shall exclude the provision of experimental and
clinically unproven procedures. (See section 409.905, F.S.)
	 
	d.	 	The plan shall provide for adult health screenings as
specified in the Agency’s Medicaid Services Coverage and
Limitations Handbooks.

AHCA Contract No. FA523, Attachment I, Page 11 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	e.	 	The provisions of sections 641.19, 641.31 and 641.51,
F.S. are incorporated by reference and as such the plan shall
allow members to use network chiropractic, dermatological
services, podiatric services, and OB/GYN services without
authorization.
	 
	f.	 	Pursuant to section 4712 of the Balanced Budget Act of
1997, plans contracting with FQHCs and rural health clinics (RHCs)
must reimburse those entities at rates comparable to those rates
paid for similar services in the FQHC’s or RHC’s community. The
plan shall report quarterly to the Agency the payment rates and
the payment amounts made to FQHCs and RHCs for contractual
services provided by these entities.
	 
	g.	 	Notwithstanding subsection 20.8.9, Public Provider
Claims, without prior authorization, the plan shall pay, at the
contracted rate or the Medicaid fee-for-service rate, all valid
claims initiated in any CHD for office visits, prescribed drugs,
and laboratory services directly related to DCF emergency shelter
medical screening, and tuberculosis as specified in section
110.1, Laboratory Tests And Associated Office Visits To Be Paid
By Plan Without Prior Authorization When Initiated By County
Health Department, once the CHD has notified the plan and has
provided the plan’s primary care provider with results of such
testing and the associated office visit. Reimbursement by the
plan for such services is required only if the CHD provides the
plan with copies of the appropriate medical record.
	 
	h.	 	The 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. Medical necessity shall be determined in accordance
with section 641.31, F.S.

10.8.11.1 Pregnancy Related Requirements

	a.	 	Florida’s Healthy Start Prenatal Risk Screening.
	 
	 	 	The plan shall ensure that the provider offers, as required by
section 383.14, F.S., and Rule 64C-7.009, F.A.C., Florida’s Healthy
Start prenatal risk screening to each member who is pregnant as part
of her first prenatal visit. The plan shall ensure the provider uses
the DOH prenatal risk DH Form 3134, which can be obtained from the
local county health department. The plan shall ensure the provider
retains a copy of the completed screening instrument in the member’s
medical record and shall provide a copy to the member. The plan
shall ensure the provider submits the completed DH Form 3134 to the
county health department in the county where the prenatal screen was
completed within ten business days of completion. The plan is
strongly encouraged to collaborate with the Healthy Start care
coordinator within the patient’s county of residence to assure
risk-appropriate care is delivered.
	 
	b.	 	Florida’s Healthy Start Infant (Postnatal) Screening Instrument.
	 
	 	 	Risk factor information for the Florida’s Healthy Start Infant
(Postnatal) Risk Screening Instrument (DH Form 3135) is taken from
the Certificate of Live Birth and is generally completed by the
staff who complete the Certificate of Live Birth. Plans providing
birthing services shall ensure the provider completes Florida’s
Healthy Start Infant (Postnatal) Risk Screening Instrument on each
live birth and offer the family referral to further Healthy Start
services as appropriate. The plan must ensure the provider submits
the Infant (Postnatal) Risk Screening Instrument with the
Certificate of Live Birth to the CHD in the county where the infant
was born. DH Form 3135 can be obtained from the local county health
department. The plan shall ensure the provider retains a copy of the
completed screening instrument in the member’s medical record and
provide a copy to the member.
	 
	c.	 	Pregnant women 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:

AHCA Contract No. FA523, Attachment I, Page 12 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	1.	 	If the referral is to be made at the same time the risk
screen is administered, the provider may indicate on the risk
screening form that the woman or infant is invited to
participate based on factors other than score.
	 
	 	2.	 	If the determination is made subsequent to risk screening,
the provider may directly refer the woman or infant to the Healthy
Start care coordination provider based on assessment of actual or
potential factors associated with high risk, such as HIV, Hepatitis
B, substance abuse, or domestic violence.

	d.	 	The plan shall refer all pregnant, breastfeeding and postpartum
women, infants and children up to age five to the local Women, Infants
and Children (WIC) office. For the initial referral for WIC
certification, the plan must complete the Florida WIC program Medical
Referral Form with the current height or length and weight (taken
within 60 days of the WIC appointment); hemoglobin or hematocrit (see
chart below); and any identified medical/nutritional problems. For
subsequent WIC certifications the plan shall encourage its providers to
coordinate with the local WIC office to provide the above referral data
from the most recent CHCUP. Each time a WIC Referral Form is completed,
the plan shall ensure the provider gives a copy of the WIC Referral
Form to the member and retains a copy in the member’s medical record.

	 	 	 
	WIC Category
	 	WIC Blood Work Screening Schedule

	Pregnant Woman

	 	Once during the current pregnancy
	 
	 	 
	Breastfeeding Woman up to 1 year postpartum

	 	Once after delivery
	 
	 	 
	Postpartum Woman (not breastfeeding) up to 6
months postpartum

	 	Once after delivery/termination of pregnancy
	 
	 	 
	Infant

	 	Once between 6-12 months of age (preferably
between 9-12 months)
	 
	 	 
	Child 1 — 2 years

	 	Once, preferably between 15 — 18 months
	 
	 	 
	Child 2 — 5 years

	 	Once every year unless an abnormal value is
found, (<11.lgm/dl hemoglobin, <33% hematocrit)
then a follow-up blood test is required at six month
intervals

	e.	 	The plan shall ensure the provider provides, as required by Chapter
381, F.S., all women of childbearing age HIV counseling and offer them
HIV testing. For prevention, early identification of women with HIV
infection, and reduction of perinatal transmission, the plan shall
ensure that its providers counsel and offer HIV testing to all women of
childbearing age. Florida law requires all pregnant women to be
counseled and offered HIV testing at the initial prenatal care visit and
again at 28-32 weeks. If a pregnant woman declines HIV testing, a signed
objection must be attempted, in accordance with section 384.31, F.S. and
Ch. 64D-3.019, Florida Administrative Code. The plan shall ensure that
all pregnant women who are HIV infected are counseled about and offered
the latest antiretroviral regimen recommended by the U.S. Department of
Health and Human Services, Public Health Service Task Force 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 Florida Department of Health, Bureau of HIV/AIDS
at (850) 245-4334, or you may reach the DHHS website at
http:llaidsinfo.nih.gov/guidelines/.
	 
	f.	 	The plan shall ensure that providers routinely screen all Medicaid
eligible women receiving prenatal care for the Hepatitis B surface
antigen (HBsAg) early in each pregnancy, preferably during the first
prenatal visit. All pregnant women shall be routinely tested for the
hepatitis B surface antigen (HBsAg) at the time of the first
examination relating to the current pregnancy. Pregnant women who
tested negative at the first visit and are considered high-risk for
hepatitis B infection shall have a second HBsAG test performed at 28 to
32 weeks of pregnancy. This test shall be performed at the same time
that other routine prenatal screening is ordered. All HBsAg-positive
women shall be reported to the local county health department. Women
who are HBsAg-positive shall be referred to Healthy Start regardless of
their Healthy Start screening score.

AHCA Contract No. FA523, Attachment I, Page 13 of 166

Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	g.	 	Infants born to HBsAg-positive members shall receive
Hepatitis B Immune Globulin (HBIG) and the Hepatitis B vaccine
once they are physiologically stable, preferably within 12 hours
of birth and shall complete the hepatitis B vaccine series
according to the recommended vaccine schedule per the guidelines
established by the appropriate Recommended Childhood Immunization
Schedule for the United States. These infants shall be tested for
HBsAg and Hepatitis B surface antibodies (anti-HBs) six months
after the completion of the vaccine series to monitor the success
or failure of the therapy.
A positive HBsAg result in any child aged 24 months or less shall be
report to the local county health department within 24 hours. Infants
born to women who are HBsAg-positive shall be referred to Healthy
Start regardless of their Healthy Start screening score.
	 
	h.	 	All HBsAg-positive prenatal or postpartum women, their
infants, and contacts shall be reported to the Perinatal Hepatitis B
Prevention Coordinator at the local County Health Department.
Information collected for each individual shall include: name, date
of birth, race, ethnicity, address, ex (infants and contacts),
laboratory test performed and date sample collected, due date or
EDC, whether or not prenatal care was received (prenatal woman), and
immunization dates (infants and contacts). Use of the current
Perinatal Hepatitis B Case and Contact Report (DH Form 1876) is
strongly encouraged but not required. This form may be obtained from
the Department of Health. For further information please see Rule
64D-3.013 of the Florida Administrative Code at website:
http://fac.dos.state.fl.us/faconline/chapter64.pdf and/ or contact
your county or state Perinatal Hepatitis B Prevention Coordinator.
	 
	 	 	The plan shall allow pregnant women to choose the plan’s contracted
or staff OB/GYNs as their primary care physicians to the extent that
the OB/GYN is willing to participate as a primary care provider. The
plan shall not require more restrictive authorization criteria for
OB/GYN primary care physicians than it has for non-OB/GYN primary
care physicians. If the plan requires prior authorization for
ancillary services, it may require that an OB/GYN obtain prior
authorization for certain pregnancy-related ancillary services (such
as non-stress-tests, ultrasounds), and amniocentesis.
	 
	J.	 	The plan is required to provide the most appropriate and
highest level of quality care for pregnant members. Required care
also includes the following:

	 	1.	 	Prenatal Care: Requirements include a pregnancy test and
a nursing assessment with referrals to a physician, physician’s
assistant or nurse practitioner for comprehensive evaluation;
case management through the gestational period according to the
needs of the client; referrals and follow-up. The high medical
risk diagnoses are listed in Appendix B of the Medicaid Physician
Services Coverage and Limitations Handbook and require direct
care by the physician.
	 
	 	 	 	The plan must schedule return or more frequent visits as the
member’s condition warrants, at least every four weeks until the
32nd week, every two weeks until the 36th week, and every week
thereafter until delivery, unless the member’s condition requires
more frequent visits.
	 
	 	 	 	For members who fail to keep appointments, the plan must contact the
members as soon as possible and arrange for their necessary and
continued prenatal care. Members must be assisted if necessary in
making delivery arrangements.
	 
	 	 	 	All pregnant women must be screened for tobacco use with
provision of smoking cessation counseling and appropriate
treatment as needed.
	 
	 	2.	 	Nutrition Assessment/Counseling: The plan shall ensure
the provider provides nutrition assessment and counseling to all
pregnant members. Nutrition assessment/counseling should include
the provision of safe and adequate nutrition for infants by the
protection and promotion of breastfeeding and by the proper use of
breast milk substitutes. The plan should make a mid-level
nutrition assessment. Individualized diet counseling and a
nutrition care plan are to be provided by public health
nutritionists, nurses or physicians following nutrition
assessments. The nutrition care plan must be documented in the
member’s medical record by the person providing counseling.

AHCA Contract No. FA523, Attachment I, Page 14 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	3.	 	Obstetrical Delivery: The plan must develop and use
generally accepted and approved protocols for both low risk and
high risk deliveries which shall reflect the highest standards
of the medical profession, including Healthy Start, prenatal
screen specified in section B.4.h Florida’s Healthy Start
Prenatal Risk Screening, of this attachment, and ensure that
its providers use such protocols. A preterm delivery risk
assessment must be determined and documented in the member’s
medical record by the 28th week.
	 
	 	 	 	If the delivery is determined to be high risk, obstetrical care
during labor and delivery must include preparation by all
attendants of extraordinary symptomatic evaluation, progress
through the final stages of labor and immediate postpartum care.
The high medical risk diagnoses are listed in Appendix B of the
Medicaid Physician Services Coverage and Limitations Handbook and
require direct care by the physician.
	 
	 	4.	 	Newborn Care: The plan must ensure the provider
provides for the highest level of care for the newborn
beginning immediately after birth, which must include but is
not limited to:

	 	a)	 	Instilling of a prophylaxis into
each eye of the newborn in accordance with section
383.04 F.S.
	 
	 	b)	 	Securing of a cord blood sample for
laboratory testing for type Rh determination and
direct Coombs test when the mother is Rh negative.
	 
	 	c)	 	Weighing and measuring of the newborn.
	 
	 	d)	 	Inspecting for abnormalities and/or complications.
	 
	 	e)	 	Administering of one half milligram of vitamin K.
	 
	 	f)	 	APGAR scoring.
	 
	 	g)	 	Any other necessary and immediate need
for referral and consultation from a specialty
physician, such as the Healthy Start (postnatal) infant
screen, as specified in section B.4.i., Florida’s
Healthy Start Infant (Postnatal), of this attachment.
	 
	 	h)	 	Newborn Hearing Screenings: All newborn
and infant hearing screenings must be conducted by an
audiologist licensed under Chapter 468, F.S.; a physician
licensed under Chapter 458 or 459, F.S.; 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 licensed
audiologist.

	 	5.	 	Postpartum Care: Plans must provide a postpartum
examination for the mother within six weeks after delivery.
This visit shall include voluntary family planning, including a
discussion of all methods of contraception, as appropriate. The
plan shall ensure that eligible newborns be appropriately
enrolled and that continuing care of the newborn be provided
through the Child Health Check-Up program component.

10.8.11.2 Hysterectomies, Sterilizations, and Abortions

The plan must maintain a log of all hysterectomy, sterilization, and
abortion procedures performed for plan members. The log must include,
at a minimum, member name and identifying information and date and type
of procedure.

10.8.12 Prescribed Drug Services

These services are defined as those products and services associated
with the dispensing of medicinal drugs pursuant to a valid prescription
as defined in chapter 465, F.S. (the “Florida Pharmacy Act”). This
benefit

AHCA Contract No. FA523, Attachment I, Page 15 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	generally includes all legend drugs dispensed to members in outpatient
settings and includes patent or proprietary preparations as well.
Covered drugs, injectables, food supplements and other prescribed drug
services are described in the Prescribed Drugs Services Coverage,
Limitations and Reimbursement Handbook. These services also include
payment for Medicaid reimbursable psychotropic drugs. Policy
requirements include:
	 
	a.	 	The plan shall make available those drugs and dosage
forms currently covered by the Medicaid Program.
	 
	b.	 	The plan shall not arbitrarily deny or reduce the
amount, duration, or scope of prescriptions solely because of
the diagnosis, type of illness, or condition. The plan may place
appropriate limits on prescriptions based on criteria such as
medical necessity or for the purpose of utilization control,
provided the services can reasonably be expected to achieve the
purpose set forth in the State Plan. The plan may not place
limits on prescription drugs listed in section 409.912, F.S.,
such as anti-psychotics, anti-depressants and HIV-specific
anti-retrovirals.
	 
	c.	 	The plan’s pharmacy benefit shall comply with all
applicable federal and state laws. The plan shall submit for
Agency review a description of its pharmacy benefit, including
but not limited to its formulary and prior authorization process.
This information must be submitted to the Agency within 30 days
following the effective date of this contract and prior to any
changes.
	 
	d.	 	The plan shall provide one course of twelve weeks duration
or the manufacturer’s recommendation per year of nicotine
replacement therapy, either nicotine transdermal patches or
nicotine gum, to members who are currently smoking and desire to
quit smoking in accordance with the Medicaid Prescribed Drug
Services Coverage, Limitations and Reimbursement Handbook.
	 
	e.	 	The plan shall comply with the settlement agreement for
Hernandez, et. al. v. Medows, case number 02-20964
Civ-Gold/Simonton. The plan shall ensure that its enrollees are
receiving the functional equivalent of those goods and services
received by Medicaid fee-for-service recipients in accordance
with the Hernandez settlement. Additionally, the plan shall
maintain a log of all correspondence and communications from
enrollees relating to the Ombudsman process. Plan enrollees are
third party beneficiaries for this section of this contract.
	 
	f.	 	The plan shall conduct surveys of participating plan
pharmacies for compliance with the Hernandez settlement and this
contract. The plan shall document these surveys and maintain the
survey documents and site visit results for at least five years.
	 
	g.	 	The plan shall provide name brand drugs in compliance
with Florida law. The plan shall reimburse a pharmacy for the cost
of a multi-source brand drug if the prescriber writes in his or
her own handwriting on the valid prescription that the drug is
medically necessary (and otherwise complies with F.S. 465.025) and
the prescriber submits a form to the plan. The form shall be the
functional equivalent of the F.D.A. MedWatch form. The form will
require the prescriber to confirm in writing that an individual
patient has had an adverse reaction to a generic drug or has had,
in his or her medical opinion, better medical results when taking
the brand name drug.

10.8.13 Therapy Services

Medicaid therapy services provide physical, speech-language (including
augmentative and alternative communication systems), occupational and
respiratory therapies. Medicaid pays only for therapy services that are
medically necessary for the provision of therapy evaluations and
individual therapy treatment. Medicaid therapy services are limited to
children and young people who are under the age of 21 as specified in
the Therapy Services Coverage and Limitations Handbook. In addition,
adults are covered for physical and respiratory therapy services under
the outpatient hospital services program as specified in the Medicaid
Hospital Services Coverage and Limitations Handbook. Policy
requirements include:

AHCA Contract No. FA523, Attachment I, Page 16 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	a.	 	Members must be referred to appropriate service
providers for further assessment and treatment of conditions.
	 
	b.	 	Members must be offered scheduling assistance in
making treatment appointments and obtaining transportation.
	 
	c.	 	This service includes the maintenance of a coordinated
system to follow the member through the entire range of screening
and treatment.
	 
	d.	 	The Agency shall reimburse schools participating in
the certified school match program pursuant to sections
236.0812 and 409.908, F.S., for school-based therapy services
rendered to members in accordance with section 20.8.10,
Certified School Match Program.
	 
	e.	 	The provision of school-based therapy services to a
plan member is not a replacement, substitution, or fulfillment
of a service prescription or doctors’ orders for therapy
services external to this plan.

10.8.14 Transportation Services (optional)

These services are the arrangement and provision of an appropriate
mode of transportation for members to receive necessary medical care
services. Types of transportation services include: ambulance,
non-emergency medical vehicles, public and private transportation
vehicles and air ambulances as specified in the Medicaid
Transportation Services Coverage and Limitations Handbook. Policy
requirements include:

	a.	 	The plan must assure that providers of transportation
are appropriately licensed and insured in accordance with the
provisions of the Medicaid Transportation Services Coverage
and Limitations Handbook.
	 
	b.	 	The plan must provide transportation for its members
seeking necessary Medicaid services whether or not those
services are covered under terms of this contract.
	 
	c.	 	The plan is not required to follow the requirements of
the Commission for the Transportation Disadvantaged or the
Transportation Coordinating Boards as set forth in chapter 427,
Florida Statutes.
	 
	d.	 	The plan will be responsible for the cost of
transporting a member from a non-participating facility or
hospital to a participating facility or hospital if the reason
for transport is solely for the plan’s convenience, regardless
of whether the plan covers Medicaid transportation services.

10.8.15 Visual Services

These services include a visual examination; the fitting, dispensing,
and adjustment of eyeglasses; follow-up examinations, and contact
lenses as specified in the Medicaid Visual and Optometric Services
Coverage and Limitations Handbooks. Examinations for eye diseases and
treatment are part of the physician and optometric services programs.
Lenses must meet American National Standards Institute (ANSI)
standards. Eyeglasses are available through Prison Rehabilitative
Industries and Diversified Enterprise (PRIDE) if available at lower
prices for comparable quality than those charged by the Division of
Corrections optical laboratory. An abbreviated list of
products/services available from PRIDE may be obtained by contacting
PRIDE’s Tallahassee branch office at (850) 487-3774 or Suncom
277-3774.

     10.9 Quality and Benefit Enhancements

In addition to those covered services specified in this section, the
plan shall offer those quality and benefit enhancements to enrolled
Medicaid beneficiaries as specified below. Quality and benefit
enhancements shall be offered in community settings that are accessible
to members. The plan shall inform members and providers of the quality
and benefit enhancement programs, and how to access those services,
through the member and provider handbooks. The plan shall develop and
maintain written policies and procedures to implement these
enhancements. Annual training of providers that is sponsored by
multiple plans shall meet

AHCA Contract No. FA523, Attachment I, Page 17 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

the provider training requirements for the programs listed below
provided that the plan is a co-sponsor of the training. The plan is
encouraged to actively collaborate with community agencies and
organizations, including county health departments, local Early
Intervention Programs, Healthy Start Coalitions, and local school
districts in offering these services. If the plan involves the member in
existing community programs for purposes of meeting the quality and
benefit enhancements requirements, the plan is encouraged to document
referrals and follow-up on the member’s receipt of services from the
community provider.

Children’s Programs: The plan shall provide regular general wellness
programs targeted specifically towards plan members from birth to the
age of five or the plan shall make a good faith effort to involve
members in existing community children’s programs. Programs shall
promote increased utilization of prevention and early intervention
services for at risk families with children in the target population.
The plan shall pay for services recommended by the Early Intervention
Program when they are covered services and medically necessary. The plan
shall offer annual training for providers that promotes proper
nutrition, breastfeeding, immunizations, CHCUP, wellness, prevention and
early intervention services.

Domestic Violence: The plan shall have primary care physicians screen
members for signs of domestic violence, and shall offer referral
services to applicable domestic violence prevention community
agencies.

Pregnancy Prevention: Regularly scheduled pregnancy prevention
programs shall be conducted by the plan or the plan shall make a good
faith effort to involve members in existing community pregnancy
prevention programs, such as the Abstinence Education Program. The
programs shall be targeted towards teen members, but shall be open to
all members, regardless of age, gender, pregnancy status or parental
consent.

Prenatal/Postpartum Pregnancy Programs: The plan shall provide regular
home visits, conducted by a home health nurse or aide, and counseling
and educational materials to pregnant members and postpartum members
who are not in compliance with the plan’s prenatal and postpartum
programs. The plan shall coordinate with the Healthy Start care
coordinator to prevent duplication of services.

Smoking Cessation: Regularly scheduled smoking cessation programs shall
be conducted by the plan as an option for all plan members or the plan
shall make a good faith effort to involve members in existing community
smoking cessation programs. Members shall also have access to smoking
cessation counseling. The plan shall provide primary care physicians
with the Quick Reference Guide, a distilled version of the Public Health
Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and
Dependence, to assist in identifying tobacco users and supporting and
delivering effective smoking cessation interventions. Copies of this
guide may be obtained by contacting the DHHS, Agency for Health Care
Research and Quality (AHR) Publications Clearinghouse, at 1-800-358-9295
or write to P.O. Box 8547, Silver Spring, MD 20907.

Substance Abuse: The plan shall have primary care physicians screen
members for signs of substance abuse as part of prevention evaluation
at the following times and in the following circumstances: initial
contact with a new enrollee; routine physical examination; initial
prenatal contact; when the enrollee evidences serious overutilization
of medical, surgical, trauma, or emergency services; and when
documentation of emergency room visit suggests need. Targeted members
shall be asked to attend community or plan sponsored substance abuse
programs. The plan shall offer substance abuse screening training to
its providers on an annual basis. The plan is encouraged to use the
Florida Supplement to the American Society of Addictions Medicine
Patient Placement Criteria for coordination and treatment of
substance-related disorders with substance abuse providers.

10.10 Incentive Programs

The plan may offer incentives for members to receive preventive care
services. The plan shall receive written approval from the Agency prior
to the use of any special incentive items for members. Any incentive
program offered must be provided to all eligible individuals and will
not be used to direct individuals to select providers. Additionally,
any limitations and requirements below apply to all incentive programs.

AHCA Contract No. FA523, Attachment I, Page 18 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibt 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	a.	 	Services which are eligible for incentive programs
include CHCUP, immunizations, adult health screenings, family
planning, prenatal care, smoking/tobacco cessation, preventive
health classes, health education for management of chronic
conditions, education in appropriate use of plan services and
adolescent/teen good citizen sessions. All incentive programs must
be approved, in writing, by the Agency prior to use.
	 
	b.	 	Incentives must 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 10 percent of their copy and ads to health related
subjects, membership in clubs advocating educational advancement
and healthy lifestyles, etc.). Incentive dollar values must be in
proportion to the importance of the health service to be utilized
(e.g., a tee-shirt for attending one prenatal class but a car seat
for completion of a series of classes).
	 
	c.	 	Incentives shall be limited to a dollar value of $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 $50. A special exception to the dollar value
shall be made for infant car seats, strollers, and cloth baby
carriers or slings. Funds spent on transportation of members to
services or childcare provided during the provision of services
shall not be included in the dollar limits on incentives to use
services.
	 
	d.	 	The plan may offer an Agency-approved program for
pregnant women in order to encourage the commencement of prenatal
care visits in the first trimester of pregnancy and successful
completion of prenatal and post-partum care to promote early
intervention and prenatal care to decrease infant mortality and
low birth weight and to enhance healthy birth outcomes. The
program may include the provision of maternity and health related
items and education as an incentive. The request for approval must
contain a detailed description of the program and its mission.

10.11 Behavioral Health Care

The plan shall provide medically necessary behavioral health care
services pursuant to this section and section 10.1, General, for all
members once it has demonstrated its ability to provide such
services. The plan shall demonstrate its ability by the following:
submittal of a behavioral health services implementation plan that
shall be submitted to the Agency, and through an Agency conducted
on-site survey. See section 60.3 for behavioral health reporting
requirements.

All provisions in the Medicaid HMO contract that are not in conflict
with this section are still in effect and are to be performed at the
levels specified in the contract. Where there is a conflict, the
requirements in section 10.11, Behavioral Health Care, prevail.

10.11.1 Service Requirements (Behavioral Health)

The plan shall provide a full range of behavioral health care service
categories authorized under the State Medicaid Plan; sections 2.2, 2.3
and 2.5 of the Area specific Prepaid Mental Health Plan (PMHP)
requests for proposals (RFP) will apply to the respective Area
members.

The plan shall comply with the Mental Health Targeted Case
Management Coverage and Limitations Handbook, the Community Mental
Health Services Coverage and Limitations Handbook, and specific
service requirements as described in the general service
requirements of the PMHP RFP specific to the Medicaid Area except as
provided below:

The plan shall continue to provide Prescribed Drug Services in
accordance with section 10.8.12 of this contract.

The plan shall continue to provide outpatient medical services in
accordance with section 10.8.8.2 of this contract.

AHCA Contract No. FA523, Attachment I, Page 19 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

During the contract period the plan will work in conjunction with the
Managed Mental Health Care Advisory Group, Prepaid Providers, and
Behavioral Health Providers to establish clubhouse services in each
AHCA area.

In addition to the above requirements, the plan shall also adhere to the
requirements specified below.

	a.	 	Community Treatment of Patients Discharged from State Mental Hospitals
	 
	 	 	The plan shall provide medically necessary behavioral health services
to members who have been discharged from any state mental hospital.
The plan of care shall be aimed at encouraging the members to achieve
a high quality of life while living in the community in the least
restrictive environment which is medically appropriate; and reducing
the likelihood that these members shall be readmitted to a state
mental hospital.
	 
	b.	 	Evaluation and Treatment Services for Enrolled Children
	 
	 	 	The plan shall provide the medically necessary evaluation and
treatment services for children referred by DCF, DJJ, and by the
elementary, middle and secondary schools.
	 
	 	 	The plan shall establish medically necessary children’s services in
such a way as to minimize disruption of services available to
high-risk populations currently served by DCF (e.g., children in
delinquent programs, and other in-reach initiatives in schools and
housing projects). The plan shall promptly evaluate, provide
psychological testing to, and serve children (including delinquent
and dependent children) referred by the department in accordance
with medical necessity, and within the time limits specified in e.
below.
	 
	 	 	The plan shall provide court-ordered evaluation and treatment
required for children who are members pursuant to the specifications
in the Medicaid Community Mental Health Services Coverage and
Limitations Handbook.
	 
	 	 	For any child receiving services through the plan, the plan must
participate in all DCF or school staffing that may result in the
provision of services for which the plan is responsible. The plan
shall refer children to DCF when residential treatment is medically
necessary. The plan shall not be responsible for providing any
residential treatment for children enrolled in the plan. Placement
shall be coordinated with the appropriate DCF ADM or DJJ district
program office.
	 
	 	 	The plan’s case management of children in the plan is to include
involvement of persons, schools, programs, networks and agencies that
figure importantly in the child’s life. The plan shall make
determinations about care based on a comprehensive evaluation,
consultation from the above parties, as indicated, and appropriate
protocols for admission and retention. The Agency shall monitor
services for adequacy and conformity with agreements.
	 
	c.	 	Psychiatric Evaluations for Members Applying for Nursing Home Admission
	 
	 	 	The plan shall, upon request from the Alcohol, Drug Abuse and Mental
Health District (ADM) Offices, promptly arrange for and authorize
psychiatric evaluations for members applying for admission to a
nursing facility pursuant to OBRA 1987, and who, on the basis of a
screening conducted by CARES workers, are thought to need mental
health treatment. The examination shall be adequate to determine the
need for “specialized treatment” under the Act. State regulations have
been interpreted by the state to permit any “mental health
professional” defined under section 394.455, F.S., to make the
observations preparatory to the evaluation, although a psychiatrist
must sign such evaluations. The plan shall not be responsible for
annual resident reviews or for providing services as a result of a
Pre-admission Screening Assessment Annual Resident Review (PASSAR)
evaluation.
	 
	d.	 	The plan shall operate, as part of its crisis
support/emergency services, a 24 hours a day, seven days a week,
crisis emergency hot-line to be available to all members.

AHCA Contract No. FA523, Attachment I, Page 20 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	e.	 	The plan shall adhere to the minimum staffing,
availability, and access standards described in the minimum
access and staffing standards, of the Medicaid PMHPs RFPs except
for the following provisions: For a rural county, the Agency may
waive the requirement, in writing, that at least one board
certified adult psychiatrist and at least one board certified
child psychiatrist, or one who meets all education and training
criteria for board certification, are available within thirty
minutes typical travel time of all enrolled beneficiaries if a
provider with this experience is not available.
	 
	f.	 	For all members meeting the criteria for mental health
targeted case management as specified in the Medicaid Targeted
Case Management Services Coverage and Limitations Handbook, the
plan shall adhere to the staffing ratio of at least 1 FTE
behavioral health care case manager per 20 children, and at least
1 FTE behavioral care case manager per 40 adults. Direct service
behavioral health care providers shall not be counted as
behavioral health care case managers.

10.11.2 Non Covered Services (Behavioral Health)

If the plan determines the need for behavioral health services not
covered under the contract, the plan shall refer the member to the
appropriate service provider. The plan may request the assistance of
the Medicaid Field Office or the DCF Districts’ ADM offices for
referral to the appropriate service setting.

Long term care institutional services of a nursing home, an
institution for persons with developmental disabilities, specialized
therapeutic foster care, children’s residential treatment services, or
state hospital services are not covered. For members requiring those
services, the plan shall consult the Medicaid Field Office and/or the
Districts’ DCF ADM offices to identify appropriate methods of
assessment and referral. The plan is responsible for transition and
referral to appropriate service providers. Members receiving those
services shall be disenrolled from the plan.

10.11.3 Care Coordination and Management (Behavioral Health)

The plan shall be responsible for the coordination and management of
behavioral health care and continuity of care for all enrolled Medicaid
beneficiaries through the following minimum functions:

	a.	 	Contacting each new member to authorize the release of
their clinical records within 30 days of enrollment and for
current members within 5 days after their first behavioral health
service provision. The plan shall then request the clinical
records from the previous behavioral health care providers.
	 
	b.	 	Minimizing disruption to the member as a result of any
change in service provider or behavioral health care case manager
occurring as a result of this contract. For current members, upon
implementation of this attachment, and for new members,
thereafter, who have been receiving behavioral health care
services, the plan shall continue to authorize and pay valid
claims for services until the plan has reviewed the member’s
treatment plan and developed and implemented an appropriate
written transition plan. However, if the previous treating
provider is unable to allow the plan access to the member’s
clinical record because the member refuses to release the medical
record, then the plan shall be responsible for up to four sessions
of individual or group therapy, or one psychiatric medical
session, or two one-hour Intensive Therapeutic On Site or Home and
Community Based Rehabilitative Sessions, or six days of Day
Treatment Services.
	 
	c.	 	Documenting in behavioral clinical records all member
emergency behavioral encounters and appropriate follow-up and,
where medical in nature, in the primary care physician’s medical
record.
	 
	d.	 	Documenting all referral services in the members’ behavioral clinical
records.
	 
	e.	 	Monitoring members admitted to state mental health
institutions as follows: the plan shall participate in discharge
planning and community placement of members who are being
discharged within sixty days of losing their plan enrollment due
to state institutionalization. The Agency may sanction the plan
for any inappropriate over-utilization of state mental hospital
services for its members.

AHCA Contract No. FA523, Attachment I, Page 21 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	f.	 	Coordinating hospital and/or institutional discharge
planning for psychiatric admissions and substance abuse
detoxification that includes appropriate post-discharge care.
	 
	g.	 	Providing appropriate referral of the member for
non-covered services to the appropriate service setting, and
requesting referral assistance, as needed, from the Medicaid
Field Office. The plan is encouraged to use the Florida
Supplement to the American Society of Addictions Medicine Patient
Placement Criteria for coordination and treatment of
substance-related disorders with substance abuse providers.
Coordination of care with community-based substance abuse
agencies shall be included in protocols developed for continuity
of care practices for enrollees with dual diagnoses of mental
illnesses and substance abuse or dependency.
	 
	h.	 	Entering, prior to commencement of services, into
agreements with agencies funded pursuant to chapter 394, Part IV,
F.S., that shall not be a part of the plan’s provider network,
regarding coordination of care and treatment of members jointly or
sequentially served. A listing of these agencies is available at
the Medicaid Office. These agreements shall be approved by the
Agency. The plan shall be released from this requirement by the
Agency if good faith efforts are made by the plan and no agreement
is consummated.
	 
	i.	 	Providing court ordered mental health evaluations for its
members. The plan shall also provide expert mental health
testimony for its enrolled beneficiaries.
	 
	J.	 	Providing appropriate screening, assessment, crisis
intervention and support for members who are in the care and
custody of the state pursuant to the specifications indicated in
the Medicaid Community Mental Health Services Coverage and
Limitations Handbook.
	 
	k.	 	Requesting current behavioral health provider information
from all new members upon enrollment. The plan shall solicit
these current providers to enroll in the plan’s provider network.
The plan may request in writing that the Agency grant an
exemption for the plan from soliciting a specific provider on a
case-by-case basis.
	 
	1.	 	Providing, upon an Assisted Living Facility’s (ALF)
request, the plan’s procedures for the ALF to follow should an
emergent condition arise with one of its members that reside in
an ALF, as specified in section 409.912, F.S.
	 
	m.	 	The plan shall participate, as requested by the DCF
district administrators, in each DCF district’s ADM planning
process pursuant to chapter 394.75, F.S.

10.11.4 Behavioral Clinical Record Requirement (Behavioral Health)

The plan shall maintain a behavioral clinical record for each member
under this contract. The record shall include documentation sufficient
to disclose the quality, quantity, appropriateness and timeliness of
services performed under this contract. Each member’s record must be
legible and maintained in detail consistent with good clinical and
professional practice which facilitates effective internal and external
peer review, medical audit, and adequate follow-up treatment.
Identification of the physician or other service provider, date of
service, the units of service and type of service must be clearly
evident for each service provided.

10.11.5 Functional Assessments (Behavioral Health)

The plan shall ensure its providers administer functional assessments
using the Functional Assessment Rating Scales (FARS) (for persons over
age 18) and Child Functional Rating Scale (CFARS) (for persons age 18
and under). The plan shall ensure the provider administers and maintains
the FARS and CFARS for beneficiaries of behavioral health care services
and upon termination of providing such services. Additionally, the plan
must evaluate these data and report outcome measures to the Agency on an
annual basis by August 15.

AHCA Contract No. FA523, Attachment I, Page 22 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

10.11.6 Out-of-Plan Use (Behavioral Health)

The provisions of the Medicaid service requirements of the current
Medicaid Areas PMHP RFPs govern
the payment of emergency behavioral health services within the contract
service area. However, the out-of area, non-contract provider must notify
the plan within 24 hours of the member presenting for emergency
behavioral health services that the member has come to the non-contract
provider for treatment. In cases in which the member has no
identification, or is unable to verbally identify himself when
presenting for services, the provider must notify the plan within 24
hours of learning the member’s identity. The provider must also provide
clinical records to the plan that document that the identity of the
member could not be ascertained due to the member’s condition.

If the non-contract provider fails to provide the plan with an
accounting of the member’s presence and status within 24 hours after
the member presents for treatment and provides identification, the plan
shall be obligated to pay only for the time period required for
emergency services, as documented by the patient’s clinical record.

The plan must review and approve or disapprove out-of-plan emergency
mental health service claims based on the definition of emergency
(behavioral health) services specified in section 100.0, Glossary,
within the time frames specified for emergency claims payment in section
20.10, Emergency Care Requirements, of this contract.

The plan must submit to the Agency for review and final determination
denied appeals from providers for denied emergency behavioral health
service claims. Such denied appeals must be submitted within ten days
after the plan has made final appeal determination. The plan must pay
within 35 days previously denied emergency mental health service
claims if the decision by the Agency is to honor the claim. The 35-day
period begins when notification of the final decision from the Agency
is received by the plan.

The plan must evaluate and authorize or deny payment for care for
members presenting at non-plan receiving facilities (that are not crisis
stabilization units) within the contract service area for involuntary
examination within three hours of being notified by phone by the
receiving facility. The receiving facility at which the member presents
must notify the plan within four hours of the member presenting that the
member has come to the receiving facility for treatment. If the
receiving facility fails to provide the plan with an accounting of the
member’s presence and status within four hours, the plan shall be
obligated to pay only for the first four hours of the enrollee’s
treatment, subject to medical necessity.

If the receiving facility is a non-plan receiving facility and documents
in the clinical record that it is unable (after good faith effort) to
identify the patient as a plan member and, therefore, fails to notify
the plan of the member’s presence, the plan shall be obligated to pay
for medical stabilization lasting no more than three days from the date
the member presented at the receiving facility, as documented by the
patient’s medical record and subject to medical necessity, unless there
is irrefutable evidence in the clinical record that a longer period was
required.

Refer to the provisions of section 20.9, Out-of-plan Use of Non Emergency Services.

10.11.7 Outreach Requirements (Behavioral Health)

At a minimum, the plan shall have an outreach plan that is designed to
encourage members to seek behavioral health care assistance with the
plan when assistance is perceived to be needed. In addition, the
outreach plan shall provide for the following:

	a.	 	Outreach communications that are written at the fourth grade reading
level.
	 
	b.	 	Outreach communications that are written in a language spoken by the
member.
	 
	c.	 	The plan shall develop and implement a program
designed to assist primary care providers in the
identification and management of clinical depression.

AHCA Contract No. FA523, Attachment I, Page 23 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

	 	 	 
	July 2004

	 	Medicaid HMO Contract

10.11.8 Quality Improvement Requirements (Behavioral Health)

The plan’s quality improvement program shall include a behavioral
health component in order to monitor and assure that behavioral health
services provided are sufficient in quantity, of acceptable quality,
and meet the needs of the enrolled population. Specifically, treatment
plans must identify reasonable and appropriate objectives, planned
services that are appropriate to meet the identified objective, and
retrospective reviews that must confirm that the care provided and its
outcomes were consistent with approved treatment plans and appropriate
for the members’ needs.

In determining if behavioral health care is acceptable under current
standards, the plan shall perform the following:

	a.	 	A quarterly review of a random selection of 10 percent or
50 member records, whichever is fewer, of members who have
received behavioral health care services during the previous
quarter.
	 
	b.	 	Review elements for these reviews shall include
management of specific diagnoses, appropriateness and timeliness
of care, comprehensiveness of and compliance with the plan of
care, and evidence of special screening for high-risk individuals
or conditions.

The plan shall send representation to the local advisory groups that
convene quarterly and report to the Agency on behavioral health
advocacy and programmatic concerns. These groups shall provide
technical and policy advice to the Agency regarding prepaid behavioral
health care.

10.11.9 Administrative Staff Requirements (Behavioral Health)

The plan must identify a plan staff person with oversight
responsibility for the behavioral health services required in this
section and to act as liaison to the Agency.

The plan’s medical director shall appoint a board certified or
board eligible psychiatrist to oversee the proper provision of
covered behavioral health services to members. This appointment may
be to a subcontractor of the plan.

The Agency shall review and approve the plan’s staff and subcontracted
behavioral health care providers in order to determine the plan’s
compliance with the requirements of section 20.5, Licensure of Staff, of
this contract, prior to the plan’s expansion.

10.11.10 Behavioral Health Subcontracts

If the plan subcontracts with a Managed Behavioral Health
Organization (MBHO) for the provision of services stipulated in this
section, the MBHO shall be accredited by one of the recognized
national accreditation organizations.

The plan must submit model subcontracts for each behavioral health
specialist type or facility for Agency approval.

All subcontracts must adhere to the requirements set forth in this
contract, section 70.18, Subcontracts.

10.11.11 Management Information
System (Behavioral Health)

	 	 	The plan shall perform the following management information system functions:
	 
	a.	 	Maintain member behavioral health service,
utilization, and expenditure profiles, and current and
historical data with beginning and ending dates.

AHCA Contract No. FA523, Attachment I, Page 24 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	b.	 	Maintain data documenting behavioral health service
utilization by service, (including procedure code), encounter or
claim information, date of service per encounter/claim,
beneficiary Medicaid ID number, diagnosis, designated groups of
beneficiaries, and providers.
	 
	c.	 	Maintain data documenting behavioral health management,
administrative, and service costs.
	 
	d.	 	Maintain data sufficient to document behavioral health
services authorized but not yet claimed by direct service
provider and by member.
	 
	e.	 	Maintain critical incident data.
	 
	f.	 	Maintain clinical and functional member behavioral
health outcomes data.

10.11.12 Monitoring (Behavioral
Health)

Upon implementation, the Agency shall periodically monitor the
behavioral health operation of the plan for compliance with the
provisions of the contract and applicable federal and state laws and
regulations. Such monitoring activities shall include, but are not
limited to, inspection of plan’s facilities; review of mental health
staffing patterns and ratios; audit and/or review of all records
developed under this behavioral health benefit, including clinical and
financial records; review of management information systems and
procedures developed under the contract, including appropriate
procedures for Clozaril prescription refills; desk audits of information
and behavioral health outreach provided by the plan; and review of any
other areas or materials relevant to or pertaining to the behavioral
health benefit.

The Agency shall conduct an annual behavioral health clinical audit of
the plan requiring management data be identified and collected for use
by medical audit personnel. Data collected must include information on
the use of behavioral health services and reasons for enrollment and
termination.

10.12 Frail/Elderly Program (expanded service)

The Frail Elderly program is defined in Exhibit 110.4

AHCA Contract No. FA523, Attachment I, Page 25 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

20.0 SCOPE OF WORK

20.1 Availability/Accessibility of Services

The plan shall make available and accessible facilities, service
locations, service sites, and personnel sufficient to provide the
covered services. In accordance with section 1932(b)(7) of the Social
Security Act (as enacted by section 4704(a) of the Balanced Budget Act
of 1997), the plan shall provide the Agency with adequate assurances
that the plan, with respect to a service area, has the capacity to
serve the expected enrollment in such service area, including
assurances that the plan: offers an appropriate range of services and
access to preventive and primary care services for the populations
expected to be enrolled in such service area; and maintains a
sufficient number, mix, and geographic distribution of providers of
services. Emergency medical care as required by this agreement shall be
available on a 24 hours a day, seven days a week basis. The plan must
assure that primary care physician services and referrals to specialty
physicians are available on a timely basis, to comply with the
following standards: urgent care — within one day; routine sick patient
care — within one week; and well care — within one month. Each medical
or osteopathic provider shall maintain hospital privileges if hospital
privileges are required for the performance of plan services. This does
not preclude the provider from using admitting panels to comply with
this section. The plan shall have telephone call policies and
procedures that shall include requirements for call response times,
maximum hold times, and maximum abandonment rates.

Primary care physicians and hospital services must be available within
30 minutes typical travel time, and specialty physicians and ancillary
services must be within 60 minutes typical travel time from the
member’s residence. For rural areas, if the plan is unable to contract
with specialty or ancillary providers who are within the typical
travel time requirements, the Agency may waive, in writing, these
requirements.

If the plan is unable to provide medically necessary services
covered under the contract to a particular beneficiary, the plan
must adequately and timely cover these services outside of the
network for the beneficiary for as long as the plan is unable to
provide them.

The 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.

The plan must allow each enrollee to choose his or her health care
professional, as defined in section 100.0, Glossary, to the extent
possible and appropriate.

Each plan shall provide the Agency with documentation of compliance
with access requirements no less frequently than the following:

	a.	 	At the time it enters into a contract with the Agency.
	 
	b.	 	At any time there has been a significant change in the
plan’s operations that would affect adequate capacity and
services, including but not limited to:

	 	1.	 	Changes in plan services, benefits, geographic service area, or
payments.
	 
	 	2.	 	Enrollment of a new population in the plan.

20.2 Minimum Standards

	 	 	Plans shall provide the following:
	 
	a.	 	At least one FTE primary care physician, per county,
representing at least each of these specialties: family
practice, pediatrics, and internal medicine. The plan must
ensure primary care physicians sufficient to ensure adequate
accessibility to all primary care services for all enrolled
beneficiaries at all ages.

AHCA Contract No. FA523, Attachment I, Page 26 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	b.	 	One FTE primary care physician per 1,500 HMO members for
contracted physicians. The ratio may be increased by 750 members
for each FTE advanced registered nurse practitioner or FTE
physician assistant affiliated with the physician or staff
physician as a provider in the practice.
	 
	c.	 	One fully accredited general acute care hospital. The
Agency may waive, in writing, the accreditation requirement in
rural areas.
	 
	d.	 	One birth delivery facility licensed under chapter 383,
F.S., or a hospital with birth delivery facilities licensed under
chapter 395. The delivery facility may be part of a hospital or a
freestanding facility.
	 
	e.	 	One licensed pharmacy per 2,500 members.
	 
	f.	 	A birthing center licensed under chapter 383, F.S., that is
accessible to low risk patients. The Agency may waive, in writing,
this requirement if the plan cannot reach an agreement with those
centers within reasonable travel time for a rate no greater than
the Medicaid rate for those centers.
	 
	g.	 	A designated emergency services facility, within 30 minutes
typical travel time, providing care on a 24 hours a day, seven days
a week basis. Such designated emergency service facility shall have
one or more physicians and one or more nurses on duty in the
facility at all times. The Agency may waive, in writing, the travel
time requirement in rural areas.
	 
	h.	 	At least one pediatrician or one county health department, a
federally qualified health center or a rural health clinic within
30 minutes of typical travel time, providing care or coverage on a
24 hours a day, 7 days a week basis. The Agency may waive this
requirement in writing for rural areas and where there are no
pediatricians, county health departments, federally qualified
health centers, or rural health clinics within typical travel time.
	 
	 	 	i            Facilities with access for persons with disabilities.
	 
	 	 	j            Adequate space, supplies, good sanitation, smoke free, fire and safety procedures in operation.
	 
	 	 	k            Specialists as required in section 20.7, Specialty Coverage.

Pursuant to section 4707(a) of the Balanced Budget Act of 1997 and
upon development by the federal government, the plan must require
each physician who provides Medicaid services to have a unique
identifier in accordance with the system established under section
1173(b) of the Social Security Act.

Pursuant to section 409.9122, F.S., the plan shall at least annually
review each primary care physician’s active patient load and shall
ensure that additional Medicaid recipients are not assigned to
physicians that have a total active patient load of more than 3,000
patients. As used in this paragraph, the term “active patient” means a
patient who is seen by the same primary care physician, or by a
physician assistant or advanced nurse practitioner under the
supervision of the primary care physician, at least three times within
a calendar year.

Pursuant to section 409.9122, F.S., each primary care physician shall
annually certify to the plan whether or not his or her patient load
exceeds the limits established under this paragraph and the plan shall
accept such certification on face value as compliance with this
paragraph. The Agency shall accept the plan’s representations that it is
in compliance with this paragraph based on the certification of its
primary care physician, unless the Agency has an objective indication
that access to primary care is being compromised, such as receiving
complaints or grievances relating to access to care. If the Agency
determines that an objective indication exists that access to primary
care is being compromised, it may verify the patient load certifications
submitted by the plan’s primary care physicians and that the plan is not
assigning Medicaid beneficiaries to primary care physicians who have an
active patient load of more than 3,000 patients.

AHCA Contract No. FA523, Attachment I, Page 27 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

20.3 Administration and Management

The plan’s governing body shall set policy and has overall
responsibility for the organization. The plan shall be responsible for
the administration and management of all aspects of this contract.
Pursuant to 42 CFR 438.210(b)(2), the plan is responsible for ensuring
consistent application of review criteria for authorization decisions
and consulting with the requesting provider when appropriate. Any
delegation of activities does not relieve the plan of this
responsibility. This includes all subcontracts, employees, agents and
anyone acting for or on behalf of the plan. The plan must have written
policies and procedures for selection and retention of providers. These
policies and procedures must not discriminate against particular
providers that serve high-risk populations or specialize in conditions
that require costly treatments.

	a.	 	If the plan delegates claims adjudication functions to a
third party administrator (TPA), the TPA must be licensed to do
business as a TPA in the state of Florida.
	 
	b.	 	The relationship between management personnel and the
governing body shall be set forth in writing, including each
person’s authority, responsibilities, function, and position
descriptions for key personnel.
	 
	c.	 	If any function of the administration or management of the
plan is delegated to another entity, the plan shall:

	 	1.	 	Adhere to all requirements set forth in section
70.18, Subcontracts, in relation to the delegated entity and
any further subcontractors;
	 
	 	2.	 	Notify the Agency within 10 working days after such
functions are delegated (full or partial delegation), specify
what functions are delegated, identify the plan staff who
is/are responsible for the monitoring of the delegated
functions, and define how the plan will routinely monitor such
functions. Additionally, the plan shall submit a list of all
entities to which the plan has delegated any functions,
including addresses and phone numbers.

	d.	 	If any service authorization function is delegated to
another entity, the plan shall ensure that such entity’s service
authorization system(s) provide for the following as specified in
the plan’s policies and procedures:
	 
	 	 	Timely authorizations;
	 
	 	 	Effective dates for the authorization, if appropriate; and
	 
	 	 	Written confirmation of adverse determination to the provider
and the subscriber as described in section 641.51 F.S.
	 
	e.	 	Any delegation of service authorization, claims
payment and/or member services shall include a requirement
that the provider and any further subcontractor adhere to the
plan’s telephone requirements for call response times, maximum
hold times and maximum abandonment rates.
	 
	f.	 	Pursuant to 42 CFR 438.236(b), the plan shall adopt
practice guidelines that meet the following requirements:
	 
	 	 	Are based on valid and reliable clinical evidence or a consensus
of health care professionals in the particular field;
	 
	 	 	Consider the needs of the enrollees.
	 
	 	 	Are adopted in consultation with contracting
health care professionals. Are reviewed and
updated periodically as appropriate.

AHCA Contract No. FA523, Attachment I, Page 28 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

The plan shall disseminate the guidelines to all affected providers
and, upon request, to enrollees and potential enrollees. The
decisions for utilization management, enrollee education, coverage
of services, and other areas to which the guidelines apply shall be
consistent with the guidelines.

20.4 Staff Requirements

The staffing for the HMO developed under this contract must be
capable of fulfilling all contractual requirements. The minimum
staff requirements are as follows:

	a.	 	A full-time administrator specifically identified to
administer the day-to-day business activities of the contract.
This person cannot be designated to any other position in this
subsection.
	 
	b.	 	Sufficient medical and professional support staff to
conduct daily business in an orderly manner, including having
member services staff directly available during business hours
for membership services consultation, as determined through
management and medical reviews. The plan shall maintain
sufficient medical staff available 24 hours per day to handle
emergency care inquiries. The plan shall be required to maintain
sufficient medical staff during non-business hours unless the
plan’s computer system auto-approves all emergency service
claims related to screening and treatment.
	 
	c.	 	A full-time, licensed physician to serve as medical
director to oversee and be responsible for the proper provision of
covered services to members. The plan’s medical director shall be
licensed in accordance with chapter 458 or 459, F.S.
	 
	d.	 	A designated person, qualified by training and
experience, to ensure subcontractors’ compliance with the medical
records requirements as described in section 20.13 of this
contract. This person shall maintain medical record standards and
conduct medical record reviews according to section 20.14. If the
plan is a staff model HMO, the plan shall designate a person to
oversee its medical record systems.
	 
	e.	 	A person trained and experienced in data processing
and data reporting as required to ensure that computer system
reports that are provided to the Agency are accurate, and
that computer systems operate in an accurate and timely
manner.
	 
	f.	 	A designated person, qualified by training and
experience, to be responsible for the plan’s marketing
responsibilities if the plan engages in preenrollment
activities.
	 
	g.	 	A designated person, qualified by training and experience, in
quality improvement.
	 
	h.	 	A designated person, qualified by training and
experience, to be responsible for the plan’s utilization
management program.
	 
	i.	 	A designated person, qualified by training and
experience, in the processing and resolution of appeals and
grievances, to be responsible for the grievance system.
	 
	J.	 	A designated person qualified by training and experience,
to investigate fraudulent claims by providers pursuant to sections
641.3915, 626.9891, and 626.989, F.S.
	 
	k.	 	Sufficient case management staff, qualified by training
and experience, to conduct case management as defined in section
100.0, Glossary.

20.4.1 Fraud Prevention Policies and Procedures

The plan shall develop and maintain written policies and procedures for
fraud prevention which contain the following:

	a.	 	A comprehensive employee training program to investigate potential
fraud.

AHCA Contract No. FA523, Attachment I, Page 29 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	b.	 	A review process for claims which
shall include:

	 	1.	 	review of providers who consistently demonstrate a
pattern of encounter or service reports that did not occur;
	 
	 	2.	 	review of providers who consistently demonstrate
a pattern of overstated reports or up-coded levels of
service;
	 
	 	3.	 	review of providers who altered, falsified, or destroyed clinical
record documentation;
	 
	 	4.	 	review of providers who make false statements about credentials;
	 
	 	5.	 	review of providers who misrepresent medical information to
justify referrals;
	 
	 	6.	 	review of providers who fail to render medically
necessary covered services that they are obligated to provide
according to their subcontracts;
	 
	 	7.	 	Review of providers who charge Medicaid beneficiaries for covered
services.

The policies and procedures for fraud prevention shall provide for use
of the List of Excluded Individuals and Entities (LEIE) or its
equivalent, to identify excluded parties during the process of
enrolling providers to ensure the plan providers are not in a
non-payment status or excluded from participation in federal health
care programs under section 1128 or section 1128A of the Social
Security Act. The plan must not employ or contract excluded providers
and must terminate providers if they become excluded.

20.5 Licensure of Staff

The plan is responsible for assuring that all persons, whether they be
employees, agents, subcontractors or anyone acting for or on behalf of
the plan, are properly licensed under applicable state law and/or
regulations and are eligible to participate in the Medicaid program.
The plan shall credential and recredential all plan physicians and
other providers. Hospital ancillary service providers are not required
to be independently credentialed by the plan if those providers only
provide services to the plan through the hospital. School-based service
providers are not required to be credentialed by the plan if the plan
can document that the school has signed one of the credentialing
agreements provided in Appendix A of the Florida Medicaid Certified
School Match Program Services Coverage and Limitations Handbook
assuring that school-based service providers are Medicaid credentialed.

20.5.1 Credentialing and Recredentialing Policies and Procedures

The plan’s credentialing and recredentialing policies and procedures shall
include the following:

	a.	 	Written policies and procedures for credentialing.
	 
	b.	 	Formal delegations and approvals of the credentialing process.
	 
	c.	 	A designated credentialing committee.
	 
	d.	 	Identification of providers who fall under its scope of authority.
	 
	e.	 	A process which provides for verification of the following core
credential information:

	 	1.	 	The practitioner’s current valid license.
Practitioner’s current license must be on file at all times
pursuant to section 641.495, F.S.
	 
	 	2.	 	The practitioner’s current valid Drug
Enforcement Administration (DEA) certificate where
applicable.

AHCA Contract No. FA523, Attachment I, Page 30 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	3.	 	Proof of the practitioner’s medical school graduation,
completion of a residency, and other postgraduate training.
Evidence of Board certification shall suffice in lieu of
proof of medical school graduation, residency and other
postgraduate training.
	 
	 	4.	 	Evidence of specialty board certification, if applicable.
	 
	 	5.	 	Evidence of the practitioner’s professional liability claims
history.
	 
	 	6.	 	History of final disciplinary actions, as described in section
456.039, F.S.
	 
	 	7.	 	Any sanctions imposed on the practitioner by Medicare or Medicaid.

	f.	 	The credentialing process must also include verification of the
following information:

	 	1.	 	The practitioner’s work history
	 
	 	2.	 	Evidence of the provider’s good standing privileges at
the hospital designated as the primary admitting facility by the
practitioner or good standing of privileges at the hospital by
another plan physician with whom the practitioner has entered
into an arrangement for hospital coverage.
	 
	 	3.	 	The plan must obtain a statement from each practitioner applicant
regarding the following:

	 	(a)	 	Any physical or mental health problems that may
affect the practitioner’s ability to provide health care.
	 
	 	(b)	 	Any history of chemical dependency/substance abuse.
	 
	 	(c)	 	Any history of loss of license and/or felony convictions.
	 
	 	(d)	 	Any history of loss or limitation of privileges or disciplinary
activity.
	 
	 	(e)	 	Attestation to correctness/completeness of the practitioner’s
application.
	 
	 	(f)	 	For primary care physicians, attestation of
the total active patient load (all populations: Medicaid
Fee-for-Service, Medicaid HMO, MediPass, Medicare, or
commercial) in accordance with section 409.9122, F.S.

	 	4.	 	Documentation of an initial visit to the office of
each primary care physician and OB/GYN to review the site.
Documentation shall include the following:

	 	(a)	 	The plan has evaluated the provider site against the plan’s
organizational standards.
	 
	 	(b)	 	The plan has evaluated the physician’s medical
record keeping practices at each site to ensure conformity
with the plan’s organizational standards.
	 
	 	(c)	 	The plan has determined that the following
documents are posted: The Agency’s statewide consumer call
center telephone number including hours of operation and a
copy of the summary of Florida Patient’s Bill of Rights and
Responsibilities, in accordance with section 381.026, F.S. A
complete copy of the Florida Patient’s Bill of Rights and
Responsibilities shall be available, upon request by a
member, at each primary care physician’s office. The Florida
Patient’s Bill of Rights is found in section 110.5, Florida
Patient’s Bill of Rights and Responsibilities.
	 
	 	 	 	A consumer assistance notice shall also be prominently
displayed in the reception area of the provider in accordance
with section 641.511, F.S.

AHCA Contract No. FA523, Attachment I, Page 31 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	g.	 	The process for periodic
recredentialing which shall include the following:

	 	1.	 	The procedure for recredentialing shall be implemented at least
every three years.
	 
	 	2.	 	The plan shall verify the current standing for each practitioner
on items 20.5.1 e. and f.
	 
	 	3.	 	Documentation of periodic visits to the primary
care physician offices documenting site reviews, including
review of the items listed in section 20.5.1 f. 4 of this
section to ensure continued conformance with the plans’
standards.

	h.	 	The plan shall develop and implement policies and
procedures for approval of new providers, and imposition of
sanctions, termination, suspension, and restrictions of
existing providers.
	 
	i.	 	The plan shall develop and implement a mechanism for
identifying quality deficiencies which result in the plan’s
restriction, suspension, termination, or sanctioning of a
practitioner.
	 
	J.	 	The plan shall develop and implement an appellate
process for sanctions, restrictions, suspensions and terminations
imposed by the plan against practitioners.
	 
	k.	 	The plan shall submit provider networks for initial or
expansion review to the Agency for approval only when the plan
has satisfactorily completed the minimum standards required in
section 20.2, Minimum Standards and the minimum credentialing
steps required in section 20.5.1 e. and f.

20.6 Physician Choice

The plan agrees to offer each member a choice of primary care
physicians. After making a choice, each member shall have a single
primary care physician.

For Title XXI MediKids and for members assigned by Medicaid, the plan
shall assign primary care physicians taking into consideration last
primary care provider of service (if the provider is known and
available in the plan’s network), closest location within the service
area, zip code location, keeping children within the same family
together, age (adults versus children), and sex (OB/GYN). The plan
shall inform members of the following: (1) their primary care physician
assignment, (2) their ability to choose a different primary care
provider, (3) a list of providers from which to make a choice, and (4)
the procedures for making a change. The plan shall provide this written
notice to assigned members by the first day of enrollment.

20.7 Specialty Coverage

The plan shall assure the availability of the following specialists, as
appropriate for both adult and pediatric members, on at least a
referral basis: allergist; cardiologist; endocrinologist; general
surgeon; obstetrical/gynecology (OB/GYN); neurologist; nephrologist;
orthopedist; urologist; dermatologist; otolaryngologist; pulmonologist;
chiropractic physician; podiatrist; ophthalmologist; optometrist;
neurosurgeon; gastroenterologist; oncologist; radiologist; pathologist;
anesthesiologist; psychiatrist; oral surgeon; physical, respiratory,
speech and occupational therapists; and an infectious disease
specialist. If the infectious disease specialist does not have
expertise in HIV and its treatment and care, then the plan must have
another physician with such expertise.

The plan must use specialists with pediatric expertise for children
where the need for pediatric specialty care is significantly
different from the need for adult specialists (e.g., a pediatric
cardiologist for children with congenital heart defects).

The plan must assure access for patients in one or more of Florida’s
Regional Perinatal Intensive Care Centers (RPICC) as designated in
sections 383.15 — 383.21, F.S., or a hospital licensed by the Agency
for Neonatal Intensive Care Unit (NICU) Level III beds. The plan must
assure that care for medically high risk

AHCA Contract No. FA523, Attachment I, Page 32 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

perinatal clients is provided in a facility with a neonatal intensive
care unit to meet the appropriate level of need for the client.

The plan must assure access to certified nurse midwife services or
licensed midwife services in accordance with section 641.31, F.S., for
low risk patients. If the plan cannot reach an agreement with those
certified nurse midwives and licensed midwives within reasonable travel
time for a rate no greater than the Medicaid rate for such services,
then the plan must request a waiver and provide documentation of a “good
faith” effort.

20.8 Case Management/Continuity of Care

The plan shall be responsible for the management of medical care and
continuity of care for all enrolled Medicaid beneficiaries. The plan
shall maintain written case management continuity of care protocol(s)
that include the following minimum functions:

	a.	 	The plan shall have an outreach program and other
strategies for identifying every pregnant member. This shall
include case management, claims analysis, and use of health risk
assessment, etc. The plan shall require its participating
providers to notify the plans of any Medicaid patient who is
identified as being pregnant.
	 
	b.	 	Appropriate referral and scheduling assistance of
members needing specialty health care and transportation
services, including those identified through CHCUP
screening.
	 
	c.	 	Documentation of referral services in members’ medical records,
including results.
	 
	d.	 	Monitoring of members 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 member and providers, ensuring the member is
receiving routine medical care, ensuring that the member has
adequate support at home, assisting members 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 member in developing
community resources to manage the member’s medical condition. For
members residing in areas where behavioral health has been
implemented, see section 10.11, Behavioral Health Care of the
contract.
	 
	e.	 	Documentation of emergency care encounters in
members’ records with appropriate medically indicated
follow-up.
	 
	f.	 	Coordination of hospital/institutional discharge
planning that includes post-discharge care, including skilled
short-term rehabilitation, and skilled nursing facility care, as
appropriate.
	 
	g.	 	Determining the need for non-covered services and
referring the member for assessment and referral to the
appropriate service setting (to include referral to the Women,
Infants and Children program (WIC) and Healthy Start) utilizing
assistance as needed by the Medicaid Field Office. The plan must
also refer CHCUP eligibles to the Medicaid Field Office to obtain
assistance in scheduling dental services and transportation
services, if these services are not covered by the plan.

Pursuant to 42 CFR 438.208(b), the plan must implement procedures
to deliver primary care to and coordinate health care service for
all beneficiaries that:

	a.	 	Ensure that each enrollee has an ongoing source of
primary care appropriate to his/her needs and a person or entity
formally designated as primarily responsible for coordinating
the health care services furnished to the beneficiary.
	 
	b.	 	Coordinate the services the plan furnishes to the
beneficiary with the services the beneficiary receives from any
other managed care entity during the same period of enrollment.

AHCA Contract No. FA523, Attachment I, Page 33 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	c.	 	Share with other managed care organizations serving the
beneficiary with special health care needs the results of its
identification and assessment of the beneficiary’s needs to
prevent duplication of those activities.
	 
	d.	 	Ensure that in the process of coordinating care, each
beneficiary’s privacy is protected in accordance with the privacy
requirements in 45 CFR Part 160 and 164 Subparts A and E, to the
extent that they are applicable.

20.8.1 Chronic and Disabling Conditions

In accordance with section 641.51, F.S., the plan shall provide
standing referrals to members with chronic and disabling conditions
that require ongoing specialty care. The plan shall develop and
maintain policies and procedures for such referrals.

20.8.2 Members with Developmental Disabilities

When a member has a developmental disability, the plan shall monitor
the member’s ongoing medical condition by asking the member or
parent/guardian if the member is receiving services from the DCF,
Office of Developmental Services (DS). If the member is receiving
services from DS, the plan shall:

	a.	 	Contact the member, or parent/guardian, as appropriate,
for DS contact information and obtain authorization (if not
already obtained) to seek further information from the member’s
DS support coordinator or waiver support coordinator.
	 
	b.	 	Contact the member’s DS support coordinator or waiver
support coordinator to obtain DS service information and review
the need to coordinate care.
	 
	c.	 	Continue to contact the member or the member’s
parent/guardian and provider regarding the ongoing coordination
of care, as appropriate.

20.8.3 Coordination with Community Mental Health Care Providers

When a member residing in an area other than the Agency’s areas known
to be receiving behavioral health services, the plan shall ask the
member or parent/guardian if the member is receiving behavioral health
treatment services from a community mental health center, clinic, or
private behavioral health provider. If the member is receiving such
services, the plan shall:

	a.	 	Contact the member, or parent/guardian, as
appropriate, and obtain authorization (if not already
obtained) to seek further information from the member’s
behavioral health treatment provider.
	 
	b.	 	Contact the member’s behavioral health treatment provider
to obtain the member’s current behavioral health treatment plan,
and review the information in order to coordinate care (this is
particularly relevant for individuals who are taking prescribed
psychotropic medications).
	 
	c.	 	Coordinate the member’s care with the behavioral health provider, as
appropriate.

For members residing in Agency areas where behavioral health care has
been implemented, see section 10.11, Behavioral Health of the
contract.

20.8.4 New Member Procedures

The plan shall contact each new member at least two times, if necessary,
within 90 calendar days of enrollment, to urge scheduling of an initial
appointment with the primary care provider for the purpose of a health
risk assessment (information regarding the health risk assessment/CHCUP
screening for members under the age of 21 may be found in section
10.8.1, CHCUP).

AHCA Contract No. FA523, Attachment I, Page 34 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	a.	 	For this subsection, contact is defined as mailing a notice to,
or telephoning, a member at the most recent address or telephone
number available.
	 
	b.	 	The plan will urge members to see their primary care physicians within
180 days of enrollment.
	 
	c.	 	The plan shall contact each new member within 30 calendar days
of enrollment to request the member to authorize release of his or
her medical records to the plan or its health services
subcontractors from practitioners who treated the member prior to
plan enrollment. The plan shall request or assist the member’s new
practitioner in requesting medical records from the previous
practitioners.
	 
	d.	 	The plan must use the health risk assessments or the released
medical records to identify members who have not received CHCUP
screenings in the past according to the Agency approved periodicity
schedule.
	 
	e.	 	The plan must contact, up to two times if necessary, any
members who are more than two months behind in the periodicity
screening schedule to urge those members or their legal
representative to make an appointment for a screening visit.
	 
	f.	 	Within 30 calendar days of enrollment, the plan shall advise
members of and ensure the availability of, a screening for all
members known to be pregnant or who advise the plan that they may be
pregnant. The plan shall refer pregnant members and members reporting
they may be pregnant for appropriate prenatal care (refer to section
10.8.11.1, Pregnancy Related Requirements).
	 
	g.	 	For beneficiaries voluntarily enrolling, Title XXI MediKids
and for beneficiaries who have been automatically reinstated due to
regaining Medicaid eligibility, the plan shall honor any written
documentation of prior authorization of ongoing covered services for
a period of 10 calendar days after the effective date of enrollment
or until the plan’s primary care physician assigned to that member
reviews the member’s treatment plan, whichever comes first.
	 
	h.	 	For beneficiaries that the state has assigned, the plan shall
honor any written documentation of prior authorization of ongoing
services for a period of one month after the effective date of
enrollment or until the plan’s primary care physician assigned to
that member reviews the member’s treatment plan, whichever comes
first.
	 
	i.	 	For both voluntary and assigned members, written
documentation of prior authorization of ongoing services includes
the following, provided that the services were prearranged prior to
enrollment in the plan:

	 	1.	 	Prior existing orders,
	 
	 	2.	 	Provider appointments, surgeries, and
	 
	 	3.	 	Prescriptions (including prescriptions at non-participating
pharmacies).

	 	 	The plan cannot delay service authorization if written documentation
is not available in a timely manner; however, the plan is not
required to pay claims for which it has received no written
documentation. The plan shall not deny claims submitted by a
non-contracting provider solely based on the period between the date
of service and the date of clean claim submission unless that period
exceeds 365 days.
	 
	 	 	The plan shall be responsible for payment of covered services to the
existing treating provider at a prior negotiated rate or lesser of
the provider’s usual and customary rate or the established Medicaid
fee-for-service rate for such services until the plan is able to
evaluate the need for ongoing services.
	 
	J.	 	For members in the Frail/Elderly program, the plan shall
contact each new member within five days of enrollment and develop a
plan of care. The plan is developed with the member and with others
in the

AHCA Contract No. FA523, Attachment I, Page 35 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	member’s care support network, if desired by the member. If the
member has been adjudicated incompetent in accordance with law, is
found by his or her physician to be medically incapable of
understanding his/her rights, or exhibits a significant
communication barrier, the member’s guardian, next of kin, or
legally authorized responsible person is permitted to act on the
member’s behalf in matters relating to the member’s enrollment,
plan of care or services.
	 	 	 
	 	 	If urgent needs are identified, the plan shall take immediate
action to address them. Urgent means any sudden or unforeseen
situation which requires immediate action to prevent
hospitalization or nursing home placement. Examples of urgent
situations may be: hospitalization of spouse or caregiver or
increased impairment of a member living alone who suddenly cannot
manage basic needs without immediate help, hospitalization, or
nursing home placement.
	 	 	 
	20.8.5	 	Pediatrician Assignment to Pregnant Women
	 	 	 
	 	 	The plan must assign a pediatrician or other appropriate primary care
physician to all pregnant members for the care of their newborn babies
no later than the beginning of the last trimester of gestation. If the
plan was not aware that the member was pregnant until she presented for
delivery, the plan must assign a pediatrician or a primary care
physician to the newborn baby within one workday after birth. The plan
shall advise all pregnant members of the members’ responsibility to
notify their plan and their DCF public assistance specialists (case
workers) of their pregnancies and the births of their babies.
	 	 	 
	20.8.6	 	Protective Custody
	 	 	 
	 	 	The plan shall, for enrolled members, comply with Rule 65C-12.002,
Florida Administrative Code (F.A.C.), which requires that all children
taken into protective custody, emergency shelter, or into the foster
care program by the DCF, be physically screened within 72 hours, or
immediately, if required. The plan shall provide such required
examinations or, if unable to do so within the required time frames,
pay claims for such examinations at the lower of a prior negotiated
rate or the established Medicaid fee-for-service rate for such
services. The plan shall pay a prior negotiated rate or the lesser of
the provider’s usual and customary rate or the established Medicaid
fee-for-service rate for CHCUP screenings for children whose enrollment
and Medicaid eligibility are undetermined at the time of entry into the
care and custody of the DCF and who are later determined to be enrolled
members at the time the examinations took place.
	 	 	 
	20.8.7	 	Immunization from Non-Plan Provider
	 	 	 
	 	 	When a member receives immunizations from a non-plan provider, the
plan shall be liable for an immunization administration fee at no less
than the Medicaid rate, as long as the provider contacts the plan at
the time of service delivery and the plan is unable to document to the
provider that the immunization has already been provided to the
member, and the provider has submitted to the plan a claim for such
services and medical records documenting the immunization. The
provision of immunization services by a public provider is described
in section 20.8.9, Public Provider Claims.
	 	 	 
	20.8.8	 	Immunization Data Sharing
	 	 	 
	 	 	The plan shall encourage its primary care physicians to provide
immunization information to the DCF upon receipt of the member’s
written permission and DCF’s request, for members requesting temporary
cash assistance from the DCF in order to document that the member has
met the immunization requirements for beneficiaries receiving temporary
cash assistance.
	 	 	 
	20.8.9	 	Public Provider Claims
	 	 	 
	 	 	In accordance with sections 381.0407, F.S. and 409.9122, F.S.,
without prior authorization, the plan shall pay claims initiated by
any public provider for:
	 	 	 
	 	 	a.	 	The diagnosis and treatment of sexually transmitted diseases and other
communicable diseases such as
tuberculosis and human immunodeficiency syndrome (refer to section 110.1,
Laboratory Tests and

AHCA Contract No. FA523, Attachment I, Page 36 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	Associated Office Visits to be Paid by Plan without Prior
Authorization when Initiated by County Health Department).
	 
	b.	 	The provision of immunizations.
	 
	c.	 	Family planning services and related pharmaceuticals.
	 
	d.	 	School health services listed in a., b, and c above
and for services rendered on an urgent basis by public
providers. Services rendered on an urgent basis are those
health care services needed to immediately relieve pain or
distress for medical problems such as injuries, nausea and
fever, and services needed to treat infectious diseases and
other similar conditions.
	 
	e.	 	In the event that a vaccine-preventable disease
emergency is declared, the plan shall reimburse county health
departments for the cost of the administration of vaccines.
	 
	 	 	Public providers shall attempt to contact the plan before providing
health care services to their members. Public providers shall provide
the plan with the results of the office visit, including test results,
and shall be reimbursed by the plan at the rate negotiated between the
plan and the public provider or, if a rate has not been negotiated, at
the lesser of either the rate charged by the public provider or the
Medicaid fee-forservice reimbursement rate. The plan shall not deny
public health care services claims for claims submitted by a
non-contracting public provider solely based on the period between the
date of service and the date of clean claim submission unless that
period exceeds 365 days.
	 
	 	 	For purposes of this subsection, public providers are defined as a
county health department or 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,
as specified in section 381.0407, F.S.

	20.8.10	 	Certified School Match Program
	 	 	 
	 	 	The Agency shall reimburse schools participating in the certified
school match program pursuant to sections 1011.70 and 409.908, F.S.,
for the following school-based services rendered to members as
referenced in the Medicaid Certified School Match Program Services
Coverage and Limitations Handbook:
	 	 	 
	 	 	a.	 	Speech, occupational and physical therapy services;
	 
	 	 	b.	 	Behavioral health services;
	 
	 	 	c.	 	Transportation services; and
	 
	 	 	d.	 	Other school-based services implemented by the Agency.
	 	 	 
	 	 	School districts participating in the certified school match program
may be authorized by Medicaid to cover any one, a combination, or all
of the above services indicated. The provision of school-based
services will not be considered a replacement, substitution, or
fulfillment of a service prescription or doctor’s orders.
	 	 	 
	20.8.11	 	Continued Care from Terminated Providers
	 	 	 
	 	 	In accordance with section 641.51, F.S., the plan shall provide
continued care from terminated providers as follows. The plan shall
develop and maintain policies and procedures for the provision of such
care. 
	 	 	 
	 	 	The plan shall allow members for whom treatment is active to continue
care with a terminated treating provider when medically necessary,
through completion of treatment of a condition for which the member
was receiving care at the time of the termination, until the member
selects another treating provider or during the next open enrollment
period, whichever is longer, but not longer than 6 months after the
termination of the contract.

AHCA Contract No. FA523, Attachment I, Page 37 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

The plan shall allow pregnant members who have initiated a course of
prenatal care, regardless of trimester in which care was initiated, to
continue care with a terminated treating provider until completion of
postpartum care.

These requirements do not prevent a provider from refusing to continue
to provide care to a member who is abusive or non-compliant.

For care continued under this section, the plan and the provider shall
continue to abide by the same terms, conditions and payment
arrangements as they existed in the terminated contract.

These requirements shall not apply for treating providers who have
been terminated from the plan for cause.

20.8.12 Out-of-Plan Specially Qualified Providers

In accordance with section 641.51, F.S., the plan shall determine when
exceptional referrals to out-of-plan specially qualified providers are
needed to address the unique medical needs of a member (for example,
when a member’s medical condition requires testing by a geneticist).
Financial arrangements for the provision of such services shall be
agreed to prior to the provision of services. The plan shall develop
and maintain policies and procedures for such referrals.

20.8.13 Individuals with Special Health Care Needs

The plan shall implement mechanisms for identifying, assessing and
ensuring the existence of a treatment plan for individuals with special
health care needs, as specified in section 20.12, Quality Improvement.
Mechanisms shall include evaluation of health risk assessments, claims
data, and, if available 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), a treatment
plan for an enrollee determined to need a course of treatment or
regular care monitoring must be developed by the enrollee’s care

provider 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 42 CFR 438.208(c)(4), for enrollees with special health care
needs determined through an assessment by appropriate health care
professionals (consistent with 42 CFR 438.208(c)(2)) to need a course
of treatment or regular care monitoring, each plan must have a
mechanism in place to allow enrollees to directly access a specialist
(for example, through a standing referral or an approved number of
visits) as appropriate for the enrollee’s condition and identified
needs.

20.9 Out-of-Plan Use of Non-Emergency Services

Unless otherwise specified in this contract, where a member utilizes
services available under the plan other than emergency services from a
non-contract provider, the plan shall not be liable for the cost of
such utilization unless the plan referred the member to the
non-contract provider or authorized such out-of-plan utilization. The
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 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
business day from the request for approval. The member 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 plan shall reimburse any
hospital or physician that is outside the plan’s authorized geographic
service area for 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:

AHCA Contract No. FA523, Attachment I, Page 38 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	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.

20.10 Emergency Care Requirements

	 	 	The plan shall make provisions for and advise all members of the
provisions governing emergency use. Emergency services are defined in
section 100.0, Glossary of this contract. In accordance with section
743.064, F.S., the plan shall not deny claims for emergency medical
treatment in a hospital due to lack of parental consent.
	 
	 	 	Pursuant to section 409.9128, F.S., requirements for the plan to
provide emergency services and care are as follows:

	 	a.	 	In providing for emergency services and care as a covered service, the plan shall not:

	 	1.	 	Require prior authorization for the receipt of
pre-hospital transport or treatment or for emergency services
and care.
	 
	 	2.	 	Indicate that emergencies are covered only if care is 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.
	 
	 	4.	 	Deny payment based on the member’s or the
hospital’s failure to notify the plan in advance or within a
certain period of time after the care is given.

	 	b.	 	The plan shall provide pre-hospital and hospital-based
trauma services and emergency services and care to a member of
the plan as required under sections 395.1041, 395.4045, and
401.45, F.S.
	 
	 	c.	 	Pursuant to section 409.9128, F.S., when a member is
present at the hospital seeking emergency services and care, the
determination as to whether an emergency medical condition (as
defined in section 409.901, F.S., and provided in section 100.0,
Glossary) exists shall be made, for the purpose of treatment, by a
physician of the hospital or, to the extent permitted by
applicable law, by other appropriate personnel under the
supervision of the hospital physician. The physician or the
appropriate personnel shall indicate in the patient’s chart the
results of the screening, examination, and evaluation. The plan
shall compensate the provider for the screening, evaluations and
examination that is reasonably calculated to assist the health
care provider in arriving at a determination as to whether the
patient’s condition is an emergency medical condition. The plan
shall compensate the provider for emergency services and care. If
a determination is made that an emergency medical condition does
not exist, the plan is not responsible for payment for services
rendered subsequent to that determination.
	 
	 	d.	 	If a determination has been made that an emergency
medical condition exists and the member has notified the
hospital, or the hospital emergency personnel otherwise has
knowledge, that the patient is a member of the plan, the
hospital must make a reasonable attempt to notify the member’s
primary care physician, if known, or the plan, if the plan has
previously requested in writing that the notification be made
directly to the plan, of the existence of the emergency medical
condition. If the primary care physician is not known, or has
not been contacted, the hospital must:

	 	1.	 	Notify the plan as soon as possible prior to
discharge of the member from the emergency care area; or
	 
	 	2.	 	Notify the plan within 24 hours or on the next
business day after admission of the member as an inpatient to
the hospital.

AHCA Contract No. FA523, Attachment I, Page 39 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	if the notification required by this paragraph is not accomplished,
the hospital must document its attempt(s) to notify the plan or
document the circumstances that precluded attempts to notify the plan.
The plan shall not deny payment for emergency services and care based
on a hospital’s failure to comply with the notification requirements
of this paragraph.
	 
	 	e.	 	If the member’s primary care physician responds to the
notification, the hospital physician and the primary care physician
may discuss the appropriate care and treatment of the member. The
plan may have a member of the hospital staff with whom it has a
contract participate in the treatment of the member within the scope
of the physician’s hospital staff privileges. The member may be
transferred, in accordance with state and federal law, to a hospital
that has a contract with the plan and has the service capability to
treat the member’s emergency medical condition. Notwithstanding any
other state law, a hospital may request and collect insurance or
financial information from a patient in accordance with federal law,
which is necessary to determine if the patient is a member of the
plan, if emergency services and care are not delayed.
	 
	 	f.	 	In accordance with 42 CFR 438.114, the plan must also cover
post-stabilization services without authorization, regardless of
whether the beneficiary obtains the service within or outside the
plan’s network, for the following situations:

	 	1.	 	Post-stabilization care services that were pre-approved
by the plan; or were not pre-approved by the plan because the plan
did not respond to the treating provider’s request for
pre-approval within one hour after being requested to approve such
care, or could not be contacted for pre-approval.
	 
	 	2.	 	Post stabilization services are services subsequent to
an emergency that a treating physician views as medically
necessary after an emergency medical condition has been
stabilized. These are not emergency services, but are
non-emergency services that the plan could choose not to cover
out-of-plan except in the circumstances described above.

	 	g.	 	In accordance with section 409.9128, F.S., reimbursement for services
provided to a member of a plan under this section by a provider that does not
have a contract with the plan shall be the lesser of:

	 	1.	 	The provider’s charges;
	 
	 	2.	 	The usual and customary provider charges for
similar services in the community where the services were
provided;
	 
	 	3.	 	The charge mutually agreed to by the plan and the
provider within 60 calendar days after submittal of the claim; or
	 
	 	4.	 	The Medicaid rate.

	 	 	 	The plan shall not deny emergency services claims for claims submitted
by a non-contracting provider solely based on the period between the
date of service and the date of clean claim submission unless that
period exceeds 365 days.
	 
	 	h.	 	Notwithstanding the requirements stated above, payment by the
plan for claims for emergency services rendered by a non-contract
provider shall be made pursuant to section 641.3155, F.S. If third
party liability exists, payment of claims shall be determined in
accordance with section 70.20, Third Party Resources.
	 
	 	i.	 	The plan must review and approve or disapprove emergency
service claims based on the definition of emergency services and
care, and emergency medical condition, specified in section 100.0,
Glossary.

AHCA Contract No. FA523, Attachment I, Page 40 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

20.11 Grievance System Requirements

	 	 	 	The plan must have an enrollee grievance system in place that includes a
grievance process, an appeal process, and access to the Medicaid fair
hearing system. The plan must develop, implement and maintain a
grievance system that complies with the requirements in s. 641.511,
F.S., and with federal laws and regulations, including 42 CFR 431.200
and 438, Subpart F, “Grievance System.” The system must include written
policies and procedures that are approved by the Agency. The plan shall
refer all enrollees and providers who are dissatisfied with the plan or
its action to the grievance/appeal coordinator for processing and
documentation in accordance with this contract and the approved policies
and procedures. The nature of the expression of dissatisfaction
determines which of the processes the plan must follow. The grievance
process is the procedure for addressing enrollee grievances, which are
expressions of dissatisfaction about any matter other than an action, as
“action” is defined in section 100.0, Glossary. The appeal process is
the procedure for addressing enrollee appeals, which are requests for
review of an action, as “action” is defined in section 100.0, Glossary.
	 
	 	 	 	The 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. The plan must acknowledge receipt of each grievance and
appeal in writing. The plan must ensure that decision makers on
grievances and appeals were not involved in previous levels of review or
decision-making and are health care professionals with clinical
expertise in treating the enrollee’s condition or disease when deciding
any of the following:

	 	a.	 	An appeal of a denial that is based on lack of medical necessity.
	 
	 	b.	 	A grievance regarding denial of expedited resolution of an appeal.
	 
	 	c.	 	A grievance or appeal that involves clinical issues.

	 	 	 	The plan must provide information on grievance, appeal, and fair
hearing, and their respective policies, procedures, and time frames, to
all providers and subcontractors at the time they enter into a
contract. Procedural steps must be clearly specified in the member
handbook for members and the provider manual for providers, including
the address, telephone number, and office hours of the grievance
coordinator. The information must include:

	 	a.	 	Enrollee rights to Medicaid fair hearing, the method for
obtaining a hearing, the rules that govern representation at the
hearing, and the DCF address for pursuing a fair hearing, which
is Office of Appeals Hearings, 1317 Winewood Boulevard, Building
5, Room 203, Tallahassee, Florida 32399-0700.
	 
	 	b.	 	Enrollee rights to file grievances and appeals and requirements and
time frames for filing.
	 
	 	c.	 	The availability of assistance in the filing process.
	 
	 	d.	 	The toll-free numbers to file oral grievances and appeals.
	 
	 	e.	 	Enrollee rights to request continuation of benefits
during an appeal or Medicaid fair hearing process and, if the
plan’s action is upheld in a hearing, the fact that the enrollee
may be liable for the cost of any continued benefits.
	 
	 	f.	 	Enrollee rights to appeal to the Agency and the Subscriber
Assistance Program, formerly named the Statewide Provider and
Subscriber Assistance Panel (Panel) after exhausting the plan’s
appeal or grievance process in accordance with s. 408.7056 and
641.511, F.S., with the following exception: a grievance taken to
Medicaid fair hearing will not be considered by the Panel. The
information must explain that a request for Panel review must be
made by the enrollee within one year of receipt of the final
decision letter from the plan, must explain how to initiate such a
review, must include the Panel’s address and telephone number as
follows: Agency for Health Care Administration, Bureau of Managed
Health Care, Building 1, Room 339, 2727 Mahan Drive, Tallahassee,
Florida 32308, (850) 921-5458.

AHCA Contract No. FA523, Attachment I, Page 41 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	g.	 	Notice that the plan must continue
enrollee benefits if:

	 	1.	 	The appeal is filed timely, meaning on or before the later of the
following:

	 	(a)	 	Within 10 days of the date on the notice of
action (Add 5 days if the notice is sent via U.S. mail).
	 
	 	(b)	 	The intended effective date of the 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; and
	 
	 	5.	 	The enrollee requests extension of benefits.

	 	 	 	The plan must maintain records of grievances and appeals in
accordance with the terms of this contract, including a separate log
for calls regarding the Hernandez Settlement, Hernandez, et al. v.
Medows, case number 02-20964 Civ-Gold/Simonton. The ‘Hernandez’ log
shall contain at a minimum the name of the enrollee, the address of
the enrollee, a telephone number for the enrollee, and a brief
description of the issue (including the name of the drug involved.)

20.11.1 Appeal Process

	 	 	An appeal is a request for review of an “action” as defined in
section 100.0, Glossary. A beneficiary may file an appeal, and a
provider, acting on behalf of the beneficiary and with the
beneficiary’s written consent, may file an appeal. The appeal
procedure must be the same for all beneficiaries.

	 	a.	 	Filing Requirements
	 
	 	 	 	The beneficiary or provider may file an appeal within 30 days of
the date of the notice of action. If the plan does not issue a
written notice of action, the enrollee or provider may file an
appeal within one year of the action.
	 
	 	 	 	The beneficiary 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 plan receives the oral filing.
	 
	 	b.	 	General Plan Duties
	 
	 	 	 	The plan must:

	 	1.	 	Ensure that oral inquiries seeking to appeal an
action are treated as appeals and confirm those inquiries in
writing, unless the beneficiary or the provider requests
expedited resolution.
	 
	 	2.	 	Provide a reasonable opportunity to present
evidence, and allegations of fact or law, in person as well
as in writing.
	 
	 	3.	 	Allow the beneficiary and representative
opportunity, before and during the appeals process, to
examine the beneficiary’s case file, including medical
records, and any other documents and records.
	 
	 	4.	 	Consider the beneficiary, representative, or
estate representative of a deceased beneficiary as parties
to the appeal.

AHCA Contract No. FA523, Attachment I, Page 42 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	5.	 	Resolve each appeal, and provide notice, as
expeditiously as the beneficiary’s health condition requires,
within State-established time frames not to exceed 45 days from
the day the plan receives the appeal.
	 
	 	6.	 	Continue the enrollee’s benefits if:

	 	(a)	 	The appeal is filed timely, meaning on or before the later of
the following:
	 
	 	 	 	Within 10 days of the date on the notice of action (Add 5
days if the notice is sent via U.S. mail).
	 
	 	 	 	The intended effective date of the plan’s proposed action.
	 
	 	(b)	 	The appeal involves the termination,
suspension, or reduction of a previously authorized course
of treatment;
	 
	 	(c)	 	The services were ordered by an authorized provider;
	 
	 	(d)	 	The authorization period has not expired; and
	 
	 	(e)	 	The beneficiary requests extension of benefits.

	 	7.	 	Provide written notice of disposition that includes the
results and date of appeal resolution and for decisions not
wholly in the beneficiary’s favor that includes:

	 	(a)	 	Notice of the right to request a Medicaid fair hearing.
	 
	 	(b)	 	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 1, Room 309,
Tallahassee, Florida 32399-0700.
	 
	 	(c)	 	Notice of the right to continue to receive benefits pending a
hearing.
	 
	 	(d)	 	Information about how to request the continuation of benefits.
	 
	 	(e)	 	Notice that if the plan’s action is upheld in a
hearing, the enrollee may be liable for the cost of any
continued benefits.
	 
	 	 	 	(0 Notice that if the appeal is not resolved to the
satisfaction of the beneficiary, the beneficiary has one year
in which to request review of the plan’s decision concerning
the appeal by the Subscriber Assistance Program, formerly
named the Statewide Provider and Subscriber Assistance
Program, as provided in s. 408.7056, F.S. The notice must
explain how to initiate such a review and must include the
addresses and toll-free telephone numbers of the Agency and
the Subscriber Assistance Program.

	 	8.	 	Provide the Agency with a copy of the written notice of disposition
upon request.
	 
	 	9.	 	Ensure that punitive action is not taken against a
provider who files an appeal on a beneficiary’s behalf or
supports a beneficiary’s appeal.

	 	 	 	The plan may extend the resolution time frames by up to 14 calendar
days if the beneficiary requests the extension or the plan documents
that there is need for additional information and that the delay is in
the beneficiary’s interest. If the extension is not requested by the
beneficiary the plan must give the beneficiary written notice of the
reason for the delay.

AHCA Contract No. FA523, Attachment I, Page 43 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	If the plan continues or reinstates beneficiary benefits while the
appeal is pending, the benefits must be continued until one of
following occurs:

	 	1.	 	The beneficiary withdraws the appeal.
	 
	 	2.	 	10 days pass from the date of the plan’s adverse
plan decision and the beneficiary has not requested a
Medicaid fair hearing with continuation of benefits until a
Medicaid fair hearing decision is reached. (Add 5 days if the
notice is sent via U.S. mail.)
	 
	 	3.	 	A Medicaid fair hearing decision adverse to the beneficiary is made.
	 
	 	4.	 	The authorization expires or authorized service limits are met.

	 	 	 	If the final resolution of the appeal is adverse to the beneficiary, the
plan 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.
	 
	 	 	 	The plan must authorize or provide the disputed services promptly, and as
expeditiously as the beneficiary’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.
	 
	 	 	 	The 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.

	c.	 	Expedited Process

	 	 	 	Each plan must establish and maintain an expedited review process for
appeals when the plan determines (if requested by the beneficiary) or the
provider indicates (in making the request on the enrollee’s behalf or
supporting the beneficiary’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.
	 
	 	 	 	The beneficiary or provider may file an expedited appeal either
orally or in writing. No additional beneficiary follow-up is
required.
	 
	 	 	 	The plan must:

	 	1.	 	Inform the beneficiary of the limited time available
for the enrollee to present evidence and allegations of fact
or law, in person and in writing.
	 
	 	2.	 	Resolve each expedited appeal and provide notice, as
expeditiously as the beneficiary’s health condition requires,
within State-established time frames not to exceed 72 hours
after the plan receives the appeal.
	 
	 	3.	 	Provide written notice of disposition.
	 
	 	4.	 	Make reasonable efforts to also provide oral notice of disposition.
	 
	 	5.	 	Ensure that punitive action is not taken against a
provider who requests an expedited resolution on the beneficiary’s
behalf or supports a beneficiary’s request for expedited
resolution.

	 	 	 	The plan may extend the resolution time frames by up to 14 calendar days
if the beneficiary requests the extension or the plan documents that
there is need for additional information and that the delay is in the
beneficiary’s interest. If the extension is not requested by the
beneficiary, the plan must give the enrollee written notice of the
reason for the delay.

AHCA Contract No. FA523, Attachment I, Page 44 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	If the plan denies a request for expedited resolution of an appeal, the
plan must:

	 	1.	 	Transfer the appeal to the standard time frame of
no longer than 45 days from the day the plan receives the
appeal with a possible 14-day extension.
	 
	 	2.	 	Make reasonable efforts to provide prompt oral notice of the
denial
	 
	 	3.	 	Provide written notice of the denial within two calendar days.
	 
	 	4.	 	Fulfill all general plan duties listed above.

20.11.2 Grievance Process

	 	 	 	A grievance is an expression of dissatisfaction about any matter
other than an action, as “action” is defined in 100.0, Glossary. An
enrollee may file a grievance, and a provider, acting on behalf of
the beneficiary and with the beneficiary’s written consent, may
file a grievance.

	 	a.	 	Filing Requirements
	 
	 	 	 	The beneficiary or provider may file a grievance within one year
after the date of occurrence that initiated the grievance.
	 
	 	 	 	The beneficiary or provider may file a grievance either orally or
in writing. An oral request may be followed up with a written
request, but the time frame for resolution begins the date the plan
receives the oral filing.
	 
	 	b.	 	General Plan Duties
	 
	 	 	 	The plan must:

	 	1.	 	Resolve each grievance, and provide notice, as
expeditiously as the beneficiary’s health condition requires,
within State-established time frames not to exceed 90 days from
the day the plan receives the grievance.
	 
	 	2.	 	Provide written notice of disposition that includes
the results and date of grievance resolution and for decisions
not wholly in the beneficiary’s favor that includes:

	 	(a)	 	Notice of the right to request a Medicaid fair hearing.
	 
	 	(b)	 	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.
	 
	 	(c)	 	Notice of the right to continue to receive benefits pending a
hearing.
	 
	 	(d)	 	Information about how to request the continuation of benefits.
	 
	 	(e)	 	Notice that if the plan’s action is upheld
in a hearing, the beneficiary may be liable for the cost
of any continued benefits.

	 	3.	 	Provide the Agency with a copy of the written notice of
disposition upon request.
	 
	 	4.	 	Ensure that punitive action is not taken against a
provider who files a grievance on a beneficiary’s behalf or
supports an enrollee’s grievance.

AHCA Contract No. FA523, Attachment I, Page 45 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	The plan may extend the resolution time frames by up to 14 calendar
days if the beneficiary requests the extension or the 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
beneficiary, the plan must give the beneficiary written notice of the
reason for the delay.

20.11.3 Medicaid Fair Hearing System

	 	 	 	The Medicaid fair hearing policy and process is detailed in Rule
65-2.042, F.A.C. The plan’s grievance system policy and appeal and
grievance processes shall state that the beneficiary has the right to
request a Medicaid fair hearing in addition to pursuing the plan’s
grievance process. A provider acting on behalf of the beneficiary and
with the beneficiary’s written consent may request a Medicaid fair
hearing. Parties to the Medicaid fair hearing include the plan, as
well as the beneficiary and his or her representative or the
representative of a deceased enrollee’s estate.

	 	a.	 	Request Requirements
	 
	 	 	 	The beneficiary or provider may request a Medicaid fair hearing
within 90 days of the date of the notice of action.
	 
	 	 	 	The beneficiary 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.
	 
	 	b.	 	General Plan Duties

	 	 	 	The plan must:
	 
	 	1.	 	Continue the beneficiary’s benefits while Medicaid fair hearing is
pending if:

	 	(a)	 	The Medicaid fair hearing is filed timely, meaning on or
before the later of the following:
	 
	 	 	 	Within 10 days of the date on the notice of action (Add 5
days if the notice is sent via U.S. mail).
	 
	 	 	 	The intended effective date of the plan’s proposed action.
	 
	 	(b)	 	The Medicaid fair hearing involves the
termination, suspension, or reduction of a previously
authorized course of treatment;
	 
	 	(c)	 	The services were ordered by an authorized provider;
	 
	 	(d)	 	The authorization period has not expired; and
	 
	 	(e)	 	The beneficiary requests extension of benefits.

	 	2.	 	Ensure that punitive action is not taken against a
provider who requests a Medicaid fair hearing on the
beneficiary’s behalf or supports an enrollee’s request for a
Medicaid fair hearing.

	 	 	 	If the plan continues or reinstates beneficiary benefits while the
Medicaid fair hearing is pending, the benefits must be continued
until one of following occurs:
	 
	 	1.	 	The beneficiary withdraws the request for Medicaid fair hearing.
	 
	 	2.	 	10 days pass from the date of the plan’s adverse
plan decision and the beneficiary has not requested a
Medicaid fair hearing with continuation of benefits until a
Medicaid fair hearing decision is reached. (Add 5 days if
the notice is sent via U.S. mail.)

AHCA Contract No. FA523, Attachment I, Page 46 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	3.	 	A Medicaid fair hearing decision adverse to the beneficiary is
made.
	 
	 	4.	 	The authorization expires or authorized service limits are met.

	 	 	 	The plan must authorize or provide the disputed services promptly,
and as expeditiously as the beneficiary’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.
	 
	 	 	 	The 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.

20.12 Quality Improvement

	 	 	 	The plan shall have an ongoing quality improvement (QI) program 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
Medicaid population. The 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. The 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. The plan and its quality
improvement program shall demonstrate in their care management how
specific interventions better manage the care and impact healthier
patient outcomes. The goal shall be to provide comprehensive, high
quality, accessible, cost effective, and efficient health care to
Medicaid beneficiaries.
	 
	 	 	 	The plan shall provide a written descriptive QI program that identifies
FTE staff specifically trained to handle the Medicaid business and
delineates how staffing is organized to interact and resolve problems,
define measures and expectations, and demonstrate the process for
decision making (i.e. projects selection, interventions) and
reevaluation.
	 
	 	 	 	The plan shall cooperate with the Agency and the External Quality
Review Organization (EQRO) vendor. The Agency will set methodology and
standards for QI performance improvement with advice from the EQRO.
Prior to implementation, the Agency and/or the EQRO shall review the QI
program. The quality improvement program must be approved, in writing,
by the Agency no later than three months following the effective date
of this contract. If the plan has submitted and received approval for
the present calendar year, an extension may be granted for the
submission of new projects.
	 
	 	 	 	The quality improvement program shall be based on the minimum
requirements listed below.

	 	a.	 	The plan’s QI governing body shall monitor, evaluate,
and oversee results to improve care. The governing body shall
have written guidelines and standards defining their
responsibilities for:

	 	•	 	Supervision and maintenance of an active QI committee,
	 
	 	•	 	Ensuring ongoing QI activity coordination
with other management activity, demonstrated through
written, retrievable documentation from meetings or
activities,
	 
	 	•	 	Planning, decisions, interventions, and
assessment of results to demonstrate coordination of QI
processes,
	 
	 	•	 	Oversight of QI program activities, and
	 
	 	•	 	A written diagram that demonstrates the QI system process.

	 	b.	 	The plan shall have a quality improvement review authority which
shall:

	 	•	 	Direct and review quality improvement activities;

AHCA Contract No. FA523, Attachment I, Page 47 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	•	 	Assure that quality improvement activities take place throughout the plan;
	 
	 	•	 	Review and suggest new or improved quality improvement activities;
	 
	 	•	 	Direct task forces/committees in the review of focused concern;
	 
	 	•	 	Designate evaluation and study design procedures;
	 
	 	•	 	Publicize findings to appropriate staff and departments within the plan;
	 
	 	•	 	Report findings and recommendations to the appropriate executive authority; and
	 
	 	•	 	Direct and analyze periodic reviews of members’ service utilization patterns.

	 	c.	 	The plan shall provide for quality improvement staff
specifically trained to handle the Medicaid business which have the
responsibility for: identifying their Medicaid beneficiaries’ needs
and problems related to quality of care for covered health care and
professional services, measuring how well these needs are met, and
improving processes to meet these needs. The plan shall evaluate ways
in which care is provided, identify outliers to specific indicators,
determine what shall be accomplished, ascertain how to determine if a
change is an improvement, and initiate interventions that will result
in an improved quality of care for covered health care and
professional services. The plan shall prioritize problem areas for
resolution and design strategies for change; implement improvement
activities and measure success.
	 
	 	d.	 	The systematic process of quality assessment and improvement
shall be objective in systematically monitoring and evaluating the
quality and appropriateness of care and service delivery (or the
failure of delivery) to the Medicaid population through quality of
care projects and related activities. Opportunities for improvement
shall be on an ongoing basis. The plan shall assess, evaluate,
decrease inappropriate care, decrease inappropriate service denials,
and increase coordination of care. The plan shall document in its QI
program that it is monitoring the range of quality of care across
services and all treatment modalities. This review of the range of
care shall be carried out over multiple review periods and not only
on a concurrent basis.
	 
	 	e.	 	At least four Agency-approved quality-of-care projects must be
performed by the plan. Each study/project must include a
statistically significant sample of Medicaid lives. One of the four
projects must be a (QAPI) Project on Language and Culture: Clinical
Health Care Disparities or Culturally and Linguistically Appropriate
Services, initiated by January 31, 2005. The plan shall provide
notification to the Agency prior to implementation. The notification
shall include the general description, justification, and methodology
for each project and document the potential for meaningful
improvement. The plan shall report quarterly to the Agency within 30
days of the reporting quarter. The report shall include the current
status of the project, including but not limited to goals,
anticipated outcomes, and ongoing interventions. The results shall be
reported no less than annually. Each project shall have been through
the plan’s quality process, including reporting and assessments by
the quality committee and reporting to the board of directors:
	 
	 	 	 	Pursuant to 42 CFR 438.240, the project shall focus on clinical care
and non-clinical areas (i.e. health services delivery). These projects
must be designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in
clinical care and non-clinical care areas that are expected to have a
favorable effect on health outcomes and enrollee satisfaction. Each
performance improvement project must be completed in a reasonable time
period so as to generally allow information on the success of
performance improvement projects in the aggregate to produce new
information on quality of care every year. The Centers for Medicare
and Medicaid Services (CMS), in consultation with states and other
stakeholders, may specify performance measures and topics for
performance improvement projects. If CMS specifies performance
improvement projects, the plan will participate and this will count
towards the Agency-approved quality-of-care projects. Each individual
CMS project can be counted as one of the Agency-approved quality of
care projects. The quality-of-care projects used to measure
performance improvement projects shall include diagrams (e.g.
algorithms and /or flow charts) for monitoring and shall:

	 	1.	 	Target specific conditions and specific health
service delivery issues for focused individual practitioner
and system-wide monitoring and evaluation.

AHCA Contract No. FA523, Attachment I, Page 48 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	2.	 	Use clinical care standards or practice guidelines to
objectively evaluate the care the entity delivers or fails
to deliver for the targeted clinical conditions.
	 
	 	3.	 	Use appropriate quality indicators derived from the
clinical care standards or practice guidelines to screen and
monitor care and services delivered.
	 
	 	4.	 	Implement system interventions to achieve improvement in quality.
	 
	 	5.	 	Evaluate the effectiveness of the interventions.
	 
	 	6.	 	Provide sufficient information to plan and
initiate activities for increasing or sustaining
improvement.
	 
	 	7.	 	Monitor the quality and appropriateness of care
furnished to enrollees with special health care needs.
	 
	 	8.	 	Reflect the population served in terms of age groups, disease
categories, and special risk status.
	 
	 	9.	 	Ensure that appropriate health professionals analyze data.
	 
	 	10.	 	Ensure that multi-disciplinary teams will address system issues.
	 
	 	11.	 	Include objectives and quantifiable measures based on
current scientific knowledge and clinical experience and have an
established goal or benchmark.
	 
	 	12.	 	Identify and use quality indicators that are measurable and
objective.
	 
	 	13.	 	Validate the design to assure that the data to be
abstracted during the QI project is accurate, reliable and
developed according to generally accepted principles of
scientific research and statistical analysis.
	 
	 	14.	 	Maintain a system for tracking issues over time to
ensure that actions for improvement are effective.

	 	 	 	The plan’s quality improvement information shall be used in such processes
as recredentialing, recontracting, and annual performance ratings of
individuals. It shall also be coordinated with other performance
monitoring activities, including utilization management, risk management,
and resolution and monitoring of member grievances. There shall also be a
link between other management activities such as network changes, benefits
redesign, medical management systems (e.g., precertification), practice
feedback to physicians, patient education, and member services.
	 
	 	 	 	The plan’s quality improvement program shall have a peer review component
with the authority to review practice methods and patterns of individual
physicians and other health care professionals, morbidity/mortality, and
all grievances related to medical treatment; evaluate the appropriateness
of care rendered by professionals; implement corrective action when
deemed necessary; develop policy recommendations to maintain or enhance
the quality of care provided to Medicaid enrollees; conduct a review
process which includes the appropriateness of diagnosis and subsequent
treatment, maintenance of medical records requirements, adherence to
standards generally accepted by professional group peers, and the process
and outcome of care; maintain written minutes of the meetings; receive
all written and oral allegations of inappropriate or aberrant service;
and educate recipients and staff on the role of the peer review authority
and the process to advise the authority of situations or problems.

	 	f.	 	Pursuant to 42 CFR 438.208(c)(1), the plan shall implement
mechanisms to identify persons with special health care needs, as
those persons are defined by the Agency.

AHCA Contract No. FA523, Attachment I, Page 49 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	g.	 	Plan Service Performance

	 	 	 	The following table designates the weight assigned to each
performance measure in Agency-defined categories.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	(Minimum of 3) QUALITY	 	 
	 	 	 	 	 	 	 	 	 	 	IMPROVEMENT &	 	 
	 	 	 	 	 	 	ON-SITE AUDIT	 	PERFORMANCE	 	 
	CAHPS
	 	CHCUP
	 	COMPLIANCE
	 	INDICATORS
	 	ACCREDITATION

	15%
	 	 	20	%	 	 	15	%	 	 	35	%	 	 	15	%

	 	 	 	The External Quality Review Organization vendor (EQRO) may recommend
how items will be scored to get these ratings. Overall scoring will
apply until modified by the EQRO and would be measured as:

	 	 	 	 	 
	Rating
	 	Score

	Excellent
	 	 	91-100	 
	Commendable
	 	 	81-90	 
	Passing
	 	 	71-80	 
	Provisional
	 	 	61-70	 
	Failed
	 	 	<60	 

	 	1.	 	Consumer Assessment of Health Plans Study (CAHPS)
Survey results in yearly conducted survey data regarding the
member’s assessment of their satisfaction with health care
services. See section 20.12.2. Starting with the 2004 HMO
report, the plans will be rated in five areas based on the
latest CAHPS survey:

Overall Plan Satisfaction

Ease in Getting to See A Specialist

Ease in Getting Needed Care, Tests, or Treatment 

How WellProviders Communicate with Members

Getting Help from Customer Service

	 	 	 	All of the above items correspond to one question in the consumer
survey except for “How Well Providers Communicate with Members.”
It contains the combined results to four survey questions about
how well providers communicate.
	 
	 	 	 	Possible ratings are 0 to 5 stars in each area. The plan
performance scoring is based on the value given by the CAHPS
survey and is converted to stars. The CAHPS survey stars will be
equated to points for this section of the contract. The points are
totaled and averaged into a composite overall rating for this
section. For example, if two categories scored five stars (= 2 x
15 points), two categories scored four stars (= 2 x 12 points),
and one scored three stars (= 1 x 8 points), the total score is 62
points averaged by the number of categories (rounded to the
nearest whole number). The example’s composite plan performance
score in this section of the contract is 12 points.

	 	 	 	 	 
	PLAN PERFORMANCE
	 	POINTS AWARDED

	*****
	 	 	15	 
	****
	 	 	12	 
	***
	 	 	8	 
	**
	 	 	4	 
	*
	 	 	1	 
	No Stars
	 	 	0	 

	 	2.	 	CHCUP Participation Goal of 80 percent. Plan
performance should be measured in improvement and
statutory benchmarks using federal definitions and
audited data.

AHCA Contract No. FA523, Attachment I, Page 50 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	 	 
	 	 	POINTS
	PLAN
PERFORMANCE
	 	AWARDED

	80% or above
	 	 	20	 
	Equal to or greater than 66% and <80%
	 	 	18	 
	15% annual improvement
	 	 	16	 
	10-14% annual improvement
	 	 	14	 
	7-9% annual improvement
	 	 	12	 
	5-6% annual improvement
	 	 	10	 
	>3% annual improvement
	 	 	8	 
	>1% annual improvement
	 	 	5	 

	 	3.	 	In the On-Site Compliance Audit by the Agency’s Bureau
of Managed Care, contract compliance is assessed, reviewed, and
evaluated. This scoring is used to measure plan performance by
recording the “percentage met” of all the standards currently
contained in the Medicaid HMO contract. This is considered a
critical element and failure to meet partial compliance may
require immediate corrective action. This audit is conducted
every year by the Agency. The EQRO may monitor the survey
results and may advise the Agency to modify weights.

	 	 	 	 	 	 	 	 	 
	PLAN	 	 	 	 	 	POINTS
	PERFORMANCE
	 	COMPLIANCE
	 	AWARDED

	95-100%
	 	Total Compliance	 	 	15	 
	94-90%
	 	Substantial Compliance	 	 	10	 
	89-85%
	 	Partial Compliance	 	 	5	 
	80-84%
	 	Minimal Compliance	 	 	1	 
	<80%
	 	Non-Compliance	 	 	0	 

	 	4.	 	Quality Improvement and Performance Indicators are a
combination of (2) HEDIS measurements and (1) plan selected
indicator, Maternity Care. The two HEDIS measures will be based
on those for which the most plans reported and show the greatest
overall improvement. Benchmarks will be based on national or
regional Medicaid rates. Improvement in HEDIS measurement shall
be measured using baseline data. The HEDIS 2004 contains
measurement year 2003 data and HEDIS 2005 contains measurement
year 2004 data. Health plans will be reporting to AHCA October 1,
2004, measurement year 2003 data that will be published in the
2005 HMO REPORT (Choosing A Quality Health Plan). Health plans
will be reporting to AHCA October 1, 2005, measurement year 2004
data that will be published in the 2006 HMO REPORT (Choosing a
Quality Health Plan).

	 	 	 	 	 
	 	 	POINTS
	PLAN PERFORMANCE
	 	AWARDED

	Meet/exceed benchmarks - 3 indicators
	 	 	35	 
	Meet/exceed benchmarks - 2 of 3 indicators
	 	 	30	 
	Substantial improvement demonstrated - 3 of 3
	 	 	25	 
	Substantial improvement demonstrated - 2 of 3
	 	 	20	 
	Substantial improvement demonstrated -1 of 3
	 	 	15	 
	Minimal improvement demonstrated - 3 of 3
	 	 	10	 
	Interventions implemented - 3 of 3
	 	 	0	 
	Interventions in place without success and/or noncompliance
	 	 	0	 

AHCA Contract No. FA523, Attachment I, Page 51 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

DEFINITIONS FOR BENCHMARKS

	 	 	 
	PLAN PERFORMANCE
	 	DEFINITION

	Meet/exceed benchmarks

	 	>5% increase from prior year
	Substantial improvement demonstrated
	 	>3% increase from prior year
	Minimal improvement demonstrated	 	 
	Interventions implemented
	 	>1% increase from prior year
	Interventions in place without
success and/or noncompliance	 	No Improvement

Indicators:

	 	a.	 	HEDIS measures pursuant to Agency rule.
	 	b.	 	A HEDIS measure for Maternity Care.

	 	5.	 	Accreditation is performed and scored by a national
accrediting body, pursuant to section 40.6, every 1 to 3 years
depending on the outcome of previous audit and accrediting body
program. The accrediting organization ascertains the plan’s
capability in assessing, measuring, demonstrating, and
providing comprehensive, effective, and efficient care.

	 	 	 	 	 
	PLAN PERFORMANCE
	 	POINTS AWARDED

	EXCELLENT
	 	 	15	 
	COMMENDABLE
	 	 	10	 
	PROVISIONAL
	 	 	5	 
	CONDITIONAL
	 	 	0	 

	 	 	 	 	 	 	 	 	 	 	 
	PLAN	 	 	 	 	 	 	 	 	 	 
	PERFORMANCE
	 	JCAHO
	 	URAC
	 	AAAHC
	 	NCQA
	 	Score

	EXCELLENT

	 	Fu11	 	Full	 	Full
	 	Full
	 	15
	
	 	compliance
	 	compliance	 	compliance
	 	compliance	 	 
	
	 	3 years	 	2 Years
	 	3 years	 	3 years	 	 
	COMMENDABLE
	 	Accreditation with
	 	Conditional
	 	One Year
	 	Commendable
	 	10
	
	 	requirements for	 	 	 	 	 	 	 	 
	
	 	improvement	 	 	 	 	 	 	 	 
	PROVISIONAL
	 	Provisional
	 	Corrective
	 	6 months
	 	Accredited
	 	5
	
	 	 	 	Action	 	 	 	 	 	 
	CONDITIONAL
	 	Conditional
	 	 	 	 	 	Provisional
	 	0
	
	 	Denied
	 	Denied
	 	Denied
	 	Denied
	 	0

20.12.1 Utilization Management

	 	 	 	The plan’s quality improvement program shall have a utilization
management component that includes the following:

	 	a.	 	The plan must develop and have in place utilization
management policies and procedures that include protocols for
prior approval and denial of services, hospital discharge
planning, physician profiling, and retrospective review of
both inpatient and ambulatory claims meeting pre-defined
criteria.
	 
	 	b.	 	The plan must develop procedures for
identifying patterns of over-and under-utilization of
members and for addressing potential problems identified
as a result of these analyses.

AHCA Contract No. FA523, Attachment I, Page 52 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	c.	 	The plan’s internal utilization management policies and
procedures must be consistent with the utilization control
program requirements in 42 CFR 456.
	 
	 	d.	 	The plan shall report fraud and abuse information
identified through the utilization management program to the
Agency in accordance with 42 CFR 455.1(a)(1).
	 
	 	e.	 	The plan shall have a procedure for members to obtain a
second medical opinion and shall be responsible for payment of
such services. The plan shall clearly state its procedure for
obtaining a second medical opinion in the member handbook. The
plan’s second opinion procedure shall comply with section 641.51,
F.S.
	 
	 	f.	 	The plan’s service authorization systems shall provide
authorization numbers, effective dates for the authorization, and
written confirmation to the provider of denials, as appropriate.
Pursuant to 42 CFR 438.210(b)(3), any decision to deny a service
authorization request or to authorize a service in an amount,
duration, or scope that is less than requested, must be made by a
health care professional who has appropriate clinical expertise in
treating the enrollee’s condition or disease. Pursuant to 42 CFR
438.210(c), the plan must notify the requesting provider of any
decision to deny a service authorization request or to authorize a
service in an amount, duration, or scope that is less than
requested. The notice to the provider need not be in writing. The
plan must notify the enrollee in writing of any decision to deny a
service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested.
	 
	 	 	 	Pursuant to 42 CFR 438.404(a), 42 CFR 438.404(c) and 42 CFR
438.210(b) and (c), the plan must give the enrollee written notice
of any “action” as defined in section 100.0, Glossary, within the
time frames for each type of action. Pursuant to 42 CFR 438.404(b)
and 42 CFR 438.210(c), the notice must explain:

	 	1.	 	The action the plan has taken or intends to take.
	 
	 	2.	 	The reasons for the action.
	 
	 	3.	 	The enrollee’s or the provider’s right to file a
grievance/appeal.
	 
	 	4.	 	The enrollee’s right to request a Medicaid Fair Hearing.
	 
	 	5.	 	Procedures for exercising enrollee rights to appeal or grieve.
	 
	 	6.	 	Circumstances under which expedited resolution is available and
how to request it.
	 
	 	7.	 	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.

	 	 	 	Pursuant to 42 CFR 438.404 (a) and (c), the notice must be in
writing and must meet the language and format requirements of 42
CFR 438.10(c) and (d) to ensure ease of understanding.
The plan must mail the notice within the following time frames:

	 	1.	 	For termination, suspension, or reduction of
previously authorized Medicaid-covered services, within the
time frames specified in 42 CFR 431.211, 431.213, and 42 CFR
431.214.
	 
	 	2.	 	For denial of payment, at the time of any action affecting the

claim.
	 
	 	3.	 	For standard service authorization decisions that
deny or limit services, within the time frame specified in 42
CFR 438.210(d)(1).

AHCA Contract No. FA523, Attachment I, Page 53 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	4.	 	If the plan extends the time frame in accordance with 42 CFR
438.210(d)(1), it must:
	 
	 	 	 	Give the enrollee written notice of the reason for the
decision to extend the time frame and inform the enrollee of
the right to file a grievance if he or she disagrees with
that decision.
	 
	 	 	 	Issue and carry out its determination as expeditiously as
the enrollee’s health condition requires and no later than
the date the extension expires.
	 
	 	5.	 	For service authorization decisions not reached
within the time frames specified in 42 CFR 438.210(d) (which
constitutes a denial and is thus an adverse action), on the
date that the time frames expire.
	 
	 	6.	 	For expedited service authorization
decisions, within the time frames specified in 42 CFR
438.210(d).

20.12.2 Independent Member Satisfaction Survey

	 	 	 	The plan shall participate in enhanced managed care quality improvement
including at least the following:

	 	a.	 	The plan shall participate in an independent survey of
member satisfaction, currently the Consumer Assessment of Health
Plans Study survey (CARPS), conducted by the Agency on an annual
basis in accordance with section 409.912, F.S.
	 
	 	b.	 	The plan shall use the results of the annual member
satisfaction survey to develop and implement plan-wide activities
designed to improve member satisfaction. These activities shall
include, but not be limited to, analyses of the following: formal
and informal member complaints, claims timely payment,
disenrollment reasons, policies and procedures, and any pertinent
internal improvement plan implemented to improve member
satisfaction. Activities pertaining to improving member
satisfaction resulting from the annual member satisfaction survey
must be reported to the Agency on a quarterly basis within 30 days
after the end of a reporting quarter.

20.13 Medical Records Requirements

	 	 	 	The plan shall ensure medical records are maintained for each member
enrolled under this contract in accordance with this section. The
record shall include the quality, quantity, appropriateness and
timeliness of services performed under this contract.

	 	a.	 	The following medical record standards must be
included/followed in each member’s records as appropriate:

	 	1.	 	Identifying information on the member, including
name, member identification number, date of birth and sex, and
legal guardianship.
	 
	 	2.	 	Each record must be legible and maintained in detail.
	 
	 	3.	 	A summary of significant surgical procedures, past
and current diagnosis or problems, allergies, untoward
reactions to drugs and current medications.
	 
	 	4.	 	All entries must be dated and signed.
	 
	 	5.	 	All entries must indicate the chief complaint or
purpose of the visit; the objective findings of
practitioner; diagnosis or medical impression.
	 
	 	6.	 	All entries must indicate studies ordered, for example: lab,
x-ray, EKG, and referral reports.

AHCA Contract No. FA523, Attachment I, Page 54 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	7.	 	All entries must indicate therapies administered and prescribed.
	 
	 	8.	 	All entries must include the name and profession
of practitioner rendering services, for example: M.D., D.O.,
O.D., including signature or initials of practitioner.
	 
	 	9.	 	All entries must include the disposition,
recommendations, instructions to the patient, 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 on Smoking/ETOH (ethyl
alcohol)/substance abuse.
	 
	 	12.	 	All records must contain record of emergency care and hospital
discharge summaries.
	 
	 	13.	 	All records must reflect the primary language
spoken by the member and translation needs of the member.
	 
	 	14.	 	All records must identify members needing
communication assistance in the delivery of health care
services.
	 
	 	15.	 	All records must contain documentation that the
member was provided written information concerning the member’s
rights regarding advanced directives (written instructions for
living will or power of attorney), and whether or not the
member has executed an advance directive. The provider shall
not, as a condition of treatment, require the member to execute
or waive an advance directive in accordance with section
765.110, F.S. The plan must comply with the requirements of 42
CFR 422.128 for maintaining written policies and procedures for
advance directives.

	 	b.	 	The plan shall have a policy to ensure the confidentiality
of patient 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, F.S.
	 
	 	c.	 	The plan shall have a policy to ensure compliance with
the Privacy and Security provisions of the Health Insurance
Portability and Accountability Act (HIPAA).
	 
	 	d.	 	The plan shall have a procedure to capture in its medical
records, services provided to its members by non-plan 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.

20.14 Medical Record Review

	 	 	 	If the plan is not accredited under the provisions of 641.512, F.S. or
if the plan is accredited by an entity that does not review the
medical records of the plan’s primary care physicians, then the plan
shall conduct medical record reviews of Medicaid members to ensure
that practitioners provide high quality health care that is documented
according to established standards. These standards, which must
include all medical record documentation requirements addressed in
this contract, must be distributed to all providers. The plan must
conduct these reviews at all primary care practice sites that serve 50
members or more. Practice sites include both individual offices and
large group facilities. Each practice site meeting these criteria must
be reviewed at least once during the two-year contract period. The
plan must review a reasonable number of records at each site to
determine compliance. Five to 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. The plan shall report the results of all medical
record reviews to the plan analyst within 30 calendar days of the
review.
	 
	 	 	 	The plan must maintain a written strategy for conducting these
reviews. This strategy must include designated staff who will
perform this duty, the method of case selection, the anticipated
number of reviews by practice site, and the tool that will be used.
The plan must also indicate how the compiled

AHCA Contract No. FA523, Attachment I, Page 55 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	information will be linked to other plan functions, such as quality
improvement, credentialing, and peer review.

20.15 Quality and Performance Measures

	 	 	 	Quality and performance measures shall be evaluated at least once
annually at dates to be determined by the Agency or as otherwise
specified by this contract. The plan will implement an enhanced
quality improvement and performance measurement system to provide for
the delivery of quality care with the primary goal of improving the
health status of members.
	 
	 	 	 	The plan in conjunction with the Agency will participate in
workgroups to plan further quality improvement strategies and
learning to use best practice methods for enhancing quality of
health care.
	 
	 	 	 	If CARPS, the AHCA quality indicators, the annual medical record audit
or the external quality review indicate that the plan’s performance is
not acceptable, then the Agency may restrict the plan’s enrollment
activities including but not limited to termination of mandatory
assignments.
	 
	 	 	 	For plan performance that is not acceptable, the Agency shall require
the plan to submit a corrective action plan. Failure to provide a
corrective action plan within the time specified shall be cause for the
Agency to immediately terminate all enrollment activities and mandatory
assignment. When considering whether to impose a limitation on
enrollment activities or mandatory assignment, the Agency may consider
the HMOs cumulative performance on all quality and performance measures.

20.16 Annual Medical Record Audit

	 	 	 	The Agency may conduct an annual medical record audit of the plan. The
plan shall furnish specific data requested by the Agency in order to
conduct the audit. If the medical audit indicates that quality of care
is not acceptable pursuant to contractual requirements, the Agency may
restrict the plan’s enrollment activities pending attainment of
acceptable quality of care.

20.17 Independent Medical Review (External Quality Review)

	 	 	 	The Agency shall provide for an independent review of Medicaid services
provided or arranged by the provider. The plan shall provide
information necessary for the review based upon the requirements of the
Agency or the Agency’s independent peer review contractor. The
information shall include quality outcomes concerning timeliness of and
access to services covered under the contract. The review shall be
performed at least once annually by an entity outside state government.
If the medical audit indicates that quality of care is not acceptable
pursuant to contractual requirements, the Agency may restrict the
plan’s enrollment activities pending attainment of acceptable quality
of care.

AHCA Contract No. FA523, Attachment I, Page 56 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

30.0 MARKETING AND ENROLLMENT

30.1 Marketing, Pre-enrollment Materials and Post-enrollment Materials

	 	 	 	The plan shall ensure that all marketing, pre-enrollment, member,
disenrollment, and grievance materials developed for the Medicaid
population adhere to the following policies and procedures:

	 	a.	 	All materials developed for the Medicaid population must
be at or near the fourth-grade comprehension level so that the
materials are understandable (in accordance with section
1932(a)(5) of the Social Security Act as enacted by section 4701
of the Balanced Budget Act of 1997), and be available in
alternative communication methods (such as large print, video or
audio recordings, or Braille) appropriate for persons with
disabilities.
	 
	 	b.	 	The plan shall assure that appropriate foreign language
versions of all materials are developed and available to members
and potential members. The plan shall provide interpreter services
in person where practical, but otherwise by telephone, for
applicants or members whose primary language is a foreign
language. Foreign language versions of materials are required if,
as provided annually by the Agency, the population speaking a
particular foreign (non-English) language in a county is greater
than five percent.
	 
	 	c.	 	For each new contract period, the plan shall submit to
the Agency for written approval, pursuant to section 409.912,
F.S., its marketing strategy and all marketing and
pre-enrollment materials no later than 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 60 calendar days prior to implementation.
The marketing materials must be distributed in the plan’s entire
service area in accordance with section 4707 of the Balanced
Budget Act of 1997.
	 
	 	d.	 	Marketing materials include, but are not limited to,
all solicitation materials; forms; brochures; fact sheets;
posters; lectures; Medicaid recruitment materials and
presentations; pre-enrollment applications, etc.
	 
	 	e.	 	To announce a specific event, the plan shall submit a
request to market pursuant to section 30.2.2.1, Approval
Process, and include the announcement of the event that will be
given out to the public.
	 
	 	f.	 	General advertising materials and general marketing
materials used by an HMO to solicit both non-Medicaid and
Medicaid beneficiaries are not subject to prior approval of the
Agency.

30.2 Marketing Activities

	 	 	 	The plan shall be responsible for developing and implementing a written
plan designed to solicit enrollment from Medicaid eligible persons and
to control the actions of its marketing staff. All of the marketing
policies set forth in this contract apply to staff, subcontractors,
plan volunteers and all persons acting for or on behalf of the plan.
All materials developed shall be governed by the following
requirements.

	 	a.	 	Market Area. The plan shall limit its market area to
residents identified in section 90.0, Payment and Maximum
Authorized Enrollment Levels, or in any amendment of this
contract. The plan shall not solicit applications for enrollment
from residents of a service area which is not authorized by the
contract.
	 
	 	b.	 	Marketing Practices. The plan is not authorized
to make any presentations or engage in any recruitment
activities that are not approved, in writing, by the
Agency.

	 	 	 	Violations of any of the policies listed below shall subject the
plan to rescission of its authorization to market in all or
specific locations, or through any or all methods, as determined by
the Agency. The plan may dispute rescission of marketing
authorization for a period in excess of one month pursuant to
section 70.10, Disputes.

AHCA Contract No. FA523, Attachment I, Page 57 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

30.2.1 Prohibited Activities

	 	 	 	The plan is prohibited from engaging in any of the following practices
or activities:

	 	a.	 	In accordance with section 409.912, 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.	 	In accordance with section 409.912, F.S., activities
that could mislead or confuse beneficiaries, or misrepresent
the organization, its marketing representatives, or the
Agency. No fraudulent, misleading, or misrepresentative
information shall be used in marketing including information
regarding other governmental programs.
	 
	 	c.	 	Overly aggressive solicitation, such as repeated
telephoning, continued recruitment after an offer for enrollment
is declined by a beneficiary, or similar techniques. Plan
representatives shall not directly solicit individuals for the
purpose of enrolling in the plan except as provided in section
30.2.2, Permitted Activities.
	 
	 	d.	 	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.
	 
	 	e.	 	Direct or indirect cold call marketing for solicitation
of Medicaid beneficiaries, either by door-to-door, telephone or
other, in accordance with section 4707 of the Balanced Budget Act
of 1997, and section 409.912, F.S. Cold call marketing is defined
as any unsolicited personal contact with a potential enrollee by
an employee or agent of a managed care entity for the purpose of
influencing the individual to enroll with the entity.
	 
	 	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
beneficiaries except as authorized in writing by the Agency.
	 
	 	h.	 	In accordance with section 409.912, F.S., false
or misleading claims that the state or county recommends
that a Medicaid beneficiary enroll with the plan.
	 
	 	i.	 	In accordance with section 409.912, F.S., claims that a
Medicaid beneficiary will lose benefits under the Medicaid
program or any other health or welfare benefits to which the
beneficiary is legally entitled, if the beneficiary does not
enroll with the plan.
	 
	 	J.	 	In accordance with 42 CFR 438.104(b)(2)(i), any assertion or statement
(whether written or oral) that
the beneficiary must enroll in the plan in order to obtain benefits or in order
to not lose benefits.
	 
	 	k.	 	In accordance with section 409.912, F.S. and 42 CFR
438.104(b)(2)(ii), false or misleading claims that the entity is
recommended or endorsed by any federal, state or county
government, the Agency, CMS, or any other organization which has
not certified its endorsement in writing to the plan.
	 
	 	1.	 	In accordance with section 409.912, F.S., false or
misleading claims that marketing representatives are employees or
representatives of the state or county, or of anyone other than
the entity or the organization by whom they are reimbursed.
	 
	 	m.	 	Offers of material or financial gain to any persons
soliciting, referring or otherwise facilitating beneficiary
enrollment except for authorized licensed marketing
representatives. The plan shall ensure that only licensed
marketing representatives market the plan to beneficiaries.
	 
	 	n.	 	Giving away promotional items in excess of a $1.00 retail value to attract
attention. Items to be given away shall bear the plan’s name and shall only be
given away at health fairs or other general public

AHCA Contract No. FA523, Attachment I, Page 58 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	events. In addition, such promotional items must be offered to
the general public and shall not be limited to persons who
indicate they will enroll in the plan.
	 
	 	o.	 	 The plan may not market prior to enrollment the
incentives that shall be offered to the member as described in
section 10.10, Incentive Programs. Marketing may describe the
programs (not the incentives) that shall be offered (e.g.,
prenatal classes). The plan may inform members once they are
actually enrolled in the plan about the specific incentives
available. No incentives shall be of a gambling or controlled
substance nature (e.g., lottery tickets, tobacco products, drugs,
alcohol, etc.).
	 
	 	 	 	In accordance with section 409.912, F.S., marketing 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 their managed care plans to Medicaid beneficiaries only in designated
areas and in such a way as to not interfere with the beneficiaries’ activities
in the state office. The plan shall not use any other state facility, program,
or procedure in the recruitment of Medicaid beneficiaries except as authorized
in writing by the Agency. Request for approval of activities at state offices
must be submitted to the plan analyst at least 30 calendar days prior to the
activity.
	 
	 	p.	 	Marketing face-to-face to assigned members unless the member contacts the
plan and requests a marketing interview. The plan shall keep documentation of
such contacts and visits in the member’s file. However, upon the effective
date of enrollment, plan marketing staff or other plan staff may visit

members in order to obtain completed new member materials. All such visits
must be documented in the member’s file.
	 
	 	r.	 	Providing any gift, commission, or any form of
compensation to the enrollment and disenrollment services
contractor, including the contractor’s full-time, part-time or
temporary employees and subcontractors. The Agency shall
sanction any such actions as provided for in section 70.17,
Sanctions.
	 
	 	s.	 	All activities included in section 641.3903, F.S. 30.2.2 Permitted
Activities The plan may engage in the following activities under the
supervision and with the approval of the Agency:
	 
	 	a.	 	The plan upon notifying the Agency may have a marketer in
provider offices as long as the provider approves and the marketer
provides information to the beneficiary only upon request. In
addition, the plan and the provider shall not require the
beneficiary to visit the marketer, nor shall the marketer approach
the beneficiary. No sales activities (i.e., enrollment
applications) will be allowed in provider offices. However, the
plan may leave Agency approved referral cards in provider offices,
at public events and health fairs. These cards may be completed by
Medicaid beneficiaries and delivered to the plan or turned in at
the provider office. Information on the card is limited to name,
address and telephone number of the prospective member and space
for a signature. A space to note a contact time may be provided. A
follow up visit to the beneficiary’s home may not occur prior to
the referral being logged by the plan’s regional or headquarters
member services office. Twenty-four hours or the next business day
must elapse after the request is logged before the home visit may
occur.
	 
	 	b.	 	The plan may market at state offices, health fairs and
public events and contact thereafter, in person, potential
enrollees who request further information about the plan in
accordance with section 4707 of the Balanced Budget Act of 1997.
The plan shall submit, for review and approval by the Agency, its
intent to market at health fairs and public events at least two
weeks prior to the event. The plan shall obtain a completed
Agency approved disclosure form from each organization
participating in a health fair or public event prior to the
event. The disclosure form is only required when the plan is the
primary organizer of the health fair or public event. If the plan
has been invited by a community organization to be a sponsor of
an event, the plan shall provide the Agency with a copy of the

AHCA Contract No. FA523, Attachment I, Page 59 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	invitation in lieu of the disclosure form. All completed disclosure
forms must be sent to the Agency with the plan’s request for
approval of the event.
	 
	 	c.	 	A “health fair” means an event conducted in a setting
which is open to the public or a segment of the public (such as
the “elderly” or “school children”) at which information about
health care services, facilities, research, preventive
techniques, or other health care information is disseminated. At
least two health related organizations must actively participate
in the health fair.
	 
	 	d.	 	A “public event” is an event sponsored for the public or
segment of the public by two or more actively participating
organizations, one of which may be a health organization.
	 
	 	e.	 	The main purpose of a health fair or a public event shall
not be Medicaid plan marketing, but Medicaid plan marketing may be
provided at these events, subject to Agency rules and oversight.
	 
	 	f.	 	Marketing face-to-face to Medicaid beneficiaries may be
allowed if the Medicaid beneficiary contacts the plan’s
headquarters or regional member services office directly to
request a home visit. The plan shall not allow the visit to the
Medicaid beneficiary’s home to occur before the next business day
or 24 hours have elapsed since the request for the visit. The plan
must be able to provide evidence to the Agency that the 24-hour or
next business day requirement has been met. The plan will be
required upon request by the Agency to provide a log that shows
how initial contact with the beneficiary was made. Only Agency
registered marketing representatives shall be allowed to make home
visits. Each 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 Medicaid beneficiary’s
homes.

30.2.2.1 Approval Process

	 	 	 	Health Fairs and public events shall be approved or denied by the Agency
using the following process:

	 	a.	 	A plan shall submit its bi-monthly marketing schedule to
the Agency, two weeks in advance of each month. The marketing
schedule may be revised if a plan provides notice to the Agency one
week prior to the public event or the health fair. The Agency may
expedite this process as needed.
	 
	 	b.	 	The Agency shall approve or deny the plan’s bi-monthly
marketing schedule and revision request no later than the
following working day.
	 
	 	c.	 	The Agency shall establish a standard form that shall
be used by the plan. The form shall include minimum
requirements for necessary information. The Agency shall
explain in writing what is sufficient information for each
requirement.
	 
	 	d.	 	The Agency shall establish a statewide log to track the
approval and disapproval of health fairs, public events, and
events in provider offices, and state offices.
	 
	 	e.	 	The Agency may provide verbal approvals or disapprovals to
meet the next working day requirement, but the Agency shall follow
up in writing with specific reasons for disapprovals.

30.2.3 Subcontractor’s Compliance

	 	 	 	The plan shall ensure its health care providers comply with the
following marketing requirements:

	 	a.	 	Health care providers may give out plan brochures at
health fairs or in their own offices comparing the benefits of
different plans with which they contract. However, they cannot
orally compare benefits among plans unless marketing
representatives from each plan are present.
	 
	 	b.	 	Health care providers may co-sponsor events, such as
health fairs and cooperatively market and advertise with the
plan in indirect ways; such as, television, radio, posters,
fliers, and print advertisements.

AHCA Contract No. FA523, Attachment I, Page 60 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	c.	 	Health care providers may announce a new affiliation
with a plan or give a list of plans they contract with to their
patients.
	 
	 	d.	 	Health care providers cannot furnish lists of their
fee-for-service beneficiaries to plans with which they contract,
nor can providers furnish other HMOs’ membership lists to any
plan, nor can providers take applications in their offices.

30.3 Marketing Representatives

	 	 	 	The plan shall not subcontract with any brokerage firm or independent
agent for purposes of marketing or pre-enrollment activities.
	 
	 	 	 	The plan shall, prior to allowing the marketing representative to
pre-enroll beneficiaries, verify with the DFS that all marketing
representatives are properly licensed pursuant to the requirements of
chapter 641, F.S. The plan shall also verify the marketing
representative is in good standing with the DFS.
	 
	 	 	 	The 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 plans
with which the representative was previously employed; and the name of
the Medicaid plan with which the agent is presently employed. The plan
shall provide the Agency on a monthly basis information on terminations
of all marketing representatives. The 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
plan to recruit beneficiaries.
	 
	 	 	 	The plan shall report to the Department of Financial Services and the
Agency any marketing representative who violates any of these contract
requirements, within 15 calendar days of knowledge of such violation.
	 
	 	 	 	While marketing, authorized marketing representatives shall wear
picture identification that includes their DFS license number and
identifies the plan represented.
	 
	 	 	 	The marketing representative shall inform the beneficiary that the
representative is not an employee of the state, but is a
representative of the plan.
	 
	 	 	 	The plan shall not pay commission compensation, or shall recoup
commissions paid, to marketing representatives for new members whose
voluntary disenrollment is effective within the first three months of
their initial enrollment, unless the disenrollment is due to the member
moving out of the county in which the plan has been authorized to
operate. In addition, the plan shall not pay commission compensation,
or shall recoup commissions paid, to marketing representatives for
Medicaid ineligible beneficiaries outlined in section 10.3, Ineligible
Beneficiaries, who were enrolled in error. A marketing representative’s
monthly commission cannot exceed 40 percent of the marketing
representative’s total monthly compensation, excluding benefits.
	 
	 	 	 	The plan shall instruct and provide initial and periodic training to
its marketing representatives regarding the marketing,
pre-enrollment, and general service provisions requirements of the
contract.
	 
	 	 	 	The plan shall implement procedures for background and reference
checks for use in its marketing representative hiring practices.

30.4 Marketing and Pre-enrollment Grievances

	 	 	 	The plan shall develop and maintain procedures to log and resolve
marketing and pre-enrollment grievances, including procedures that
address the resolution of repeated grievances against marketing staff.
The procedures shall contain a provision that a plan employee outside
the marketing department must handle the resolution of all repeated
marketing grievances.

AHCA Contract No. FA523, Attachment I, Page 61 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

30.5 Pre-enrollment Activities

	 	 	 	The plan shall refer beneficiaries interested in enrolling in the plan
to the enrollment and disenrollment services contractor. However, the
plan may perform pre-enrollment under the supervision of the Agency or
its designee pursuant to Agency pre-enrollment and marketing
guidelines. Pursuant to section 409.912, F.S., pre-enrollment means the
provision of marketing and educational materials to a Medicaid
recipient and assistance in completing the pre-enrollment application,
but shall not include actual enrollment into a managed care plan. A
request for enrollment shall not be deemed complete until the Agency or
its agent verifies that the recipient made an informed, voluntary
choice.
	 
	 	 	 	Upon approval of the Agency, the plan may assist the beneficiary with
the completion of a pre-enrollment application, also known as request
to enroll (RTE), in accordance with section 409.912, F.S., and Agency
pre-enrollment and marketing guidelines.
	 
	 	 	 	Pre-enrollment applications may be for an individual or for a family.
For voluntary members, all such applications must contain at least the
following information for each applicant: name; address (home and
mailing); county of residence; telephone number; Medicaid ID number;
social security number; date of birth; date of application;
applicant’s signature or signature of parent or guardian; and
marketing representative’s signature and DFS license number. No health
status information may be asked on the pre-enrollment application.
	 
	 	 	 	The plan shall furnish the beneficiary, at the time of
application, with a copy of the completed pre-enrollment
application.
	 
	 	 	 	For pre-enrollment including assignment, the plan shall accept the
beneficiary in the health condition the beneficiary is in at the
time of pre-enrollment.
	 
	 	 	 	The plan shall accept pre-enrollment applications only from
beneficiaries who reside within the authorized service area. In
addition, the plan shall enroll beneficiaries using the provider
number associated with the county in which the beneficiary resides.
	 
	 	 	 	The plan shall provide a release form, in new member materials or
in another format acceptable to the Agency, to each applicant
authorizing the plan to release medical information to the federal
and state governments or their duly appointed agents.
	 
	 	 	 	If the voluntary applicant is recognized to be in foster care by the
plan, and is dependent, prior to enrollment the plan must receive
written authorization from (1) a parent, (2) a legal guardian, or
(3) the Department of Children and Families (DCF), or DCF’s
delegate. If a parent is unavailable, the plan shall obtain
authorization from the DCF.
	 
	 	 	 	The plan must provide a reasonable written explanation of the plan to
the beneficiary prior to accepting the pre-enrollment application. The
information must comply with CFR 438.10, to ensure that, before
enrolling, the beneficiary receives, from the plan or the enrollment
and disenrollment services contractor, accurate oral and written
information he or she needs to make an informed decision on whether to
enroll.
	 
	 	 	 	The plan shall explain to all applicants that the family may choose to
have all members served by the same primary care provider or they may
choose different primary care providers based on each member’s needs.
	 
	 	 	 	The plan shall not market to mandatory assigned beneficiaries prior
to the effective enrollment date of the beneficiary, unless the
beneficiary calls and requests a visit.

30.6 Enrollment

	 	 	 	The Agency or its designee, upon receipt of the pre-enrollment
transmission and upon receipt of Title XXI MediKids voluntary
enrollment information from the Agency’s MediKids’ enrollment
contractor, shall be responsible for:

AHCA Contract No. FA523, Attachment I, Page 62 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	a.	 	Determining the applicant’s eligibility for enrollment in the plan.
	 
	 	b.	 	Forwarding to the plan a list of all new members on a monthly
basis, which shall include any voluntary MediKids enrollees to be
enrolled by the plan.

	 	 	 	The plan shall provide to the Agency’s enrollment and disenrollment
services contractor complete Medicaid voluntary pre-enrollment
application data in the agreed upon format and transmission method.
Pre-enrollment application information shall be submitted to the Agency’s
enrollment and disenrollment services contractor as often as daily,
according to the Agency-approved data rules for pre-enrollment
application submissions. Error-free applications will remain pending up
to 60 days awaiting beneficiary confirmation. Applications that are not
confirmed and processed within 60 days of the pre-enrollment application
date will be cancelled and must be retaken by the applicant.
	 
	 	 	 	Plan enrollment may be temporarily suspended upon the plan’s written
request if approved by the Agency or as provided for in section 70.17
Sanctions.
	 
	 	 	 	Membership begins at 12:01 a.m. on the first day of the calendar month
that the member’s name appears on the automated enrollment report.
However, if the Agency requests the enrollment of a specific beneficiary,
enrollment begins immediately upon notification. Membership is in whole
months unless otherwise specified.
	 
	 	 	 	If the plan’s contract is renewed, the enrollment status of all members shall
continue uninterrupted.
	 
	 	 	 	The Agency, after processing the enrollment transmission from the
enrollment and disenrollment services contractor and determining the
applicant’s eligibility for enrollment in the plan, shall forward to the
plan a list of all new members and their respective plan primary care
providers on a monthly basis. Additional enrollment data collected by
the enrollment and disenrollment services contractor shall be provided
to the plan upon the Agency taking into consideration any plan requests
regarding transmittal items or formats. The Agency shall be responsible
for informing the plan of resulting items and formats.
	 
	 	 	 	New eligibles and existing beneficiaries subject to open enrollment who
change from their current Medicaid managed health care plan shall remain
enrolled in their plan for 12 months. Additionally, beneficiaries who are
reinstated or regain eligibility within 60 days during their 12-month
enrollment period shall remain “locked-in” until the date for the next
open enrollment period. Members that move to a new county shall remain a
member of their current plan if the plan operates in the new county.
Beneficiaries will only be allowed to disenroll from plans outside of the
annual open enrollment period if they meet a “good cause change” reason.
The Agency shall forward to the plan the open enrollment status of the
plan’s current enrollees monthly.
	 
	 	 	 	Pursuant to 1932(a)(4)(A) and (B) of the Social Security Act, the
enrollment and disenrollment services contractor shall permit an
individual eligible for medical assistance under the State plan who is
enrolled with the plan to terminate (or change) such enrollment for good
cause at any time (consistent with section 1903(m)(2)(A)(vi)), and without
cause during the 90-day period following the date of the beneficiary’s
initial enrollment or the date the State sends the beneficiary notice of
the enrollment, whichever is later, and at least every 12 months
thereafter. The enrollment and disenrollment services contractor shall
provide for notice to each enrollee of opportunity to terminate (or
change) enrollment under such conditions. Such notice shall be provided at
least 60 days before each annual enrollment opportunity.
	 
	 	 	 	The plan accepts individuals eligible for enrollment in the order in
which they apply without restriction (unless authorized by the CMS
Regional Administrator), up to the limits set under the contract. The
plan will not discriminate against individuals eligible to enroll on the
basis of race, color, or national origin, and will not use any policy or
practice that has the effect of discriminating on any basis including but
not limited to race, color, or national origin.
	 
	 	 	 	Enrollment is voluntary, except in the case of mandatory enrollment
programs that comply with 42 CFR 438.50(a).

AHCA Contract No. FA523, Attachment I, Page 63 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

30.6.1 Behavioral Health Enrollment

	 	 	 	To the maximum extent possible, the plan shall distribute to members in
Agency areas, where behavioral health care has been implemented, to the
plan’s direct service behavioral health care providers based upon
member choice and proximity of the member’s residence to the plan
service provider’s location.
	 
	 	 	 	For children in the care and custody of the DCF Foster Care, the plan
shall consult with the appropriate DCF Family Safety and Preservation
worker in order for the plan to identify an appropriate plan direct
service behavioral health care provider who shall be responsible for
monitoring all aspects of the beneficiary’s behavioral health care.
	 
	 	 	 	Upon new enrollment or re-enrollment of a member, in addition to
the requirements of section 30.7, Member Notification, the plan
shall provide the following information to the plan member:

	 	a.	 	Procedures for obtaining required behavioral health
services, including any additional plan phone numbers to be used
for obtaining services;
	 
	 	b.	 	List of plan’s behavioral health service centers (including city and
county);
	 
	 	c.	 	Member Handbook that shall include the following:

	 	1.	 	A notice that clearly states that the member may
select an alternative behavioral health care coordinator or
direct service behavioral health care provider within the
plan, if one is available;
	 
	 	2.	 	Description of behavioral health services
provided, including limitations, exclusions and out-ofplan
use;
	 
	 	3.	 	Description of emergency behavioral health
services and procedures both in and out of the plan’s service
area;
	 
	 	4.	 	Information to assist the member in assessing a potential
behavioral health problem.

	 	 	 	Upon the initial request for services, the plan shall provide the
member with the name of the assigned behavioral health provider and an
appointment with the provider that is within the required access times
indicated in this section.

30.7 Member Notification

	 	 	 	The plan shall develop and implement written enrollment procedures,
which shall be used to notify members of enrollment. The plan must give
each beneficiary written notice of any change in the information
required by this section, 42 CFR 438.10(f)(6), and 42 CFR 438.10(g) and
(h), at least 30 days before the intended effective date of the change.

	 	a.	 	Prior to, or upon enrollment, the plan shall provide the following
information to all new members:

	 	1.	 	A written notice providing the actual or
estimated date of enrollment, and the name, telephone number
and address of the member’s primary care physician.
	 
	 	2.	 	Termination of a contracted provider, within 15
days after receipt or issuance of the termination notice, to
each enrollee who received his or her primary care from, or was
seen on a regular basis, by the terminated provider. The plan
must make a good faith effort to give written notice of such
termination to the enrollee.

AHCA Contract No. FA523, Attachment I, Page 64 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	3.	 	An explanation that assigned members or
applicants may choose to have all family members served by
the same primary care provider or they may choose different
primary care providers based on each member’s needs.
	 
	 	4.	 	An explanation of the applicable restrictions of the
plan, especially that the beneficiary must use the plan
providers and secure appropriate referrals to receive care from
providers outside the plan.

	 	b.	 	The plan shall have procedures advising applicants and
members of plan service delivery and provider network changes
including the following:

	 	1.	 	Restrictions on provider access, including
providers who are not taking new patients. Current members
shall be advised on at least a six-month basis.
	 
	 	2.	 	Termination of their assigned primary care
physicians within five business days after the effective date
of the termination.
	 
	 	3.	 	Termination of hospital agreements within the
service area within five business days after the effective
date of the termination.
	 
	 	4.	 	Providers’ objections to counseling and referral
services based on moral or religious grounds within 90
calendar days after the plan’s change in policy regarding
such a counseling or referral service as required by section
1932(b)(3), Social Security Act (enacted by section 4704 of
the Balanced Budget Act of 1997).
	 
	 	5.	 	Members’ option to change primary care providers.
	 
	 	6.	 	Members’ responsibility to notify the plan if
they change county of residence, and to request a
disenrollment if moving out of the service area, or choose a
new primary care doctor if the member shall remain in the
plan service area.

	 	c.	 	Pursuant to 42 CFR 422.208 and 42 CFR 422.210, the plan
shall provide information on the plan’s physician incentive
plans or on the plan’s structure and operation to any Medicaid
recipient, upon request.

30.7.1 Member Services Handbook

	 	 	 	The member services handbook shall include the following information:
Terms and conditions of enrollment including the reinstatement process;
a description of the open enrollment process; description of services
provided, including limitations and general restrictions on provider
access, exclusions and out-ofplan use; procedures for obtaining required
services, including second opinions; the toll-free telephone number of
the statewide Consumer Call Center; emergency services and procedures
for obtaining services both in and out of the plan’s service area; the
extent to which, and how, after-hours and emergency coverage are
provided; procedures for enrollment, including member rights and
procedures ; grievance system components; member rights and procedures
for disenrollment; procedures for filing a “good cause change” request,
including the Agency’s toll-free telephone number for the enrollment and
disenrollment services contractor; information regarding newborn
enrollment, including the mother’s responsibility to notify the plan and
the mother’s DCF caseworker of the newborn’s birth and assignment of
pediatricians and other appropriate physicians; member rights and
responsibilities; including the extent to which, and how, enrollees may
obtain benefits from out-of-network providers and the right to obtain
family planning services from any participating Medicaid provider
without prior authorization for such services; the choices of approved
nursing facilities (Frail/Elderly); information on emergency
transportation and non-emergency transportation, counseling and referral
services available under the plan and how to access these; information
that interpretation services and alternative communications systems are
available, free of charge for all foreign languages, and how to access
these services; 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); information that services
will continue upon appeal of a suspended authorization and

AHCA Contract No. FA523, Attachment I, Page 65 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	that the enrollee may have to pay in case of an adverse ruling;
information regarding the health care advance directives pursuant to
chapter 765, F.S., 42 CFR 422.128; cost sharing, if any; and
information that enrollees may obtain from the plan information
regarding quality performance indicators, including aggregate enrollee
satisfaction data; and how and where to access any benefits that are
available under the State plan but are not covered under the contract,
including any cost sharing, and how transportation is provided. For a
counseling or referral service that the plan does not cover because of
moral or religious objections, the plan need not furnish information on
how and where to obtain the service. Written information regarding
advance directives provided by the plan must reflect changes in state
law as soon as possible, but no later than 90 days after the effective
date of the change.
	 
	 	 	 	The plan will provide enrollee information in accordance with 42 CFR
438.10(f). In accordance with 42 CFR 438.10(f)(2), the plan must
notify enrollees at least on an annual basis of their right to
request and obtain information.

30.7.2 Provider Directory

	 	 	 	The provider directory shall identify all service sites, pharmacies,
hospitals, specialists, certified nurse midwives and licensed
midwives, and ancillary providers. The directory shall include
location addresses and telephone numbers for all primary care
providers. For pharmacies, specialists, certified nurse midwives and
licensed midwives, and ancillary providers, the directory shall
include the providers’ names and cities. If all pharmacy providers,
within the plan’s service area, in a chain are under contract with the
plan, the provider directory need only list the chain name. In
addition, pursuant to section 409.912, F.S., any lists of providers
made available to Medicaid recipients shall be arranged
alphabetically, showing the provider’s name and specialty and,
separately, by specialty, in alpha order. In accordance with section
1932(b)(3) of the Social Security Act (enacted in section 4704 of the
Balanced Budget Act of 1997), the provider directory must include an
advisement that some providers may not perform certain services based
on religious or moral beliefs.

30.7.3 Member Information

	 	 	 	In accordance with section 641.54, F.S., the plan shall make available
the following items to members upon request:

	 	a.	 	A detailed description of the plan’s authorization and
referral process for health care services which shall include
reasons for denial of services based on moral or religious
grounds as required by section 1932(b)(3), Social Security Act
(enacted in section 4704 of the Balanced Budget Act of 1997).
	 
	 	b.	 	A detailed description of the plan’s process used to
determine whether health care services are medically
necessary.
	 
	 	c.	 	A description of the plan’s quality improvement program.
	 
	 	d.	 	Policies and procedures relating to the plan’s prescription drug
benefits program.
	 
	 	e.	 	Policies and procedures relating to the confidentiality and
disclosure of the member’s medical records.
	 
	 	f.	 	The decision-making process used for approving or
denying experimental or investigational medical treatments.
	 
	 	g.	 	A detailed description of the plan’s
credentialing process.

30.7.4 New Member Materials

	 	 	 	Immediately upon the assigned beneficiaries’ and the Title XXI Medikids’
enrollment, the plan shall mail to the new member materials as required
in section 30.7, Member Notification, and the following additional
materials:

AHCA Contract No. FA523, Attachment I, Page 66 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	a.	 	A request for the following information, including
updates to this information: assigned member’s name, address
(home and mailing), county of residence, telephone number,
social security number; a completed, signed and dated release
form authorizing the plan to release medical information to the
federal and state governments or their duly appointed agents;
and, for beneficiaries in Agency areas where behavioral health
care has been implemented, current behavioral health care
provider information as described in section 10.11, Behavioral
Health Care.
	 
	 	b.	 	A notice that members who lose eligibility and are
disenrolled shall be automatically reenrolled in the plan if
eligibility is regained within 60 days.
	 
	 	c.	 	Each mailing shall include a postage paid, pre-addressed
return envelope. The mailing envelope shall include a request for
address correction.
	 
	 	d.	 	The initial mailing may be combined with the primary care
physician assignment notification specified in section 20.6,
Physician Choice. Each mailing shall be documented in the plan’s
records.

30.7.4.1 Undeliverable Materials

	 	 	 	For voluntary members, if new member materials are sent via mail and
the envelope is returned as undeliverable to the plan, the plan shall
note such in member’s file. The plan shall then make another
reasonable effort to provide the required materials to the member such
as contacting the member by phone to obtain a more current address.
	 
	 	 	 	For assigned beneficiaries whose new member materials are returned
undeliverable to the plan, the plan shall keep the returned envelope
in the members’ files and may use any of the following methods during
the members’ first three-month enrollment period to contact the
members and document such methods in the members’ files.

	 	a.	 	Telephone contact at the telephone number obtained
from the local telephone directory, directory assistance, city
directory or other directory.
	 
	 	b.	 	Telephone contact with the DCF Economic
Self-Sufficiency Services office staff to determine if they have
updated address information and telephone number.
	 
	 	c.	 	Routine checks (at least once a month for the first
three months of enrollment) on services or claims authorized or
denied by the plan to determine if the member has received
services, and to locate updated address and telephone number
information.

	 	 	 	If a new address is secured and the plan materials requiring signature
have not been received by the plan or are returned unsigned, the plan
must mail the materials to the new address within ten working days of
the receipt of the new address.
	 
	 	 	 	The plan may use other methods to locate assigned members. The plan
shall maintain policies and procedures on the methods used to locate
assigned members and to document such members use of plan services.

30.8 Enrollment Reinstatements

	 	 	 	Pre-enrollment applications and new member materials are not required
for a former member who was disenrolled because of the loss of
Medicaid eligibility and who regains his/her eligibility within 60
days and is automatically reinstated as a plan member. In addition,
unless requested by the beneficiary, pre-enrollment and new member
materials are not required for a former member 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 plan member.
The plan is responsible for assigning all reinstated beneficiaries to
the primary care physician who was treating them prior to loss

AHCA Contract No. FA523, Attachment I, Page 67 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	•	 	of eligibility, unless the beneficiary specifically requests another
primary care physician, the primary care physician no longer
participates in the plan or is at capacity, or the member has changed
geographic areas. A notation of the effective date of the
reinstatement is to be made on the most recent application or
conspicuously identified in the member’s administrative file.
Beneficiaries, who were previously enrolled in a managed care plan,
lose and regain eligibility after 60 days, will be treated as new
eligibles.
	 
	 	 	 	The 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
beneficiaries subject to open enrollment and beneficiaries not subject
to open enrollment and shall include information regarding good cause
change procedures or general plan change procedures through the
Agency’s toll-free enrollment and disenrollment services contractor
telephone number as appropriate. The notification shall also instruct
the beneficiary to contact the plan if a new member card and/or a new
member handbook are needed. The plan shall provide such notice to each
affected person by the first day of the month following the plan’s
receipt of the notice of reinstatement.

30.9 Newborn Enrollment

	 	 	 	All Medicaid eligible newborns of members are the responsibility of the
plan and the plan is responsible for payment of medically necessary and
well child care regardless of lack of notification by DCF of the
newborn’s Medicaid identification number. The plan remains responsible
for the newborn, regardless of the mother’s Medicaid eligibility or HMO
enrollment status, for the birth month and the next two consecutive
months. Newborn enrollment shall occur through the following procedures,
or in another format acceptable to the Agency:

	 	a.	 	Upon identification of a member’s pregnancy, the plan shall
immediately notify the DCF of the unborn beneficiary. The plan must
provide this notification by completing and submitting to DCF the
Form DCF-ES 2039. In addition, the plan must indicate its name and
address as the entity initiating referral;
	 
	 	b.	 	The plan shall use the DCF-ES 2039 completed form to
identify the unborn’s Medicaid identification number and inactive
enrollment in Medicaid;.
	 
	 	c.	 	Upon birth or upon the hospital notifying the plan of
such birth, the plan shall initiate the Unborn Activation
Process, either electronically or by faxing the correctly
completed form to the Agency’s fiscal agent. The electronic
Unborn Activation Process is described in the AHCA/ACS 834
companion guide. This process results in the activation of the
Medicaid identification number, the update of demographic
information, retroactive enrollment of the newborn in mother’s
HMO for no more than three months, and retroactive and
appropriate payment of capitation;
	 
	 	d.	 	The plan shall inform the hospital and the newborn’s
attending and consulting physicians that the newborn is a plan
member and that they must seek reimbursement from the plan;
	 
	 	e.	 	The plan shall reimburse the Agency for any
fee-for-service claims the Agency has paid for covered services
provided to plan newborns that occurred within the first three
months of life, unless the plan provides documentation that the
services were already reimbursed by the plan.

30.10 Enrollment Levels

	 	 	 	The plan is assigned enrollment levels for the operational area(s)
indicated in section 90.0, Payment and Maximum Authorized Enrollment
Levels, of this contract. The number of Medicaid beneficiaries enrolled
in the plan may not exceed the maximum authorized enrollment level per
county. The cost of care for any Medicaid beneficiaries enrolled over
the maximum level per county is a liability for the plan and shall not
be charged to the Agency or the enrolled beneficiary. The plan shall
notify the enrollment and disenrollment services contractor when
enrollment has reached the maximum number authorized.
	 
	 	 	 	The plan must request a contract amendment for an enrollment level
increase.

AHCA Contract No. FA523, Attachment I, Page 68 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

30.11 Disenrollment

	 	 	 	The Agency shall be responsible for processing disenrollments.

	 	a.	 	The plan’s responsibility is to:

	 	1.	 	At the time of enrollment for new members, notify
each member of the right to disenroll without cause during
the open enrollment period or at any time for “good cause”
and how to initiate the disenrollment process through the
Agency’s enrollment and disenrollment services contractor.
Such notification must adhere to approved wording
specifications provided by the Agency;
	 
	 	2.	 	Ensure that disenrollees who wish to file an appeal are afforded
the opportunity to do so.

	 	b.	 	Except for the following reasons for proposed
disenrollment, all members must be afforded the right to file an
appeal: disenrollments due to moving out of the service area;
disenrollments due to loss of Medicaid eligibility; and
disenrollments due to death.

30.11.1 Voluntary Disenrollments

	 	 	 	For voluntary disenrollments, the plan shall comply with the following
requirements:

	 	a.	 	The effective date for disenrollment shall be the
last day of the month in which disenrollment was effectuated
by the Agency, unless the Agency requests an earlier or later
date;
	 
	 	b.	 	The plan shall ensure that it does not restrict the member’s right
to disenroll voluntarily in any way;
	 
	 	c.	 	The plan and its agents shall not provide or assist in
the completion of a disenrollment request form or assist the
Agency’s enrollment and disenrollment services contractor in the
disenrollment process, except for their own members at those
members’ request;
	 
	 	d.	 	The plan shall ensure that all written and oral
disenrollment requests are promptly referred to the Agency’s
enrollment and disenrollment services contractor helpline as
follows:

	 	1.	 	For oral requests, the plan shall immediately
refer the member to contact the enrollment and
disenrollment services contractor helpline number; and
	 
	 	2.	 	The plan shall send, within three business days of
the plan’s receipt of any written request, a letter to the
member advising the member to call the enrollment and
disenrollment services contractor helpline.

	 	e.	 	The plan shall keep a daily written log or electronic
documentation of all oral and written disenrollment requests and
the disposition of such requests. The log shall include the
following: the date the request was received by the plan; the
date the member was referred to the enrollment and disenrollment
services contractor or the date of the letter advising them of
the disenrollment procedure, as appropriate; and the reason that
the member is requesting disenrollment;
	 
	 	f.	 	A beneficiary may request disenrollment as follows:

	 	1.	 	For good cause, at any time.
	 
	 	2.	 	Without cause, at the following times:
	 
	 	 	 	(a) During the 90 days following the beneficiary’s initial
enrollment or the date the Agency sends the beneficiary notice of
the enrollment, whichever is later;

AHCA Contract No. FA523, Attachment I, Page 69 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	(b) At least every 12 months thereafter;
	 
	 	 	 	(c) Upon enrollment reinstatement according to section 30.8,
Enrollment Reinstatements, of this contract, if the temporary loss
of Medicaid eligibility has caused the beneficiary to miss the
annual disenrollment opportunity;
	 
	 	 	 	(d) When the Agency grants the beneficiary the right to terminate
enrollment without cause as an intermediate sanction specified in
42 CFR 438.702(a)(3).

	 	g.	 	If a disenrollment request is not reviewed by the
Agency within the time frames specified in this section, the
disenrollment is considered approved.

30.11.2 Involuntary Disenrollments

	 	 	 	With proper written documentation, the following are acceptable
reasons for which the plan shall submit involuntary disenrollments to
the Agency: member death; fraudulent use of the beneficiary ID card;
beneficiaries moving outside the plan’s authorized service area; or
the plan discovers that the member is ineligible for enrollment based
on the criteria specified in section 10.3, Ineligible Beneficiaries.
The plan shall promptly submit such disenrollments to the Agency. In
no event shall the plan submit such disenrollment at such a date as
would cause the disenrollment to be effective later than 59 calendar
days after the plan’s receipt of the reason for involuntary
disenrollment. The plan shall ensure that involuntary disenrollment
documents are maintained in an identifiable member record.

	 	a.	 	If the plan discovers that an ineligible beneficiary has
been enrolled, then it must notify the beneficiary in writing that
the beneficiary shall be disenrolled the next contract month or
earlier if necessary. Until the beneficiary is disenrolled, the
plan shall be responsible for the provision of services to that
beneficiary.
	 
	 	b.	 	On a monthly basis, the plan shall review its ongoing
enrollment report (FLMR 8200-R004) to ensure that all members are
residing in the plan’s authorized service area. For beneficiaries
with out-ofservice area addresses on the enrollment report, the
plan shall notify the beneficiary in writing that the beneficiary
should contact the enrollment and disenrollment services
contractor to choose another managed care option and that the
member will be disenrolled. The plan shall involuntarily
disenroll the beneficiary during the next available transmission.
	 
	 	c.	 	For beneficiaries who have elected services through a
hospice program, the plan shall submit a disenrollment request to
the Agency for the beneficiary immediately upon obtaining notice
that the beneficiary has been or shall receive hospice services.
The disenrollment shall be effective upon the date of admission
to the hospice program. Capitation payment made to the plan shall
be reduced on a prorated basis for members whose disenrollment is
effective after the first day of a month in accordance with
section 409.912, F.S.
	 
	 	d.	 	For those beneficiaries admitted to an institution,
including nursing home admittance for a member who has been
assessed at a nursing home level of care, the plan shall submit a
disenrollment request for the beneficiary to the Agency
immediately upon obtaining notice that the beneficiary has been
or shall be admitted. The disenrollment shall be effective upon
the first day of the month following the date the disenrollment
transmission was sent to the Agency.
	 
	 	e.	 	The plan may submit an involuntary disenrollment request
to the Agency plan analyst after providing to the member at least
one verbal and at least one written warning of the full
implications of his/her failure of actions:

	 	1.	 	For a member who continues not to comply with a
recommended plan of health care or misses three consecutive
appointments within a continuous six month period. Such
requests must be submitted at least 60 calendar days prior to
the requested effective date.

AHCA Contract No. FA523, Attachment I, Page 70 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	2.	 	For a member whose behavior is disruptive, unruly,
abusive or uncooperative to the extent that his or her
membership in the plan seriously impairs the organization’s
ability to furnish services to either the member or other
members.

	 	 	 	The analyst may approve such requests provided the plan documents
that attempts were made to educate the member regarding his/her
rights and responsibilities, assistance which would enable the
member to comply was offered through case management, and it has
been determined that the member’s behavior is not related to the
member’s medical or behavioral condition. Beneficiaries who are
disenrolled through this section are not eligible for re-enrollment
without the permission of the plan.
	 
	 	f.	 	The plan shall submit involuntary disenrollment
requests to the Agency for assigned members that meet both of
the following requirements:
	 
	 	 	 	The plan was unable to contact the member by mail, phone, or
personal visit within the first four months of enrollment, and
	 
	 	 	 	The plan was unable to document the use of plan services by the
member, or another family unit member, within the first four months
of enrollment. Such disenrollments shall be submitted through the
Agency approved transmission medium specified in section 60.0,
Reporting Requirements on the first available transmission after
the end of the members’ fourth month of enrollment. The plan shall
keep documentation of its inability to contact the member and that
it has no record of providing services to the member, or to another
family unit member, in the member’s file.
	 
	 	g.	 	The following are unacceptable reasons for the plan, on
its own initiative, to request disenrollment of a member:
pre-existing medical condition; changes in health status; volume
of utilization, and periodically missed appointments.
	 
	 	h.	 	For all involuntary disenrollments submitted by the
plan, the plan shall document its reason for the involuntary
disenrollment in the member’s file.
	 
	 	i.	 	The plan shall promptly provide involuntary disenrollment
data via an Agency approved transmission medium, on the first
available transmission after receiving the Agency’s approval of
such request or, for assigned members, by the timeframe indicated
in f. of this subsection.
	 
	 	J.	 	For involuntary disenrollments, documentation must
contain the following minimum information: name; address;
telephone number; reason for disenrollment with brief
explanation; date; signature by plan staff and an indication as
to whether or not the member wishes to file a grievance.
	 
	 	k.	 	The plan shall send to the Agency a monthly summary report
of all plan submitted involuntary disenrollments pursuant to
section 60.2.2, Medicaid Disenrollment Summary. This report must
specify the reason for such disenrollments. It will be reconciled
to the Disenrollment Report processed by the Agency for the
applicable month and shall be reviewed by the Agency for compliance
with acceptable reasons for disenrollment. The Agency may reinstate
enrollment for any member whose reason for disenrollment is not
consistent with established guidelines.

30.11.2.1 Frail/Elderly Disenrollment

	 	 	 	The plan may request the Agency to disenroll the member at the
beginning of a recontracting period if it can be demonstrated the
member would benefit from disenrollment, or if the member is
institutionalized in a long term nursing facility at the conclusion of
the state fiscal year and the plan furnishes written documentation
based upon a CARES assessment or written assurance from the member’s
primary care physician or the administrator of the nursing facility
where the member is placed that the nursing home placement is permanent
and not temporary. All disenrollments for institutionalized members
must have written prior approval by the Agency and be submitted as
involuntary disenrollments on the first available

AHCA Contract No. FA523, Attachment I, Page 71 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	transmission to the fiscal agent after receiving Agency approval of the
request. Such approval shall not be unreasonably withheld.

30.12 Enrollment/Disenrollment Verification

	 	 	 	The Agency shall arrange for the plan to receive a monthly list of
eligible members and a list of those members ineligible or disenrolled
from the HMO. The plan shall be responsible for notifying, in writing,
enrollees involuntarily disenrolled by the plan of the disenrollment
effective date and the reason for disenrollment, in accordance with
section 30.11.2 d. and e., Involuntary Disenrollments.
	 
	 	 	 	THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 72 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

40.0 ASSURANCES AND CERTIFICATIONS

40.1 Monitoring Provisions

	 	 	 	In addition to the monitoring requirements specified in the Agency’s
core contract, section I.E.2., Monitoring, the plan shall permit the
Agency, entities authorized by the Agency, and DHHS to evaluate,
through inspection or other means, the quality, appropriateness and
timeliness of services provided under the contract.

40.2 Certification of Laboratories and Portable X-Ray Companies

	 	 	 	All independent laboratory testing sites providing services under this
contract must be freestanding clinical laboratories certified under
the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The
laboratory may provide only those specific laboratory test specialties
and subspecialties covered by CLIA certification.
	 
	 	 	 	All portable x-ray companies providing services to members at their
place of residence must have been certified by the Agency in
accordance with Title XVIII (Medicare) standards.

40.3 Good Faith Effort with School Districts

	 	 	 	In accordance with section 409.9122, F.S., the plan assures it shall
make a good faith effort to execute agreements (refer to section
110.5, Memorandum of Agreement) with school districts participating
in the certified match program regarding the coordinated provision of
school-based services pursuant to sections 236.0812 and 409.908(21),
F.S.; and to ensure that duplication of services does not occur.

40.4 Good Faith Effort with County Health Departments

	 	 	 	The plan assures it shall make a good faith effort to execute memoranda
of agreement (refer to section 110.2 for a model Memorandum of
Agreement) with the local county health departments 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, DCF foster
care emergency shelter medical screenings, school-based services
pursuant to section 409.9122., and services related to Healthy Start
prenatal and postnatal screenings. Refer to section 20.13, Medical
Records Requirements, and sections 10.8.11, Physician Services, and
10.8.10, Independent Laboratory and Portable X-ray Services.

40.5 Good Faith Effort with Midwives

	 	 	 	The plan assures it shall make a good faith effort to execute
contracts with certified nurse midwives to provide services in
accordance with section 641.31, F.S., for low risk patients.

40.6 Accreditation

	 	 	 	Commercially licensed plans shall achieve accreditation by an external
accreditation organization approved in accordance with section
641.512, F.S.

40.7 Minority Recruitment and Retention Plan

	 	 	 	The plan shall implement and maintain a minority recruitment and
retention plan in accordance with section 641.217, F.S. The 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.

40.8 Ownership and Management Disclosure

	 	 	 	Federal and state laws require full disclosure of ownership, management
and control of Medicaid HMOs.

AHCA Contract No. FA523, Attachment I, Page 73 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	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 and then submitted on an annual
basis. The plan shall disclose any changes in management as soon as
those occur. In addition, the plan shall submit to the Agency full
disclosure of ownership and control of Medicaid HMOs at least 60
calendar days before any change in the 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:
	 
	 	 	 	Owns, indirectly or directly 5 percent or more of the plan’s
capital or stock, or receives 5 percent or more of its
profits;
	 
	 	 	 	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 of the total property or assets; or
	 
	 	 	 	Is an officer or director of the 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 plan’s assets used to secure the
obligation. Thus, if a person owns 10 percent of a note secured
by 60 percent of the plan’s assets, the person owns 6 percent of
the 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 10 percent of the stock in
a corporation, which owns 80 percent of the plan stock, the
person owns 8 percent of the plan.

	 	c.	 	The following definitions apply to management disclosure:
	 
	 	 	 	Changes in management are defined as any change in the management
control of the plan. Examples of such changes are those listed below
or equivalent positions by another title.

	 	1.	 	Changes in the board of directors or officers of the
plan, medical director, chief executive officer, administrator,
and chief financial officer.
	 
	 	2.	 	Changes in the management of the plan where the plan has
decided to contract out the operation of the plan to a management
corporation. The plan shall disclose such changes in management
control and provide a copy of the contract to the Agency for
approval at least 60 calendar days prior to the management
contract start date.

	 	d.	 	In accordance with section 409.912, F.S., the plan shall
annually conduct a background check with the Florida Department of
Law Enforcement on all persons with five percent or more ownership
interest in the plan, or who have executive management
responsibility for the managed care plan, or have the ability to
exercise effective control of the plan. The plan shall submit
information to the Agency for such persons who have a record of
illegal conduct according to the background check. The 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., plans with an initial
contract beginning on or after July
I , 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.

AHCA Contract No. FA523, Attachment I, Page 74 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	2.	 	Principals of the plan shall be as
defined in section 409.907, F.S.

	 	e.	 	The plan shall submit to the Agency, within five
working days, any information on any officer, director, agent,
managing employee, or owner of stock or beneficial interest in
excess of five percent of the 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 plan that has an officer, director,
agent, managing employee, or owner of stock or beneficial
interest in excess of five percent of the plan, who has
committed any of the above listed offenses. In order to avoid
termination, the plan must submit a corrective action plan,
acceptable to the Agency, that ensures that such person is
divested of all interest and/or control and has no role in the
operation and management of the plan.

40.9 Independent Provider

	 	 	 	It is expressly agreed that the plan and any subcontractors and
agents, officers, and employees of the 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 plan or
any subcontractor and the Agency and the State of Florida.

40.10 General Insurance Requirements

	 	 	 	The plan shall obtain and maintain at all times 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 in
Rule 690-191.069, 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.

40.11 Worker’s Compensation Insurance

	 	 	 	The 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.

40.12 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.

40.13 Health Insurance Portability and Accountability Act Compliance

	 	 	 	The plan assures that it will be in compliance with
the HIPAA regulations.

40.14 Systems Compliance

	 	 	 	The plan warrants that each item of hardware, software, and/or firmware
required for the provision of service under this contract shall be able
to accurately process date data (including, but not limited to,
calculating, comparing, and sequencing) including leap year
calculations, when used in accordance with the

AHCA Contract No. FA523, Attachment I, Page 75 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	item documentation provided by the plan, provided that all items (e.g.,
hardware, software, firmware) used in combination with other designated
items properly exchange date data with it.

40.15 Certification of Reported Data

	 	 	 	Data reported as provided in section 60.0, Reporting Requirements, and data
specified in 42 CFR 438.604, must be certified by one of the following: the
plan’s chief executive officer, the chief financial officer, or an
individual who has delegated authority to sign for and who reports directly
to the plan’s chief executive officer or chief financial officer.
	 
	 	 	 	Based on best knowledge, information, and belief, the certification must
attest to the accuracy, completeness, and truthfulness of the data and of
the documents specified by the Agency. The plan must submit the
certification concurrently with the certified data.
	 
	 	 	 	THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 76 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

50.0 FINANCIAL REQUIREMENTS

50.1 Insolvency Protection

	 	 	 	The 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 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 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 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 plan shall submit an attestation to this effect
annually. A sample form (Multiple Signature Verification Agreement) may
be found as section 110.3. All such agreements or other signature cards
must be approved in advance by the Agency.

	 	a.	 	In the event that a determination is made by the Agency
that the plan is insolvent, as defined in section 100.0, Glossary,
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 plan under
this contract. A statement of account balance shall be provided by
the plan within 15 calendar days of request of the Agency.
	 
	 	b.	 	If the contract is terminated, expired, or not continued,
the account balance shall be released by the Agency to the plan
upon receipt of proof of satisfaction of all outstanding
obligations incurred under this contract.
	 
	 	c.	 	In the event the contract is terminated or not renewed
and the plan is insolvent, the Agency may draw upon the
insolvency protection account to pay any outstanding debts the
plan owes the Agency including, but not limited to, overpayments
made to the 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
plan is unable to pay all of its outstanding debts to health care
providers, the Agency and the 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.

50.2 Insolvency Protection Account Waiver

	 	 	 	Pursuant to section 409.912, the Agency may waive the insolvency
protection account requirement, in writing, when evidence of
adequate insolvency insurance and reinsurance are on file with the
Agency which shall protect members in the event the plan is unable
to meet its obligations.

50.3 Surplus Start Up Account

	 	 	 	All new plans, after initial contract execution but prior to initial
member 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 months of operating expenses or $200,000, whichever is greater.
This provision shall not apply to plans that have been providing
services to members for a period exceeding three continuous months.

50.4 Surplus Requirement

	 	 	 	In accordance with section 409.912, F.S., the 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 plan’s

AHCA Contract No. FA523, Attachment I, Page 77 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	insolvency protection account) or the Department of Financial Services,
a surplus amount equal to one and one half times the plan’s monthly
Medicaid prepaid revenues. In the event that the plan’s surplus (as
defined in section 100.0, Glossary) falls below an amount equal to one
and one half times the plan’s monthly Medicaid prepaid revenues, the
Agency shall prohibit the plan from engaging in marketing and
pre-enrollment activities, shall cease to process new enrollments until
the required balance is achieved, or may terminate the plan’s contract.

50.5 Interest

	 	 	 	Interest generated through investments made by the plan under this
contract shall be the property of the plan and shall be used at the
plan’s discretion.

50.6 Savings

	 	 	 	The plan shall retain any savings realized under this contract after
all bills, charges, and fines are paid.

50.7 Fidelity Bonds

	 	 	 	The 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 provider and
subcontractors, if any. Proof of coverage must be submitted to the
Agency’s contracting officer within 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. Proof of the fidelity
bond shall be submitted to the Agency annually during the
re-contracting and renewal period.

50.8 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.
	 
	 	 	 	THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 78 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

			
	 	 	 
	July 2004
	 	Medicaid HMO Contract

	60.1	 	Fiscal Agent Reports
	 
	 	 	THE FOLLOWING INFORMATION WILL BE PROVIDED BY THE MEDICAID FISCAL
AGENT TO THE CONTRACT MEDICAID HMO:

	1.	 	Transaction Input Summary Report (FLMR 8200-R005) -
Indicates the errors that were made in the
enrollment/disenrollment data submitted.
	 
	2.	 	New Enrollee Report (FLMR 8200-R001) — Lists the new enrollees as of
the report’s effective date.
	 
	3.	 	Cancellation Report (FLMR 8200-R002) — Lists those persons who were
previously enrolled
erroneously and are being removed. Their effective cancellation dates
are the same as their enrollment
dates.
	 
	4.	 	Disenrollment Report (FLMR 8200-R003) — Lists those persons who are
no longer eligible for
Medicaid or who have been disenrolled from the plan as of the report’s
effective date.
	 
	5.	 	New Enrollees Under 21 (FLMR 8200-R007) — Lists those eligible
members newly enrolled.
	 
	6.	 	Disenrollment under 21 (FLMR 8200-R006) — Lists those eligible
members newly disenrolled.
	 
	7.	 	Ongoing Report (FLMR 8200-R004) — Lists all persons who are enrolled
in the plan as of the report’s
effective date.
	 
	8.	 	HMO Reinstatement Report (FLMR 8200-R009) — Lists those
persons who were re-enrolled in the plan, because they lost and
then regained eligibility within a 60-day window. Reinstatements
are processed and reported twice each month, during the primary
processing cycle called “monthly magic” and again during month-end
processing.

	 	 	The plan shall review these reports for accuracy and will notify the
agency if discrepancies are found.
The fiscal agent will make a full conversion to the use of
HIPAA-compliant standard transactions. At that time, all beneficiary
enrollment maintenance and reporting will be done using the X12N 834
transaction. The plan must be capable of receiving and processing the
834 transaction. Additionally, during the transition period from
proprietary to standard formats, the plan must cooperatively
participate in the transition process, including formal testing, when
asked to do so by the Agency.
	 
	60.2	 	HMO Reporting Requirements
	 
	 	 	The plan is responsible for complying with all the reporting
requirements established by the Agency. The plan is responsible for
assuring the accuracy, completeness, and timely submission of each
report. 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. Before October 1 of each contract year,
the plans shall deliver to the Agency certifications by an Agency
approved independent auditor that the CHCUP screening rate reports in
Tables 10 and 11 have been fairly and accurately presented. In addition,
before October 1, the plans shall deliver to the Agency a certification
by an Agency approved independent auditor that the quality indicator
data reported for the previous calendar year have been fairly and
accurately presented. If a reporting due date falls on a weekend, the
report will be due to the Agency on the following Monday. The Agency
will furnish the plan with the appropriate reporting formats,
instructions, submission timetables and technical assistance as
required.
	 
	 	 	The Agency requires certification of data as provided in 42 CFR 438.606.
The data that must be certified include but are not limited to
enrollment information, encounter data, and other information required
by the Agency.
	 
	 	 	The Agency reserves the right to modify the reporting requirements to
which the plan must adhere but will allow the plan 90 calendar days to
complete the implementation, unless otherwise required by law. The
Agency shall provide the plan written notification of modified
reporting requirements. The reporting requirements specifications are
outlined in this section. Failure of the plan to submit required
reports accurately and within the time frames specified may result in
sanctions being levied.

AHCA Contract No. FA523, Attachment I, Page 79 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	 	 	During fiscal year 2003/04, the Agency contracted with Thomson Medstat to
develop a strategic plan for the implementation of a Medicaid Encounter
Data System, referred to as MEDS. The Agency will continue its work
towards the development, installation and initial operation of MEDS
during fiscal year 2004/05. Once a comprehensive MEDS design and
implementation plan has been finalized, it will be available to the plans
for review. From this design plan, the Agency, in collaboration with the
plan, will define the stages of implementation for MEDS, along with a
specific timeframe for completion.
	 
	 	 	During FY2004/05, the plan must provide the Agency with a strategic plan
that outlines the steps the plan will take to achieve system readiness for
participation in MEDS. The plan shall be prepared to meet all system
requirements, to submit encounter data, and to conform to the technical
enhancements required by the Agency for full participation in MEDS.
	 
	 	 	The Agency shall provide instruction and guidance to the plan during
each stage of development. Once MEDS installation requirements specific
to the plan have been defined, the Agency shall work with the plan to
establish a deadline for plan readiness.

Table 1. Summary of Reporting Requirements for Medicaid Contracted

Health Maintenance Organizations

Medicaid HMO Reports Required by AHCA

	 	 	 	 	 	 	 
	Report Name
	 	Level of Analysis
	 	Frequency
	 	Submission Media

	‘Proprietary’ Enrollment and
DisenrollmentUploaded File Table
2

	 	Location Level
	 	Monthly
	 	File Transfer to fiscal agent via a secure Internet
site
	Medicaid HMO/PHP

Disenrollment Summary

Table 3

	 	Location Level
	 	Monthly, within
15 days from
the beginning of
the reporting
month
	 	Electronic mail or diskette submission
	Frail Elderly Disenrollment

Summary

	 	Location Level
	 	Annually, due

by June 1
	 	Electronic mail or diskette submission
	Service Utilization Summary
Tables 4 and 5

	 	Plan Level
	 	Quarterly,
within 45 days
of end of
reporting
quarter
	 	Electronic mail or diskette submission
	Appeals Reporting

Table 6

	 	Individual Level
	 	Quarterly,
within 45 days
of end of
reporting
quarter
	 	Electronic mail or diskette submission
	Inpatient Discharge Report

Table 7

	 	Individual Level
	 	Quarterly,
within 30 days
of the end of the
reporting
quarter
	 	Electronic mail or diskette submission
	Claims Inventory Summary Report

	 	Plan Level
	 	Quarterly,
within 45 days
of the end of the
reporting
quarter
	 	Electronic mail on diskette submission
	Marketing Rep. Report
Table 8

	 	Plan Level
	 	Monthly, within
30 days from
the end of the
reporting month
	 	Electronic mail or diskette submission AHCA

supplied spreadsheet template
	Provider Network Report

Table 9

	 	Location Level
	 	At least

monthly
	 	Electronic submission to enrollment and
disenrollment services contractor in format
specified by enrollment and disenrollment
contractor
	Child Health Check-Up Reporting Table 10

	 	Plan Level
	 	Annually, for

previous federal
	 	Electronic mail or diskette submission of
completed Child Health Check-Up Reporting

AHCA Contract No. FA523, Attachment I, Page 80 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	 	 	 	 	 	 	 
	

	 	 	 	fiscal year (Oct-
Sept) due by
January 15.
Audited report
is due by Oct 1.
	 	spreadsheet file
	Child Health Check-Up Reporting,

Table 11

	 	Plan Level
	 	Annually, for
previous federal
fiscal year (Oct-
Sept) due by
January 15. As
required by
Section 10.8.1 f.
of this contract.
Audited report
is due by Oct. 1
	 	Electronic mail or diskette submission of
completed spreadsheet file
	AHCA Quality

Indicators

	 	Plan Level
	 	Annually, for
previous
calendar year,
due October 1.
	 	Electronic mail, CD ROM or diskette

submission
	Frail/Elderly Care Service

Utilization Report

	 	Individual Level
	 	Quarterly,
within 45 days
of end of
reporting
quarter
	 	Electronic mail, CD ROM or diskette

submission
	Financial Reporting

	 	Plan Level
	 	Quarterly,
within 45 days
of end of
reporting
quarter
	 	AHCA supplied spreadsheet template on

diskette
	_

Audited Financial Report

	 	Plan Level
	 	Annually,
within 90 days
of end of plan
Fiscal Year
	 	Electronic mail or diskette submission
	Minority Business Enterprise

Contract Reporting

	 	Individual Level
	 	Monthly by the

fifteenth
	 	Electronic mail
	Suspected Fraud Reporting

	 	Plan Level
	 	As required by
section 60.2.14
	 	As required by section 60.2.14
	Behavioral Health Quarterly Report

	 	Area 1 and Area 6 and
upon implementation of
prepaid mental health in
other Areas Location
	 	Quarterly,
within 45 days
of the end of the
quarter
	 	Electronic mail or diskette submission of
completed agency-supplied template
	FARS/CFARS

	 	Level
Area 1 and Area 6 and
upon implementation of
prepaid mental health in
other Area
s
	 	Annually, due
no later than
August 15.
	 	As required by section 10.11.5
	Behavioral Health: Annual

Expenditure Report

	 	Area 6 and Area I and
upon implementation of
prepaid mental health in
other Areas Plan Level
	 	Annually, due
no later than
April 1.
	 	Electronic mail or diskette submission of
completed agency-supplied template
	Emergency Management Plan

	 	Plan Level
	 	Annually, due

by May 31
	 	As required by Section 70.11

	 	 	All plans must use the same naming convention for all submitted
reports. Unless otherwise noted, each report will have an 8-digit file
name, constructed as follows:

	 	 	 	 	 
	Digit I

	 	Report Identifier
	 	Indicates the report type. Use H for hospital
discharge data, G for grievance report, M for
Medicaid disenrollment, F for Frail Elder
Disenrollment, S for Service utilization.
	Digits 2, 3, and 4

	 	Plan Identifier
	 	Indicates the specific plan submitting the data by
the use of 3 unique alpha digits. Comports to the
plan identifier used in exchanging data with the
enrollment broker.
	Digits 5 and 6

	 	Year
	 	Indicates the year. For example, reports submitted

AHCA Contract No. FA523, Attachment I, Page 81 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	 	 	 	 	 
	

	 	 	 	in 2004 should indicate 04.
	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.

     These files can be put on a diskette and mailed to the following
address:

	 	 	 
	

	 	Agency for Health Care Administration
	

	 	Bureau of Managed Health Care
	

	 	Data Analysis Unit Mail
	

	 	Stop Code #26 2727
	

	 	Mahan Drive
	

	 	Tallahassee, FL 32308

	 	 	OR
	 
	 	 	Attached to an Internet e-mail message and electronically
mailed to the Agency for Health Care Administration at the
following address:

	 	 	MMCDATA I FDHC.STATE.FL.US

	 	 	AHCA supplied spreadsheet templates on diskette. The agency will
provide templates to the plans for financial and CHCUP reporting.
These templates can be used with Excel spreadsheet applications.
The spreadsheets are to be completed and the diskette mailed to
the address indicated above or attached to an Internet e-mail
message and electronically mailed to the Agency for Health Care
Administration at the email address noted above. Financial
reports only must be sent to the following e-mail address:

	 	 	MMCFIN(a~,FDHC.STATE.FL.US

	60.2.1	 	‘Proprietary’ Enrollment and Disenrollment Uploaded File

	 	 	Until the transition to the use of the 834 transaction has been
completed, this report is to be submitted monthly to the Florida
Medicaid fiscal agent for every person who is to be involuntarily
disenrolled (using an action code 2 transaction), or transferred
to a different county of operation within the plan (using an
action code 2 transaction with the old provider number county and
an action code 1 with the new provider number county). No
enrollment transactions should be submitted, since all enrollment
transactions are completed by the agency-contracted enrollment
broker. The file uploaded to the Medicaid fiscal agent’s secure
Internet site will be a fixed record length ASCII file (80 bytes)

Table 2. File Layout

_Monthly Enrollment, Disenrollment. and Cancellation Report for Payment File Specification

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Field	 	 	 	Start	 	End	 	Character
	Data Element
	 	Name
	 	Length
	 	Column
	 	Column
	 	or Numeric

	1=enrollment transfer,
	 	Action Code	 	1	 	1	 	1	 	 	N	 
	2=disenrollment,
	 	 	 	 	 	 	 	 	 	 	 	 
	7=unable to locate
	 	 	 	 	 	 	 	 	 	 	 	 
	Valid 9 digit provider number
	 	Provider Number	 	9	 	2	 	10	 	 	N	 
	Valid 10 digit Medicaid recipient
	 	Recipient Medicaid	 	 	 	 	 	 	 	 	 	 
	I.D. number
	 	Number	 	10	 	11	 	20	 	 	N	 
	Recipient’s last name
	 	Recipient Last Name	 	12	 	21	 	32	 	 	C	 
	Recipient’s first name
	 	Recipient First Name	 	9	 	33	 	41	 	 	C	 
	Recipient’s date of birth
	 	Recipient Date of Birth –	 	8	 	42	 	49	 	 	N	 

AHCA Contract No. FA523, Attachment I, Page 82 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 
	(MMDDYYYY)
	 	MMDDYYYY	 	 	 	 	 	 	 	 	 	 
	HMO/PHP assigned recipient I.D
	 	HMO Recipient ID	 	9	 	50	 	58	 	 	C	 
	HMO location, assigned by plan
	 	HMO Location	 	9	 	59	 	67	 	 	C	 
	Reserved for Fiscal Agent Use
	 	Filler	 	1	 	68	 	68	 	 	 	 
	Inactive field, zero fill
	 	Filler	 	8	 	69	 	76	 	 	C	 
	Transaction date (MMYY) This
should reflect the date the transaction
will be effective. Must be the month
following the submission of the file
	 	HMO Transaction Date-	 	 	 	 	 	 	 	 	 	 
	.
	 	MMYY	 	4	 	77	 	80	 	 	C	 

	 	 	Once the transition to the exclusive use of the 834 transaction is
complete, the plans must comply with all the federal requirements of
administrative simplification, as documented in the National Electronic
Data Interchange Transaction Set Implementation Guide for the Benefit
Enrollment and Maintenance ASC X12N 834 Transaction, as well as the
ACS/AHCA ANSI ASC X12N 834 Companion Guide.

THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 83 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	60.2.2	 	Medicaid HMO Disenrollment Summary(M***YYMM.dbl)

	 	 	This report provides a uniform means of reporting each HMO’s
monthly involuntary disenrollments and transfers from one county
of plan operation to another. This is a summary report of the
number of transactions submitted to the fiscal agent for
processing. The report is required to enable the agency to assess
the reasons for each HMO and to assure that members are
disenrolled in compliance with contract guidelines.
	 
	 	 	The plan will submit one record per location (unique 9
digit Medicaid provider number) in the M***YYMM.dbf file
format.
	 
	 	 	The plan will submit this report monthly, by the 15th
day of the month being reported. The M***YYMM.dbf file
will be submitted to the agency via Internet e-Mail to
MMCDATA(FDHC.STATE.FL. US or on a high density 3.5” diskette
(IBM compatible, 1.44 Mb) received by the due date at the address
given in Section 60.2.
	 
	 	 	Agency staff will perform site reviews of disenrollee files to
assess the accuracy of these reports and to review the
documentation of reasons for disenrollment. On a random basis,
transactions submitted by the plan directly to the fiscal agent
will also be compared to the reported number of transactions for a
given month.

Table 3. File Layout for Medicaid HMO Disenrollment Summary Reporting
File

	 	 	 	 	 	 	 
	Field Name
	 	Description
	 	Type
	 	Width

	PLAN_ID
	 	9 digit provider code (includes 2 digit location)	 	Character	 	9
	FROM_DATE
	 	The beginning date of the reporting period	 	Date	 	8
	TO_DATE
	 	The ending date of the reporting period	 	Date	 	8
	II
	 	Missed 3 consecutive appointments in continuous 6 month period	 	Numeric	 	7
	12
	 	Moved out of service area	 	Numeric	 	7
	13
	 	Admitted to long term care facility	 	Numeric	 	7
	14
	 	Fraudulent use of Medicaid or plan ID card	 	Numeric	 	7
	15
	 	Death of enrollee	 	Numeric	 	7
	16
	 	Loss of Medicaid eligibility	 	Numeric	 	7
	17
	 	Resident of state hospital or correctional institution	 	Numeric	 	7
	18
	 	Unable to locate	 	Numeric	 	7
	19
	 	Resident of an ICF/DD	 	Numeric	 	7
	110
	 	Hospice	 	Numeric	 	7
	Ill
	 	Participants of the Project AIDS Care waiver program	 	Numeric	 	7
	112
	 	Participants of the assisted living waiver	 	Numeric	 	7
	113
	 	Residents of a prescribed pediatric extended care center	 	Numeric	 	7
	114
	 	Members of the Florida Assertive Community Treatment Team (FACT)	 	Numeric	 	7
	115
	 	Enrolled in Medicare HMO	 	Numeric	 	7
	116
	 	Major medical third party coverage	 	Numeric	 	7
	117
	 	Enrolled in + receiving services through Children's Med. Services.	 	Numeric	 	7
	118
	 	Admission to a DJJ residential commitment program/facility	 	Numeric	 	7
	Tin
	 	Number of Transfers Into This County of Plan Operation	 	Numeric	 	7
	Tout
	 	Number of Transfers Out of This County of Plan Operation	 	Numeric	 	7

AHCA Contract No. FA523, Attachment I, Page 84 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	60.2.3	 	Frail/Elderly Annual Disenrollment Summary Report (E***YY06.dbf)

	 	 	This report provides a uniform means of reporting disenrollments from
the frail/elderly program.
	 
	 	 	The plan will submit one record per location (unique 9
digit Medicaid provider number) in the F***YY06.dbf file
format defined in this section.
	 
	 	 	The plan will submit this report annually, by June 1. The file will
be submitted to the agency via Internet e-Mail to
MMCDATA@FDNC.STATE.FL. US or on a high density 3.5” diskette
(IBM compatible, 1.44 Mb) received by the due date at the address
given in Section 60.2.
	 
	 	 	Agency staff will perform site reviews of disenrollee files to
assess the accuracy of these reports and to review the
documentation of reasons for disenrollment. These reviews will
include a review of disenrollment due to patient deaths and
disenrollments for reasons reported as other.

	 	 	File Layout for Frail/Elderly Disenrollment Summary Reporting File

	 	 	 	 	 	 	 
	Filed Name	 	Description	 	I	 	yl~idth
	PLAN_ID
	 	9 digit provider                code (includes 2 digit location)	 	Character	 	9
	FROM_DATE
	 	The beginning date of the reporting period (mm/dd/yy)	 	Date	 	8
	TO_DATE
	 	The ending date of the reporting period (mm/dd/yy)	 	Date	 	8
	V1
	 	Expects to move	 	Numeric	 	7
	V2
	 	Wishes to see private M.D, or practitioner, or attend another clinic	 	Numeric	 	7
	V3
	 	Dissatisfied with plan policies or procedures	 	Numeric	 	7
	V4
	 	Enrolled/Enrolling in MediPass	 	Numeric	 	7
	V5
	 	Marketing representative complaint or misrepresentation of plan	 	Numeric	 	7
	V6
	 	Enrolled/Enrolling in other Medicaid HMO	 	Numeric	 	7
	V7
	 	Other Voluntary	 	Numeric	 	7
	V8
	 	Participants of the Assistive Care Services Program	 	Numeric	 	7
	I1
	 	Missed 3 consecutive appointments in continuous 6 month period	 	Numeric	 	7
	I2
	 	Moved out of service area	 	Numeric	 	7
	I3
	 	Admitted to long term care facility	 	Numeric	 	7
	I4
	 	Fraudulent use of Medicaid or plan ID card	 	Numeric	 	7
	15
	 	Death of enrollee	 	Numeric	 	7
	I6
	 	Loss of Medicaid eligibility	 	Numeric	 	7
	I7
	 	Other involuntary	 	Numeric	 	7
	I9
	 	Resident of an ICF/DD	 	Numeric	 	7
	I10
	 	Hospice	 	Numeric	 	7
	Ill
	 	Participants of the Project AIDS Care waiver program	 	Numeric	 	7
	112
	 	Participants of the Assisted Living Waiver	 	Numeric	 	7
	114
	 	Members of the Florida Assertive Community Treatment Team	 	Numeric	 	7
	 
	 	(FACT)	 	 	 	 
	115
	 	Enrolled in Medicare HMO	 	Numeric	 	7
	I16
	 	Major medical third party coverage	 	Numeric	 	7

AHCA Contract No. FA523, Attachment I, Page 85 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	60.2.4	 	Service Utilization Summary (S***YYQ*.dbf)

	 	 	The plan will submit service utilization reports to the agency in the
format defined below. This data includes services provided to MediKids
members. This report is due within 45 calendar days after the end of
the quarter being reported. For reporting purposes, calendar year
quarters end as follows: Quarter 1, March; Quarter 2, June; Quarter 3,
September; Quarter 4, December. The agency reserves the right to modify
information and format.
	 
	 	 	The plan will submit quarterly service utilization reports in the
format of the dBASE III+ compatible file (S***YYQ*.dbf) defined below.

	1.	 	Medicaid ID: The 7 digit Medicaid provider number for a Medicaid
contracted plan.
	 
	2.	 	Report Type: Fill in the field rept_type with the
value SUT to indicate the service utilization report.
	 
	3.	 	Reporting Period: Complete the from_date and to_date
fields with the beginning and ending dates of the quarter you are
reporting. All date fields must be completed in traditional dbf
format of mm/dd/yy.
	 
	4.	 	Service Utilization Measures:

	 	 	Each Service Utilization measure described below will be reported
by recipient eligibility category as defined on Table 4. These
categories are AFDC related (AFDC, foster care, SOBRA), SSI with no
Medicare, SSI with Medicare part B, SSI with Medicare part A and B,
and persons served under the Frail Elderly program. Please note
that only those plans that operate an Agency-approved Frail Elder
expanded benefit should include Frail Elderly program data in this
report.

	A)	 	Hospital Inpatient (Days): Enrollee inpatient days
provided in the quarter. Do not report the number of stays or
visits.
	 
	B)	 	Emergency Center (Visits): Enrollee visits emergency
centers (e.g., hospital emergency rooms and emergency clinics).
	 
	C)	 	Physician Office (Visits): Enrollee visits to
physician’s offices (e.g., primary or specialty care by medical
doctor or doctor of osteopathic medicine).
	 
	D)	 	Non-Physician Office (Visits): Enrollee visits to
non-physicians’ offices for a variety of treatment reasons,
modalities and services, including: Physicians Assistant;
Advanced Registered Nurse Practitioner.
	 
	E)	 	Prescribed Medicine: Enter the number of
prescriptions. If a prescription is refillable, each refill is
counted separately. Include all services for which the plan
paid, whether provided in house, contracted, or community
pharmacies.
	 
	F)	 	Nursing Home Days: Enter the number of nursing home
days experienced by plan enrollees. Do not enter the number of
stays or visits.
	 
	G)	 	Live Births: Number of children born to members of your health
plan.
	 
	H)	 	Outpatient Center (Visits): Enrollee visits to
outpatient centers (e.g. hospital outpatient agencies,
ambulatory surgery centers and diagnostic centers).
	 
	I)	 	Community Mental Health Services: Number of Community
Mental Health Services provided by the plan to enrollees in your
Medicaid contracted plan. These services include procedure codes
90801, 90825, 90843, 90844, 90853, 90862, 90887, 99214, W1023,
W1027, W1044, W1046, W1058, W1059, W1060, W1061, W1064, W1067
through W1075.
	 
	J)	 	Targeted Case Management Services: Number of mental
health targeted case management services provided by the plan.
Included services are: mental health case management for
children under 18 (Medicaid procedure code W9891), mental
health case management for adults (W9892), intensive team
mental health case management (W9899).
	 
	K)	 	Transportation Services: Number of trips provided by
your plan to plan enrollees. Count a round trip as two trips.
	 
	L)	 	Dental Services (if covered): Number of Dental
Services provided by your plan to your plan members. Report
all dental categories of service (DO100-D9999) provided.
These services comprise CPT codes 10060 through 99285.

AHCA Contract No. FA523, Attachment I, Page 86 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	M)	 	Total Enrollee Months: The number multiplied by the
number of months served during the quarter. For example, if a
person is enrolled in your plan for the entire quarter, then that
corresponds to 3 months multiplied by 1 enrollee, that is a 3
enrollee months. This information can be obtained by summing the
enrollee months for the quarter by eligibility category from the
summary page of each month’s final HMO Ongoing Report.

THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 87 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

			
	 	 	 
	July 2004
	 	Medicaid HMO Contract

Table 4. Field Names for Service Utilization Summary File (S***YYQ*.dbt)

	 	 	HMO SERVICE UTILIZATION REPORT LAYOUT

     Medicaid ID: PLAN ID            REPT TYPE: SUT            Renortinsi Period: From FROM DATE to TO DATE

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Utilization Measures
	 	Eligibility Categories

	 	 	 	 	 	 	 	 	 	 	SSI - Part	 	 
	 	 	 	 	AFDC / Foster	 	SSI - No	 	SSI - Part B	 	A&B	 	Frail
	Services
	 	Unit of Measure
	 	Care / SOMA
	 	Medicare
	 	Medicare
	 	Medicare
	 	Elderly**

	Hospital Inpatient

	 	Days
	 	AFDC_HI
	 	SSI_HI
	 	SSIB_HI
	 	SSIAB_HI
	 	FE_HI**
	Emergency Center

	 	Visits
	 	AFDC_EC
	 	SSI_EC
	 	SSIB_EC
	 	SSIAB_EC
	 	FE_EC**
	Physician Office

	 	Visits
	 	AFDC_PO
	 	SSI_PO
	 	SSIB_PO
	 	SSIAB_PO
	 	FE_PO**
	Non-Physician Office

	 	Visits
	 	AFDC_NO
	 	SSI_NO
	 	SSIB_NO
	 	SSIAB_NO
	 	FE_NO**
	Prescribed Medicines

	 	Number of Prescriptions
	 	AFDC_RX
	 	SSI_RX
	 	SSIB_RX
	 	SSIAB_RX
	 	FE_RX**
	Nursing Home

	 	Days
	 	AFDC_NH
	 	SSI_NH
	 	SSIB_NH
	 	SSIAB_NH
	 	FE_NH**
	Live Births

	 	Number of Births
	 	AFDC_LB
	 	SSI_LB
	 	SSIB_LB
	 	SSIAB_LB
	 	FE_LB**
	Outpatient/Ambulatory Surgeries

	 	Number of Outpatient Surgeries
	 	AFDC_AS
	 	SSI_AS
	 	SSIB_AS
	 	SSIAB_AS
	 	FE_AS**
	Community Mental Health

	 	Number of Community Mental	 	 	 	 	 	 	 	 	 	 
	Services

	 	Health Services
	 	AFDC_MH
	 	SSI_MH
	 	SSIB_MH
	 	SSIAB_MH
	 	FE_MH**
	Targeted Case Management

	 	Number of Targeted Case	 	 	 	 	 	 	 	 	 	 
	Services

	 	Management Services
	 	AFDC_CM
	 	SSI_CM
	 	SSIB_CM
	 	SSIAB_CM
	 	FE_CM**
	Transportation Services

	 	Number of Trips
	 	AFDC_TR
	 	SSI_TR
	 	SSIB_TR
	 	SSIAB_TR
	 	FE_TR**
	Dental Services

	 	Number of Services Provided
	 	AFDC_DN
	 	SSI_DN
	 	SSIB_DN
	 	SSIAB_DN
	 	FE_DN**
	Total Enrollee Months

	 	 	 	AFDC_EM
	 	SSI_EM
	 	SSIB_EM
	 	SSIAB_EM
	 	FE_EM**

	**	 	INCLUDE THIS DATA ONLY IF YOUR PLAN OPERATES AN AGENCY-APPROVED FRAIL
ELDER EXPANDED BENEFIT.

AHCA Contract No. FA523, Attachment I, Page 88 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

Table 5. Structure for
Service Utilization Summary Reporting File (S***YYQ*.dbf)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Field
	 	Field Name
	 	Type
	 	Width
	 	Field
	 	Field Name
	 	Type
	 	Width
	 	Field
	 	Field Name
	 	Type
	 	Width

	1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

	 	PLANID

FROM_DATE

TO_DATE

REPT_TYPE

AFDC_HI

SSI_HI

SSIB_HI

SSIAB_HI

FE_HI

AFDC_EC

SSI_EC

SSIB_EC

SSIAB_EC

FE_EC

AFDC_PO

SSI_PO

SSIB_PO

SSIAB_PO

FE_PO

AFDC_NO

SSI_NO

SSIB_NO

SSIAB_NO
	 	Character

Date

Date

Character

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric
	 	7

8

8

5

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9
	 	24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46
	 	FE_NO

AFDC_RX

SSI_RX

SSIB_RX

SSIAB_RX

FE_RX

AFDC_NH

SSI_NH

SSIB_NH

SSIAB_NH

FE_NH

AFDC_LB

SSI_LB

SSIB_LB

SSIAB_LB

FE_LB

AFDC_AS

SSI_AS

SSIB_AS

SSIAB_AS

FE_AS

AFDC_MH

SSI_MH
	 	Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric
	 	9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9
	 	47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69
	 	SSIB_MH

SSIAB_MH

FE_MH

AFDC_CM

SSI_CM

SSIB_CM

SSIAB_CM

FE_CM

AFDC_TR

SSI_TR

SSIB_TR

SSIAB_TR

FE_TR

AFDC_DN

SSI_DN

SSIB_DN

SSIAB_DN

FE_DN

AFDC_EM

SSI_EM

SSIB_EM

SSIAB_EM

FE_EM
	 	Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric

Numeric
	 	9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

9

AHCA Contract No. FA523, Attachment I, Page 89 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	60.2.5	 	Appeals Report (A***YYQ*.dbf)

	 	 	The Appeals Report provides the agency with detailed information about
the plan’s ability to handle member appeals through its internal
grievance system. Please refer to Section 100.0 of this contract for
the definitions of grievances, actions and appeals.
	 
	 	 	The A*** YYQ*.dbf file will be submitted to the Agency for Health Care
Administration via Internet e-Mail to MMCDATA@FDHC.STATE.FL.US or
on a high density 3.5” diskette (IBM compatible, 1.44 Mb) received
within 45 calendar days following the end of the reported quarter. An
appeals report must be submitted each quarter by each plan. If no new
appeals have arisen in any counties of plan operation, or if the status
of an unresolved appeal has not changed to ‘Resolved,’ please submit one
record only. This record must contain the PLAN_ID field only, with the
first 7 digits of the 9-digit Medicaid provider number.

Table 6. Structure for Appeal Reporting File

	 	 	 	 	 	 	 	 	 
	I:ield Name
	 	Ty~c
	 	Width
	 	Decrihtiun

	PLAN_ID
	 	Character	 	9	 	Your nine digit Medicaid provider number.	 	 
	RECIP_ID
	 	Character	 	9	 	The recipient's 9 digit Medicaid ID number	 	 
	LAST_NAME
	 	Character	 	15	 	The recipient's last name	 	 
	FIRST_NAME
	 	Character	 	15	 	The recipient's first name	 	 
	MID_INIT
	 	Character	 	1	 	The recipient's middle initial	 	 
	APP_DATE
	 	Date	 	8	 	The date of the appeal	 	 
	EXPED_REQ
	 	Character	 	1	 	Indicate whether or not the appeal was an expedited request	 	 
	 
	 	 	 	 	 	Y =Yes	 	N = No
	APP_TYPE
	 	Character	 	1	 	Indicate whether the appeal is related to a behavioral health service	 	 
	 
	 	 	 	 	 	Y = Yes	 	N=No
	APP_TYPE
	 	Numeric	 	2	 	The type of appeal:	 	 
	 
	 	 	 	 	 	1. Quality of Care	 	9. Enrollment/Disenrollment
	 
	 	 	 	 	 	2. Access to Care	 	10. Termination of Contract
	 
	 	 	 	 	 	3. Emergency Services	 	11. Services after termination
	 
	 	 	 	 	 	4. Not Medically Necessary	 	12. Unauthorized out of plan svcs
	 
	 	 	 	 	 	5. Pre-Existing Condition	 	13. Unauthorized in-plan svcs
	 
	 	 	 	 	 	6. Excluded Benefit	 	14. Benefits available in plan
	 
	 	 	 	 	 	7. Billing Dispute	 	15. Experimental/Investigational
	 
	 	 	 	 	 	8. Contract Interpretation	 	16. Other
	DISP_DATE
	 	Date	 	8	 	The date of the disposition (mm/dd/yy)	 	 
	DISP
	 	Numeric	 	2	 	The disposition of the appeal:	 	 
	 
	 	 	 	 	 	1. Referral made to specialist	 	10. In HMO Grievance System
	 
	 	 	 	 	 	2. PCP Appointment made	 	11. Referred to Area Office
	 
	 	 	 	 	 	3. Bill Paid	 	12. Member sent OLC form
	 
	 	 	 	 	 	4. Procedure scheduled	 	13. Lost contact with member
	 
	 	 	 	 	 	5. Reassigned PCP	 	14. Hospitalized / Institutionalized
	 
	 	 	 	 	 	6. Reassigned Center	 	15. Confirmed original decision
	 
	 	 	 	 	 	7. Disenrolled Self	 	16. Reinstated in HMO
	 
	 	 	 	 	 	8. Disenrolled by plan	 	17. Other
	 
	 	 	 	 	 	9. In HMO QA Review	 	 
	DISP_STAT
	 	Character	 	1	 	R= Resolved	 	U = Unresolved
	 
	 	 	 	 	 	Note: Any appeal reported as
unresolved must be reported again
when resolved. Appeals that are resolved in the quarter prior to reporting should be reported for the first time as resolved.	 	 

AHCA Contract No. FA523, Attachment I, Page 90 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	60.2.6	 	Inpatient Discharge Report (H***YYQ*.dbf)

	 	 	The Inpatient Discharge Report provides the agency with detailed
hospital inpatient utilization information. This includes general
acute care and inpatient psychiatric services. The plan must submit a
DBF file with the following record layout to the Agency via Internet
e-mail to MMCDATA@FDHC.STATE.FL.US, on a high density 3.5”
diskette (IBM compatible, 1.44 Mb), or on a CD, quarterly within 30
calendar days following the end of the reported quarter. During the
first year of the contract period, these data records will be
submitted to the fiscal agent’s State Healthcare Clearinghouse using
the HIPAA-compliant X12N 837 transaction. The Agency will provide
adequate written notice prior to beginning this conversion.

Table 7. Structure for Inpatient Discharge Reporting File

	 	 	 	 	 	 	 	 	 
	Field Name
	 	'T#pe
	 	11 idth
	 	Description

	PLAN_ID

	 	Character
	 	 	9	 	 	9 Digit Medicaid provider number of health plan
	RECIP_ID

	 	Character
	 	 	9	 	 	9 Digit Medicaid ID number of plan member
	RECIP_LAST

	 	Character
	 	 	20	 	 	Last name of plan member
	RECIP_FIRS

	 	Character
	 	 	10	 	 	First name of plan member
	RECIP_DOB

	 	Date
	 	 	8	 	 	Plan member’s date of birth
	HOSP_ID

	 	Character
	 	 	9	 	 	AHCA ID Number of admitting hospital
	HOSP_NAME

	 	Character
	 	 	50	 	 	Optional Field if ID not on agency-supplied list; Please use
upper
case only.
	ADMIT

	 	Date
	 	 	8	 	 	Date of Admission
	DISCH

	 	Date
	 	 	8	 	 	Date of Discharge
	ADMIT_TYPE

	 	Character
	 	 	1	 	 	Indicates the Type of Admission.
	

	 	 	 	 	 	 	 	1=General Acute Care
	

	 	 	 	 	 	 	 	2=Inpatient Psych
	TPL

	 	Numeric
	 	 	5	 	 	Amount paid by third party (whole dollars)
	DIAGI

	 	Character
	 	 	7	 	 	Primary ICD-9 Diagnosis
	DIAG2

	 	Character
	 	 	7	 	 	Secondary ICD-9 Diagnosis (if applicable)
	DIAG3

	 	Character
	 	 	7	 	 	Tertiary ICD-9 Diagnosis (if applicable)
	PROC1

	 	Character
	 	 	5	 	 	For an surgical or obstetrical admission, the principal ICD-9

Procedure Code
	PROC2

	 	Character
	 	 	5	 	 	For an surgical or obstetrical admission, the secondary ICD-9

Procedure Code
	PROC3

	 	Character
	 	 	5	 	 	For an surgical or obstetrical admission, the tertiary ICD-9

Procedure Code

	60.2.7	 	Marketing Representative Report (R***YYMM.xls)

	 	 	The plan shall be required to register each marketing representative
with the agency as outlined in Section 30.3, Marketing
Representatives. The R***YYMM.xls file will be submitted within five
days of the reporting month to the agency at the following e-mail
address: petriega,fdhc.state.fl.us. The agency-supplied
spreadsheet template must be used. This template contains the
following data elements:

	 	 	Table 8: Required Information for Marketing Representative Report
Template()

	 	 	 
	PlanI~iformat n

	 	~la1kcting~ Representative Information
	Plan Name

	 	Last Name
	Address

	 	First Name
	Contact Person

	 	DOI License Number
	Phone

	 	Address
	Fax

	 	City

AHCA Contract No. FA523, Attachment I, Page 91 of 166

AHCA Form 2100-0003
(Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

	 	 	 
	Email Address

	 	State
	

	 	Zip
	

	 	Office Phone
	

	 	Cell Phone
	

	 	Last HMO Employer

	60.2.8	 	Provider Network Report

	 	 	The agency shall collect provider network information from the Medicaid
contracted HMOs. The plan shall submit to the enrollment and
disenrollment services contractor, via FTP, the plan’s provider
directory for each county on at least a monthly basis, and in the
format described below. This report serves dual purposes. The
enrollment services contractor loads this information into their BESST
system for use in answering beneficiary questions and to enable primary
care provider (PCP) selection at the time of voluntary plan enrollment.
The agency uses the file to monitor the plan’s compliance with required
provider network composition and PCP to member ratios, and for other
uses deemed pertinent. The plan must ensure that this is an electronic
representation of the plan’s network of contracted providers, not a
listing of entities for whom claims have been paid.
	 
	 	 	The file is an ASCII flat file and is a complete refresh of the provider
information. The file must be submitted on the Monday preceding the
second to the last Saturday of each month. If this Monday deadline falls
on a holiday, the file must be submitted on the Friday before the
holiday. Both the enrollment services contractor and the Agency will use
this required file. The plan may also choose to submit the file a second
time each month, on the third business day before the end of the month.
The plan may use this optional file submission opportunity to ensure
that the information presented to beneficiaries is the most current data
available. Updated provider network information is available to the
enrollment specialists two to three business days after the submission
deadline.
	 
	 	 	THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 92 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

			
	July 2004
	 	Medicaid HMO Contract

Table 9. File Layout for Medicaid HMO Provider Networks

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Field	 	Required	 	Field	 	 	 	 
	Field Name
	 	Length
	 	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	 	 

AHCA Contract
No. FA523, Attachment I, Page 93 of 166

AHCA Form 2100-0003
(Rev. APR04)

 

 

Exhibit 10.25

	 	 	 	 	 
	July 2004

	 	 	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	City	 	 	30	 	 	X	 	alpha	 	Left	 	Physical city location of the provider or practice. UPPER CASE ONLY PLEASE
	

	 	 	 	 	 	 	 	 	 	Left	 	 	 	 
	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. Valid values: P =
Yes, the provider is a PCP; N = No, the provider is not a PCP. This field should not be
used to note group providers as PCPs, since members must be assigned to specific
providers, not group practices.
	Provider	 	 	1	 	 	Required if	 	alpha	 	Left	 	X = Accepting new patients
	Limitation	 	 	 	 	 	PCP Indicator	 	 	 	 	 	N = Not accepting new patients but remaining a contracted network provider
	 	 	 	 	 	 	= P	 	 	 	 	 	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
	HMO/MediPass	 	 	1	 	 	X	 	alpha	 	Left	 	H = HMO
	Indicator	 	 	 	 	 	 	 	 	 	 	 	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

001 Adolescent Medicine

003 Anesthesiology

005 Dermatology

007 Emergency Medicine

009 General Family Practice

011 General Practice

013 Geriatrics

015 Hematology

017 Infectious Diseases

019 Neonatal/Perinatal
	 	describes

002 Allergy

004 Cardiovascular Medicine

006 Diabetes

008 Endocrinology

010 Gastroenterology

012 Preventative Medicine

014 Gynecology

016 Immunology

018 Internal Medicine

020 Neoplastic Diseases

AHCA Contract No. FA523, Attachment I, Page 94 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 	 	 
	July 2004

	 	 	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	 	 	 	 	 	 	 	 	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 Family Planning
	

	 	 	 	 	 	 	 	 	 	065 Maternal/Fetal

067 Physical Therapist
	 	066 Therapeutic Comprehensive

Assessment

068 Therapeutic Foster Care
	

	 	 	 	 	 	 	 	 	 	069 UNUSED
	 	070 Adult Dentures Only
	

	 	 	 	 	 	 	 	 	 	071 General Dentistry

073 Pedodontist
	 	072 Oral Surgeon (Dentist)

074 Other Dentist
	

	 	 	 	 	 	 	 	 	 	075 Adult Primary Care Nurse Practitioner
	 	076 Clinical Nurse Spec. Psych Mental with Nurse
	

	 	 	 	 	 	 	 	 	 	077 College Health Nurse Practitioner
	 	078 Diabetic Nurse Practitioner
	

	 	 	 	 	 	 	 	 	 	079 UNUSED
	 	080 Family Nurse Practitioner
	

	 	 	 	 	 	 	 	 	 	081 Family Planning Nurse

Practitioner
	 	082 Geriatric Nurse Practitioner
	

	 	 	 	 	 	 	 	 	 	083 Maternal/Child Family Planning

Nurse Practitioner
	 	084 Cert. Reg. Nurse Anesthetist
	

	 	 	 	 	 	 	 	 	 	085 Certified Registered Nurse
	 	086 OB/GYN Nurse Practitioner Midwife
	

	 	 	 	 	 	 	 	 	 	087 Pediatric Nurse Practitioner
	 	088 Orthodontist
	

	 	 	 	 	 	 	 	 	 	089 Assisted Living for the Elderly
	 	090 Occupational Therapist
	

	 	 	 	 	 	 	 	 	 	091 Physical Therapist
	 	092 Speech Therapist
	

	 	 	 	 	 	 	 	 	 	093 Respiratory Therapist
	 	094 Katie Beckett
	

	 	 	 	 	 	 	 	 	 	095 Aged/Disabled Adults
	 	096 Developmental Services Disability

AHCA Contract No. FA523, Attachment I, Page 95 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	 	 	 	 	 	 	 	 	 	 	097 Channeling
	 	098 Community Supported Living
Arrangement	 	 	 	 	 	 	 	 	 	 
	

	 	 	 	 	 	 	 	 	 	 	 	099 Project AIDS Care
	 	100 Chiropractor	 	 	 	 	 	 	 	 	 	 
	

	 	 	 	 	 	 	 	 	 	 	 	101 Optometrist
	 	102 Podiatrist	 	 	 	 	 	 	 	 	 	 
	

	 	 	 	 	 	 	 	 	 	 	 	103 Urologist	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	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

	 	 	 	 	 	 	 	numeric	 	Left withleading	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Affiliation 2

	 	 	9	 	 	 	 	 
	 	zeros
	 	as above	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospital

	 	 	 	 	 	 	 	numeric	 	Left with leading	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Affiliation 3

	 	 	9	 	 	 	 	 
	 	zeros
	 	as above	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospital

	 	 	 	 	 	 	 	numeric	 	Left with leading	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Affiliation 4

	 	 	9	 	 	 	 	 
	 	zeros
	 	as above	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Hospital

	 	 	 	 	 	 	 	numeric	 	Left with leading	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Affiliation 5

	 	 	9	 	 	 	 	 
	 	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	 	 	10	 	 	X	 	alpha/	 	 	 	Must be included for all health care professionals. License number is formatted with up

AHCA Contract No. FA523, Attachment I, Page 96 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 
	License Number

	 	 	 	 	 	 	 	numeric
	 	 	 	to 3 alpha characters followed by up to 7 numeric digits.
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	AHCA Hospital

ID

	 	 	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	 	 	 	 	 	 

Trailer Record

The trailer record is used to balance the number of records received with the number loaded on BESST. The data
from the Trailer Record is not loaded on BESST.

RECORD LENGTH: 76

	 	 	 	 	 	 	 	 	 
	 	 	Field	 	Field	 	 
	Filed Name	 	Length	 	Format	 	Values
	Trailer Record Text

	 	 	36	 	 	Alpha
	 	‘TRAILER RECORD DATA’
	 
	 	 	 	 	 	 	 	 
	Record Count

	 	 	7	 	 	Numeric
	 	Total number of records on file
excluding the trailer record (right
justified, zero filled)
	 
	 	 	 	 	 	 	 	 
	System Process date

	 	 	8	 	 	Alpha
	 	Mmddyyyy
	 
	 	 	 	 	 	 	 	 
	Filler

	 	 	25	 	 	 	 	 

AHCA Contract No. FA523, Attachment I, Page 97 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

60.2.9 Child Health Check-Up Reporting

	 	 	This annual EPSDT (CHCUP-CMS 416) report provides basic information on
participation in the Medicaid Child Health Check-Up program. The
information is used to comply with Federal EPSDT (CMS 416) reporting
requirements and allows the state to assess the effectiveness of EPSDT
programs operated by the plans. Child health screening services are
defined for purposes of reporting on this form as initial or periodic
screens required to be provided according to Florida’s screening
periodicity schedule.
	 
	 	 	This report is due by the January 15th following the end of the reporting
period. The reporting period is from October 1 through September 30. For
example, the report covering October 1, 2002 through September 30, 2002
will be due on or before January 2003. A reporting template will be
provided with all formulas entered. The method of calculation is provided
in the detailed instructions below for your information. By October 1 of
the following year, the plans shall deliver to the Agency a certification
by an Agency approved independent auditor that the Child Health Checkup
data have been fairly and accurately presented.
	 
	 	 	Detailed Instructions - 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
	 
	 	 	Plan Name. Enter the name of your
Health Plan.
	 
	 	 	Fiscal Year. Enter the federal fiscal year being reported. Example
October 1, 2001 — September 30, 2002 is Federal Fiscal year 2001-2002.
	 
	 	 	Line 1 — Total Individuals Eligible for EPSDT (CHCUP) - Enter the total
unduplicated number of all individuals under the age of 21 enrolled in
the plan, distributed by age and by basis of Medicaid eligibility.
Unduplicated means that an eligible person is reported only once
although he or she may have had more than one period of eligibility
during the year. Medicaid-eligible individuals under age 21 are
considered eligible for EPSDT (CHCUP) services, regardless of whether
they have been informed about the availability of EPSDT (CHCUP) services
or whether they accept EPSDT (CHCUP) services at the time of informing.
Do not count your MediKids populations.
	 
	 	 	Line 2a — State Periodicity Schedule
- 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 individuals in each age group in line 1 during the
reporting year.
	 
	 	 	Line 3b — Average Period of Eligibility - Calculated by dividing the
total months of eligibility by line 1. Divide that number by 12 and
enter the quotient. This number represents the portion of the year that
individuals remain Medicaid eligible during the reporting year,
regardless of whether eligibility was maintained continuously.
	 
	 	 	Line 4 — Expected Number of Screenings per Eligible Multiplied -
Calculated by multiplying line 2c by line 3b. Enter the product. This
number reflects the expected number of initial or periodic screenings
per child per year based on the number required by the state-specific
periodicity schedule and the average period of eligibility.

AHCA Contract No. FA523, Attachment I, Page 98 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	Line 5 — Expected Number of Screenings - Calculated by multiplying line
4 by line 1. Enter the product. This reflects the total number of
initial or periodic screenings expected to be provided to the eligible
individuals in line 1.
	 
	 	 	 Line 6 — Total Screens Received - Enter the total number of initial or
periodic screens furnished to eligible individuals under either
fee-for-service or managed care arrangements. This includes those initial
screens billed to Medicaid’s fiscal agent in accordance with Section 80.1
a. of this contract. Use the CPT codes listed below or any plan-specific
EPSDT (CHCUP) codes you may have developed in the plan for these screens.
Use of these proxy codes is for reporting purposes only. Plans must
continue to ensure that all five age-appropriate elements of an EPSDT
(CHCUP) screen, as defined by law, are provided to EPSDT (CHCUP)
recipients.
	 
	 	 	NOTE: 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” EPSDT
(CHCUP) screening. (A catch-up EPSDT (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 furnished under capitated arrangements.
The codes to be used to document the receipt of an initial or periodic
screen are as follows:
	 
	 	 	CPT-4 codes: 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)
	 
	 	 	99385 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)
	 
	 	 	99395 Established patient (ages 18-39 years)
	 
	 	 	99431 Newborn care (history and examination)
	 
	 	 	99432 Normal newborn care
	 
	 	 	99435 Newborn Care (history and examination) or
	 
	 	 	CPT-4 codes: Evaluation and
	 
	 	 	Management Codes
	 
	 	 	99201-99205 NewPatient
	 
	 	 	99211-99215 Established Patient
	 
	 	 	(NOTE: These CPT-4 Evaluation and Management codes must be used in
conjunction with V codes V20-V20.2 and/or V70.0 and/or V70.3-70.9.)
	 
	 	 	Do not count MediKids population who have had a check-up.
	 
	 	 	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 EPSDT (CHCUP) eligibles 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 plan shall adopt annual screening goals to achieve at
least 80% EPSDT (CHCUP) screening ratio pursuant to Section 5360, Annual
Participation Goals, of the State Medicaid Manual.

AHCA Contract No. FA523, Attachment I, Page 99 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	Line 8 — Total Eligibles Who Should Receive at Least One Initial or
Periodic Screen - The number of persons who should receive at least one
initial or periodic screen is dependent on the state’s periodicity
schedule. Use the following calculations:

	1.	 	Look at the number entered in line 4 of this form. If that
number is greater than 1, use the number 1. If the number in line
4 is less than or equal to 1, use the number in line 4. (This
procedure will eliminate situations where more than one visit is
expected in any age group in a year.)
	 
	2.	 	Multiply the number from calculation 1 above by the number in
line 1 of the form. Enter the product on line 8.

	 	 	Line 9 — Total Eligibles Receiving at Least One Initial or Periodic
Screen - Enter the unduplicated count of individuals, including those
enrolled in managed care arrangements, who received at least one
documented initial or periodic screen during the year. Refer to codes in
line 6.
	 
	 	 	Do not count MediKids population who have had a check-up.
	 
	 	 	Line 10 — Participant Ratio - Calculated by dividing line 9 by line 8.
This ratio indicates the extent to which eligibles are receiving any
initial and periodic screening services during the year. The plan shall
adopt annual participating goals to achieve at least 80% EPSDT (CHCUP)
participating ratio 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 individuals, including those in managed care
arrangements, who, as the 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. For reporting on the EPSDT (CHCUP)
only count the referral codes “T” and “V”.
	 
	 	 	The new federally required referral codes are:

	 	 	 
	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 periodic check-up (not including dental referrals)
	 
	 	 
	V

	 	Patient Refused Referral Indicator is used when the patient refused a referral.

	 	 	Line 12a — Total Eligibles Receiving Any Dental Services - Enter the
unduplicated number of children receiving any dental service as defined
by HCPC codes D0100 — D9999 (ADA codes 00100 — 09999). Include
Procedure Code W5301.
	 
	 	 	Line 12b — Total Eligibles Receiving Preventive Dental Services -
Enter the unduplicated number of children receiving a preventive
dental service as defined by HCPC codes D1000 — D1999 (ADA codes 01000
 — 01999). Include Procedure Code W5301.
	 
	 	 	Line 12c — Total Eligibles Receiving Dental Treatment Services - Enter
the unduplicated number of children receiving treatment services as
defined by HCPC codes D2000 — D9999 (ADA codes 02000 — 09999).

AHCA Contract No. FA523, Attachment I, Page 100 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	NOTE: For purposes of reporting the information on dental services,
unduplicated means that each child is counted once for each line of data
requested. For 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 fee-forservice
and managed care arrangements. Lines 12b and 12c do not equal to total
services reflected on line 12a.
	 
	 	 	Line 13 — Total Eligibles Enrolled in Managed Care - This number is
reported for informational purposes only. This number represents all
individuals eligible for EPSDT (CHCUP) services in the plan who were
enrolled at any time during the reporting year. These individuals should
be included in the total number of unduplicated eligibles on line 1 and
the number of initial or periodic screenings provided to these
individuals should be included in lines 6 and 8 for purposes of
determining the state’s screening and participation rates. The number of
individuals referred for corrective treatment and receiving dental
services should be reflected in lines 11 and 12, respectively.
	 
	 	 	Do not count your MediKids populations.
	 
	 	 	Line 14 — Total Number of Screening Blood Lead Tests - Enter the total
number of screening blood lead tests furnished to eligible individuals
enrolled in your plan. Blood lead tests done on persons who have been
diagnosed or treated for lead poisoning should not be counted. This is a
required element. Do not make entries in the shaded columns.
	 
	 	 	To report number of screening blood lead tests do the following: Count the
number of times CPT code 83655 (“lead”) or any state-specific (local)
codes including W9979 used for a blood lead tests 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 for those who have not been previously
screened for lead poisoning.

AHCA Contract No. FA523, Attachment I, Page 101 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Table 10.
Sample of Child Health Check-Up Reporting
Template

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Enter Data in Blue Colored Out-Lined
Cells
Only	 	 	 	 
	 	 	 	 	CHILD HEALTH CHECK-UP REPORT (CHCUP)
	 	 
	 	 	Seven Digit Medicaid Provider Number:	 	 	 	 	 	I This report is due to the Agency no later
	 	than January
	 	15.

	 	 	Plan Name	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Federal Fiscal Year :
	 	 	 	 	 	 	 	 	 	 	 	 	 	The Audited Report
	 	 	 	 	Age Groups	 	 	 	 	 	 	 	 	 	 	 	is due October
	 	1.

	 	 	 	 	-	 	 	 	-	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Less than 1 Year
	 	1-2 Years *
	 	3-5Years
	 	6-9 Years
	 	10-14 Years
	 	15-18 Years
	 	19-20 Years
	 	Total All Years

	 
	 	otal Individuals Eligible for CHCUP	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	1
	 	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.
	 	nnualized State Periodicity Schedule	 	6.00	 	2.00	 	1.00	 	0.50	 	1.00	 	1.00	 	1.00	 	1.24
	3a.
	 	otal Months of Eligibility	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	3b.
	 	verage Period of Eligibility	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	4.
	 	Expected Number of screenings per Eligible	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	5.
	 	Expected Number of screenings	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	6.
	 	otal Screens Received	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	7.
	 	Screening Ratio	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	otal Eligible who should receive at least one	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	8
	 	Initial or periodic screening	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	9.
	 	otal Eligibles receiving at least one Initial or	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	periodic screen (Undu . licated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	10.
	 	Participation Ratio	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	otal eligibles referred for corrective	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	11.
	 	reatment (Unduplicated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12a.
	 	otal Eligibles receiving any dental services	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	(Unduplicated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

AHCA Contract No. FA523, Attachment I, Page 102 of 166

AHCA Form 2100 - 0003
(Rev. APR 04)

 

 

Exhibit 10.25

	 	 	 	 
	July 2004	
Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Total Eligibles receiving preventative dental	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12b.
	 	services (Unduplicated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Total Eligibles receiving dental treatment	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	12C.
	 	services (Unduplicated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	13.
	 	Total Eligibles Enrolled in Plan	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	14.
	 	Total number of Screening Blood Lead Tests	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	*	 	Includes 12-month visit

AHCA Contract No. FA523, Attachment I, Page 103 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	Table l 1. Child Health Check-Up Report — Florida 60 % Screening
Ratio Template Filing Instructions

This report is due by January 15"' following the end of the reporting
period. The reporting period is from October 1 through September 30. The
Agency will supply a reporting template that includes all formulas already
entered. By October 1 of the following year, the plan shall deliver to the
Agency a certification by an Agency approved independent auditor that the
Child Health Checkup data has been fairly and accurately presented.

Detailed Instructions: 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.

Plan Name:Enter the name of the
managed health care plan.

Fiscal Year: Enter the Federal Fiscal year being reported. Example: October
1, 1999 — September 30, 2000 would be Federal fiscal year 1999-2000.

Line I — Total Individuals Eligible for Child Health Check-Up (EPSDT): Enter
the total unduplicated number of all individuals under the age of 21
enrolled in the health plan continuously for 8 months, distributed by age
and by basis of Medicaid eligibility. Unduplicated means that an eligible
person is reported only once although he or she may have had more than one
period of eligibility during the year. Medicaid eligible individuals under
age 21 are considered eligible for EPSDT (CHCUP) services, regardless of
whether they have been informed about the availability of EPSDT services or
whether they accept EPSDT (CHCUP) services at the time of the informing.
Do not count your 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 individuals in each age group in Line 1 during the reporting year.

Line 3b — Average Period of 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 individuals 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 Line3 b. This number reflects the expected number
of initial or periodic screenings per child per year based on the number
required by the state-specific periodicity schedule and the average period
of eligibility.

Line S — 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 eligible individuals in Line 1.

Line 6 — Total Screenings Received - Enter the total number of initial or
periodic screens furnished to eligible individuals under managed care
arrangements. Use the CPT codes listed below or any plan-specific EPSDT
(CHCUP) codes the plan may have developed for these screens. Use of these
proxy codes is for reporting purposes only. Plans must continue to ensure
that all five age-appropriate elements of an EPSDT (CHCUP) screen, as
defined by law, are provided to EPSDT (CHCUP) recipients.

NOTE: 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” EPSDT
(CHCUP) screening. (A catch-up EPSDT

AHCA Contract No. FA523, Attachment I, Page 104 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

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 furnished under capitated
arrangements. The codes to be used to document the receipt of an initial or
periodic screen are as follows:

	 	 	Medicaid locally assigned procedure code W9881
	 
	 	 	CPT-4 codes 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)

99385 New Patient (ages
18-39 years)

99391 Established
patient under one year

99392 Established patient (ages 1-4
years)

99393 Established patient
(ages 5-1 ]years)

99394 Established patient (ages 12-17
years)

99395 Established patient
(ages 18-39 years)

99431 Newborn
care (history and examination)

99432 Normal newborn care

99435 Newborn Care (history and examination)

or

	 	 	CPT-4 Codes, Evaluation and Management Codes

99201-99205 New
Patient

99211-99215 Established Patient

Note: These CPT-4 Codes must be used in conjunction with V codes
V20-V20.2 and/or V70.0 and/or V70.3-V70.9.

Do not count your MediKids population who have had a check-up.

Line 7-Screenin2
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 EPSDT (CHCUP) eligibles 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.

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AHCA Contract No. FA523, Attachment I, Page 105 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Table 11. Sample of Child Health Check-Up Report -Florida 60% Screening Ratio

Template

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Enter Data in Blue Colored Out-lined Cells
	 	CHILD HEALTH CHECKUP REPORT (EPSDT) 60% Screening Ratio

	 	 	Seven Digit Medicaid Provider ID	 	 	 	 	 	This report is due to the
	 	A enc no later than January.
	 	 
	 	 	Number :
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	This report reflects only those
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	eligibles that have at least 8

	 	 	Plan Name :
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	409.912(26),
	 	months of continuous
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	enrollment

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	!;

	_
	 	Federal Fiscal Year :
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Age Groups	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Less than 1 Year
	 	1-2 Years *
	 	[I 3-5 Years
	 	6-9Years
	 	10-14 Years
	 	15-18Years
	 	19-20 Years
	 	Total All Years

	 	 	a	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	Total Individuals Eligible for EPSDT	 	 	 	 	 	[ EE	 	 	 	 	 	 	 	 	 	 
	 
	 	(Unduplicated)	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	2a.
	 	State Periodicity Schedule	 	6	 	4	 	E 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	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

AHCA Contract No. FA523, Attachment I, Page 106 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	 	 
	 
	 	 	
	 
	6. Total Screens Received
	 	 	 	 
	

	 	 	
	 
	7. Screening Ratio — F.S. 409.912(26)
	 	 	 	 

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AHCA Contract No. FA523, Attachment I, Page 107 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	60.2.10	 	AHCA Quality Indicators

	 	 	Completion of AHCA Quality Indicators
	 
	 	 	The AHCA Quality Indicators will be calculated for each calendar
year; that is from January 1 through December 31. The AHCA Quality
Indicators are due by October 1 subsequent to the measurement year.
	 
	 	 	The measures will constitute a subset of the HEDIS and will be based
on the current recommendation of the National Committee for Quality
Assurance (NCQA) for Medicaid HMO HEDIS reporting. Detailed
instructions and valuable information for calculating these measures
can be found in the HEDIS documentation available from NCQA. Technical
specification for the quality indicators can be found in the current
HEDIS Technical Specifications Manual available from the National
Committee for Quality Assurance, 2000 L Street NW, Suite 500,
Washington, DC 20036. (800) 839-6487.
	 
	 	 	Plans shall refer to and comply with Rule Chapter 59B-13, Florida
Administrative Code, for reporting instructions regarding the
report format, electronic reporting and other information
pertaining to Medicaid membership reporting for these quality
indicators.
	 
	 	 	Do not include Florida Healthy Kids or MediKids with your Medicaid
data for the AHCA Quality Indicators.
	 
	60.2.11	 	Frail/Elderly Care Service Utilization Reporting (F***YYQ*.dbf)
	 
	 	 	Any plan that operates an Agency-approved Frail Elder expanded
benefit must submit recipient-specific service utilization data in
the electronic format specified below. The services reported
represent the comprehensive array of services that might be necessary
to maintain a member at home while avoiding nursing home placement,
including acute and long-term care services.
	 
	 	 	These reports must be provided as ASCII, fixed length text files, with
two files, per recipient, per month. There will be one file for
long-term care services and one file for acute care services. For
example, if a recipient were enrolled for an entire quarter, you would
have three separate records in each of two separate files that are
submitted once for the entire quarter. These two files, the LTC
Services file and the Acute Care Services file, must be submitted once
every quarter to your DOEA/AHCA contract manager. You will have up to
three months after the last month in a specific quarter to submit the
quarterly report.
	 
	 	 	Right justify all fields unless noted otherwise. For amount paid,
include the sum of Medicaid and Medicare crossover claims (deductibles
and co-pays for Medicare claims).* If you have questions about the
definitions of these services please reference the appropriate Medicaid
coverage and limitations handbook for Medicaid state plan services.
Note: Please do not use commas between fields. Round currency to the
nearest dollar amount.

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AHCA Contract No. FA523, Attachment I, Page 108 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

FILE 1: Long-Term Care Services

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	Field	 	Start	 	 	 	 
	Field Name
	 	Description
	 	Unit of Measurement
	 	Length
	 	Col.
	 	End Col.
	 	Text/Numeric

	SSN

	 	Social Security Number (left justify)
	 	 	000000000	 	 	 	9	 	 	 	1	 	 	 	9	 	 	Numeric
	MEDICAID

	 	Medicaid ID Number
	 	 	0000000000	 	 	 	10	 	 	 	10	 	 	 	19	 	 	Numeric
	ENROL

	 	Initial Date of Program Enrollment
	 	MMYYYY
	 	 	6	 	 	 	20	 	 	 	25	 	 	Numeric
	DISENROL

	 	Date of Disenrollment, if Applicable
	 	MMYYYY
	 	 	6	 	 	 	26	 	 	 	31	 	 	Numeric
	REINST

	 	Reinstate date
	 	MMYYYY
	 	 	6	 	 	 	32	 	 	 	37	 	 	Numeric
	ALF

	 	ALF Resident Indicator
	 	1=Yes;2=No
	 	 	1	 	 	 	38	 	 	 	38	 	 	Numeric
	MONTH

	 	Report Month
	 	MMYYYY
	 	 	6	 	 	 	39	 	 	 	44	 	 	Numeric
	LTC

SERVICES

	 	DESCRIPTION
	 	UNIT OF SERVICE/

COST
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	ADCOMP

	 	Adult Companion Services
	 	15 Minute Unit
	 	 	4	 	 	 	45	 	 	 	48	 	 	Numeric
	ADAYHLTH

	 	Adult Day Health Services
	 	15 Minute Unit
	 	 	4	 	 	 	49	 	 	 	52	 	 	Numeric
	ALFSVS

	 	Assisted Living Services
	 	Days
	 	 	2	 	 	 	53	 	 	 	54	 	 	Numeric
	ALFSVS$$

	 	Assisted Living Services
	 	Amount Paid
	 	 	6	 	 	 	55	 	 	 	60	 	 	Numeric
	ATTCARE

	 	Attendant Care Services
	 	15 Minute Unit
	 	 	4	 	 	 	61	 	 	 	64	 	 	Numeric
	CASEAID

	 	Case Aide
	 	15 Minute Unit
	 	 	4	 	 	 	65	 	 	 	68	 	 	Numeric
	CASEMGMT

	 	Case Management (Internal
	 	15 Minute Unit
	 	 	4	 	 	 	69	 	 	 	72	 	 	Numeric
	CHORE

	 	Chore Services
	 	15 Minute Unit
	 	 	2	 	 	 	73	 	 	 	74	 	 	Numeric
	COM_MH

	 	Community Mental Health
	 	Visit
	 	 	2	 	 	 	75	 	 	 	76	 	 	Numeric
	CNMS_$$

	 	Consumable Medical Supplies
	 	Amount Paid
	 	 	6	 	 	 	77	 	 	 	82	 	 	Numeric
	COUNSEL

	 	Counseling
	 	15 Minute Unit
	 	 	4	 	 	 	83	 	 	 	86	 	 	Numeric
	DME_$$

	 	Durable Medical Equipment
	 	Amount Paid
	 	 	6	 	 	 	87	 	 	 	92	 	 	Numeric
	ENVIRAA

	 	Environmental Accessibility Adaptations
	 	Job
	 	 	2	 	 	 	93	 	 	 	94	 	 	Numeric
	ESCORT

	 	Escort Services
	 	15 Minute Unit
	 	 	4	 	 	 	95	 	 	 	98	 	 	Numeric
	FAMT_I

	 	Family Training Services (Individual)
	 	15 Minute Unit
	 	 	2	 	 	 	99	 	 	 	100	 	 	Numeric
	FAMT_G

	 	Family Training Services (Group)
	 	15 Minute Unit
	 	 	2	 	 	 	101	 	 	 	102	 	 	Numeric
	FINARRS

	 	Financial Assessment/Risk Reduction

Services
	 	15 Minute Unit
	 	 	4	 	 	 	103	 	 	 	106	 	 	Numeric
	FINM_RRS

	 	Financial Maintenance/Risk Reduction

Services
	 	15 Minute Unit
	 	 	4	 	 	 	107	 	 	 	110	 	 	Numeric
	HDMEAL

	 	Home Delivered Meals
	 	Meal
	 	 	2	 	 	 	111	 	 	 	112	 	 	Numeric
	HOMESRVS

	 	Homemaker Services
	 	15 Minute Unit
	 	 	4	 	 	 	113	 	 	 	116	 	 	Numeric
	MH_CM

	 	Mental Health Case Management
	 	15 Minute Unit
	 	 	4	 	 	 	117	 	 	 	120	 	 	Numeric
	SNF

	 	Nursing Facility Services- Long-term
	 	Days
	 	 	2	 	 	 	121	 	 	 	122	 	 	Numeric
	NUTR_RRS

	 	Nutritional Assessment/Risk Reduction

Services
	 	15 Minute Unit
	 	 	4	 	 	 	123	 	 	 	126	 	 	Numeric
	OT

	 	Occupational Therapy
	 	15 Minute Unit
	 	 	4	 	 	 	127	 	 	 	130	 	 	Numeric
	PCS

	 	Personal Care Services
	 	15 Minute Unit
	 	 	4	 	 	 	131	 	 	 	134	 	 	Numeric
	PERS_I

	 	Personal Emergency Response System

Installation
	 	Job
	 	 	2	 	 	 	135	 	 	 	136	 	 	Numeric
	PERS_M

	 	Personal Emergency Response System -
	 	Day
	 	 	2	 	 	 	137	 	 	 	138	 	 	Numeric

AHCA Contract No. FA523, Attachment I, Page 109 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Field	 	Start	 	 	 	 
	Field Name
	 	Description
	 	Unit of Measurement
	 	Length
	 	Col.
	 	End Col.
	 	Text/Numeric

	

	 	Maintenance	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	PEST_I

	 	Pest Control — Initial Visit
	 	Job
	 	 	2	 	 	 	139	 	 	 	140	 	 	Numeric
	PEST_M

	 	Pest Control — Maintenance
	 	Month
	 	 	1	 	 	 	141	 	 	 	141	 	 	Numeric
	PT

	 	Physical Therapy
	 	15 Minute Unit
	 	 	4	 	 	 	142	 	 	 	145	 	 	Numeric
	RISKREDU

	 	Physical Risk Assessment and Reduction
	 	15 Minute Unit
	 	 	4	 	 	 	146	 	 	 	149	 	 	Numeric
	PRIVNURS

	 	Private Duty Nursing Services
	 	15 Minute Unit
	 	 	4	 	 	 	150	 	 	 	153	 	 	Numeric
	PT_R

	 	Registered Physical Therapist
	 	Visit
	 	 	2	 	 	 	154	 	 	 	155	 	 	Numeric
	RSPTH

	 	Respiratory Therapy
	 	15 Minute Unit
	 	 	4	 	 	 	156	 	 	 	159	 	 	Numeric
	RESP_HM

	 	Respite Care — In Home
	 	15 Minute Unit
	 	 	4	 	 	 	160	 	 	 	163	 	 	Numeric
	RESP_FAC

	 	Respite Care — Facility-Based
	 	Days
	 	 	2	 	 	 	164	 	 	 	165	 	 	Numeric
	NURSE

	 	Skilled Nursing
	 	Visit
	 	 	4	 	 	 	166	 	 	 	169	 	 	Numeric
	SPTH

	 	Speech Therapy
	 	15 Minute Unit
	 	 	4	 	 	 	170	 	 	 	173	 	 	Numeric
	TRANSPOR

	 	Transportation Services (not included in Escort

or Adult Day Health services)
	 	Trips
	 	 	3	 	 	 	174	 	 	 	176	 	 	Numeric
	OTH_UNIT

	 	Other LTC Service not listed (unit)
	 	Unit/ Visit
	 	 	6	 	 	 	177	 	 	 	182	 	 	Numeric
	DESCR_1

	 	Description of other LTC service
	 	 	 	 	35	 	 	 	183	 	 	 	217	 	 	Text
	OTH_$$

	 	Other LTC service not listed (amount)
	 	Amount Paid
	 	 	6	 	 	 	218	 	 	 	223	 	 	Numeric
	DESCR_2

	 	Description of other LTC service
	 	 	 	 	35	 	 	 	224	 	 	 	258	 	 	Text

File 2: Acute Care Services

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	Field	 	Start	 	 	 	 
	Field Name
	 	Description
	 	Unit of Measurement
	 	Length
	 	Col.
	 	End Col.
	 	Text/Numeric

	ACUTE

	 	 	 	UNITS OF SERVICE/
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SERVICES

	 	DESCRIPTION
	 	COST
	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSN

	 	Social Security Number (left justify)
	 	 	000000000	 	 	 	9	 	 	 	1	 	 	 	9	 	 	Numeric
	MEDICAID

	 	Medicaid ID Number
	 	 	0000000000	 	 	 	10	 	 	 	10	 	 	 	19	 	 	Numeric
	MONTH

	 	Report Month
	 	MMYYYY
	 	 	6	 	 	 	20	 	 	 	25	 	 	Numeric
	CLINIC

	 	Clinic Services
	 	Visit
	 	 	2	 	 	 	26	 	 	 	27	 	 	Numeric
	CLINIC$$

	 	Clinic Services Costs
	 	Visit
	 	 	2	 	 	 	28	 	 	 	29	 	 	Numeric
	DENTAL

	 	Dental Services
	 	Visit
	 	 	6	 	 	 	30	 	 	 	35	 	 	Numeric
	DENTAL$$

	 	Dental Services Costs
	 	Amount Paid
	 	 	6	 	 	 	36	 	 	 	41	 	 	Numeric
	DIALYSIS

	 	Dialysis Center
	 	Visit
	 	 	2	 	 	 	42	 	 	 	43	 	 	Numeric
	DIALYS$$

	 	Dialysis Center Costs
	 	Amount Paid
	 	 	6	 	 	 	44	 	 	 	49	 	 	Numeric
	ER

	 	Emergency Room Services
	 	Visit
	 	 	2	 	 	 	50	 	 	 	51	 	 	Numeric
	ER_$$

	 	Emergency Room Services Costs
	 	Amount Paid
	 	 	6	 	 	 	52	 	 	 	57	 	 	Numeric
	FQHC

	 	FQHC Services
	 	Visit
	 	 	2	 	 	 	58	 	 	 	59	 	 	Numeric
	FQHC_$$

	 	FQHC Services Costs
	 	Amount Paid
	 	 	6	 	 	 	60	 	 	 	65	 	 	Numeric
	HEAR

	 	Hearing Services including hearing aids
	 	Amount Paid
	 	 	6	 	 	 	66	 	 	 	71	 	 	Numeric

AHCA Contract No. FA523, Attachment I, Page 110 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Field	 	Start	 	 	 	 
	Field Name
	 	Description
	 	Unit of Measurement
	 	Length
	 	Col.
	 	End Col.
	 	Text/Numeric

	INPTSVS

	 	Inpatient Hospital Services
	 	Day
	 	 	3	 	 	 	72	 	 	 	74	 	 	Numeric
	INPTSV$$

	 	Inpatient Hospital Services Costs
	 	Amount Paid
	 	 	6	 	 	 	75	 	 	 	80	 	 	Numeric
	LAB

	 	Independent Laboratory or Portable X-ray

Services
	 	Amount Paid
	 	 	6	 	 	 	81	 	 	 	86	 	 	Numeric
	ARNP

	 	Nurse Practitioner Services
	 	Visit
	 	 	2	 	 	 	87	 	 	 	88	 	 	Numeric
	ARNP_$$

	 	Nurse Practitioner Services Costs
	 	Amount Paid
	 	 	6	 	 	 	89	 	 	 	94	 	 	Numeric
	RX_$$

	 	Pharmaceuticals
	 	Amount Paid
	 	 	6	 	 	 	95	 	 	 	100	 	 	Numeric
	PA

	 	Physical Assistant
	 	Visit
	 	 	2	 	 	 	101	 	 	 	102	 	 	Numeric
	PA_$$

	 	Physical Assistant Costs
	 	Amount Paid
	 	 	6	 	 	 	103	 	 	 	108	 	 	Numeric
	MD

	 	Physician Services
	 	Visit
	 	 	2	 	 	 	109	 	 	 	110	 	 	Numeric
	MD_$$

	 	Physician Services Costs
	 	Amount Paid
	 	 	6	 	 	 	111	 	 	 	116	 	 	Numeric
	OUTPT

	 	Outpatient Hospital Services
	 	Encounter
	 	 	3	 	 	 	117	 	 	 	119	 	 	Numeric
	OUTPT_$$

	 	Outpatient Hospital Services Costs
	 	Amount Paid
	 	 	6	 	 	 	120	 	 	 	125	 	 	Numeric
	PODIATRY

	 	Podiatry
	 	Visit
	 	 	2	 	 	 	126	 	 	 	127	 	 	Numeric
	PODIAT$$

	 	Podiatry Costs
	 	Amount Paid
	 	 	6	 	 	 	128	 	 	 	133	 	 	Numeric
	RURAL

	 	Rural Health Services
	 	Visit
	 	 	2	 	 	 	134	 	 	 	135	 	 	Numeric
	RURAL$$

	 	Rural Health Services Costs
	 	Amount Paid
	 	 	6	 	 	 	136	 	 	 	141	 	 	Numeric
	SNFREHA$

	 	Skilled nursing facility services-

rehabilitation**
	 	Amount Paid
	 	 	6	 	 	 	142	 	 	 	147	 	 	Numeric
	EYE_$$

	 	Visual Services including eyeglasses
	 	Amount Paid
	 	 	6	 	 	 	148	 	 	 	153	 	 	Numeric
	OTH_UNIT

	 	Other Acute Service not listed (unit)
	 	Unit/ Visit
	 	 	6	 	 	 	154	 	 	 	159	 	 	Numeric
	DESCR_1

	 	Description of other Acute service
	 	 	 	 	35	 	 	 	160	 	 	 	194	 	 	Text
	OTH_$$

	 	Other Acute service not listed (amount)
	 	Amount Paid
	 	 	6	 	 	 	195	 	 	 	200	 	 	Numeric
	DESCR_2

	 	Description of other Acute service
	 	 	 	 	35	 	 	 	201	 	 	 	235	 	 	Text

**Medicare crossovers are amounts that are billed to Medicaid for
those Medicaid clients who are also eligible for Medicare.

THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 111 of 166

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	60.2.12	 	Financial Reporting

GENERAL INFORMATION, DEFINITIONS AND INSTRUCTIONS

The plan is required to submit to the agency annual audited
financial statements and four quarterly unaudited financial
statements.

The audited financial statements are due no later than three calendar
months after the end of the provider’s fiscal year. The Agency will
accept audited financial statements that have been prepared in
conformity with accounting practices prescribed or permitted by the
Department of Financial Services. The accountant preparing the audited
financial statements must be an independent certified public accountant.
The unaudited quarterly financial statements are to be prepared on a
GAAP basis and are due no later than 45 days after the calendar quarter
and shall include a: Balance Sheet, Statement of Revenues and Expenses,
and Statement of Changes in Financial Position and Net Worth. These
financial statements shall be filed on diskette, or by Internet e-mail
to MMCFINcei FDHC.STATE.FL. US using the agency supplied spreadsheet
template.

Annual and quarterly financial statements shall be specific to the
operation of the Medicaid HMO rather than to a parent or umbrella
organization. If the HMO is under a guarantee agreement, which was
approved by the Agency, then the HMO must also file an audited
financial statement of the guaranteeing organization, which reflects
twelve months of operation.

The financial template contains the following (sheets/tabs):

Master sheet — this is the balance sheet, consolidated revenue
and expense statement and changes in financial position. This
statement reflects four (4) quarters plus fiscal year totals.

	 	1.	 	Enrollment — consists of quarterly enrollment detailed by county, and
product line.
	 
	 	2.	 	Profit and Loss — tracks operational performance by product line.
	 
	 	3.	 	Aggregate write-in -tracks any information recorded on the
balance sheet or profit and loss statements, which needs further
explanation.
	 
	 	4.	 	Jurat — shows the plan name, plan address, telephone number, etc.
	 
	 	5.	 	Claims and IBNR-provides an aging schedule of claims by quarter and
product line.
	 
	 	6.	 	FQHC/RHC- Federally Qualified Health Centers and Rural
Health Clinics summary information.

BALANCE SHEET

	 	1.	 	Cash and equivalents — Cash in the bank or on hand, available for
current use.
	 
	 	2.	 	Short-Term Investments — Readily saleable investments
acquired with temporarily unneeded cash. Does not include
restricted securities.
	 
	 	3.	 	Premiums Receivable — Net — Gross amounts collectible
from groups or individuals who receive from the plan, less the
amount accrued from premiums determined to be uncollectible for
the period.
	 
	 	4.	 	Interest Receivable — Interest earned on investments but not
received.

AHCA Contract No. FA523, Attachment I, Page 112 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	5.	 	Other Receivables — Net — Gross amounts collectible from
sources other than plan members or groups, less the amount
accrued for receivables determined to be uncollectible during
the period. Example: fee-for-service. This should not include
restricted receivables.
	 
	 	6.	 	Prepaid Expenses — Future expenses paid in advance such as unexpired
insurance.
	 
	 	7.	 	Aggregate Write-ins For Current Assets — Show non-restricted
current assets, including inventories, not included in the other
Current Assets categories.
	 
	 	8.	 	Total Current Assets — Sum total of all current assets.
	 
	 	9.	 	Restricted Funds — Assets held for contract (i.e., Medicaid)
grants, reserves including cash, securities, receivables, other,
etc.
	 
	 	10.	 	Loan Escrow — Funds for which loan notes have been signed
by the provider but not drawn down. Funds may be held by the
provider or an escrow agent.
	 
	 	11.	 	Long-Term Investments — Investments held for a period longer than
twelve months.
	 
	 	12.	 	Intangible Assets and Goodwill — Net — Assets of no physical
substance. These may include patents, copyrights, licenses, and
franchises. Provide gross amount less amortization.
	 
	 	13.	 	Aggregate Write-ins for other Assets — Show non-current
assets not included in the Other Assets categories.
	 
	 	14.	 	Total Other Assets — Sum total of all other assets.
	 
	 	15.	 	Land — Real estate owned by the plan.
	 
	 	16.	 	Buildings & Improvements — Buildings owned by the plan and
improvements made to provider-owned buildings.
	 
	 	17.	 	Construction in Progress — Buildings or improvements in
progress or under construction. These will be capitalized upon
completion or utilization.
	 
	 	18.	 	Furniture and Equipment — Includes medical equipment, office
equipment and furniture owned by the plan.
	 
	 	19.	 	Aggregate Write-ins for Other Equipment — Include automobiles,
fixtures and other fixed assets not reported in other Property and
Equipment categories.
	 
	 	20.	 	Total Property and Equipment — Net — Total of Property and
Equipment categories, less Accumulated Depreciation — the cumulative
amount of depreciation on property and equipment. Depreciation is an
accounting practice recognizing the consumption of the value of a
fixed asset during the asset’s useful life. Depreciation expenses are
charged to the expense categories representing the cost center to
which the fixed asset is assigned.
	 
	 	21.	 	Total Assets — Total of Current Assets, Other Assets and Net Property
and Equipment.
	 
	 	1.	 	Accounts Payable — Amounts due to creditors for the
acquisition of goods and services (trade and vendors rather than
health care providers) on a credit basis.
	 
	 	2.	 	Claims Payable (Reported) — Claims reported and booked as payables.

AHCA Contract No. FA523, Attachment I, Page 113 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	3.	 	Accrued Inpatient Claims (Not reported) — Hospital and institutional
care claims incurred but not reported and/or booked as payables.
	 
	 	4.	 	Accrued Physician Claims (Not reported) — Claims
incurred but not reported and/or booked as payables for
physicians and ancillary (such as lab and x-ray) services by
providers under an arrangement with the HMO. These may include
capitation payments to medical groups or fees to IPAs.
	 
	 	5.	 	Accrued Referral Claims (Not reported) — Claims incurred
but not reported and/or booked as payables for consultants and
referrals to providers outside a plan arrangement. These claims
are usually paid on a fee-for-service basis.
	 
	 	6.	 	Accrued Other Medical (Not Reported) — Other incurred
medical expenses but not reported and/or booked as payables
including emergency room, out-of-area services, payroll, etc.
	 
	 	7.	 	Accrued Provider Incentive Pool — Accruals for withholds
from IPAs or capitated medical groups and other such
arrangements in which the provider may return incentive funds to
plans.
	 
	 	8.	 	Unearned Premiums — Income received or booked in advance
of the period to which it applies. A liability exists to render
service in the future.
	 
	 	9.	 	Loans and Noted Payable — Current — The principal amount on loans due
within one year.
	 
	 	10.	 	Aggregate Write-Ins for Current Liabilities — Show current
liabilities not included in other Current Liabilities categories;
include accrued payroll and taxes.
	 
	 	11.	 	Total Current Liabilities — Total of Current Liability Categories.
	 
	 	12.	 	Loans and Notes — Loans and notes signed by the plan not
including current portion payable. Includes federal loans.
	 
	 	13.	 	Statutory Liability — Reserve required as a
liability by statute (e.g., government purchaser
requirements).
	 
	 	14.	 	Aggregate Write-ins for Other Liabilities — Show other liabilities of
a long-term nature.
	 
	 	15.	 	Total Other Liabilities — Total of Other Liability Categories.
	 
	 	16.	 	Total Liabilities — Sum of current and other liabilities.
	 
	 	17.	 	Contributed Capital — Capital donated to an organization.
	 
	 	18.	 	Common
Stock-Ordinary capital
            shares of the corporation.
	 
	 	19.	 	Preferred Stock- Stock having priority over the corporation’s common
stock.
	 
	 	20.	 	Paid in Surplus — Amount over stated value of Line 17.
Reflects actual amount in excess of par or stated value.
	 
	 	21.	 	Unassigned Surplus — Unassigned Retained Earnings. Cumulative
earnings or deficit from operations, net of reserves and restricted
funds.
	 
	 	22.	 	Aggregate Write-ins for Other Net Worth Items — May
include statutory reserves, subordinated debt, and accrued
interest on subordinated debt.
	 
	 	23.	 	Total Net Worth — Total Assets minus Total Liabilities.

AHCA Contract No. FA523, Attachment I, Page 114 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	24.	 	Total Liabilities and Net Worth — Total liabilities plus net worth, Details
of Write-ins Aggregated for Other

Net Worth Items -

STATEMENT OF REVENUES, EXPENSES AND NET WORTH

	 	1.	 	Premium — Revenue recognized on a prepaid basis from
individuals and groups for provision of a specified range of
health services over a defined period of time, normally three
months. Premium shall be separated by line of business, such as
Commercial, Medicaid and Medicare.
	 
	 	2.	 	Fee-for-Service — Revenue recognized by the plan entity for
provision of health services to non-members by plan providers and
to members through provision of health services excluded from their
prepaid benefit packages.
	 
	 	3.	 	Copayments — Revenue recognized by the plan entity from plan
members on a utilization related basis for certain health services
included in the HMO benefit package.
	 
	 	4.	 	Title XVIII — Medicare — Revenue as a result of an
arrangement between a provider and the Centers for Medicare and
Medicaid Services for services to a Medicare beneficiary.
	 
	 	5.	 	Title XIX — Medicaid — Revenue as a result of an arrangement
between a plan and a Medicaid State Agency for services to a
Medicaid beneficiary.
	 
	 	6.	 	Interest — Interest earned from all sources, including the federal loan
in escrow and reserve accounts.
	 
	 	7.	 	C.O.B. and Insurance Recoveries — Income from Coordination of Benefits
and insurance recoveries.
	 
	 	8.	 	Reinsurance Recoveries — Income from the settlement of stop-loss
(reinsurance) claims.
	 
	 	9.	 	Aggregate write-ins- Revenue from sources not covered in the
previous revenue accounts, such as recovery of bad debts or gain on
sales of capital assets, etc.
	 
	 	10.	 	Total Revenue — Total of the revenue accounts.
	 
	 	11.	 	Physician Services — Expenses for physician services provided
under contractual arrangement to the plan including the following:
salaries, including fringe benefits, paid to physicians for delivery
of medical services; capitated payments paid by the plan to
physicians for delivery of medical services to plan subscribers; and
fees paid by the plan to physicians on a fee-for-service basis for
delivery of medical services to plan subscribers. .
	 
	 	12.	 	Other Professional Services — Compensation, including fringe
benefits, paid by the plan to non-physician providers engaged in the
delivery of medical services and to personnel engaged in activities
in direct support of the provision of medical services. This
includes dentists, psychologists, optometrists, podiatrists,
extenders, nurses, clinical personnel such as ambulance drivers,
technicians, paraprofessionals, janitors, quality improvement
analysts, administrative supervisors, secretaries to medical
personnel, and medical records clerks.
	 
	 	13.	 	Outside Referrals — Expenses for providers not under provider
arrangement such as consultations.
	 
	 	14.	 	Emergency Room, Out-of-Area, Other — Expenses for other
non-contracted health delivery services incurred by plan members for
which the plan is responsible on a fee-for-service basis. These
include emergency room costs and out-of-area emergency physician and
hospital costs.

AHCA Contract No. FA523, Attachment I, Page 115 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	15.	 	Occupancy, Depreciation and Amortization — Expenses associated with
medical services including the amount of depreciation and
amortization expense which is directly associated with the delivery
of medical services. The costs of occupancy to the plan which are
directly associated with the delivery of medical services. Included
in occupancy are costs of using a facility, fire and theft insurance,
utilities, maintenance, lease, etc.
	 
	 	16.	 	Inpatient — Inpatient hospital costs of routine and ancillary
services for plan members while confined to an acute care hospital.
Does not include out-of-area hospitalization.
	 
	 	 	 	Routine hospital service includes regular room and board (including
intensive care units, coronary care units, and other special inpatient
hospital units), dietary and nursing services, medical and surgical
supplies, medical social services, and the use of certain equipment and
facilities for which the plan does not customarily make a separate
charge.
	 
	 	 	 	Ancillary services may also include laboratory, radiology, drugs,
delivery room and physical therapy services. Ancillary services may
also include other special items and services for which charges are
customarily made in addition to routine service charges. Charges for
non-plan physician services provided in a hospital are included in this
line item only if included as an unidentified portion of charges by a
hospital to the plan. (If separately itemized or billed, physician
charges must be included in referrals, above.) Include the cost of
utilizing skilled nursing and intermediate care facilities. Skilled
nursing facilities are primarily engaged in providing skilled nursing
care and related services for patients who require medical or nursing
care or rehabilitation service. Intermediate care facilities are for
individuals who do not require the degree of care and treatment which a
hospital or nursing care facility provides, but do not require care and
services above the level of room and board.
	 
	 	17.	 	Reinsurance Expenses — Expenses for Reinsurance or “stop-loss”
insurance.
	 
	 	18.	 	Other Medical — Costs directly associated with the delivery
of medical services under plan arrangement that are not
appropriately assignable to the medical expense categories
defined above, e.g., costs of medical supplies, medical
administration expense (except compensation), malpractice
insurance, etc.
	 
	 	19.	 	Incentive Pool Adjustment — A contra category for adjusting
the full medical expenses reported. For example, physician withholds
or hospital volume discounts returned by or to the provider should
be included here. Adjustments should be made on the annual report
only.
	 
	 	20.	 	Total Medical and Hospital — Total of the above categories.
	 
	 	21.	 	Compensation — All expenses for administrative services
including compensation and fringe benefits for personnel time devoted
to or in direct support of administration. Include expenses for
management contracts. Do not include marketing expenses. However,
when a management company pays rent, insurance, and other non-salary
or non-commission payments, these amounts should not be reported as
compensation.
	 
	 	22.	 	Interest Expenses — Interest on loans paid during period.
	 
	 	23.	 	Occupancy, Depreciation and Amortization — Expenses
associated with administrative services including the costs of
occupancy to the plan entity which are directly associated with
plan administration. Included in occupancy are costs of using a
facility, fire and theft insurance, utilities, maintenance, lease,
etc. Do not include expenses for marketing in this category.
The amount of depreciation and amortization expense which is directly
associated with administrative services. Depreciation expense is the
incremental consumption of the value of a fixed asset during the
asset’s useful life.

AHCA Contract No. FA523, Attachment I, Page 116 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	24.	 	Marketing — Expenses directly related to marketing activities
including advertising, printing, marketing representative
compensation and fringe benefits, commissions, broker fees,
travel, occupancy, and other expenses allocated to the
marketing activity.
	 
	 	25.	 	Aggregate Write-In- Costs, which are not appropriately
assignable to the health, plan administration categories defined
above. Included are costs to update member records, servicing of
member inquiries and complaints, claims adjudication and payment,
legal, audit, data processing, accounting, insurance, bad debts, all
taxes except federal income taxes, etc.
	 
	 	26.	 	Total Administration — Total of the above categories.
	 
	 	27.	 	Total Expenses — Total of Medicaid and Hospital and Administration
Expenses.
	 
	 	28.	 	Income (Loss) — Total revenues minus total expenses.
	 
	 	29.	 	Extraordinary Item — A non-recurring gain or loss that meets the
following criteria:
	 
	 	 	 	The event must be unusual. It should be highly abnormal and unrelated
to, or only incidentally related to, the ordinary activities of the
entity.
	 
	 	 	 	The event must occur infrequently. It should be of a type that would
not reasonably be expected to recur in the foreseeable future.
	 
	 	 	 	The following gains and losses are specifically not extraordinary:
write-down or write off of accounts receivable, inventory, or
intangible assets: gains or losses from changes in the value of
foreign currency; gains or losses on disposal of a segment of a
business; gains or losses from the disposal of fixed assets; effects
of a strike; and adjustments of accruals on long-term contracts.
	 
	 	30.	 	Provision for taxes — State and federal taxes for period (for-profit
organization only).
	 
	 	31.	 	Net Income (Loss) — Total revenues minus total expenses
less extraordinary items and state and federal taxes.
	 
	 	 	 	STATEMENT OF CHANGES IN FINANCIAL POSITION
AND NET WORTH
	 
	 	 	 	SOURCES: Sources of funds used in operations including
the following: 1. Net
	 
	 	 	 	Income (Loss) — Report the
figure calculated for this line.

Add items not affecting working capital in the current period:
Depreciation amortization and deferred taxes are expenses and
affecting working capital. These expenses are added back.

	 	2.	 	Depreciation and Amortization
	 
	 	3.	 	Deferred Taxes — These are accrued taxes for the
period, which are held for payment to the government during a
later period.
	 
	 	4.	 	Show other expenses not affecting working capital.
	 
	 	 	 	Other Additions to Working Capital: Additions are generally from
borrowing or from liquidating non-current assets and include the
following:
	 
	 	5.	 	Proceeds from borrowing — Additions from borrowing which increase
current asset accounts.
	 
	 	6.	 	Show other additions to working capital.
	 
	 	7.	 	Total Sources of Funds -Total of the above categories.

AHCA Contract No. FA523, Attachment I, Page 117 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	 	 	APPLICATIONS: Uses of Working Capital, usually additions to non-current
assets or reductions in long-term liabilities, including the following:
	 
	 	8.	 	Additions to Property and Equipment — Increase in property and
equipment from last period.
	 
	 	9.	 	Reductions in Long-Term Debt — Decrease in long-term liabilities from
last period.
	 
	 	10.	 	Show other uses of Working Capital.
	 
	 	11.	 	Total Applications of Funds — Total of the above categories.
	 
	 	12.	 	Increase (Decrease) in Working Capital — Excess or
deficiency of sources over applications of Funds.

              NET
WORTH:

	 	13.	 	Net Worth Beginning of Period
	 
	 	14.	 	Increase (Decrease) in Donated Capital
	 
	 	15.	 	Increase (Decrease) in Capital — (Current year less previous year)
	 
	 	16.	 	Increase (Decrease) in Paid in Surplus — (Current year less previous
year)
	 
	 	17.	 	Increase (Decrease) in Reserves and Restricted Funds — (Current year
less previous year)
	 
	 	18.	 	Increase (Decrease) in Unassigned Surplus — (Current year less
previous year)
	 
	 	19.	 	Net Worth End of Period

	60.2.13	 	Minority Business Enterprise Contract Reporting

The Agency for Health Care Administration encourages the Vendor to use
Minority and Certified Minority businesses as subvendors when procuring
commodities or services to meet the requirements of the contract.

The Agency requires information regarding the Vendor’s use of minority
owned businesses as subvendors 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
0), 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).

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.

AHCA Contract No. FA523, Attachment I, Page 118 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	60.2.14	 	Suspected Fraud Reporting

Upon detection of a potentially or suspected fraudulent claim by a
provider, the plan shall file a report to the agency. At minimum, the
report shall contain the name of the provider, the provider number or
the tax identification number, and a description of the suspected
fraudulent act. This report must be sent in narrative fashion to the
plan analyst.

	60.2.15	 	Claims Inventory Summary Report

The plan shall file an aging claim summary report quarterly, noting paid, denied and unpaid claims by
provider type . The plan will submit this report using the CLAIMS
AGING TEMPLATE.xls file supplies by the following email address:
mmcclms@fdhc.state.fl.us.

	60.3	 	Behavioral Health Reporting Requirements

In all AHCA Areas where the plan is capitated for and provides
behavioral health care services, the agency requires additional
quarterly reporting using an agency-supplied template. The template
must be submitted within 45 days of the end of the quarter being
reported. A separate template must be completed and submitted for each
AHCA Area in which the plan provides behavioral health care services.
All data must be compiled by the plan prior to submitting the template.

Failure of the plan to submit required reports accurately and within
the time frames specified may result in penalties in accordance with
Section 70.17, Sanctions of this contract.

The template contains five separate worksheets that must be completed
each quarter. By completing each worksheet within the template, the
plan will provide a summary of service utilization, caseload reports
of targeted case management and intensive team case management, an
report of allocation of recipients, by age and eligibility category,
by provider, and a summary of all critical incidents.

	60.3.1	 	Patient Satisfaction Reporting

In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall conduct a behavioral health patient
satisfaction survey in both English and Spanish by March 1, of each
year.

The plan shall report the results of the survey to the agency by May
15, of each year. The sampling for the survey shall be a statistically
significant sample of each category represented for members having
received behavioral health services during the period reflected in the
report.

	60.3.2	 	Appeals Reporting

In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall include in its quarterly appeals reports, a
sub-listing of all current behavioral health related appeals and the
status of such appeals to the Agency as required in Section 60.2, HMO
Reporting Requirements, of this contract.

	60.3.3	 	Quality Improvement Reporting

In Areas 1 and 6 and upon implementation of prepaid mental health in
other Areas, the plan shall submit to the plan analyst, on a quarterly
basis, a summary of the plan’s behavioral health quality improvement
activities and findings for that quarter, as well as a summary on the
status of any unresolved prior quarter behavioral health care services
issues. In addition, the plan shall include behavioral health quality
improvement activities and reporting as part of the plan’s general
assurance activities as required in Section 20.12, Quality Improvement,
of this contract.

AHCA Contract No. FA523, Attachment I, Page 119 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	60.3.4	 	Inpatient Discharge Reporting

The plan shall report all discharges from acute care hospitals in
Section 60.2.6 Inpatient Discharge report. These discharges are
accompanied by up to three diagnosis codes. The agency will use these
detailed discharge records to evaluate utilization of inpatient
services for behavioral health diagnoses, as well as compare the
utilization patterns and the behavioral health status of members of
contracted plans.

	60.3.5	 	Critical Incident Reporting

In addition to supplying a summary of critical incidents in the
quarterly reporting template, additional critical incident reporting
must be done in the manner prescribed by the appropriate district’s DCF
Alcohol, Drug Abuse Mental Health office, using their reporting forms
and procedures.

	60.3.6	 	Behavioral Health Care Expenditure Report

By April 1 of each year, plans with members in Areas 1 and 6 and upon
implementation of prepaid mental health in other Areas shall provide a
breakdown of expenditures related to the provision of behavioral
health care, using the spreadsheet template provided by the agency.
Pursuant to Section 409.912(3)(b), F.S., 80 percent of the capitation
paid to the plan shall be expended for the provision of behavioral
health care services. In the event the plan expends less than 80
percent of the capitation, the difference shall be returned to the
agency no later than May 1 of each year.

For reporting purposes in accordance with this section, ‘behavioral
health services’ are defined as those services that the Plan is
required to provide as listed in the Community Mental Health Services
Coverage and Limitations handbook and the Targeted Case Management
Coverage and Limitations handbook.

For reporting purposes in accordance with this section ‘expended’
means the total amount, in dollars, paid directly or indirectly to
behavioral health providers solely for the provision of behavioral
health services defined above, not including administrative expenses
or overhead of the plan.

THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 120 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	70.0	 	TERMS AND CONDITIONS

	70.1	 	Agency Contract Management

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
beneficiaries it serves being the prime consideration. The Agency
shall provide final interpretation of general Medicaid policy. When
interpretations are required, the plan shall submit written requests
to the Agency’s contract manager.

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.

	70.2	 	Applicable Laws and Regulations

The 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;
chapter 641, parts I and III, F.S., in regard to managed care; 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 plan is subject to any
changes in federal and state law, rules, or regulations.

	70.3	 	Assignment

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 plan, including
by way of an asset or stock purchase of the plan and shall not be
subject to execution, attachment or similar process by the plan.

	 	a.	 	As provided by section 409.912, F.S., when a merger or
acquisition of a 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
Medicaid HMO contract upon the request of the surviving entity of
the merger or acquisition if the 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 90 days prior to the
anticipated effective date.

AHCA Contract No. FA523, Attachment I, Page 121 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	b.	 	To be in good standing, a plan must not have failed
accreditation or committed any material violation of the
requirements of section 641.52, F.S., and must meet the Medicaid
contract requirements.
	 
	 	c.	 	For the purposes of this section, a merger or
acquisition means a change in controlling interest of a plan,
including an asset or stock purchase.

	70.4	 	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.

	70.5	 	Conflict of Interest

The contract is subject to the provisions of chapter 112, Florida
Statutes. The plan must 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 plan must disclose the name of any state
employee who owns, directly or indirectly, an interest of five percent
or more in the offerer’s firm or any of its branches. The 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 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.

	70.6	 	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 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
provider 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.

	70.7	 	Court of Jurisdiction or Venue

For purposes of any legal action occurring as a result of or under
this contract, between the plan and the Agency, the place of proper
venue shall be Leon County.

	70.8	 	Crossover Claims for Medicaid/Medicare Eligible Members

The plan shall reimburse non-participating providers for Medicare
deductibles and co-insurance payments for Medicare dually eligible
members according to the lesser of the following: the rate negotiated
with the provider or the reimbursement amount as stipulated in
section 409.908, F.S.

The plan shall reimburse providers for such services no later than 35
calendar days after submittal of a clean claim which includes an
explanation of Medicare benefits, or, if no explanation of Medicare
benefits is provided, the plan shall comply with the third party
payor requirements in section 70.20, Third Party Resources.

AHCA Contract No. FA523, Attachment I, Page 122 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	70.9	 	Damages for Failure to Meet Contract Requirements

In addition to any remedies available through this contract, in law
or equity, the plan shall reimburse the Agency for any federal
disallowances or sanctions imposed on the Agency as a result of the
provider’s failure to abide by the terms of this contract.

	70.10	 	Disputes

The plan may request in writing an interpretation of the contract from
the contract manager. In the event the plan disputes this
interpretation, the plan may request the dispute be decided by the
Division of Medicaid. Any disputes that arise out of or relate to this
contract shall be decided by the Agency’s Division of Medicaid which
shall reduce the decision to writing and serve a copy on the 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 plan and the Agency, unless, at the sole
discretion of the Division director, the division allows an oral
presentation by the plan and the Agency. If such a presentation is
allowed, the information presented will be considered in rendering the
division’s decision. Should the plan challenge an Agency decision
through arbitration as provided below, the action shall not be stayed
except by order of an arbitrator. Thereafter, a 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 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 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 plan and such clarification shall govern. Pending
final determination of any dispute over an Agency decision, the plan
shall proceed diligently with the performance of the contract and in
accordance with the Agency’s Division of Medicaid direction.

	70.11	 	Force Majeure

The Agency shall not be liable for any excess cost to the 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 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
plan. These include destruction to the facilities due to hurricanes,
fires, war, riots, and other similar acts. Annually by May 31, the plan
shall submit to the Agency for approval an emergency management plan
specifying what actions the plan shall conduct to ensure the ongoing
provisions of health services in a disaster or man-made emergency.

	70.12	 	Legal Action Notification

The plan shall give the Agency by certified mail immediate written
notification (no later than 30 calendar days after service of
process) of any action or suit filed or of any claim made against the
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 plan shall immediately advise
the Agency of

AHCA Contract No. FA523, Attachment I, Page 123 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

the insolvency of a subcontractor or of the filing of a petition
in bankruptcy by or against a principal subcontractor.

	70.13	 	Licensing

In accordance with section 409.912, F.S., all entities that provide
Medicaid prepaid health care services must be commercially licensed in
accordance with the provisions of Part I and Part III of chapter 641,
F.S.

	70.14	 	Misuse of Symbols, Emblems, or Names in Reference to Medicaid

No person or 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 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.

	70.15	 	Non-Renewal

This contract shall be renewed only upon mutual consent of the parties.
Either party may decline to renew the contract for any reason. Chapter
120, F.S. does not apply to a decision by the Agency not to renew this
contract.

	70.16	 	Offer of Gratuities

By signing this agreement, the 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.

	70.17	 	Sanctions

In accordance with section 4707 of the Balanced Budget Act of 1997,
and section 409.912, F.S., the Agency may impose any of the
following sanctions against the plan if it determines that the plan
has violated any provision of this contract, or the applicable
statutes or rules governing Medicaid HMOs:

	 	a.	 	Suspension of the plan’s voluntary enrollments and
participation in the assignment process for Medicaid
enrollment;
	 
	 	b.	 	Suspension or revocation of payments to the plan for
Medicaid beneficiaries enrolled during the sanction period. If
the plan has violated the contract, the Agency may order the plan
to reimburse the complainant for out-of-pocket medically
necessary expenses incurred or order the plan to pay non-network
plan providers who provide medically necessary services;
	 
	 	c.	 	Suspension of all marketing activities to Medicaid beneficiaries;
	 
	 	d.	 	Imposition of a fine for violation of the contract with the
Agency, pursuant to section 409.912, F.S. With respect to any
nonwillful violation, such fine shall not exceed $2,500 per
violation. In no event shall such fine exceed and aggregate amount
of $10,000 for all nonwillful violations arising out of the same
action. With respect to any knowing and willful violation of
section 409.912, F.S. or the contract with the Agency, the Agency
may impose a fine upon the entity in an amount not to exceed
$20,000

AHCA Contract No. FA523, Attachment I, Page 124 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

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.

	 	e.	 	Termination pursuant to paragraph III.B. (3) of the Agency core
contract and section 70.19, Termination Procedures, if the plan fails
to carry out substantive terms of its contract or fails to meet
applicable requirements in sections 1932, 1903(m) and 1905(t) of the
Social Security Act. After the Agency notifies the plan that it
intends to terminate the contract, the Agency may give the plan’s
enrollees written notice of the state’s intent to terminate the
contract and allow the enrollees to disenroll immediately without
cause.
	 
	 	f.	 	The Agency may impose intermediate sanctions in accordance with 42 CFR
438.702, including:

	 	1.	 	Civil monetary penalties in the amounts specified in section
409.912, F.S.
	 
	 	2.	 	Appointment of temporary management for the plan. Rules
for temporary management pursuant to 42 CFR 438.706 are as
follows:

	 	(a)	 	The State may impose temporary management only if
it finds (through onsite survey, enrollee complaints,
financial audits, or any other means) that—

	 	(1)	 	There is continued egregious behavior by
the plan, including but not limited to behavior that is
described in 42 CFR 438.700, or that is contrary to any
requirements of sections 1903(m) and 1932 of the Social
Security Act; or
	 
	 	(2)	 	There is substantial risk to enrollees’ health; or
	 
	 	(3)	 	The sanction is necessary to ensure the health of the plan’s
enrollees—

	 	(i)	 	While improvements are made to remedy violations under 42
CFR 438.700; or
	 
	 	(ii)	 	Until there is an orderly termination or reorganization
of the plan.

	 	(b)	 	The State must impose temporary management (regardless of any
other sanction that may be imposed) if it finds that a plan has
repeatedly failed to meet substantive requirements in section
1903(m) or section 1932 of the Social Security Act or 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.
	 
	 	(c)	 	The State may not delay imposition of temporary
management to provide a hearing before imposing this
sanction.
	 
	 	(d)	 	The State may not terminate temporary
management until it determines that the plan can ensure
that the sanctioned behavior will not recur.

	 	3.	 	Granting enrollees the right to terminate enrollment
without cause and notifying affected enrollees of their right to
disenroll.
	 
	 	4.	 	Suspension or limitation of all new enrollment,
including default enrollment, after the effective date of the
sanction.
	 
	 	5.	 	Suspension of payment for beneficiaries enrolled 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.
	 
	 	6.	 	Denial of payments provided for under the contract for
new enrollees when, and for so long as, payment for those
enrollees is denied by CMS in accordance with 42 CFR 438.730.

AHCA Contract No. FA523, Attachment I, Page 125 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

Before imposing any intermediate sanctions, the state must give
the plan timely notice according to 42 CFR 438.710.

	 	g.	 	In accordance with section 409.912, F.S., if the plan’s
Child Health Check-Up screening compliance rate is below 60
percent, it must submit to the Agency, and implement, an Agency
accepted corrective action plan. If the plan does not meet the
standard established in the corrective action plan during the time
period indicated in the corrective action plan, the Agency has the
authority to impose sanctions in accordance with this section.

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.

	70.18	 	Subcontracts

The plan is responsible for all work performed under this contract, but
may, with the written 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 plan must meet the following requirements and
all model provider subcontracts must be approved, in writing, by the
Agency in advance of implementation. 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.
Subcontracts are required with all major providers of services including
all primary care sites.

The plan shall not discriminate with respect to participation,
reimbursement, or indemnification as to any provider who is acting
within the scope of the provider’s license, or certification under
applicable state law, solely on the basis of such license, or
certification, in accordance with section 4704 of the Balanced Budget
Act of 1997. This paragraph shall not be construed to prohibit a plan
from including providers only to the extent necessary to meet the needs
of the plan’s enrollees or from establishing any measure designed to
maintain quality and control costs consistent with the responsibilities
of the organization. If the plan declines to include individual
providers or groups of providers in its network, it must give the
affected providers written notice of the reason for its decision.

In all contracts with health care professionals, the plan must comply
with the requirements specified in 42 CFR 438.214 which includes but
is not limited to selection and retention of providers, credentialing
and recredentialing requirements, and nondiscrimination.

No subcontract which the plan enters into with respect to performance
under the contract shall in any way relieve the plan of any
responsibility for the performance of duties under this contract. The
plan shall assure that all tasks related to the subcontract are
performed in accordance with the terms of this contract. The plan
shall identify in its subcontracts any aspect of service that may be
further subcontracted by the subcontractor.

All model and executed subcontracts and amendments used by the plan
under this contract must be in writing, signed, and dated by the
plan and the subcontractor and meet the following requirements:

a. Identification of conditions and method of payment:

	 	1.	 	The plan agrees to make payment to all subcontractors pursuant to
section 641.3155, F.S. 42 CFR
447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45 (d)(3), 42 CFR 447.45
(d)(5) and 42 CFR 447.45
(d)(6); If third party liability exists, payment of claims shall
be determined in accordance with
section 70.20, Third Party Resources.
	 
	 	2.	 	Provide for prompt submission of information needed to make
payment.
	 
	 	3.	 	Make full disclosure of the method and amount of
compensation or other consideration to be received from the
plan. The provider shall not charge for any service provided to
the member at a

AHCA Contract No. FA523, Attachment I, Page 126 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

rate in excess of the rates established by the plan’s subcontract
with the provider in accordance with section 1128B(d)(1), Social
Security Act (enacted by section 4704 of the Balanced Budget Act
of 1997).

	 	4.	 	Require an adequate record system be maintained for
recording services, charges, dates and all other commonly
accepted information elements for services rendered to
beneficiaries under the contract.
	 
	 	5.	 	Physician incentive plans must comply with 42 CFR
417.479, 42 CFR 438.6(h), 42 CFR 422.208 and 42 CFR 422.210.
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.
	 
	 	 	 	The plan must disclose information on provider 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.
	 
	 	6.	 	Specify whether the plan will assume full
responsibility for third party collections in accordance with
section 70.20, Third Party Resources.

b. Provisions for monitoring and inspections:

	 	1.	 	Provide that the Agency and DHHS may evaluate through
inspection or other means the quality, appropriateness and
timeliness of services performed.
	 
	 	2.	 	Provide for inspections of any records pertinent to the contract by
the Agency and DHHS.
	 
	 	3.	 	Require that records be maintained for a period not
less than five 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
provider if the subcontract is continuous.)
	 
	 	4.	 	Provide for monitoring and oversight by the plan and the
subcontractor to provide assurance that all licensed medical
professionals are credentialed in accordance with the plan’s and
the Agency’s credentialing requirements as found in section
20.5.1, Credentialing and Recredentialing Policies and
Procedures, if the plan has delegated the credentialing to a
subcontractor.
	 
	 	5.	 	Provide for monitoring of services rendered to beneficiaries
sponsored by the provider.

c. Specification of functions of the subcontractor:

	 	1.	 	Identify the population covered by the subcontract.
	 
	 	2.	 	Specify the amount, duration and scope of services to be
provided by the subcontractor, including a requirement that the
subcontractor continue to provide services through the term of the
capitation period for which the Agency has paid the plan.
	 
	 	3.	 	Provide for timely access to physician appointments to
comply with the following availability schedule: urgent care -
within one day; routine sick care — within one week; well care -
within one month. Require that the network providers offer hours
of operation that are no less than the hours of operation offered
to commercial beneficiaries or comparable to Medicaid
fee-for-service if the provider serves only Medicaid
beneficiaries.

AHCA Contract No. FA523, Attachment I, Page 127 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	4.	 	Provide for submission of all reports and clinical information required
by the plan, including Child Health Check-Up reporting (if
applicable).
	 
	 	5.	 	Provide for the participation in any internal and
external quality improvement, utilization review, peer review,
and grievance procedures established by the plan.

d. Protective clauses:

	 	1.	 	Require safeguarding of information about beneficiaries according to
42 CFR, Part 438.224.
	 
	 	2.	 	Require compliance with HIPAA privacy and security provisions.
	 
	 	3.	 	Require an exculpatory clause, which survives
subcontract termination including breach of subcontract due to
insolvency, that assures that beneficiaries or the Agency may not
be held liable for any debts of the subcontractor and, in
accordance with 42 CFR 447.15, that the beneficiary is not liable
to the provider for any services for which the health maintenance
organization is liable as specified in section 641.315, F.S.
	 
	 	4.	 	Contain a clause indemnifying, defending and holding the
Agency and the plan members 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 plan members, 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 plan. Such insurance shall comply
with the Florida’s Worker’s Compensation Law.
	 
	 	6.	 	Pursuant to section 641.315, F.S., contain no provision
that prohibits the physician from providing inpatient services in
a contracted hospital to a subscriber if such services are
determined by the organization to be medically necessary and
covered services under the organization’s contract with the
contract holder.
	 
	 	7.	 	Contain no provision restricting the provider’s ability
to communicate information to the provider’s patient regarding
medical care or treatment options for the patient when the
provider deems knowledge of such information by the patient to
be in the best interest of the health of the patient.
	 
	 	8.	 	Pursuant to section 641.315, contain no provision
requiring providers to contract for more than one HMO product
or otherwise be excluded.
	 
	 	9.	 	Pursuant to section 641.315, F.S., contain no
provision that in any way prohibits or restricts the health
care provider from entering into a commercial contract with any
other plan.
	 
	 	10.	 	Specify that if the subcontractor delegates or
subcontracts any functions of the plan, that the subcontract
or delegation includes all the requirements of this section
and section 20.3.
	 
	 	11.	 	Make provisions for a waiver of those terms of the
subcontract, which, as they pertain to Medicaid beneficiaries, are
in conflict with the specifications of this contract.
	 
	 	12.	 	Specify procedures and criteria for extension,
renegotiation and termination, and that the provider must give 60
days’ advance written notice to the plan, and the Office of
Insurance Regulation

AHCA Contract No. FA523, Attachment I, Page 128 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

before canceling the contract with the plan for any reason.
Nonpayment for goods or services rendered by the provider to the
plan is not a valid reason for avoiding the 60-day advance notice
of cancellation pursuant to section 641.315, F.S. A copy of the
notice shall be filed simultaneously with the Agency.

Pursuant to section 641.315, F.S., specify that the plan will
provide 60 days’ advance written notice to the provider and the
Office of Insurance Regulation 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 submitted to the Office of
Insurance Regulation shall be filed simultaneously with the
Agency.

13. Provide for revoking delegation or imposing other
sanctions if the subcontractor’s performance is inadequate.

	70.18.1	 	Hospital Subcontracts

All hospital subcontracts must meet the requirements outlined in
section 70.18, Subcontracts. In addition such subcontracts must
require that the hospitals notify the plan of births where the mother
is a plan member. The subcontract must also specify which entity
(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.

	70.19	 	Termination Procedures

In conjunction with section III.B., Termination, on page 3 of the
Agency’s core contract, termination procedures are required. The plan
agrees to extend the thirty (30) calendar days notice found in
section III.B.1., Termination at Will, on page 3 of the Agency’s core
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.

Upon receipt of final notice of termination, on the date and to
the extent specified in the notice of termination, the plan
shall:

	 	a.	 	Stop work under the contract, but not before the termination date.
	 
	 	b.	 	Cease enrollment of new beneficiaries 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 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 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 plan and in which the Agency has been granted or may
acquire an interest.

AHCA Contract No. FA523, Attachment I, Page 129 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

     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 plan all written and properly
executed documents as required by the written instructions of the
Agency.

     h. At least 60 calendar days prior to the termination
effective date, provide written notification to all members of
the following information: the date on which the plan will no
longer participate in the State’s Medicaid program; and
instructions on contacting the Agency’s enrollment and
disenrollment services help line to obtain information on
members’ enrollment options and to request a change in managed
care enrollment.

In addition, through separate written notification, the plan shall
inform the parents or guardians of members enrolled in the MediKids
program that they must contact the MediKids help line to make
another managed care selection in order to continue to be eligible
for the program and receive services.

	70.20	 	Third Party Resources

The 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 plan has determined that third party liability
exists for part or all of the services provided directly by the
plan to a member, the plan shall make reasonable efforts to
recover from third party liable sources the value of services
rendered.
	 
	 	b.	 	If the plan has determined that third party liability
exists for part or all of the services provided to a member by a
subcontractor or referral provider, and the third party is
reasonably expected to make payment within 120 calendar days,
the 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 plan may assume full responsibility for third party
collections for service provided through the subcontractor or
referral provider.
	 
	 	c.	 	The plan may not withhold payment for services provided
to a member 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 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 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 plan. If the plan elects to
authorize the Agency to recover on its behalf, the 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 plan.

	70.21	 	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

AHCA Contract No. FA523, Attachment I, Page 130 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

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.

	70.22	 	Withdrawing Services from a County

If the plan intends to withdraw services from a county, it shall
provide written notice to its members in that county at least 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 subsection h. of section 70.19, Termination Procedures.
The plan shall also provide written notice of the withdrawal to all
subcontractors in the county.

	70.23	 	MyFloridaMarketPlace Vendor Registration

Each Vendor doing business with the State of Florida for the sale of
commodities or contractual services as defined in section 287.012,
Florida Statutes, shall register in MyFloridaMarketPlace, in compliance
with Rule 60A-1.030, Florida Administrative Code, unless exempt under
Rule 60A-1.030(3) Florida Administrative Code.

	70.23.1	 	MyFloridaMarketPlace Transaction Fee

The State of Florida, through the Department of Management Services,
has instituted MyFloridaMarketPlace, a statewide eProcurement system.
Pursuant to section 287.057(23), Florida Statutes (2002), all payments
for commodities and/or contractual services as defined in Section
287.012, Florida Statutes, shall be assessed a Transaction Fee of one
percent (1.0%), which the Vendor shall pay to the State, unless exempt
under Rule 60A-1.032, Florida Administrative Code. Notwithstanding the
provisions of Rule 60A-1.030, et seq., the assessment of a transaction
fee shall be contingent upon Federal approval of the transaction fee
assessment program and continued payment of applicable federal
matching funds.

For payments within the State accounting system (FLAIR or its
successor), the Transaction Fee shall, when possible, be automatically
deducted from payments to the Vendor. If automatic deduction is not
possible, the Vendor shall pay the Transaction Fee pursuant to Rule
60A-l.031(2), Florida Administrative Code. By submission of these
reports and corresponding payments, Vendor certifies their correctness.
All such reports and payments shall be subject to audit by the State or
its designee.

The Vendor shall receive a credit for any Transaction Fee paid by the
Vendor for the purchase of any item(s) if such item(s) are returned to
the Vendor through no fault, act, or omission of the Vendor.
Notwithstanding the foregoing, a Transaction Fee is non-refundable when
an item is rejected or returned, or declined, due to the Vendor’s
failure to perform or comply with specifications or requirements of the
agreement.

Failure to comply with these requirements shall constitute grounds for
declaring the Vendor in default and recovering re-procurement costs
from the Vendor in addition to all outstanding fees. VENDORS
DELINQUENT IN PAYING TRANSACTION FEES MAY BE EXCLUDED FROM CONDUCTING
FUTURE BUSINESS WITH THE STATE.

	70.23.2	 	MyFloridaMarketplace Vendor Registration and Transaction Fee Exemption

This contract will provide health care services at or below Medicaid
rates and are therefore exempt from the Vendor Registration under Rule
60A-l.030(2)(d)(l), and the one percent (1.0%) Transaction Fee under
Rule 60A-1.032(1)(h) of the Florida Administrative Code.

AHCA Contract No. FA523, Attachment I, Page 131 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

80.0 METHOD OF PAYMENT

80.1 Payment to Plan by Agency

This is a fixed price unit cost contract. The Agency or its appointed
fiscal agent shall make payment to the plan on a monthly basis for the
plan’s satisfactory performance of its duties and responsibilities as
set forth in this contract. To accommodate payments, the plan is
enrolled as an HMO provider with the Medicaid fiscal agent. Section
60.2, HMO Reporting Requirements, details the enrollment reports, the
monthly payment request processing, and service utilization procedures.

	 	a.	 	Plans will be eligible to participate in the Child
Health Check-Up (CHCUP) incentive program when the plan has
exceeded both the federal 80% participation and screening ratio
goals and the 60% state screening ratio as outlined in section
10.8.1. The Agency will determine which plans will participate
based upon the audited CHCUP reports submitted each October 1 as
outlined in section 60.2.9.
	 
	 	 	 	The amount of the incentive payment shall be calculated as follows.
The ratio of a qualified plan’s screenings to the total of all
plans’ screenings will be multiplied by the total amount in the fund
for the incentive payment. The ratios will be based on the plans’
audited CHCUP reports. The total amount in the fund will be
determined at the discretion of the Agency and in no event shall the
total monies allotted to the incentive program be in excess of the
funds paid to the plans for CHCUP fee-for-service claims for the
fiscal year ending June 30, 2003 (this will be the latest complete
fiscal year for which fee-for-service claims have been finalized).
In addition, pursuant to 42 CFR 438.6 (c) (1) (iv) and (5) (iii),
the payment to any one plan shall not be in excess of 5% of the
capitation amount paid for Child Health Check-Up services pursuant
to this contract for the contract year ending June 30, 2005.
	 
	 	b.	 	The Agency shall pay the applicable capitation rate for
each member whose name appears on the HMO ONGOING REPORT (FLMR
8200-R004) and the HMO REINSTATEMENT REPORT (FLMR 8200-R009) for
each month, except that the Agency shall not pay for any part of
the total enrollment that exceeds the maximum authorized
enrollment level(s) expressed in this contract. The payment amount
shall depend upon the number of members in each capitation
category, at a rate as provided for by this contract, or as
adjusted pursuant to the contract when necessary. The plan is
obligated to provide services pursuant to the terms of this
contract for all members for whom the plan has received capitation
payment or for whom the Agency has assured the plan that
capitation payment is forthcoming.
	 
	 	c.	 	The capitation rates to be paid are developed using
historical rates paid by Medicaid fee-for-service for similar
services in the same geographic area, adjusted for inflation,
where applicable and in accordance to 42 CFR 438.6(c). .
	 
	 	d.	 	For plans participating in the frail/elderly program, the
plan is paid a capitation rate for each member who has received
the appropriate CARES assessment based on the Medicaid
fee-for-service claims experience of a like group of similarly
assessed beneficiaries. The rate merges the claims experience from
both the community setting and the nursing home setting for the
rate base group of beneficiaries for the rate base year. The plan
receives the “nursing home” capitation rate for each member for as
long as the member remains a member and continues to meet the
minimum nursing home level of care. If the member, upon
reassessment by CARES, loses the nursing home level of care, the
member reverts back to the standard community capitation rate
applicable to his/her eligibility group.
	 
	 	e.	 	The capitation rates to be paid shall be as
indicated in section 90.0, Payment and Authorized
Enrollment Levels, which indicates an initial and maximum
authorized enrollment levels and capitation rates
applicable to each authorized eligibility category.
	 
	 	f.	 	At such time as the Agency receives legislative
direction to assess plans for enrollment and disenrollment
services costs, the Agency shall apply assessments, in quarterly
installments each year, against the plan’s next capitation
payment to pay for enrollment and disenrollment services
contractor costs as follows:

AHCA Contract No. FA523, Attachment I, Page 132 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

	 	1.	 	July 1, for costs estimated for the Agency’s
enrollment and disenrollment services contractor system and
contract for July and the following two months.
	 
	 	2.	 	October 1, for costs related to the third party
enrollment and disenrollment services contract for October
and the following two months.
	 
	 	3.	 	January 1, for costs related to maintaining the
third party enrollment and services contract for January and
the following two months.
	 
	 	4.	 	April 1, for costs related to maintaining the
third party enrollment and disenrollment services contract
for April and the following two months.

	 	g.	 	Unless otherwise specified in this contract, the plan
shall accept the capitation payment received each month as
payment in full by the Agency for all services provided to
members covered under this contract and the administrative costs
incurred by the plan in providing or arranging for such services.
Any and all costs incurred by the plan in excess of the
capitation payment shall be borne in total by the plan.
	 
	 	h.	 	Potentially, several frail/elderly members may be
receiving care from the plan prior to actually being listed on
the monthly enrollment roster. The plan may be eligible to
receive retroactive capitation payments for those members once
they are enrolled and listed on the monthly roster. Retroactive
capitation payments will not be granted due to retroactive
Medicaid eligibility, however. In order to receive the
retroactive capitation payment, the following must be met:

	 	1.	 	The member must meet established Level of Care (LOC) requirements.
	 
	 	2.	 	The member is eligible for Medicaid, and is
successfully enrolled on the monthly enrollment roster
under the appropriate county’s frail/elderly Medicaid
provider number.
	 
	 	3.	 	The member’s LOC must be dated prior to the
first day of the month retroactive capitation payment is
being requested.
	 
	 	4.	 	Proof of the care provided must be presented
(e.g., copy of a paid claim for the care provided in the
retro month).
	 
	 	5.	 	A letter from the plan requesting that the
retroactive capitation payment be considered, with the
required documentation included.

	80.2	 	Newborn Payment and Procedures

The plan is responsible for payment of all covered services provided
to newborns for up to the first three months of life.

	 	a.	 	The agency shall pay a capitation rate for each newborn enrolled in
the plan.
	 
	 	b.	 	The plan shall use the Unborn Activation Process to enroll all
babies born to member mothers.

	80.3	 	Rate Adjustments

The plan and the Agency acknowledge that the capitation rates paid under
this contract as specified in section 90.0, 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

AHCA Contract No. FA523, Attachment I, Page 133 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

July 2004

Medicaid HMO Contract

payments have been made for beneficiaries who are determined not to
have been eligible for HMO membership during the period for which
the capitation payments were made. In such events, the plan agrees
to refund any overpayment and the Agency agrees to pay any
underpayment.

	 	b.	 	The Agency agrees to adjust capitation rates to reflect
budgetary changes in the Medicaid fee-forservice program. The
rate of payment and total dollar amount may be adjusted with a
properly executed amendment when Medicaid fee-for-service
expenditure changes have been established through the
appropriations process and subsequently identified in the
Agency’s operating budget. Legislatively-mandated changes shall
take effect on the dates specified in the legislation.
	 
	 	c.	 	If the Agency has received legislative direction as
specified in section 80.1 e., Payment to Plan by Agency, the
Agency shall annually, or more frequently, determine the actual
expenditures for enrollment and disenrollment services. The
Agency will compare capitation rate assessments to the actual
costs for enrollment and disenrollment services. The following
factors will enter into any cost settlement process:

	 	1.	 	If the amount of capitation assessments are less
than the actual cost of providing enrollment and disenrollment
services, the plan will return the difference to the Agency
within thirty calendar days of settlement.
	 
	 	2.	 	If the amount of capitation assessments exceeds the
actual cost of providing enrollment, and disenrollment
services, the Agency will make up the difference to the plan
within thirty calendar days of the settlement.

	80.4	 	Errors

Plans are expected to prepare carefully all reports and monthly payment
requests for submission to the Agency. If after preparation and
electronic submission, a plan error is discovered either by the plan or
the Agency, the plan has 30 business days from its discovery of the
error, or 30 business days after receipt of notice by the Agency, to
correct the error and re-submit accurate reports and/or invoices.
Failure to respond within the 30 business day period may result in a
loss of any money due the plan for such errors.

	80.5	 	Member Payment Liability Protection

The plan shall not hold members liable for the following in
accordance with section 1932 (b)(6), Social Security Act (enacted by
section 4704 of the Balanced Budget Act of 1997):

	 	a.	 	For debts of the plan, in the event of the plan’s insolvency.
	 
	 	b.	 	For payment of covered services provided by the plan if
the plan has not received payment from the Agency for the
services, or if the health care provider, under contract or other
arrangement with the plan, fails to receive payment from the
Agency or the plan.
	 
	 	c.	 	For payments to the health care provider, including
referral providers, that furnished covered services under a
contract, or other arrangement with the plan, that are in excess
of the amount that normally would be paid by the member if the
service had been received directly from the plan.

	80.6	 	Copayments

The plan shall not require any copayment or cost sharing for services
listed in section 10.4., Covered Services, section 10.5, Optional
Services, if provided, or 10.6, Expanded Services, nor may the plan
charge members for missed appointments.

AHCA Contract No. FA523, Attachment I, Page 134 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

Amerigroup of Florida, Inc. 

July 1, 2004

Medicaid HMO Contract

	90.0	 	PAYMENT AND AUTHORIZED ENROLLMENT LEVELS

The plan is assigned an authorized maximum enrollment level for each
operational county, and shall be paid capitation payments for each
Agency operational area, in accordance with the following table. The
plan shall be paid capitation payments based on the Agency
operational area (or rate zone) age group, and gender, in accordance
with Table 2; and Table 3 for areas where behavioral health care has
been implemented.

The authorized maximum enrollment level is in effect on July 1, 2004,
or upon contract execution, whichever is later. The Agency must
approve in writing any increase in the plan’s maximum enrollment level
for each operational county. Such approval shall not be unreasonably
withheld, and shall be based on the plan’s satisfactory performance of
terms of the contract and approval of the plan’s administrative and
service resources, as specified in this contract, in support of each
enrollment level.

The Agency has developed estimated rates, for examination and
evaluation by its actuary, Milliman and Co., to be paid to the
Contractor for services provided in Fiscal Year 2004-2005. These
estimated rates represent the Agency’s best efforts to develop accurate
rates. They are included as Attachment VI; entitled “ESTIMATED 04-05
HMO RATES; NOT FOR USE UNLESS APPROVED BY CMS.” The Agency may use, or
may amend and use these estimated rates, only after certification by
its actuary and approval by the Centers for Medicare and Medicaid
Services, and by notice in a contract amendment to the Contractor.
Inclusion of these estimated rates is not intended to convey or imply
any rights, duties or obligations of either party, nor is it intended
to restrict, restrain or control the rights of either party that may
have existed independently of this section of the Agreement. By
signature of this document, the parties explicitly agree that this
section shall not independently convey any inherent rights,
responsibilities or obligations of either party, relative to these
rates, and shall not itself be the basis for any cause of
administrative, legal or equitable action brought by either party.

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

Upon receipt of CMS approval of 2004-2005 capitation rates, the
Agency shall amend this contract to reflect accepted capitation
rates effective July 1, 2004.

Upon CMS approval of 2005-2006 capitation rates, the Agency shall
amend this contract to reflect CMS approved and actuarially
certified capitation rates effective July 1, 2005.

Table 1 provides the plan’s contract enrollment levels.

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

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

AHCA Contract No. FA523, Attachment I, Page 135 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

Amerigroup of Florida, Inc. 

July 1, 2004

Medicaid HMO Contract

Table 1 Enrollment Levels

	 	 	 	 	 
	County	Maximum Enrollment Level
	BROWARD
	 	 	14,000	 
	DADE
	 	 	25,000	 
	HILLSBOROUGH
	 	 	40,000	 
	LEE
	 	 	18,000	 
	MANATEE
	 	 	3,500	 
	ORANGE
	 	 	30,000	 
	OSCEOLA
	 	 	8,500	 
	PALM BEACH
	 	 	12,000	 
	PASCO
	 	 	15,000	 
	PINELLAS
	 	 	25,000	 
	POLK
	 	 	30,000	 
	SARASOTA
	 	 	8,000	 
	SEMINOLE
	 	 	8,000	 

AHCA Contract No. FA523, Attachment I, Page 136 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

Amerigroup of Florida, Inc.

July 1, 2004

Medicaid HMO Contract

Table 2

Area

Area 05

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	285.33	 	 	 	69.91	 	 	 	44.12	 	 	 	49.85	 	 	 	107.97	 	 	 	123.86	 	 	 	191.30	 	 	 	290.61	 	 	 	290.61	 
	SSI/No Medicare

	 	 	1640.03	 	 	 	302.32	 	 	 	161.06	 	 	 	169.11	 	 	 	169.11	 	 	 	511.37	 	 	 	511.37	 	 	 	524.95	 	 	 	524.95	 
	SSI/Part B

	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 	 	 	217.17	 
	501/Part A & B

	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	276.42	 	 	 	195.20	 
	 
	Area 07
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	279.36	 	 	 	68.56	 	 	 	43.44	 	 	 	49.09	 	 	 	105.94	 	 	 	121.92	 	 	 	188.01	 	 	 	286.09	 	 	 	286.09	 
	SSI/No Medicare

	 	 	1590.95	 	 	 	293.73	 	 	 	157.71	 	 	 	165.37	 	 	 	165.37	 	 	 	499.72	 	 	 	499.72	 	 	 	512.25	 	 	 	512.25	 
	SSI/Part B

	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 	 	 	265.79	 
	SSI/Part A & B

	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	259.85	 	 	 	183.50	 
	 
	Area 08
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	257.19	 	 	 	63.11	 	 	 	40.00	 	 	 	45.22	 	 	 	97.50	 	 	 	112.18	 	 	 	173.06	 	 	 	263.38	 	 	 	263.38	 
	SSI/No Medicare

	 	 	1611.33	 	 	 	297.66	 	 	 	159.63	 	 	 	167.51	 	 	 	167.51	 	 	 	505.95	 	 	 	505.95	 	 	 	519.07	 	 	 	519.07	 
	SSI/Part B

	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 	 	 	250.97	 
	SSI/Part A & B

	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	253.44	 	 	 	179.15	 
	 
	Area 09
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	278.08	 	 	 	68.26	 	 	 	43.21	 	 	 	48.86	 	 	 	105.44	 	 	 	121.17	 	 	 	186.89	 	 	 	284.35	 	 	 	284.35	 
	SSI/NO Medicare

	 	 	1801.74	 	 	 	333.04	 	 	 	179.03	 	 	 	187.98	 	 	 	187.98	 	 	 	567.15	 	 	 	567.15	 	 	 	581.73	 	 	 	581.73	 
	SSI/Part B

	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 	 	 	251.63	 
	SSI/Part A & B

	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	290.09	 	 	 	204.83	 
	 
	Area 10

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	292.87	 	 	 	71.99	 	 	 	45.66	 	 	 	51.65	 	 	 	111.29	 	 	 	128.28	 	 	 	197.65	 	 	 	301.04	 	 	 	301.04	 
	SSI/No Medicare

	 	 	2177.44	 	 	 	402.11	 	 	 	215.86	 	 	 	226.70	 	 	 	226.70	 	 	 	684.10	 	 	 	684.10	 	 	 	701.42	 	 	 	701.42	 
	SSI/Part B

	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 	 	 	267.12	 
	SSI/Part A & B

	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	319.69	 	 	 	225.90	 
	 
	Area 11
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	

	 	<1 year
	 	 	1-5	 	 	 	6-13	 	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA

	 	 	346.97	 	 	 	84.89	 	 	 	53.53	 	 	 	60.41	 	 	 	130.98	 	 	 	150.12	 	 	 	231.97	 	 	 	352.05	 	 	 	352.05	 
	SSI/No Medicare

	 	 	2343.27	 	 	 	432.47	 	 	 	231.39	 	 	 	242.81	 	 	 	242.81	 	 	 	734.42	 	 	 	734.42	 	 	 	753.18	 	 	 	753.18	 
	SSI/Part B

	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 	 	 	420.82	 
	SSI/Part A & B

	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	357.12	 	 	 	252.28	 

AHCA Contract No. FA523, Attachment I, Page 137 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	Amerigroup of Florida, Inc.

	 	Medicaid HMO Contract
	July 1, 2004
	 	 

Table 3 

Area

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

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 06
	 	<1 year
	 	1-5
	 	6-13
	 	14-20 Male
	 	14-20 Female
	 	21-54 Male
	 	21-54 Female
	 	55-64
	 	65+

	TANF/FC/SOBRA
	 	 	279.29	 	 	 	71.17	 	 	 	59.81	 	 	 	65.79	 	 	 	122.52	 	 	 	124.65	 	 	 	190.77	 	 	 	289.28	 	 	 	289.28	 
	SSI/No Medicare
	 	 	1498.70	 	 	 	293.07	 	 	 	243.27	 	 	 	196.57	 	 	 	196.57	 	 	 	526.87	 	 	 	526.87	 	 	 	511.41	 	 	 	511.41	 
	SSI/Part B
	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 	 	 	242.93	 
	SSI/Part A & B
	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	263.55	 	 	 	187.50	 

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

Notwithstanding the payment amounts which may be computed with the above rate
table, the sum of total capitation payments under this contract shall not
exceed the total contract amount of $658,826,195.00 expressed on page
seven of this contract.

THIS REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY.

AHCA Contract No. FA523, Attachment I, Page 138 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	100.0	 	GLOSSARY

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. In
the event of a conflict in language between the definitions,
attachments and other sections of the contract, the language in the
Standard Contract and Attachment I shall govern.

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
timeframes 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.

ADL — Activities of Daily Living are activities that
reflect the client’s ability to perform tasks that are essential
for self-care such as bathing, feeding oneself, dressing,
toileting, transferring from a bed to a chair, etc.

ADM — Alcohol, Drug Abuse, and Mental Health Office of the
Florida Department of Children and Families (also referred to as
DCF).

ALF — Assisted Living Facility.

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

Agent - a person or entity who has employment or a contract
with the plan for the provision of items and services that are
significant and material to the plan’s contract with the Agency.

Ancillary Medical Services - secondary medical services in
support of primary care services, such as laboratory services.

APD — Agency for People with Disabilities (formally the
Developmental Services Program Office of the Florida Department of
Children and Families)

Appeal - 42 CFR 438.400 — a
request for review of action.

Baker
Act - the Florida Mental Health Act,
chapter 394, F.S.

Behavioral Health Services    services that the plan is required
to provide as listed in the Community Mental Health Services Coverage
and Limitations Handbook and the Targeted Case Management Coverage and
Limitations Handbook.

Behavioral Health Care Case Manager - an individual who
provides mental health care case management services directly to or
on behalf of a member on an individual basis, as defined in 65E-15,
F.A.C., and the Medicaid Targeted Case Management Handbook.

Behavioral Health Care Provider - a licensed mental health
professional, as defined in section 394.455(2), F.S., or a registered
nurse, licensed under chapter 464, F.S., and 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 chapter 458 or chapter 459, F.S.

Beneficiary — any individual whom the Department of Children
and Families (DCF), or the Social Security Administration on behalf of
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 is enrolled in
the Medicaid program. Also see “Member.”

AHCA Contract No. FA523, Attachment I, Page 139 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Benefits — a schedule of health care services to be delivered to
members covered in the plan developed under this contract as set forth in
sections 10.4, Covered Services, 10.5, Optional Services 10.8, Manner of
Service Provision and 10.9, Quality and Benefit Enhancements, incorporated
into and made a part of this contract.

Capitation Rate - the monthly fee that is paid by the Agency
to a plan for each Medicaid beneficiary enrolled under a contract for
the provision of Medicaid services during the payment period.

Care Coordination - the manner or practice of planning,
directing, and coordinating the provision and utilization of mental
health care services of enrolled beneficiaries.

CARES — Comprehensive Assessment and Review for Long Term Care
Services.

Case Management - a process which assesses, plans, implements,
coordinates, monitors, and evaluates the options and services required to
meet an individuals health needs, using communication and available
resources to promote quality cost-effective outcomes and occurs across a
continuum of care, addressing ongoing individual needs rather than being
restricted to a single practice setting.

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.

CFR — Code of Federal Regulations.

CHCUP (Child Health Check-Up), the early and periodic screening,
diagnosis and treatment program administered by the Medicaid program
(formerly EPSDT).

CHD - County Health Department, previously known as
county public health unit (CPHU).

Children/Adolescents -
Medicaid beneficiaries under the age of 21.

Children and Families Services Program Office - Children and
Families Safety and Preservation Program Office, located in the
Department of Children and Families, is responsible for overseeing
programs that identify and protect abused and neglected children and
that prevent domestic violence.

Clinic — a facility that is organized and operated independent
of any institution to furnish preventive, diagnostic, therapeutic,
rehabilitative, or palliative Medicaid care, goods, or services to
outpatients.

Clinical Record - a single complete record kept at the site of the
member’s behavioral health care provider, that documents all of the
service implementation plans developed for, and mental health services
received by, the member.

Clozaril - the registered trademark of the SANDOZ Corporation for
the drug clozapine.

CMS — Centers for Medicare and Medicaid Services, the unit of
the United States Department of Health and Human Services that provides
administration and funding for Medicare under Title XVIII and Medicaid
under Title XIX of the Social Security Act.

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

Contracting Officer - the Secretary of the Agency for Health Care
Administration or his/her delegate.

Coverage and Limitations Handbook or Provider Manual - a document
that provides information to a Medicaid provider regarding Medicaid
beneficiary eligibility, claims submission and processing, provider
participation, covered care, goods, or services and limitations,
procedure codes and fees, and other matters

AHCA Contract No. FA523, Attachment I, Page 140 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

related to Medicaid program participation. May also be
referred to as provider handbook.

Covered
Services — see “Benefits.”

CPT — the Physicians’ Current Procedural Terminology, (CPT),
which is a systematic listing and coding of procedures and services that
is published yearly by the American Medical Association.

Crisis Emergency Hot-Line - a crisis emergency hot-line is
defined as a toll-free telephone line that is answered by a mental
health care professional on a 24-hour basis to handle mental health
emergencies.

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 24 hours a day, seven days a week for intervention.
Examples include: mobile crisis, crisis/emergency screening, crisis
hot-line, and emergency walk-in.

Custodial Care - care, which does not provide continued medical
or paramedical attention, given to assist a person in performing daily
living activities.

DCF — Department of Children and Families (formerly the
Department of Health and Rehabilitative Services or “HRS”).

DEA — Drug Enforcement Administration.

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

DOH - Department of Health.

DHHS - United States Department of Health and Human Services.

Disenrollment - the Agency-approved discontinuance of a member’s
membership in an HMO. Also see “Member.”

DJJ — Department of Juvenile Justice.

Downward Substitution of Care - the use of less restrictive,
lower cost services, than might otherwise have been provided, which are
considered clinically acceptable and necessary to meet specified
objectives outlined in a member’s plan of treatment, provided as an
alternative to higher cost State plan services. Downward substitution of
care may include care provided by private practice psychologists and
social workers, inpatient care in institutions for mental disease,
community detoxification and residential substance abuse services,
psycho-social rehabilitation, housing, drop-in centers and other
services the plan considers are clinically appropriate, more cost
effective, and less restrictive than hospital inpatient care, Medicaid
community mental health services, or Medicaid mental health targeted
case management services.

DS — The Developmental Services Program Office of the Florida
Department of Children and Families (DCF). See “APD” definition.

Durable Medical Equipment (DME) - medical equipment that can
withstand repeated use; is primarily and 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 patient’s home.

Emergency Medical Condition - pursuant to section 409.901, F.S., an
emergency medical condition is: (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, pursuant to section
4704 of the 1997 Balanced Budget Act, who possesses an average knowledge
of health and medicine, could reasonably expect the

AHCA Contract No. FA523, Attachment I, Page 141 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

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 a 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.

Emergency Mental 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 at a level of severity that would meet the
requirements for involuntary examination pursuant to section 394.463,
F.S., and who, in the absence of a suitable alternative or psychiatric
medication, would require hospitalization.

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, and if it does,
the care, treatment, or surgery for a covered service by a physician which
is necessary to relieve or eliminate the emergency medical
condition, within the service capability of a hospital.

Enrollee - according to 42 CFR 438.10(a) means a Medicaid
beneficiary who is currently enrolled in an HMO as defined in 42 CFR
438.10(a); See “Member.”

Enrollment - the process by which an eligible beneficiary becomes a
member of the HMO.

Enrollment/Disenrollment Services Contractor -a corporation or
other legal entity that has contracted with the Agency to provide a
telephone helpline and enrollment and disenrollment services, including
new eligible and other enrollment information packet, enrollment,
disenrollment and plan change confirmation, and open enrollment and other
disenrollment reminder notification mailings. The contractor also
maintains the Agency’s Medicaid managed care lock-in/Open Enrollment
database. The current enrollment and disenrollment services contractor is
ACS State Healthcare, LLC.

EPSDT - the Early and Periodic Screening, Diagnosis and
Treatment program administered by the Medicaid program.

Expanded Benefit — a covered service of an HMO that is either
not a Medicaid covered service, or is a Medicaid covered service
furnished by an HMO for which the plan receives no capitation payment.

Expedited Appeal Process- each MCO and PIHP must establish and
maintain an expedited review process for appeals, when the MCO or PIHP
determines (for a request from 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.

Facility — any premises (a) owned, leased, used or operated
directly or indirectly by or for the plan or its affiliates for purposes
related to this contract; or (b) maintained by a sub-contractor to
provide services on behalf of the plan.

Family Services Planning Team — a multi-agency team comprised of
core members and child-specific members, including the child’s parents
and/or foster parents, who convene to assist parents in developing a
holistic service plan and in securing the least restrictive, most relevant
and appropriate services necessary to keep their child living in the home
and community.

Fee-for-Service — a method of making payment for medical or allied
care, goods, or services based on fees set by the agency for defined care,
goods or services.

AHCA Contract No. FA523, Attachment I, Page 142 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Fiscal Agent - any corporation or other legal entity that has
contracted with the agency to receive, process and adjudicate claims
under the Medicaid program. The current fiscal agent for the Medicaid
Program is ACS.

Florida Mental Health Act - chapter 394, F.S., that includes the
Baker Act, that covers involuntary admissions for persons who are
considered in an emergency mental health condition (a threat to
themselves or others).

FQHC — Federally Qualified Health Center — A clinic that is
receiving a grant from the Public Health Service (PHS) under the PHS Act
as defined in section 1905(1)(2)(B) of the Social Security Act. FQHCs
provide primary health care and related diagnostic services. In
addition, FQHCs may provide dental, optometric, podiatry, chiropractic
and mental health services. An FQHC employs, contracts or obtains
volunteer services from licensed health care practitioners to provide
the above services.

FTE — full time equivalent position.

Functional Assessment of Need - an assessment of a person’s
physical health, ability to perform activities of daily living, existing
social support and mental functioning.

Furnished - means supplied, given, prescribed, ordered,
provided, or directed to be provided in any manner.

Good Cause - special reasons that allow beneficiaries to change
their managed care option outside their open enrollment period such as:
the enrollee moves out of the plan’s service area; the plan does not,
because of moral or religious objections, cover the service the enrollee
seeks; the enrollee needs related services (for example a cesarean section
and a tubal ligation) to be performed at the same time; not all related
services are available within the network; and the enrollee’s primary care
provider or another provider determines that receiving the services
separately would subject the enrollee to unnecessary risk; other reasons,
including but not limited to, poor quality of care, lack of access to
services covered under the contract, or lack of access to providers
experienced in dealing with the enrollee’s health care needs.

Note: Federal law uses the term “cause” rather than “good cause.”
In the context with beneficiary disenrollment, this contract uses
the term “good cause.”

Grievance - means an expression of dissatisfaction about any
matter other than an action, as “action” is defined in this section.
The term is also used to refer to the overall system that includes
grievances and appeals handled at the plan level and access to the
Medicaid fair hearing process. (Possible subjects for grievances
include, but are not limited to, the quality of care or services
provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee,
or failure to respect the enrollee’s rights.) (42 CFR 438.2)

Grievance Procedure - the procedure for addressing enrollees’
grievances. A grievance is an enrollee’s expression of dissatisfaction
with any aspect of their care other than the appeal of actions (which is
an appeal).

Grievance System - the system for reviewing and resolving
enrollee grievances or appeals. Components must include a grievance
process, an appeal process, and access to the Medicaid fair hearing
system.

Hal S. Marchmann Alcohol and Other Drug Abuse Services Act of
1993 - chapter 397 F.S. — The chapter of Florida Statutes that
regulates substance abuse services in Florida. This chapter includes
provisions for licensure, standards of care, and other involuntary
assessment and treatment.

Health Assessment — a complete health assessment combines health
history, physical assessment and the monitoring of physical and
psychological growth and development.

AHCA Contract No. FA523, Attachment I, Page 143 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Health Care Professional - means a physician or any of the
following: a 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), licensed certified social worker, registered
respiratory therapist, and certified respiratory therapy technician.

Health Fair - an event conducted in a setting which is open to
the public or a segment of the public (such as the “elderly” or “school
children”) at which information about health care services, facilities,
research, preventive techniques, or other health care information is
disseminated. At least two health related organizations that are not
affiliated under common ownership must actively participate in the
health fair.

HIPAA — Health Insurance Portability and Accountability Act.

HMO - Health Maintenance Organization as certified pursuant to
chapter 641, F.S., or in accordance with the Florida Medicaid State plan
definition of an HMO. See also “MCO”.

Hospital - a facility licensed in accordance with the provisions
of chapter 395, F.S., or the applicable laws of the state in which the
service is furnished.

IADL — Instrumental Activities of Daily Living are activities
that reflect the client’s ability to perform household and other
tasks needed to meet his/her needs within the community. Such tasks
include shopping, cooking, cleaning, managing money, and getting
around in the community.

Individuals with Special Health Care Needs - November 6, 2000
Report to Congress — Individuals with special health care needs are
adults and children who daily face physical, mental, or environmental
challenges that place at risk their health and ability to fully function
in society. They include, for example, 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 from
many years of chronic illness such as arthritis, emphysema or diabetes;
and children and adults with certain environmental risk factors such as
homelessness or family problems that lead to the need for placement in
foster care.

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

LEIE — List of Excluded Individuals and Entities — a database
maintained by the U.S. Department of Health and Human Services Office of
Inspector General which provides information to the public, health care
providers, patients and others relating to parties excluded from
participation in the Medicare, Medicaid and all Federal health care
programs.

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

Mandatory Assignment - the process the Agency uses to assign
Medicaid beneficiaries to the plan because the beneficiaries did not
voluntarily choose a plan or MediPass in accordance with section
409.9122, F.S. Such beneficiaries may also be referred to as
“assigned” beneficiaries or “Agency assigned.”

Marketing - any activity conducted by or on behalf of the plan
where information regarding the services offered by the plan is
disseminated in order to encourage eligible beneficiaries to enroll in
the HMO developed under this contract.

Market Area - the geographic area in which the plan is authorized
to market and to conduct pre-enrollment activities.

AHCA Contract No. FA523, Attachment I, Page 144 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

MCO (Managed Care Organization) — an entity that has, or is seeking
to qualify for, a comprehensive risk contract under this part (42 CFR,
Part 438.2), and that is-

	 	1.	 	A Federally qualified HMO that meets the advance
directives requirements of subpart I of part 489 of this
chapter; or
	 
	 	2.	 	Any public or private entity that meets the advance
directives requirements and is determined to also meet the
following conditions:

(i) Makes the services it provides to its Medicaid enrollees as
accessible (in terms of timeliness, amount, duration, and scope)
as those services are to other Medicaid recipients within the
area served by the entity

(ii) Meets the solvency standards of section 438.116. (Also, see
definition of “HMO”).

Medicaid — the medical assistance program authorized by Title XIX
of the federal Social Security Act, 42 U.S.C. s.1396 et seq., and
regulations thereunder, as administered in this state by the Agency under
section 409.901 et seq., F.S.

Medically Necessary or Medical Necessity - services provided
in accordance with 42 CFR section 438.210(a)(4) and as defined in
section 59G-1.010(166), F.A.C., to include that medical or allied
care, good, or services furnished or ordered must:

(a) Meet the following conditions:

	 	1.	 	Be necessary to protect life, to prevent significant
illness or significant disability, or to alleviate severe
pain;
	 
	 	2.	 	Be individualized, specific, and consistent with
symptoms or confirmed diagnosis of the illness or injury under
treatment, and not in excess of the patient’s needs;
	 
	 	3.	 	Be consistent with the generally accepted
professional medical standards as determined by the Medicaid
program, and not experimental or investigational;
	 
	 	4.	 	Be reflective of the level of service that can be
safely furnished, and for which no equally effective and more
conservative or less costly treatment is available, statewide;
and
	 
	 	5.	 	Be furnished in a manner not primarily intended
for the convenience of the beneficiary, the beneficiary’s
caretaker, or the provider.

	 	(b)	 	“Medically necessary” or “medical necessity” for inpatient
hospital services requires that those services furnished in a
hospital on an inpatient basis could not, 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.
	 
	 	(c)	 	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.

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

AHCA Contract No. FA523, Attachment I, Page 145 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Medicare - the medical assistance program authorized by Title XVIII of
the federal Social Security Act, 42 U.S.C. s. 1395 et seq., and
regulations thereunder.

MediKids - a Title XXI health insurance program that provides
certain children who are not Medicaid eligible with Medicaid benefits
provided a certain premium is paid and provided the children are
enrolled in a Medicaid HMO or MediPass as specified in section 409.8132,
F.S.

MediPass - the primary care case management program administered
by the Florida Medicaid Program.

Member - an eligible Medicaid
beneficiary who is an enrollee of an HMO. See “Enrollee.”
Newborn — a live child born to a member during her membership
under this contract.

Non-Covered Service — a service that is not a covered service or
benefit. (See Covered Services definition and Benefits definition.)

Nursing Facility - an institutional care facility licensed under
chapter 395, F.S., or chapter 400, F.S., that furnishes medical or
allied inpatient care and services to individuals needing such services.

Open Enrollment - the policy wherein Medicaid beneficiaries are
enrolled into a managed care option for 12 months as long as they retain
Medicaid eligibility. Beneficiaries subject to Open Enrollment are given
an annual Open Enrollment period, i.e., 60 days at the end of their
enrollment year wherein they may choose to change plans for the following
enrollment year. Dually eligible individuals, American Indians, foster
children, children in subsidized adoption arrangements, CMS children, and
SSI beneficiaries under age 19 are not subject to Open Enrollment.

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
24-hour period regardless of the hour of admission, whether or not a bed
is used, or whether or not the patient remains in the facility past
midnight.

PAHP-a Prepaid Ambulatory Health Plan is an entity that provides
medical services to enrollees under contract with the State agency, and
on the basis of prepaid capitation payments, or other payment
arrangements that do not use State plan payment rates; does not provide
for or arrange for, and is not otherwise responsible for the provision
of any inpatient hospital or institutional services for its enrollees;
and does not have a comprehensive risk contract.

PDHP - Prepaid Dental Health Plan is the prepaid ambulatory health
plan (PAHP) developed by the Contractor in performance of its duties and
responsibilities under this contract; or a contractual arrangement
between the Agency and a prepaid ambulatory health plan contractor for
the provision of Medicaid care, goods, or services on a prepaid basis to
Medicaid beneficiaries for dental services. PDHPs are classified as
prepaid ambulatory health plans by 42 CFR 438.

Peer Review — an evaluation of the professional practices of a
Medicaid provider by peers of the provider 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.

Physically Secure Facility — Residential Facilities, such as
juvenile boot camps, and high and maximum risk programs, operated by the
Florida Department of Juvenile Justice as hardware secure facilities.

PIHP - a Prepaid Inpatient Health Plan is an entity that provides
medical services to enrollees under contract with the State agency, and
on the basis of prepaid capitation payments, or other payment
arrangements that do not use State plan payment rates; provides,
arranges for, or otherwise has responsibility for the provision of any
inpatient hospital or institutional services for its enrollees; and does
not have a comprehensive risk contract.

AHCA Contract No. FA523, Attachment I, Page 146 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Plan - See definition
of “Vendor.”

PMHP -
Prepaid Mental Health
Plan.

Portable X-Ray Equipment - x-ray equipment transported to a
setting other than a hospital, clinic, or office of a physician or
other practitioner of the healing arts.

Potential Enrollee - according to 42 CFR 438.10(a) means a
Medicaid beneficiary who is subject to mandatory enrollment or may
voluntarily elect to enroll in a given managed care program, but is not
yet an enrollee of a specific managed care program.

Pre-Enrollment Application - also referred to as the Request
to Enroll (RTE) form, completed by a Medicaid beneficiary with the
assistance of a plan representative, and submitted by the plan to the
enrollment and disenrollment services contractor to initiate the
enrollment process.

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 Physician - pursuant to sections 641.19, 641.31 and
641.51, F.S., a Medicaid HMO staff or subcontracted physician practicing
as a general or family practitioner, internist, pediatrician,
obstetrician, gynecologist, or other specialty approved by the Agency,
who furnishes primary care and patient management services to a
beneficiary.

Prior Authorization - the act of authorizing specific services
before they are rendered. Plans with automated authorization systems may
not require paper authorization as a condition of receiving treatment.

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 who has a Medicaid provider
agreement in effect with the Agency, or a subcontractual agreement
with a subcontractor, and is in good standing with the Agency.

Public Event - an event sponsored for the public or a segment
of the public by two or more actively participating organizations,
one of which may be a health organization.

Public Provider - a county health department or a migrant health
center funded under s. 329 of the Public Health Services Act or a
community health center funded under s. 330 of the Public Health Services
Act.

Quality Improvement - the process of assuring that the delivery
of health care is appropriate, timely, accessible, available and
medically necessary.

Receiving Facility - as defined in Part I of chapter 394, F.S., a
facility designated by the Department of Children and Families (DCF) that
receives patients under emergency conditions or for psychiatric
evaluation and provides short-term treatment. The term “receiving
facility” does not include a county jail.

Recipient or Medicaid Recipient - any individual whom the
Department of Children and Families (DCF), or the Social Security
Administration on behalf of 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 is enrolled in the Medicaid program. Also see “member or beneficiary.”

Residential Services - as applied to Juvenile Justice, refers to
the out-of-home placement for youth in a level 4, 6, 8, or 10 facility
as result of a delinquency disposition order. Also referred to as
residential commitment programs.

AHCA Contract No. FA523, Attachment I, Page 147 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

Risk — the potential for loss that is assumed by a plan and that may
arise because the cost of providing care, goods, or services may exceed
the capitation or other payment made by the Agency to the plan under
terms of the contract.

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

RFP - Request for Proposal.

Rural Health Clinic (RHC) - a clinic that is located in a rural
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 the above services.

Sales Activities — actions performed by an agent of an HMO,
including the acceptance of pre-enrollment applications, for the
purpose of enrollment.

Screen or Screening - assessment of a beneficiary’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
plan is authorized by contract to furnish covered services to plan
members and within which the members reside.

Service Location - any location at which a member obtains any
health care service provided by the plan under the terms of this
contract.

Service Site - the locations designated by the plan at which
members shall receive primary care physician services.

Shall — indicates a mandatory requirement or a condition to be met.

Shelter Services - As applied to Juvenile Justice, refers to the
temporary out-of-home placement of youth in a CINS/FINS shelter.

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

SOBRA — Sixth Onmibus Budget
Reconciliation Act

State — State of
Florida.

Subcontract - an agreement entered into by a plan for provision of
services on its behalf. Subcontracts include, but are not limited to the
following: agreements with all providers of medical or ancillary services,
unless directly employed by the plan; management or administrative
agreements; third party billing or other indirect administrative/fiscal
services, including provision of mailing lists or direct mail services;
and any contract which benefits any person with a control interest in the
plan.

Subcontractor - any person to which a plan has contracted or
delegated some of its functions, services or its responsibilities for
providing medical or allied care, goods, or services; or its claiming or
claims preparation or processing functions or responsibilities. A
typical subcontractor is a hospital.

Surplus - net worth, i.e., total assets minus total liabilities.

Third Party Resources - an individual, entity, or program,
excluding Medicaid, that is, may be, could be, should be, or has been
liable for all or part of the cost of medical services related to any
medical assistance covered by Medicaid. An example is an individual’s
auto insurance company, which typically provides

AHCA Contract No. FA523, Attachment I, Page 148 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

payment of some medical expenses related to automobile accidents and
injuries.

Title XXI Medikids — a Title XXI health insurance program that
provides certain children who are not Medicaid eligible with Medicaid
benefits provided a certain premium is paid and provided the children
are enrolled in a Medicaid HMO or MediPass as specified in section
409.8132, F.S.

Transportation - an appropriate means of conveyance furnished to
a beneficiary to obtain Medicaid or other authorized services.

Urgent Behavioral Health Care - Are those situations that require
immediate attention and assessment within 23 hours though the individual
is not an immediate danger to self and others and is able to cooperate in
treatment.

Urgent Care - those problems, 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) or do substantially restrict a member’s
activity (e.g., infectious illnesses, flu, respiratory ailments, etc.).

Urgent Grievance - means an adverse determination when the
standard time frame of the grievance procedure would seriously
jeopardize the life or health of a member or would jeopardize the
member’s ability to regain maximum function.

Vendor- - the organizational entity serving as the primary
contractor and with whom this agreement is executed. The term contractor
shall include all employees, subcontractors, agents, volunteers, and
anyone acting on behalf of, in the interest of, or for a contractor.
Also referred to as the plan.

Violation - each determination by the Agency that a plan failed to
act as specified in the contract or in applicable statutes or rules
governing Medicaid HMOs. Each day that an ongoing violation continues may
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 beneficiaries is considered
for purposes of this contract to be a separate violation.

Voluntary Applicant - an applicant who chooses to enroll in a
Medicaid HMO. May also be referred to as voluntary member.

Well Care — a routine medical visit for one of the following:
Child Health Check-Up visit, family planning, routine follow up to a
previously treated condition or illness, adult physicals and any
other routine visit for other than the treatment of an illness.

WIC — the Special Supplemental Nutrition Program for Women, Infants
and Children (WIC), administered by the Department of Health, Bureau of
WIC and Nutrition Services, provides nutrition counseling, nutrition
education, breastfeeding promotion and support and nutritious foods to
pregnant, postpartum, and breastfeeding women, infants, and children up to
the age of five 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 a member of a family which
includes a pregnant woman or infant certified eligible to receive
Medicaid. WIC serves as an adjunct to good health care during critical
times of growth and development, in order to prevent the occurrence of
health problems and to improve health and nutritional status.

AHCA Contract No. FA523, Attachment I, Page 149 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

110.0 EXHIBITS

EXHIBIT 110.1

LABORATORY TESTS AND ASSOCIATED OFFICE VISITS TO BE PAID BY PLAN WITHOUT PRIOR

AUTHORIZATION WHEN INITIATED BY COUNTY HEALTH DEPARTMENT

	 	 	 	 	 
	Description
	 	CPT CODE

	Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury), quantitative, each
	 	 	83015	 
	Molecular diagnostics; separation
	 	 	83894	 
	Nucleic acid probe
	 	 	83896	 
	Poylmerease chain reaction
	 	 	83898	 
	Interpretation and report
	 	 	83912	 
	CBC with differential, automated
	 	 	85025	 
	CBC automated, without differential
	 	 	85027	 
	Red blood cell count
	 	 	85041	 
	Reticulocyte
	 	 	85044	 
	White blood cell count
	 	 	85048	 
	Platelet (elec tech)
	 	 	85049	 
	Fluorescent antibody; screen, each antibody
	 	 	86255	 
	Fluorescent antibody, titer, each antibody
	 	 	86256	 
	Hemagglutination inhibition test (HAI)
	 	 	86280	 
	Hepatitis B surface antigen (HBsAg)
	 	 	86692	 
	Hepatitis B core antibody (HBcAb); IgG and IgM
	 	 	86704	 
	Hepatitis B core antibody; IgM
	 	 	86705	 
	Hepatitis B surface antibody (HBcAb)
	 	 	86706	 
	Immunoassay for infectious agent antigen, qualitative or semiquantitative; multiple step method
	 	 	83516	 
	Immunoassay for infectious agent antibody, quantitative, not elsewhere specified
	 	 	83520	 
	Rubella screen
	 	 	86762	 
	Immunoelectrophoresis; serum
	 	 	86320	 
	Immunodiffussion; gel diffusion, qualitative (Ouchterlony), each
	 	 	86331	 
	Neutralization test, viral
	 	 	86382	 
	Particle agglutination; screen; each antibody
	 	 	86403	 
	Syphilis test; qualitative (VDRL, RPR, ART)
	 	 	86592	 
	Syphilis test, quantitative
	 	 	86593	 
	Antibody; cytomegalovirus (CMV)
	 	 	86644	 
	Encephalitis, Eastern equine
	 	 	86652	 
	Encephalitits, St. Louis
	 	 	86653	 
	Antibody Enterovirus
	 	 	86658	 
	HIV antibody, confirmatory test
	 	 	86689	 
	HIV-1
	 	 	86701	 
	HIV-2
	 	 	86702	 
	HIV-1 & HIV-2
	 	 	86703	 
	Rubella
	 	 	86762	 
	Rubeola
	 	 	86765	 
	Toxoplasma
	 	 	86777	 
	Toxoplasma, IgM
	 	 	86778	 
	Treponema pallidum, confirmatory test
	 	 	86781	 
	Varicella-zoster
	 	 	86787	 
	Antibody screen, RBC, each serum technique
	 	 	86850	 

AHCA Contract No. FA523, Attachment I, Page 150 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	 	 	 	 
	Blood typing; ABO
	 	 	86900	 
	Rh(D)
	 	 	86901	 
	RBC antigens, other than ABO or Rh (D), each
	 	 	86905	 
	Concentration (any type), for parasites, OVA, or tubercle bacillus (TB, AFB)
	 	 	87015	 
	Culture, bacterial, definitive; stool
	 	 	87045	 
	Culture, bacterial, definitive; throat or nose
	 	 	87060	 
	Culture, definitive, any other source
	 	 	87070	 
	Culture or direct bacterial identification method, each organism, by commercial kit, any source
except urine
	 	 	87071	 
	Culture, bacterial, any source, anaerobic (isolation)
	 	 	87075	 
	Anaerobe identification
	 	 	87076	 
	Culture, bacterial, screening only, for single organisms
	 	 	87081	 
	Culture, fungi, isolation (with or without presumptive identification); skin
	 	 	87101	 
	Culture, fungi, isolation (with or without presumptive identification); other source, (except blood)
	 	 	87102	 
	Culture, fungi, blood
	 	 	87103	 
	Culture, fungi, definitive identification of each fungus (use in addition to codes 87101, 87102, or
87103 when appropriate)
	 	 	87106	 
	Culture, tubercle or other acid-fast bacilli (TB, AFB, mycobacteria); concentration plus isolation
	 	 	87116	 
	Culture, mycobacteria, definitive identification of each organism
	 	 	87118	 
	Culture, typing; gas liquid chromatography (GLC) method
	 	 	87143	 
	Culture, typing; serologic method, agglutination grouping, per antiserum
	 	 	87147	 
	Culture, typing; serologic method, speciation
	 	 	87151	 
	Culture, typing; precipitin method, grouping, per antiserum
	 	 	87155	 
	Culture, any source, additional identification methods required
	 	 	87163	 
	Endotoxin, bacterial (pyrogens); homogenization, tissue, for culture
	 	 	87176	 
	OVA and parasites, direct smears, concentration and identification
	 	 	87177	 
	Microbial identification, nucleic acid probes, each probe used
	 	 	88365	 
	Microbial identification, nucleic acid probes, each probe used; with amplification, e.g. polymerase
chain reaction (PCR)
	 	 	87179	 
	Sensitivity studies, antibiotic; agar diffusion method, per antibiotic
	 	 	87181	 
	Sensitivity studies, antibiotic; tubercle bacillus (TB, AFB), each drug
	 	 	87190	 
	Smear, primary source, with interpretation; routine stain for bacteria, fungi or cell types
	 	 	87205	 
	Smear, primary source, with interpretation; fluorescent and/or acid fast stain for bacteria, fungi or
cell types
	 	 	87206	 
	Smear, primary source, with interpretation; special stain for inclusion bodies or intracellular
parasites (e.g. malaria, kala-azar, herpes)
	 	 	87207	 
	Smear, primary source, with interpretation; direct or concentrated, dry, for OVA and parasites
	 	 	87207	 
	Smear, primary source, with interpretation; wet mount with simple stain, for bacteria, fungi, OVA,
and/or parasites
	 	 	87210	 
	Smear, primary source, with interpretation; wet and dry mount, for OVA and parasites
	 	 	87211	 
	Tissue examination for fungi (e.g. KOH slide)
	 	 	87220	 
	Tissue culture inoculation and observation
	 	 	87252	 
	Tissue culture, additional studies
	 	 	87253	 
	Flow cytometry
	 	 	88180	 
	Viral load (AIDS)
	 	 	W1875	 

AHCA Contract No. FA523, Attachment I, Page 151 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

EXHIBIT 110.2

Model Memorandum of Agreement between the __________________ Department of
Health County Health Department and the

________________________________________ (HMO).

1. This agreement is entered into between the State of Florida, Department of
Health ,

_______________________ County Health Department, hereinafter referred to as
the “CHD” and the _______________________________________
HMO hereinafter referred to as the “HMO”, for the purpose of improving
services to patients through coordinated, cooperative health care
interactions between the HMO and the CHD, pursuant to section 409.9122, F.S.

2. Power and Authority of the CHD.

     Pursuant to chapter 154, F.S., the Department of Health county health
departments of Florida are responsible for the promotion of the public’s
health, the control and eradication of preventable diseases, and the provision
of primary health care for special populations. The CHD must comply with
established public health protocols and applicable state law when providing
health care services.

3. Power and Authority of the HMO.

     The HMO has contracted with the Agency for Health Care Administration
(hereinafter referred to as the “Agency”) as a Medicaid HMO provider. The HMO
must comply with all established requirements and applicable state law when
providing health care services.

4. The HMO agrees to:

     A. Reimburse without prior authorization, medical screenings for foster
care children and emergency shelter care children.

     B. In accordance with section 381.0407(4), F.S., reimburse without prior
authorization, the CHD for school-based urgent care services; and the
diagnosis and treatment of sexually transmitted disease and other
communicable diseases, such as tuberculosis and human immunodeficiency
syndrome. This shall include the clinical, medical and laboratory services
provided by the CHD to an HMO patient.

     C. Offer the Healthy Start prenatal screen to each member who is
pregnant. (Section 383.14, F.S., 10J-8.010, F.A.C.)

     D. Refer all pregnant women meeting Healthy Start high risk screening
criteria to the local CHD for Healthy Start care coordination. (Section
383.14, F.S., 19J-8.010, F.A.C.)

     E. Offer the Healthy Start postnatal (infant) screen to each woman for
her newborn. (Section 383.14, F.S., 10J-8.010 F.A.C.)

     F. Refer all infants meeting Healthy Start high risk screening criteria
to the local CHD for Healthy Start care coordination. (1OJ-8.010, F.A.C.)

     G. Refer all pregnant women, postpartum women (up to six months after
delivery), breastfeeding women (up to one year after delivery), infants and
children up to the age of five to the Special Supplemental Nutrition Program
for Women, Infants and Children (WIC) available through the local CHD.

     H. Reimburse without prior authorization services for a member’s
immunizations.

     I. Reimburse without prior authorization for family planning services and
related pharmaceuticals.

AHCA Contract No. FA523, Attachment I, Page 152 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

5. The CHD agrees to:

     A. Attempt to contact the HMO before providing health care services to their
members.

     B. Provide the plan with a copy of the member immunization record at the
time that the immunization is provided to the plan member. The CHD shall not
submit a claim for the immunization if the plan documents to the CHD that the
immunization has already been provided.

     C. Notify the HMO within      hours when HMO patients are treated in the CHD.

     D. Forward to the HMO within      days all medical records relating to an HMO
patient being seen at the CHD.

     E. Refer HMO patients back to the HMO for ongoing primary care following
provision of services covered in this agreement.

6. Both parties mutually agree to:

     A. Make good faith effort to work in a cooperative manner.

     B. Forward any unresolved concerns involving the HMO and the CHD to the
Division of Medicaid.

	 	 	 
	

CHD Director/Administrator - signature

	 	Date
	

CHD Director/Administrator - type or print name
	 	 
	

Authorized Representative of HMO - signature

	 	Date
	

Authorized Representative of HMO - type or print name
	 	 

AHCA Contract No. FA523, Attachment I, Page 153 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

EXHIBIT 110.3

SAMPLE MULTIPLE SIGNATURE VERIFICATION AGREEMENT

Account Number: _________

In consideration of the mutual promises and undertakings expressed herein,
this Agreement is entered into between
______________ Bank (“Bank”) and _________ Health plan (“Health plan”), effective as of the ________ day of
___________,2004.

1. Health plan is opening the Bank business investment account referenced by
number above (“the Account”), pursuant to the conditions contained in the
agreement entered between Health plan and the Office of the Director of
Medicaid, State of Florida Agency for Health Care Administration (“Medicaid”)
dated July 1,2004.

2. Pursuant to its agreement with Medicaid, Health plan desires, and Bank
agrees to provide, a “hold” on the account so that withdrawals may be made
only by properly authorized written request, and upon manual examination
of the requests, which service shall be subject to the terms and
restrictions set forth below.

3. Bank will only honor written requests for withdrawals which bear the
signatures of two authorized representatives of Medicaid and two signatures
of authorized representatives of Health plan. Medicaid and Health plan will
provide to Bank examples of the signatures of the authorized representatives.

4. Health plan will present the written, properly executed requests for
withdrawal to _________________ , at
Bank, located at _____________________ ___________, Florida,       , between the hours of 8:00 am and 4:00 pm, EST,
during banking business days. The request will contain the Account number,
the amount of the funds to be withdrawn, a description of the payee who shall
receive the funds, and the signatures of two authorized representatives of
Medicaid and two signatures of authorized representatives of Health plan.

5. Bank agrees to review the requests; draft the Account for the amount of the
requested withdrawal, and prepare a Bank Official Check in the withdrawn
amount, in accordance with the terms of the request. Bank agrees to undertake
the above and make the Check available to Health plan no later than the close
of the banking day following the banking day in which the request was
presented to Bank in accordance with Paragraph 4, above. [Optional language:
Health plan agrees to pay to Bank a fee of $5.00 for each Official Bank Check
issued.]

6. Bank shall return to Health plan any request that does not meet the
above-described requirements. Bank shall have the sole discretion to
determine whether the requirements have been met.

7. Pursuant to its agreement with Medicaid, Health plan agrees that in the
event that Medicaid determines Health plan to be insolvent and notifies Bank
of its determination, Medicaid may make withdrawals on the account by two
authorized representatives of Medicaid, without authorized signatures from
Health plan. Bank shall not be responsible or liable for determining
insolvency. Bank shall not be required to permit withdrawals upon the sole
order of Medicaid until written notification is received from Medicaid at the
address described in Paragraph 4, and Bank has had a reasonable time to act
thereon but in no event later than two (2) business days.

8. Except to the extent that Bank is negligent in performing its duties under
this Agreement, Health plan shall indemnify and hold Bank harmless against
any claim, loss, liability, damage, cost or expense (including reasonable
attorneys’ fees incurred by Bank) arising out of or in any way relating to
Bank’s compliance with the terms of this Agreement.

9. This Agreement shall supplement the Bank Deposit Agreement, any corporate or
other resolution of Health plan relating to the Account, and any other
agreements or terms affecting the Account. All legal rights and obligations of
Health plan and Bank under such other documents and pursuant to any applicable
laws and banking regulations shall remain in effect, except as expressly
modified by this Agreement.

AHCA Contract No. FA523, Attachment I, Page 154 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

10. This Agreement shall be executed by all currently authorized signers on the
Account, and it shall continue in effect notwithstanding any subsequent
change of authorized signers, and without any requirement that it be
re-executed or amended.

11. This Agreement may
be terminated at any time by Bank or Health plan,
provided Health plan provides Bank written approval from Medicaid, and provided
that the indemnification provision of paragraph 7 above shall continue in
effect after any such termination with respect to any withdrawals or requests
handled by Bank prior to such termination. This Agreement shall be binding upon
and shall inure to the benefit of any successors and assigns of Health plan,
Medicaid, and Bank.

The undersigned parties have executed this Agreement through their duly
authorized representatives as of the date shown above.

BANK

	 	 	 
	By:
	 	 
	

	 	
 
	Title:
	 	 
	

	 	
 

HEALTH PLAN

	 	 	 
	By:
	 	 
	

	 	
 
	Title:
	 	 

HEALTH PLAN’S CERTIFICATION OF AUTHORITY

The undersigned
hereby certifies that: (1) (s)he is the Secretary of        Health
plan; and (2) the foregoing Agreement is consistent with any corporate or
other resolution(s) of Health plan previously or contemporaneously provided
to Bank.

	 	 	 
	By:
	 	 
	

	 	
 
	Title:

	 	 
	Date of Certification:
	 	 
	

	 	
 

[Affix corporate seal]

AUTHORIZED SIGNATURES

	 	 	 
	HEALTH PLAN

	 	AGENCY FOR HEALTH CARE ADMINISTRATION
	
Title

	 	
Director of Medicaid
	Print Name:

	 	Print Name:

	
Title

	 	
Bureau of Managed Health Care, Chief
	Print Name:

	 	Print Name:
	
Title

	 	
Bureau of Managed Health Care, Operations
	Print Name:

	 	Administrator
Print Name:

AHCA Contract No. FA523, Attachment I, Page 155 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

EXHIBIT 110. 4

FRAIL/ELDERLY PROGRAM

110.4.1 Frail/Elderly Program (expanded service)

The purpose of the frail/elderly portion of a Medicaid HMO is to
provide, coordinate and manage services for the frail and elderly who
need services to prevent or delay placement in a nursing home. A
variety of mandatory and supportive services shall be available to
members to achieve this goal. The plan shall also conduct quality of
care projects for the frail/elderly component as required by section
20.12, Quality
Improvement. In order to be eligible for the frail/elderly program,
beneficiaries must be:

	 	a.	 	Assessed by CARES as having met nursing home level
of care and in need of a service(s) to live in their homes or
in the homes of relatives or caregivers as an alternative to
being placed in a nursing home facility
	 
	 	b.	 	21 years of age or older
	 
	 	c.	 	An SSI beneficiary
	 
	 	d.	 	Ineligibility criteria are listed in Section 10.3, Ineligible Recipients.

            
         110.4.2 Mandatory Service Requirements
(Frail/Elderly)

The plan shall provide comprehensive and medically necessary health
care services pursuant to this contract. The plan shall maintain a
maximum ratio of 1:40 (case manager to enrollees). A case manager
shall be assigned to each enrollee. A case manager shall be
responsible for arranging all program service provisions and
implementing the service prescription appropriate to the plan of care.
For dually eligible plan members, case managers are responsible for
long-term care service planning and for developing and carrying out
strategies to coordinate the delivery of all acute and long-term care
services.

	 	a.	 	Plan of Care — The plan shall perform a needs assessment
and develop a plan of care for each member. The plan of care must
be based on a comprehensive assessment of the enrollee’s health
status, physical and cognitive functioning, environment, and
social supports. The plan shall not impose service limitations
based solely on the members’ place of residence. The plan of care
must detail all interventions designed to address specific
barriers to independent functioning. The plan must clearly
identify barriers to the enrollee and caregivers, if applicable.
The case manager must discuss barriers and explore potential
solutions with the enrollee and caregivers when applicable. In
developing the plan of care the plan must:

	 	1.	 	Assess the immediacy of the new enrollee’s services
needs and include a description of the member’s condition
(e.g., Activities of Daily Living, (ADL) and Instrumental
Activities of Daily Living (IADL) limitations, incontinence,
cognitive impairment, arthritis, high blood pressure), as
identified through an appropriate comprehensive assessment and
a medical history review.
	 
	 	2.	 	Identify any existing care plans and service providers and assess
the adequacy of current services.
	 
	 	3.	 	Ensure that the care plan contains, at minimum,
information about the enrollee’s medical condition, the type of
services to be furnished, the amount, frequency and duration of
each service, and the type of provider to furnish each service.
	 
	 	4.	 	Ensure that treatment interventions address
identified problems, needs and conditions in consultation
with the enrollee and, as appropriate, the enrollee’s legal
guardian or caregiver.

AHCA Contract No. FA523, Attachment I, Page 156 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	5.	 	Ensure that, at minimum, a quarterly review of the plan of care
occurs to determine the appropriateness and adequacy of services
and to ensure that the services furnished are consistent with
the nature and severity of the enrollee’s needs.
	 
	 	6.	 	Ensure that a face-to-face review of the care plan is
performed through contact with the enrollee at least every six
months to determine the appropriateness and adequacy of services
and to ensure that the services furnished are consistent with the
nature and severity of the enrollee’s needs.
	 
	 	7.	 	Ensure that the care plan is reviewed sooner than the
minimum required time frame if, in the opinion of the medical
professionals involved in the care of the enrollee, there is
reason to believe significant changes have occurred in the
enrollee’s condition or in the services the enrollee receives.
The care plan shall also be reviewed if an enrollee or an
enrollee’s legal representative requests another review due to
the changes in the enrollee’s physical or mental condition.
	 
	 	8.	 	Primary caregivers, family, neighbors and other
volunteers will be integrated into an enrollee’s plan of care
when it is determined through multi-disciplinary assessment and
care planning that these volunteer services would improve the
enrollee’s capability to live safely in the home setting and are
agreed to by the enrollee.
	 
	 	9.	 	Revise the plan of care in consultation with the
enrollee, the caregiver and, when feasible, the primary care
physician. If the member is dually-eligible and the primary care
physician is not under contract with the plan to deliver
services to the enrollee, an effort must be made to obtain the
physician’s input regarding care plan revisions. Changes in
service provision resulting from a care plan review must be
implemented within ten calendar days of the review date.

b. Coordination of Care/Case Management.

The plan is responsible for assessing, planning, and managing the
care and services provided to members. The plan shall:

	 	1.	 	Develop a systematic process for coordinating care
with organizations which are not part of the plan’s network.
	 
	 	2.	 	Develop procedures that ensure acute care services and
program services for the plan’s Medicaid only members are
coordinated with the member’s primary care provider.
	 
	 	3.	 	Develop protocols that ensure acute care services and
program services for beneficiaries who receive their medical
care from the Medicare fee-for-service system are coordinated
to the maximum extent feasible with the member’s treating
physicians and other care providers.
	 
	 	4.	 	Ensure coordination with the medical, nursing or
administrative staff designated by the facility to ensure that
the plan’s assisted living or nursing facility enrolled members
have timely and appropriate access to the plan’s providers and
to coordinate care between those providers and the facility’s
providers.
	 
	 	5.	 	Facilitate and coordinate the enrollee gaining
referral and receiving access to other needed services and
agencies outside the plan’s network.
	 
	 	6.	 	Work to ensure the maintenance or creation of an
enrollee’s informal network of caregivers and service
providers.
	 
	 	7.	 	Develop a system of case management which the plan shall
use for the identification of the individual member’s needs,
development of immediate and long-term goals, and arrangements and
monitoring of services for as long as necessary to meet the
established goals for the member.
	 
	 	8.	 	Components essential to the case management system are:

AHCA Contract No. FA523, Attachment I, Page 157 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	a.	 	Outreach, including information distribution;
	 
	 	b.	 	Intake and referral;
	 
	 	c.	 	Diagnosis and evaluation;
	 
	 	d.	 	Needs assessment;
	 
	 	e.	 	Plan of care development;
	 
	 	f.	 	Resource assessment;
	 
	 	g.	 	Plan implementation;
	 
	 	h.	 	Routine monitoring of providers by appropriate staff;
	 
	 	i.	 	Progress reports;
	 
	 	j.	 	Reassessment and revision of plan; and
	 
	 	k.	 	Routine conferences or meetings of the care
team with formal methods of communicating changes to all
concerned.

	 	c.	 	Adaptive Equipment — These services are physical adaptations to
the home that include grab bars, cushioned grips, ramps, modification
of bathroom facilities and other minor adaptations and equipment
which assist the member’s caregiver in providing supportive care and
allow the member to remain independent, able to perform ADLs, and/or
reduces the risk of falls without which the enrollee’s safety in the
home may be at risk.
	 
	 	d.	 	Adult Day Health Care — This is a center-based program which
assures a protective environment for frail elders and disabled
adults. It provides preventive, remedial, and restorative services,
in addition to therapeutic recreation and nutrition services. For
example, physical, occupational, and speech therapies indicated in
the enrollee’s plan of care are furnished as components of this
service. In addition, physician services, nursing services, social
work services and transportation services may also be included.
	 
	 	e.	 	Homemaker/Personal Care — These are services which help the
member manage activities of daily living (ADLs) and instrumental
ADLs. This service includes preparation of meals, but not the cost
of meals themselves. This service may also include housekeeping
chores such as bed making, dusting and vacuuming, which are
incidental to the care furnished or are essential to the health and
welfare of the enrollee rather than the enrollee’s family.
	 
	 	f.	 	Supplies — These include items like disposable diapers,
pads, ointments, or other items as deemed necessary by the plan.
	 
	 	g.	 	Home Health Services — These are services which provide
medically necessary care to an eligible Medicaid recipient whose
medical condition, illness or injury requires the care to be
delivered in the recipient’s place of residence. Physician ordered
and maintained under the direction of the attending physician, home
health services must be provided by qualified staff and consistent
with accepted standards of medical and nursing practice in
execution of an individualized, written physician-approved plan of
care. The medical need for home health care shall be identified
with appropriate nursing interventions resulting in expected health
outcomes. The plan shall contract for their member needs with a
sufficient number of home health agencies licensed in accordance
with Chapter 400, Part IV, F.S. and Chapter 59A-8, F.A.C.

AHCA Contract No. FA523, Attachment I, Page 158 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

110.4.2.1 Nursing Facility Placement (Frail/Elderly)

The plan shall adequately network with nursing facility providers to
maintain sufficient bed census capable to ensure access to their
enrolled members. The plan shall provide at a minimum choice of two or
more nursing facilities within a 15 mile radius or 30 minute drive
within the enrollee’s zip code of residence and service area. The plan
shall also contract with nursing facilities having most recent
Licensure & Certification Survey ratings of satisfactory or above from
the Agency’s Division of Health Quality Assurance, and make a good
faith effort to contract with out of network nursing facility providers
where or when necessary. The plan shall disclose the choices of
approved nursing facilities in the Member Services Handbook.

For members who require the level of care provided in a nursing
facility, the plan shall admit the members to a nursing facility which
participates in Medicaid, accepts the members at the appropriate level
of care, has a written agreement with the plan to accept members under
plan sponsorship, agrees to keep the members under plan sponsorship,
and agrees to maintain the members if sponsorship is transferred to
Medicaid fee-for-service nursing facility program.

The plan is responsible for continuing to provide all covered services
which the member needs and which are not included in the nursing home
rate. The plan shall be liable for the costs of the nursing facility
care for the time specified in the contract with the Agency. The member
will continue to be enrolled in the plan for the duration of the
contract and through recontracting, excepting disenrollments as
described in section 30.11.2.1, Frail/Elderly Disenrollment.

110.4.2.2 Quality of Care (Frail/Elderly)

	 	a.	 	Quality of Care Projects: The plan is responsible for
operating an ongoing quality management program which includes
quality assessment an performance improvement, in accordance with
federal and State requirements. The plan shall monitor the quality
appropriateness and effectiveness of enrollee home and community
based services. The plan must also participate in annual external
quality reviews conducted by the External Quality Review
Organization vendor. The plan must conduct quality of care
projects to monitor the quality, appropriateness, and
effectiveness of enrollee care in the Frail/Elderly program. These
projects must include quarterly reviews of long-term care records
of enrollees who have received services during the previous
quarter. Review elements include management of diagnosis,
appropriateness and timeliness of care, comprehensiveness of and
compliance with the plan of care, and evidence of special
screening for, and monitoring of, high-risk persons and
conditions.
	 
	 	 	 	The projects must:

1. Target specific conditions and health service delivery
issues appropriate to enrollees for focused monitoring and
evaluation.

2. Use clinical care standards or practice guidelines to
objectively evaluate health services delivery issues and the
care the contractor delivers or rails to deliver for acute and
long-term care conditions.

3. Use quality indicators derived from the clinical care
standards or practice guidelines to screen and monitor care and
services delivered.

4. The selection of conditions and issues to study should be based
on member profile data and focus on areas of concern in the care
of the frail elders; for example: falls, incontinence, dementia,
depressions, congestive heart failure, inadequate family care,
family caregiver stress, family conflict, out-of-home placements,
alcohol problems, and problems of compliance in procedures of
medical treatment.

AHCA Contract No. FA523, Attachment I, Page 159 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	b.	 	The plan must annually develop at least two specific
quality goals and provide documentation on each project,
describing:

	 	1.	 	The objective;
	 
	 	2.	 	The expected outcomes;
	 
	 	3.	 	A brief justification with background on each objective;
	 
	 	4.	 	How each quality goal will be measured;
	 
	 	5.	 	The target population;
	 
	 	6.	 	The method of evaluating change in the quality goals;
	 
	 	7.	 	Communication process; and,
	 
	 	8.	 	Documentation requirements.

	 	c.	 	The plan must ensure that sufficient quality management
resources (skilled staff and resources) specifically trained to
handle a quality Frail/Elderly program. The staff shall have
access to people with expertise in the following areas:

	 	1.	 	Quality Management Director: an identified
senior-level director who will oversee all quality management
and performance-improvement activities. The quality
management director must have expertise in geriatric care.
	 
	 	2.	 	Medical Director: a medical director with
a current active license by Florida Board of Medicine
with geriatric expertise and experience in geriatric
care.
	 
	 	3.	 	Geriatrician: a qualified geriatrician, with a
current active license by Florida Board of Medicine and
further certified in Geriatric Medicine, who will be
responsible for establishing and monitoring the
implementation and administration of geriatric management
protocols to support geriatric practice.
	 
	 	4.	 	Behavioral Health Clinician: a qualified
behavioral health clinician, with expertise in geriatric
service, who will be responsible for establishing
behavioral health protocols and providing specialized
support to primary care physicians and primary care
therapists.

	 	d.	 	Continuous Quality Improvement: All clinical and
non-clinical aspects of plan management must be based on
principles of Continuous Quality Improvement (CQI). Continuous
quality improvement is defined in section 100.0, Glossary. The
quality management program must:

	 	1.	 	Recognize that opportunities for improvement are unlimited;
	 
	 	2.	 	Be data driven;
	 
	 	3.	 	Rely heavily on enrollee input;
	 
	 	4.	 	Rely heavily on input from all employees of the plan and its
subcontractors; and
	 
	 	5.	 	Require measurement of effectiveness,
continuing development, and implementation of
improvements as appropriate.

	 	e.	 	The plan shall develop and periodically review written
guidelines, procedures and protocols on areas of concern in the
care of the frail/elderly.

The plan may be granted an extension period for implementing the
new quality requirements.

110.4.3 Expanded Supportive Services Requirements (Frail/Elderly)

The plan shall provide other supportive services as deemed necessary.
Services which are especially useful with this population include:

AHCA Contract No. FA523, Attachment I, Page 160 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	 	a.	 	Caregiver Training — Services designed to increase the ability of family
and caregivers to care for the member.
	 
	 	b.	 	Emergency Alert Response Services — Such services monitor
the safety of individuals in their own homes which will alert and
dispatch qualified assistance to the member when in need.
	 
	 	c.	 	Expanded Home Health — Services incorporating health and
medical services, including nutrition, occupational, physical, and
speech therapies, supervised by a health professional including a
registered nurse or a medical doctor. Such services must be provided
in compliance with applicable Florida statutes and rules.
	 
	 	d.	 	Financial Education — Services which include training,
counseling and assistance with personal financial management
particularly to help the member avoid financial exploitation.
	 
	 	e.	 	Identity Bracelets — A bracelet that identifies the member and
includes a phone number to call to get additional information about
the member. This is particularly useful for people with cognitive
deficits, or those who wander and become disoriented.
	 
	 	f.	 	Pharmaceutical Management — Services provided by an
appropriately trained and licensed practitioner. This service is
designed to help the member and the team gain the most value from any
pharmaceutical regimen and helps the member use medication correctly.
It includes an assessment of over-the-counter or home remedies the
member uses that may impact on the member’s care, treatment, or which
may interact with other prescribed medications.
	 
	 	g.	 	Respite — Services provided to relieve the caregiver
temporarily of the responsibilities of care giving and supervision.
Providers of this service must be licensed as required under
Florida Statutes.

THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 161 of 166

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

EXHIBIT 110.5

Florida Patient’s Bill of Rights and Responsibilities

381.026, F.S.

(1) SHORT TITLE. This section may be cited as the “Florida Patient’s Bill of
Rights and Responsibilities.”

(2) DEFINITIONS. As used in this section, the term:

     (a) “Health care facility” means a facility licensed under chapter 395.

     (b) “Health care provider” means a physician licensed under chapter
458, an osteopathic physician licensed under chapter 459, or a podiatrist
licensed under chapter 461.

     (c) “Responsible provider” means a health care provider who is primarily
responsible for patient care in a health care facility or provider’s office.

(3) PURPOSE. It is the purpose of this section to promote the interests and
well-being of the patients of health care providers and health care facilities
and to promote better communication between the patient and the health care
provider. It is the intent of the Legislature that health care providers
understand their responsibility to give their patients a general understanding
of the procedures to be performed on them and to provide information
pertaining to their health care so that they may make decisions in an informed
manner after considering the information relating to their condition, the
available treatment alternatives, and substantial risks and hazards inherent
in the treatments. It is the intent of the Legislature that patients have a
general understanding of their responsibilities toward health care providers
and health care facilities. It is the intent of the Legislature that the
provision of such information to a patient eliminate potential
misunderstandings between patients and health care providers. It is a public
policy of the state that the interests of patients be recognized in a
patient’s bill of rights and responsibilities and that a health care facility
or health care provider may not require a patient to waive his rights as a
condition of treatment. This section shall not be used for any purpose in any
civil or administrative action and neither expands nor limits any rights or
remedies provided under any other law.

(4) RIGHTS OF PATIENTS. Each health care facility or provider shall observe the
following standards:

     (a) Individual dignity.

          1. The individual dignity of a patient must be respected at all times and
upon all occasions.

          2. Every patient who is provided health care services retains certain
rights to privacy, which must be respected without regard to the patient’s
economic status or source of payment for his care. The patient’s rights to
privacy must be respected to the extent consistent with providing adequate
medical care to the patient and with the efficient administration of the health
care facility or provider’s office. However, this subparagraph does not
preclude necessary and discreet discussion of a patient’s case or examination
by appropriate medical personnel.

          3. A patient has the right to a prompt and reasonable response to a
question or request. A health care facility shall respond in a reasonable
manner to the request of a patient’s health care provider for medical services
to the patient. The health care facility shall also respond in a reasonable
manner to the patient’s request for other services customarily rendered by the
health care facility to the extent such services do not require the approval
of the patient’s health care provider or are not inconsistent with the
patient’s treatment.

          4. A patient in a health care facility has the right to retain and use
personal clothing or possessions as space permits, unless for him to do so
would infringe upon the right of another patient or is medically or
programmatically contraindicated for documented medical, safety, or
programmatic reasons.

     (b) Information.

          1. A patient has the right to know the name, function, and qualifications
of each health care provider who is providing medical services to the patient.
A patient may request such information from his responsible provider or the
health care facility in which he is receiving medical services.

          2. A patient in a health care facility has the right to know what
patient support services are available in the facility.

          3. A patient has the right to be given by his health care provider
information concerning diagnosis, planned course of treatment, alternatives,
risks, and prognosis, unless it is medically inadvisable or impossible to give
this information to the patient, in which case the information must be given
to the patient’s guardian or a person designated as the patient’s
representative. A patient has the right to refuse this information.

          4. A patient has the right to refuse any treatment based on information
required by this paragraph, except as otherwise provided by law. The
responsible provider shall document any such refusal.

AHCA Contract No. FA523, Attachment I, Page 162 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

          5. A patient in a health care facility has the right to know what facility
rules and regulations apply to patient conduct.

          6. A patient has the right to express grievances to a health care
provider, a health care facility, or the appropriate state licensing agency
regarding alleged violations of patients’ rights. A patient has the right to
know the health care provider’s or health care facility’s procedures for
expressing a grievance.

          7. A patient in a health care facility who does not speak English has
the right to be provided an interpreter when receiving medical services if
the facility does not have a person readily available who can interpret on
behalf of the patient.

     (c) Financial information and disclosure.

          1. A patient has the right to be given, upon request, by the
responsible provider, his designee, or a representative of the health care
facility full information and necessary counseling on the availability of
known financial resources for the patient’s health care.

          2. A health care provider or a health care facility shall, upon request,
disclose to each patient who is eligible for Medicare, in advance of treatment,
whether the health care provider or the health care facility in which the
patient is receiving medical services accepts assignment under Medicare
reimbursement as payment in full for medical services and treatment rendered in
the health care provider’s office or health care facility.

          3. A health care provider or a health care facility shall, upon request,
furnish a person, prior to provision of medical services, a reasonable estimate
of charges for such services. Such reasonable estimate shall not preclude the
health care provider or health care facility from exceeding the estimate or
making additional charges based on changes in the patient’s condition or
treatment needs.

          Each licensed facility not operated by the state shall make available to
the public on its Internet website or by other electronic means a description
of and a link to the performance outcome and financial data that is published
by the agency pursuant to s. 408.05(3)(1). The facility shall place a notice in
the reception area that such information is available electronically and the
website address. The licensed facility may indicate that the pricing
information is based on a compilation of charges for the average patient and
that each patient’s bill may vary from the average depending upon the severity
of illness and individual resources consumed. The licensed facility may also
indicate that the price of service is negotiable for eligible patients based
upon the patient’s ability to pay.

          5. A patient has the right to receive a copy of an itemized bill upon
request. A patient has a right to be given an explanation of charges upon
request.

     (d) Access to health care.

          1. A patient has the right to impartial access to medical treatment or
accommodations, regardless of race, national origin, religion, physical
handicap, or source of payment.

          2. A patient has the right to treatment for any emergency medical
condition that shall deteriorate from failure to provide such treatment.

     (e) Experimental research.

          In addition to the provisions of section 766.103, F.S., a patient has the
right to know if medical treatment is for purposes of experimental research and
to consent prior to participation in such experimental research. For any
patient, regardless of ability to pay or source of payment for his care,
participation must be a voluntary matter; and a patient has the right to refuse
to participate. The patient’s consent or refusal must be documented in the
patient’s care record.

     (f) Patient’s knowledge of rights and responsibilities.

	 	 	In receiving health care, patients have the right to know what their rights
and responsibilities are.

(5) RESPONSIBILITIES OF PATIENTS. Each patient of a health care provider or
health care facility shall respect the health care provider’s and health care
facility’s right to expect behavior on the part of patients which, considering
the nature of their illness, is reasonable and responsible. Each patient shall
observe the responsibilities described in the following summary.

(6) SUMMARY OF RIGHTS AND RESPONSIBILITIES. Any health care provider who treats
a patient in an office or any health care facility that admits and treats a
patient shall adopt and make public, in writing, a statement of the rights and
responsibilities of patients, including:

AHCA Contract No. FA523, Attachment I, Page 163 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

 

	 	 	 
	July 2004

	 	Medicaid HMO Contract

SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your health care provider or health care facility
recognize your rights while you are receiving medical care and that you respect
the health care provider’s or health care facility’s right to expect certain
behavior on the part of patients. You may request a copy of the full text of
this law from your health care provider or health care facility. A summary of
your rights and responsibilities follows:

     A patient has the right to be treated with courtesy and respect, with
appreciation of his individual dignity, and with protection of his need for
privacy.

     A patient has the right to a prompt and reasonable response to questions and
requests.

     A patient has the right to know who is providing medical services and who is
responsible for his care.

     A patient has the right to know what patient support services are
available, including whether an interpreter is available if he does not speak
English.

     A patient has the right to know what rules and regulations apply to his
conduct.

     A patient has the right to be given by his health care provider
information concerning diagnosis, planned course of treatment, alternatives,
risks, and prognosis.

     A patient has the right to refuse any treatment, except as otherwise
provided by law.

     A patient has the right to be given, upon request, full information and
necessary counseling on the availability of known financial resources for his
care.

     A patient who is eligible for Medicare has the right to know, upon request
and in advance of treatment, whether the health care provider or health care
facility accepts the Medicare assignment rate.

     A patient has the right to receive, upon request, prior to treatment, a
reasonable estimate of charges for medical care.

     A patient has the right to receive a copy of a reasonably clear and
understandable, itemized bill and, upon request, to have the charges
explained.

     A patient has the right to impartial access to medical treatment or
accommodations, regardless of race, national origin, religion, physical
handicap, or source of payment.

     A patient has the right to treatment for any emergency medical condition
that shall deteriorate from failure to provide treatment.

     A patient has the right to know if medical treatment is for purposes
of experimental research and to give his consent or refusal to participate
in such experimental research.

     A patient has the right to express grievances regarding any violation
of his rights, as stated in Florida law, through the grievance procedure
of the health care provider or health care facility which served him and
to the appropriate state licensing agency.

     A patient is responsible for providing to his health care provider, to
the best of his knowledge, accurate and complete information about present
complaints, past illnesses, hospitalizations, medications, and other
matters relating to his health.

     A patient is responsible for reporting unexpected changes in his condition
to his health care provider.

     A patient is responsible for reporting to his health care provider whether
he comprehends a contemplated course of action and what is expected of him.

     A patient is responsible for following the treatment plan recommended by his
health care provider.

     A patient is responsible for keeping appointments and, when he is unable
to do so for any reason, for notifying the health care provider or health
care facility.

     A patient is responsible for his actions if he refuses treatment or
does not follow the health care provider’s instructions.

     A patient is responsible for assuring that the financial obligations of
his health care are fulfilled as promptly as possible.

     A patient is responsible for following health care facility rules
and regulations affecting patient care and conduct.

AHCA Contract No. FA523, Attachment I, Page 164 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

EXHIBIT 110.6

Memorandum of Understanding between School District and HMO

	I.	 	General

     This agreement
is entered into between the      County School District,
hereinafter referred to as the “School District” and      hereinafter referred to
as the “HMO”, for the purpose of improving services to students qualified
under the Medicaid certified school match program through coordinated,
cooperative health care interaction between the school district and the HMO.

Both parties understand and agree that coordinating the health care needs and
treatment of Medicaid eligible students is critical to providing quality
services within and outside the school setting, and preventing possible
duplication of medical services. Both parties devote their efforts to
continuity and quality of care in pursuit of the students’ needs for health
care services as required by Florida law.

	II.	 	Power and Authority of the School District Regarding the
Certified School Match Program Reimbursement through Medicaid:

     Pursuant to sections 409.9071 and 236.0812, Florida Statutes, and chapter
59G, Florida Administrative Code, School Districts in the State of Florida are
eligible to receive Medicaid fee-for-service reimbursement for certain
services provided to Medicaid-eligible students under the Medicaid certified
school match program. These health care services are physical therapy,
speech-language pathology, respiratory therapy, augmentative and communicative
devices, nursing, medication administration and behavioral health (psychology,
social work, etc). In addition, Medicaid reimburses transportation as a
related service under the certified school match program.

III. Power and Authority of the HMO Regarding the Certified School Match
Program Reimbursement through Medicaid:

     The HMO has contracted with AHCA as a Medicaid HMO provider. The HMO must
comply with all established contract requirements and applicable state and
federal law when providing health care services. In accordance with section
409.9122, Florida Statutes, the HMO shall make a good faith effort to execute
an agreement with a School District for services authorized by Florida law.

IV. The School District agrees to the following:

     1. Request parents or legal guardians to sign a release form for the
release of medical records, plan of care and Individual Education Plan (IEP) or
Family Support Plan (FSP) to the HMO for Medicaid certified school match
services.

     2. Refer students to the HMO for ongoing primary care services.

     3. Provide the HMO with a plan of care regarding the student’s plan of
treatment within days of plan of care development, provided the School
District has received the parent’s or legal guardian’s signed release of
records.

     4. Forward to the HMO either a summary of services or the medical
records relating to the health care services provided under the Medicaid
certified school match program to an HMO student member upon request by the
HMO within    days after the HMO patient is treated in the school, or on a
quarterly basis, as agreed upon between the School District and the HMO.

     5. Forward any unresolved health care concerns regarding the student,
including concerns which require continuity of treatment during school
vacation, to the HMO.

     6. Provide a contact person to the HMO for coordinating services.

AHCA Contract No. FA523, Attachment I, Page 165 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

	 	 	 
	July 2004

	 	Medicaid HMO Contract

	7.	 	As appropriate, include a representative of the HMO in staffing for
the IEP or FSP for each student covered under the Medicaid certified
school match program unless there is objection from a parent/guardian.
In instances where the HMO does not attend the IEP meeting, the School
District will provide other methods of communicating the student’s
health care needs.

V. The Medicaid HMO Agrees to the Following:

     1. Provide an HMO contact person to the schools who is responsible for
coordination of services.

     2. Refer students to primary care providers for ongoing services.

     3. As appropriate, participate in IEP or FSP staff meetings, review
documentation received from the School District, and take action to ensure
coordination of care.

     4. Release medical records to the school upon receiving the parent’s or
guardian’s consent for such release.

VI. Both Parties Agree to:

A. Make good faith effort to work in a cooperative manner.

B. Forward any unresolved concerns involving the HMO and the School District
to the appropriate Agency area Bureau of Managed Health Care office, as
appropriate.

VII.This agreement shall
take effect ___________________________

and shall remain in effect until terminated by either party, by written
notice to the other party upon certified or registered mail received.

	 	 	 
	____________________________________

School District
	 	 
	 
	 	 
	____________________________________

Authorized Representative of School District

	 	Date
	 
	 	 
	____________________________________

HMO
	 	 
	 
	 	 
	____________________________________

Authorized Representative of HMO

	 	Date

THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK.

AHCA Contract No. FA523, Attachment I, Page 166 of 166

AHCA Form 2100-0003 (Rev. APR04)

 

 

Exhibit 10.25

ATTACHMENT II

FINANCIAL AND COMPLIANCE AUDIT

The administration of resources awarded by the Agency for Health Care
Administration to the recipient may be subject to audits and/or monitoring by
the Agency as described in this section.

MONITORING

In addition to reviews of audits conducted in accordance with OMB Circular
A-133 and Section 215.97, F.S., as revised (see “AUDITS” below), monitoring
procedures may include, but not be limited to, on-site visits by Agency staff,
limited scope audits as defined by OMB Circular A-133, as revised, and/or other
procedures. By entering into this agreement, the recipient agrees to comply and
cooperate with any monitoring procedures/processes deemed appropriate by the
Agency. In the event the Agency determines that a limited scope audit of the
recipient is appropriate, the recipient agrees to comply with any additional
instructions provided by the Agency to the recipient regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews,
investigations, or audits deemed necessary by the Comptroller or Auditor
General.

AUDITS

PART I: FEDERALLY FUNDED

This Attachment is applicable if the recipient is a State or local government
or a non-profit organization as defined in OMB Circular A-133, as revised.

	1.	 	In the event that the recipient expends $300,000 or more in Federal
awards in its fiscal year, the recipient must have a single or
program-specific audit conducted in accordance with the provisions of OMB
Circular A-133, as revised. PART VI of this agreement indicates Federal
resources awarded through the Agency. In determining the Federal awards
expended in its fiscal year, the recipient shall consider all sources of
Federal awards, including Federal resources received from the Agency. The
determination of amounts of Federal awards expended should be in
accordance with the guidelines established by OMB Circular A-133, as
revised. An audit of the recipient conducted by the Auditor General in
accordance with the provisions of OMB Circular A-133, as revised, will
meet the requirements of this part.
	 
	2.	 	In connection with the audit requirements addressed in Part I, paragraph
1., the recipient shall fulfill the requirements relative to auditee
responsibilities as provided in Subpart C of OMB Circular A-133, as
revised.
	 
	3.	 	If the recipient expends less than $300,000 in Federal awards in its
fiscal year, an audit conducted in accordance with the provisions of OMB
Circular A-133, as revised, is not required. In the event that the
recipient expends less than $300,000 in Federal awards in its fiscal year
and elects to have an audit conducted in accordance with the provisions of
OMB Circular A-133, as revised, the cost of the audit must be paid from
non-Federal resources (i.e., the cost of such an audit must be paid from
recipient resources obtained from other than Federal entities).
	 
	4.	 	Information concerning this section can be found on the Federal Office of
Management and Budget Web page at: http:llwww.whitehouse.gov/omb/index

PART II: STATE FUNDED

This part is applicable if the recipient is a non-state entity as defined by
Section 215.97(2)(1), Florida Statutes.

	1.	 	In the event that the recipient expends a total amount of State Financial
Assistance (i.e., State financial assistance provided to the recipient to
carry out a State project) equal to or in excess of $300,000 in any fiscal
year of such recipient, the recipient must have a State single or
project-specific audit for such fiscal year in accordance with Section
215.97, Florida Statutes; applicable rules of the Executive Office of the
Governor and the Comptroller, and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for-profit organizations), Rules of the
Auditor General. PART VI of this agreement indicates State Financial
Assistance awarded through the Agency by this agreement. In determining
the State Financial Assistance expended in its fiscal year, the recipient
shall consider all sources of State Financial Assistance, including State
Financial Assistance received from the Agency, other state agencies, and
other non-state entities. State Financial Assistance does not include
Federal direct or pass-through awards and resources received by the
non-state entity for Federal program matching requirements.

AHCA Contract No. FA523, Attachment II, Page 1 of 3

 

 

Exhibit 10.25

	2.	 	In connection with the audit requirements addressed in Part II, paragraph
1, the recipient shall ensure that the audit complies with the
requirements of Section 215.97(7), Florida Statutes. This includes
submission of a financial reporting package as defined by Section
215.97(2)(d), Florida Statutes, and Chapters 10.550 (local governmental
entities) or 10.650 (nonprofit and for-profit organizations), Rules of the
Auditor General.
	 
	3.	 	If the recipient expends less than $300,000 in State Financial Assistance
in its fiscal year, an audit conducted in accordance with the provisions
of Section 215.97, Florida Statutes, is not required. In the event that
the recipient expends less than $300,000 in State Financial Assistance in
its fiscal year and elects to have an audit conducted in accordance with
the provisions of Section 215.97, Florida Statutes, the cost of the audit
must be paid from the nonstate entity’s resources (i.e., the cost of such
an audit must be paid from the recipient’s resources obtained from other
than State entities).
	 
	4.	 	Information concerning this section can be found
on the State of Florida Web page at:
http://www.myflorida.
com/myflorida/government/governorinitiatives/fs
aa/

PART III: OTHER AUDIT REQUIREMENTS

	1.	 	45 CFR, Part 74.26(d) extends OMB requirements, as stated in
Part I above, to for-profit organizations.

PART IV: REPORT SUBMISSION

	1.	 	Copies of reporting packages for audits conducted in accordance with OMB
Circular A-133, as revised, and required by PART I of this agreement shall
be submitted, when required by Section .320 (d), OMB Circular A-133, as
revised, by or on behalf of the recipient directly to each of the
following:

	A.	 	The Agency for Health Care
Administration at the following
address:

     See AHCA Standard Contract
document, Section III,C,1

	B.	 	The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections .320
(d)(1) and (2), OMB Circular A-133, as revised, should be submitted
to the Federal Audit Clearinghouse), at the following address:

Federal
Audit Clearinghouse

Bureau of the Census

1201 East 10th Street

Jeffersonville, IN 47132

	C.	 	Other Federal agencies and pass-through entities in accordance
with Sections .320 (e) and (f), OMB Circular A-133, as revised.

	2.	 	Pursuant to Section .320 (f), OMB Circular A-133, as revised, the
recipient shall submit a copy of the financial reporting package described
in Section .320 (c), OMB Circular A-133, as revised, and any management
letters issued by the auditor, to the Agency at the following address:

	A.	 	The Agency for Health Care Administration at the
address indicated in the Standard Contract document,
Section III, C, 1.
	 
	B.	 	To the Federal Agency or pass-through entity making the request for a
copy of the reporting package.

	3.	 	Copies of financial reporting packages required by PART II of this
agreement shall be submitted by or on behalf of the recipient
directly to each of the following:

	A.	 	The Agency for Health Care Administration at the
address indicated in the Standard Contract document,
Section III, C,1.
	 
	B.	 	The Auditor General’s Office at the following address:

Auditor
General’s Office
Room 401, Pepper Building

111 West Madison Street

Tallahassee,

Florida 32399-1450

 

 

Exhibit 10.25

	4.	 	Copies of reports or management letters required by PART III of this
agreement shall be submitted by or on behalf of the recipient
directly to:

	A.	 	The Agency for Health Care Administration at the address
indicated in the Standard Contract document, Section III, 0,1.
	 
	B.	 	The Federal Department of Health and Human Services

National
External Audit Resources Unit
323 West 8th St., Lucas
Place-Room 514

Kansas City, MO 64105.

	C.	 	The Federal Audit Clearinghouse designated in OMB Circular
A-133, as revised (the number of copies required by Sections .320
(d)(1) and (2), OMB Circular A-133, as revised, should be submitted
to the following address:

Federal Audit

Clearinghouse
Bureau of the Census

1201 East 10th Street

Jeffersonville, IN 47132

	5.	 	Any reports, management letters, or other information required to be
submitted to the Agency pursuant to this agreement shall be submitted
timely in accordance with OMB Circular A-133, Florida Statutes, and
Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and
for-profit organizations), Rules of the Auditor General, as applicable.

	6.	 	Recipients, when submitting financial reporting packages to the Agency
for audits done in accordance with OMB Circular A-133, or Chapters 10.550
(local government entities) or 10.650 (nonprofit and for-profit)
organizations, Rules of the Auditor General, should indicate the date that
the reporting package was delivered from the auditor to the recipient in
correspondence accompanying the reporting package. This can be
accomplished by providing the cover letter from the reporting package
received from the auditor or a cover letter indicating the date the
reporting package was received by the recipient.

PART V: RECORD RETENTION

	1.	 	The recipient shall retain sufficient records demonstrating its
compliance with the terms of this agreement for a period of five (5) years
from the date the audit report is issued, and shall allow the Agency or
its designee, Comptroller, or Auditor General access to such records upon
request. The recipient shall ensure that audit working papers are made
available to the Agency or its designee, Comptroller, or Auditor General
upon request for a period of five (5) years from the date the audit report
is issued unless extended in writing by the Agency.

		
	NOTE: 	Section .400(d) of the OMB Circular A-133, as revised, and Section
215.97(5)(a), Florida Statutes, require that the information about Federal
Programs and State Projects included in Part VI of this attachment be
provided to the Vendor organization if the Vendor is determined to be a
recipient. If Part VI is not included the Vendor has not been determined
to be a recipient as defined by the above referenced federal and state
laws.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FA523, Attachment II, Page 3 of 3

AHCA Form 2100-004 (Rev. JAN03)

 

 

Exhibit 10.25

ATTACHMENT III

CERTIFICATION

REGARDING HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 COMPLIANCE

This certification is required for compliance with the requirements of the
Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The undersigned Vendor certifies and agrees as to abide by the following:

	1.	 	Protected Health Information. For purposes of this
Certification, Protected Health Information shall have the same
meaning as the term “protected health information” in 45 C.F.R. §
164.501, limited to the information created or received by the Vendor
from or on behalf of the Agency.
	 
	2.	 	Limits on 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 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 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. A
violation of this paragraph shall be a material violation of this
Contract.
	 
	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. I64.504(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 Agents. The Vendor agrees to enter into an
agreement with 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. Such agreement shall
contain 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.
	 
	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

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

AHCA Form 2100-0017 (Rev. JAN03)

 

 

Exhibit 10.25

	 	 	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.	 	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.

CERTIFICATION

	 	 	The Vendor has caused this Certification to be signed and delivered by its
duly authorized representative, as of the date set forth below.

	 	 	Vendor Name:

	 	 	 	 	 
	

	 	/s/ Karen Bornhauser

	 	7/1/04

	

	 	Signature
	 	Date

	 	 	Karen Bornhauser CEO
Name and Title of Authorized Signer

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

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

AHCA Form 2100-0017 (Rev. JAN03)

 

Exhibit 10.25

10/01/02

ATTACHMENT IV

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/ Karen Bornhauser
	 	7/1/04
	
Signature
	 	
Date
	 
	Karen Bornhauser
	 	 
	

	 	

	Name of Authorized Individual
	 	Application or Contact Number
	 
	AMERIGROUP Florida 4200 W. Express #900 Tampa, FL 33607
	 	 
	

	 	 
	Name
and Address of Organization
	 	

AHCA Contract No. FA523, Attachment IV, Page 1 of 1

AHCA Form 2100-0009 Rev. (OCT 02)

 

Exhibit 10.25

ATTACHMENT V

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, Vendorss who audit federal programs
must also sign, regardless of the contract amount. The Agency for Health
Care Administration cannot contract with these types of Vendorss 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/ Karen
Bornhauser

Signature	 	7/1/04
Date
	 
	 	 	 	 
	 
	 	Karen
Bornhauser CEO

Name and Title of Authorized Signer	 	 

AHCA Contract No. FA523, Attachment V, Page 1 of 1

AHCA Form 2100-0009 (JAN
03)

 

Exhibit 10.25

ATTACHMENT VI

ESTIMATED 2004-2005 HMO RATES;

NOT FOR USE UNLESS APPROVED BY CMS

	 	 	 
	AMERIGROUP FLORIDA INC

	 	Medicaid 11140 Contract
	July 1, 2004

	 	   contract Number : 523

Table 2.

Area wide Age-banded Capitation Rates for all agency areas of

the state other than Area 6 and Area 1.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 05	 	<1 year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	344.75	 	 	 	77.20	 	 	 	47.92	 	 	 	53.39	 	 	 	110.51	 	 	 	134.26	 	 	 	206.44	 	 	 	287.43	 	 	 	287.43	 
	SSI/No Medicare
	 	 	3312.84	 	 	 	399.97	 	 	 	207.73	 	 	 	217.58	 	 	 	217.58	 	 	 	622.27	 	 	 	622.27	 	 	 	600.49	 	 	 	600.49	 
	SSI/Part B
	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 	 	 	262.11	 
	SSI/Part A & B
	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	279.92	 	 	 	240.03	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 07	 	<1year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	336.57	 	 	 	75.50	 	 	 	47.25	 	 	 	52.60	 	 	 	108.28	 	 	 	132.13	 	 	 	202.76	 	 	 	283.08	 	 	 	283.08	 
	SSI/No Medicare
	 	 	3320.10	 	 	 	402.55	 	 	 	211.07	 	 	 	220.72	 	 	 	220.72	 	 	 	631.77	 	 	 	631.77	 	 	 	609.58	 	 	 	609.58	 
	SSI/Part B
	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 	 	 	261.32	 
	SSI/Part A & B
	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	251.20	 	 	 	217.86	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 08	 	<1year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	295.59	 	 	 	66.21	 	 	 	41.16	 	 	 	45.89	 	 	 	94.88	 	 	 	115.33	 	 	 	177.31	 	 	 	247.08	 	 	 	247.08	 
	SSI/No Medicare
	 	 	3101.85	 	 	 	374.62	 	 	 	194.07	 	 	 	203.31	 	 	 	203.31	 	 	 	582.39	 	 	 	582.39	 	 	 	561.96	 	 	 	561.96	 
	SSI/Part B
	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 	 	 	239.50	 
	SSI/Part A & B
	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	253.81	 	 	 	219.39	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 09	 	<1year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	315.38	 	 	 	70.51	 	 	 	43.83	 	 	 	48.82	 	 	 	101.05	 	 	 	122.63	 	 	 	188.58	 	 	 	262.53	 	 	 	262.53	 
	SSI/No Medicare
	 	 	3369.20	 	 	 	408.36	 	 	 	212.88	 	 	 	222.97	 	 	 	222.97	 	 	 	638.43	 	 	 	638.43	 	 	 	615.96	 	 	 	615.96	 
	SSI/Part B
	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 	 	 	262.75	 
	SSI/Part A & B
	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	285.85	 	 	 	244.68	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 10	 	<1year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	327.60	 	 	 	73.59	 	 	 	46.05	 	 	 	51.31	 	 	 	105.60	 	 	 	128.95	 	 	 	197.71	 	 	 	276.31	 	 	 	276.31	 
	SSI/No Medicare
	 	 	4270.73	 	 	 	518.41	 	 	 	272.09	 	 	 	283.90	 	 	 	283.90	 	 	 	812.87	 	 	 	812.87	 	 	 	784.90	 	 	 	784.90	 
	SSI/Part B
	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 	 	 	282.31	 
	SSI/Part A & B
	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	307.18	 	 	 	266.50	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 11	 	<1year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	408.42	 	 	 	91.09	 	 	 	56.29	 	 	 	62.75	 	 	 	130.48	 	 	 	157.53	 	 	 	243.00	 	 	 	337.44	 	 	 	337.44	 
	SSI/No Medicare
	 	 	4662.01	 	 	 	564.13	 	 	 	294.32	 	 	 	307.60	 	 	 	307.60	 	 	 	880.79	 	 	 	880.79	 	 	 	849.95	 	 	 	849.95	 
	SSI/Part B
	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 	 	 	441.72	 
	SSI/Part A & B
	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	325.70	 	 	 	303.69	 

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

AHCA Form 2100-0039 (APR04)

 

 

Exhibit 10.25

ATTACHMENT VI

ESTIMATED 2004-2005 HMO RATES;

NOT FOR USE UNLESS APPROVED BY CMS

	 	 	 
	AMERIGROUP FLORIDA INC

	 	Medicaid HOM Contract
	July 1, 2004

	 	   contract Number : 

Table 3.

Area 6 or Area 1 Age-banded Capitation Rates, Including Community Mental Health

and Mental Health Targeted Case Management.

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

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

AHCA Form 2100-0039 (APR04)exv10w25w2

 

Exhibit 10.25.2

	 	 	 
	AMERIGROUP. OF FLORIDA, INC.

	 	Medicaid HMO Contract

AHCA CONTRACT NO. FA523

AMENDMENT NO. 1

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

	1.	 	Attachment I, section 10.4, Covered Services is hereby amended to read:

The plan shall ensure the provision of services is sufficient in amount,
duration, and scope to reasonably be 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 sections 10.1,
General and 10.8, Manner of Service Provision:

	 	 	 
	Child Health Check-Up

	 	Inpatient Hospital Services
	 
	 	 
	Community Mental Health Services.

	 	Mental Health Targeted Case Management
	 
	 	 
	Family Planning Services

	 	Outpatient Hospital and Emergency Services
	 
	 	 
	Freestanding Dialysis Centers

	 	Physician Services
	 
	 	 
	Hearing Services

	 	Prescribed Drug Services
	 
	 	 
	Home Health Services and Durable Medical

	 	Therapy Services
	Equipment
	 	 
	 
	 	 
	Independent Laboratory and X-Ray Services

	 	Visual Services

The plan shall 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 plan may place appropriate limits on a service
on the basis of criteria such as medical necessity or for utilization
control, consistent with this contract, provided the services furnished
can reasonably be expected to achieve their purpose.

	2.	 	Attachment I, section 10.8.11.2, Hysterectomies, Sterilizations, and
Abortions, is hereby amended to include the following:

     The plan may only provide for abortions in the following situations:

	•	 	If the pregnancy is the result of an act of rape or incest or
	 
	•	 	The physician certifies that the woman is in
danger of death unless an abortion is performed.

	3.	 	Attachment I, section 20.4.1, Fraud Prevention Policies and
Procedures, the first paragraph is hereby amended to now read:

The plan shall have administrative and management arrangements or
procedures and a mandatory compliance plan and shall comply with program
integrity requirement as required in 42 CFR 438.608 to develop and
maintain written policies and procedures for fraud and abuse prevention.
In addition, the policies shall contain the following:

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

 

 

Exhibit 10.25.2

	 	 	 
	AMERIGROUP OF FLORIDA, INC.

	 	Medicaid HMO Contract

	4.	 	Attachment I, section 20.10, Emergency Care Requirements is
hereby amended as follows:

• The first paragraph is hereby
amended to include the following:

In addition, the plan may not deny payment for treatment obtained
when a representative of the plan instructs the enrollee to seek
emergency services.

• Section e. is hereby amended to now read:

If the member’s primary care physician responds to the notification, the
hospital physician and the primary care physician may discuss the
appropriate care and treatment of the member. The plan may have a member
of the hospital staff with whom it has a contract participate in the
treatment of the member within the scope of the physician’s hospital
staff privileges. The member may be transferred, in accordance with
state and federal law, to a hospital that has a contract with the plan
and has the service capability to treat the member’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 or discharge, and that
determination is binding on the entities identified in 42 CFR 438.114(b)
as responsible for coverage and payment. Notwithstanding any other state
law, a hospital may request and collect insurance or financial
information from a patient in accordance with federal law, which is
necessary to determine if the patient is a member of the plan, if
emergency services and care are not delayed.

• Section f. is hereby amended to now read:

In accordance with 42 CFR 438.114 and 42 CFR 422.113(c), the plan must
also cover poststabilization services without authorization,
regardless of whether the beneficiary obtains the service within or
outside the plan’s network for the following situations:

	5.	 	Attachment I, section 20.11, Grievance System Requirements, third
paragraph, Item a., is hereby amended to now read:

	 	a.	 	Enrollee rights to Medicaid fair hearing, the method for
obtaining a hearing, the rules that govern representation at the
hearing, and the DCF address for pursuing a fair hearing, which is
Office of Appeal Hearings, 1317 Winewood Boulevard, Building 5,
Room 203, Tallahassee, Florida 32399-0700.

	6.	 	Attachment I, section 20.1 1.1, Appeal Process, first paragraph, Item
b. 7 (b) is hereby amended to now read:

	 	(b)	 	Information about how to request a Medicaid
fair hearing, including the DCF address for pursuing a fair
hearing, which is Office of Appeal Hearings, 1317 Winewood
Boulevard, Building 5, Room 203, Tallahassee, Florida
32399-0700.

	7.	 	Attachment I, section 20.11.2, Grievance Process is
hereby amended as follows:

•The first paragraph is hereby
amended to include the following:
The grievance process must be completed in time to permit the
disenrollment to be effective in accordance with the timeframe
specified in 42 CFR 438.56(e)(1).

•Item b. 2 (b) is hereby amended to now read:

AHCA Contract No. FA523, Amendment No. 1, Page 2 of 4

 

 

Exhibit 10.25.2

	 	 	 
	AMERIGROUP OF FLORIDA, INC.

	 	Medicaid HMO Contract

	 	(b)	 	Information about how to request a Medicaid
fair hearing, including the DCF address for pursuing a fair
hearing, which is Office of Appeal Hearings, 1317 Winewood
Boulevard, Building 5, Room 203, Tallahassee, Florida
32399-0700.

	8.	 	Attachment I, section 20.11.3, Medicaid Fair Hearing System, Item a,
the second paragraph is hereby amended to now read:

The beneficiary or provider may request a Medicaid fair hearing by
contacting DCF at the Office of Appeal Hearings, 1317 Winewood
Boulevard, Building 5, Room 203 Tallahassee, Florida 32399-0700.

	9.	 	Attachment I, section 30.1 Marketing, Pre-enrollment Materials and
Post-enrollment Materials, Item f. is hereby deleted in it’s entirety.
	 
	10.	 	Attachment I, section 30.7.1, Member Services Handbook, the first
paragraph and sixth line is hereby amended as follows:

....both in and out of the plan’s service area; to include the enrollee
has a right to use any hospital or other setting for emergency use; the
extent to which...

	11.	 	Attachment I, section 40.8, Ownership and Management Disclosure, Item
b.1, the first subparagraph is hereby amended to now read:

Owns, indirectly or directly 5 percent or more of the plan’s
capital or stock, has ownership of 5% or more in a plan’s
provider or subcontractor, or receives 5 percent or more of its
profits;

	12.	 	Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, is
hereby amended effective as provided in Tables 2 and 3 shown below. The
amended rates below apply to services rendered beginning July 1, 2004. Any
capitation claims calculated based on rates different than those indicated
below are subject to recoupment in accordance with Section I.J, of the
Standard Contract.

Table 2.

Area wide Age-banded Capitation Rates for all
agency areas of the state other than Area 6
and Area 1.

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 05	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	345.76	 	 	 	77.31	 	 	 	48.55	 	 	 	53.69	 	 	 	110.74	 	 	 	136.76	 	 	 	208.19	 	 	 	291.55	 	 	 	291.55	 
	SSI/No Medicare
	 	 	3265.62	 	 	 	394.06	 	 	 	204.41	 	 	 	214.18	 	 	 	214.18	 	 	 	612.49	 	 	 	612.49	 	 	 	591.04	 	 	 	591.04	 
	SSI/Part B
	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 
	SSI/Part A & B
	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	216.32	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 07	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	337.19	 	 	 	75.53	 	 	 	47.77	 	 	 	52.81	 	 	 	108.40	 	 	 	134.29	 	 	 	204.16	 	 	 	286.57	 	 	 	286.57	 
	SSI/No Medicare
	 	 	3217.89	 	 	 	389.79	 	 	 	203.90	 	 	 	213.35	 	 	 	213.35	 	 	 	610.58	 	 	 	610.58	 	 	 	589.11	 	 	 	589.11	 
	SSI/Part B
	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 
	SSI/Part A & B
	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	198.62	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 08	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	296.66	 	 	 	66.37	 	 	 	41.76	 	 	 	46.19	 	 	 	95.19	 	 	 	117.62	 	 	 	179.02	 	 	 	250.96	 	 	 	250.96	 
	SSI/No Medicare
	 	 	3079.30	 	 	 	371.80	 	 	 	192.49	 	 	 	201.68	 	 	 	201.68	 	 	 	577.71	 	 	 	577.71	 	 	 	557.45	 	 	 	557.45	 
	SSI/Part B
	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 
	SSI/Part A & B
	 	 	285.08	 	 	 	285.08	 	 	 	265.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	199.47	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 09	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	316.78	 	 	 	70.74	 	 	 	44.52	 	 	 	49.17	 	 	 	101.48	 	 	 	125.24	 	 	 	190.60	 	 	 	266.97	 	 	 	266.97	 
	SSI/No Medicare
	 	 	3344.05	 	 	 	405.22	 	 	 	211.12	 	 	 	221.15	 	 	 	221.15	 	 	 	633.22	 	 	 	633.22	 	 	 	610.93	 	 	 	610.93	 
	SSI/Part B
	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 
	SSI/Part A & B
	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	224.19	 

AHCA Contract No. FA523, Amendment No. 1, Page 3 of 4

 

 

Exhibit 10.25.2

	
AMERIGROUP OF FLORIDA, INC.	Medicaid HMO
Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 10	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	328.74	 	 	 	73.77	 	 	 	46.68	 	 	 	51.61	 	 	 	105.94	 	 	 	131.31	 	 	 	199.49	 	 	 	280.33	 	 	 	280.33	 
	SSI/No Medicare
	 	 	4151.82	 	 	 	503.54	 	 	 	263.75	 	 	 	275.32	 	 	 	275.32	 	 	 	788.23	 	 	 	788.23	 	 	 	761.08	 	 	 	761.08	 
	SSI/Part B
	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 
	SSI/Part A & B
	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	245.95	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 11	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	409.16	 	 	 	91.08	 	 	 	56.97	 	 	 	62.97	 	 	 	130.55	 	 	 	160.40	 	 	 	244.76	 	 	 	341.98	 	 	 	341.98	 
	SSI/No Medicare
	 	 	4551.55	 	 	 	550.33	 	 	 	286.57	 	 	 	299.62	 	 	 	299.62	 	 	 	857.90	 	 	 	857.90	 	 	 	827.83	 	 	 	827.83	 
	SSI/Part B
	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 	 	 	449.17	 
	SSI/Part A & B
	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	416.90	 	 	 	292.00	 

Table 3.

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

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 06	 	< year	 	1-5	 	6-13	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	55-64	 	65+
	TANF/FC/SOBRA
	 	 	330.07	 	 	 	75.91	 	 	 	61.92	 	 	 	67.67	 	 	 	122.23	 	 	 	135.83	 	 	 	204.29	 	 	 	282.98	 	 	 	282.98	 
	SSI/No Medicare
	 	 	3017.05	 	 	 	371.69	 	 	 	265.72	 	 	 	243.82	 	 	 	243.82	 	 	 	647.81	 	 	 	647.81	 	 	 	587.26	 	 	 	587.26	 
	SSI/Part B
	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 
	SSI/Part A & B
	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	202.64	 

	13.	 	Attachment I, section 100.0, Glossary, is hereby amended to include the
following:

Post-stabilization Care Services defined in 42 CFR 438.114, means
covered services, related to an emergency medical condition that are
provided after an enrollee is stabilized in order to maintain the
stabilized condition, or, under the circumstances described in paragraph
(e) of 42 CFR 438.114, to improve or resolve the enrollee’s condition.

	14.	 	This amendment shall begin on August 12, 2004, or the date on which the
amendment has been signed by both parties, whichever is later.

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

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

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

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

          IN WITNESS WHEREOF, the parties hereto have caused this 4 page amendment
(including all attachments) to be executed by their officials thereunto duly
authorized.

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

	 	 	 	SIGNED	 	 
	BY:

	 	/s/ Don Gilmore

	 	BY:
	 	/s/ Alan Levine

	NAME:

	 	Don Gilmore
	 	NAME:
	 	Alan Levine
	

	 	 	 	TITLE:
	 	 Secretary
	TITLE:

	 	CEO	 	 	 	 
	DATE:

	 	8/20/04
	 	DATE:
	 	9/15/04

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

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00073-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00073-of-00352.parquet"}]]