Document:

exv10w25w10

 

Exhibit
10.25.10

STATE OF ILLINOIS

DEPARTMENT OF PUBLIC AID

			
	AMERIGROUP FLORIDA, INC.
	 	Medicaid HMO Contract

AHCA CONTRACT NO. FA523

AMENDMENT NO. 10

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

	1.	 	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, is hereby deleted in its
entirety and replaced with the following:

	 	90.0	 	PAYMENT AND AUTHORIZED ENROLLMENT LEVELS

	 	a.	 	The Agency assigns the Plan an authorized maximum enrollment level for each operational
county, and the Agency shall pay the Plan capitation payments for each Agency operational area, in
accordance with the following table. The Agency shall pay the Plan capitation payments based on
the Agency operational area (or rate zone) age group, gender and authorized services, in accordance
with Attachment VIII-A.
	 
	 	b.	 	The authorized maximum enrollment level is in effect as of July 1, 2005, or upon Contract
execution, whichever is later. The Agency must approve in writing any increase in the Plan’s
maximum enrollment level for each operational county. Such approval shall not be unreasonably
withheld, and shall be based on the Plan’s satisfactory performance of terms of the Contract and
approval of the Plan’s administrative and service resources, as specified in this Contract, in
support of each enrollment level.
	 
	 	c.	 	Table 1 provides the Plan’s Contract enrollment levels.
	 
	 	d.	 	Table 2 provides the authorized areas of operation and respective capitation rates, which are
located in Attachment VIII-A.

Table 1

Enrollment Levels

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

AHCA Contract No. FA523, Amendment No. 10, Page 1 of 3

 

 

			
	AMERIGROUP FLORIDA, INC.
	 	Medicaid HMO Contract

Table 2

Capitation Rates

	 	(i)	 	General Capitation Rates plus Mental Health Rates (Attachment VIII-A, Table 4):

Area 5 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Pasco
	 	 	015005304	 
	Pinellas
	 	 	015005305	 

Area 6 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Hillsborough
	 	 	015005300	 
	Polk
	 	 	015005307	 
	Manatee
	 	 	015005318	 

Area 7 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Orange
	 	 	015005308	 
	Seminole
	 	 	015005313	 
	Osceola
	 	 	015005314	 
	Brevard
	 	 	015005336	 

Area 8 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Lee
	 	 	015005302	 
	Sarasota
	 	 	015005306	 

Area 9 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Palm Beach
	 	 	015005310	 

Area 10 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Broward
	 	 	015005311	 

Area 11 Counties:

	 	 	 	 	 
	County	 	Provider Number
	Dade
	 	 	015005312	 

	 	e.	 	For Plans participating in the frail/elderly program, the community rate shall be paid for
all members in each eligibility category except for those SSI members determined by the
Comprehensive Assessment and Review for Long Term Care (CARES) Unit to be at risk of nursing home
institutionalization. Evidence of such assessments shall be provided to the

AHCA Contract No. FA523, Amendment No. 10, Page 2 of 3

 

 

			
	AMERIGROUP FLORIDA, INC.
	 	Medicaid HMO Contract

	 	 	 	Agency by the Plan prior to authorization by the Agency of payment of the institutional rates.
Payment of institutional rates for any eligible enrollee shall continue only so long as the
enrollee meets the level of care requirements for institutionalization, otherwise, the community
capitation rate applies.
	 
	 	f.	 	Notwithstanding the payment amounts which may be computed with the rate table outlined in
Attachment VIII-A, the sum of total capitation payments under this Contract shall not exceed the
total Contract amount of $680,379,083.00 expressed on page seven (7) of this Contract.

	2.	 	Attachment VIII, Estimated 2005-2006 Rates; Not for use unless approved by CMS, is hereby
deleted in its entirety and replaced with Attachment VIII-A, 2005/2006 Medicaid HMO Capitation
Rates.
	 
	3.	 	This Amendment shall have an effective date of March 1, 2006, or the date on which both
parties execute the Amendment, whichever is later.

          All provisions in the Contract and any attachments thereto in conflict with this Amendment shall be
and are hereby changed to conform with this Amendment.

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

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

          This Amendment can not be executed unless all previous Amendments to this Contract have been fully
executed.

          IN WITNESS WHEREOF, the parties hereto have caused this 6 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.

	 	 	 	 	 
	AMERIGROUP FLORIDA, INC.

	 	STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION
	 	 
	 
	 	 	 	 
	SIGNED

	 	SIGNED	 	 
	BY:
/s/ Don Gilmore

	 	BY: /s/ Alan Levine	 	 
	 
 

	 	 
	 	 
	 
	 	 	 	 
	NAME: Don Gilmore

	 	NAME: Alan Levine	 	 
	 
	 	 	 	 
	TITLE: CEO

	 	TITLE: Secretary	 	 
	 
	 	 	 	 
	DATE: 2-20-06

	 	DATE: 2-27-06	 	 

List of attachments included as part of this Amendment:

	 	 	 	 	 
	Specify Type	 	Number	 	Description
	 
	Attachment

	 	VIII-A
	 	2005/2006 HMO Rates (3 pages)

AHCA Contract No. FA523, Amendment No. 10, Page 3 of 3

 

 

ATTACHMENT VIII-A

2005/2006 MEDICAID HMO CAPITATION RATES

By Area, Age and Eligibility Category

Effective from July 1, 2005 thru June 30, 2006

             TABLE 1

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05-Dec. 31, 05	 	 	Effect from Jan. 1, 06 - June 30, 06
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	SSI-B	 	SSI-AB
	Area	 	BTHMO+2MC	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	BTHMO+2MC	 	3MO-11MO	 	AGE (1-5)	 	AGE(6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE(65+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	856.86	 	 	 	169.63	 	 	 	82.99	 	 	 	52.46	 	 	 	116.16	 	 	 	58.88	 	 	 	223.51	 	 	 	144.11	 	 	 	299.66	 	 	 	8,379.19	 	 	 	1,456.16	 	 	 	373.32	 	 	 	192.70	 	 	 	211.00	 	 	 	636.93	 	 	 	598.54	 	 	 	359.76	 	 	 	314.95	 	 	 	219.52	 	 	 	 	213.89	 	 	 	77.80	 	 	 	67.94	 
	02
	 	 	856.85	 	 	 	169.63	 	 	 	82.99	 	 	 	52.46	 	 	 	116.16	 	 	 	58.88	 	 	 	223.51	 	 	 	144.11	 	 	 	299.66	 	 	 	8,379.19	 	 	 	1,456.16	 	 	 	373.32	 	 	 	192.70	 	 	 	211.00	 	 	 	636.93	 	 	 	598.84	 	 	 	359.76	 	 	 	314.85	 	 	 	219.52	 	 	 	 	213.89	 	 	 	77.80	 	 	 	67.94	 
	03
	 	 	956.50	 	 	 	190.36	 	 	 	93.47	 	 	 	59.66	 	 	 	130.82	 	 	 	66.71	 	 	 	252.75	 	 	 	163.57	 	 	 	340.95	 	 	 	8,796.55	 	 	 	1,536.62	 	 	 	394.23	 	 	 	205.64	 	 	 	225.15	 	 	 	679.21	 	 	 	639.39	 	 	 	347.95	 	 	 	292.11	 	 	 	203.81	 	 	 	 	229.06	 	 	 	75.70	 	 	 	66.16	 
	04
	 	 	877.98	 	 	 	175.54	 	 	 	86.37	 	 	 	56.47	 	 	 	120.97	 	 	 	62.05	 	 	 	234.40	 	 	 	152.22	 	 	 	317.36	 	 	 	8,571.65	 	 	 	1,495.56	 	 	 	363.99	 	 	 	199.57	 	 	 	218.39	 	 	 	659.82	 	 	 	620.93	 	 	 	333.59	 	 	 	294.49	 	 	 	205.57	 	 	 	 	207.10	 	 	 	77.20	 	 	 	67.39	 
	05
	 	 	919.97	 	 	 	183.42	 	 	 	90.13	 	 	 	57.68	 	 	 	126.15	 	 	 	64.46	 	 	 	244.02	 	 	 	158.18	 	 	 	328.69	 	 	 	9,248.01	 	 	 	1,615.40	 	 	 	414.34	 	 	 	216.54	 	 	 	236.27	 	 	 	713.54	 	 	 	671.66	 	 	 	327.78	 	 	 	311.44	 	 	 	217.30	 	 	 	 	209.72	 	 	 	74.11	 	 	 	64.73	 
	06
	 	 	839.69	 	 	 	168.12	 	 	 	82.82	 	 	 	53.24	 	 	 	115.99	 	 	 	58.58	 	 	 	224.94	 	 	 	146.07	 	 	 	306.02	 	 	 	8,536.48	 	 	 	1,494.27	 	 	 	383.80	 	 	 	201.12	 	 	 	219.94	 	 	 	663.51	 	 	 	624.96	 	 	 	318.14	 	 	 	263.93	 	 	 	198.16	 	 	 	 	200.02	 	 	 	66.93	 	 	 	60.15	 
	07
	 	 	894.04	 	 	 	178.56	 	 	 	87.80	 	 	 	58.33	 	 	 	122.97	 	 	 	63.04	 	 	 	238.18	 	 	 	154.51	 	 	 	322.34	 	 	 	8,976.51	 	 	 	1,573.97	 	 	 	404.61	 	 	 	212.74	 	 	 	232.25	 	 	 	701.12	 	 	 	661.11	 	 	 	306.90	 	 	 	264.61	 	 	 	198.64	 	 	 	 	199.32	 	 	 	72.42	 	 	 	63.28	 
	08
	 	 	765.52	 	 	 	156.85	 	 	 	77.12	 	 	 	49.44	 	 	 	107.84	 	 	 	56.29	 	 	 	209.14	 	 	 	136.62	 	 	 	282.90	 	 	 	8,247.93	 	 	 	1,440.20	 	 	 	369.54	 	 	 	192.51	 	 	 	211.13	 	 	 	636.41	 	 	 	599.00	 	 	 	306.59	 	 	 	265.63	 	 	 	201.43	 	 	 	 	185.30	 	 	 	69.18	 	 	 	60.36	 
	09
	 	 	850.65	 	 	 	169.56	 	 	 	83.32	 	 	 	53.28	 	 	 	116.63	 	 	 	59.62	 	 	 	225.69	 	 	 	148.30	 	 	 	304.86	 	 	 	8,123.67	 	 	 	1,599.06	 	 	 	410.92	 	 	 	216.11	 	 	 	235.92	 	 	 	711.70	 	 	 	670.95	 	 	 	286.69	 	 	 	317.25	 	 	 	221.58	 	 	 	 	179.44	 	 	 	76.11	 	 	 	66.48	 
	10
	 	 	864.17	 	 	 	170.66	 	 	 	84.11	 	 	 	54.07	 	 	 	117.82	 	 	 	60.56	 	 	 	228.53	 	 	 	148.48	 	 	 	309.60	 	 	 	11,134.67	 	 	 	1,955.16	 	 	 	602.14	 	 	 	254.85	 	 	 	289.16	 	 	 	873.08	 	 	 	823.33	 	 	 	316.19	 	 	 	341.03	 	 	 	235.55	 	 	 	 	205.90	 	 	 	81.99	 	 	 	71.69	 
	11
	 	 	1,110.67	 	 	 	220.94	 	 	 	108.54	 	 	 	69.06	 	 	 	151.73	 	 	 	77.37	 	 	 	293.07	 	 	 	189.70	 	 	 	396.11	 	 	 	12,135.43	 	 	 	2,122.04	 	 	 	545.24	 	 	 	284.82	 	 	 	311.87	 	 	 	940.59	 	 	 	885.79	 	 	 	450.68	 	 	 	420.85	 	 	 	294.28	 	 	 	 	269.25	 	 	 	112.55	 	 	 	95.31	 

             TABLE 2

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Transportation Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05 - Dec. 31, 05	 	 	Effect from Jan. 1, 06 - June 30, 06
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	SSI-B	 	SSI-AB
	Area	 	THMO+2M0	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	THMO+2MO	 	3MO-11MO	 	AGE (1-6)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	859.90	 	 	 	170.76	 	 	 	83.89	 	 	 	53.10	 	 	 	117.81	 	 	 	59.91	 	 	 	226.17	 	 	 	145.81	 	 	 	302.65	 	 	 	8,391.86	 	 	 	1,468.01	 	 	 	360.72	 	 	 	194.81	 	 	 	214.64	 	 	 	651.77	 	 	 	609.36	 	 	 	374.05	 	 	 	331.44	 	 	 	226.36	 	 	 	 	228.18	 	 	 	94.29	 	 	 	74.78	 
	02
	 	 	859.90	 	 	 	170.76	 	 	 	83.89	 	 	 	53.10	 	 	 	117.81	 	 	 	59.91	 	 	 	226.17	 	 	 	145.61	 	 	 	302.65	 	 	 	8,391.86	 	 	 	1,468.01	 	 	 	360.72	 	 	 	194.81	 	 	 	214.64	 	 	 	651.77	 	 	 	609.36	 	 	 	374.05	 	 	 	331.44	 	 	 	226.36	 	 	 	 	228.18	 	 	 	94.29	 	 	 	74.78	 
	03
	 	 	959.98	 	 	 	191.56	 	 	 	94.50	 	 	 	60.41	 	 	 	132.70	 	 	 	67.68	 	 	 	255.60	 	 	 	165.52	 	 	 	344.37	 	 	 	8,811.57	 	 	 	1,550.92	 	 	 	403.17	 	 	 	208.19	 	 	 	229.78	 	 	 	697.16	 	 	 	652.10	 	 	 	358.59	 	 	 	316.61	 	 	 	213.61	 	 	 	 	239.70	 	 	 	99.10	 	 	 	75.86	 
	04
	 	 	880.32	 	 	 	176.41	 	 	 	87.06	 	 	 	55.97	 	 	 	122.24	 	 	 	62.84	 	 	 	236.46	 	 	 	153.53	 	 	 	319.66	 	 	 	8,558.73	 	 	 	1,511.34	 	 	 	393.66	 	 	 	202.38	 	 	 	223.50	 	 	 	679.81	 	 	 	634.95	 	 	 	340.18	 	 	 	317.93	 	 	 	215.29	 	 	 	 	213.69	 	 	 	100.94	 	 	 	77.11	 
	05
	 	 	922.10	 	 	 	184.21	 	 	 	90.75	 	 	 	58.14	 	 	 	127.30	 	 	 	66.18	 	 	 	245.89	 	 	 	159.37	 	 	 	331.78	 	 	 	8,257.23	 	 	 	1,624.00	 	 	 	419.72	 	 	 	218.07	 	 	 	239.06	 	 	 	724.34	 	 	 	679.53	 	 	 	333.32	 	 	 	325.59	 	 	 	223.17	 	 	 	 	216.28	 	 	 	86.26	 	 	 	70.60	 
	06
	 	 	842.31	 	 	 	169.02	 	 	 	83.53	 	 	 	53.76	 	 	 	117.30	 	 	 	60.38	 	 	 	227.06	 	 	 	147.42	 	 	 	307.40	 	 	 	8,546.66	 	 	 	1,504.05	 	 	 	389.72	 	 	 	202.87	 	 	 	223.11	 	 	 	675.78	 	 	 	633.85	 	 	 	322.90	 	 	 	298.45	 	 	 	204.18	 	 	 	 	204.78	 	 	 	83.45	 	 	 	66.17	 
	07
	 	 	896.76	 	 	 	179.20	 	 	 	88.31	 	 	 	56.70	 	 	 	123.90	 	 	 	63.62	 	 	 	239.68	 	 	 	155.47	 	 	 	324.02	 	 	 	8,987.84	 	 	 	1,584.55	 	 	 	411.12	 	 	 	214.63	 	 	 	235.67	 	 	 	714.39	 	 	 	670.51	 	 	 	314.35	 	 	 	301.66	 	 	 	205.65	 	 	 	 	204.77	 	 	 	89.57	 	 	 	70.37	 
	08
	 	 	786.64	 	 	 	158.01	 	 	 	78.04	 	 	 	50.11	 	 	 	109.62	 	 	 	66.34	 	 	 	211.86	 	 	 	137.36	 	 	 	285.97	 	 	 	8,269.67	 	 	 	1,451.18	 	 	 	376.39	 	 	 	194.48	 	 	 	214.68	 	 	 	650.16	 	 	 	608.74	 	 	 	316.39	 	 	 	304.12	 	 	 	207.55	 	 	 	 	195.10	 	 	 	84.67	 	 	 	86.75	 
	09
	 	 	853.54	 	 	 	170.64	 	 	 	84.16	 	 	 	53.90	 	 	 	118.15	 	 	 	60.59	 	 	 	228.21	 	 	 	147.91	 	 	 	307.69	 	 	 	9,136.00	 	 	 	1,610.56	 	 	 	416.13	 	 	 	216.16	 	 	 	239.64	 	 	 	726.15	 	 	 	681.19	 	 	 	293.10	 	 	 	336.49	 	 	 	229.56	 	 	 	 	183.85	 	 	 	95.35	 	 	 	74.46	 
	10
	 	 	856.36	 	 	 	171.67	 	 	 	84.76	 	 	 	54.54	 	 	 	119.01	 	 	 	61.30	 	 	 	230.45	 	 	 	149.70	 	 	 	311.95	 	 	 	11,151.24	 	 	 	1,670.64	 	 	 	511.81	 	 	 	267.61	 	 	 	294.16	 	 	 	892.47	 	 	 	837.08	 	 	 	322.46	 	 	 	363.21	 	 	 	247.75	 	 	 	 	212.17	 	 	 	104.17	 	 	 	80.79	 
	11
	 	 	1,112.08	 	 	 	221.47	 	 	 	108.96	 	 	 	69.38	 	 	 	152.49	 	 	 	77.84	 	 	 	294.30	 	 	 	190.48	 	 	 	396.50	 	 	 	12,145.44	 	 	 	2,131.36	 	 	 	551.08	 	 	 	286.49	 	 	 	314.69	 	 	 	962.30	 	 	 	894.10	 	 	 	455.34	 	 	 	433.98	 	 	 	299.72	 	 	 	 	273.91	 	 	 	125.86	 	 	 	103.75	 

             TABLE 3

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Dental Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05 - Dec. 31, 05	 	 	Effect from Jan. 1, 06-June 30, 06
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	SSI-B	 	SSI-AB
	Area	 	THMO+2M0	 	3MO-11MO	 	AGE (1-6)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	THMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (55+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	856.85	 	 	 	169.64	 	 	 	85.68	 	 	 	57.82	 	 	 	122.00	 	 	 	63.64	 	 	 	224.53	 	 	 	144.95	 	 	 	300.28	 	 	 	8,379.19	 	 	 	1,456.20	 	 	 	375.81	 	 	 	196.65	 	 	 	214.57	 	 	 	638.22	 	 	 	599.71	 	 	 	359.86	 	 	 	315.91	 	 	 	219.89	 	 	 	 	213.99	 	 	 	78.76	 	 	 	66.31	 
	02
	 	 	856.85	 	 	 	169.64	 	 	 	86.68	 	 	 	57.82	 	 	 	122.00	 	 	 	63.64	 	 	 	224.53	 	 	 	144.95	 	 	 	300.28	 	 	 	8,379.19	 	 	 	1,456.20	 	 	 	375.81	 	 	 	196.65	 	 	 	214.57	 	 	 	638.22	 	 	 	599.71	 	 	 	359.86	 	 	 	315.91	 	 	 	219.89	 	 	 	 	213.99	 	 	 	78.76	 	 	 	66.31	 
	03
	 	 	956.50	 	 	 	190.37	 	 	 	96.77	 	 	 	66.24	 	 	 	137.98	 	 	 	72.54	 	 	 	258.08	 	 	 	166.32	 	 	 	342.99	 	 	 	8,796.55	 	 	 	1,536.66	 	 	 	397.67	 	 	 	211.11	 	 	 	230.10	 	 	 	681.91	 	 	 	641.21	 	 	 	349.31	 	 	 	294.26	 	 	 	204.63	 	 	 	 	230.42	 	 	 	77.85	 	 	 	66.98	 
	04
	 	 	877.98	 	 	 	175.55	 	 	 	88.68	 	 	 	60.09	 	 	 	125.99	 	 	 	66.14	 	 	 	237.63	 	 	 	164.89	 	 	 	319.33	 	 	 	8,571.85	 	 	 	1,495.60	 	 	 	366.54	 	 	 	203.61	 	 	 	222.05	 	 	 	662.50	 	 	 	622.74	 	 	 	334.80	 	 	 	286.81	 	 	 	206.45	 	 	 	 	208.31	 	 	 	79.52	 	 	 	68.27	 
	05
	 	 	919.98	 	 	 	183.44	 	 	 	93.94	 	 	 	66.28	 	 	 	134.42	 	 	 	71.19	 	 	 	254.18	 	 	 	166.58	 	 	 	335.91	 	 	 	8,248.01	 	 	 	1,615.44	 	 	 	419.19	 	 	 	224.23	 	 	 	243.23	 	 	 	718.05	 	 	 	675.60	 	 	 	332.66	 	 	 	317.69	 	 	 	219.69	 	 	 	 	214.62	 	 	 	80.36	 	 	 	67.12	 
	06
	 	 	839.89	 	 	 	168.13	 	 	 	85.94	 	 	 	59.43	 	 	 	122.74	 	 	 	85.05	 	 	 	231.04	 	 	 	151.11	 	 	 	308.75	 	 	 	8,636.48	 	 	 	1,494.30	 	 	 	387.15	 	 	 	206.75	 	 	 	225.03	 	 	 	666.52	 	 	 	628.34	 	 	 	320.73	 	 	 	288.82	 	 	 	200.03	 	 	 	 	202.61	 	 	 	73.82	 	 	 	62.02	 
	07
	 	 	894.04	 	 	 	178.57	 	 	 	90.51	 	 	 	61.74	 	 	 	128.65	 	 	 	67.53	 	 	 	243.93	 	 	 	159.26	 	 	 	325.86	 	 	 	8,976.51	 	 	 	1,574.00	 	 	 	407.86	 	 	 	218.05	 	 	 	237.05	 	 	 	704.74	 	 	 	663.55	 	 	 	310.08	 	 	 	287.80	 	 	 	159.80	 	 	 	 	200.50	 	 	 	73.71	 	 	 	64.52	 
	08
	 	 	785.52	 	 	 	156.86	 	 	 	79.85	 	 	 	54.89	 	 	 	113.87	 	 	 	60.13	 	 	 	214.88	 	 	 	140.36	 	 	 	286.42	 	 	 	8,247.93	 	 	 	1,440.22	 	 	 	372.40	 	 	 	197.06	 	 	 	215.24	 	 	 	641.03	 	 	 	602.12	 	 	 	309.05	 	 	 	292.56	 	 	 	202.94	 	 	 	 	187.76	 	 	 	73.11	 	 	 	61.87	 
	09
	 	 	850.66	 	 	 	169.68	 	 	 	86.88	 	 	 	60.40	 	 	 	124.36	 	 	 	65.93	 	 	 	229.41	 	 	 	149.37	 	 	 	307.13	 	 	 	9,123.67	 	 	 	1,599.08	 	 	 	414.10	 	 	 	221.16	 	 	 	240.49	 	 	 	714.60	 	 	 	672.91	 	 	 	269.96	 	 	 	319.90	 	 	 	222.59	 	 	 	 	180.71	 	 	 	78.76	 	 	 	67.49	 
	10
	 	 	854.17	 	 	 	170.87	 	 	 	87.29	 	 	 	60.49	 	 	 	124.73	 	 	 	66.19	 	 	 	231.56	 	 	 	150.99	 	 	 	311.65	 	 	 	11,134.67	 	 	 	1,955.21	 	 	 	606.08	 	 	 	271.11	 	 	 	294.81	 	 	 	876.08	 	 	 	826.36	 	 	 	317.65	 	 	 	344.02	 	 	 	239.70	 	 	 	 	207.36	 	 	 	64.98	 	 	 	72.74	 
	11
	 	 	1,110.68	 	 	 	220.96	 	 	 	112.49	 	 	 	76.98	 	 	 	180.31	 	 	 	64.36	 	 	 	296.12	 	 	 	192.22	 	 	 	396.87	 	 	 	12,136.43	 	 	 	2,122.07	 	 	 	649.62	 	 	 	291.76	 	 	 	315.16	 	 	 	943.63	 	 	 	887.86	 	 	 	462.12	 	 	 	423.86	 	 	 	295.43	 	 	 	 	270.59	 	 	 	115.56	 	 	 	99.46	 

AHCA Contract No. FA523, Attachment VIII-A, Page 1 of 3

 

 

     

          TABLE 4

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Mental Health Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	
		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05 - Dec. 31, 05	 	 	Effect from Jan. 1, 06 - June 30, 06
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	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+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	856.86	 	 	 	169.64	 	 	 	84.58	 	 	 	64.23	 	 	 	128.68	 	 	 	71.38	 	 	 	227.66	 	 	 	148.26	 	 	 	303.38	 	 	 	5,379.21	 	 	 	1,456.20	 	 	 	384.40	 	 	 	263,28	 	 	 	284.40	 	 	 	732.06	 	 	 	631.82	 	 	 	367.49	 	 	 	331.54	 	 	 	236.11	 	 	 	 	221.62	 	 	 	94.39	 	 	 	84.63	 
	02
	 	 	856.87	 	 	 	169.66	 	 	 	85.36	 	 	 	69.26	 	 	 	128.93	 	 	 	71.65	 	 	 	226.66	 	 	 	147.16	 	 	 	302.78	 	 	 	8,379.20	 	 	 	1,466.19	 	 	 	388.93	 	 	 	276.27	 	 	 	264.36	 	 	 	690.26	 	 	 	621.15	 	 	 	360.78	 	 	 	328.39	 	 	 	232.86	 	 	 	 	234.92	 	 	 	91.24	 	 	 	61.38	 
	03
	 	 	956.61	 	 	 	190.37	 	 	 	94.52	 	 	 	67.12	 	 	 	136.49	 	 	 	72.38	 	 	 	254.10	 	 	 	164.92	 	 	 	342.33	 	 	 	6,796.66	 	 	 	1,536.63	 	 	 	401.17	 	 	 	243.67	 	 	 	248.87	 	 	 	702.91	 	 	 	649.30	 	 	 	368.64	 	 	 	299.65	 	 	 	211.36	 	 	 	 	237.65	 	 	 	83.24	 	 	 	73.70	 
	04
	 	 	877.99	 	 	 	176.66	 	 	 	87.58	 	 	 	63.92	 	 	 	127.38	 	 	 	68.47	 	 	 	236.93	 	 	 	153.75	 	 	 	318.93	 	 	 	8,571.86	 	 	 	1,495.69	 	 	 	394.00	 	 	 	254.46	 	 	 	252.62	 	 	 	694.02	 	 	 	836.24	 	 	 	342.17	 	 	 	311.98	 	 	 	223.04	 	 	 	 	215.68	 	 	 	94.67	 	 	 	84.86	 
	05
	 	 	919.98	 	 	 	183.43	 	 	 	91.16	 	 	 	64.87	 	 	 	131.62	 	 	 	69.93	 	 	 	246.33	 	 	 	159.49	 	 	 	331.03	 	 	 	9,248.02	 	 	 	1,615,41	 	 	 	420.86	 	 	 	262.27	 	 	 	266.55	 	 	 	735.60	 	 	 	681.19	 	 	 	332.63	 	 	 	321.24	 	 	 	227.10	 	 	 	 	214.69	 	 	 	83.91	 	 	 	74.53	 
	06
	 	 	839.91	 	 	 	168.14	 	 	 	84.80	 	 	 	87.94	 	 	 	131.69	 	 	 	76.16	 	 	 	230.12	 	 	 	161.25	 	 	 	309,66	 	 	 	8,536.50	 	 	 	1,494.29	 	 	 	383.28	 	 	 	262.76	 	 	 	264.04	 	 	 	746.69	 	 	 	853.76	 	 	 	319.38	 	 	 	288.23	 	 	 	202.46	 	 	 	 	201.26	 	 	 	73.23	 	 	 	84.45	 
	07
	 	 	894.06	 	 	 	178.67	 	 	 	89.54	 	 	 	68.84	 	 	 	132.32	 	 	 	72.39	 	 	 	240.41	 	 	 	166.74	 	 	 	324.62	 	 	 	8,976.52	 	 	 	1,673.98	 	 	 	414.04	 	 	 	264.97	 	 	 	264.82	 	 	 	733.66	 	 	 	874.72	 	 	 	312.76	 	 	 	296.22	 	 	 	210.26	 	 	 	 	203.20	 	 	 	84.13	 	 	 	74.97	 
	08
	 	 	765.63	 	 	 	166.88	 	 	 	76.13	 	 	 	66.61	 	 	 	113.39	 	 	 	60.74	 	 	 	210.44	 	 	 	136.92	 	 	 	284.23	 	 	 	8,247.94	 	 	 	1,440.21	 	 	 	376.25	 	 	 	229.28	 	 	 	234.06	 	 	 	669.32	 	 	 	608.69	 	 	 	313.20	 	 	 	297.40	 	 	 	210.20	 	 	 	 	191.91	 	 	 	77.96	 	 	 	69.13	 
	09
	 	 	860.66	 	 	 	169.67	 	 	 	84.46	 	 	 	61.30	 	 	 	122.72	 	 	 	66.71	 	 	 	227.14	 	 	 	147.76	 	 	 	306.35	 	 	 	9,123.68	 	 	 	1,599.07	 	 	 	417.49	 	 	 	252.14	 	 	 	268.39	 	 	 	734.16	 	 	 	680.34	 	 	 	292.37	 	 	 	328.87	 	 	 	233.20	 	 	 	 	183.12	 	 	 	67.73	 	 	 	78.10	 
	10
	 	 	864.19	 	 	 	170.66	 	 	 	86.07	 	 	 	67.92	 	 	 	128.34	 	 	 	71.08	 	 	 	231.04	 	 	 	160.99	 	 	 	312.37	 	 	 	11,134.68	 	 	 	1,966.19	 	 	 	610.19	 	 	 	308.82	 	 	 	316.67	 	 	 	900.47	 	 	 	834.79	 	 	 	319.50	 	 	 	346.90	 	 	 	244.42	 	 	 	 	209.21	 	 	 	87.86	 	 	 	77.46	 
	11
	 	 	1,110.68	 	 	 	220.95	 	 	 	110.34	 	 	 	81.84	 	 	 	161.42	 	 	 	87.06	 	 	 	295.39	 	 	 	192.02	 	 	 	397.48	 	 	 	12,136.44	 	 	 	2,122.05	 	 	 	664.29	 	 	 	334.42	 	 	 	342.80	 	 	 	971.48	 	 	 	898.72	 	 	 	457.65	 	 	 	426.65	 	 	 	300.08	 	 	 	 	276.22	 	 	 	118.36	 	 	 	104.11	 

          TABLE 5

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Mental Health + Dental Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	
		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05 - Dec. 31, 05	 	 	Effect from Jan. 1, 06 - June 30, 06
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	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+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	856.86	 	 	 	169.86	 	 	 	87.27	 	 	 	69.60	 	 	 	134.50	 	 	 	76.14	 	 	 	228.68	 	 	 	149.10	 	 	 	304.00	 	 	 	8,379.21	 	 	 	1,456.22	 	 	 	386.89	 	 	 	267.23	 	 	 	287.97	 	 	 	733.35	 	 	 	632.69	 	 	 	367.59	 	 	 	332.50	 	 	 	236.48	 	 	 	 	221.72	 	 	 	95.35	 	 	 	64.90	 
	02
	 	 	656.87	 	 	 	169.88	 	 	 	88.05	 	 	 	74.82	 	 	 	134.77	 	 	 	76.41	 	 	 	227.58	 	 	 	148.00	 	 	 	303.40	 	 	 	8,379.20	 	 	 	1,466.21	 	 	 	391.42	 	 	 	282.22	 	 	 	267.93	 	 	 	691.54	 	 	 	622.02	 	 	 	380.89	 	 	 	329.36	 	 	 	233.33	 	 	 	 	235.02	 	 	 	92.20	 	 	 	81.75	 
	03
	 	 	956.51	 	 	 	190.36	 	 	 	87.82	 	 	 	73.70	 	 	 	143.85	 	 	 	73.21	 	 	 	267.43	 	 	 	167.67	 	 	 	344.37	 	 	 	8,796.58	 	 	 	1,536.66	 	 	 	404.61	 	 	 	249.14	 	 	 	253.82	 	 	 	705.81	 	 	 	651.12	 	 	 	367.90	 	 	 	301.60	 	 	 	212.17	 	 	 	 	239.01	 	 	 	86.39	 	 	 	74.52	 
	04
	 	 	677.99	 	 	 	175.56	 	 	 	89.67	 	 	 	68.54	 	 	 	132.41	 	 	 	72.56	 	 	 	239.16	 	 	 	166.42	 	 	 	320.90	 	 	 	8,671.86	 	 	 	1,495.61	 	 	 	396.55	 	 	 	258.50	 	 	 	266.28	 	 	 	686.70	 	 	 	637.05	 	 	 	343.38	 	 	 	314.26	 	 	 	223.92	 	 	 	 	216.69	 	 	 	96.99	 	 	 	85.74	 
	05
	 	 	919.99	 	 	 	183.45	 	 	 	94.96	 	 	 	72.47	 	 	 	139.89	 	 	 	78.66	 	 	 	256.49	 	 	 	187.69	 	 	 	337.26	 	 	 	9,248.02	 	 	 	1,615.46	 	 	 	426.71	 	 	 	259.96	 	 	 	265.51	 	 	 	741.31	 	 	 	884.91	 	 	 	337.63	 	 	 	327.49	 	 	 	229.49	 	 	 	 	219.49	 	 	 	90.18	 	 	 	76.92	 
	06
	 	 	839.91	 	 	 	168.15	 	 	 	87.92	 	 	 	74.13	 	 	 	136.34	 	 	 	80.65	 	 	 	236.22	 	 	 	166.29	 	 	 	313.39	 	 	 	8,536.60	 	 	 	1,494.32	 	 	 	396.83	 	 	 	268.38	 	 	 	289.13	 	 	 	751.60	 	 	 	667.14	 	 	 	321.97	 	 	 	293.12	 	 	 	204.33	 	 	 	 	203.66	 	 	 	76.12	 	 	 	66.32	 
	07
	 	 	894.05	 	 	 	176.68	 	 	 	92.25	 	 	 	74.05	 	 	 	136.20	 	 	 	77.18	 	 	 	246.16	 	 	 	161.49	 	 	 	326.14	 	 	 	8,976.52	 	 	 	1,674.01	 	 	 	417.39	 	 	 	270.26	 	 	 	269.62	 	 	 	737.28	 	 	 	677.16	 	 	 	313.96	 	 	 	299.51	 	 	 	211.61	 	 	 	 	204.38	 	 	 	87.42	 	 	 	76.23	 
	08
	 	 	785.53	 	 	 	156.67	 	 	 	80.66	 	 	 	82.06	 	 	 	119.32	 	 	 	65.68	 	 	 	216.18	 	 	 	141.66	 	 	 	287.76	 	 	 	6,247.94	 	 	 	1,440.23	 	 	 	379.11	 	 	 	233.83	 	 	 	238.17	 	 	 	663.94	 	 	 	611.71	 	 	 	315.68	 	 	 	301.33	 	 	 	211.71	 	 	 	 	194.37	 	 	 	81.86	 	 	 	70.64	 
	09
	 	 	850.67	 	 	 	169.69	 	 	 	88.02	 	 	 	68.42	 	 	 	130.47	 	 	 	72.02	 	 	 	230.86	 	 	 	160.62	 	 	 	306.62	 	 	 	9,123.68	 	 	 	1,599.09	 	 	 	420.87	 	 	 	257.19	 	 	 	262.96	 	 	 	737.05	 	 	 	682.30	 	 	 	293.64	 	 	 	331.52	 	 	 	234.21	 	 	 	 	184.39	 	 	 	90.36	 	 	 	79.11	 
	10
	 	 	854.19	 	 	 	170.89	 	 	 	89.25	 	 	 	74.28	 	 	 	135.25	 	 	 	76.71	 	 	 	234.07	 	 	 	163.50	 	 	 	314.22	 	 	 	11,134.68	 	 	 	1,956.22	 	 	 	514.10	 	 	 	315.08	 	 	 	322.23	 	 	 	903.47	 	 	 	838.82	 	 	 	320.96	 	 	 	349.89	 	 	 	246.57	 	 	 	 	210.67	 	 	 	90.86	 	 	 	78.61	 
	11
	 	 	1,110.69	 	 	 	220.97	 	 	 	114.29	 	 	 	89.72	 	 	 	170.00	 	 	 	94.05	 	 	 	296.44	 	 	 	184.64	 	 	 	399.34	 	 	 	12,135.44	 	 	 	2,122.08	 	 	 	558.67	 	 	 	341.36	 	 	 	349.08	 	 	 	974.53	 	 	 	900.78	 	 	 	459.09	 	 	 	429.56	 	 	 	301.23	 	 	 	 	277.66	 	 	 	121.36	 	 	 	105.26	 

          TABLE 6

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Mental Health + Transportation Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	
		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 06 - Dec. 31, 06 	 	 	Effect from Jan. 1, 06 - June, 30, 06
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	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 (66+)	 	 	 	 	 	AGE (65-)	 	AGE (65+)	 	 	 	 	 	 	AGE (65-)	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	859.91	 	 	 	170.77	 	 	 	85.48	 	 	 	64.88	 	 	 	130.31	 	 	 	72.41	 	 	 	230.32	 	 	 	149.96	 	 	 	306.37	 	 	 	6,391.68	 	 	 	1,468.03	 	 	 	391.80	 	 	 	265.39	 	 	 	268.24	 	 	 	746.90	 	 	 	642.34	 	 	 	381.78	 	 	 	348.03	 	 	 	242.96	 	 	 	 	235.91	 	 	 	110.88	 	 	 	91.37	 
	02
	 	 	869.92	 	 	 	170.78	 	 	 	86.26	 	 	 	69.90	 	 	 	130.68	 	 	 	72.88	 	 	 	229.22	 	 	 	148.86	 	 	 	306.77	 	 	 	6,391.87	 	 	 	1,468.02	 	 	 	396.33	 	 	 	280.38	 	 	 	268.20	 	 	 	705.09	 	 	 	631.67	 	 	 	396.08	 	 	 	344.68	 	 	 	239.80	 	 	 	 	249.21	 	 	 	107.73	 	 	 	68.22	 
	03
	 	 	959.99	 	 	 	191.67	 	 	 	95.65	 	 	 	67.87	 	 	 	138.37	 	 	 	73.55	 	 	 	257.16	 	 	 	166.87	 	 	 	345.76	 	 	 	8,611.66	 	 	 	1,550.93	 	 	 	410.11	 	 	 	246.22	 	 	 	263.50	 	 	 	720.86	 	 	 	682.01	 	 	 	367.18	 	 	 	323.05	 	 	 	221.05	 	 	 	 	248.29	 	 	 	106.64	 	 	 	83.40	 
	04
	 	 	880.33	 	 	 	178.42	 	 	 	68.25	 	 	 	64.42	 	 	 	128.66	 	 	 	69.26	 	 	 	237.96	 	 	 	165.06	 	 	 	321.23	 	 	 	8,588.74	 	 	 	1,611.35	 	 	 	403.87	 	 	 	267.27	 	 	 	257.73	 	 	 	713.61	 	 	 	849.26	 	 	 	348.76	 	 	 	335.40	 	 	 	232.76	 	 	 	 	222.27	 	 	 	118.11	 	 	 	94.58	 
	05
	 	 	922.11	 	 	 	184.22	 	 	 	91.78	 	 	 	66.33	 	 	 	132.77	 	 	 	70.66	 	 	 	247.20	 	 	 	160.68	 	 	 	333.12	 	 	 	9,257.24	 	 	 	1,624.01	 	 	 	426.24	 	 	 	263.80	 	 	 	261.34	 	 	 	746.60	 	 	 	888.84	 	 	 	338.19	 	 	 	335.39	 	 	 	232.97	 	 	 	 	220.15	 	 	 	95.06	 	 	 	80.40	 
	06
	 	 	842.33	 	 	 	169.04	 	 	 	65.61	 	 	 	68.45	 	 	 	132.90	 	 	 	75.88	 	 	 	232.24	 	 	 	152.60	 	 	 	312.04	 	 	 	8,646.98	 	 	 	1,504.07	 	 	 	398.40	 	 	 	264.50	 	 	 	287.21	 	 	 	758.66	 	 	 	862.46	 	 	 	324.14	 	 	 	302.75	 	 	 	208.48	 	 	 	 	206.02	 	 	 	87.75	 	 	 	70.47	 
	07
	 	 	895.76	 	 	 	179.21	 	 	 	90.05	 	 	 	69.01	 	 	 	133.25	 	 	 	72.97	 	 	 	241.91	 	 	 	157.70	 	 	 	326.30	 	 	 	8,687.65	 	 	 	1,684.56	 	 	 	420.65	 	 	 	266.86	 	 	 	268.24	 	 	 	746.93	 	 	 	684.12	 	 	 	318.23	 	 	 	313.37	 	 	 	217.36	 	 	 	 	208.65	 	 	 	101.28	 	 	 	82.06	 
	08
	 	 	788.66	 	 	 	168.02	 	 	 	79.05	 	 	 	67.26	 	 	 	116.07	 	 	 	61.79	 	 	 	213.16	 	 	 	138.66	 	 	 	287.30	 	 	 	8,259.66	 	 	 	1,451.17	 	 	 	383.10	 	 	 	231.23	 	 	 	237.61	 	 	 	673.07	 	 	 	616.33	 	 	 	323.00	 	 	 	312.89	 	 	 	216.62	 	 	 	 	201.71	 	 	 	93.44	 	 	 	75.56	 
	09
	 	 	863.65	 	 	 	170.66	 	 	 	65.31	 	 	 	61.92	 	 	 	124.27	 	 	 	69.68	 	 	 	229.68	 	 	 	149.36	 	 	 	309.18	 	 	 	9,136.01	 	 	 	1,610.59	 	 	 	424.70	 	 	 	254.19	 	 	 	262.11	 	 	 	748.60	 	 	 	690.58	 	 	 	298.78	 	 	 	348.11	 	 	 	241.18	 	 	 	 	187.53	 	 	 	106.97	 	 	 	56.08	 
	10
	 	 	856.38	 	 	 	171.69	 	 	 	86.72	 	 	 	66.39	 	 	 	129.53	 	 	 	71.82	 	 	 	232.96	 	 	 	162.21	 	 	 	314.52	 	 	 	11,151.25	 	 	 	1,970.65	 	 	 	519.53	 	 	 	311.58	 	 	 	321.58	 	 	 	919.86	 	 	 	848.54	 	 	 	325.77	 	 	 	399.08	 	 	 	263.62	 	 	 	 	215.48	 	 	 	110.04	 	 	 	86.68	 
	11
	 	 	1,112.09	 	 	 	221.48	 	 	 	110.76	 	 	 	62.14	 	 	 	162.18	 	 	 	87.63	 	 	 	298.62	 	 	 	192.80	 	 	 	398.87	 	 	 	12,145.46	 	 	 	2,131.39	 	 	 	660.13	 	 	 	336.09	 	 	 	346.82	 	 	 	883.20	 	 	 	907.03	 	 	 	462.31	 	 	 	439.76	 	 	 	305.52	 	 	 	 	280.86	 	 	 	131.46	 	 	 	109.55	 

AHCA Contract No. FA523, Attachment VIII-A, Page 2 of 3

 

     TABLE 7

     

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Dental + Transportation Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	
		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 06 - Dec. 31, 05	 	 	Effect from Jan. 1, 06 - June 30, 06
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	SSI-B	 	SSI-AB
	Area	 	THMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-64)	 	AGE (65+)	 	THMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE(6-13)	 	AGE (14-20)	 	AGE(21-54)	 	AGE (66+)	 	 	 	 	 	AGE (65-)	 	AGE(66+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	869.90	 	 	 	170.77	 	 	 	86.68	 	 	 	68.47	 	 	 	123.96	 	 	 	64.67	 	 	 	227.19	 	 	 	146.65	 	 	 	303.27	 	 	 	8,391.86	 	 	 	1,468.03	 	 	 	363.21	 	 	 	198.76	 	 	 	218.41	 	 	 	663.06	 	 	 	610.23	 	 	 	374.15	 	 	 	332.40	 	 	 	226.73	 	 	 	 	228.28	 	 	 	95.25	 	 	 	75.15	 
	02
	 	 	869.90	 	 	 	170.77	 	 	 	86.68	 	 	 	56.47	 	 	 	123.65	 	 	 	64.67	 	 	 	227.19	 	 	 	146.65	 	 	 	303.27	 	 	 	8,391.66	 	 	 	1,468.03	 	 	 	363.21	 	 	 	198.76	 	 	 	218.41	 	 	 	653.06	 	 	 	610.23	 	 	 	374.15	 	 	 	332.40	 	 	 	226.73	 	 	 	 	228.28	 	 	 	96.25	 	 	 	75.16	 
	03
	 	 	969.88	 	 	 	191.67	 	 	 	97.80	 	 	 	66.99	 	 	 	139.86	 	 	 	73.71	 	 	 	259.13	 	 	 	168.27	 	 	 	346.41	 	 	 	8,811.87	 	 	 	1,650.95	 	 	 	406.61	 	 	 	213.66	 	 	 	234.73	 	 	 	698.86	 	 	 	663.92	 	 	 	359.95	 	 	 	317.66	 	 	 	214.33	 	 	 	 	241.06	 	 	 	101.26	 	 	 	79.68	 
	04
	 	 	880.32	 	 	 	176.42	 	 	 	89.37	 	 	 	60.59	 	 	 	127.26	 	 	 	86.93	 	 	 	239.68	 	 	 	156.20	 	 	 	321.63	 	 	 	8,588.73	 	 	 	1,511.36	 	 	 	396.41	 	 	 	206.42	 	 	 	227.16	 	 	 	682.26	 	 	 	636.76	 	 	 	341.38	 	 	 	320.25	 	 	 	216.17	 	 	 	 	214.90	 	 	 	102.96	 	 	 	77.99	 
	05
	 	 	922.11	 	 	 	184.23	 	 	 	94.57	 	 	 	66.74	 	 	 	136.67	 	 	 	71.91	 	 	 	266.05	 	 	 	167.77	 	 	 	338.00	 	 	 	9,267.23	 	 	 	1,824.04	 	 	 	424.57	 	 	 	225.76	 	 	 	246.02	 	 	 	729.85	 	 	 	683.26	 	 	 	338.22	 	 	 	331.84	 	 	 	226.56	 	 	 	 	220.18	 	 	 	94.61	 	 	 	72.99	 
	06
	 	 	842.31	 	 	 	169.03	 	 	 	88.65	 	 	 	59.94	 	 	 	124.05	 	 	 	66.87	 	 	 	233.16	 	 	 	152.46	 	 	 	311.13	 	 	 	8,546.96	 	 	 	1,504.08	 	 	 	393.27	 	 	 	208.60	 	 	 	226.20	 	 	 	860.79	 	 	 	637.03	 	 	 	325.49	 	 	 	303.34	 	 	 	206.05	 	 	 	 	207.37	 	 	 	86.34	 	 	 	68.04	 
	07
	 	 	896.76	 	 	 	179.21	 	 	 	91.02	 	 	 	62.11	 	 	 	129.78	 	 	 	68.41	 	 	 	246.43	 	 	 	160.22	 	 	 	327.54	 	 	 	8,987.84	 	 	 	1,684.58	 	 	 	414.47	 	 	 	219.94	 	 	 	240.47	 	 	 	718.01	 	 	 	672.96	 	 	 	315.53	 	 	 	304.86	 	 	 	206.91	 	 	 	 	205.96	 	 	 	92.86	 	 	 	71.63	 
	08
	 	 	788.84	 	 	 	158.02	 	 	 	80.77	 	 	 	56.58	 	 	 	115.55	 	 	 	61.18	 	 	 	217.80	 	 	 	142.10	 	 	 	289.49	 	 	 	8,259.67	 	 	 	1,451.18	 	 	 	379.25	 	 	 	189.01	 	 	 	218.79	 	 	 	664.78	 	 	 	611.86	 	 	 	318.86	 	 	 	308.06	 	 	 	209.36	 	 	 	 	197.66	 	 	 	88.60	 	 	 	68.29	 
	09
	 	 	663.65	 	 	 	170.66	 	 	 	67.75	 	 	 	61.02	 	 	 	125.93	 	 	 	66.90	 	 	 	231.93	 	 	 	160.98	 	 	 	309.96	 	 	 	9,136.00	 	 	 	1,610.60	 	 	 	421.31	 	 	 	223.21	 	 	 	244.21	 	 	 	729.05	 	 	 	683.16	 	 	 	294.37	 	 	 	339.14	 	 	 	230.67	 	 	 	 	185.12	 	 	 	98.00	 	 	 	75.47	 
	10
	 	 	656.36	 	 	 	171.68	 	 	 	87.94	 	 	 	60.90	 	 	 	126.92	 	 	 	66.93	 	 	 	233.48	 	 	 	152.21	 	 	 	313.80	 	 	 	11,161.24	 	 	 	1,970.67	 	 	 	515.75	 	 	 	273.87	 	 	 	299.62	 	 	 	896.47	 	 	 	839.11	 	 	 	323.92	 	 	 	388.20	 	 	 	248.90	 	 	 	 	213.63	 	 	 	107.16	 	 	 	81.94	 
	11
	 	 	1,112.09	 	 	 	221.49	 	 	 	112.91	 	 	 	77.26	 	 	 	161.07	 	 	 	84.83	 	 	 	297.35	 	 	 	193.00	 	 	 	398.36	 	 	 	12,145.44	 	 	 	2,131.41	 	 	 	555.46	 	 	 	283.43	 	 	 	321.17	 	 	 	955.35	 	 	 	898.16	 	 	 	456.78	 	 	 	436.97	 	 	 	300.87	 	 	 	 	276.35	 	 	 	128.67	 	 	 	104.80	 

     TABLE 8

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	General + Mental Health + Transportation + Dental Rates:	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 		 	 	
		 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Effect from July 1, 05 - Dec. 31, 06	 	 	Effect
from Jan. 1, 06 - June 30, 06 
	 	 	TANF	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	SSI-NO-MEDICARE	 	 	 	 	 	 	 	 	 	SSI-B	 	SSI-AB	 	 	SSI-B	 	SSI-AB
	Area	 	THMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE(66+)	 	THMO+2MO	 	3MO-11MO	 	AGE (1-5)	 	AGE (6-13)	 	AGE (14-20)	 	AGE (21-54)	 	AGE (56+)	 	 	 	 	 	AGE (66-)	 	AGE (65+)	 	 	 	 	 	 	AGE (65-)	 	AGE (65+)
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Female	 	Male	 	Female	 	Male	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	01
	 	 	859.91	 	 	 	170.78	 	 	 	86.17	 	 	 	70.26	 	 	 	136.16	 	 	 	77.17	 	 	 	231.34	 	 	 	160.80	 	 	 	306.99	 	 	 	8,391.88	 	 	 	1,468.06	 	 	 	394.29	 	 	 	269.34	 	 	 	291.61	 	 	 	748.19	 	 	 	643.21	 	 	 	381.88	 	 	 	348.99	 	 	 	243.32	 	 	 	 	236.01	 	 	 	111.64	 	 	 	91.74	 
	02
	 	 	859.92	 	 	 	170.79	 	 	 	68.95	 	 	 	75.27	 	 	 	136.42	 	 	 	77.44	 	 	 	230.24	 	 	 	149.70	 	 	 	306.39	 	 	 	8,391.87	 	 	 	1,468.04	 	 	 	398.82	 	 	 	284.33	 	 	 	271.77	 	 	 	709.38	 	 	 	832.54	 	 	 	396.18	 	 	 	345.84	 	 	 	240.17	 	 	 	 	249.31	 	 	 	108.69	 	 	 	86.69	 
	03
	 	 	969.99	 	 	 	191.68	 	 	 	98.85	 	 	 	74.45	 	 	 	146.53	 	 	 	79.38	 	 	 	260.48	 	 	 	169.62	 	 	 	347.79	 	 	 	8,811.88	 	 	 	1,550.86	 	 	 	413.65	 	 	 	251.69	 	 	 	258.46	 	 	 	723.66	 	 	 	663.83	 	 	 	360.64	 	 	 	325.20	 	 	 	221.87	 	 	 	 	249.66	 	 	 	108.79	 	 	 	84.22	 
	04
	 	 	880.33	 	 	 	176.43	 	 	 	90.56	 	 	 	69.04	 	 	 	133.68	 	 	 	73.36	 	 	 	241.21	 	 	 	157.73	 	 	 	323.20	 	 	 	8,588.74	 	 	 	1,611.37	 	 	 	406.42	 	 	 	261.31	 	 	 	261.38	 	 	 	716.49	 	 	 	651.07	 	 	 	349.97	 	 	 	337.72	 	 	 	233.64	 	 	 	 	223.48	 	 	 	120.43	 	 	 	96.46	 
	05
	 	 	922.12	 	 	 	164.24	 	 	 	95.59	 	 	 	72.93	 	 	 	141.04	 	 	 	77.38	 	 	 	257.36	 	 	 	169.08	 	 	 	339.34	 	 	 	9,267.24	 	 	 	1,624.06	 	 	 	431.09	 	 	 	261.49	 	 	 	268.30	 	 	 	752.11	 	 	 	692,56	 	 	 	343.09	 	 	 	341.64	 	 	 	235.36	 	 	 	 	225.05	 	 	 	104.31	 	 	 	82.79	 
	06
	 	 	842.33	 	 	 	169.05	 	 	 	88.63	 	 	 	74.64	 	 	 	139.86	 	 	 	81.47	 	 	 	238.34	 	 	 	157.64	 	 	 	316.77	 	 	 	6,546.98	 	 	 	1,504.10	 	 	 	402.95	 	 	 	270.13	 	 	 	292.30	 	 	 	763.67	 	 	 	666.63	 	 	 	326.73	 	 	 	307.64	 	 	 	210.35	 	 	 	 	208.61	 	 	 	92.64	 	 	 	72.34	 
	07
	 	 	695.76	 	 	 	179.22	 	 	 	92.76	 	 	 	74.42	 	 	 	139.13	 	 	 	77.76	 	 	 	247.66	 	 	 	162.45	 	 	 	328.82	 	 	 	6.887.86	 	 	 	1,684.58	 	 	 	424.00	 	 	 	272.17	 	 	 	273.04	 	 	 	750.55	 	 	 	656.56	 	 	 	319.41	 	 	 	316.66	 	 	 	218.62	 	 	 	 	209.63	 	 	 	104.57	 	 	 	83.34	 
	08
	 	 	788.65	 	 	 	158.03	 	 	 	81.78	 	 	 	82.73	 	 	 	121.00	 	 	 	66.63	 	 	 	218.90	 	 	 	143.40	 	 	 	290.82	 	 	 	8,259.68	 	 	 	1,451.19	 	 	 	386.96	 	 	 	236.76	 	 	 	241.72	 	 	 	677.68	 	 	 	621.46	 	 	 	326.46	 	 	 	316.82	 	 	 	218.13	 	 	 	 	204.17	 	 	 	97.37	 	 	 	77.06	 
	09
	 	 	853.56	 	 	 	170.67	 	 	 	88.88	 	 	 	69.04	 	 	 	132.02	 	 	 	72.99	 	 	 	233.38	 	 	 	162.43	 	 	 	311.46	 	 	 	9,136.01	 	 	 	1,610.61	 	 	 	427.88	 	 	 	259.24	 	 	 	266.68	 	 	 	751.60	 	 	 	692.54	 	 	 	298.06	 	 	 	360.76	 	 	 	242.19	 	 	 	 	168.80	 	 	 	108.62	 	 	 	87.09	 
	10
	 	 	866.36	 	 	 	171.70	 	 	 	89.90	 	 	 	74.76	 	 	 	136.44	 	 	 	77.45	 	 	 	236.99	 	 	 	154.72	 	 	 	316.37	 	 	 	11,151.25	 	 	 	1,970.68	 	 	 	523.77	 	 	 	317.64	 	 	 	327.24	 	 	 	922.88	 	 	 	860.57	 	 	 	327.23	 	 	 	372.07	 	 	 	254.77	 	 	 	 	218.94	 	 	 	113.03	 	 	 	87.81	 
	11
	 	 	1,112.10	 	 	 	221.50	 	 	 	114.71	 	 	 	90.02	 	 	 	170.76	 	 	 	94.52	 	 	 	299.67	 	 	 	195.32	 	 	 	400.73	 	 	 	12,145.45	 	 	 	2,131.42	 	 	 	564.51	 	 	 	343.03	 	 	 	352.10	 	 	 	986.25	 	 	 	909.09	 	 	 	463.76	 	 	 	442.77	 	 	 	308.67	 	 	 	 	282.32	 	 	 	134.47	 	 	 	110.70	 

AHCA Contract No. FA523, Attachment VIII-A, Page 3 of 3exv10w29w1

 

Exhibit
10.29.1

APPENDIX X

	 	 	 
	Agency Code 12000

	 	Contract No. C020429
	Period 10/1/05 – 9/30/08

	 	Funding Amount for Period Based on approved capitation rates

This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York
State Department of Health, having its principal office at Corning Tower, Room 2001,
Empire State Plaza, Albany NY 12237, (hereinafter referred to as the STATE), and
CarePlus, LLC, (hereinafter referred to as the CONTRACTOR), to modify Contract Number
C020429 by substituting the attached Appendix L “Approved Capitation Payment Rates.” The
effective date of these modifications is October 1, 2005.

All other provisions of said AGREEMENT shall remain in full force and effect.

IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing
under their signatures.

	 	 	 	 	 	 	 	 	 	 	 	 	 
	CONTRACTOR SIGNATURE	 	 	 	STATE AGENCY SIGNATURE	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	By:

	 	/s/ Nasry Michelen
	 	 	 	By:	 	 	 	 	 	 
	 

	 	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	Nasry Michelen	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	Printed Name
	 	 	 	 	 	Printed Name	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	Title:

	 	Chief Executive Officer
	 	 	 	Title:	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	Date:

	 	3/12/06
	 	 	 	Date:	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	State Agency Certification.:
	 	 	 	 	 	 	In addition to the acceptance of this contract,
I also certify that original copies of this
signature page will be attached to all other
exact copies of this contract.

	 	 	 	 	 	 	 
	STATE OF NEW YORK

	 	 	)	 	 	 
	 

	 	 	)	 	 	SS.:
	County of New York

	 	 	)	 	 	 

On the 13TH day of March 2006, before me personally appeared
Nasry Michelen, to me known, who being by me duly sworn, did depose
and say that he/she resides at 11 Wells Ave., Goton on Hudson, NY 10520 that he/she
is the CEO of Careplus Health Plan LLc, the
corporation described herein which executed the foregoing instrument; and that he/she
signed his/her name thereto by order of the board of directors of said corporation.

	 	 	 	 	 	 	 	 	 
	(Notary)     [ILLEGIBLE]

	 	 	 	 	 	/s/ [ILLEGIBLE]	 	 
	 
	 	 	 	 	 	 	 	 
	STATE COMPTROLLER’S SIGNATURE

	 	 	 	Title:	 	 	 	 
	 

	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	 

	 	 	 	Date:	 	 	 	 
	 

	 	 	 	 	 	 	 	 

 

 

APPENDIX L

Approved Capitation Payment Rates

APPENDIX L

October 1, 2005

L-l

 

 

CAREPLUS, LLC

Medicaid Managed Care Rates

	 	 	 
	MMIS ID #: 01617894

	 	Effective Date: 10/01/05
	Approved by DOB: Yes

	 	Region: Northern Metro
	DOH HMO #: 05-035

	 	County: PUTNAM
	Reinsurance: No

	 	Status: Voluntary

	 	 	 	 	 
	Premium Group	 	Rate Amount	 
	TANF/SN <6mo M/F
	 	$	204.87	 
	TANF/SN 6mo-14 F
	 	$	67.30	 
	TANF/SN 15-20 F
	 	$	158.53	 
	TANF/SN 6mo-20 M
	 	$	72.23	 
	TANF 21+ M/F
	 	$	177.28	 
	SN 21-29 M/F
	 	$	214.04	 
	SN 30+ M/F
	 	$	304.57	 
	SSI 6mo-20 M/F
	 	$	249.18	 
	SSI 21-64 M/F
	 	$	429.38	 
	SSI 65+ M/F
	 	$	454.10	 
	Maternity Kick Payment
	 	$	3,819.45	 
	Newborn Kick Payment
	 	$	2,216.32	 

Optional Benefits Offered:

	 	 	 
	o  Emergency Transportation

	 	o  Dental
	 
	 	 
	o  Non-Emergent Transportation

	 	þ  Family Planning

Box will be checked if the optional benefit is covered by the plan

 

 

CAREPLUS, LLC

Family Health Plus Rates

Effective September 1, 2005

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Optional
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	benefits covered
	 	 	Adults with	 	Adults without	 	Adults without	 	 	 	 	 	Family	 	 
	County	 	Children 19 - 64	 	Children 19 - 29	 	Children 30 - 64	 	Maternity Kick	 	Planning	 	Dental
	NEW YORK CITY
	 	$	183.45	 	 	$	198.39	 	 	$	258.07	 	 	$	4,700.67	 	 	Yes	 	Yes

Date: 7/28/05

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00103-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00103-of-00352.parquet"}]]