Document:

exv10w2

 

	 	 	 
	HEALTHEASE OF FLORIDA, INC.

	 	Medicaid HMO Contract

AHCA CONTRACT NO. FA521

AMENDMENT NO. 4

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

	1.  	Standard Contract, Section II.A Contract Amount, the first sentence is hereby amended to now
read:
	 
	   	To pay for contracted services according to the conditions of Attachment I in an amount not
to exceed $811,772,712.00 (an increase of $4,829,812.00), subject to the availability of
funds.
	 
	2.  	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 2 is
hereby amended to
now read as follows:

Table 2.

Area
wide Age-banded Capitation Rates for All Plan Operational Counties
where plan services do not include Community Mental Health and Mental Health Targeted Case
Management.

Area 02 General Rates Plan -  015019315(GADSDEN) 015019318(JEFFERSON)
015019320(LEON) 015019322(MADISON) 015019336(WAKULLA) 015019340(CALHOUN)
015019342(LIBERTY)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	308.57	 	 	 	68.17	 	 	 	42.09	 	 	 	46.69	 	 	 	97.60	 	 	 	118.89	 	 	 	182.09	 	 	 	253.05	 	 	 	253.05	 
	SSI/No Medicare
	 	 	3048.45	 	 	 	366.34	 	 	 	187.89	 	 	 	197.31	 	 	 	197.31	 	 	 	564.87	 	 	 	564.87	 	 	 	545.39	 	 	 	545.39	 
	SSI/Part B
	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 
	SSI/Part A & B
	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	218.99	 

Area 03 General Rates Plan
—  015019309(CITRUS) 015019319(LAKE)
015019323(MARION) 015019329(PUTNAM)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	350.92	 	 	 	78.21	 	 	 	49.06	 	 	 	54.22	 	 	 	112.21	 	 	 	138.15	 	 	 	210.55	 	 	 	294.57	 	 	 	294.57	 
	SSI/No Medicare
	 	 	3231.65	 	 	 	390.26	 	 	 	202.93	 	 	 	212.35	 	 	 	212. 35	 	 	 	607.41	 	 	 	607.41	 	 	 	586.66	 	 	 	586.66	 
	SSI/Part B
	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 	 	 	302.31	 
	SSI/Part A & B
	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	288.40	 	 	 	201.67	 

Area 04 General Rates Plan —  015019313(DUVAL) 015019335(VOLUSIA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 Year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	316.95	 	 	 	71.10	 	 	 	44.92	 	 	 	49.61	 	 	 	101.93	 	 	 	126.35	 	 	 	191.96	 	 	 	269.58	 	 	 	269.58	 
	SSI /No Medicare
	 	 	3103.82	 	 	 	374.05	 	 	 	193.41	 	 	 	202.51	 	 	 	202.51	 	 	 	580.16	 	 	 	580.16	 	 	 	559.62	 	 	 	559.62	 
	SSI/Part B
	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	213.15	 	 	 	273.15	 
	SSI/Part A & B
	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	204.72	 

Area 05 General Rates Plan
— 015019302(PASCO) 015019303(PINELLAS)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/ FC/SOBRA
	 	 	345.76	 	 	 	77.31	 	 	 	48.55	 	 	 	53.69	 	 	 	110.74	 	 	 	136.76	 	 	 	208.19	 	 	 	291.55	 	 	 	291.55	 
	SSI/No Medicare
	 	 	3265.62	 	 	 	394.06	 	 	 	204.41	 	 	 	214.18	 	 	 	214.18	 	 	 	612.49	 	 	 	612.49	 	 	 	591.04	 	 	 	591.04	 
	SSI/Part B
	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 	 	 	266.55	 
	SSI /Part A & B
	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	309.27	 	 	 	216.32	 

Area 07 General Rates Plan
— 015019308(BREVARD)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<l year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC /SOBRA
	 	 	337.19	 	 	 	75.53	 	 	 	47.77	 	 	 	52.81	 	 	 	108.40	 	 	 	134.29	 	 	 	204.16	 	 	 	286.57	 	 	 	286.57	 
	SSI /No Medicare
	 	 	3217.89	 	 	 	389.79	 	 	 	203.90	 	 	 	213.35	 	 	 	213.35	 	 	 	610.58	 	 	 	610.58	 	 	 	589.11	 	 	 	589.11	 
	SSI/Part B
	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 
	SSI/Part A & B
	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	198.62	 

Area 08 General Rates Plan — 015019332(SARASOTA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	296.66	 	 	 	66.37	 	 	 	41.76	 	 	 	46.19	 	 	 	95.19	 	 	 	117.62	 	 	 	179.02	 	 	 	250.96	 	 	 	250.96	 
	SSI/No Medicare
	 	 	3079.30	 	 	 	371.80	 	 	 	192.49	 	 	 	201.68	 	 	 	201.68	 	 	 	577 .71	 	 	 	577.71	 	 	 	557.45	 	 	 	557.45	 
	SSI/Part B
	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 
	SSI/Part A & B
	 	 	283.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	199.47	 

AHCA Contract No. FA521, Amendment No. 4, Page 1 of 3

 

 

			
	HEALTHEASE OF FLORIDA, INC.
	 	Medicaid HMO Contract

Area 09 General Rates Plan
— 015019324(MARTIN) 015019339(PALM BEACH)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	316.78	 	 	 	70.14	 	 	 	44.52	 	 	 	49.17	 	 	 	101.48	 	 	 	125.24	 	 	 	190.60	 	 	 	266.91	 	 	 	266.97	 
	SSI /No Medicare
	 	 	3344.05	 	 	 	405.22	 	 	 	211.12	 	 	 	221.15	 	 	 	221.15	 	 	 	633.22	 	 	 	633.22	 	 	 	610.93	 	 	 	610.93	 
	SSI/Part B
	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	261.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 
	SSI/Part A & B
	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	224.19	 

Area 10 General Rates Plan
— 015019337(BROWARD)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	328.74	 	 	 	73.77	 	 	 	46.68	 	 	 	51.61	 	 	 	105.94	 	 	 	131.31	 	 	 	199.49	 	 	 	280.33	 	 	 	280.33	 
	SSI /No Medicare
	 	 	4151.82	 	 	 	503.54	 	 	 	263.75	 	 	 	275.32	 	 	 	275.32	 	 	 	788.23	 	 	 	768.23	 	 	 	761.08	 	 	 	761.08	 
	SSI/Part B
	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 
	SSI/Pant A & B
	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	245.95	 

Area 11 General Rates plus
Transportation Plan — 015019338(DADE)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	409.89	 	 	 	91.51	 	 	 	57.28	 	 	 	63.45	 	 	 	131.27	 	 	 	161.21	 	 	 	245.94	 	 	 	343.29	 	 	 	343.29	 
	SSI /No
Medicare
	 	 	4561.77	 	 	 	556.46	 	 	 	268.69	 	 	 	302.80	 	 	 	302.80	 	 	 	869.67	 	 	 	869.67	 	 	 	836.38	 	 	 	836.38	 
	SSI/Part B
	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 
	SSI/Part A & B
	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	297.22	 

	3.  	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 3 is hereby
amended to now read as follows:

Table 3.

Area wide Age-banded Capitation Rates for All Plan Operational Counties where plan services
include Community Mental Health
and Mental Health Targeted Case Management.

Area 01 General Rates plus Mental Health Plan- 015019314(ESCAMBIA) 015019331(SANTA ROSA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/ FC/SOBRA
	 	 	308.58	 	 	 	69.00	 	 	 	49.05	 	 	 	52.61	 	 	 	103.52	 	 	 	121.46	 	 	 	184.66	 	 	 	257.30	 	 	 	257.30	 
	SSI /No Medicare
	 	 	3048.46	 	 	 	371.81	 	 	 	243.40	 	 	 	238.17	 	 	 	238.17	 	 	 	607.82	 	 	 	607.82	 	 	 	569.75	 	 	 	569.75	 
	SSI/Part B
	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 
	SSI/Part A & B
	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	234.66	 

Area 06 General Rates plus Mental Health Plan- 015019300(HILLSBOROUGH)
015019301(MANATEE) 015019304(POLK) 015019317(HIGHLANDS)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-64 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/FC/SOBRA
	 	 	330.07	 	 	 	75.91	 	 	 	61.52	 	 	 	67.67	 	 	 	122.23	 	 	 	135.83	 	 	 	204.29	 	 	 	282.98	 	 	 	282.98	 
	SSI/No Medicare
	 	 	3017.05	 	 	 	371.69	 	 	 	265.72	 	 	 	243.82	 	 	 	243.62	 	 	 	647.81	 	 	 	647.81	 	 	 	587.26	 	 	 	587,26	 
	SSI/Part B
	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 
	SSI/Part A & B
	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	286.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	202.64	 

Area 07 General Rates plus Mental Health Plan- 015019327(ORANGE)
015019328(OSCEOLA) 015019333(SEMINOLE)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 	 	65+	 
	TANF/ FC/SOBRA
	 	 	337.20	 	 	 	76.92	 	 	 	58.07	 	 	 	59.10	 	 	 	114.69	 	 	 	136.45	 	 	 	206.32	 	 	 	287.87	 	 	 	287.87	 
	SSI/No Medicare
	 	 	3217.90	 	 	 	406.84	 	 	 	260.45	 	 	 	239.73	 	 	 	239.73	 	 	 	628.24	 	 	 	628.24	 	 	 	594.96	 	 	 	594.96	 
	SSl/Part B
	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 
	SSI/Part A & B
	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	208.25	 

	4.  	Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table 3, the
second paragraph is
hereby amended to now read:
	 
	   	Notwithstanding the payment amounts which may be computed with the above rate table, the sum
of total capitation payments under this contract shall not exceed the total contract amount
of $811,772,712.00 (an increase of $4,829,812.00), expressed on page seven of this contract.
	 
	5.  	This amendment shall begin on April 1, 2005, or the date on which the amendment has been
signed by
both parties, whichever is later.

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

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

AHCA Contract No. FA521, Amendment No. 4, Page 2 of 3

 

 

			
	HEALTHEASE OF FLORIDA, INC.
	 	Medicaid HMO Contract

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

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

     IN WITNESS WHEREOF, the parties hereto have caused this 3 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.

	 	 	 	 	 	 	 
	HEALTHEASE OF FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR
	 	 	 	 	HEALTH CARE ADMINISTRATION
	 
	 	 	 	 	 	 
	SIGNED

	 	 	 	SIGNED	 	 
	BY:

	 	/s/ Imtiaz (MT) Sattaur
	 	BY:
	 	[ILLEGIBLE]
	

	 	 
	 	 	 	 
	

	 	Imtiaz (MT) Sattaur

President, Florida	 	 	 	 
	 
	 	 	 	 	 	 
	NAME:

	 	Todd S. Farha 	 	NAME:
	 	Alan Levine
	 
	 	 	 	 	 	 
	TITLE:

	 	President & CEO
	 	TITLE:
	 	Secretary
	 
	 	 	 	 	 	 
	DATE:

	 	4/1/05
	 	DATE:
	 	4/1/05

THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY

AHCA Contract No. FA521, Amendment No. 4, Page 3 of 3exv10w3

 

			
	HEALTHEASE OF FLORIDA, INC.
	 	Medicaid HMO Contract

AHCA CONTRACT NO. FA521

AMENDMENT NO. 5

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

	1.  	Standard Contract, Section II.A, Contract Amount, the first sentence is hereby amended to now read:
	 
	   	To pay for contracted services according to the conditions of Attachment I in an amount
not to exceed $815,961,749.00 (an increase of $4,189,037.00), subject to the availability
of funds.
	 
	2.  	Attachment 1, section 90.0, Payment and Authorized Enrollment Levels, Table 2 is
hereby amended to read as follows:

Table 2.

Area wide Age-banded capitation Rates for All Plan Operational Counties where plan
services do not include Community Mental Health and Mental Health Targeted Case
Management.

Area 02 General Rates Plan
— 015019315(GADSDEN) 015019318 (JEFFERSON) 015019320(LEON)
015019322(MADISON) 015019336(WAKULLA) 015019340(CALHOUN) 015019342(LIBERTY)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	308.57	 	 	 	68.17	 	 	 	42.09	 	 	 	46.69	 	 	 	97.60	 	 	 	118.89	 	 	 	182.09	 	 	 	253.05	 
	253.05
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No Medicare
	 	 	3048.45	 	 	 	366.34	 	 	 	187.89	 	 	 	197.31	 	 	 	197.31	 	 	 	564.87	 	 	 	564.87	 	 	 	545.39	 
	545.39
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 	 	 	323.29	 
	323.29
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 	 	 	312.99	 
	218.99
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 04 General Rates Plan — 015019313(DUVAL) 015019335(VOLUSIA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	316.95	 	 	 	71.10	 	 	 	44.92	 	 	 	49.61	 	 	 	101.93	 	 	 	126.35	 	 	 	191.96	 	 	 	269.58	 
	269.58
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No Medicare
	 	 	3103.82	 	 	 	374.05	 	 	 	193.41	 	 	 	202.51	 	 	 	202.51	 	 	 	580.16	 	 	 	580.16	 	 	 	559.62	 
	559.62
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 	 	 	273.15	 
	273.15
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 	 	 	292.54	 
	204.72
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 07 General Rates Plan
— 015019308 (BREVARD)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	337. 19	 	 	 	75.53	 	 	 	47.77	 	 	 	52.81	 	 	 	108.40	 	 	 	134.29	 	 	 	204.16	 	 	 	286.57	 
	286.57
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No Medicare
	 	 	3217.89	 	 	 	389.79	 	 	 	203.90	 	 	 	213.35	 	 	 	213.35	 	 	 	610.58	 	 	 	610.58	 	 	 	589.11	 
	589.11
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 	 	 	265.77	 
	265. 77
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 	 	 	283.96	 
	198.62
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 08 General Rates Plan — 015019332 (SARASOTA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14 -20 Female	 	 	21-51 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	296.66	 	 	 	66.37	 	 	 	41.76	 	 	 	46.19	 	 	 	95.19	 	 	 	117.62	 	 	 	179.02	 	 	 	250.96	 
	250.96
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /No Medicare
	 	 	3079.30	 	 	 	371.80	 	 	 	192.49	 	 	 	201.68	 	 	 	201.68	 	 	 	577.11	 	 	 	577.11	 	 	 	557.45	 
	557. 4 5
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	243. 56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 	 	 	243.56	 
	243.56
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 	 	 	285.08	 
	199. 41
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 09 General Rates Plan — 015019324 (MARTIN) 015019339 (PALM BEACH)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	316.78	 	 	 	70.74	 	 	 	44.52	 	 	 	49.17	 	 	 	101.48	 	 	 	125.24	 	 	 	190.60	 	 	 	266.97	 
	266.97
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

AHCA Contract No. FA521, Amendment No. 5, Page 1 of 3

 

 

			
	HEALTHEASE OF FLORIDA, INC.
	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No Medicare
	 	 	3344.05	 	 	 	405.22	 	 	 	211.12	 	 	 	221.15	 	 	 	221.15	 	 	 	633.22	 	 	 	633.22	 	 	 	610.93	 
	610.93
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 	 	 	267.20	 
	267.20
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 	 	 	320.32	 
	224.19
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 10 General Rates Plan — 015019337 (BROWARD)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	328.74	 	 	 	73.77	 	 	 	46.68	 	 	 	51.61	 	 	 	105.94	 	 	 	131.31	 	 	 	199.49	 	 	 	280.33	 
	280.33
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /No
Medicare
	 	 	4151.82	 	 	 	503.54	 	 	 	263.75	 	 	 	275.32	 	 	 	275.32	 	 	 	788.23	 	 	 	788.23	 	 	 	761.08	 
	761.08
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	287. 04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 	 	 	287.04	 
	287.04
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A
& B
	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 	 	 	351.55	 
	245.95
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 11 General Rates plus Transportation plan — 015019338(DADE)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	409.89	 	 	 	91.51	 	 	 	57.28	 	 	 	63.45	 	 	 	131.27	 	 	 	161.21	 	 	 	245.94	 	 	 	343.29	 
	343.29
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /No
Medicare
	 	 	4561.77	 	 	 	556.46	 	 	 	288.69	 	 	 	302.80	 	 	 	302.80	 	 	 	869.67	 	 	 	869.67	 	 	 	836.38	 
	836.38
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 	 	 	453.72	 
	453.72
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 	 	 	429.61	 
	297.22
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	3.  	Attachment I, section 90.0, Payment and Authorized Enrollment Levels, Table 3 is hereby
amended to read as follows:

Table 3.

Area wide Age-banded
Capitation Rates for All Plan Operational Counties where plan
services include Community Mental Health and Mental Health Targeted Case Management.

Area 01 General Rates plus
Mental Health Plan – 015019314(ESCAMBIA) 015019331(SANTA ROSA)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	308.58	 	 	 	69.00	 	 	 	49.05	 	 	 	52.61	 	 	 	103.52	 	 	 	121.46	 	 	 	184.66	 	 	 	257.30	 
	257.30
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No
Medicare
	 	 	3048.46	 	 	 	371.81	 	 	 	243.40	 	 	 	238.17	 	 	 	238.17	 	 	 	607.82	 	 	 	607.82	 	 	 	569.75	 
	569.75
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 	 	 	330.18	 
	330.18
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A
& B
	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 	 	 	328.66	 
	234.66
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 03 General Rates plus
Mental Health Plan — 015019309(CITRUS) 015019319
(LAKE) 015019323(MARION) 015019329 (PUTNAM)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	350.93	 	 	 	79.08	 	 	 	55.35	 	 	 	58.65	 	 	 	116.64	 	 	 	139.68	 	 	 	212.08	 	 	 	294.58	 
	294.58
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No
Medicare
	 	 	3231.66	 	 	 	408.26	 	 	 	247.79	 	 	 	236.33	 	 	 	236.33	 	 	 	626.37	 	 	 	626.37	 	 	 	591.60	 
	591.60
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 	 	 	302.32	 
	302.32
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /Part A & B
	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 	 	 	295.89	 
	209.16
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 05 General Rates plus
Mental Health Plan —  015019302(PASCO)
015019303(PINELLAS)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	345.77	 	 	 	79.28	 	 	 	51.94	 	 	 	57.32	 	 	 	114.37	 	 	 	139.01	 	 	 	210.44	 	 	 	291.84	 
	291.84
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /No
Medicare
	 	 	3265.63	 	 	 	429.24	 	 	 	240.86	 	 	 	235.59	 	 	 	235.59	 	 	 	628.37	 	 	 	628.37	 	 	 	594.95	 
	594.95
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 	 	 	266.87	 
	266.87
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 	 	 	318.72	 
	225.77
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 06 General Rates plus Mental Health Plan-
015019300(HILLSBOROUGH) 015019301
(MANATEE) 015019304 (POLK) 015019317(HIGHLANDS)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	330.07	 	 	 	75.91	 	 	 	61.92	 	 	 	67.67	 	 	 	122.23	 	 	 	135.83	 	 	 	204.29	 	 	 	282.98	 
	282.98
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

AHCA Contract No. FA521, Amendment No. 5, Page 2 of 3

 

 

			
	HEALTHEASE OF FLORIDA, INC.
	 	Medicaid HMO Contract

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/No Medicare
	 	 	3017.05	 	 	 	371.69	 	 	 	265.72	 	 	 	243.82	 	 	 	243.82	 	 	 	647.81	 	 	 	647.81	 	 	 	587.26	 
	587.26
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 	 	 	242.29	 
	242.29
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 	 	 	288.09	 
	202.64
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

Area 07 General Rates plus Mental
Health Plan — 015019327 (ORANGE) 015019328
(OSCEOLA) 015019333 (SEMINOLE)

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	<1 year	 	 	1-5	 	 	6-13	 	 	14-20 Male	 	 	14-20 Female	 	 	21-54 Male	 	 	21-54 Female	 	 	55-64	 
	65+
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	TANF/FC/SOBRA
	 	 	337.20	 	 	 	76.92	 	 	 	58.07	 	 	 	59.10	 	 	 	114.69	 	 	 	136.45	 	 	 	206.32	 	 	 	287.87	 
	287.87
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI /No Medicare
	 	 	3217.90	 	 	 	406.84	 	 	 	260.45	 	 	 	239.73	 	 	 	239.73	 	 	 	628.24	 	 	 	628.24	 	 	 	594.96	 
	594.96
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part B
	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 
	266.03
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SSI/Part A & B
	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 
	208.25
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

	4.  	Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table 3, the second
paragraph is hereby amended to now read:
	 
	   	Notwithstanding the payment amounts which may be computed with the above rate table, the sum
of total capitation payments under this contract shall not exceed the total contract amount
of $815,961,749.00, (an increase of $4,189,037.00), expressed on page seven of this
contract.
	 
	5.  	This amendment shall begin on May 1, 2005, or the date on which the amendment has been signed
by both parties, whichever is later.
	 
	   	All provisions in the Contract and any attachments thereto in conflict with this amendment
shall be and are hereby changed to conform with this amendment.
	 
	   	All provisions not in conflict with this amendment are still in effect and are to be
performed at the level specified in the Contract.
	 
	   	This amendment and all its attachments are hereby made a part of the Contract.
	 
	   	This amendment cannot be executed unless all previous amendments to this Contract have been
fully executed.

     IN WITNESS WHEREOF, the parties hereto have caused this 3 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.

	 	 	 	 	 	 	 
	HEALTHEASE OF FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR
	 	 	HEALTH CARE ADMINISTRATION
	 
	 	 	 	 	 	 
	SIGNED	 	SIGNED
	BY:

	 	/s/ Imtiaz H. Sattaur
	 	BY:   
	/s/ Alan Levine
	

	 	 
	 	 	 
	 
	 	 	 	 	 	 
	NAME: Imtiaz H. Sattaur	 	NAME: Alan Levine
	 
	 	 	 	 	 	 
	TITLE: President	 	TITLE: Secretary
	 
	 	 	 	 	 	 
	DATE: April 28, 2005	 	DATE: 4.28.2005

THE REMAINDER OF THIS PAGE LEFT BLANK INTENTIONALLY

AHCA Contract No. FA521, Amendment No. 5, Page 3 of 3

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00085-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00085-of-00352.parquet"}]]