Document:

fa904amendment7.htm

Return to Form 8-k

 

 

  

	 WellCare of Florida, Inc.	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	 AHCA CONTRACT NO. FA904
	 AMENDMENT NO. 7

 

	     THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and WELLCARE OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF FLORIDA, hereinafter referred to as the "Vendor" or “Health Plan”, is hereby amended as follows:

 

	
  

	
1.

	
Effective January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a. is hereby amended to include Table 6-B, Revised Expanded Services, as follows.  All references in the Contract to Table 6, Expanded Services and Table 6-A, Revised Expanded Services, shall hereinafter also refer to Table 6-B, as appropriate.

	
TABLE 6-B

	
Revised Expanded Services

	
Effective January 1, 2012

	
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies.

 

 

	
  

	
2.

	
Effective September 1, 2011, Attachment I, Scope of Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non- Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract.  All references in the Contract to Exhibit 2-NR-B, shall hereinafter also refer to Exhibit 2-NR-C, as appropriate.

 

	
  

	
3.

	
Attachment II, Core Contract Provisions, Section XVI., Terms and Conditions, is hereby amended to include Item HH. as follows:

 

	
  

	
HH.

	 	
Scrutinized Companies Lists

 

	
  

	 	 	
The Vendor shall complete Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, attached hereto and made a part of the Contract, certifying that it is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, created pursuant to section 215.473, Florida Statutes (F.S.). Pursuant to section 287.135(5), F.S., the Vendor agrees the Agency may immediately terminate this Contract for cause if the Vendor is found to have submitted a false certification or if the Vendor is placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities  in  the  Iran  Petroleum  Energy  Sector  List  during  the  term  of  the Contract

 

	
  

	
4.

	
Attachment VI, Vendor Certification Regarding Scrutinized Companies Lists, is hereby attached and made a part of the Contract.

 

	
  

	
 

	
Unless otherwise stated, this amendment is effective upon execution by both Parties.

 

	
  

	
 

	
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the Contract.

 

	
AHCA Contract No. FA904, Amendment No. 7, Page 1 of 2

  

  

  

	
 

 

	
 

 

	WellCare of Florida, Inc.	 Medicaid HMO Non-Reform Contract
	 d/b/a Staywell Health Plan of Florida	 

 

	 	
 

	
This amendment and all its attachments are hereby made a part of the Contract.

 

	 	
 

	
This amendment cannot be executed unles all previous amendments to this Contract have been fully executed.

 

	 	
 

	
IN WITNESS WHEREOF, the Parties hereto have caused this eight (8) page amendment (including all attachments) to be executed by their officials thereunto duly authorized.

 

	
WELLCARE OF FLORIDA, INC., D/B/A

STAYWELL HEALTH PLAN OF FLORIDA

	
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION

	
SIGNED

BY:

	/s/ Christina Cooper	  	
SIGNED

BY:

	
/s/Tonya Kidd for

	 NAME:  	
 

Christina Cooper

	  	NAME: 	
 

Elizabeth Dudek

	 TITLE:  	
 

President, FL & HI Division­­

	  	TITLE:	
 

Secretary

	  

DATE:

	
12/27/11

	  	DATE:	
12/29/11

List of Attachments/Exhibits included as part of this amendment:

 

	
Specify

Type

	
Letter/

Number

	
 

Description

	
 

	
Attachment I

	
Exhibit 2-NR-C

	Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011 (5 pages)	
 

 

	
Attachment

	VI	Vendor Certification Regarding Scrutinized Companies Lists (1Page)	
 

       

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

  

  

  

 

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
General Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE(1-5)

	
AGE(6-13)

	
AGE(14-20)

	
AGE(21-54)

	
AGE(55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE(1-5)

	
AGE(6-13)

	
AGE(14-20)

	
AGE(21-54)

	
AGE(55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.58

	
184.93

	
99.14

	
62.81

	
127.84

	
67.50

	
271.85

	
155.86

	
430.03

	
12,534.08

	
1,853.67

	
459.10

	
183.60

	
219.90

	
719.01

	
846.95

	
304.31

	
95.72

	
75.16

	
02

	
809.74

	
158.54

	
85.26

	
55.17

	
110.84

	
59.12

	
234.16

	
134.73

	
369.40

	
10,634.20

	
1,571.89

	
378.61

	
129.11

	
165.06

	
567.50

	
702.50

	
304.31

	
85.34

	
66.80

	
03

	
977.48

	
191.38

	
102.88

	
66.37

	
133.57

	
71.13

	
282.47

	
162.44

	
445.78

	
13,033.48

	
1,927.78

	
480.73

	
199.09

	
235.25

	
760.70

	
885.63

	
304.31

	
86.58

	
67.80

	
04

	
982.26

	
192.25

	
101.91

	
59.51

	
127.52

	
64.77

	
277.81

	
157.18

	
443.92

	
13,413.62

	
1,983.70

	
490.64

	
194.84

	
234.00

	
766.84

	
905.39

	
304.31

	
79.94

	
62.45

	
05

	
1,109.71

	
217.27

	
116.92

	
75.94

	
152.20

	
81.32

	
321.19

	
184.92

	
506.42

	
14,476.72

	
2,141.09

	
531.81

	
215.85

	
257.04

	
836.50

	
980.51

	
304.31

	
74.93

	
58.42

	
06

	
1,021.04

	
199.94

	
108.39

	
73.89

	
143.78

	
78.57

	
298.90

	
173.52

	
468.21

	
13,062.91

	
1,932.30

	
484.19

	
205.34

	
240.45

	
771.66

	
891.12

	
304.31

	
73.50

	
57.26

	
07

	
966.83

	
189.24

	
100.39

	
58.99

	
125.91

	
64.15

	
273.80

	
155.07

	
437.19

	
13,593.51

	
2,010.10

	
494.41

	
190.58

	
231.59

	
766.17

	
913.39

	
304.31

	
72.84

	
56.74

	
08

	
952.04

	
186.41

	
100.57

	
66.44

	
131.76

	
70.95

	
276.63

	
159.73

	
435.19

	
12,412.16

	
1,835.77

	
456.44

	
186.23

	
221.31

	
719.07

	
841.38

	
304.31

	
80.42

	
62.84

	
09

	
1,032.49

	
202.14

	
108.41

	
68.86

	
139.93

	
73.98

	
297.32

	
170.54

	
470.17

	
14,347.56

	
2,121.42

	
519.54

	
195.54

	
239.92

	
799.72

	
960.67

	
304.31

	
82.17

	
64.25

	
10

	
1,028.53

	
201.37

	
108.26

	
69.90

	
140.62

	
74.92

	
297.28

	
170.98

	
469.11

	
17,915.36

	
2,649.60

	
657.40

	
265.37

	
316.67

	
1,032.39

	
1,212.35

	
304.31

	
92.58

	
72.64

	
11

	
1,187.84

	
232.59

	
125.70

	
84.02

	
165.46

	
89.59

	
346.10

	
200.24

	
543.62

	
15,014.29

	
2,220.47

	
549.99

	
220.03

	
263.49

	
861.45

	
1,014.60

	
304.31

	
120.99

	
95.51

	
6B *

	
1,020.54

	
199.85

	
108.39

	
74.07

	
143.91

	
78.73

	
298.94

	
173.63

	
468.11

	
13,061.73

	
1,932.14

	
484.22

	
205.49

	
240.58

	
771.87

	
891.14

	
304.31

	
73.50

	
57.26

 

TABLE 2

	
General + Mental Health Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE(1-5)

	
AGE(6-13)

	
AGE(14-20)

	
AGE(21-54)

	
AGE(55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE(1-5)

	
AGE(6-13)

	
AGE(14-20)

	
AGE(21-54)

	
AGE(55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.04

	
101.42

	
73.90

	
138.20

	
77.86

	
281.21

	
165.22

	
436.32

	
12,535.85

	
1,855.44

	
479.56

	
233.51

	
260.16

	
798.67

	
877.14

	
321.65

	
105.67

	
85.11

	
02

	
809.82

	
158.62

	
86.94

	
63.35

	
118.47

	
66.75

	
241.06

	
141.63

	
374.03

	
10,636.65

	
1,574.34

	
406.90

	
198.14

	
220.74

	
677.67

	
744.25

	
321.65

	
95.29

	
76.75

	
03

	
977.58

	
191.48

	
104.95

	
76.48

	
143.01

	
80.57

	
291.00

	
170.97

	
451.51

	
13,035.03

	
1,929.33

	
498.65

	
242.81

	
270.52

	
830.48

	
912.07

	
321.65

	
96.53

	
77.75

	
04

	
982.44

	
192.43

	
105.47

	
76.86

	
143.72

	
80.97

	
292.45

	
171.82

	
453.76

	
13,415.57

	
1,985.65

	
513.21

	
249.90

	
278.41

	
854.72

	
938.69

	
321.65

	
89.89

	
72.40

	
05

	
1,109.82

	
217.38

	
119.15

	
86.82

	
162.35

	
91.47

	
330.37

	
194.10

	
512.59

	
14,478.63

	
2,143.00

	
553.88

	
269.70

	
300.48

	
922.45

	
1,013.08

	
321.65

	
84.88

	
68.37

	
06

	
1,021.10

	
200.00

	
109.62

	
79.88

	
149.37

	
84.16

	
303.96

	
178.58

	
471.61

	
13,064.26

	
1,933.65

	
499.77

	
243.36

	
271.12

	
832.34

	
914.11

	
321.65

	
83.45

	
67.21

	
07

	
967.00

	
189.41

	
103.81

	
75.65

	
141.46

	
79.70

	
287.85

	
169.12

	
446.63

	
13,595.73

	
2,012.32

	
520.10

	
253.26

	
282.15

	
866.20

	
951.30

	
321.65

	
82.79

	
66.69

	
08

	
952.12

	
186.49

	
102.22

	
74.49

	
139.28

	
78.47

	
283.42

	
166.52

	
439.76

	
12,413.76

	
1,837.37

	
474.89

	
231.24

	
257.62

	
790.90

	
868.60

	
321.65

	
90.37

	
72.79

	
09

	
1,032.61

	
202.26

	
110.86

	
80.78

	
151.06

	
85.11

	
307.38

	
180.60

	
476.93

	
14,350.11

	
2,123.97

	
548.96

	
267.31

	
297.81

	
914.26

	
1,004.08

	
321.65

	
92.12

	
74.20

	
10

	
1,028.64

	
201.48

	
110.43

	
80.47

	
150.48

	
84.78

	
306.20

	
179.90

	
475.10

	
17,917.79

	
2,652.03

	
685.44

	
333.77

	
371.85

	
1,141.56

	
1,253.72

	
321.65

	
102.53

	
82.59

	
11

	
1,187.93

	
232.68

	
127.53

	
92.93

	
173.78

	
97.91

	
353.62

	
207.76

	
548.67

	
15,016.41

	
2,222.59

	
574.45

	
279.72

	
311.64

	
956.71

	
1,050.70

	
321.65

	
130.94

	
105.46

	
6B *

	
1,020.60

	
199.91

	
109.57

	
79.84

	
149.30

	
84.12

	
303.81

	
178.50

	
471.38

	
13,063.07

	
1,933.48

	
499.73

	
243.33

	
271.10

	
832.26

	
914.03

	
321.65

	
83.45

	
67.21

 

 

  

  AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 1 of 5

  

 

	ATTACHMENT I
	EXHIBIT 2-NR-C
	
MEDICAID NON-REFORM HMO CAPITATION RATES

	ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	
By Area, Age and Eligibility Category

	 Effective September 1, 2011

 

TABLE 3

	
General + MH + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	  
	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.06

	
103.23

	
76.91

	
140.85

	
80.79

	
282.97

	
166.83

	
439.41

	
12,535.91

	
1,855.47

	
481.31

	
235.72

	
262.09

	
800.18

	
879.25

	
323.95

	
106.76

	
86.03

	
02

	
809.83

	
158.64

	
89.86

	
68.21

	
122.74

	
71.49

	
243.79

	
144.12

	
378.82

	
10,636.74

	
1,574.39

	
409.58

	
201.51

	
223.69

	
679.30

	
746.53

	
323.95

	
96.63

	
77.87

	
03

	
977.59

	
191.53

	
110.77

	
86.18

	
151.54

	
90.02

	
294.80

	
174.45

	
458.19

	
13,035.24

	
1,929.45

	
504.95

	
250.74

	
277.45

	
832.71

	
915.19

	
323.95

	
98.64

	
79.52

	
04

	
982.45

	
192.46

	
108.89

	
82.56

	
148.73

	
86.53

	
296.76

	
175.76

	
461.32

	
13,415.69

	
1,985.72

	
516.72

	
254.31

	
282.27

	
857.39

	
942.42

	
323.95

	
92.21

	
74.35

	
05

	
1,109.84

	
217.44

	
125.83

	
97.95

	
172.14

	
102.32

	
334.38

	
197.77

	
519.63

	
14,478.85

	
2,143.13

	
560.70

	
278.28

	
307.98

	
924.69

	
1,016.22

	
323.95

	
87.28

	
70.38

	
06

	
1,021.11

	
200.04

	
114.54

	
88.08

	
156.58

	
92.15

	
306.21

	
180.64

	
475.56

	
13,064.42

	
1,933.74

	
504.77

	
249.66

	
276.62

	
833.92

	
916.32

	
323.95

	
85.20

	
68.68

	
07

	
967.01

	
189.46

	
109.65

	
85.37

	
150.01

	
89.18

	
290.76

	
171.78

	
451.74

	
13,595.93

	
2,012.43

	
526.15

	
260.87

	
288.80

	
868.02

	
953.84

	
323.95

	
84.50

	
68.13

	
08

	
952.14

	
186.58

	
112.21

	
91.13

	
153.91

	
94.69

	
286.81

	
169.62

	
445.71

	
12,414.04

	
1,837.53

	
483.35

	
241.89

	
266.93

	
792.93

	
871.43

	
323.95

	
92.29

	
74.40

	
09

	
1,032.63

	
202.32

	
118.34

	
93.24

	
162.01

	
97.26

	
310.56

	
183.50

	
482.50

	
14,350.33

	
2,124.09

	
555.67

	
275.75

	
305.19

	
916.18

	
1,006.76

	
323.95

	
93.99

	
75.77

	
10

	
1,028.65

	
201.51

	
114.40

	
87.08

	
156.30

	
91.23

	
307.29

	
180.90

	
477.01

	
17,917.96

	
2,652.12

	
690.55

	
340.20

	
377.47

	
1,142.86

	
1,255.53

	
323.95

	
103.74

	
83.61

	
11

	
1,188.00

	
232.75

	
137.40

	
108.70

	
186.71

	
110.84

	
355.80

	
209.75

	
552.50

	
15,016.42

	
2,222.60

	
586.08

	
291.88

	
320.59

	
959.38

	
1,054.43

	
323.95

	
134.01

	
108.03

	
6B *

	
1,020.61

	
199.95

	
114.49

	
88.04

	
156.51

	
92.11

	
306.06

	
180.56

	
475.33

	
13,063.23

	
1,933.57

	
504.73

	
249.63

	
276.60

	
833.84

	
916.24

	
323.95

	
85.20

	
68.68

 

TABLE 4

	
General + MH + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.62

	
187.12

	
102.70

	
74.71

	
140.05

	
80.81

	
284.50

	
169.78

	
440.86

	
12,591.13

	
1,898.82

	
487.69

	
238.50

	
269.54

	
826.05

	
900.84

	
324.43

	
109.55

	
88.28

	
02

	
816.21

	
160.54

	
88.12

	
64.09

	
120.17

	
69.47

	
244.09

	
145.84

	
378.22

	
10,685.88

	
1,612.98

	
414.14

	
202.58

	
229.10

	
702.06

	
765.36

	
324.43

	
98.51

	
79.37

	
03

	
984.48

	
193.55

	
106.22

	
77.28

	
144.85

	
83.50

	
294.27

	
175.51

	
456.03

	
13,083.83

	
1,967.63

	
505.83

	
247.21

	
278.80

	
854.65

	
932.99

	
324.43

	
100.56

	
81.04

	
04

	
988.24

	
194.17

	
106.54

	
77.53

	
145.26

	
83.43

	
295.20

	
175.63

	
457.56

	
13,465.86

	
2,025.12

	
520.61

	
254.44

	
286.95

	
879.63

	
960.26

	
324.43

	
94.30

	
75.99

	
05

	
1,114.99

	
218.93

	
120.10

	
87.42

	
163.73

	
93.67

	
332.82

	
197.50

	
515.98

	
14,525.16

	
2,179.52

	
560.72

	
273.90

	
308.38

	
945.50

	
1,033.03

	
324.43

	
88.93

	
71.67

	
06

	
1,026.36

	
201.58

	
110.59

	
80.49

	
150.77

	
86.40

	
306.46

	
182.04

	
475.06

	
13,112.00

	
1,971.11

	
506.79

	
247.67

	
279.22

	
855.98

	
934.58

	
324.43

	
87.18

	
70.25

	
07

	
972.68

	
191.11

	
104.86

	
76.31

	
142.97

	
82.11

	
290.54

	
172.85

	
450.35

	
13,646.03

	
2,051.80

	
527.50

	
257.80

	
290.69

	
891.11

	
972.87

	
324.43

	
85.88

	
69.21

	
08

	
958.75

	
188.48

	
103.44

	
75.26

	
141.04

	
81.29

	
286.56

	
170.88

	
444.10

	
12,462.04

	
1,875.26

	
481.99

	
235.60

	
265.82

	
814.81

	
889.30

	
324.43

	
93.02

	
74.95

	
09

	
1,039.33

	
204.28

	
112.10

	
81.56

	
152.85

	
87.97

	
310.57

	
185.02

	
481.33

	
14,399.99

	
2,163.12

	
556.29

	
271.81

	
306.28

	
938.96

	
1,025.47

	
324.43

	
96.06

	
77.41

	
10

	
1,034.50

	
203.24

	
111.51

	
81.15

	
152.04

	
87.27

	
308.98

	
183.75

	
478.93

	
17,971.60

	
2,694.26

	
693.35

	
338.63

	
380.98

	
1,168.21

	
1,276.79

	
324.43

	
106.30

	
85.66

	
11

	
1,192.81

	
234.14

	
128.43

	
93.50

	
175.08

	
99.98

	
355.93

	
210.97

	
551.86

	
15,061.69

	
2,258.13

	
581.11

	
283.81

	
319.33

	
979.14

	
1,070.12

	
324.43

	
134.22

	
108.13

	
6B *

	
1,025.86

	
201.49

	
110.54

	
80.45

	
150.70

	
86.36

	
306.31

	
181.96

	
474.83

	
13,110.81

	
1,970.94

	
506.75

	
247.64

	
279.20

	
855.90

	
934.50

	
324.43

	
87.18

	
70.25

 

 

  

ACHAContract No. FA904, Attachment I, Exhibit 2-NR, Page 2 of 5  

  

 

	ATTACHMENT I
	EXHIBIT 2-NR-C
	
MEDICAID NON-REFORM HMO CAPITATION RATES

	
ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS

	
By Area, Age and Eligibility Category

	Effective September 1, 2011

 

	
TABLE 5

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
General + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	 	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE( 55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.51

	
187.01

	
100.42

	
63.62

	
129.69

	
70.45

	
275.14

	
160.42

	
434.57

	
12,589.36

	
1,897.05

	
467.23

	
188.59

	
229.28

	
746.39

	
870.65

	
307.09

	
99.60

	
78.33

	
02

	
816.13

	
160.46

	
86.44

	
55.91

	
112.54

	
61.84

	
237.19

	
138.94

	
373.59

	
10,683.43

	
1,610.53

	
385.85

	
133.55

	
173.42

	
591.89

	
723.61

	
307.09

	
88.56

	
69.42

	
03

	
984.38

	
193.45

	
104.15

	
67.17

	
135.41

	
74.06

	
285.74

	
166.98

	
450.30

	
13,082.28

	
1,966.08

	
487.91

	
203.49

	
243.53

	
784.87

	
906.55

	
307.09

	
90.61

	
71.09

	
04

	
988.06

	
193.99

	
102.98

	
60.18

	
129.06

	
67.23

	
280.56

	
160.99

	
447.72

	
13,463.91

	
2,023.17

	
498.04

	
199.38

	
242.54

	
791.75

	
926.96

	
307.09

	
84.35

	
66.04

	
05

	
1,114.88

	
218.82

	
117.87

	
76.54

	
153.58

	
83.52

	
323.64

	
188.32

	
509.81

	
14,523.25

	
2,177.61

	
538.65

	
220.05

	
264.94

	
859.55

	
1,000.46

	
307.09

	
78.98

	
61.72

	
06

	
1,026.30

	
201.52

	
109.36

	
74.50

	
145.18

	
80.81

	
301.40

	
176.98

	
471.66

	
13,110.65

	
1,969.76

	
491.21

	
209.65

	
248.55

	
795.30

	
911.59

	
307.09

	
77.23

	
60.30

	
07

	
972.51

	
190.94

	
101.44

	
59.65

	
127.42

	
66.56

	
276.49

	
158.80

	
440.91

	
13,643.81

	
2,049.58

	
501.81

	
195.12

	
240.13

	
791.08

	
934.96

	
307.09

	
75.93

	
59.26

	
08

	
958.67

	
188.40

	
101.79

	
67.21

	
133.52

	
73.77

	
279.77

	
164.09

	
439.53

	
12,460.44

	
1,873.66

	
463.54

	
190.59

	
229.51

	
742.98

	
862.08

	
307.09

	
83.07

	
65.00

	
09

	
1,039.21

	
204.16

	
109.65

	
69.64

	
141.72

	
76.84

	
300.51

	
174.96

	
474.57

	
14,397.44

	
2,160.57

	
526.87

	
200.04

	
248.39

	
824.42

	
982.06

	
307.09

	
86.11

	
67.46

	
10

	
1,034.39

	
203.13

	
109.34

	
70.58

	
142.18

	
77.41

	
300.06

	
174.83

	
472.94

	
17,969.17

	
2,691.83

	
665.31

	
270.23

	
325.80

	
1,059.04

	
1,235.42

	
307.09

	
96.35

	
75.71

	
11

	
1,192.72

	
234.05

	
126.60

	
84.59

	
166.76

	
91.66

	
348.41

	
203.45

	
546.81

	
15,059.57

	
2,256.01

	
556.65

	
224.12

	
271.18

	
883.88

	
1,034.02

	
307.09

	
124.27

	
98.18

	
6B *

	
1,025.80

	
201.43

	
109.36

	
74.68

	
145.31

	
80.97

	
301.44

	
177.09

	
471.56

	
13,109.47

	
1,969.60

	
491.24

	
209.80

	
248.68

	
795.51

	
911.61

	
307.09

	
77.23

	
60.30

 

 

TABLE 6

	
General + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.58

	
184.95

	
100.95

	
65.82

	
130.49

	
70.43

	
273.61

	
157.47

	
433.12

	
12,534.14

	
1,853.70

	
460.85

	
185.81

	
221.83

	
720.52

	
849.06

	
306.61

	
96.81

	
76.08

	
02

	
809.75

	
158.56

	
88.18

	
60.03

	
115.11

	
63.86

	
236.89

	
137.22

	
374.19

	
10,634.29

	
1,571.94

	
381.29

	
132.48

	
168.01

	
569.13

	
704.78

	
306.61

	
86.68

	
67.92

	
03

	
977.49

	
191.43

	
108.70

	
76.07

	
142.10

	
80.58

	
286.27

	
165.92

	
452.46

	
13,033.69

	
1,927.90

	
487.03

	
207.02

	
242.18

	
762.93

	
888.75

	
306.61

	
88.69

	
69.57

	
04

	
982.27

	
192.28

	
105.33

	
65.21

	
132.53

	
70.33

	
282.12

	
161.12

	
451.48

	
13,413.74

	
1,983.77

	
494.15

	
199.25

	
237.86

	
769.51

	
909.12

	
306.61

	
82.26

	
64.40

	
05

	
1,109.73

	
217.33

	
123.60

	
87.07

	
161.99

	
92.17

	
325.20

	
188.59

	
513.46

	
14,476.94

	
2,141.22

	
538.63

	
224.43

	
264.54

	
838.74

	
983.65

	
306.61

	
77.33

	
60.43

	
06

	
1,021.05

	
199.98

	
113.31

	
82.09

	
150.99

	
86.56

	
301.15

	
175.58

	
472.16

	
13,063.07

	
1,932.39

	
489.19

	
211.64

	
245.95

	
773.24

	
893.33

	
306.61

	
75.25

	
58.73

	
07

	
966.84

	
189.29

	
106.23

	
68.71

	
134.46

	
73.63

	
276.71

	
157.73

	
442.30

	
13,593.71

	
2,010.21

	
500.46

	
198.19

	
238.24

	
767.99

	
915.93

	
306.61

	
74.55

	
58.18

	
08

	
952.06

	
186.50

	
110.56

	
83.08

	
146.39

	
87.17

	
280.02

	
162.83

	
441.14

	
12,412.44

	
1,835.93

	
464.90

	
196.88

	
230.62

	
721.10

	
844.21

	
306.61

	
82.34

	
64.45

	
09

	
1,032.51

	
202.20

	
115.89

	
81.32

	
150.88

	
86.13

	
300.50

	
173.44

	
475.74

	
14,347.78

	
2,121.54

	
526.25

	
203.98

	
247.30

	
801.64

	
963.35

	
306.61

	
84.04

	
65.82

	
10

	
1,028.54

	
201.40

	
112.23

	
76.51

	
146.44

	
81.37

	
298.37

	
171.98

	
471.02

	
17,915.53

	
2,649.69

	
662.51

	
271.80

	
322.29

	
1,033.69

	
1,214.16

	
306.61

	
93.79

	
73.66

	
11

	
1,187.91

	
232.66

	
135.57

	
99.79

	
178.39

	
102.52

	
348.28

	
202.23

	
547.45

	
15,014.30

	
2,220.48

	
561.62

	
232.19

	
272.44

	
864.12

	
1,018.33

	
306.61

	
124.06

	
98.08

	
6B *

	
1,020.55

	
199.89

	
113.31

	
82.27

	
151.12

	
86.72

	
301.19

	
175.69

	
472.06

	
13,061.89

	
1,932.23

	
489.22

	
211.79

	
246.08

	
773.45

	
893.35

	
306.61

	
75.25

	
58.73

  

  AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 3 of 5

  

 

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
TABLE 7

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
General + Dental + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.51

	
187.03

	
102.23

	
66.63

	
132.34

	
73.38

	
276.90

	
162.03

	
437.66

	
12,589.42

	
1,897.08

	
468.98

	
190.80

	
231.21

	
747.90

	
872.76

	
309.39

	
100.69

	
79.25

	
02

	
816.14

	
160.48

	
89.36

	
60.77

	
116.81

	
66.58

	
239.92

	
141.43

	
378.38

	
10,683.52

	
1,610.58

	
388.53

	
136.92

	
176.37

	
593.52

	
725.89

	
309.39

	
89.90

	
70.54

	
03

	
984.39

	
193.50

	
109.97

	
76.87

	
143.94

	
83.51

	
289.54

	
170.46

	
456.98

	
13,082.49

	
1,966.20

	
494.21

	
211.42

	
250.46

	
787.10

	
909.67

	
309.39

	
92.72

	
72.86

	
04

	
988.07

	
194.02

	
106.40

	
65.88

	
134.07

	
72.79

	
284.87

	
164.93

	
455.28

	
13,464.03

	
2,023.24

	
501.55

	
203.79

	
246.40

	
794.42

	
930.69

	
309.39

	
86.67

	
67.99

	
05

	
1,114.90

	
218.88

	
124.55

	
87.67

	
163.37

	
94.37

	
327.65

	
191.99

	
516.85

	
14,523.47

	
2,177.74

	
545.47

	
228.63

	
272.44

	
861.79

	
1,003.60

	
309.39

	
81.38

	
63.73

	
06

	
1,026.31

	
201.56

	
114.28

	
82.70

	
152.39

	
88.80

	
303.65

	
179.04

	
475.61

	
13,110.81

	
1,969.85

	
496.21

	
215.95

	
254.05

	
796.88

	
913.80

	
309.39

	
78.98

	
61.77

	
07

	
972.52

	
190.99

	
107.28

	
69.37

	
135.97

	
76.04

	
279.40

	
161.46

	
446.02

	
13,644.01

	
2,049.69

	
507.86

	
202.73

	
246.78

	
792.90

	
937.50

	
309.39

	
77.64

	
60.70

	
08

	
958.69

	
188.49

	
111.78

	
83.85

	
148.15

	
89.99

	
283.16

	
167.19

	
445.48

	
12,460.72

	
1,873.82

	
472.00

	
201.24

	
238.82

	
745.01

	
864.91

	
309.39

	
84.99

	
66.61

	
09

	
1,039.23

	
204.22

	
117.13

	
82.10

	
152.67

	
88.99

	
303.69

	
177.86

	
480.14

	
14,397.66

	
2,160.69

	
533.58

	
208.48

	
255.77

	
826.34

	
984.74

	
309.39

	
87.98

	
69.03

	
10

	
1,034.40

	
203.16

	
113.31

	
77.19

	
148.00

	
83.86

	
301.15

	
175.83

	
474.85

	
17,969.34

	
2,691.92

	
670.42

	
276.66

	
331.42

	
1,060.34

	
1,237.23

	
309.39

	
97.56

	
76.73

	
11

	
1,192.79

	
234.12

	
136.47

	
100.36

	
179.69

	
104.59

	
350.59

	
205.44

	
550.64

	
15,059.58

	
2,256.02

	
568.28

	
236.28

	
280.13

	
886.55

	
1,037.75

	
309.39

	
127.34

	
100.75

	
6B *

	
1,025.81

	
201.47

	
114.28

	
82.88

	
152.52

	
88.96

	
303.69

	
179.15

	
475.51

	
13,109.63

	
1,969.69

	
496.24

	
216.10

	
254.18

	
797.09

	
913.82

	
309.39

	
78.98

	
61.77

 

 

TABLE 8

	
General + Mental Health + Dental + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.62

	
187.14

	
104.51

	
77.72

	
142.70

	
83.74

	
286.26

	
171.39

	
443.95

	
12,591.19

	
1,898.85

	
489.44

	
240.71

	
271.47

	
827.56

	
902.95

	
326.73

	
110.64

	
89.20

	
02

	
816.22

	
160.56

	
91.04

	
68.95

	
124.44

	
74.21

	
246.82

	
148.33

	
383.01

	
10,685.97

	
1,613.03

	
416.82

	
205.95

	
232.05

	
703.69

	
767.64

	
326.73

	
99.85

	
80.49

	
03

	
984.49

	
193.60

	
112.04

	
86.98

	
153.38

	
92.95

	
298.07

	
178.99

	
462.71

	
13,084.04

	
1,967.75

	
512.13

	
255.14

	
285.73

	
856.88

	
936.11

	
326.73

	
102.67

	
82.81

	
04

	
988.25

	
194.20

	
109.96

	
83.23

	
150.27

	
88.99

	
299.51

	
179.57

	
465.12

	
13,465.98

	
2,025.19

	
524.12

	
258.85

	
290.81

	
882.30

	
963.99

	
326.73

	
96.62

	
77.94

	
05

	
1,115.01

	
218.99

	
126.78

	
98.55

	
173.52

	
104.52

	
336.83

	
201.17

	
523.02

	
14,525.38

	
2,179.65

	
567.54

	
282.48

	
315.88

	
947.74

	
1,036.17

	
326.73

	
91.33

	
73.68

	
06

	
1,026.37

	
201.62

	
115.51

	
88.69

	
157.98

	
94.39

	
308.71

	
184.10

	
479.01

	
13,112.16

	
1,971.20

	
511.79

	
253.97

	
284.72

	
857.56

	
936.79

	
326.73

	
88.93

	
71.72

	
07

	
972.69

	
191.16

	
110.70

	
86.03

	
151.52

	
91.59

	
293.45

	
175.51

	
455.46

	
13,646.23

	
2,051.91

	
533.55

	
265.41

	
297.34

	
892.93

	
975.41

	
326.73

	
87.59

	
70.65

	
08

	
958.77

	
188.57

	
113.43

	
91.90

	
155.67

	
97.51

	
289.95

	
173.98

	
450.05

	
12,462.32

	
1,875.42

	
490.45

	
246.25

	
275.13

	
816.84

	
892.13

	
326.73

	
94.94

	
76.50

	
09

	
1,039.35

	
204.34

	
119.58

	
94.02

	
163.80

	
100.12

	
313.75

	
187.92

	
486.90

	
14,400.21

	
2,163.24

	
563.00

	
280.25

	
313.66

	
940.88

	
1,028.15

	
326.73

	
97.93

	
78.98

	
10

	
1,034.51

	
203.27

	
115.48

	
87.76

	
157.86

	
93.72

	
310.07

	
184.75

	
480.84

	
17,971.77

	
2,694.35

	
698.46

	
345.06

	
386.60

	
1,169.51

	
1,278.60

	
326.73

	
107.51

	
86.68

	
11

	
1,192.88

	
234.21

	
138.30

	
109.27

	
188.01

	
112.91

	
358.11

	
212.96

	
555.69

	
15,061.70

	
2,258.14

	
592.74

	
295.97

	
328.28

	
981.81

	
1,073.85

	
326.73

	
137.29

	
110.70

	
6B *

	
1,025.87

	
201.53

	
115.46

	
88.65

	
157.91

	
94.35

	
308.56

	
184.02

	
478.78

	
13,110.97

	
1,971.03

	
511.75

	
253.94

	
284.70

	
857.48

	
936.71

	
326.73

	
88.93

	
71.72

  

AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 4 of 5

  

 

	ATTACHMENT I 
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
Area

	
Corresponding  Counties

	  	  
	
Area 1

	
Escambia, Okaloosa, Santa Rosa, Walton

	
Area 2

	
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla

	
Area 3

	
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union

	
Area 4

	
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia

	
Area 5

	
Pasco, Pinellas

	
Area 6

	
Hardee, Highlands, Manatee, Polk

	
Area 6B *

	
Hillsborough

	
Area 7

	
Brevard, Orange, Osceola, Seminole

	
Area 8

	
Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota

	
Area 9

	
Indian River, Okeechobee, St. Lucie, Martin, Palm Beach

	
Area 10

	
Broward

	
Area 11

	
Dade, Monroe

  

AHCA Contract No. FA904, Attachment I, Exhibit 2-NR-C, Page 5 of 5

  

 

	 ATTACHMENT VI
	 VENDOR CERTIFICATION REGARDING
	 SCRUTINIZED COMPANIES LIST

 

	 

	 	 	 	 
	Vendor Name:	 WellCare of Florida Inc.	 	 

	 

	Vendor FEIN:	 59-2583622	 	 

	 

	Vendor's Authorized Representative Name and Title:	Christina Cooper, President	 	 

	 

	Address:	 8735 Henderson Road	 

	 	 	 
	City:	Tampa	 State:	FL	 Zip:	33634	 

	 	 	 
	Telephone Number:	813-206-3213	 	 

	 	 	 
	Email Address:	chrissie.cooper@wellcare.com	 
	 	 	 
	 	 	 

 

 

	Section 287.135, Florida Statutes, prohibits agencies from contracting with companies, for goods or services over $1,000,000, that are on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  Both lists are created pursuant to section 215.473, Florida Statutes.

 

	As the person authorized to sign on behalf of the Vendor, I hereby certify that the company identified above in the section entitled "Vendor Name" is not listed on either the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List.  I understand that pursuant to section 287.135, Florida Statutes, the submission of a false certification may subject company to civil penalties, attorney's fees, and/or costs.

 

 

	 	 	 	 
	 	 	 	 
	Certified By:	/s/Christina Cooper	 ,	 
	 	 	 	 
	who is authorized to sign on behalf of the above referenced company.	 	 
	 	 	 	 
	Authorized Signature Print Name and Title:	Christina Cooper, President	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 
	 	 	 	 

 

 

AHCA Contract No. FA904, Attachment VI, Page 1of 1fa905amendment8.htm

Return to Form 8-k

 

	 HealthEase of Florida, Inc.	 	 Medicaid HMO Non-Reform Contract
	 	AHCA CONTRACT NO. FA905	 
	 	AMENDMENT NO. 8	 
	 	 	 

 

	 	THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE  ADMINISTRATION,  hereinafter  referred  to  as  the  "Agency"  and  HEALTHEASE  OF FLORIDA, INC., hereinafter referred to as the "Vendor" or “Health Plan,” is hereby amended as follows:

 

	 	
1.

	
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 1., Covered Medicaid Services, sub-item b.(3)(c), is hereby amended to include Table 5-A, Revised Health Plan Covered Services Chart, as follows.  All references in the Contract to Table 5, Health Plan Covered Services Chart shall hereinafter also refer to Table 5-A, Revised Health Plan Covered Services Chart, as appropriate.

 

 

	
TABLE 5-A

	
Revised Health Plan Covered Services Chart

	
Non- Reform Covered

	
Reform

Covered

	
Advanced Registered Nurse Practitioner Services

	
X

	  
	
Ambulatory Surgical Center Services

	
X

	  
	
Birth Center Services

	
X

	  
	
Child Health Check-Up Services

	
X

	  
	
Chiropractic Services

	
X

	  
	
Community Behavioral Health Services

	
X

	  
	
County Health Department Services

	
X

	  
	
Dental Services*

	  	  
	
Durable Medical Equipment and Medical Supplies

	
X

	  
	
Dialysis Services

	
X

	  
	
Emergency Room Services

	
X

	  
	
Family Planning Services

	
X

	  
	
Federally Qualified Health Center Services

	
X

	  
	
Frail/Elderly Program Services*

	  	  
	
Freestanding Dialysis Centers

	
X

	  
	
Hearing Services

	
X

	  
	
Home Health Care Services

	
X

	  
	
Hospital Services – Inpatient

	
X

	  
	
Hospital Services – Outpatient

	
X

	  
	
Immunizations

	
X

	  
	
Independent Laboratory Services

	
X

	  
	
Licensed Midwife Services

	
X

	  
	
Optometric Services

	
X

	  
	
Physician Services

	
X

	  
	
Physician Assistant Services

	
X

	  
	
Podiatry Services

	
X

	  

 

 AHCA Contract No. FA905, Amendment No. 8, Page 1 of 3

  

 

	HealthEase of Florida, Inc.	 	 Medicaid HMO Non-Reform Contract

	
TABLE 5-A

	  	  
	
Revised Health Plan Covered Services Chart

	
Non- Reform Covered

	
Reform

Covered

	
Portable X-ray Services

	
X

	  
	
Prescribed Drugs

	
X

	  
	
Prescribed Pediatric Extended Care Services

	  	  
	
Primary Care Case Management Services

	
X

	  
	    Private Duty Nursing (for Specialty Plan for Children with Chronic Conditions ONLY)	 	
 

	
Rural Health Clinic Services

	
X

	  
	
Targeted Case Management

	
X

	  
	
Therapy Services: Occupational

	
X

	  
	
Therapy Services: Physical

	
X

	  
	
Therapy Services: Respiratory

	
X

	  
	
Therapy Services: Speech

	
X

	  
	
Transplant Services

	
X

	  
	
Transportation Services*

	  	  
	
Vision Services

	
X

	  

 

 

 

	 	
2.

	
Effective, January 1, 2012, Attachment I, Scope of Services, Capitated Health Plans, Section D., Service(s) to be Provided, Item 2., Approved Expanded Benefits, sub-item a., is hereby amended to include Table 6-B, Revised Expanded Services, as follows.  All references in the Contract to Table 6, Expanded Services, and Table 6-A, Revised Expanded Services shall hereinafter also refer to Table 6-B, as appropriate.

 

	
TABLE 6-B

	
Revised Expanded Services

	
Effective January 1, 2012

	
Up to $25 credit per household each month for selected over the counter drugs and/or health supplies.

 

 

	 	
3.  

	
Effective September 1, 2011, Attachment I, Scope of  Services, Capitated Health Plans, Exhibit 2-NR-B, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2010, is hereby deleted in its entirety and replaced with Exhibit 2-NR-C, Medicaid Non-Reform HMO Capitation Rates, Effective September 1, 2011, attached hereto and made a part of this Contract.  All references in the Contract to Exhibit 2-NR-B, shall hereinafter refer to Exhibit 2- NR-C, as appropriate.

 

	 	Unless otherwise stated, this amendment is effective upon execution.

 

	 	All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the Contract. 

 

	 	This amendment, and all its attachments, are hereby made part of the Contract.

 

AHCA Contract No. FA905, Amendment No. 8, Page 2 of 3

  

  

 

	HealthEase of Florida, Inc.	 	 Medicaid HMO Non-Reform 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 eight (8) page amendment (including all attachments) to be executed by their officials thereunto duly authorized.

 

	HEALTHEASE OF FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR 	 
	 	 	HEALTH CARE ADMINISTRATION	 
	 	 	 	 
	By:	/s/Christina Cooper	 	By:	/s/ Tonya Kidd for	 
	 	 	 	 
	Name:	Christina Cooper	 	Name:	Elizabeth Dudek	 
	 	 	 	 
	Title: 	President, FL & HI Division	 	Title:	Secretary	 
	 	 	 	 
	Date:  	12/27/11	 	Date:	12/29/11	 

 

 

List of Attachments/Exhibits included as part of this amendment:

 

 

	
Specify

Type

	
Letter/

Number

	
 

Description

	 Attachment I	Exhibit 2-NR-C	
Medicaid Non-Reform HMO Capitation Rates, 

Effective September 1, 2011 (5 pages)

 

 

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

  AHCA Contract No. FA905, Amendment No. 8, Page 3 of 3

  

  

 

 

 

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
General Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.58

	
184.93

	
99.14

	
62.81

	
127.84

	
67.50

	
271.85

	
155.86

	
430.03

	
12,534.08

	
1,853.67

	
459.10

	
183.60

	
219.90

	
719.01

	
846.95

	
304.31

	
95.72

	
75.16

	
02

	
809.74

	
158.54

	
85.26

	
55.17

	
110.84

	
59.12

	
234.16

	
134.73

	
369.40

	
10,634.20

	
1,571.89

	
378.61

	
129.11

	
165.06

	
567.50

	
702.50

	
304.31

	
85.34

	
66.80

	
03

	
977.48

	
191.38

	
102.88

	
66.37

	
133.57

	
71.13

	
282.47

	
162.44

	
445.78

	
13,033.48

	
1,927.78

	
480.73

	
199.09

	
235.25

	
760.70

	
885.63

	
304.31

	
86.58

	
67.80

	
04

	
982.26

	
192.25

	
101.91

	
59.51

	
127.52

	
64.77

	
277.81

	
157.18

	
443.92

	
13,413.62

	
1,983.70

	
490.64

	
194.84

	
234.00

	
766.84

	
905.39

	
304.31

	
79.94

	
62.45

	
05

	
1,109.71

	
217.27

	
116.92

	
75.94

	
152.20

	
81.32

	
321.19

	
184.92

	
506.42

	
14,476.72

	
2,141.09

	
531.81

	
215.85

	
257.04

	
836.50

	
980.51

	
304.31

	
74.93

	
58.42

	
06

	
1,021.04

	
199.94

	
108.39

	
73.89

	
143.78

	
78.57

	
298.90

	
173.52

	
468.21

	
13,062.91

	
1,932.30

	
484.19

	
205.34

	
240.45

	
771.66

	
891.12

	
304.31

	
73.50

	
57.26

	
07

	
966.83

	
189.24

	
100.39

	
58.99

	
125.91

	
64.15

	
273.80

	
155.07

	
437.19

	
13,593.51

	
2,010.10

	
494.41

	
190.58

	
231.59

	
766.17

	
913.39

	
304.31

	
72.84

	
56.74

	
08

	
952.04

	
186.41

	
100.57

	
66.44

	
131.76

	
70.95

	
276.63

	
159.73

	
435.19

	
12,412.16

	
1,835.77

	
456.44

	
186.23

	
221.31

	
719.07

	
841.38

	
304.31

	
80.42

	
62.84

	
09

	
1,032.49

	
202.14

	
108.41

	
68.86

	
139.93

	
73.98

	
297.32

	
170.54

	
470.17

	
14,347.56

	
2,121.42

	
519.54

	
195.54

	
239.92

	
799.72

	
960.67

	
304.31

	
82.17

	
64.25

	
10

	
1,028.53

	
201.37

	
108.26

	
69.90

	
140.62

	
74.92

	
297.28

	
170.98

	
469.11

	
17,915.36

	
2,649.60

	
657.40

	
265.37

	
316.67

	
1,032.39

	
1,212.35

	
304.31

	
92.58

	
72.64

	
11

	
1,187.84

	
232.59

	
125.70

	
84.02

	
165.46

	
89.59

	
346.10

	
200.24

	
543.62

	
15,014.29

	
2,220.47

	
549.99

	
220.03

	
263.49

	
861.45

	
1,014.60

	
304.31

	
120.99

	
95.51

	
6B *

	
1,020.54

	
199.85

	
108.39

	
74.07

	
143.91

	
78.73

	
298.94

	
173.63

	
468.11

	
13,061.73

	
1,932.14

	
484.22

	
205.49

	
240.58

	
771.87

	
891.14

	
304.31

	
73.50

	
57.26

 

 

TABLE 2

	
General + Mental Health Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.04

	
101.42

	
73.90

	
138.20

	
77.86

	
281.21

	
165.22

	
436.32

	
12,535.85

	
1,855.44

	
479.56

	
233.51

	
260.16

	
798.67

	
877.14

	
321.65

	
105.67

	
85.11

	
02

	
809.82

	
158.62

	
86.94

	
63.35

	
118.47

	
66.75

	
241.06

	
141.63

	
374.03

	
10,636.65

	
1,574.34

	
406.90

	
198.14

	
220.74

	
677.67

	
744.25

	
321.65

	
95.29

	
76.75

	
03

	
977.58

	
191.48

	
104.95

	
76.48

	
143.01

	
80.57

	
291.00

	
170.97

	
451.51

	
13,035.03

	
1,929.33

	
498.65

	
242.81

	
270.52

	
830.48

	
912.07

	
321.65

	
96.53

	
77.75

	
04

	
982.44

	
192.43

	
105.47

	
76.86

	
143.72

	
80.97

	
292.45

	
171.82

	
453.76

	
13,415.57

	
1,985.65

	
513.21

	
249.90

	
278.41

	
854.72

	
938.69

	
321.65

	
89.89

	
72.40

	
05

	
1,109.82

	
217.38

	
119.15

	
86.82

	
162.35

	
91.47

	
330.37

	
194.10

	
512.59

	
14,478.63

	
2,143.00

	
553.88

	
269.70

	
300.48

	
922.45

	
1,013.08

	
321.65

	
84.88

	
68.37

	
06

	
1,021.10

	
200.00

	
109.62

	
79.88

	
149.37

	
84.16

	
303.96

	
178.58

	
471.61

	
13,064.26

	
1,933.65

	
499.77

	
243.36

	
271.12

	
832.34

	
914.11

	
321.65

	
83.45

	
67.21

	
07

	
967.00

	
189.41

	
103.81

	
75.65

	
141.46

	
79.70

	
287.85

	
169.12

	
446.63

	
13,595.73

	
2,012.32

	
520.10

	
253.26

	
282.15

	
866.20

	
951.30

	
321.65

	
82.79

	
66.69

	
08

	
952.12

	
186.49

	
102.22

	
74.49

	
139.28

	
78.47

	
283.42

	
166.52

	
439.76

	
12,413.76

	
1,837.37

	
474.89

	
231.24

	
257.62

	
790.90

	
868.60

	
321.65

	
90.37

	
72.79

	
09

	
1,032.61

	
202.26

	
110.86

	
80.78

	
151.06

	
85.11

	
307.38

	
180.60

	
476.93

	
14,350.11

	
2,123.97

	
548.96

	
267.31

	
297.81

	
914.26

	
1,004.08

	
321.65

	
92.12

	
74.20

	
10

	
1,028.64

	
201.48

	
110.43

	
80.47

	
150.48

	
84.78

	
306.20

	
179.90

	
475.10

	
17,917.79

	
2,652.03

	
685.44

	
333.77

	
371.85

	
1,141.56

	
1,253.72

	
321.65

	
102.53

	
82.59

	
11

	
1,187.93

	
232.68

	
127.53

	
92.93

	
173.78

	
97.91

	
353.62

	
207.76

	
548.67

	
15,016.41

	
2,222.59

	
574.45

	
279.72

	
311.64

	
956.71

	
1,050.70

	
321.65

	
130.94

	
105.46

	
6B *

	
1,020.60

	
199.91

	
109.57

	
79.84

	
149.30

	
84.12

	
303.81

	
178.50

	
471.38

	
13,063.07

	
1,933.48

	
499.73

	
243.33

	
271.10

	
832.26

	
914.03

	
321.65

	
83.45

	
67.21

  

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 1 of 5  

  

 

 

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

 

	
 

TABLE 3

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
General + MH + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	  
	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.69

	
185.06

	
103.23

	
76.91

	
140.85

	
80.79

	
282.97

	
166.83

	
439.41

	
12,535.91

	
1,855.47

	
481.31

	
235.72

	
262.09

	
800.18

	
879.25

	
323.95

	
106.76

	
86.03

	
02

	
809.83

	
158.64

	
89.86

	
68.21

	
122.74

	
71.49

	
243.79

	
144.12

	
378.82

	
10,636.74

	
1,574.39

	
409.58

	
201.51

	
223.69

	
679.30

	
746.53

	
323.95

	
96.63

	
77.87

	
03

	
977.59

	
191.53

	
110.77

	
86.18

	
151.54

	
90.02

	
294.80

	
174.45

	
458.19

	
13,035.24

	
1,929.45

	
504.95

	
250.74

	
277.45

	
832.71

	
915.19

	
323.95

	
98.64

	
79.52

	
04

	
982.45

	
192.46

	
108.89

	
82.56

	
148.73

	
86.53

	
296.76

	
175.76

	
461.32

	
13,415.69

	
1,985.72

	
516.72

	
254.31

	
282.27

	
857.39

	
942.42

	
323.95

	
92.21

	
74.35

	
05

	
1,109.84

	
217.44

	
125.83

	
97.95

	
172.14

	
102.32

	
334.38

	
197.77

	
519.63

	
14,478.85

	
2,143.13

	
560.70

	
278.28

	
307.98

	
924.69

	
1,016.22

	
323.95

	
87.28

	
70.38

	
06

	
1,021.11

	
200.04

	
114.54

	
88.08

	
156.58

	
92.15

	
306.21

	
180.64

	
475.56

	
13,064.42

	
1,933.74

	
504.77

	
249.66

	
276.62

	
833.92

	
916.32

	
323.95

	
85.20

	
68.68

	
07

	
967.01

	
189.46

	
109.65

	
85.37

	
150.01

	
89.18

	
290.76

	
171.78

	
451.74

	
13,595.93

	
2,012.43

	
526.15

	
260.87

	
288.80

	
868.02

	
953.84

	
323.95

	
84.50

	
68.13

	
08

	
952.14

	
186.58

	
112.21

	
91.13

	
153.91

	
94.69

	
286.81

	
169.62

	
445.71

	
12,414.04

	
1,837.53

	
483.35

	
241.89

	
266.93

	
792.93

	
871.43

	
323.95

	
92.29

	
74.40

	
09

	
1,032.63

	
202.32

	
118.34

	
93.24

	
162.01

	
97.26

	
310.56

	
183.50

	
482.50

	
14,350.33

	
2,124.09

	
555.67

	
275.75

	
305.19

	
916.18

	
1,006.76

	
323.95

	
93.99

	
75.77

	
10

	
1,028.65

	
201.51

	
114.40

	
87.08

	
156.30

	
91.23

	
307.29

	
180.90

	
477.01

	
17,917.96

	
2,652.12

	
690.55

	
340.20

	
377.47

	
1,142.86

	
1,255.53

	
323.95

	
103.74

	
83.61

	
11

	
1,188.00

	
232.75

	
137.40

	
108.70

	
186.71

	
110.84

	
355.80

	
209.75

	
552.50

	
15,016.42

	
2,222.60

	
586.08

	
291.88

	
320.59

	
959.38

	
1,054.43

	
323.95

	
134.01

	
108.03

	
6B *

	
1,020.61

	
199.95

	
114.49

	
88.04

	
156.51

	
92.11

	
306.06

	
180.56

	
475.33

	
13,063.23

	
1,933.57

	
504.73

	
249.63

	
276.60

	
833.84

	
916.24

	
323.95

	
85.20

	
68.68

 

 

 

TABLE 4

	
General + MH + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	
TANF

	  	  	  	  	  	  	
SSI-N

	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.62

	
187.12

	
102.70

	
74.71

	
140.05

	
80.81

	
284.50

	
169.78

	
440.86

	
12,591.13

	
1,898.82

	
487.69

	
238.50

	
269.54

	
826.05

	
900.84

	
324.43

	
109.55

	
88.28

	
02

	
816.21

	
160.54

	
88.12

	
64.09

	
120.17

	
69.47

	
244.09

	
145.84

	
378.22

	
10,685.88

	
1,612.98

	
414.14

	
202.58

	
229.10

	
702.06

	
765.36

	
324.43

	
98.51

	
79.370

	
03

	
984.48

	
193.55

	
106.22

	
77.28

	
144.85

	
83.50

	
294.27

	
175.51

	
456.03

	
13,083.83

	
1,967.63

	
505.83

	
247.21

	
278.80

	
854.65

	
932.99

	
324.43

	
100.56

	
81.04

	
04

	
988.24

	
194.17

	
106.54

	
77.53

	
145.26

	
83.43

	
295.20

	
175.63

	
457.56

	
13,465.86

	
2,025.12

	
520.61

	
254.44

	
286.95

	
879.63

	
960.26

	
324.43

	
94.30

	
75.99

	
05

	
1,114.99

	
218.93

	
120.10

	
87.42

	
163.73

	
93.67

	
332.82

	
197.50

	
515.98

	
14,525.16

	
2,179.52

	
560.72

	
273.90

	
308.38

	
945.50

	
1,033.03

	
324.43

	
88.93

	
71.67

	
06

	
1,026.36

	
201.58

	
110.59

	
80.49

	
150.77

	
86.40

	
306.46

	
182.04

	
475.06

	
13,112.00

	
1,971.11

	
506.79

	
247.67

	
279.22

	
855.98

	
934.58

	
324.43

	
87.18

	
70.25

	
07

	
972.68

	
191.11

	
104.86

	
76.31

	
142.97

	
82.11

	
290.54

	
172.85

	
450.35

	
13,646.03

	
2,051.80

	
527.50

	
257.80

	
290.69

	
891.11

	
972.87

	
324.43

	
85.88

	
69.21

	
08

	
958.75

	
188.48

	
103.44

	
75.26

	
141.04

	
81.29

	
286.56

	
170.88

	
444.10

	
12,462.04

	
1,875.26

	
481.99

	
235.60

	
265.82

	
814.81

	
889.30

	
324.43

	
93.02

	
74.95

	
09

	
1,039.33

	
204.28

	
112.10

	
81.56

	
152.85

	
87.97

	
310.57

	
185.02

	
481.33

	
14,399.99

	
2,163.12

	
556.29

	
271.81

	
306.28

	
938.96

	
1,025.47

	
324.43

	
96.06

	
77.41

	
10

	
1,034.50

	
203.24

	
111.51

	
81.15

	
152.04

	
87.27

	
308.98

	
183.75

	
478.93

	
17,971.60

	
2,694.26

	
693.35

	
338.63

	
380.98

	
1,168.21

	
1,276.79

	
324.43

	
106.30

	
85.66

	
11

	
1,192.81

	
234.14

	
128.43

	
93.50

	
175.08

	
99.98

	
355.93

	
210.97

	
551.86

	
15,061.69

	
2,258.13

	
581.11

	
283.81

	
319.33

	
979.14

	
1,070.12

	
324.43

	
134.22

	
108.13

	
6B *

	
1,025.86

	
201.49

	
110.54

	
80.45

	
150.70

	
86.36

	
306.31

	
181.96

	
474.83

	
13,110.81

	
1,970.94

	
506.75

	
247.64

	
279.20

	
855.90

	
934.50

	
324.43

	
87.18

	
70.25

  

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 2 of 5

  

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
 

TABLE 5

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
General + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.51

	
187.01

	
100.42

	
63.62

	
129.69

	
70.45

	
275.14

	
160.42

	
434.57

	
12,589.36

	
1,897.05

	
467.23

	
188.59

	
229.28

	
746.39

	
870.65

	
307.09

	
99.60

	
78.33

	
02

	
816.13

	
160.46

	
86.44

	
55.91

	
112.54

	
61.84

	
237.19

	
138.94

	
373.59

	
10,683.43

	
1,610.53

	
385.85

	
133.55

	
173.42

	
591.89

	
723.61

	
307.09

	
88.56

	
69.42

	
03

	
984.38

	
193.45

	
104.15

	
67.17

	
135.41

	
74.06

	
285.74

	
166.98

	
450.30

	
13,082.28

	
1,966.08

	
487.91

	
203.49

	
243.53

	
784.87

	
906.55

	
307.09

	
90.61

	
71.09

	
04

	
988.06

	
193.99

	
102.98

	
60.18

	
129.06

	
67.23

	
280.56

	
160.99

	
447.72

	
13,463.91

	
2,023.17

	
498.04

	
199.38

	
242.54

	
791.75

	
926.96

	
307.09

	
84.35

	
66.04

	
05

	
1,114.88

	
218.82

	
117.87

	
76.54

	
153.58

	
83.52

	
323.64

	
188.32

	
509.81

	
14,523.25

	
2,177.61

	
538.65

	
220.05

	
264.94

	
859.55

	
1,000.46

	
307.09

	
78.98

	
61.72

	
06

	
1,026.30

	
201.52

	
109.36

	
74.50

	
145.18

	
80.81

	
301.40

	
176.98

	
471.66

	
13,110.65

	
1,969.76

	
491.21

	
209.65

	
248.55

	
795.30

	
911.59

	
307.09

	
77.23

	
60.30

	
07

	
972.51

	
190.94

	
101.44

	
59.65

	
127.42

	
66.56

	
276.49

	
158.80

	
440.91

	
13,643.81

	
2,049.58

	
501.81

	
195.12

	
240.13

	
791.08

	
934.96

	
307.09

	
75.93

	
59.26

	
08

	
958.67

	
188.40

	
101.79

	
67.21

	
133.52

	
73.77

	
279.77

	
164.09

	
439.53

	
12,460.44

	
1,873.66

	
463.54

	
190.59

	
229.51

	
742.98

	
862.08

	
307.09

	
83.07

	
65.00

	
09

	
1,039.21

	
204.16

	
109.65

	
69.64

	
141.72

	
76.84

	
300.51

	
174.96

	
474.57

	
14,397.44

	
2,160.57

	
526.87

	
200.04

	
248.39

	
824.42

	
982.06

	
307.09

	
86.11

	
67.46

	
10

	
1,034.39

	
203.13

	
109.34

	
70.58

	
142.18

	
77.41

	
300.06

	
174.83

	
472.94

	
17,969.17

	
2,691.83

	
665.31

	
270.23

	
325.80

	
1,059.04

	
1,235.42

	
307.09

	
96.35

	
75.71

	
11

	
1,192.72

	
234.05

	
126.60

	
84.59

	
166.76

	
91.66

	
348.41

	
203.45

	
546.81

	
15,059.57

	
2,256.01

	
556.65

	
224.12

	
271.18

	
883.88

	
1,034.02

	
307.09

	
124.27

	
98.18

	
6B *

	
1,025.80

	
201.43

	
109.36

	
74.68

	
145.31

	
80.97

	
301.44

	
177.09

	
471.56

	
13,109.47

	
1,969.60

	
491.24

	
209.80

	
248.68

	
795.51

	
911.61

	
307.09

	
77.23

	
60.30

 

 

 

TABLE 6

	
General + Dental Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
944.58

	
184.95

	
100.95

	
65.82

	
130.49

	
70.43

	
273.61

	
157.47

	
433.12

	
12,534.14

	
1,853.70

	
460.85

	
185.81

	
221.83

	
720.52

	
849.06

	
306.61

	
96.81

	
76.08

	
02

	
809.75

	
158.56

	
88.18

	
60.03

	
115.11

	
63.86

	
236.89

	
137.22

	
374.19

	
10,634.29

	
1,571.94

	
381.29

	
132.48

	
168.01

	
569.13

	
704.78

	
306.61

	
86.68

	
67.92

	
03

	
977.49

	
191.43

	
108.70

	
76.07

	
142.10

	
80.58

	
286.27

	
165.92

	
452.46

	
13,033.69

	
1,927.90

	
487.03

	
207.02

	
242.18

	
762.93

	
888.75

	
306.61

	
88.69

	
69.57

	
04

	
982.27

	
192.28

	
105.33

	
65.21

	
132.53

	
70.33

	
282.12

	
161.12

	
451.48

	
13,413.74

	
1,983.77

	
494.15

	
199.25

	
237.86

	
769.51

	
909.12

	
306.61

	
82.26

	
64.40

	
05

	
1,109.73

	
217.33

	
123.60

	
87.07

	
161.99

	
92.17

	
325.20

	
188.59

	
513.46

	
14,476.94

	
2,141.22

	
538.63

	
224.43

	
264.54

	
838.74

	
983.65

	
306.61

	
77.33

	
60.43

	
06

	
1,021.05

	
199.98

	
113.31

	
82.09

	
150.99

	
86.56

	
301.15

	
175.58

	
472.16

	
13,063.07

	
1,932.39

	
489.19

	
211.64

	
245.95

	
773.24

	
893.33

	
306.61

	
75.25

	
58.73

	
07

	
966.84

	
189.29

	
106.23

	
68.71

	
134.46

	
73.63

	
276.71

	
157.73

	
442.30

	
13,593.71

	
2,010.21

	
500.46

	
198.19

	
238.24

	
767.99

	
915.93

	
306.61

	
74.55

	
58.18

	
08

	
952.06

	
186.50

	
110.56

	
83.08

	
146.39

	
87.17

	
280.02

	
162.83

	
441.14

	
12,412.44

	
1,835.93

	
464.90

	
196.88

	
230.62

	
721.10

	
844.21

	
306.61

	
82.34

	
64.45

	
09

	
1,032.51

	
202.20

	
115.89

	
81.32

	
150.88

	
86.13

	
300.50

	
173.44

	
475.74

	
14,347.78

	
2,121.54

	
526.25

	
203.98

	
247.30

	
801.64

	
963.35

	
306.61

	
84.04

	
65.82

	
10

	
1,028.54

	
201.40

	
112.23

	
76.51

	
146.44

	
81.37

	
298.37

	
171.98

	
471.02

	
17,915.53

	
2,649.69

	
662.51

	
271.80

	
322.29

	
1,033.69

	
1,214.16

	
306.61

	
93.79

	
73.66

	
11

	
1,187.91

	
232.66

	
135.57

	
99.79

	
178.39

	
102.52

	
348.28

	
202.23

	
547.45

	
15,014.30

	
2,220.48

	
561.62

	
232.19

	
272.44

	
864.12

	
1,018.33

	
306.61

	
124.06

	
98.08

	
6B *

	
1,020.55

	
199.89

	
113.31

	
82.27

	
151.12

	
86.72

	
301.19

	
175.69

	
472.06

	
13,061.89

	
1,932.23

	
489.22

	
211.79

	
246.08

	
773.45

	
893.35

	
306.61

	
75.25

	
58.73

  

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 3 of 5

  

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
TABLE 7

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
General + Dental + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.51

	
187.03

	
102.23

	
66.63

	
132.34

	
73.38

	
276.90

	
162.03

	
437.66

	
12,589.42

	
1,897.08

	
468.98

	
190.80

	
231.21

	
747.90

	
872.76

	
309.39

	
100.69

	
79.25

	
02

	
816.14

	
160.48

	
89.36

	
60.77

	
116.81

	
66.58

	
239.92

	
141.43

	
378.38

	
10,683.52

	
1,610.58

	
388.53

	
136.92

	
176.37

	
593.52

	
725.89

	
309.39

	
89.90

	
70.54

	
03

	
984.39

	
193.50

	
109.97

	
76.87

	
143.94

	
83.51

	
289.54

	
170.46

	
456.98

	
13,082.49

	
1,966.20

	
494.21

	
211.42

	
250.46

	
787.10

	
909.67

	
309.39

	
92.72

	
72.86

	
04

	
988.07

	
194.02

	
106.40

	
65.88

	
134.07

	
72.79

	
284.87

	
164.93

	
455.28

	
13,464.03

	
2,023.24

	
501.55

	
203.79

	
246.40

	
794.42

	
930.69

	
309.39

	
86.67

	
67.99

	
05

	
1,114.90

	
218.88

	
124.55

	
87.67

	
163.37

	
94.37

	
327.65

	
191.99

	
516.85

	
14,523.47

	
2,177.74

	
545.47

	
228.63

	
272.44

	
861.79

	
1,003.60

	
309.39

	
81.38

	
63.73

	
06

	
1,026.31

	
201.56

	
114.28

	
82.70

	
152.39

	
88.80

	
303.65

	
179.04

	
475.61

	
13,110.81

	
1,969.85

	
496.21

	
215.95

	
254.05

	
796.88

	
913.80

	
309.39

	
78.98

	
61.77

	
07

	
972.52

	
190.99

	
107.28

	
69.37

	
135.97

	
76.04

	
279.40

	
161.46

	
446.02

	
13,644.01

	
2,049.69

	
507.86

	
202.73

	
246.78

	
792.90

	
937.50

	
309.39

	
77.64

	
60.7

	
008

	
958.69

	
188.49

	
111.78

	
83.85

	
148.15

	
89.99

	
283.16

	
167.19

	
445.48

	
12,460.72

	
1,873.82

	
472.00

	
201.24

	
238.82

	
745.01

	
864.91

	
309.39

	
84.99

	
66.61

	
09

	
1,039.23

	
204.22

	
117.13

	
82.10

	
152.67

	
88.99

	
303.69

	
177.86

	
480.14

	
14,397.66

	
2,160.69

	
533.58

	
208.48

	
255.77

	
826.34

	
984.74

	
309.39

	
87.98

	
69.03

	
10

	
1,034.40

	
203.16

	
113.31

	
77.19

	
148.00

	
83.86

	
301.15

	
175.83

	
474.85

	
17,969.34

	
2,691.92

	
670.42

	
276.66

	
331.42

	
1,060.34

	
1,237.23

	
309.39

	
97.56

	
76.73

	
11

	
1,192.79

	
234.12

	
136.47

	
100.36

	
179.69

	
104.59

	
350.59

	
205.44

	
550.64

	
15,059.58

	
2,256.02

	
568.28

	
236.28

	
280.13

	
886.55

	
1,037.75

	
309.39

	
127.34

	
100.75

	
6B *

	
1,025.81

	
201.47

	
114.28

	
82.88

	
152.52

	
88.96

	
303.69

	
179.15

	
475.51

	
13,109.63

	
1,969.69

	
496.24

	
216.10

	
254.18

	
797.09

	
913.82

	
309.39

	
78.98

	
61.77

 

 

TABLE 8

	
General + Mental Health + Dental + Transportation Rates:

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	
TANF

	  	  	  	  	  	  	  	  	  	
SSI-N

	  	  	  	  	  	
SSI-B

	
SSI-AB

	
Area

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	
BTHMO+2MO

	
3MO-11MO

	
AGE (1-5)

	
AGE (6-13)

	
AGE (14-20)

	
AGE (21-54)

	
AGE (55+)

	  	
AGE (65-)

	
AGE  (65+)

	  	  	  	  	  	
Female

	
Male

	
Female

	
Male

	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	
01

	
951.62

	
187.14

	
104.51

	
77.72

	
142.70

	
83.74

	
286.26

	
171.39

	
443.95

	
12,591.19

	
1,898.85

	
489.44

	
240.71

	
271.47

	
827.56

	
902.95

	
326.73

	
110.64

	
89.20

	
02

	
816.22

	
160.56

	
91.04

	
68.95

	
124.44

	
74.21

	
246.82

	
148.33

	
383.01

	
10,685.97

	
1,613.03

	
416.82

	
205.95

	
232.05

	
703.69

	
767.64

	
326.73

	
99.85

	
80.49

	
03

	
984.49

	
193.60

	
112.04

	
86.98

	
153.38

	
92.95

	
298.07

	
178.99

	
462.71

	
13,084.04

	
1,967.75

	
512.13

	
255.14

	
285.73

	
856.88

	
936.11

	
326.73

	
102.67

	
82.81

	
04

	
988.25

	
194.20

	
109.96

	
83.23

	
150.27

	
88.99

	
299.51

	
179.57

	
465.12

	
13,465.98

	
2,025.19

	
524.12

	
258.85

	
290.81

	
882.30

	
963.99

	
326.73

	
96.62

	
77.94

	
05

	
1,115.01

	
218.99

	
126.78

	
98.55

	
173.52

	
104.52

	
336.83

	
201.17

	
523.02

	
14,525.38

	
2,179.65

	
567.54

	
282.48

	
315.88

	
947.74

	
1,036.17

	
326.73

	
91.33

	
73.68

	
06

	
1,026.37

	
201.62

	
115.51

	
88.69

	
157.98

	
94.39

	
308.71

	
184.10

	
479.01

	
13,112.16

	
1,971.20

	
511.79

	
253.97

	
284.72

	
857.56

	
936.79

	
326.73

	
88.93

	
71.72

	
07

	
972.69

	
191.16

	
110.70

	
86.03

	
151.52

	
91.59

	
293.45

	
175.51

	
455.46

	
13,646.23

	
2,051.91

	
533.55

	
265.41

	
297.34

	
892.93

	
975.41

	
326.73

	
87.59

	
70.65

	
08

	
958.77

	
188.57

	
113.43

	
91.90

	
155.67

	
97.51

	
289.95

	
173.98

	
450.05

	
12,462.32

	
1,875.42

	
490.45

	
246.25

	
275.13

	
816.84

	
892.13

	
326.73

	
94.94

	
76.56

	
09

	
1,039.35

	
204.34

	
119.58

	
94.02

	
163.80

	
100.12

	
313.75

	
187.92

	
486.90

	
14,400.21

	
2,163.24

	
563.00

	
280.25

	
313.66

	
940.88

	
1,028.15

	
326.73

	
97.93

	
78.98

	
10

	
1,034.51

	
203.27

	
115.48

	
87.76

	
157.86

	
93.72

	
310.07

	
184.75

	
480.84

	
17,971.77

	
2,694.35

	
698.46

	
345.06

	
386.60

	
1,169.51

	
1,278.60

	
326.73

	
107.51

	
86.68

	
11

	
1,192.88

	
234.21

	
138.30

	
109.27

	
188.01

	
112.91

	
358.11

	
212.96

	
555.69

	
15,061.70

	
2,258.14

	
592.74

	
295.97

	
328.28

	
981.81

	
1,073.85

	
326.73

	
137.29

	
110.70

	
6B *

	
1,025.87

	
201.53

	
115.46

	
88.65

	
157.91

	
94.35

	
308.56

	
184.02

	
478.78

	
13,110.97

	
1,971.03

	
511.75

	
253.94

	
284.70

	
857.48

	
936.71

	
326.73

	
88.93

	
71.72

  

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 4 of 5

  

 

	 ATTACHMENT I
	 EXHIBIT 2-NR-C
	 MEDICAID NON-REFORM HMO CAPITATION RATES
	 ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
	 By Area, Age and Eligibility Category
	 Effective September 1, 2011

 

	
Area

	
Corresponding  Counties

	  	  
	
Area 1

	
Escambia, Okaloosa, Santa Rosa, Walton

	
Area 2

	
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Washington, Wakulla

	
Area 3

	
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamiliton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union

	
Area 4

	
Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia

	
Area 5

	
Pasco, Pinellas

	
Area 6

	
Hardee, Highlands, Manatee, Polk

	
Area 6B *

	
Hillsborough

	
Area 7

	
Brevard, Orange, Osceola, Seminole

	
Area 8

	
Charlotte, Collier, De Soto, Glades, Hendry, Lee, Sarasota

	
Area 9

	
Indian River, Okeechobee, St. Lucie, Martin, Palm Beach

	
Area 10

	
Broward

	
Area 11

	
Dade, Monroe

AHCA Contract No. FA905, Attachment I, Exhibit 2-NR-C, Page 5 of 5

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