Document:

Exhibit 10.13

 

 

[_____], 2014

 

Ivelin M. Dimitrov

c/o Fifth Street

777 West Putnam Avenue, 3rd
Floor

Greenwich, CT 06830

 

		Re:	Employment Letter Agreement

 

Dear Ivelin:

 

As you know, Fifth Street Asset Management,
Inc. (“FSAM”) is in the process of preparing for an initial public offering of FSAM’s Class A common stock (the
“IPO”). In connection with the IPO, Fifth Street Management LLC (the “Company”) believes it is appropriate
to recognize your contributions to the Company and is pleased to offer you continued employment with FSC CT, Inc. on the terms
set forth below.

 

1. Salary; Bonus; Equity.
 Your annual salary will continue to be $420,000; paychecks are issued semi-monthly on the fifteenth day of each month and
the last business day of each month. If the fifteenth day of the month falls on a weekend, paychecks will be issued the Friday
prior to or the Monday following the weekend. If the day is a holiday, paychecks will be issued the following business day. You
will receive a performance review each year and will be considered eligible for annual salary increases based on your performance.

 

While employed, each
year you shall remain eligible to receive a discretionary bonus. Such discretionary bonuses shall be based on the achievement of
such performance goals and other factors as the Company may in its sole discretion determine. All bonuses shall be paid in accordance
with the Fifth Street Deferred Bonus and Retention Plan (the “Plan”), a copy of which has previously been provided
to you, so long as the Plan remains in effect; provided that, (i) for purposes of amounts that may be deferred under the Plan,
the definition of “Cause” shall be as defined in this letter agreement, and (ii) for purposes of the Plan your resignation
for “Good Reason” (as defined in Annex B hereto) will be treated in the same manner as a termination by the Company
without Cause.

 

In connection with
the execution of this letter agreement, and conditioned on your continued employment through the grant date (other than in connection
with your termination by the Company without Cause or your resignation for Good Reason), you will be granted upon the pricing of
the IPO on or prior to March 31, 2015, (i) [861,000] options to purchase Class A shares of FSAM (the “Options”) and
(ii) [156,333] restricted stock units of FSAM (the “RSUs”). The terms of the grant of Options and RSUs are set forth
on Annex A hereto.

 

2. Benefits. You will continue
to be eligible to participate in Fifth Street’s health insurance plan on the same terms (including the same employee contribution
amount) on which you currently participate in such plans. From time to time, we may make changes to such plans in the future and
you will be notified of and subject to any such changes.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 2

 

You will be entitled to 25 days paid vacation
each year (which shall accrue and be earned pro rata over the course of the year), four sick days and holidays in accordance with
Fifth Street’s written policies.

 

You will remain eligible to participate
in Fifth Street’s 401(k) plan, subject to the terms of the plan which may be amended from time to time.

 

Your business expenses will be reimbursed
under the Company’s business expenses and reimbursement policies as in effect from time to time. You will be eligible for
first class air travel.

 

3. At-Will Employment; Policies.
Your employment will continue to be “at-will.” This means that either you or we may terminate your employment at any
time, for any or no reason. In the event that your employment is terminated, you will receive any unpaid salary and benefits (including
reimbursement for reimbursable business expenses incurred prior to such termination) owed to you as of the date of such termination.

 

You will perform your duties diligently
and to the best of your ability and will comply with Fifth Street’s policies and procedures, copies of which have been provided
to you previously. It is your responsibility to read and understand these policies and procedures, and if you have any questions
now or in the future, it is your responsibility to make the appropriate inquiries.

 

4. Non-Solicitation and Non-Disclosure.
As a condition to your continued employment, you will be required to execute a Non-Competition, Non-Solicitation and Non-Disclosure
Agreement, a copy of which is provided with this letter agreement.

 

5. Miscellaneous.
This offer is subject to the provisions of Annex C hereto, with respect to matters arising under Sections 409A and 4999/280G
of the Code.

 

This letter agreement (together with the
Non-Competition, Non-Solicitation and Non-Disclosure Agreement) sets forth the entire agreement and understanding between us and
you relating to your employment and supersedes all prior agreements and understandings between you and the Company with respect
to your employment, except that it is expressly understood that this letter agreement does not supersede, alter or amend, in any
respect, the terms of the limited liability company agreement of Fifth Street Management LLC.

 

All payments pursuant to this letter agreement
will be subject to applicable withholding taxes.

 

If the terms of this letter agreement are
acceptable to you, please sign a copy of this letter and return it to me on or before [_____], 2014.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 3

 

We look forward to your continued contributions
to the Company’s success!

 

	 	Sincerely,
	 	 
	 	[NAME]

 

[Remainder of page intentionally left blank]

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 4

 

I understand that my employment is at will and can be terminated
by either party at any time with or without cause and with or without notice. I specifically acknowledge and agree that I am an
exempt employee and am therefore not eligible to receive overtime pay.

 

	ACCEPTED AND AGREED:	 
	 	 
	 	 
	Signature	 
	 	 
	 	 
	Print Name	 
	 	 
	 	 
	Date	 

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 5

 

Annex A – Option and RSU Terms

 

1.     Option
Category and Term: The Options will have an option term of ten years. The actual number of such options to be granted will
be determined based on final valuation determinations with respect to such options as of the date of grant. The options granted
to you will have an exercise price that is no less than fair market value of FSAM Class A common stock on the date of grant.

 

2.     Restricted
Stock Units: You will be granted RSUs representing the right to receive shares of FSAM Class A common stock subject to
fulfillment of vesting and other conditions.

 

3.     Vesting
and Exercise:

a.     Options
– 1/3rd of the Options will vest annually commencing on each of the 4th, 5th and 6th
anniversaries of the date of grant, subject to continued employment on such dates.

b.     RSUs
– 1/3rd of the RSUs will vest annually commencing on each of the 4th, 5th and 6th
anniversaries of the date of grant, subject to continued employment on such dates.

c.     Accelerated
Vesting of Options and RSUs

i.  Upon
a termination by the Company without Cause or termination by you for Good Reason, in each case after the Grant Date:

1.     Options
– Vesting to be determined based on full months of service from date of grant plus 12 months as a percentage of 72 months
(without regard to the vesting schedule set forth in 3a. above).

2.     RSUs
– Vesting to be determined based on full months of service from date of grant plus 12 months as a percentage of 72 months
(without regard to the vesting schedule set forth in 3b. above).

ii. Upon
a “Change of Control” while you are employed – In the event that Leonard Tannenbaum and his affiliated entities
collectively cease to have beneficial voting control of FSAM (or, if an IPO has not occurred, of Fifth Street Holdings, LP), 100%
of your then unvested Options and RSUs shall vest.

d.     Exercise
– All Options will be exercisable within 1 year following termination by the Company without Cause or by you for Good Reason;
in other cases, exercise terms will be as provided for under the terms of grant.

e.     Manner
of Exercise – Options to be subject to the same manner of exercise afforded to other senior executives receiving options
in FSAM, including broker assisted cashless exercise if available.

f.     Settlement
of RSUs – No later than 60 days following each vesting date, one share of FSAM Class A common stock shall be issued for each
RSU that becomes vested on such vesting date.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 6

 

4.     Liquidity
on Shares Realized Upon Exercise and Settlement

a.     Options
– 100% of the net option shares acquired upon exercise of the vested Options may be sold as follows: 25% after the 6th
anniversary of the Grant Date, an additional 25% after the 7th anniversary of the Grant Date, an additional 25% after
the 8th anniversary of the Grant Date, and an additional 25% after the 9th anniversary of the Grant Date.

b.     RSUs
– 100% of the net shares acquired upon settlement of vested RSUs may be sold as follows: 25% after the 6th anniversary
of the Grant Date, an additional 25% after the 7th anniversary of the Grant Date, an additional 25% after the 8th
anniversary of the Grant Date, and an additional 25% after the 9th anniversary of the Grant Date.

c.     Following
Termination By Company without Cause/Termination by you for Good Reason – 50% of option shares held by you resulting from
your exercise of the Options may be sold within the first year immediately following such termination, and all option shares held
by you resulting from your exercise of Options may be sold after the 1st anniversary of such termination. 50% of the
shares received upon vesting of RSUs may be sold within the first year immediately following such termination, and all such shares
received upon vesting of RSUs may be sold after the 1st anniversary of such termination.

Other Restrictions – In all cases you shall
remain subject to any restrictions on the sale of options shares or RSUs arising under applicable law or imposed by the Company
or its underwriters in connection with any capital markets transactions or securities trading policies, in each case to the extent
equally applicable to all current senior executives of comparable status (other than the Chairman).

 

5.     Other
Provisions

a.     The
foregoing terms will be reflected in, and subject to, one or more written Option and RSU agreements as soon as reasonably practicable
following the effective date of grant, dated as of such grant date. Except as provided for above, the terms of the Options and
RSUs will be subject to the provisions of plan pursuant to which such Options and RSUs are granted, as well as the provisions of
the Option and RSU grants, as the case may be, otherwise applicable to all senior executives of the Company (e.g. with respect
to forfeiture, clawbacks and post-termination exercise periods).

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 7

 

Annex B – “Cause” and “Good Reason”

 

“Cause” for termination means: (i) the commission
of, conviction or admission of, or plea of nolo contendere with respect to, a felony or a crime involving moral turpitude
(other than a motor vehicle offense); (ii) conduct reasonably tending to bring the Company or its affiliates into public disgrace
or disrepute or otherwise materially injurious to their business, reputation or goodwill; (iii) an act of fraud, misappropriation
or embezzlement, (iv) gross negligence, willful misconduct or material breach of fiduciary duty; (v) breach of a material term
or representation of this letter agreement; (vi) commission of a reportable violation of any applicable banking, securities or
commodities laws, rules or regulations that constitutes a serious offense or could or does result in a significant fine; (vii)
violation of material policies, practices and standards of behavior of the Company or its affiliates (including, without limitation,
any securities trading, conflict of interest or code of conduct policies); or (viii) a willful failure to follow the lawful directives
of the Board or other governing body of the Company or material breach in the performance of your obligations under your letter
agreement, in each case under sub-clauses (vii) or (viii) which remains uncured by you after you have been provided with notice
and ten (10) days to cure (to the extent curable). To the extent that within 120 days following your resignation or termination
other than for “Cause” the Company determines that facts or circumstances existed that would have otherwise constituted
“Cause” under sub-clauses (i)-(iii) or (vi) above, and such facts or circumstances were not actually known to the Company
or should have otherwise been known to the Company through the exercise of reasonable care in each case at the time of such resignation
or termination, then the Company may treat such resignation or termination as a termination for “Cause” for all purposes.

 

“Good Reason” shall mean the occurrence of any of
the following events, without your express written consent, unless such events are cured by the Company within thirty (30) days
following written notification by you to the Company that you intend to terminate your employment for one of the reasons set forth
below:

 

(i)          Material
diminution in your base salary at the rate in effect immediately prior to the reduction or the failure to pay you any salary or
any earned and due bonus or incentive payments; or

 

(ii)         Material
diminution in your duties, authorities or responsibilities (other than temporarily while physically or mentally incapacitated or
as required by applicable law and other than in connection with any service on any informal management committees associated with
the Company or its affiliates); or

 

(iii)        the
termination of your rights to any material employee benefits, except to the extent that any such benefit is replaced with a comparable
benefit, or a material reduction in scope or value thereof, other than as a result of across-the-board reductions or terminations
affecting senior executives of comparable status of the Company generally; or

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 8

 

(iv)        a
change by the Company in the location at which Executive performs his principal duties for the Company to a new location that is
more than sixty (60) miles from Greenwich, CT.

 

You shall provide the Company with a written notice detailing
the specific circumstances alleged to constitute Good Reason within thirty (30) days after the first occurrence of such circumstances
(or any claim of such circumstances as “Good Reason” shall be deemed irrevocably waived by you), and in no event shall
you be entitled to resign for “Good Reason” more than one hundred and eighty (180) days following the occurrence of
any event alleged to constitute “Good Reason.”

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 9

 

Annex C – Section 409A Matters

 

a.           It
is intended that the provisions of the letter agreement comply with Code Section 409A of the Internal Revenue Code, and all provisions
of the letter agreement shall be construed in a manner consistent with the requirements for avoiding taxes or penalties under Code
Section 409A. Notwithstanding the foregoing, the Company shall have no liability with regard to any failure to comply with Code
Section 409A so long as it has acted in good faith with regard to compliance therewith.

 

b.           If,
under the letter agreement, an amount is to be paid in two or more installments, for purposes of Code Section 409A, each installment
shall be treated as a separate payment.

 

c.           A
termination of employment shall not be deemed to have occurred for purposes of any provision of the letter agreement providing
for the payment of amounts or benefits upon or following a termination of employment unless such termination is also a “Separation
from Service” within the meaning of Code Section 409A and, for purposes of any such provision of the Agreement, references
to a “resignation,” “voluntary termination,” “termination,” “termination of employment”
or like terms shall mean Separation from Service.

 

d.           If
you are deemed on the date of termination of your employment to be a “specified employee” within the meaning of that
term under Section 409A(a)(2)(B) of the Code and using the identification methodology selected by the Company from time to time,
or if none, the default methodology, then:

 

i.             With
regard to any payment, the providing of any benefit or any distribution of equity upon Separation from Service that constitutes
“deferred compensation” subject to Code Section 409A, such payment, benefit or distribution shall not be made or provided
prior to the earlier of (i) the expiration of the six-month period measured from the date of your Separation from Service or (ii)
the date of your death; and

 

ii.           On
the first day of the seventh month following the date of your Separation from Service or, if earlier, on the date of your death,
(x) all payments delayed pursuant to this Section (d) (whether they would otherwise have been payable in a single sum or in installments
in the absence of such delay) shall be paid or reimbursed to you in a lump sum, and any remaining payments and benefits due under
the Agreement shall be paid or provided in accordance with the normal dates in accordance with the terms of the Agreement, and
(y) all distributions of equity delayed pursuant to this Section (d) shall be made to you.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 10

 

In determining the amounts that
are subject to the six-month delay requirement described above, the Company shall use all exclusions from the six-month delay rule
that are available to the payments made to you. Please be advised that the Company reserves the right to adopt an alternate method
of complying with the six-month delay requirement which may result in you being deemed a specified employee.

 

e.           Whenever
a payment under the letter agreement specifies a payment period with reference to a number of days (e.g., “payment shall
be made within thirty (30) days following the date of termination”), the actual date of payment within the specified period
shall be within the sole discretion of the Company.

 

f.            With
regard to any provision in the letter agreement that provides for reimbursement of costs and expenses or in-kind benefits, except
as permitted by Code Section 409A, (i) the right to reimbursement or in-kind benefits shall not be subject to liquidation or exchange
for another benefit, (ii) the amount of expenses eligible for reimbursement, of in-kind benefits, provided during any taxable year
shall not affect the expenses eligible for reimbursement, or in-kind benefits to be provided, in any other taxable year, provided
that the foregoing clause (ii) shall not be violated without regard to expenses reimbursed under any arrangement covered by Section
105(b) of the Code solely because such expenses are subject to a limit related to the period the arrangement is in effect and (iii)
such payments shall be made on or before the last day of your taxable year following the taxable year in which the expense occurred.

 

Annex C – Section 4999/280G Matters

 

If any payment or benefit
(including payments and benefits pursuant to this letter agreement) that you would receive from the Company or in connection with
a change of effective ownership or control of the Company (“Transaction Payment”) would (i) constitute a “parachute
payment” within the meaning of Section 280G of the Code, and (ii) but for this provision, be subject to the excise tax imposed
by Section 4999 of the Code (the “Excise Tax”), then the Company shall cause to be determined, before any amounts of
the Transaction Payment are paid to you, which of the following two alternative forms of payment would result in your receipt,
on an after-tax basis, of the greater amount of the Transaction Payment notwithstanding that all or some portion of the Transaction
Payment may be subject to the Excise Tax: (1) payment in full of the entire amount of the Transaction Payment (a “Full Payment”),
or (2) payment of only a part of the Transaction Payment so that you receive the largest payment possible without the imposition
of the Excise Tax (a “Reduced Payment”).

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 11

 

For purposes of determining whether to
make a Full Payment or a Reduced Payment, the Company shall cause to be taken into account all applicable federal, state and local
income and employment taxes and the Excise Tax (all computed at the highest applicable marginal rate, net of the maximum reduction
in federal income taxes which could be obtained from a deduction of such state and local taxes). If a Reduced Payment is made,
(x) you shall have no rights to any additional payments and/or benefits constituting the Transaction Payment, and (y) reduction
in payments and/or benefits shall occur in the manner that results in the greatest economic benefit to you as determined in this
paragraph. If more than one method of reduction will result in the same economic benefit, the portions of the Payment shall be
reduced pro rata.

 

The independent registered public accounting
firm engaged by the Company as of the day prior to the effective date of the change of ownership or control of the Company shall
make all determinations required to be made under this Annex C. If the independent registered public accounting firm so engaged
by the Company is serving as accountant or auditor for the individual, entity or group effecting the change of control, the Company
shall appoint a nationally recognized independent registered public accounting firm that is reasonably acceptable to you (and such
acceptance shall not be unreasonably withheld) to make the determinations required hereunder. The Company shall bear all reasonable
expenses with respect to the determinations by such independent registered public accounting firm required to be made hereunder.
The independent registered public accounting firm engaged to make the determinations under this Annex C shall provide its calculations,
together with detailed supporting documentation, to the Company and you within fifteen (15) calendar days after the date on which
your right to a Transaction Payment is triggered or such other time as reasonably requested by the Company or you. If the independent
registered public accounting firm determines that no Excise Tax is payable with respect to the Transaction Payment, either before
or after the application of the Reduced Amount, it shall furnish the Company and you with detailed supporting calculations of its
determinations that no Excise Tax will be imposed with respect to such Transaction Payment. Any good faith determinations of the
accounting firm made hereunder shall be final, binding and conclusive upon the Company and you.

 

Notwithstanding the foregoing, in the event
the IPO does not occur, or following the IPO the Company’s common stock ceases for any reason to be registered under the
Securities Act of 1933, as amended, in lieu of the foregoing, if you execute a waiver of the portion of such excess parachute payment
such that all non-waived payments would not be subject to the Excise Tax, the Company shall agree to seek approval of its stockholders
in a manner that complies with Section 280G(b)(5)(B) of the Code and Treasury Regulation Section 1.280G-1 such that if such stockholder
approval is obtained, the waived payments shall be restored.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 12

 

EXHBIT B

 

WAIVER AND RELEASE AGREEMENT

 

1.          In
consideration for the severance benefits to be provided to me under Section 2 of the Non-Competition, Non-Solicitation and Non-Disparagement
Agreement between me and FSC CT, Inc. (the “Company”) dated as of [_____], 2014 (hereinafter referred to as
the “Non-Competition Agreement Agreement”) and accelerated vesting of the Options and RSUs as provided for in Annex
A to the letter agreement between me and the Company dated as of [_____], 2014 (hereinafter referred to as the “Employment
Agreement”), I, Ivelin M. Dimitrov, on behalf of myself and my heirs, executors, administrators, attorneys and assigns, hereby
waive, release and forever discharge FSC CT, Inc., Fifth Street Management LLC, Fifth Street Asset Management Inc. (“FSAM”),
Fifth Street Holdings, L.P., Fifth Street Finance Corp., Fifth Street Senior Floating Rate Corp., Fifth Street Senior Loan Fund
I Operating Entity, LLC, Fifth Street Senior Loan Fund II Operating Entity, LLC, Fifth Street Credit Opportunities Fund, L.P.,
Fifth Street Mezzanine Partners II, L.P., Fifth Street Capital LLC, Fifth Street Capital West, Inc., FSC, Inc., FSC Midwest, Inc.,
and any entities formed after the date hereof which engage any such entity to provide services, and any affiliates of such entities
formed after the date hereof together with each of their respective subsidiaries, divisions and affiliates, whether direct or indirect,
their respective joint ventures and joint venturers (including each of their respective directors, officers, employees, stockholders,
partners and agents, past, present, and future), and each of their respective successors and assigns, members, branches, divisions,
business units or groups, portfolio companies, agencies, predecessors, successors, assigns, any employee benefit plans established
or maintained by any of the foregoing entities and each and all of their past, present or future officers, directors, employees,
partners, members, trustees, plan administrators, agents, fiduciaries, shareholders, attorneys, representatives and advisors (hereinafter
collectively referred to as “Releasees”), from any and all known or unknown actions, causes of action, claims or liabilities
of any kind which have been or could be asserted against the Releasees, including, without limitation, those arising out of or
related to my employment with and/or separation from employment with the Company and/or any of the other Releasees up to and including
the date of this Waiver and Release Agreement, including but not limited to claims, actions, causes of action or liabilities arising
under Title VII of the Civil Rights Act of 1964, as amended, the Civil Rights Act of 1866, as amended, the Connecticut Fair Employment
Practices Act, the Connecticut Human Rights and Opportunities Act, the Connecticut Equal Pay Law, the Connecticut Family and Medical
Leave Act, the Connecticut Whistleblower Protection Law, the Connecticut Worker’s Compensation Retaliation Law, Connecticut
Age Discrimination and Employee Benefits Law, the Connecticut Employment Privacy Law, the Connecticut Wage Payment Laws, the Connecticut
Occupational Safety and Health Act, the New York Labor Law, the New York State and New York City Human Rights Laws, the Age Discrimination
in Employment Act of 1967 (“ADEA”), the Older Workers Benefit Protection Act, the Americans with Disabilities Act,
The Family and Medical Leave Act, the Employee Retirement Income Security Act of 1974, as amended (other than with respect to any
vested benefit as of the date of termination of employment), the Consolidated
Omnibus Budget Reconciliation Act of 1985, the Equal Pay Act,
the Worker Adjustment and Retraining Notification Act
and the Fair Labor Standards Act, and all other Federal, state or local laws.

 

Capitalized terms used, but not defined herein,
shall have the meanings ascribed to such terms in the Employment Agreement.

 

2.          (a)          I
also agree never to sue any of the Releasees or become party to a lawsuit on the basis of any claim of any type whatsoever arising
out of or related to my employment with and/or separation from employment with the Company and/or any of the other Releasees (except
for claims not released under Section 2(b) below) and/or to challenge the enforceability of this Waiver and Release Agreement,
except I may bring a lawsuit to challenge this Waiver and Release Agreement under the ADEA.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 13

 

(b)          Notwithstanding
any provision of this Waiver and Release Agreement to the contrary, by executing this Waiver and Release Agreement, I am not releasing
(i) claims to enforce this Waiver and Release Agreement and any rights or remedies in respect thereof and my rights under the provisions
of the Employment Agreement and the Non-Competition Agreement that are intended to survive my termination of employment, (ii) claims
that arise after the execution of the Waiver and Release Agreement or that cannot be released by law, (iii) rights to vested and
accrued benefits under any applicable plan, agreement, program, award, policy or arrangement of the Company or any of their subsidiaries
or affiliates, or (iv) any rights I may have to indemnification and D&O coverage under any applicable charter, by-laws or agreements
with the Company or insurance policies in effect with respect to my period of service, or to obtain contribution as permitted by
law in the event of entry of judgment against me as a result of any act or failure to act for which I, on the one hand, and any
of the Releasees, on the other hand, are jointly liable.

 

3.          I
further acknowledge and agree that if I breach the provisions of Paragraph 2 above, then (a) the Company shall be entitled to apply
for and receive an injunction to restrain any violation of Paragraph 2 above, (b) the Company shall not be obligated to continue
payment of severance benefits to me under Section 2 of the Non-Competition Agreement (except for any earned but unpaid base salary
and any properly incurred but unpaid business expenses in accordance with Company policies), (c) I shall be obligated to pay to
the Company its costs and expenses in enforcing this Waiver and Release Agreement and defending against such lawsuit (including
court costs, expenses and reasonable legal fees), and (d) as an alternative to (c), at the Company’s option, I shall be obligated
upon demand to repay to the Company all but $100 of severance benefits paid or made available to me under Section 2 of the Non-Competition
Agreement. I further agree that the foregoing covenants in this Paragraph 3 shall not affect the validity of this Waiver and Release
Agreement and shall not be deemed to be a penalty nor a forfeiture.

 

4.          I
further waive my right to any monetary recovery should any foreign, federal, state, or local administrative agency pursue any claims
on my behalf arising out of or related to my employment with and/or separation from employment with the Company and/or any of the
other Releasees. I also acknowledge that I have not suffered any on-the-job injury for which I have not already filed a claim.
In connection with my waiver of this provision, I acknowledge that I may later discover facts different from or in addition to
those that I know or believe to be true with respect to my claims and I agree that in such event this Release shall nonetheless
remain effective in all respects.

 

5.          I
further waive, release and discharge Releasees from any reinstatement rights I have or could have and agree that, unless otherwise
solicited, I will not at any time in the future apply for, or otherwise seek, employment with the Company or any of its subsidiaries,
affiliates or divisions.

 

6.          Upon
the reasonable request of the Company from time to time after the date hereof, I also agree to testify on behalf of the Company,
at deposition, trial or hearing or in an affidavit or otherwise, in connection with any litigation or claim or action brought against
the Company by any present or former employee (including but not limited to those employees or former employees whom I supervised
or managed while employed by the Company), including but not limited to any litigation or claim or action brought under the state
workers’ compensation laws (a “Cooperation”); provided such Cooperation is not contrary to my own legal interests
or the legal interests of my employer and the Company promptly reimburses me in accordance with the Company policy for reasonable
costs and expenses incurred by me as a result of providing such Cooperation.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 14

 

7.          I
acknowledge that I have been given at least [twenty-one (21)][forty-five (45)]1 days to consider this Waiver and Release
Agreement thoroughly. If executed prior to the end of such [twenty-one (21)][forty-five (45)] day period, I acknowledge that I
voluntarily waive the balance of such period.

 

8.          I
acknowledge that I have been advised in writing to consult with an attorney at my own expense prior to signing this Waiver and
Release Agreement.

 

9.          I
understand that I may revoke this Waiver and Release Agreement within seven (7) days after its signing and that any revocation
must be made in writing and submitted within such seven day period to [__________]. I further understand that if I revoke this
Waiver and Release Agreement, I shall not receive severance benefits under Section 2 the Non-Competition Agreement.

 

10.         I
also understand that the severance benefits under the Non-Competition Agreement which I will receive in exchange for signing and
not later revoking this Waiver and Release Agreement (as provided for in Paragraph 1) are in addition to anything of value to which
I already am entitled.

 

11.         BOTH
PARTIES FURTHER UNDERSTAND THAT, EXCEPT AS OTHERWISE PROVIDED HEREIN, THIS WAIVER AND RELEASE AGREEMENT INCLUDES A RELEASE OF ALL
KNOWN AND UNKNOWN CLAIMS TO DATE.

 

12.         It
is the desire and intent of the parties that the provisions of this Release shall be enforced to the fullest extent permissible
under the laws and public policies applied in each jurisdiction in which enforcement is sought. I acknowledge and agree that if
any provision of this Waiver and Release Agreement is found, held or deemed by a court of competent jurisdiction to be void, invalid,
unlawful or unenforceable under any applicable statute or controlling law, this Release shall be deemed amended to delete therefrom
the portion thus adjudicated to be invalid, unlawful or unenforceable, such deletion to apply only with respect to the operation
of such provision in the particular jurisdiction in which such adjudication is made, and the remainder of this Waiver and Release
Agreement shall continue in full force and effect.

 

13.         This
Waiver and Release Agreement in all respects shall be interpreted, enforced and governed under applicable federal law and in the
event reference shall be made to State law, the internal laws of the State of Connecticut shall apply.

 

14.         I
further acknowledge and agree that I have carefully read and fully understand all of the provisions of this Waiver and Release
Agreement and that I voluntarily enter into this Waiver and Release Agreement by signing below and without reservation or duress
and assent to all the terms and conditions contained herein. No promises or representations, written or oral, have been made to
me by any person to induce me to sign this Waiver and Release Agreement other than the payments and benefits as set forth herein.

 

[Remainder of page intentionally left blank]

 

1 Applicable period to conform to that required by
law based on circumstances at the time of termination.

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.com

 

    	 

    	 

    

 

Page 15

 

15.         This
Waiver and Release Agreement, together with my Employment Agreement and the Non-Competition Agreement, integrates the whole of
all agreements and understandings between the Company and me concerning the subject matter of this Waiver and Release Agreement
and any other dealings between the Company, the Releasees and me. This Waiver and Release Agreement supersedes all prior negotiations,
discussion or agreements relating to the subject matter of this Waiver and Release Agreement, if any, between the Company and/or
the Releasees, on the one hand, and me, on the other hand.

 

	Signature: 	 	 	Date:	 
	 	 	 	 	 
	 	Ivelin M. Dimitrov	 	 	 

 

FIFTH STREET MANAGEMENT LLC

 

	By:	 	 	Date:	 
	 	 	 	 	 
	 	Name:	 	 	 
	 	 	 	 	 
	 	Title:	 	 	 

 

Fifth Street
| 777 West Putnam Avenue, 3rd Floor | Greenwich, CT 06830 | 203-681-3600 | 203-681-3879 (fax) | www.fifthstreetfinance.comEx101FP020Am3

Back to Form 8-K
Exhibit 10.1

AHCA CONTRACT NO. FP020
AMENDMENT NO. 3
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 “Managed Care Plan,” is hereby amended as follows: 
		
	1.
	Effective August 1, 2014, Attachment I, Scope of Services, - Effective Date: July 1, 2014, Statewide Medicaid Managed Care Program, is hereby deleted in its entirety and replaced with Attachment I, Scope of Services, - Effective Date:  August 1, 2014, Statewide Medicaid Managed Care Program, attached hereto and made a part of this Contract. All references in this Contract to Attachment I, Scope of Services – Effective Date:  July 1, 2014, shall hereinafter refer to Attachment I, Scope of Services – Effective Date:  August 1, 2014.

		
	2.
	Standard Contract, Section III., Item B., Contract Managers, sub-item 2., is hereby amended to read as follows:

		
	2.
	The Vendor’s Contract Manager’s contact information is as follows:

Michelle Bimle
WellCare of Florida, Inc., d/b/a
Staywell Health Plan of Florida, Inc.
3031 N. Rocky Point Drive, West
Suite 600
Tampa, FL 33607
(813) 206-6952
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.
This Amendment, and all its attachments, are hereby made part of this Contract.
This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Amendment No. 3, Page 1 of 2

IN WITNESS WHEREOF, the Parties hereto have caused this twenty-nine (29) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.
	
					
	WELLCARE OF FLORIDA, INC.
	 
	STATE OF FLORIDA, AGENCY FOR

	D/B/A STAYWELL HEALTH PLAN
	 
	HEALTH CARE ADMINISTRATION

	OF FLORIDA
	 
	 
	 

	 
	 
	 
	 
	 

	SIGNED
	 
	SIGNED

	BY:
	/s/ Gregg Macdonald
	 
	BY:
	/s/ Elizabeth Dudek

	NAME:
	Gregg Macdonald
	 
	NAME:
	Elizabeth Dudek

	TITLE:
	State President
	 
	TITLE:
	Secretary

	DATE:
	9-18-14
	 
	DATE:
	9/19/14

	
					
	List of Attachments/Exhibits included as part of this Amendment

	 
	 
	 
	 
	 

	Specify
	Letter/
	 
	 
	 

	Type
	Number
	Description
	 
	 

	Attachment
	I
	Scope of Services – Effective Date:  August 1, 2014 (27 Pages)

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AHCA Contract No. FP020, Amendment No. 3, Page 2 of 2

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
SCOPE OF SERVICES - Effective Date:  August 1, 2014
STATEWIDE MEDICAID MANAGED CARE PROGRAM
		
	I.
	Services to be Provided

		
	A.
	Overview of Contract Structure

Part IV of Chapter 409, F.S. established Florida Medicaid’s statewide managed care program, referred to as statewide Medicaid managed care (SMMC). Contracted managed care plans participate in one, or both, of two SMMC programs: one for managed medical assistance (MMA) and one for long-term care (LTC). Additionally, some managed care plans participating in the MMA program component serve specialty populations who meet specified criteria based on age, condition or diagnosis.
The Contract consists of distinct parts as follows:
		
	(1)
	Attachment I, Scope of Services, includes contract provisions that are unique to the particular managed care plan.

		
	(a)
	Exhibit I-A, Approved Expanded Benefits Coverage and Limitations;

		
	(b)
	Exhibit I-B, Medicaid Provider Identification Numbers;

		
	(c)
	Exhibit I-C, Managed Care Plan Rates.

		
	(2)
	Attachment II, Core Contract Provisions, includes contract provisions that apply to all managed care plans unless specifically noted otherwise.

		
	(3)
	Exhibits to Attachment II, include contract provisions that are unique to the specific component of SMMC:

		
	(a)
	Exhibit II-A, Managed Medical Assistance (MMA) Program, i.e. the MMA Exhibit;

		
	(b)
	Exhibit II-B, Long-Term Care (LTC) Managed Care Program, i.e. the LTC Exhibit;

		
	(c)
	Exhibit II-C, Specialty Plan (if applicable).

		
	B.
	Authorized Regions and Program Enrollment Levels

The Managed Care Plan is authorized to provide services pursuant to this Contract in the region(s), and up to the maximum enrollment levels for such region(s), for the applicable SMMC program as specified in Table 1 below.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 1 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

	
				
	Table 1:  Regions and Program Enrollment Levels

	Region
	Program Component

	MMA
	LTC
	Specialty

	Region 1
	 
	 
	 

	Region 2
	117,516
	 
	 

	Region 3
	130,444
	 
	 

	Region 4
	152,143
	 
	 

	Region 5
	95,177
	 
	 

	Region 6
	118,754
	 
	 

	Region 7
	129,577
	 
	 

	Region 8
	104,607
	 
	 

	Region 9
	   
	 
	 

	Region 10
	 
	 
	 

	Region 11
	114,124
	 
	 

The authorized maximum enrollment levels listed are effective upon Contract execution unless otherwise specified. The maximum enrollment levels may be altered during the life of this Contract pursuant to Attachment II and its Exhibits.
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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 2 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

		
	C.
	Covered Services

The Managed Care Plan shall ensure the provision of covered services in accordance with the provisions of Attachment II and its Exhibits, summarized in Table 2a (MMA) and/or Table 2b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.
	
		
	 
	Table 2a:  Required MMA Services

	(1)
	Advanced Registered Nurse Practitioner

	(2)
	Ambulatory Surgical Center Services

	(3)
	Assistive Care Services

	(4)
	Behavioral Health Services

	(5)
	Birth Center and Licensed Midwife Services

	(6)
	Clinic Services

	(7)
	Chiropractic Services

	(8)
	Dental Services

	(9)
	Child Health Check Up

	(10)
	Immunizations

	(11)
	Emergency Services

	(12)
	Emergency Behavioral Health Services

	(13)
	Family Planning Services and Supplies

	(14)
	Healthy Start Services

	(15)
	Hearing Services

	(16)
	Home Health Services and Nursing Care

	(17)
	Hospice Services

	(18)
	Hospital Services

	(19)
	Laboratory and Imaging Services

	(20)
	Medical Supplies, Equipment, Prostheses and Orthoses

	(21)
	Optometric and Vision Services

	(22)
	Physician Assistant Services

	(23)
	Podiatric Services

	(24)
	Physician Services

	(25)
	Prescribed Drug Services

	(26)
	Renal Dialysis Services

	(27)
	Therapy Services

	(28)
	Transportation Services

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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 3 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

	
		
	 
	Table 2b:  Required LTC Services

	(1)
	Adult Companion Care

	(2)
	Adult Day Health Care

	(3)
	Assistive Care Services

	(4)
	Assisted Living

	(5)
	Attendant Care

	(6)
	Behavioral Management

	(7)
	Caregiver Training

	(8)
	Care Coordination/Case Management

	(9)
	Home Accessibility Adaptation Services

	(10)
	Home Delivered Meals

	(11)
	Homemaker Services

	(12)
	Hospice

	(13)
	Intermittent and Skilled Nursing

	(14)
	Medical Equipment and Supplies

	(15)
	Medication Administration

	(16)
	Medication Management

	(17)
	Nutritional Assessment/Risk Reduction Services

	(18)
	Nursing Facility Services

	(19)
	Personal Care

	(20)
	Personal Emergency Response Systems (PERS)

	(21)
	Respite Care

	(22)
	Occupational Therapy

	(23)
	Physical Therapy

	(24)
	Respiratory Therapy

	(25)
	Speech Therapy

	(26)
	Transportation

		
	D.
	Approved Expanded Benefits

The Managed Care Plan shall provide the following expanded benefits, in accordance with the provisions of Attachment II and its Exhibits and the coverage and limitations specified in Exhibit I-A of this Attachment, denoted by “X” in Table 3a (MMA) and/or Table 3b (LTC) below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.

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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 4 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

	
		
	Table 3a:  Approved MMA Expanded Benefits

	X
	Primary Care Visits (Non-Pregnant Adults)

	X
	Home Health Care (Non-Pregnant Adults)

	X
	Physician Home Visits

	X
	Prenatal/Perinatal Visits

	X
	Outpatient Services

	X
	Over-The-Counter (OTC)  Medication/Supplies

	X
	Adult Dental Services

	X
	Waived Copayments

	X
	Vision Services

	X
	Hearing Services

	X
	Newborn Circumcision

	X
	Adult Pneumonia Vaccine

	X
	Adult Influenza Vaccine

	X
	Adult Shingles Vaccine

	X
	Post Discharge Meals

	X
	Nutritional Counseling

	X
	Pet Therapy

	X
	Art Therapy

	X
	Equine Therapy

	X
	Medically Related Lodging and Food

	

	 

	Table 3b:  Approved LTC Expanded Benefits

	 
	ALF/AFCH Bed Hold

	 
	Cellular Phone Services

	 
	Dental Services

	 
	Emergency Financial Assistance

	 
	Hearing Evaluation

	 
	Mobile Personal Emergency Response System

	 
	Non-Medical Transportation

	 
	Over-The-Counter (OTC)  Medication/Supplies

	 
	Support to Transition Out of a Nursing Facility

	 
	Vision Services

	 
	Wellness Grocery Discount

	Additional LTC Expanded Benefits

	These benefits will not appear in Choice Counseling materials

	 
	Box Fan

	 
	Caregiver Information/Support

	 
	Document Keeper

	 
	Household Set-Up Kit

	 
	Welcome Home Basket

	 
	Nurse Helpline Services

	 
	Pill Organizer

		
	II.
	Manner of Service Provision

		
	A.
	Plan Qualification

The Managed Care Plan is approved to provide contracted services as a qualified entity under s 409.962(6), F.S., as denoted by “X” in Table 4 below.

AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 5 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

	
		
	Table 4:  Plan Qualification

	X
	Health Maintenance Organization (HMO)

	 
	Provider Service Network (PSN)

	 
	Exclusive Provider Organization (EPO)

	 
	Accountable Care Organization (ACO)

	 
	Other Insurer

		
	B.
	Plan Type

The Managed Care Plan is approved to provide contracted services as one or more of four plan types, denoted by authorized region(s) in Table 5 below, to enrollees of the applicable SMMC program(s) in the authorized region(s) specified in Table 1.
		
	(1)
	MMA Managed Care Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1)(a) through (cc), F.S.

		
	(2)
	LTC Managed Care Plans are those plans that provide covered services specified in the LTC Exhibit, including those covered under s. 409.98(1) through (19), F.S.

		
	(3)
	Comprehensive LTC Plans are those plans that provide services described in s. 409.973, F.S., and also provide the services described in s. 409.98, F.S.

		
	(4)
	Specialty Plans are those plans that provide covered services specified in the MMA Exhibit, including those covered under s. 409.973(1 )(a) through (cc), F.S., to only eligible recipients defined as a specialty population in the Attachment II and its Exhibits.

	
			
	Table 5:  SMMC Plan Type

	Region
	SMMC Program

	MMA/LTC
	Specialty

	Region 1
	 
	 

	Region 2
	MMA Plan
	 

	Region 3
	MMA Plan
	 

	Region 4
	MMA Plan
	 

	Region 5
	MMA Plan
	 

	Region 6
	MMA Plan
	 

	Region 7
	MMA Plan
	 

	Region 8
	MMA Plan
	 

	Region 9
	 
	 

	Region 10
	 
	 

	Region 11
	MMA Plan
	 

		
	III.
	Method of Payment

		
	A.
	Total Contract Amount

The Agency shall make payment, in a total dollar amount not to exceed $11,789,499,367.00 to the Managed Care Plan in accordance with Attachment II and its Exhibits. The Agency shall make payments through its fiscal agent using the Medicaid Provider Identification Number(s) specified in Exhibit I-B.
		
	B.
	Capitation Rates

AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 6 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

The capitation rate payment shall be in accordance with Attachment II and its Exhibits. The capitation rates are contained in Exhibit I-C of this Attachment. These rates are titled “MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”
		
	IV.
	Special Provisions

		
	A.
	Order of Precedence

The Managed Care Plan shall perform its contracted duties in accordance with this Contract, the ITN(s), including all addenda and the Vendor’s response to the ITN(s). In the event of conflict among Contract documents, any identified inconsistency in this Contract shall be resolved by giving precedence in the following order:
		
	(1)
	This Contract, including all attachments;

		
	(2)
	The ITN(s), including all addenda; and

		
	(3)
	The Vendor’s response to the ITN(s), including information provided through negotiations.

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AHCA Contract No. FP020, Attachment I, Effective 8/1/14, Page 7 of 7

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-A - Effective Date: August 1, 2014
	
		
	Approved Expanded Benefit Coverage and Limitations
Managed Medical Assistance (MMA)

	Approved Benefit
	Approved Limitations

	Primary Care Visits
(Non-Pregnant Adults)
	Unlimited visits.

	Home Health Care
(Non-Pregnant Adults)
	One (1) visit per day; subject to medical necessity and prior authorization.

	Physician Home Visits
	Unlimited visits; limited to homebound enrollees who are frail, have a chronic disability and/or complex medical needs; subject to medical necessity.

	Prenatal/Perinatal Visits
	Unlimited prenatal visits; unlimited postnatal visits for the first four (4) weeks post-partum.

	Outpatient Services
	One-thousand dollars ($1,000) for outpatient services per fiscal year (July 1-June 30); subject to prior authorization.

	Over-The Counter (OTC)
Medication/Supplies
	Twenty-five dollars ($25) per household per month; enrollee purchases limited to an approved list of products.

	Adult Dental Services
	One (1) exam every six (6) months; one (1) cleaning every six (6) months; one (1) x-ray per year.

	Waived Copayments
	Enrollees shall not be subject to co-payment charges except:  non-emergency emergency room visits and chiropractic services.

	Vision Services
	One-hundred dollars ($100) with which enrollees may purchase frames, lenses and contact lenses per year.

	Hearing Services
	One (1) hearing exam every two (2) years; one (1) hearing aid every two (2) years.

	Newborn Circumcision
	Available upon request up to three (3) months old; subject to prior authorization.

	Adult Pneumonia Vaccine
	Administered as medically advised; limit one (1) vaccination per lifetime.

	Adult Influenza Vaccine
	One (1) vaccination per year.

	Adult Shingles Vaccine
	Limit one (1) vaccination every six (6) years; subject to prior authorization.

	Post Discharge Meals
	Ten (10) meals within two weeks of an enrollee being discharged from an inpatient facility; limited to SSI and Medicare/Medicaid dual eligible enrollees; subject to prior authorization.

	Nutritional Counseling
	Unlimited visits; limited to enrollees who receive home health services with a chronic disability or a complex medical need; subject to medical necessity and prior authorization.

	Pet Therapy
	Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.

AHCA Contract No. FP020, Attachment I, Exhibit I-A, Effective 8/1/14, Page 1 of 2

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

	
		
	Art Therapy
	Unlimited visits; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; subject to medical necessity and prior authorization.

	Equine Therapy
	Ten (10) visits per year; limited to SSI, child welfare and Medicare/Medicaid dual eligible enrollees; enrollee must be more than one (1) year old; subject to prior authorization.

	Medically Related Lodging and Food
	Unlimited coverage for enrollees and traveling partners; benefit only available if enrollee is required to travel more than fifty (50) miles from their home for non-emergent specialist or hospital treatment; overnight stay required; adult enrollees are limited to one (1) travel partner; child enrollees are limited to two (2) travel partners; subject to prior authorization.

All expanded benefits are in excess of benefits specified in the Medicaid State Plan.
The Managed Care Plan may require enrollees to use an established network of providers, approved by the Agency, to obtain expanded benefits under this Contract.
Unless otherwise specified in this Exhibit, expanded benefits are not subject to prior authorization or co-payment charges.

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AHCA Contract No. FP020, Attachment I, Exhibit I-A, Effective 8/1/14, Page 2 of 2

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-B - Effective Date: August 1, 2014

	
				
	Medicaid Provider Identification Numbers

	Region
	MMA
	LTC
	Specialty

	1
	 
	 
	 

	2
	0105630-02
	 
	 

	3
	0105630-03
	 
	 

	4
	0105630-04
	 
	 

	5
	0105630-05
	 
	 

	5
	0105630-06
	 
	 

	7
	0105630-07
	 
	 

	8
	0105630-08
	 
	 

	9
	 
	 
	 

	10
	 
	 
	 

	11
	0105630-11
	 
	 

The Agency will provide Medicaid Provider Identification Numbers to the Managed Care Plan subsequent to the Agency’s completion of a plan-specific readiness review and prior to enrolling recipient in the Managed Care Plan in each authorized region.

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AHCA Contract No. FP020, Attachment I, Exhibit I-B, Effective 8/1/14, Page 1 of 1

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 2 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 2
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,094.16
	

	

	$19,072.40
	

	 
	

	$1,369.48
	

	 
	 
	 
	 

	3-11 Months
	183.32
	

	3,735.12
	

	 
	565.76
	

	 
	 
	 
	 

	1-13 Years
	111.00
	

	342.61
	

	 
	429.69
	

	 
	 
	 
	 

	14-54 Years Female
	308.78
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	132.53
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	790.05
	

	 
	678.18
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	360.48
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	156.77
	 
	 
	 
	

	$290.81
	

	

	$2,064.22
	

	Age 65+
	 
	 
	109.02
	 
	 
	 
	

	$159.36
	

	

	$1,334.05
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	155.48
	

	$
	2,697.66
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 1 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 3 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 3
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,237.57
	

	

	$22,454.93
	

	 
	

	$1,394.19
	

	 
	 
	 
	 

	3-11 Months
	207.35
	

	4,397.55
	

	 
	575.97
	

	 
	 
	 
	 

	1-13 Years
	125.55
	

	403.37
	

	 
	437.44
	

	 
	 
	 
	 

	14-54 Years Female
	349.25
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	149.90
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	930.16
	

	 
	690.42
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	407.73
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	153.34
	 
	 
	 
	

	$295.91
	

	

	$2,237.34
	

	Age 65+
	 
	 
	106.63
	 
	 
	 
	

	$161.91
	

	

	$1,445.93
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	182.12
	

	$
	2,705.71
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

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AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 2 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 4 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 4
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,146.62
	

	

	$22,224.26
	

	 
	

	$1,526.83
	

	 
	 
	 
	 

	3-11 Months
	192.11
	

	4,352.38
	

	 
	630.77
	

	 
	 
	 
	 

	1-13 Years
	116.32
	

	399.23
	

	 
	479.06
	

	 
	 
	 
	 

	14-54 Years Female
	323.58
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	138.88
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	920.61
	

	 
	756.11
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	377.76
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	173.69
	 
	 
	 
	

	$289.37
	

	

	$2,516.16
	

	Age 65+
	 
	 
	120.78
	 
	 
	 
	

	$158.16
	

	

	$1,626.12
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	155.82
	

	$
	2,500.46
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 3 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 5 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 5
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,377.91
	

	

	$24,350.08
	

	 
	

	$1,813.76
	

	 
	 
	 
	 

	3-11 Months
	230.86
	

	4,768.69
	

	 
	749.30
	

	 
	 
	 
	 

	1-13 Years
	139.79
	

	437.41
	

	 
	569.09
	

	 
	 
	 
	 

	14-54 Years Female
	388.86
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	166.90
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	1,008.67
	

	 
	898.20
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	453.97
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	131.76
	 
	 
	 
	

	$276.19
	

	

	$2,482.33
	

	Age 65+
	 
	 
	91.63
	 
	 
	 
	

	$151.15
	

	

	$1,604.26
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	154.10
	

	$
	2,887.15
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 4 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 6 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 6
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,236.35
	

	

	$22,063.22
	

	 
	

	$1,658.03
	

	 
	 
	 
	 

	3-11 Months
	207.15
	

	4,320.84
	

	 
	684.97
	

	 
	 
	 
	 

	1-13 Years
	125.42
	

	396.33
	

	 
	520.22
	

	 
	 
	 
	 

	14-54 Years Female
	348.91
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	149.75
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	913.94
	

	 
	821.08
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	407.33
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	127.88
	 
	 
	 
	

	$283.44
	

	

	$2,505.48
	

	Age 65+
	 
	 
	88.93
	 
	 
	 
	

	$154.18
	

	

	$1,619.23
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	163.88
	

	$
	2,902.00
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 5 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 7 – Effective May 1, 2014 – June 30, 2014
	
									
	REGION 7
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	3-11 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	1-13 Years
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	14-54 Years Female
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	55+ Years (Male and Female)
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Age 65+
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Medicare Advantage/D-SNP
	 
	 
	TBD
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	Not Applicable
	Not Applicable
	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 6 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 8 – Effective May 1, 2014 – June 30, 2014
	
																							
	REGION 8
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,272.58
	

	

	$24,376.24
	

	 
	

	$1,366.19
	

	 
	 
	 
	 

	3-11 Months
	213.22
	

	4,773.82
	

	 
	564.40
	

	 
	 
	 
	 

	1-13 Years
	129.10
	

	437.88
	

	 
	428.66
	

	 
	 
	 
	 

	14-54 Years Female
	359.13
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	154.14
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	1,009.75
	

	 
	676.56
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	419.26
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	137.13
	 
	 
	 
	

	$233.54
	

	

	$2,446.41
	

	Age 65+
	 
	 
	95.36
	 
	 
	 
	

	$127.84
	

	

	$1,581.05
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	$
	167.77
	

	$
	2,909.87
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 7 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 10 – Effective May 1, 2014 – June 30, 2014
	
									
	REGION 10
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	3-11 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	1-13 Years
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	14-54 Years Female
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	55+ Years (Male and Female)
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Age 65+
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Medicare Advantage/D-SNP
	 
	 
	TBD
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	Not Applicable
	Not Applicable
	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 8 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 11 – Effective May 1, 2014 – June 30, 2014
	
									
	REGION 11
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	3-11 Months
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	1-13 Years
	Not Applicable
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	14-54 Years Female
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	Not Applicable
	 
	Not Applicable
	 
	 
	 
	 

	55+ Years (Male and Female)
	Not Applicable
	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Age 65+
	 
	 
	Not Applicable
	 
	 
	 
	Not Applicable
	Not Applicable

	Medicare Advantage/D-SNP
	 
	 
	TBD
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	Not Applicable
	Not Applicable
	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 9 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 2 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 2
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,068.84
	

	

	$17,812.93
	

	 
	

	$1,309.21
	

	 
	 
	 
	 

	3-11 Months
	

	$187.39
	

	

	$3,575.66
	

	 
	

	$553.28
	

	 
	 
	 
	 

	1-13 Years
	

	$115.99
	

	

	$352.10
	

	 
	

	$429.54
	

	 
	 
	 
	 

	14-54 Years Female
	

	$312.46
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$136.40
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$802.08
	

	 
	

	$671.86
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$374.00
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$159.47
	

	 
	 
	 
	

	$297.45
	

	

	$2,051.61
	

	Age 65+
	 
	 
	

	$110.85
	

	 
	 
	 
	

	$163.17
	

	

	$1,331.90
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$159.13
	

	

	$2,795.08
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 10 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 3 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 3
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,118.07
	

	

	$19,551.78
	

	 
	

	$1,299.83
	

	 
	 
	 
	 

	3-11 Months
	

	$196.02
	

	

	$3,924.71
	

	 
	

	$549.31
	

	 
	 
	 
	 

	1-13 Years
	

	$121.33
	

	

	$386.47
	

	 
	

	$426.46
	

	 
	 
	 
	 

	14-54 Years Female
	

	$326.85
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$142.68
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$880.37
	

	 
	

	$667.04
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$391.23
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$155.75
	

	 
	 
	 
	

	$306.36
	

	

	$2,046.46
	

	Age 65+
	 
	 
	

	$108.27
	

	 
	 
	 
	

	$167.80
	

	

	$1,328.56
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$182.70
	

	

	$2,642.48
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 11 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 4 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 4
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,057.16
	

	

	$19,538.35
	

	 
	

	$1,454.69
	

	 
	 
	 
	 

	3-11 Months
	

	$185.34
	

	

	$3,922.01
	

	 
	

	$614.76
	

	 
	 
	 
	 

	1-13 Years
	

	$114.72
	

	

	$386.20
	

	 
	

	$477.27
	

	 
	 
	 
	 

	14-54 Years Female
	

	$309.04
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$134.91
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$879.77
	

	 
	

	$746.51
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$369.91
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$176.91
	

	 
	 
	 
	

	$296.28
	

	

	$2,177.66
	

	Age 65+
	 
	 
	

	$122.97
	

	 
	 
	 
	

	$162.11
	

	

	$1,413.73
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$159.24
	

	

	$2,461.15
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 12 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 5 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 5
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,302.22
	

	

	$22,081.30
	

	 
	

	$1,766.09
	

	 
	 
	 
	 

	3-11 Months
	

	$228.31
	

	

	$4,432.47
	

	 
	

	$746.36
	

	 
	 
	 
	 

	1-13 Years
	

	$141.31
	

	

	$436.47
	

	 
	

	$579.44
	

	 
	 
	 
	 

	14-54 Years Female
	

	$380.68
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$166.18
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$994.27
	

	 
	

	$906.32
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$455.67
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$134.56
	

	 
	 
	 
	

	$282.51
	

	

	$2,354.78
	

	Age 65+
	 
	 
	

	$93.54
	

	 
	 
	 
	

	$154.78
	

	

	$1,528.72
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$157.32
	

	

	$2,958.89
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 13 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 6 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 6
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,123.47
	

	

	$19,086.27
	

	 
	

	$1,572.23
	

	 
	 
	 
	 

	3-11 Months
	

	$196.97
	

	

	$3,831.26
	

	 
	

	$664.43
	

	 
	 
	 
	 

	1-13 Years
	

	$121.91
	

	

	$377.27
	

	 
	

	$515.83
	

	 
	 
	 
	 

	14-54 Years Female
	

	$328.43
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$143.37
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$859.41
	

	 
	

	$806.83
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$393.12
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$129.84
	

	 
	 
	 
	

	$291.09
	

	

	$2,226.74
	

	Age 65+
	 
	 
	

	$90.26
	

	 
	 
	 
	

	$158.54
	

	

	$1,445.60
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$167.13
	

	

	$2,868.52
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 14 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 7 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 7
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,143.19
	

	

	$19,730.90
	

	 
	

	$1,582.04
	

	 
	 
	 
	 

	3-11 Months
	

	$200.42
	

	

	$3,960.66
	

	 
	

	$668.57
	

	 
	 
	 
	 

	1-13 Years
	

	$124.06
	

	

	$390.01
	

	 
	

	$519.05
	

	 
	 
	 
	 

	14-54 Years Female
	

	$334.19
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$145.88
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$888.44
	

	 
	

	$811.87
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$400.02
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$131.26
	

	 
	 
	 
	

	$292.40
	

	

	$2,479.20
	

	Age 65+
	 
	 
	

	$91.24
	

	 
	 
	 
	

	$158.49
	

	

	$1,609.49
	

	Medicare Advantage/D-SNP
	 
	 
	TBD
	

	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$167.43
	

	

	$2,862.24
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 15 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C- Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 8 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 8
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,133.57
	

	

	$20,548.31
	

	 
	

	$1,278.24
	

	 
	 
	 
	 

	3-11 Months
	

	$198.74
	

	

	$4,124.74
	

	 
	

	$540.19
	

	 
	 
	 
	 

	1-13 Years
	

	$123.01
	

	

	$406.17
	

	 
	

	$419.38
	

	 
	 
	 
	 

	14-54 Years Female
	

	$331.38
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$144.66
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$925.24
	

	 
	

	$655.96
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$396.65
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$137.78
	

	 
	 
	 
	

	$238.39
	

	

	$2,076.58
	

	Age 65+
	 
	 
	

	$95.78
	

	 
	 
	 
	

	$130.64
	

	

	$1,348.11
	

	Medicare Advantage/D-SNP
	 
	 
	 
	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$171.11
	

	

	$2,890.62
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 16 of 17

WellCare of Florida, Inc.
d/b/a Staywell Health Plan of Florida

ATTACHMENT I
EXHIBIT I-C - Effective Date: August 1, 2014
MANAGED CARE PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS
REGION 11 – Effective July 1, 2014 – August 31, 2015
	
																									
	REGION 11
	 
	HIV/AIDS
	Long-Term Care Enrollees1

	Age Band
	TANF
	SSI No Medicare
	Dual Eligible
	Child Welfare
	Dual Eligible
	Medicaid Only
	Dual Eligible
	Medicaid Only

	0-2 Months
	

	$1,237.30
	

	

	$24,338.77
	

	 
	

	$1,902.10
	

	 
	 
	 
	 

	3-11 Months
	

	$216.92
	

	

	$4,885.62
	

	 
	

	$803.84
	

	 
	 
	 
	 

	1-13 Years
	

	$134.27
	

	

	$481.09
	

	 
	

	$624.06
	

	 
	 
	 
	 

	14-54 Years Female
	

	$361.70
	

	 
	 
	 
	 
	 
	 
	 

	14-54 Years Male
	

	$157.89
	

	 
	 
	 
	 
	 
	 
	 

	14+ Years (Male and Female)
	 
	

	$1,095.92
	

	 
	

	$976.12
	

	 
	 
	 
	 

	55+ Years (Male and Female)
	

	$432.95
	

	 
	 
	 
	 
	 
	 
	 

	Under Age 65
	 
	 
	

	$175.91
	

	 
	 
	 
	

	$293.29
	

	

	$2,511.25
	

	Age 65+
	 
	 
	

	$122.28
	

	 
	 
	 
	

	$158.71
	

	

	$1,630.30
	

	Medicare Advantage/D-SNP
	 
	 
	TBD
	

	 
	 
	 
	 
	 

	HIV-AIDS
	 
	 
	 
	 
	

	$162.86
	

	

	$3,361.00
	

	 
	 

1.  Long-Term Care Enrollees refer to those enrolled in both the MMA and LTC components of a comprehensive plan. A factor of 0.9 will be applied to the LTC Dual Eligible and LTC Medicaid Only rates for those long-term care enrollees.
2.  Rates shown reflect base rates and do not include the impacts of risk adjustment.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

AHCA Contract No. FP020, Attachment I, Exhibit I-C, Effective 8/1/14, Page 17 of 17

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